Paradoxical psoriasis in pediatric patients: A systematic review

Paradoxical psoriasis occurs in pediatric patients following treatment with biologic agents. These presentations are not well described, and optimal treatment strategies have not been established.

To describe the reported rates, demographic characteristics, clinical presentation, and treatment options for TNF-α inhibitor-induced psoriasis.

Systematic review of published cases and cohort studies of paradoxical psoriasis induced by biologic agents, with specific reference to TNF-α inhibitors.

We identified 4564 pediatric patients treated with TNF-α inhibitors, of whom 210 (4.6%) developed paradoxical psoriasis. Infliximab was the drug most likely to induce psoriasis (8.3%), followed by adalimumab (3.3%). Individual-level data were acquired from 129 individuals with a mean age of 13.6 years (SD: 4.0); 45.0% were male. The scalp was the most commonly affected area (47.5%), followed by the ears (30.8%). Most (63.3%) patients were continued on TNF-α inhibitor therapy. Among those who switched TNF-α inhibitors, only 32.0% had complete clearance of their skin lesions. Among patients who were switched to a non-TNF-α inhibitor, 81% had complete clearance of their paradoxical psoriasis.

Data were acquired from retrospective studies including case reports and case series.

TNF-α inhibitor-induced psoriasis is a common adverse effect; however, most patients can continue their original therapy and be managed with skin-directed topical or systemic medications. If a patient requires medication discontinuation, switching to a new TNF-α inhibitor is unlikely to lead to resolution of their skin lesions.