Infliximab-Associated Psoriasiform Alopecia

Abstract

Introduction: Paradoxical psoriasiform eruptions may occur with tumour necrosis factor antagonists (anti-TNFs) treatment, but cases of anti-TNF induced alopecia where scalp psoriasiform lesions cause hair loss are less commonly reported. The nature of anti-TNF induced alopecia has not been fully determined. Method: We report two cases of infliximab-associated psoriasiform alopecia that have resolved with significant hair regrowth. Results: A 14 year old girl presented with a 4 month history of an enlarging erythematous, malodorous plaque on the vertex of the scalp. The area of alopecia extended over 12 cm in diameter and was associated with multiple small psoriasiform plaques on the trunk and limbs. She had a background of Crohn's disease treated with azathioprine and infliximab over the preceding 12 months, with no previous history of psoriasis. Scalp biopsy showed psoriasiform changes. Infliximab was stopped, azathioprine maintained and topical clobetasol propionate initiated to good clinical effect, with evidence of hair regrowth after two months of treatment. Another patient, a 48 year old woman, presented with a 9 month history of an erythematous scaly patch on the left frontal scalp. She had a background of Crohn's disease and had been on infliximab for 18 months, but had no previous history of psoriasis. Despite treatment with fluocinolone acetonide gel she developed alopecia in the affected area. Scalp biopsy again showed a psoriasiform changes. Treatment with topical clobetasol propionate was started and, in conjunction with the cessation of infliximab therapy, she experienced significant hair regrowth two months later. Crohn's disease activity remained stable in both cases. Discussion: Eighteen cases of anti-TNF associated psoriasiform alopecia have been reported to date, with the majority showing non-cicatricial alopecia. Treatment strategies included additional systemic therapy (9 cases), with cessation of anti-TNF therapy or switched to another anti-TNF therapy being employed in 13 cases. Histological changes are not well defined but include psoriasiform epidermal changes and dermal inflammation; one series describes alopecia areata-like hair follicle changes. A proposed mechanism for these findings is the disruption of immune homeostasis with resulting imbalance between cutaneous inflammatory cytokines. In conclusion, we report two cases of non-cicatricial anti-TNF associated psoriasiform alopecia that responded well to potent topical steroid treatment and cessation of anti-TNF therapy.Figure 1Figure 2