Dermatomyositis associated with anti–tumor necrosis factor therapy in a patient with psoriasis
Authors: Dane Dicaro, Casey Bowen, Scott R. Dalton
Journal: Journal of the American Academy of Dermatology (2014)

To the Editor: Anti–tumor necrosis factor (a-TNF) agents have become a common treatment for many different autoimmune diseases. Due to conflicting effects mediated by TNF, a-TNF therapies both treat and induce autoimmune disease. Herein we discuss a novel case of a-TNF–induced amyopathic dermatomyositis (DM) in a patient with a history of psoriasis.A 37-year-old Brazilian woman was referred to our medical center for management of psoriasis. She had a 7-year history of biopsy-proven psoriatic plaques that had failed topical therapies and were exacerbated by UV therapy. Physical exam revealed a large 20- × 30-cm erythematous, scaly plaque on her back, and more than 20 guttate papules on her elbows and extensor forearms. She was started on adalimumab 40 mg biweekly following routine lab work and a negative tuberculosis test.One month later, her psoriasiform plaques had markedly improved, but indurated violaceous plaques overlying her knuckles with ragged cuticles and looped telangiectasias developed (Fig 1). Because she was satisfied with the resolving psoriasis, adalimumab was continued.A biopsy specimen from the periarticular dorsal hand skin papule was obtained (Fig 2).Fig 2Dermatomyositis. Hematoxylin and eosin stain of dorsal hand punch biopsy. Vacuolar interface dermatitis with sparse perivascular inflammation.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Biopsy revealed an atrophic epidermis and subtle vacuolar interface change associated with sparse superficial perivascular inflammation with increased dermal mucin. She denied myalgias or muscle weakness. Laboratory findings revealed a negative ANA, negative SCL70, a creatine kinase of 136 U/L, and a jo-1 < 1. Based on the clinical, laboratory, and pathologic findings, the diagnosis of DM was made. The patient has had negative results on age-appropriate cancer screenings, including gynecologic exam, computed tomography of abdomen/pelvis, and chest roentgenogram, as well as normal pulmonary function tests. Over the subsequent 10 months, she has had no other manifestations of DM. Her Gottron papules have softened somewhat with the addition of methotrexate. To our knowledge, anti-TNF–induced DM has not been previously reported in a patient with psoriasis.Vasculitis, psoriaform eruptions, and a lupus-like syndrome are the most common a-TNF–induced sequelae.1Ramos-Casals M. Brito-Zerón P. Soto M.-J. Cuadrado M.-J. Khamashta M.A. Autoimmune diseases induced by TNF-targeted therapies.Best Pract Res Clin Rheumatol. 2008; 22: 847-861Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar, 2Klein R. Rosenbach M. Kim E.J. Kim B. Werth V.P. Dunham J. Tumor necrosis factor inhibitor-associated dermatomyositis.Arch Dermatol. 2010; 146: 780-784Crossref PubMed Scopus (91) Google Scholar, 3Moustou A.E. Matekovits A. Dessinioti C. Antoniou C. Sfikakis P.P. Stratigos A.J. Cutaneous side effects of anti–tumor necrosis factor biologic therapy: a clinical review.J Am Acad Dermatol. 2009; 61: 486-504Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar DM has been implicated in only 9 case reports, including our own.4Liu S.W. Velez N.F. Lam C. Femia A. Granter S.R. Townsend H.B. et al.Dermatomyositis induced by anti–tumor necrosis factor in a patient with juvenile idiopathic arthritis.JAMA Dermatol. 2013; 149: 1204-1208Crossref PubMed Scopus (35) Google Scholar Five of the 8 prior cases were patients with underlying rheumatoid arthritis; one had Crohn disease, one had underlying juvenile idiopathic arthritis, and one had seronegative inflammatory arthritis.4Liu S.W. Velez N.F. Lam C. Femia A. Granter S.R. Townsend H.B. et al.Dermatomyositis induced by anti–tumor necrosis factor in a patient with juvenile idiopathic arthritis.JAMA Dermatol. 2013; 149: 1204-1208Crossref PubMed Scopus (35) Google Scholar Four of the previous 8 cases were induced by adalimumab, 3 were induced by etanercept, and 1 was induced by both adalimumab and etanercept.4Liu S.W. Velez N.F. Lam C. Femia A. Granter S.R. Townsend H.B. et al.Dermatomyositis induced by anti–tumor necrosis factor in a patient with juvenile idiopathic arthritis.JAMA Dermatol. 2013; 149: 1204-1208Crossref PubMed Scopus (35) Google Scholar In many of the previous reports, direct causality was difficult to establish due to the length of time between therapy initiation and symptom development.4Liu S.W. Velez N.F. Lam C. Femia A. Granter S.R. Townsend H.B. et al.Dermatomyositis induced by anti–tumor necrosis factor in a patient with juvenile idiopathic arthritis.JAMA Dermatol. 