Harmony or Discord: Navigating Paradoxical Eczema with Psoriasis Biologic Treatments

Original Article: Risk of Paradoxical Eczema in Patients Receiving Biologics for Psoriasis

What are the key takeaways of this article?

Biologics have become effective treatments for recalcitrant psoriasis. However, there are cutaneous adverse events associated with their administration such as paradoxical psoriasis and eczema, cutaneous lupus, and granulomatous eczema.

The event of paradoxical eczema in biologic-treated psoriasis patients can increase treatment cessation or cotreatment with biologics, both of which may have risks to patients. Interestingly, paradoxical eczema is a rare occurrence in the absence of biologic treatment due to immunological and genetic differences between the diseases. Currently, the specific risk factors that suggest which patients may be affected are understudied and not well known. Yet, understanding the risks of biologics and their possible associated adverse effects is important for patient safety and individualized treatment plans.

This prospective cohort study looked at over 24 997 psoriasis patients being treated with biologics across the United Kingdom and Ireland. The study aimed to assess the incidence of paradoxical eczema, whether the risk of incidence differed between Tumor necrosis factor (TNF) inhibitors and other biologic classes, and the clinical and demographic factors associated with paradoxical eczema. Inclusion criteria for the study included adults 18 and older with plaque psoriasis being treated with one of the following biologics; TNF inhibitors (adalimumab, certolizumab pegol, etanercept, or infliximab), IL-17 inhibitors (bi-mekizumab, brodalumab, ixekizumab, or secukinumab), IL-12/23 inhibitors (ustekinumab), or IL-23 inhibitors (guselkumab, risankizumab, or tildrakizumab). Data was collected at baseline, every 6 months for 3 years, and then annually thereafter. Variables recorded included therapy regimens, adverse events, and baseline demographics including ethnicity. In addition to the primary analysis, a secondary analysis was performed for paradoxical eczema cases.

After data analysis, a total of 265 paradoxical eczema events were found, accounting for 1% of biologic exposures. Incidence rates for specific biologic therapies included 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-12/23 inhibitors, and 0.56 per 100 000 person-years for IL-23 inhibitors. As such, patients using IL-23 inhibitors showed a lower incidence of paradoxical eczema. Furthermore, demographic analysis reported increasing age, female sex, history of atopic dermatitis (AD), and history of hay fever to be associated with higher risk of paradoxical eczema. There was no association with asthma found in this study.

In conclusion, this study demonstrates a lower incidence of paradoxical eczema in IL-23 inhibitors in comparison to IL-17, IL-12/23 and TNF inhibitors in a large cohort of adults with psoriasis being treated with biologics. Increasing age, female sex, history of AD or hay fever all had a higher associated risk of paradoxical eczema. This study has important findings that suggest IL-23 inhibitors could be considered in patients with psoriasis and/or factors associated with paradoxical eczema. Further research is needed to replicate these findings, which should importantly include a large proportion of visible minorities. 

Publication Date: January 7th, 2024

Reference: Al-Janabi A, Alabas OA, Yiu ZZN, et al. Risk of Paradoxical Eczema in Patients Receiving Biologics for Psoriasis. JAMA Dermatol. Published online December 06, 2023. doi:10.1001/jamadermatol.2023.4846

Summary By: McKenzie Van Eaton