- Email: [email protected]
Management of Recurrent Cutaneous Abscesses During Therapy With Infliximab
Clinical Therapeutics/Volume 33, Number 12, 2011
Case Report
Management of Recurrent Cutaneous Abscesses During Therapy With Infliximab Clara De Simone, MD1; Rita Murri, MD2; Alessia Maiorino, MD1; Antonio Venier, MD1; and Giacomo Caldarola, MD1 1
Department of Dermatology, Catholic University of Sacred Heart, Rome, Italy; and 2Department of Infectious Diseases, Catholic University of Sacred Heart, Rome, Italy ABSTRACT Background: Infliximab is a chimeric monoclonal antibody, belonging to the class of anti–tumor necrosis factor-␣ (TNF-␣) agents, approved for the treatment of psoriasis and psoriatic arthritis. Drugs of this class are known to be associated with an infective risk, probably because they interfere with inflammatory and immune response at different levels. Although cutaneous Staphylococcus aureus infections seem to be more frequent than any other infection in the course of anti–TNF-␣ treatment, only a few case reports in the literature deal with this side effect, and, in particular, with its management. Objective: Our aim was to report a case of recurrent methicillin-sensitive S aureus (MSSA) cutaneous abscesses during therapy with infliximab and successful management. Case summary: In July 2009, a 53-year-old white woman (weighing 85 kg) affected by psoriasis and psoriatic arthritis was administered infliximab (5 mg/kg IV), based upon clinical appearance and previous unsuccessful treatment with cyclosporine, methotrexate, etanercept, and adalimumab. Three days after the first 3 infusions (at weeks 0, 2, and 6) she complained about the recurrent onset of painful, erythematous, indurated, and pus-draining cutaneous nodules located on her abdomen. The swab always revealed the presence of MSSA, and antibiotic oral therapy with amoxicillin ⫹ clavulanic acid (875 ⫹ 125 mg BID for 7 days) was established, with complete resolution of the abscesses. Routine laboratory findings were in normal ranges, with the exception of an elevated erythrosedimentation rate and an increased white blood cell count (range, 13,000 –15,000/mm3) with neutrophilia (range, 75%– 80%). HIV infection was ruled out. In agreement with the infectious disease consul-
Decenber 2011
tant, 1 day before the fourth infusion, a prophylactic antibiotic therapy with amoxicillin ⫹ clavulanic acid (875 ⫹ 125 mg BID for 5 days) was added to the therapeutic regimen. This treatment schedule was successfully repeated at each following infusion (every 8 weeks), and no recurrence of skin abscesses was observed. The patient provided signed authorization for publication of this case. Conclusions: This case report describes a woman with psoriasis and psoriatic arthritis who developed MSSA skin abscesses after each of the first 3 infliximab infusions, which did not recur for the next 6 infusions after amoxicillin ⫹ clavulanic acid was added to her regimen, pre- and 4 days postinfusion. Adequately designed, placebo-controlled, double-blind trials are needed to determine whether such prophylactic antibiotic treatment is well tolerated or effective for this common complication of therapy with anti–TNF-␣ agents, when withdrawal of the drug is not advisable, as in this case. (Clin Ther. 2011;33:1993–1996) © 2011 Elsevier HS Journals, Inc. All rights reserved. Key words: abscesses, infliximab, psoriasis, TNF-␣ blockers.
INTRODUCTION Psoriasis is a chronic inflammatory disease characterized by an inflammatory dermal infiltrate and hyperproliferative keratinocytes. Tumor necrosis factor-␣ (TNF-␣) is considered to be a molecule with a pivotal role in the pathogenesis of this disease, and, consequently, anti–TNF-␣ agents are used to treat moderate Accepted for publication October 18, 2011. doi:10.1016/j.clinthera.2011.10.015 0149-2918/$ - see front matter © 2011 Elsevier HS Journals, Inc. All rights reserved.
