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Multicenter Study
. 2024 Jan 1;160(1):71-79.
doi: 10.1001/jamadermatol.2023.4846.

Risk of Paradoxical Eczema in Patients Receiving Biologics for Psoriasis

Ali Al-Janabi  1   2 , Oras A Alabas  3 , Zenas Z N Yiu  1   2 , Amy C Foulkes  1   2 , Steve Eyre  1   4 , Adnan R Khan  5 , Nick J Reynolds  6 , Catherine H Smith  7   8 , Christopher E M Griffiths  1   2 , Richard B Warren  1   2 ; BADBIR Study Group
Collaborators, Affiliations
Multicenter Study

Risk of Paradoxical Eczema in Patients Receiving Biologics for Psoriasis

Ali Al-Janabi et al. JAMA Dermatol. .

Abstract

Importance: Biologics used for plaque psoriasis have been reported to be associated with an atopic dermatitis (AD) phenotype, or paradoxical eczema, in some patients. The risk factors for this are unknown.

Objective: To explore risk of paradoxical eczema by biologic class and identify factors associated with paradoxical eczema.

Design, setting, and participants: This prospective cohort study used data from the British Association of Dermatologists Biologics and Immunomodulators Register for adults treated with biologics for plaque psoriasis who were seen at multicenter dermatology clinics in the UK and Ireland. Included participants were registered and had 1 or more follow-up visits between September 2007 and December 2022.

Exposures: Duration of exposure to tumor necrosis factor (TNF) inhibitors, interleukin (IL) 17 inhibitors, IL-12/23 inhibitors, or IL-23 inhibitors until paradoxical eczema onset, treatment discontinuation, last follow-up, or death.

Main outcomes and measures: Incidence rates of paradoxical eczema, paradoxical eczema risk by biologic class, and the association of demographic and clinical variables with risk of paradoxical eczema were assessed using propensity score-weighted Cox proportional hazards regression models.

Results: Of 56 553 drug exposures considered, 24 997 from 13 699 participants were included. The 24 997 included exposures (median age, 46 years [IQR, 36-55 years]; 57% male) accrued a total exposure time of 81 441 patient-years. A total of 273 exposures (1%) were associated with paradoxical eczema. The adjusted incidence rates were 1.22 per 100 000 person-years for IL-17 inhibitors, 0.94 per 100 000 person-years for TNF inhibitors, 0.80 per 100 000 person-years for IL-12/23 inhibitors, and 0.56 per 100 000 person-years for IL-23 inhibitors. Compared with TNF inhibitors, IL-23 inhibitors were associated with a lower risk of paradoxical eczema (hazard ratio [HR], 0.39; 95% CI, 0.19-0.81), and there was no association of IL-17 inhibitors (HR, 1.03; 95% CI, 0.74-1.42) or IL-12/23 inhibitors (HR, 0.87; 95% CI, 0.66-1.16) with risk of paradoxical eczema. Increasing age (HR, 1.02 per year; 95% CI, 1.01-1.03) and history of AD (HR, 12.40; 95% CI, 6.97-22.06) or hay fever (HR, 3.78; 95% CI, 1.49-9.53) were associated with higher risk of paradoxical eczema. There was a lower risk in males (HR, 0.60; 95% CI, 0.45-0.78).

Conclusions and relevance: In this study, in biologic-treated patients with psoriasis, paradoxical eczema risk was lowest in patients receiving IL-23 inhibitors. Increasing age, female sex, and history of AD or hay fever were associated with higher risk of paradoxical eczema. The overall incidence of paradoxical eczema was low. Further study is needed to replicate these findings.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Al-Janabi reported receiving grants from the Medical Research Council (MRC) during the conduct of the study; nonfinancial support from UCB, Almirall, and Janssen; and personal fees from UCB outside the submitted work. Dr Foulkes reported receiving personal fees from AbbVie, Almirall, Celgene, Eli Lilly, LEO Pharma, Novartis, Pfizer, Janssen, Sanofi, Bristol-Myers Squibb, and UCB and grants from Almirall and Novartis outside the submitted work. Prof Reynolds reported receiving grants from the National Institute for Health Research (NIHR), Newcastle NIHR Biomedical Research Centre, and NIHR AI-multiply outside the submitted work. Prof Smith reported being an investigator for the European Commission in Innovative Medicines Initiative–European Union funded consortia with multiple industry partners (BIOMAP.IMI.eu, HIPPOCRATES-imi.eu) and receiving grants from Boehringer Ingleheim, AstraZeneca, and Pfizer outside the submitted work. Prof Griffiths reported receiving personal fees from AbbVie, Bristol Myers Squibb, Boehringer Ingelheim, Evelo Bioscience, Eli Lilly, GSK, Janssen, Novartis, ONO Pharmaceuticals, and Inmagene and grants from Anaptysbio, Almirall, and UCB Pharma during the conduct of the study. Prof Warren reported receiving grants from AbbVie, Almirall, Amgen, Celgene, Janssen, Eli Lilly, LEO, Novartis, Pfizer, and UCB during the conduct of the study and personal fees from AbbVie, Almirall, Amgen, Arena, Astellas, Avillion, Biogen, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, DiCE, GSK, Janssen, Lilly, LEO, Novartis, Pfizer, Sanofi, Sun Pharma, UCB, and UNION Therapeutics outside the submitted work. No other disclosures were reported.

Figures

Figure.
Figure.. Flow Diagram of Exposure Numbers and Exclusion Reasons
BADBIR indicates British Association of Dermatologists Biologics and Immunomodulators Register; IL-12/23i, interleukin 12/23 inhibitor; IL-17i, interleukin 17 inhibitor; IL-23i, interleukin 23 inhibitor; and TNFi, tumor necrosis factor inhibitor. aMerged only if exposures were of the same drug or drug combination. Biosimilar and originator drugs were considered the same.
See this image and copyright information in PMC

References

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