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The Incidence and Management of TNF-α Inhibitor Induced Paradoxical Psoriasis in Children With Inflammatory Bowel
James Gaston1, Tai Ermongkonchai2, Andrew Chen2
1Department of Dermatology, The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia.
Insights
Paradoxical psoriasis affects 6.8% of pediatric patients with Inflammatory Bowel Disease (IBD) treated with TNF-α inhibitors. This common side effect often requires treatment changes, with ustekinumab being a frequent alternative.
Area of Science:
- Gastroenterology and Dermatology
- Pediatric Inflammatory Bowel Disease
- Biologic Therapy Adverse Events
Background:
- Paradoxical psoriasis is a known complication of anti-Tumour Necrosis Factor alpha (TNF-α) therapy in adults with Inflammatory Bowel Disease (IBD).
- Data on the incidence and management of TNF-α inhibitor-induced psoriasis in pediatric IBD patients are limited.
- Pediatric IBD patients appear disproportionately affected by these psoriatic eruptions.
Purpose of the Study:
- To systematically review and meta-analyze the incidence, clinical presentation, and management strategies of TNF-α inhibitor-induced psoriasis in pediatric IBD patients.
- To quantify the pooled incidence of paradoxical psoriasis in this population.
- To describe treatment discontinuation rates and alternative therapies used.
Main Methods:
- Systematic literature search of Medline, Embase, and Cochrane databases up to February 2025.
- Inclusion of retrospective cohort, prospective cohort, and cross-sectional studies involving pediatric IBD patients treated with TNF-α inhibitors.
- Exclusion of studies on adult patients or TNF-α inhibitors for non-IBD conditions.
Main Results:
- A total of 3349 pediatric IBD patients were analyzed; 255 (7.6%) developed paradoxical psoriasis.
- Pooled incidence from 13 studies was 6.8% (95% CI: 0.04-0.10).
- Infliximab (IFX) and adalimumab (ADA) were the most common inciting agents. 22.3% discontinued TNF-α inhibitors, and 5.7% switched, often to ustekinumab (UST).
Conclusions:
- TNF-α inhibitor-induced psoriasis is a frequent adverse event in pediatric IBD patients.
- A significant proportion of affected children require discontinuation or modification of their TNF-α inhibitor therapy.
- Further prospective studies are needed to clarify long-term outcomes with non-TNF-α biologic alternatives.
Abstract:
Paradoxical psoriasis is a well-described phenomenon following treatment with Tumour Necrosis Factor alpha (TNF-α) inhibitors in adult patients with Inflammatory Bowel Disease (IBD). The incidence and optimal treatment strategies are not well described in children with IBD. This subgroup of patients is disproportionately impacted by TNF-α inhibitor-induced psoriatic eruptions. Our systematic review and meta-analyses aims to describe the incidence, presentation, and management options for TNF-αinhibitor-induced psoriasis in paediatric patients with IBD. A systematic literature search was conducted using Medline, Embase and Cochrane databases for studies published up to February 2025. Retrospective cohort studies (n = 16), prospective cohort study (n = 1), and a cross-sectional study (n = 1) met inclusion criteria. Studies focusing on patients > 18 years or TNF-α inhibitors used for non-IBD conditions were excluded. A total of 3349 paediatric patients with IBD treated with TNF-α inhibitors were analysed, with 255 (7.6%) developing paradoxical psoriasis. Meta-analysis of 13 studies meeting sample size criteria yielded a pooled incidence of 6.8% (95% CI: 0.04-0.10). Infliximab (IFX) accounted for 151 (79.1%) of cases, whereas adalimumab (ADA) contributed to 40 (20.9%) cases. The median time to clinical eruption was 15.0 months (12.0-18.0). Among affected patients, 22.3% (51/229) discontinued their prescribed TNF-α inhibitor and 5.7% (13/229) were subsequently switched to an alternative TNF-α inhibitor. Ustekinumab (UST) was the most common non-TNF-α alternative (14/94). TNF-α inhibitor-induced psoriasis is a common adverse effect in paediatric IBD, with a significant proportion of cases necessitating treatment discontinuation. Long-term outcomes following a switch to non-TNF-α biologics remain unclear, highlighting the need for further prospective studies.
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