Original article
Treatment of coexistent psoriasis and lupus erythematosus

https://doi.org/10.1016/j.jaad.2014.10.038Get rights and content

Background

The coexistence of psoriasis and lupus erythematosus (LE) is rare. Anecdotal evidence suggests that anti–tumor necrosis factor alfa (TNF-α) agents may be efficacious in LE, although their use is commonly avoided in this disease because of concern for lupus flare.

Objective

We sought to describe the epidemiology, serologic findings, and therapeutic choices in patients with coexistent psoriasis/psoriatic arthritis and LE and to determine the risk of lupus flares with TNF-α inhibitors.

Methods

We performed a retrospective multicenter study of patients given the diagnoses of psoriasis (or psoriatic arthritis) and lupus erythematosus (systemic LE or cutaneous LE, including either subacute cutaneous LE or discoid LE) at 2 academic tertiary-care centers.

Results

A total of 96 patients with a mean age of 56 years was included. We report higher-than-expected rates of white race and psoriatic arthritis. One clinical lupus flare was observed in a patient receiving a TNF-α inhibitor, resulting in an incidence of 0.92% lupus flares per patient-year of TNF-α inhibitor use.

Limitations

Retrospective chart review, small sample size, and limited documentation.

Conclusion

Anti–TNF-α agents, ustekinumab, and abatacept may be valid treatment options for patients with concomitant LE and psoriasis. Clinical lupus flares in LE patients treated with TNF-α inhibitors were infrequent.

Introduction

Psoriasis (Ps) and lupus erythematosus (LE) are immune-mediated diseases. Whereas Ps is primarily characterized by upregulation of the helper T cell (Th) 17 and Th1 immune pathways, LE is associated with upregulation of the Th1, Th2, and Th17 pathways, with constitutive B cell activation and autoantibody production.1, 2, 3, 4

Ps is common, affecting 1% to 3% of the US population,5 whereas LE is much less common: Reported prevalence rates for SLE in the United States range from 20 to 150 cases per 100,000 for SLE.6 Cutaneous LE (CLE; including discoid LE [DLE] and subacute cutaneous LE [SCLE]) has similar prevalence rates.7 The coexistence of LE with Ps is rare.

Medications commonly used for LE, such as mycophenolate mofetil and azathioprine, are not particularly efficacious in cutaneous Ps therapy, and antimalarials are known to make Ps worse. Likewise, ultraviolet light phototherapy, used for many patients with cutaneous Ps, is generally avoided in SLE and CLE because of risk of photosensitivity or lupus exacerbation. Although TNF-α inhibitors are a well-established therapy for Ps, they often are avoided in LE because of the unclear role of TNF-α in the disease and reports of TNF-α inhibitor–induced LE and induction of antinuclear antibodies.8, 9, 10, 11, 12

The most recent case series of patients with concomitant Ps and LE was published in 1980.13 We present a comprehensive case review of 96 patients from 2 academic medical centers with Ps or psoriatic arthritis (PsA) plus LE (systemic lupus erythematosus [SLE], DLE, or SCLE). We aimed to determine the risk of clinical LE flare with use of the TNF-α inhibitors and to evaluate clinical outcomes resulting from the use of biologics in patients with Ps and SLE/CLE.

Section snippets

Methods

After local Institutional Review Board approval, a retrospective chart review of patients with coexistent psoriatic and SLE/CLE was performed at 2 tertiary-care academic institutions: Tufts Medical Center and Brigham & Women's Hospital.

Electronic and paper chart reviews of patient medical history and laboratory and pathology reports were performed. Medical records from January 1990 to February 2013 were available from the Brigham & Women's Hospital, and records from 2007 to 2013 were available

Results

Ninety-six patients fulfilled inclusion and exclusion criteria (Table I). Eighty-four (87.5%) patients were women and 12 (12.5%) were men (Table II). Most (77.1%) patients (including those with SLE or CLE) were white and had chronic plaque Ps (81.3%). In patients with SLE/CLE, Ps was present in 87 (90.6%) and PsA in 50 (52.1%). Forty patients (42.7%) had both Ps and PsA in addition to LE. Nine patients (9.4%) had LE and PsA (per clinical documentation) without cutaneous Ps. There were 85

Discussion

Cases of coexistent Ps and LE are uncommon. The 2 diseases have relatively disparate pathophysiologic mechanisms, although they share upregulation of the Th17 immune pathway with elevated levels of interleukin (IL)-17, IL-23, and IL-12.1, 2, 16 Most cases of concomitant Ps/PsA and LE in the literature are anecdotal reports and small case series.13, 17, 18, 19, 20 The most recent review of patients with coexistent LE and Ps was published in 1980 by Millns and Muller13 and presented an analysis

Conclusion

The pathophysiology of Ps/PsA arthritis occurring with SLE, DLE, or SCLE, although uncommon, may be related to the diseases' shared pathophysiology of the Th17 and Th1 immune pathways. Coexistent disease is rare but often difficult to treat, sometimes requiring multiple immunosuppressive medications with cumulative long-term toxicities.

