Clinical Gastroenterology and Hepatology
Volume 7, Issue 2 , Page A28, February 2009

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

  • Jürg Wermuth

      Affiliations

    • Division of Gastroenterology, University Department of Medicine, Kantonsspital Liestal, Liestal
    • ,
  • Fabiola Kind

      Affiliations

    • Department of Dermatology, University Hospital Basel, Basel, Switzerland
    • ,
  • Michael Steuerwald

      Affiliations

    • Division of Gastroenterology, University Department of Medicine, Kantonsspital Liestal, Liestal

published online 20 August 2008.

Article Outline

 

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.

Palmoplantar pustulosis and Acrodermatitis of Hallopeau are psoriatic manifestations of the palms and fingernails, respectively. Dermatologic side effects of tumor necrosis factor–alpha blockers are well-recognized and appear to be a class effect.1, 2 The reported skin pathologies include inflammatory disorders (eg, eczema, psoriasis), autoimmune diseases (lupus erythematosus, leukocytoclastic vasculitis), and, rarely, tumors. Gastroenterologists should be aware of these infrequent but potentially severe and long-lasting side effects.

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References 

  1. Roux CH, Brocq O, Leccia N, et al. New-onset psoriatic palmoplantaris pustulosis following infliximab therapy: a class effect?. J Rheumatol. 2007;34:434–437
  2. Lee HH, Song IH, Friedrich M, et al. Cutaneous side-effects in patients with rheumatic diseases during application of tumour necrosis factor-alpha antagonists. Br J Dermatol. 2007;156:486–491

PII: S1542-3565(08)00834-3

doi:10.1016/j.cgh.2008.08.009

Clinical Gastroenterology and Hepatology
Volume 7, Issue 2 , Page A28, February 2009