1993
Clinical Therapeutics to severe forms of psoriasis, particularly in patients who have not responded to traditional treatments,1 or who have contraindications to using them. Although this is a class of drugs that is known to be tolerable, an infective risk has been found in patients receiving this therapy, probably because of its immunomodulator role.2 Because of this, the management of concomitant chronic infections, and of the new onset of local or systemic infections during treatment, may represent a frequent concern in clinical practice. Although cutaneous Staphylococcus aureus infections seem to be more frequent than any other infection in the course of anti–TNF-␣ treatment, a review of the literature conducted on PubMed using the terms psoriasis, anti–TNF-␣ therapy, infection, and Staphylococcus aureus only found a few case reports dealing with this cutaneous side effect, and in particular with its management.3–5 (The manufacturer or regulatory authorities were not asked about similar reports). We report a case of recurrent cutaneous abscesses during therapy with an anti–TNF-␣ agent, infliximab,a successfully managed with a prophylactic antibiotic regimen.
CASE SUMMARY In July 2009, a 53-year-old white woman (weighing 85 kg) who had psoriasis and psoriatic arthritis since the age of 35 presented to our department with a severe skin involvement (Psoriasis Area and Severity Index [PASI]6 score of 28, assessed by A.M.) and with 7 swollen and/or painful peripheral joints. At that time she had been on treatment with adalimumabb (40 mg SC biweekly for 3 months, without satisfactory results. She also had diabetes mellitus and dyslipidemia and was on therapy with metforminc (2 g/d PO) and simvastatind (20 mg/d PO), respectively. Based upon the clinical appearance and the previous unsuccessful treatment with cyclosporinee (up to 300 mg/d PO for 3 months), methotrexatef (up to 15 mg/week IM), and
a
Trademark: Remicade® (Merck Sharp & Dohme (Italia) SpA, Rome, Italy). b Trademark: Humira® (Abbott Srl, Campoverde di Aprillia, Latina, Italy). c Trademark: Metforal® (Laboratori Guidotti SpA, Pisa, Italy). d Trademark: Sivastin® (Sigma-Tau SpA, Roma, Italy). e Trademark: Sandimmun Neoral® (Novartis Farma SpA, Origgio, Varese, Italy). f Trademark: Methotrexate® (Pfizer Italia Srl, Latina, Italy).
1994
etanerceptg (50 mg/week SC for 6 months), the patient was switched to infliximab (5 mg/kg IV at weeks 0, 2, 6, and then every 8 weeks) (Figure 1). Three days after the first infusion she presented to our department again because of the onset of 2 painful, erythematous, indurated, and pus-draining cutaneous nodules (2 and 3 cm in length, respectively) located on her abdomen. The swab of the nodule exudate revealed the presence of methicillin-sensitive S aureus (MSSA); antibiotic oral therapy with amoxicillin ⫹ clavulanic acidh (875 ⫹ 125 mg BID) was started and continued for 7 days. The antibiotic therapy led to a complete healing of the skin abscesses in a week. The second and third infusions were also followed in a few days by the appearance of new multiple (3 and 1, respectively) abscesses, very similar clinically to the previous ones (Figure 2), which were successfully treated with the same antibiotic course, because the same microbe, with the same antibiotic sensitivity, was found in the exudate. Routine laboratory findings, including urine analysis, and hematologic, chemical, and immunologic profiles were in the normal ranges, excluding an elevated erythrosedimentation rate and an increased white blood cell count (range, 13,000 –15,000/mm3) with neutrophilia (range, 75%– 80%). The patient’s diabetes was clinically controlled (glycosylated hemoglobin, 4.8%) and not considered a contributor to this case. HIV antibodies were absent. In agreement with the infectious disease consultant and with the patient (because this was not a standard therapy), 1 day before the fourth infusion (14 weeks after the first one), a prophylactic antibiotic therapy with amoxicillin ⫹ clavulanic acid (875 ⫹ 125 mg BID for 5 days) was added to the therapeutic regimen. This treatment was allowed and paid for by national health insurance according to the local rules. No recurrence of skin abscesses or any other infectious cutaneous disease was observed, and this treatment schedule was successfully repeated at each subsequent infusion until the time of writing. This therapy, therefore, permitted infusions with infliximab to be continued at 8-week intervals. After the fourth infusion, improvement of skin and joint psoriatic disease was evident, because the PASI score was reduced to 3.8, and just 3 isolated joints were swollen and/or tender. To date, after 12 months of treatment (9 infu-
g
Trademark: Enbrel® (Pfizer Italia Srl, Latina, Italy). Trademark: Augmentin® (GlaxoSmithKline SpA, Verona, Italy).
