Paradoxical psoriasis is well recognised in adults receiving anti-TNFα therapy for IBD.¹ Biologics are increasingly being initiated earlier in the treatment ladder for IBD in the paediatric population and they are also vulnerable to paradoxical psoriasis.² This observational study aimed to describe the clinical features and management in this group, as there is limited data on how paradoxical psoriasis differs in children.

8 patients with paradoxical psoriasis were referred between 2019–2022, comprising 5 females and 3 males and age range of 12–19 years (mean 15.4 years). They all had Crohn’s disease and were receiving infliximab (7/8 patients) or adalimumab (1/8). The onset of symptoms following anti-TNFα initiation was 3 months - 3 years (average 12.75 months) similar to adults. Involvement included scalp (7), flexural (3), trunk (4) limb (3) and face (1). In adults, palmoplantar surfaces and a pustular morphology are most commonly reported. In our cohort, some presented with eczematous flares requiring anti-bacterial agents which is rarely seen in adults. Management of the paradoxical psoriasis included switching from infliximab to usetkinumab in 3 patients; addition of methotrexate (2). Topical treatments alone were sufficient in 3 patients.

There were florid clinical presentations in our cohort and the scalp predominantly affected (7/8) which tended to be severe. 5 of 8 patients required a switch of their anti-TNFα therapy or an additional systemic treatment. It is crucial for physicians to be aware of this phenomenon and work collaboratively to recognise this early to optimise patients’ symptoms and quality of life.

References

1. Bucalo, et al. ‘PP induced by anti-TNFα treatment: evaluation of specific clinical and genetic markers’ [2020].

2. Courbette, et al. ‘Infliximab PP in Children with IBD’ [2019].