Collaborating in IMIDs: Anti-TNFs

During the Interdisciplinary Autoimmune Summit (IAS), Joseph Merola, MD, MMSc, joined his colleague Adam Cheifetz, MD, on Thursday’s opening session, “Collaborative Cases in IMIDs.”

With a key focus on collaboration between rheumatology, dermatology, and gastroenterology, both speakers shared some clinical pearls on when to refer patients, including:

• Rectal bleeding/ iron deficiency
• Nighttime symptoms
• Weight loss
• Family history of organic disease

They then proceeded to address what types of rashes can develop when a patient is on an anti-TNF. Dr Merola noted that psoriasis—particularly psoriasiform dermatitis—isn’t an uncommon scenario when dealing with anti-TNF eruptions.

“I like to use the term psoriasiform because what’s interesting is sometimes the anti-TNF induced psoriasis reactions are really a bit of a hybrid,” he stated.

Examples of cutaneous reactions to anti-TNFs include the following:

• Injection site reactions
• Cutaneous viral, bacterial, and fungal infections
• Eczematous dermatitis
• Psoriasis
• Leukocytoclastic vasculitis
• Lichen planus
• Alopecia (potentially)

Next, they discussed the question of who needs to see a dermatologist, with Dr Merola noting that patients with mild or moderate disease could be seen by a dermatologist and treated using therapies such as topical steroids. However, when it comes to patients with more severe disease, he added, “It makes sense for us to see them and that’s where the collaborative piece comes in.”

They moved on to address which patients need a biopsy, and Dr Merola shared that psoriasiform spongiotic dermatitis would be a case where working with the dermatopathologist may be helpful.

Finally, Dr Merola touched on treating anti-TNF induced psoriasis, noting that providers could:

• Treat through
• Change outside of the medication class/stop the anti-TNF
• Change within the medication class

He stressed that providers should take into consideration the severity of psoriasis and the severity of underlying IBD alongside remaining treatment options. Dr Cheifetz added that if the disease state is severe, then it’s important to stop anti-TNF treatment and look to discussing other options.

Reference
Merola J, Cheifetz A. Collaborative cases in IMIDs. Presented at: IAS 2022; April 21-24, 2022; virtual.