h
Volume 33 Number 12
C.De Simone et al.
35.0 PASI
*
30.0 25.0
Swollen and/or painful joint count Infliximab infusion
*
Abscess
* onset
20.0
Infliximab infusion + PABT
15.0
* 10.0 5.0 0.0
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96
Time (weeks)
Etanercept
Adalimumab
Infliximab
Figure 1. The graph shows the Psoriasis Area and Severity Index (PASI) score trend, and that of the swollen and/or painful joint count, during the last 3 treatments. We also underline the time of the infusions and the onset of the abscesses. PABT ⫽ prophylactic antibiotic therapy.
sions), the patient is still responsive to treatment (PASI score 0 and no swollen and/or tender joints), and she has not experienced any recurrence of bacterial skin
infection. The patient provided signed authorization for publication of this case.
DISCUSSION
Figure 2. The abdomen of the patient after the third infusion presented with painful, erythematous and indurated cutaneous nodules, and multiple scars from the previous abscesses.
Decenber 2011
Infliximab is a chimeric monoclonal antibody, an anti– TNF-␣ agent, approved for the treatment of psoriasis and psoriatic arthritis.1 Drugs of this class are known to be associated with an infective risk, probably because they interfere with inflammatory and immune response at different levels.7 In a nationwide survey of infectious disease consultants aimed at identifying infections in patients receiving these drugs, Winthrop et al8 reported that “invasive Staphylococcus aureus infections” were more frequent than any other infection. However, Bassetti et al,9 by evaluating the S aureus colonization rate of the nose, posterior pharynx, and soft palate in patients with rheumatoid arthritis, showed that the risk of becoming an S aureus carrier was not increased after this kind of treatment. Recently, Moustou et al,10 in their review of cutaneous reactions in patients receiving anti–TNF-␣ therapy, reported that bacterial infections were one of the most frequent skin side effects. However, few cases have been reported in the literature regarding this side effect,
1995
Clinical Therapeutics and little is known about its management.3–5 We presented a case of recurrent cutaneous abscesses after infliximab infusions, successfully managed by a prophylactic antibiotic regimen. This complication might represent a reason for the withdrawal of infliximab, but the severity of the disease, the previous failure of the major therapeutic alternatives, and the clinical efficacy of infliximab, encouraged us to go on with this treatment.
CONCLUSIONS This case report describes a woman with psoriasis and psoriatic arthritis who developed MSSA skin abscesses after each of the first 3 infliximab infusions, which did not recur for the next 6 infusions after amoxicillin ⫹ clavulanic acid was added to her regimen, pre- and 4 days postinfusion. Adequately designed, placebo-controlled, double-blind trials are needed to determine whether such prophylactic antibiotic treatment is well tolerated or effective for this common complication of therapy with anti–TNF-␣ agents, when withdrawal of the drug is not advisable, as in this case.
CONFLICTS OF INTEREST The authors have indicated that they have no conflicts of interest regarding the content of this article.
ACKNOWLEDGMENTS All authors contributed equally to the conduct of the study and creation of the manuscript.
REFERENCES 1. Pathirana D, Ormerod AD, Saiag P, et al. European S3-guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatol Venereol. 2009;23:1–70.