We report on a predominantly white, female population with a higher incidence of cutaneous photosensitivity and PsA than would be expected in the presence of

References (49)

  • K.B. Kulick et al.

    Serologic studies in patients with lupus erythematosus and psoriasis

    J Am Acad Dermatol

    (1983)
  • N. Shakoor et al.

    Drug-induced systemic lupus erythematosus associated with etanercept therapy

    Lancet

    (2002)
  • I. Maczynska et al.

    Proinflammatory cytokine (IL-1beta, IL-6, IL-12, IL-18 and TNF-alpha) levels in sera of patients with subacute cutaneous lupus erythematosus (SCLE)

    Immunol Lett

    (2006)
  • C.L. Leonardi et al.

    Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1)

    Lancet

    (2008)
  • J.C. Crispin et al.

    IL-17 in systemic lupus erythematosus

    J Biomed Biotechnol

    (2010)
  • M.A. Lowes et al.

    Immunology of psoriasis

    Annu Rev Immunol

    (2014)
  • A. Asarch et al.

    Th17 cells: a new therapeutic target in inflammatory dermatoses

    J Dermatolog Treat

    (2008)
  • O. Durosaro et al.

    Incidence of cutaneous lupus erythematosus, 1965-2005: a population-based study

    Arch Dermatol

    (2009)
  • M. Ramos-Casals et al.

    Autoimmune diseases induced by TNF-targeted therapies: analysis of 233 cases

    Medicine (Baltimore)

    (2007)
  • M. Aringer et al.

    The role of tumor necrosis factor-alpha in systemic lupus erythematosus

    Arthritis Res Ther

    (2008)
  • E.L. Williams et al.

    Anti-TNF-induced lupus

    Rheumatology (Oxford)

    (2009)
  • E. Soforo et al.

    Induction of systemic lupus erythematosus with tumor necrosis factor blockers

    J Rheumatol

    (2010)
  • J.L. Millns et al.

    The coexistence of psoriasis and lupus erythematosus. An analysis of 27 cases

    Arch Dermatol

    (1980)
  • C. Leonardi et al.

    Long-term safety and efficacy of etanercept in patients with psoriasis: an open-label study

    J Drugs Dermatol

    (2010)

    • Cited by (33)

    • Lack of association between tumor necrosis factor-α inhibitor use and exacerbation of lupus erythematosus: A retrospective cohort study

      2022, Journal of the American Academy of Dermatology

    • New-onset autoantibody-mediated nephritis during ustekinumab therapy for psoriasis in patients with and without prior systemic lupus erythematosus

      2019, JAAD Case Reports
      Citation Excerpt :

      Ustekinumab, a monoclonal antibody to the p40 subunits of the interleukin (IL)-12 and IL-23 receptors, is a safe and efficacious treatment for psoriasis and has been used anecdotally to treat subacute cutaneous LE4 and hypertrophic LE.5 Ustekinumab has shown possible efficacy in cutaneous LE when used to treat 5 patients with coexisting psoriasis and LE.6 Ustekinumab has recently been studied as a treatment for SLE in a phase 2 study of 102 adults showing improvement in musculoskeletal and cutaneous disease activity at 24 weeks.7

    • Psoriasis: Which therapy for which patient: Psoriasis comorbidities and preferred systemic agents

      2019, Journal of the American Academy of Dermatology
      Citation Excerpt :

      There have been several reports of the development of DLE, SCLE, and drug-induced lupus with infliximab, etanercept, and adalimumab.183-186 However, a recent study by Varada et al187 reported a low incidence of lupus flare/patient-year with TNF-α blockers (0.92%). Many other studies have confirmed the low incidence of anti–TNF-α–induced lupus, reporting rates of 0.19% to 0.22% for infliximab, 0.18% for etanercept, and 0.10% for adalimumab.188

    • Switching biologics in the treatment of psoriatic arthritis

      2017, Seminars in Arthritis and Rheumatism
      Citation Excerpt :

      However, there is some evidence from smaller studies that suggests treatment with TNFis in patients with SLE does not result in short-term harm, and may even have a possible benefit in patients with lupus nephritis [59,60]. Further, a recent retrospective study showed that the TNFis ustekinumab and abatacept may be valid treatment options for patients with concomitant SLE and psoriasis, as patients reported a relatively low incidence of 0.92% lupus flares per patient-year of TNFi use [61]. Drug-provoked psoriasiform dermatitis has been observed in patients receiving TNFis [62] and a switch to a different agent is appropriate in this situation.

    • Cutaneous lupus erythematosus, morphea profunda and psoriasis: A case report

      2020, Reumatologia Clinica

    • Pathogenesis, Molecular Mechanism and Treatment Approaches of Psoriasis: An Update

      2024, AIP Conference Proceedings
    View all citing articles on Scopus

    Funding sources: None.

    Conflicts of interest: None declared.

    View full text
    Copyright © 2014 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.