Paradoxical Eczema in Patients Receiving Biologics for Psoriasis

According to a study published in JAMA Dermatology, IL-23 inhibitors present the lowest risk of paradoxical eczema in biologic-treated patients with psoriasis.

Researchers utilized data from the British Association of Dermatologists Biologics and Immunomodulators Register, focusing on adults treated with biologics for plaque psoriasis at multicenter dermatology clinics in the UK and Ireland. Participants registered between September 2007 and December 2022 and had at least one follow-up visit.

Exposures included the duration of treatment with tumor necrosis factor (TNF) inhibitors, IL 17 inhibitors, IL-12/23 inhibitors, or IL-23 inhibitors until the onset of paradoxical eczema, treatment discontinuation, last follow-up, or death.

Main outcomes measured were the incidence rates of paradoxical eczema, risk of paradoxical eczema by biologic class, and associations of demographic and clinical variables with the risk of paradoxical eczema, using propensity score-weighted Cox proportional hazards regression models.

From 56,553 drug exposures, 24,997 exposures from 13,699 participants (median age 46 years, 57% male) were analyzed, accruing 81,441 patient-years of exposure. Paradoxical eczema was associated with 273 exposures (1%). Adjusted incidence rates per 100,000 person-years were 1.22 for IL-17 inhibitors, 0.94 for TNF inhibitors, 0.80 for IL-12/23 inhibitors, and 0.56 for IL-23 inhibitors. IL-23 inhibitors were linked to a lower risk of paradoxical eczema (HR 0.39; 95% CI 0.19-0.81) compared with TNF inhibitors, whereas IL-17 inhibitors (HR 1.03; 95% CI 0.74-1.42) and IL-12/23 inhibitors (HR 0.87; 95% CI 0.66-1.16) showed no significant association. Higher risk was linked to increasing age (HR 1.02 per year; 95% CI 1.01-1.03) and history of atopic dermatitis (AD) (HR 12.40; 95% CI 6.97-22.06) or hay fever (HR 3.78; 95% CI 1.49-9.53). Male patients had a lower risk (HR 0.60; 95% CI 0.45-0.78).

The study concluded that IL-23 inhibitors present the lowest risk of paradoxical eczema in biologic-treated patients with psoriasis. Factors such as increasing age, female sex, and a history of AD or hay fever are associated with a higher risk, while the overall incidence remains low. Further research is needed to confirm these findings.

Reference
Al-Janabi A, Alabas OA, Yiu ZZN, et al. Risk of paradoxical eczema in patients receiving biologics for psoriasis. JAMA Dermatol. 2024;160(1):71-79. doi:10.1001/jamadermatol.2023.4846