2. Dixon WG, Watson K, Lunt M, et al. Rates of serious infection, including site-specific and bacterial intracellular infection, in rheumatoid arthritis patients receiving anti– tumor necrosis factor therapy. Arthritis Rheum. 2006;54: 2368 –2376. 3. Wegscheider BJ, El-Shabrawi L, Weger M, et al. Adverse skin reactions to infliximab in the treatment of intraocular inflammation. Eye (Lond). 2007;21:547–549. 4. Kroesen S, Widmer AF, Tyndall A, Hasler P. Serious bacterial infections in patients with rheumatoid arthritis under anti-TNF-a therapy. Rheumatology. 2003;42:617– 621. 5. 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. 6. Fredriksson, T, Petterson, U. Severe psoriasis-oral therapy with a new retinoid. Dermatologica. 1978;157:238 –244. 7. Silva LC, Ortigosa LC, Benard G. Anti-TNF-␣ agents in the treatment of immune-mediated inflammatory diseases: mechanisms of action and pitfalls. Immunotherapy. 2010;2: 817– 833. 8. Winthrop KL, Yamashita S, Beekmann SE, Polgreen PM. Infectious Diseases Society of America Emerging Infections Network. Mycobacterial and other serious infections in patients receiving anti-tumor necrosis factor and other newly approved biologic therapies: case finding through the Emerging Infections Network. Clin Infect Dis. 2008;46: 1738 –1740. 9. Bassetti S, Wasmer S, Hasler P, et al. Staphylococcus aureus in patients with rheumatoid arthritis under conventional and anti-tumor necrosis factor-alpha treatment. J Rheumatol. 2005;32:2125–2129. 10. Moustou AE, Matekovits A, Dessinioti C, et al. Cutaneous side effects of anti-tumor necrosis factor biologic therapy: a clinical review. J Am Acad Dermatol. 2009;61: 486 –504.
Address correspondence to: Dr. Alessia Maiorino, Department of Dermatology, Catholic University, Largo Francesco Vito, 8 – 00168 Rome, Italy. E-mail: [email protected]
1996
Volume 33 Number 12
Case Report
Management of Recurrent Cutaneous Abscesses During Therapy With Infliximab Clara De Simone, MD1; Rita Murri, MD2; Alessia Maiorino, MD1; Antonio Venier, MD1; and Giacomo Caldarola, MD1 1
Department of Dermatology, Catholic University of Sacred Heart, Rome, Italy; and 2Department of Infectious Diseases, Catholic University of Sacred Heart, Rome, Italy ABSTRACT Background: Infliximab is a chimeric monoclonal antibody, belonging to the class of anti–tumor necrosis factor-␣ (TNF-␣) agents, approved for the treatment of psoriasis and psoriatic arthritis. Drugs of this class are known to be associated with an infective risk, probably because they interfere with inflammatory and immune response at different levels. Although cutaneous Staphylococcus aureus infections seem to be more frequent than any other infection in the course of anti–TNF-␣ treatment, only a few case reports in the literature deal with this side effect, and, in particular, with its management. Objective: Our aim was to report a case of recurrent methicillin-sensitive S aureus (MSSA) cutaneous abscesses during therapy with infliximab and successful management. Case summary: In July 2009, a 53-year-old white woman (weighing 85 kg) affected by psoriasis and psoriatic arthritis was administered infliximab (5 mg/kg IV), based upon clinical appearance and previous unsuccessful treatment with cyclosporine, methotrexate, etanercept, and adalimumab. Three days after the first 3 infusions (at weeks 0, 2, and 6) she complained about the recurrent onset of painful, erythematous, indurated, and pus-draining cutaneous nodules located on her abdomen. The swab always revealed the presence of MSSA, and antibiotic oral therapy with amoxicillin ⫹ clavulanic acid (875 ⫹ 125 mg BID for 7 days) was established, with complete resolution of the abscesses. Routine laboratory findings were in normal ranges, with the exception of an elevated erythrosedimentation rate and an increased white blood cell count (range, 13,000 –15,000/mm3) with neutrophilia (range, 75%– 80%). HIV infection was ruled out. In agreement with the infectious disease consul-
