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Delayed Psoriasiform Dermatitis in Children Treated with TNF Inhibitors

by Dr. Michael Lee โ€“ Health Editor
written by Dr. Michael Lee โ€“ Health Editor

Pediatric Dermatology Study Links JIA,Age & Immunomodulators to Delayed Onset of Psoriasis in Young TNF-Inhibitor Users

CINCINNATI,OH – A new retrospective study published in Pediatric Dermatology reveals potential predictors for the growth of psoriasis (PD) in children and adolescents undergoing treatment with Tumor Necrosis Factor inhibitors (TNFi) – a common therapy for inflammatory conditions like Crohn’s disease and juvenile idiopathic arthritis (JIA). Researchers at Cincinnati Children’s Hospital Medical Center found that a diagnosis of JIA, older age at the start of TNFi therapy, and concurrent use of immunomodulating drugs are associated with a later onset of PD.

The study, led by Muayad M.Shahin of the University of Cincinnati College of Medicine, analyzed the medical records of 3,418 pediatric patients receiving tnfi therapy between January 2018 and January 2023.The findings offer crucial insights into a known, but often challenging, side effect of these powerful medications.

Understanding TNF-Inhibitors and Psoriasis

TNFi medications – including infliximab and adalimumab – are a cornerstone of treatment for a range of autoimmune and inflammatory diseases affecting children, including Crohn’s disease, JIA, and ulcerative colitis. these drugs work by blocking TNF, a protein that plays a key role in inflammation. However, a paradoxical reaction can occur, where TNFi therapy triggers or exacerbates psoriasis, a chronic skin condition characterized by red, scaly patches.

The Cincinnati children’s study found that 70 patients (2%) developed PD during the study period. The median age at the start of TNFi treatment was 11.7 years, with PD manifesting a median of 16.9 months later. The majority of those affected were female (52.9%) and White (91.4%). Notably, 94% of patients experienced PD at multiple sites on the body.

Key Findings & Treatment Approaches

The research highlighted several important observations:

Resolution Rates: PD rashes resolved in approximately 45.7% of patients, with a median time to resolution of 15.5 months.
 Crohn’s Disease Predominance: The majority (71.4%) of patients who developed PD also had Crohn’s disease. Infliximab (52.7%) and adalimumab (44.6%) were the moast commonly used TNFi medications in this group. Treatment Strategies: Treatment for PD primarily involved topical steroids (85.7%), with a notable proportion also receiving systemic medications (15.4%) and non-steroidal topical treatments like tacrolimus, pimecrolimus, and calcipotriene (24.3%).
 Treatment Discontinuation: Over half of the patients (57.1%) had their initial TNFi discontinued due to PD. Of those, approximately 30% switched to another TNFi (with a 33% recurrence rate of PD), while 62.5% switched to a different medication class, though PD persisted in 36% of those patients.
Gender & Treatment: Girls were more likely to be prescribed high-potency topical steroids, potentially reflecting differences in disease severity or prescribing patterns.
 Predictive Factors: Statistical analysis revealed that a JIA diagnosis was associated with a delayed PD onset (22.6 months later, P = .02). Concomitant immunomodulator use also correlated with later onset (11.0 months later, P = .04), as did starting TNFi therapy at an older age (2.4 months later per year of age, P < .01). Future Research Needed

the authors acknowledge the study’s limitations, including its retrospective design which limited detailed descriptions of the skin eruptions and inconsistencies in defining “severe” PD. They emphasize the need for further research to better understand the factors influencing PD severity in pediatric patients. Specifically,they note the need to clarify whether female sex truly influences severity,as current findings are conflicting.

This research was funded by the National Institute of Arthritis and Musculoskeletal and skin Diseases Core Center and the University of Cincinnati Office of Research. One author disclosed a consulting relationship with LEO Pharma.

Source: shahin, M.M., et al. (2025). Published online July 31,2025,in Pediatric Dermatology. https://onlinelibrary.wiley.com/doi/10.1111/pde.16039

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Health

Rare Disease Fight: Challenges & Recurrence

by Dr. Michael Lee โ€“ Health Editor
written by Dr. Michael Lee โ€“ Health Editor

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Rheumatoid Nodules: Modern Treatments Reduce Incidence,Present Diagnostic Challenges

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While modern treat-to-target therapies have decreased the occurrence of extra-articular manifestations of rheumatoid arthritis (RA), including rheumatoid nodules, these nodules continue to present clinical challenges. These challenges include the need to rule out other serious conditions and address potential complications, especially those affecting the lungs.Rheumatoid nodules, recurrent inflammatory granulomas, can impact daily life both cosmetically and functionally.

understanding Rheumatoid Nodules

Dr. Christopher Edwards, a rheumatology professor at University Hospital Southampton, addressed the clinical significance and treatment of rheumatoid nodules at the 2025 Annual Meeting of the European Alliance of Associations for Rheumatology. rheumatoid nodules,once a key diagnostic criterion for RA,are granulomatous inflammatory lesions that can appear in various locations throughout the body. While often found subcutaneously, they can also occur on the sclera, larynx, heart valves, and lungs.

