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Psoriasis risk anti tnf kids with auto

my little penguin

Staff member
Psoriasis risk rises with TNF inhibitor use in children with inflammatory disorders
Publish date: October 30, 2019
By Michele G. Sullivan


Psoriasis is nearly four times more likely to develop in children who were exposed to tumor necrosis factor inhibitors for inflammatory disorders than in unexposed children, a retrospective cohort study has determined.
“The incidence rate and risk factors of psoriasis in children with IBD [inflammatory bowel disease], JIA [juvenile idiopathic arthritis], or CNO [chronic nonbacterial osteomyelitis] who are exposed to TNFi [tumor necrosis factor inhibitors] are unknown. Additionally, there is a well-established association between these inflammatory conditions and psoriasis development. Yet, as TNFi can both treat and trigger psoriasis, it is not clear how TNFi exposure affects this relationship,” wrote Lisa H. Buckley, MD, of Children’s Hospital at Vanderbilt, Nashville, Tenn., and colleagues. Their report is in Arthritis Care & Research.
The team examined the relationship in children who were treated for an inflammatory disorder at Children’s Hospital of Philadelphia during 2008-2018. IBD was most common at 74%, followed by JIA at 24% and CNO at 2%.

Among 4,111 children with those inflammatory disorders, the psoriasis incidence was 12.3 per 1,000 person-years in exposed children and 3.8 per 1,000 person-years in unexposed. This significant difference equated to a hazard ratio of 3.84 for developing psoriasis after TNFi exposure.
“These data reflect the established association between inflammatory conditions and psoriasis development and suggest that TNFi exposure further increases the risk of psoriasis,” Dr. Buckley and coauthors wrote.
The median duration of follow-up in this study was about 2.5 years for patients exposed to TNFi and 2 years for those unexposed. Among the entire cohort, 39% had been exposed to a TNFi, with 4,705 person-years of follow-up. Among the unexposed children (61%), there were 6,604 person-years of follow-up.

In all, 83 cases of psoriasis developed: 58 in the exposed group and 25 in the unexposed group. Psoriasis incidence varied by disorder. Exposed children with IBD had a higher incidence than did unexposed children (10.9 vs. 2.6 per 1,000 person-years; HR = 4.52). Exposed children with JIA also had a higher incidence than did unexposed children (14.7 vs. 5.5 per 1,000 person-years; HR = 2.90). Among those with CNO, incidences were similar for exposed and unexposed children (33.5 and 38.9 per 1,000 person-years).
A family history of psoriasis significantly increased the risk of psoriasis with a hazard ratio of 3.11, the authors noted. But none of the other covariates (age, sex, race, obesity, methotrexate exposure, and underlying diagnosis) exerted a significant additional risk.
The study had no outside funding source. The authors had no financial disclosures. Dr. Buckley conducted the research when she was a pediatric rheumatology fellow at Children’s Hospital of Philadelphia.

SOURCE: Buckley LH et al. Arthritis Care Res. 2019 Oct 23. doi: 10.1002/ACR.24100
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I suspected this was the case. It's unfortunate because anti tnf are used to treat psoriasis so that would make an occurrence in these kids harder to treat.
We have been lucky so far, 5 years on Humira (from age 4) for H and 1.5 for my son. We really haven't experienced any significant side effects. One or two incidents where we felt there was a secondary infection due to the medication. But not psoriasis.

my little penguin

Staff member
Ds hasn’t had any issues with psoriasis either
Even with two anti tnf and family history

that said. They know the kids with inflammation are prone to psoriasis
The kids with higher inflammation levels would be prescribed anti tnf vs the other groups
So is it higher inflammation levels equals higher psoriasis risk
Is anti tnf unmasking a dormant disease (higher risk with family history ) that may have shown up later ....
Anti-TNFs are known to cause psoriasis, but I would expect it to go away some months after the anti-TNF is stopped.

my little penguin

Staff member
The dermatologist we spoke to stated that in the cases where the anti tnf unmasks a second disease
Such as psoriasis (there are other diseases as well )
The second disease the majority of the time is still present
Since the drug does not cause the disease such as psoriasis
It just “activates” in individual probe to it and the psoriasis typically doesn’t go away when a med is stopped or switched
Once the immune system switch is turned on
It doesn’t turn off

my little penguin

Staff member

In the case of JIA kids were treated with enbrel and developed crohns
Stopping enbrel did not stop the individual from having crohns

jia kids have a higher rate of crohns
And crohns kids have a higher rate of JIA
Due to genetic factors
But jia kids on enbrel had an even higher rate of developing crohns after taking enbrel

my little penguin

Staff member
FWIW DS developed JIA while taking humira which treats crohns and JIA .
The JIA did not go Away when he was switched to Stelara or even when they stopped humira for a few months with no biologics
One should consider why psoriasis and not any of the other countless immune mediated diseases.

What is interesting about psoriasis is that it usually involves an immune response to the fungi malassezia on the skin. This exact same fungi has recently been found in crohn's disease.

Malassezia Is Associated with Crohn’s Disease and Exacerbates Colitis in Mouse Models

People with psoriasis are also 1.7 times more likely to develop Crohn disease than the general population.
The similarities don't just stop there though. Psoriasis is linked closely to crohn's disease. Genetic susceptibility genes overlap strongly with crohn's disease, psoriasis is genetically linked much more closely to crohn's disease than crohn's is to UC.

The treatments used for psoriasis patients is similar to those with crohn's disease.

VDR (vitamin D receptor) mutations are linked to both crohn's and psoriasis.

Both crohn's disease patients and psoriasis patients are helped with vitamin D treatment, and both CD and psoriases patients flare statistically more during winter months.

In both diseases we have now recently found malassezia. We've known for a while now that malassezia was aggrevating, if not causing, psoriasis in at least a subgroup of psoriasis patients. But we didn't know until very recently that malassezia was present in the gut and that is was associated with crohn's disease, we've literally known this for only a few months. No one thought it could cause intestinal inflammation until now.

We've known about the ASCA antibodies in crohn's disease for over a decade, but until now we couldn't identify a yeast, everyone just assumed it was cross reactivity with a commensal food antigen.
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Katharine Wrighton, who reviews Nature publications, made the joke ''Malassezia plays cards in the gut'', she is referring to the CARD9 gene mutations linked to crohn's disease, genes involved in the immune response to fungi. Thomas Dawson said that the forbidden fungi kindom opens, referring to malassezia. Up until very recently we didn't realize fungi were involved in worsening or maybe even causing the inflammation in crohn's disease. We've also recently discovered that AIEC, associated with crohn's disease (E Coli), is helped with the presence of fungi like malassezia. If you have an E Coli infection in the gut, malassezia seems to make it worse.


Well-known member
FWIW - both my girls got awful psoriasis with Remicade. O got it right away and T developed it a year later.

O stopped Remicade in March. Now on Entyvio. She stil has awful psoriasis. We had chosen to continue Remicade and just deal with the psoriasis because Crohn's was the worse disease plus the derm said a change in IBD med only works about 50% of the time. But then Remicade stopped working and we had to switch to Entyvio. We thought the upswing to that would be getting rid of the psoriasis but no such luck.
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