Decenber 2011
tant, 1 day before the fourth infusion, a prophylactic antibiotic therapy with amoxicillin ⫹ clavulanic acid (875 ⫹ 125 mg BID for 5 days) was added to the therapeutic regimen. This treatment schedule was successfully repeated at each following infusion (every 8 weeks), and no recurrence of skin abscesses was observed. The patient provided signed authorization for publication of this case. Conclusions: This case report describes a woman with psoriasis and psoriatic arthritis who developed MSSA skin abscesses after each of the first 3 infliximab infusions, which did not recur for the next 6 infusions after amoxicillin ⫹ clavulanic acid was added to her regimen, pre- and 4 days postinfusion. Adequately designed, placebo-controlled, double-blind trials are needed to determine whether such prophylactic antibiotic treatment is well tolerated or effective for this common complication of therapy with anti–TNF-␣ agents, when withdrawal of the drug is not advisable, as in this case. (Clin Ther. 2011;33:1993–1996) © 2011 Elsevier HS Journals, Inc. All rights reserved. Key words: abscesses, infliximab, psoriasis, TNF-␣ blockers.
INTRODUCTION Psoriasis is a chronic inflammatory disease characterized by an inflammatory dermal infiltrate and hyperproliferative keratinocytes. Tumor necrosis factor-␣ (TNF-␣) is considered to be a molecule with a pivotal role in the pathogenesis of this disease, and, consequently, anti–TNF-␣ agents are used to treat moderate Accepted for publication October 18, 2011. doi:10.1016/j.clinthera.2011.10.015 0149-2918/$ - see front matter © 2011 Elsevier HS Journals, Inc. All rights reserved.
1993
Clinical Therapeutics to severe forms of psoriasis, particularly in patients who have not responded to traditional treatments,1 or who have contraindications to using them. Although this is a class of drugs that is known to be tolerable, an infective risk has been found in patients receiving this therapy, probably because of its immunomodulator role.2 Because of this, the management of concomitant chronic infections, and of the new onset of local or systemic infections during treatment, may represent a frequent concern in clinical practice. Although cutaneous Staphylococcus aureus infections seem to be more frequent than any other infection in the course of anti–TNF-␣ treatment, a review of the literature conducted on PubMed using the terms psoriasis, anti–TNF-␣ therapy, infection, and Staphylococcus aureus only found a few case reports dealing with this cutaneous side effect, and in particular with its management.3–5 (The manufacturer or regulatory authorities were not asked about similar reports). We report a case of recurrent cutaneous abscesses during therapy with an anti–TNF-␣ agent, infliximab,a successfully managed with a prophylactic antibiotic regimen.
CASE SUMMARY In July 2009, a 53-year-old white woman (weighing 85 kg) who had psoriasis and psoriatic arthritis since the age of 35 presented to our department with a severe skin involvement (Psoriasis Area and Severity Index [PASI]6 score of 28, assessed by A.M.) and with 7 swollen and/or painful peripheral joints. At that time she had been on treatment with adalimumabb (40 mg SC biweekly for 3 months, without satisfactory results. She also had diabetes mellitus and dyslipidemia and was on therapy with metforminc (2 g/d PO) and simvastatind (20 mg/d PO), respectively. Based upon the clinical appearance and the previous unsuccessful treatment with cyclosporinee (up to 300 mg/d PO for 3 months), methotrexatef (up to 15 mg/week IM), and
a
Trademark: Remicade® (Merck Sharp & Dohme (Italia) SpA, Rome, Italy). b Trademark: Humira® (Abbott Srl, Campoverde di Aprillia, Latina, Italy). c Trademark: Metforal® (Laboratori Guidotti SpA, Pisa, Italy). d Trademark: Sivastin® (Sigma-Tau SpA, Roma, Italy). e Trademark: Sandimmun Neoral® (Novartis Farma SpA, Origgio, Varese, Italy). f Trademark: Methotrexate® (Pfizer Italia Srl, Latina, Italy).
