AB0948 PARADOXICAL TINEA AMIANTACEA IN A PATIENT WITH JUVENILE IDIOPATHIC ARTHRITIS RECEIVING ADALIMUMAB
Authors: Maria Costanza Caparello, Francesca Tirelli, Gabriele Simonini, Rolando Cimaz, Teresa Giani
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background</h3> Tinea amiantacea is a papulo-squamous condition of the scalp that can lead to scalp fibrosis and subsequent permanent hair loss. It is thought to represent a reaction pattern to inflammatory skin disease as psoriasis or seborrheic dermatitis (1). <h3>Objectives</h3> To highlight an adverse reaction which involved the skin in the disease course of a young JIA (juvenile idiopathic arthritis) patient, during treatment with adalimumab. <h3>Methods</h3> A 16-month-old female patient presented to our clinic with a 4-week history of knee swelling, associated with functional limitation and morning stiffness. Family history was unremarkable, while past medical history revealed atopic dermatitis in the first year of life. The baby was initially treated with NSAIDs, but one month later, due the persistence of arthritis and the appearance of uveitis, subcutaneous methotrexate was started (15 mg/m<sup>2</sup>/weekly). However 5 months later, given the persistence of uveitis and the onset of a severe hypertransaminasemia, methotrexate was interrupted and adalimumab (24 mg/m<sup>2</sup> every 2 weeks) was introduced with a prompt and stable control of ocular and articular disease and a gradual normalization of transaminases. One year later the patient developed dry, itchy, red and cracked skin behind her ears, with fissuringin the lower attachment of the ear lobe, and presented right parietal yellowish scalp lesions which were pruriginous, thick, and scaly, attached both to the scalp and to the proximal hair shafts. A first diagnosis of pityriasis amiantacea secondary to atopic dermatitis was made. A paradoxical cutaneous reaction to the anti-TNF therapy was later hypothesized (2), and 7 months later adalimumab was interrupted with quick resolution of the dermatologic lesions. However, both arthritis and uveitis rapidly recurred, showing an inadequate response to a six month cycle of abatacept treatment (10 mg/kg/month). Adalimumab was than reintroduced with a rapid improvement. <h3>Results</h3> Currently, after 16 months of adalimumab treatment, the patient still shows complete disease control, without any new dermatologic lesions up to now. <h3>Conclusion</h3> TNF antagonist-induced tinea amiantacea is a rare adverse reaction that may require the drug discontinuation. Although the exact pathogenetic mechanism is unclear, an imbalance in the cytokine milieu with a selective overexpression of type I interferon has been hypothesized. <h3>References</h3> [1] F. Osório, F. Magro, C. Lisboa, S. Lopes, G. Macedo, H. Bettencourt, F. Azevedo, S. Magina, Anti-TNF-Alpha induced psoriasiform eruptions with severe scalp involvement and alopecia: report of five cases and review of the literature. Dermatology. 2012;225(2):163-7. doi: 10.1159/000342503 [2] J. Ettler, D.A. Wetter, M.R. Pittelkow. Pityriasis amiantacea: a distinctive presentation of psoriasis associated with tumour necrosis factor-α inhibitor therapy. Clin Exp Dermatol. 2012Aug;37(6):639-41. doi: 10.1111/j.1365-2230.2011.04286.x. <h3>Disclosure of Interests</h3> Maria Costanza Caparello: None declared, Francesca Tirelli: None declared, Gabriele Simonini Grant/research support from: Abbvie, Speakers bureau: Abbvie, Rolando Cimaz: None declared, Teresa Giani: None declared