2013; 149: 1204-1208Crossref PubMed Scopus (35) Google Scholar In our case, the DM symptoms began after 1 month of treatment, making causality more likely.a-TNF agents continue to be a safe and effective treatment for various dermatologic and rheumatologic conditions. Due to the increasing popularity of these agents, practitioners should be cognizant of their potential to paradoxically induce autoimmune disease. The spectrum of presentations can be widely varied and can exhibit symptomatic overlap with other connective tissue disease. Therefore, it is imperative to maintain a high degree of clinical suspicion when prescribing these medicines. To the Editor: Anti–tumor necrosis factor (a-TNF) agents have become a common treatment for many different autoimmune diseases. Due to conflicting effects mediated by TNF, a-TNF therapies both treat and induce autoimmune disease. Herein we discuss a novel case of a-TNF–induced amyopathic dermatomyositis (DM) in a patient with a history of psoriasis. A 37-year-old Brazilian woman was referred to our medical center for management of psoriasis. She had a 7-year history of biopsy-proven psoriatic plaques that had failed topical therapies and were exacerbated by UV therapy. Physical exam revealed a large 20- × 30-cm erythematous, scaly plaque on her back, and more than 20 guttate papules on her elbows and extensor forearms. She was started on adalimumab 40 mg biweekly following routine lab work and a negative tuberculosis test. One month later, her psoriasiform plaques had markedly improved, but indurated violaceous plaques overlying her knuckles with ragged cuticles and looped telangiectasias developed (Fig 1). Because she was satisfied with the resolving psoriasis, adalimumab was continued. A biopsy specimen from the periarticular dorsal hand skin papule was obtained (Fig 2). Biopsy revealed an atrophic epidermis and subtle vacuolar interface change associated with sparse superficial perivascular inflammation with increased dermal mucin. She denied myalgias or muscle weakness. Laboratory findings revealed a negative ANA, negative SCL70, a creatine kinase of 136 U/L, and a jo-1 < 1. Based on the clinical, laboratory, and pathologic findings, the diagnosis of DM was made. The patient has had negative results on age-appropriate cancer screenings, including gynecologic exam, computed tomography of abdomen/pelvis, and chest roentgenogram, as well as normal pulmonary function tests. Over the subsequent 10 months, she has had no other manifestations of DM. Her Gottron papules have softened somewhat with the addition of methotrexate. To our knowledge, anti-TNF–induced DM has not been previously reported in a patient with psoriasis. Vasculitis, psoriaform eruptions, and a lupus-like syndrome are the most common a-TNF–induced sequelae.1Ramos-Casals M. Brito-Zerón P. Soto M.-J. Cuadrado M.-J. Khamashta M.A. Autoimmune diseases induced by TNF-targeted therapies.Best Pract Res Clin Rheumatol. 2008; 22: 847-861Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar, 2Klein R. Rosenbach M. Kim E.J. Kim B. Werth V.P. Dunham J. Tumor necrosis factor inhibitor-associated dermatomyositis.Arch Dermatol. 2010; 146: 780-784Crossref PubMed Scopus (91) Google Scholar, 3Moustou A.E. Matekovits A. Dessinioti C. Antoniou C. Sfikakis P.P. Stratigos A.J. Cutaneous side effects of anti–tumor necrosis factor biologic therapy: a clinical review.J Am Acad Dermatol. 2009; 61: 486-504Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar DM has been implicated in only 9 case reports, including our own.4Liu S.W. Velez N.F. Lam C. Femia A. Granter S.R. Townsend H.B. et al.Dermatomyositis induced by anti–tumor necrosis factor in a patient with juvenile idiopathic arthritis.JAMA Dermatol. 2013; 149: 1204-1208Crossref PubMed Scopus (35) Google Scholar Five of the 8 prior cases were patients with underlying rheumatoid arthritis; one had Crohn disease, one had underlying juvenile idiopathic arthritis, and one had seronegative inflammatory arthritis.4Liu S.W. Velez N.F. Lam C. Femia A. Granter S.R. Townsend H.B. et al.Dermatomyositis induced by anti–tumor necrosis factor in a patient with juvenile idiopathic arthritis.JAMA Dermatol. 2013; 149: 1204-1208Crossref PubMed Scopus (35) Google Scholar Four of the previous 8 cases were induced by adalimumab, 3 were induced by etanercept, and 1 was induced by both adalimumab and etanercept.4Liu S.W. Velez N.F. Lam C. Femia A. Granter S.R. Townsend H.B. et al.Dermatomyositis induced by anti–tumor necrosis factor in a patient with juvenile idiopathic arthritis.JAMA Dermatol. 2013; 149: 1204-1208Crossref PubMed Scopus (35) Google Scholar In many of the previous reports, direct causality was difficult to establish due to the length of time between therapy initiation and symptom development.4Liu S.W. Velez N.F. Lam C. Femia A. Granter S.R. Townsend H.B. et al.Dermatomyositis induced by anti–tumor necrosis factor in a patient with juvenile idiopathic arthritis.JAMA Dermatol. 2013; 149: 1204-1208Crossref PubMed Scopus (35) Google Scholar In our case, the DM symptoms began after 1 month of treatment, making causality more likely. a-TNF agents continue to be a safe and effective treatment for various dermatologic and rheumatologic conditions. Due to the increasing popularity of these agents, practitioners should be cognizant of their potential to paradoxically induce autoimmune disease. The spectrum of presentations can be widely varied and can exhibit symptomatic overlap with other connective tissue disease. Therefore, it is imperative to maintain a high degree of clinical suspicion when prescribing these medicines.