1994
etanerceptg (50 mg/week SC for 6 months), the patient was switched to infliximab (5 mg/kg IV at weeks 0, 2, 6, and then every 8 weeks) (Figure 1). Three days after the first infusion she presented to our department again because of the onset of 2 painful, erythematous, indurated, and pus-draining cutaneous nodules (2 and 3 cm in length, respectively) located on her abdomen. The swab of the nodule exudate revealed the presence of methicillin-sensitive S aureus (MSSA); antibiotic oral therapy with amoxicillin ⫹ clavulanic acidh (875 ⫹ 125 mg BID) was started and continued for 7 days. The antibiotic therapy led to a complete healing of the skin abscesses in a week. The second and third infusions were also followed in a few days by the appearance of new multiple (3 and 1, respectively) abscesses, very similar clinically to the previous ones (Figure 2), which were successfully treated with the same antibiotic course, because the same microbe, with the same antibiotic sensitivity, was found in the exudate. Routine laboratory findings, including urine analysis, and hematologic, chemical, and immunologic profiles were in the normal ranges, excluding an elevated erythrosedimentation rate and an increased white blood cell count (range, 13,000 –15,000/mm3) with neutrophilia (range, 75%– 80%). The patient’s diabetes was clinically controlled (glycosylated hemoglobin, 4.8%) and not considered a contributor to this case. HIV antibodies were absent. In agreement with the infectious disease consultant and with the patient (because this was not a standard therapy), 1 day before the fourth infusion (14 weeks after the first one), a prophylactic antibiotic therapy with amoxicillin ⫹ clavulanic acid (875 ⫹ 125 mg BID for 5 days) was added to the therapeutic regimen. This treatment was allowed and paid for by national health insurance according to the local rules. No recurrence of skin abscesses or any other infectious cutaneous disease was observed, and this treatment schedule was successfully repeated at each subsequent infusion until the time of writing. This therapy, therefore, permitted infusions with infliximab to be continued at 8-week intervals. After the fourth infusion, improvement of skin and joint psoriatic disease was evident, because the PASI score was reduced to 3.8, and just 3 isolated joints were swollen and/or tender. To date, after 12 months of treatment (9 infu-
g
Trademark: Enbrel® (Pfizer Italia Srl, Latina, Italy). Trademark: Augmentin® (GlaxoSmithKline SpA, Verona, Italy).
h
Volume 33 Number 12
C.De Simone et al.
35.0 PASI
*
30.0 25.0
Swollen and/or painful joint count Infliximab infusion
*
Abscess
* onset
20.0
Infliximab infusion + PABT
15.0
* 10.0 5.0 0.0
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96
Time (weeks)
Etanercept
Adalimumab
Infliximab
Figure 1. The graph shows the Psoriasis Area and Severity Index (PASI) score trend, and that of the swollen and/or painful joint count, during the last 3 treatments. We also underline the time of the infusions and the onset of the abscesses. PABT ⫽ prophylactic antibiotic therapy.
sions), the patient is still responsive to treatment (PASI score 0 and no swollen and/or tender joints), and she has not experienced any recurrence of bacterial skin
infection. The patient provided signed authorization for publication of this case.
DISCUSSION
Figure 2. The abdomen of the patient after the third infusion presented with painful, erythematous and indurated cutaneous nodules, and multiple scars from the previous abscesses.