Did You Know? Rheumatoid nodules are more common in individuals who are seropositive for rheumatoid factor or anti-cyclic citrullinated peptide antibodies.

Pulmonary Nodules: Diagnostic Difficulties

Pulmonary nodules can be particularly challenging to diagnose. According to Dr. Edwards, some patients are initially misdiagnosed with lung metastases, causing significant distress. Conditions like granulomatosis with polyangiitis can also mimic rheumatoid nodules, further complicating the diagnostic process. It is crucial to differentiate these nodules from infections such as tuberculosis, as RA patients are at a higher risk of infection due to their disease and immunosuppressive treatments.

Pulmonary rheumatoid nodules, similar to tuberculomas, can undergo central necrosis when exposed to tumor necrosis factor-alpha inhibitors, perhaps leading to cavitation or pneumothorax. Any cavity in the lung can become infected, emphasizing the need for careful monitoring.

Diagnosing Peripheral Nodules

Diagnosing peripheral rheumatoid nodules is generally more straightforward. These nodules typically feel rubbery and are movable relative to the underlying tissue. Differential diagnoses include gouty tophi, lipomas, epidermoid cysts, infectious granulomas, sarcoidosis, and neoplastic lesions. Imaging tools like ultrasound or fine-needle aspiration can aid in diagnosis, especially when gout is suspected. Biopsy is typically reserved for cases where there is concern about a neoplastic or malignant process.

The Decline in Rheumatoid Nodule Incidence

Dr. Edwards noted a decline in the frequency of rheumatoid nodules in his practice.epidemiological data supports this observation. The 10-year cumulative incidence of subcutaneous nodules in RA patients decreased from 30.9% between 1985 and 1999 to 15.8% between 2000 and 2014 [[1]].

This decline is likely due to earlier initiation of more effective therapies and a reduction in smoking rates. Smoking remains a significant risk factor for nodule development,along with long-standing,severe RA,male sex,and seropositivity for rheumatoid factor or anti-cyclic citrullinated peptide antibodies.

Pro Tip: Maintaining tight control of disease activity is crucial for preventing rheumatoid nodules.

Treatment and Management Strategies

The presence of nodules alone shoudl not prompt discontinuation of methotrexate (MTX), according to Dr. Edwards. While there were past concerns about MTX causing nodules, current data suggests otherwise. Other medications, such as tumor necrosis factor inhibitors like etanercept, have also been linked to nodule development, even though this might potentially be due to reporting bias.

Often, treatment is not necessary, and observation is sufficient. painful or functionally limiting nodules can be managed with local glucocorticoid injections to reduce discomfort and soften the nodules. However, injections over the elbow should be avoided due to the increased risk of infection.

Surgery might potentially be considered for nodules that ulcerate, become infected, or impair function. Pulmonary rheumatoid nodules often respond well to rituximab or abatacept,leading to shrinkage or stabilization.case reports have also documented advancement with janus kinase inhibitors.

Treatment Application Considerations
Observation Asymptomatic nodules Monitor for changes in size or symptoms
Glucocorticoid Injections Painful or functionally limiting nodules Avoid injections over the elbow
Surgery Ulcerated, infected, or functionally impairing nodules Potential for recurrence
Rituximab/Abatacept Pulmonary rheumatoid nodules Effective in shrinking or stabilizing nodules

Key Factors Influencing Rheumatoid Nodule Development

  • Smoking
  • Long-standing, severe RA
  • Male sex
  • Seropositivity for rheumatoid factor or anti-cyclic citrullinated peptide antibodies

These factors highlight the importance of addressing modifiable risk factors and managing RA effectively to minimize the risk of developing rheumatoid nodules.

What strategies have you found most effective in managing rheumatoid arthritis symptoms? Share your experiences in the comments below!

Are there any specific concerns you have about rheumatoid nodules or their treatment?

Evergreen Insights: Rheumatoid Nodules and RA

Rheumatoid nodules are a common extra-articular manifestation of rheumatoid arthritis, a chronic autoimmune disease primarily affecting the joints. While advancements in RA treatment have reduced their incidence, understanding their formation, diagnosis, and management remains crucial for rheumatologists and patients alike. Historically, the presence of rheumatoid nodules was a key diagnostic criterion for RA, reflecting the severity and progression of the disease. Today,with earlier and more effective treatments,the focus has shifted towards preventing their development through tight disease control and addressing modifiable risk factors such as smoking.

