Palmoplantar Pustulosis and Acrodermatitis in a Patient Treated With Infliximab for Crohn's Sacroiliitis

A 35-year-old woman developed pustules of the palmar and plantar skin after infusion of the chimeric tumor necrosis factor–alpha antibody infliximab (Remicade; Schering-Plough Inc, Kenilworth, NJ) for Crohn's sacroiliitis. The patient was diagnosed with Crohn's disease of the colon and terminal ileum in 1994 at the age of 22. Remission was maintained with standard medications. In 2007 she presented with bilateral sacroiliitis that did not respond to treatment with physical therapy, NSAIDs, mesalamine, corticosteroids, and azathioprine. Given the severity and intractability of her symptoms, infliximab at a standard dose was administered at 0, 2, and 6 weeks. Four weeks after the third dose, the patient developed itchy pustules on the palm of her hands and feet (Figure A). On a first skin biopsy the diagnosis of eczema was made. After subsequent doses of infliximab, the skin lesions worsened, and the patient developed painful pustules under her fingernails (Figure B). A second skin biopsy showed pustular type of psoriasis, also termed palmoplantar pustulosis. The features of the fingernail lesions were typical of acrodermatitis continua of Hallopeau. The patient was treated with occlusive steroid dressings and local application of bituminate. Fifteen months after cessation of infliximab, palmoplantar pustulosis and acrodermatitis of Hallopeau had improved but were still present.

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