Decenber 2011
Infliximab is a chimeric monoclonal antibody, an anti– TNF-␣ agent, approved for the treatment of psoriasis and psoriatic arthritis.1 Drugs of this class are known to be associated with an infective risk, probably because they interfere with inflammatory and immune response at different levels.7 In a nationwide survey of infectious disease consultants aimed at identifying infections in patients receiving these drugs, Winthrop et al8 reported that “invasive Staphylococcus aureus infections” were more frequent than any other infection. However, Bassetti et al,9 by evaluating the S aureus colonization rate of the nose, posterior pharynx, and soft palate in patients with rheumatoid arthritis, showed that the risk of becoming an S aureus carrier was not increased after this kind of treatment. Recently, Moustou et al,10 in their review of cutaneous reactions in patients receiving anti–TNF-␣ therapy, reported that bacterial infections were one of the most frequent skin side effects. However, few cases have been reported in the literature regarding this side effect,
1995
Clinical Therapeutics and little is known about its management.3–5 We presented a case of recurrent cutaneous abscesses after infliximab infusions, successfully managed by a prophylactic antibiotic regimen. This complication might represent a reason for the withdrawal of infliximab, but the severity of the disease, the previous failure of the major therapeutic alternatives, and the clinical efficacy of infliximab, encouraged us to go on with this treatment.
CONCLUSIONS This case report describes a woman with psoriasis and psoriatic arthritis who developed MSSA skin abscesses after each of the first 3 infliximab infusions, which did not recur for the next 6 infusions after amoxicillin ⫹ clavulanic acid was added to her regimen, pre- and 4 days postinfusion. Adequately designed, placebo-controlled, double-blind trials are needed to determine whether such prophylactic antibiotic treatment is well tolerated or effective for this common complication of therapy with anti–TNF-␣ agents, when withdrawal of the drug is not advisable, as in this case.
CONFLICTS OF INTEREST The authors have indicated that they have no conflicts of interest regarding the content of this article.
ACKNOWLEDGMENTS All authors contributed equally to the conduct of the study and creation of the manuscript.
REFERENCES 1. Pathirana D, Ormerod AD, Saiag P, et al. European S3-guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatol Venereol. 2009;23:1–70.
2. Dixon WG, Watson K, Lunt M, et al. Rates of serious infection, including site-specific and bacterial intracellular infection, in rheumatoid arthritis patients receiving anti– tumor necrosis factor therapy. Arthritis Rheum. 2006;54: 2368 –2376. 3. Wegscheider BJ, El-Shabrawi L, Weger M, et al. Adverse skin reactions to infliximab in the treatment of intraocular inflammation. Eye (Lond). 2007;21:547–549. 4. Kroesen S, Widmer AF, Tyndall A, Hasler P. Serious bacterial infections in patients with rheumatoid arthritis under anti-TNF-a therapy. Rheumatology. 2003;42:617– 621. 5. 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. 6. Fredriksson, T, Petterson, U. Severe psoriasis-oral therapy with a new retinoid. Dermatologica. 1978;157:238 –244. 7. Silva LC, Ortigosa LC, Benard G. Anti-TNF-␣ agents in the treatment of immune-mediated inflammatory diseases: mechanisms of action and pitfalls. Immunotherapy. 2010;2: 817– 833. 8. Winthrop KL, Yamashita S, Beekmann SE, Polgreen PM. Infectious Diseases Society of America Emerging Infections Network. Mycobacterial and other serious infections in patients receiving anti-tumor necrosis factor and other newly approved biologic therapies: case finding through the Emerging Infections Network. Clin Infect Dis. 2008;46: 1738 –1740. 9. Bassetti S, Wasmer S, Hasler P, et al. Staphylococcus aureus in patients with rheumatoid arthritis under conventional and anti-tumor necrosis factor-alpha treatment. J Rheumatol. 2005;32:2125–2129. 10. Moustou AE, Matekovits A, Dessinioti C, et al. Cutaneous side effects of anti-tumor necrosis factor biologic therapy: a clinical review. J Am Acad Dermatol. 2009;61: 486 –504.
Address correspondence to: Dr. Alessia Maiorino, Department of Dermatology, Catholic University, Largo Francesco Vito, 8 – 00168 Rome, Italy. E-mail: [email protected]
1996
Volume 33 Number 12