Skin Manifestations of Inflammatory Bowel Disease

Abstract

Inflammatory bowel disease (IBD) with its two main subtypes Crohn's disease and ulcerative colitis is not restricted to the gastrointestinal tract. Indeed, so-called extraintestinal manifestations (EIMs) are frequent and considerably affect morbidity and mortality. The prevalence of EIMs ranges from 6 to 47%. In up to one quarter of the patients, EIMs can present even before an IBD diagnosis is established. The pathophysiology of EIMs remains elusive, although data from clinical trials demonstrating anti-tumor necrosis factor (TNF) efficacy suggest a common pathogenic link between intestinal and extraintestinal disease activity. However, not all EIMs parallel intestinal disease. Skin lesions are usually classified based on their pathophysiological association with the underlying intestinal disease into four categories: (1) specific, (2) reactive, (3) associated, and (4) treatment-induced manifestations. Cutaneous manifestations include erythema nodosum (EN), pyoderma gangrenosum (PG), Sweet's syndrome, and oral lesions, with EN being the most commonly reported and PG showing the most debilitating disease course. Anti-TNF-induced skin reactions are a new, but increasingly recognized phenomenon, which can be eventually misinterpreted as psoriatic lesions. Medical treatment modalities are limited with topical and systemic steroids being the most frequently employed agents. If EIMs parallel intestinal disease activity, the therapeutic cornerstone usually is the management of underlying intestinal disease activity rather than direct treatment of the EIMs. However, increasing evidence for anti-TNF agents' efficacy in EIM management has changed the approach to complicating and debilitating disease courses. In the case of anti-TNF-induced lesions, topical steroids are usually sufficient and discontinuation of anti-TNF is seldom warranted. In this review, we summarize current knowledge on cutaneous EIMs, their diagnostic criteria and clinical presentation, natural history, pathogenesis, and treatment options.

Dual‐targeted therapy with apremilast and vedolizumab in pyoderma gangrenosum associated with Crohn’s disease

“…Cutaneous toxicity is thought to be among the most prevalent irAE. 1 A man in his 80s presented multiple metastatic melanomas on the face, which were judged as unresectable, and treatment with pembrolizumab was started. After the fifth pembrolizumab administration, a grade 2 skin rash (multiple annular erythema)…”

Higher Prevalence of Nickel and Palladium Hypersensitivity in Patients with Ulcerative Colitis

“…Several contributing factors to the mucosal inflammation have been suspected, but the etiology remains elusive. In ∼30% of UC patients, colonic symptoms occur in conjunction with a wide variety of extraintestinal manifestations including erythema nodosum of the skin, which is presumed to be caused by a delayed-type hypersensitivity (DTH) reaction [1]. No- tably, the colonic disease activity of UC changes in parallel with the erythema nodosum activity [1].…”

“…In ∼30% of UC patients, colonic symptoms occur in conjunction with a wide variety of extraintestinal manifestations including erythema nodosum of the skin, which is presumed to be caused by a delayed-type hypersensitivity (DTH) reaction [1]. No- tably, the colonic disease activity of UC changes in parallel with the erythema nodosum activity [1]. These aspects of UC suggest that the DTH reaction is a shared pathogenic mechanism between the colonic inflammation and erythema nodosum.…”

Cutaneous manifestations in inflammatory bowel disease (Review)

“…Classically, cutaneous manifestations in IBD were divided into 3 categories: i) disease-specific lesions that show the same histopathologic findings as the underlying gastrointestinal disease, ii) reactive lesions which are inflammatory lesions that share a common pathogenetic mechanism but do not share the same pathology with the gastrointestinal disease and iii) associated conditions are more frequently observed in the context of IBD, without sharing the pathogenetic mechanism or the histopathological findings with the underlying disease (8,9). Due to the continuous development of therapeutic options for IBD and the risk of cutaneous adverse reactions associated with these treatments, a fourth category of cutaneous manifestations was proposed by some researchers, namely the drug-related cutaneous reactions.…”