Key points What factors are associated with paradoxical eczema occurring in psoriasis patients treated with biologics? Findings In this cohort study of 24,997 biological exposures in 13,699 patients with psoriasis, the risk of paradoxical eczema was lower in patients receiving interleukin-23 inhibitors compared with other biological classes. Older age, history of atopic dermatitis, and history of hay fever were associated with an increased risk of paradoxical eczema; the risk was lower in men. Meaning The findings suggest that interleukin 23 inhibitors could be considered in psoriasis patients with factors associated with paradoxical eczema. |
Although biologics targeting tumor necrosis factor (TNF), interleukin (IL) 12/23, IL-17, and IL-23 are highly effective treatments for plaque psoriasis, they are associated with adverse skin events, such as paradoxical reactions, cutaneous lupus and granulomatous disorders. Some patients with psoriasis develop paradoxical eczema , a phenotype of atopic dermatitis (AD), during biological exposure because these dermatoses are genetically and immunologically divergent and rarely occur together. Additionally, there have been reports of development of psoriasis or inflammatory arthritis secondary to IL. -
In addition to the direct impact of paradoxical eczema , this could lead to discontinuation of treatment or concomitant use of immunosuppressants. It is unclear whether the risk of paradoxical eczema varies by biological class or other clinical characteristics.
The British Association of Dermatologists’ Biologics and Immunomodulators Registry (BADBIR) has recruited more than 20,000 psoriasis patients from 168 centers in the UK and Ireland.
BADBIR was used to conduct a prospective cohort study to evaluate: (1) the overall and biological class-specific incidence of paradoxical eczema, (2) whether the risk of paradoxical eczema differs between TNF inhibitors and other biological classes, and (3) demographic, clinical characteristics and factors associated with paradoxical eczema.
Importance
Biologics used for plaque psoriasis have been reported to be associated with an atopic dermatitis (AD) phenotype , or paradoxical eczema , in some patients. The risk factors for this are unknown.
Aim
To explore the risk of paradoxical eczema by biological class and identify factors associated with paradoxical eczema .
Design, environment and participants
This prospective cohort study used data from the British Association of Dermatologists’ Immunomodulators and Biologics Registry for adults treated with biologics for plaque psoriasis who were seen in dermatology clinics in the United Kingdom and Ireland. Included participants were registered and had 1 or more follow-up visits between September 2007 and December 2022.
Exhibitions
Duration of exposure to tumor necrosis factor (TNF) inhibitors, interleukin (IL) 17 inhibitors, IL-12/23 inhibitors or IL-23 inhibitors until onset of paradoxical eczema, treatment discontinuation, last follow-up Or death.
Main results and measures
Incidence rates of paradoxical eczema , risk of paradoxical eczema by biological class, and association of demographic and clinical variables with risk of paradoxical eczema were assessed by propensity scoring with weighted Cox proportional hazards regression models.
Results
Of 56,553 drug exposures considered, 24,997 of 13,699 participants were included. The 24,997 exposures included (median age, 46 years [IQR, 36-55 years]; 57% men) accumulated a total exposure time of 81,441 patient-years.
A total of 273 exposures (1%) were associated with paradoxical eczema . Adjusted incidence rates were 1.22 per 100,000 person-years for IL-17 inhibitors, 0.94 per 100,000 person-years for TNF inhibitors, 0.80 per 100,000 person-years for IL-17 inhibitors, 12/23 and 0.56 per 100,000 person-years for IL-23 inhibitors.
Compared with TNF inhibitors, IL-23 inhibitors were associated with a lower risk of paradoxical eczema (hazard ratio [HR], 0.39; 95% CI, 0.19-0.81) and not there was an association of IL-17 inhibitors (HR, 1.03; 95% CI, 0.74-1.42) or IL-12/23 inhibitors (HR, 0.87; 95% CI, 0.66 -1.16) with risk of paradoxical eczema.
Increasing age (HR, 1.02 per year; 95% CI, 1.01-1.03) and history of AD (HR, 12.40; 95% CI, 6.97-22.06) or hay fever (HR, 3.78; 95% CI, 1.49-9.53) were associated with an increased risk of paradoxical eczema. There was a lower risk in men (HR, 0.60; 95% CI, 0.45-0.78).
Conclusions and relevance
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