Exacerbation of atopic dermatitis symptoms by ustekinumab in psoriatic patients with elevated serum immunoglobulin E levels: Report of two cases

Abstract

Psoriasis is a chronic inflammatory skin disease mainly mediated by a T-helper cell subset, Th17 cells. Recently, increased levels of total serum immunoglobulin (Ig)E have been reported in a subset of psoriatic patients. Ustekinumab (UST) is one of the most commonly used biologic agents for the treatment of moderate to severe plaque psoriasis, and a previous report also documented effectiveness of UST for psoriatic patients with high serum IgE levels. We experienced two psoriatic patients with high serum IgE levels, in whom UST completely improved psoriasis but paradoxically provoked or exacerbated atopic dermatitis (AD)-like symptoms. This reciprocal phenomenon suggests the shift of Th balance toward Th2, along with altered profiles of inflammatory cytokines. It appears prudent to consider the possibility of such adverse effects when treating psoriatic patients with UST with concomitant AD symptoms, a history of AD or high serum IgE levels.

Atopic Dermatitis-like Eruption Induced by Two Different Biologics in a Patient with Psoriatic Arthritis

“…There are 2 reported cases in which patients with psoriasis developed atopic dermatitis-like eruptions after administration of ustekinumab. One of the patients had a history of atopic dermatitis, and both had high levels of IgE (6). In the patient with a history of atopic dermatitis during early childhood, psoriatic eruptions were relieved by administration of ustekinumab; however, his atopic dermatitis relapsed and worsened (7).…”

The Role of Th17-Related Cytokines in Atopic Dermatitis

“…Complete remission was achieved with ustekinumab at the fourth week and every 12 weeks afterwards. There are, however, other reports denying efficacy of ustekinumab [52][53][54]. A 21-year-old man with a 7-year history of severe psoriasis refractory to conventional systemic treatments and childhood AD history was treated with ustekinumab [52].…”

“…The eczema lasted during 12 months of follow up after the final dose of ustekinumab, supporting the diagnosis of AD. Another group reported two psoriatic patients with high serum IgE levels, in whom ustekinumab completely improved psoriasis but paradoxically provoked or exacerbated AD-like symptoms [54]. Recently, the possibility of ustekinumab for AD was tested in clinical trials all over the world [55,56].…”

Seborrhoeic dermatitis and sebopsoriasis developing in patients on dupilumab: Two case reports

“…In the psoriasis literature, atopic dermatitis has been reported as an adverse event to biologics, and it has been speculated that Th17 pathway inhibition allows upregulation of Th2-mediated immunity. 7 Conversely, there have been reports of psoriasiform eruptions, psoriasis, and inflammatory arthritis developing after initiating dupilumab, which could indicate upregulation of Th1/ Th17 cytokines. 3,4,[8][9][10] The etiology of seborrhoeic dermatitis is multifactorial, involving the interaction between intrinsic susceptibility, immunological defects, and fungal colonization.…”