Clinical, Histopathological and Outcome Analysis of Five Patients With Lichenoid Eruption Following Anti-Tumor Necrosis Factor-Alpha Therapy for Ankylosing Spondylitis: Report of One Case and Review of the Literature

Samily Oliveira,Emmanuel Pereira Benevides Magalhães,Antonio Helder Costa Vasconcelos,Fernanda Judith Vieira Corrêa,Carlos Ewerton Maia Rodrigues

doi:10.7759/cureus.10598

Samily Oliveira, Emmanuel Pereira Benevides Magalhães + Show 3 more

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https://doi.org/10.7759/cureus.10598

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Abstract

Tumor necrosis factor-alpha (TNF-ɑ) inhibitors have become the mainstay of therapy for a wide range of autoinflammatory diseases, despite concerns regarding dermatological adverse reactions. In this paper, we describe the clinical and histological findings and outcome of a case of lichenoid eruption (LE) following adalimumab therapy for ankylosing spondylitis (AS) and review four earlier reports concerning this rare clinical association. The time of onset varied considerably (three weeks to 52 months) and lesions varied within the clinical spectrum (from typical lichen planus to psoriasiform), but all had LE-compatible histology, with acanthosis, necrotic keratinocytes and lymphocytic infiltrate as hallmarks. Most patients (3/5) improved with treatment and one experienced full recovery, while in one case the lesions persisted. TNF-ɑ has been implicated in the pathogenesis of lichen planus, making it difficult to explain how TNF-ɑ antagonists can induce lichenoid reactions. The appearance of LE may in some cases justify cessation of therapy.

Highlights

Tumor necrosis factor-alpha (TNFα) inhibitors are the mainstay of therapy for a wide range of autoimmune diseases
We describe the clinical and histological findings and outcome of a case of lichenoid eruption (LE) following adalimumab therapy for ankylosing spondylitis (AS) and review four earlier reports concerning this rare clinical association
This is supported by a study involving 252 patients with rheumatoid arthritis (RA) and 183 with spondyloarthropathy treated with TNFα inhibitors and evaluated for immune-mediated skin lesions

Summary

Introduction

Tumor necrosis factor-alpha (TNFα) inhibitors are the mainstay of therapy for a wide range of autoimmune diseases. In patients with ankylosing spondylitis (AS), TNFα inhibitors have been shown to effectively bring symptoms under control, improve quality of life as well as reducing radiographic progression, especially with early initiation and longer duration of follow up [1]. The pathogenesis of LE is still not fully understood, with some considering it paradoxical [1, 4] In this context, lichen planus induced by TNFα inhibitors has been observed in some types of spondyloarthritis [5, 6]. How to cite this article Oliveira S, Vasconcelos A, Magalhães E, et al (September 22, 2020) Clinical, Histopathological and Outcome Analysis of Five Patients With Lichenoid Eruption Following Anti-Tumor Necrosis Factor-Alpha Therapy for Ankylosing Spondylitis: Report of One Case and Review of the Literature. Arrow: bandlike chronic inflammatory infiltrate; triangle: pigmentary effusion (stain: H&E, 200x magnification)

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