Frequently Asked Questions About Rheumatoid Nodules


New Guidelines Call for Increased Interstitial Lung Disease Screening in Autoimmune Patients

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BARCELONA, Spain – In a move set to reshape clinical practice, the European Alliance of Associations for Rheumatology (EULAR) and the European Respiratory Society (ERS) have jointly released new guidelines advocating for systematic screening of interstitial lung disease (ILD) in all patients diagnosed with systemic sclerosis (SSc) and mixed connective tissue disease (MCTD). The declaration was made at the EULAR 2025 Annual Meeting.

These complete, disease-specific recommendations aim to standardize the screening, diagnosis, and management of ILD across various connective tissue diseases (CTDs), including SSc, MCTD, rheumatoid arthritis (RA), idiopathic inflammatory myopathies (IIM), and Sjรถgren’s disease (SjD).The guidelines mark a notable step forward, representing the first collaborative effort between rheumatologists and pulmonologists in Europe to address ILD in this patient population.

Screening Recommendations for Interstitial Lung Disease

the cornerstone of the new guidelines is the strong recommendation for systematic ILD screening using high-resolution computed tomography (HRCT) in all SSc and MCTD patients, irrespective of pre-existing risk factors. This recommendation extends to patients with IIM, excluding those with inclusion body myositis. For individuals with RA,SjD,and other CTDs,the guidelines advise an initial assessment for disease-specific risk factors,followed by HRCT screening for those with identified risks.

Did You Know? The American Thoracic Society estimates that ILD affects approximately 15% of patients with rheumatoid arthritis[[1].

While previous recommendations supported screening in SSc, the inclusion of RA patients with risk factors marks a significant expansion. According to Dr. Bernhard Hellmich, this broadened scope is expected to identify more patients who could benefit from early therapeutic intervention, potentially leading to improved long-term outcomes.

Notably, the guidelines do not specify a screening frequency due to limited evidence. Dr. Anna-Maria Hoffmann-Vold suggests mirroring the diagnostic approach and reassessing for new ILD progression risk factors. The guidelines explicitly advise against substituting HRCT with pulmonary function tests or lung ultrasound for initial screening. However, forced vital capacity and diffusing capacity of the lungs for carbon monoxide can be incorporated in the presence of symptoms or CT abnormalities.

Monitoring ILD Progression After Diagnosis

The guidelines provide specific timeframes for monitoring ILD progression post-diagnosis, tailored to individual diseases and stratified by ILD progression risk. Clinicians are advised to assess risk based on prior lung function tests, HRCT results, the 6-minute walking test, and risk factors such as disease-specific circulating markers, disease activity, and HRCT patterns.

Based on these assessments, patients are categorized as high or low risk. Monitoring frequency varies accordingly. for high-risk patients with any CTD, lung function tests are recommended every 3-6 months during the initial years, followed by every 6-12 months thereafter. Lower-risk patients should undergo lung function tests every 6-12 months initially, and then annually.

Treatment Strategies for Interstitial Lung Disease

the new guidelines offer detailed treatment recommendations, outlining available options for each disease and providing guidance on selecting the most appropriate medication for individual patients. The guidelines strongly recommend tocilizumab for SSc-ILD patients with early diffuse SSc and signs of inflammation. For IIM-ILD patients, immunosuppressive treatment, including glucocorticoids, calcineurin inhibitors, rituximab, mycophenolate, or azathioprine, is recommended.

Other treatment recommendations are conditional, reflecting limited patient populations and a scarcity of randomized controlled trials. Individual treatment algorithms are provided for SSc-ILD, RA-ILD, and IIM-ILD.

Dr. Hellmich believes that these comprehensive guidelines will facilitate earlier treatment initiation, potentially improving patient prognosis. He noted that the inclusion of certain therapies in the EULAR guidelines may encourage their use in clinical practice,even if they are currently considered off-label.

Pro Tip: Staying informed about the latest research and guidelines is crucial for providing optimal care to patients with connective tissue diseases and interstitial lung disease.

The full guidelines are slated for publication next month in the Annals of the Rheumatic Diseases and European Respiratory Journal.

Key Recommendations

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Health

Upadacitinib Beats Mycophenolate for SSc-ILD: New Study

by Dr. Michael Lee โ€“ Health Editor
written by Dr. Michael Lee โ€“ Health Editor

Upadacitinib Shows Promise in Treating Systemic Sclerosis-Associated Interstitial Lung Disease

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A recent clinical trial has revealed that the JAK inhibitor upadacitinib demonstrates effectiveness in treating systemic sclerosis-associated interstitial lung disease (SSc-ILD). The study, presented at the European Alliance of Associations for Rheumatology (EULAR) 2024 annual Meeting, indicates that upadacitinib reduces the rate of decline in forced vital capacity (FVC) in patients with SSc-ILD, compared to the current standard treatment, mycophenolate mofetil.

Upadacitinib Outperforms Standard Treatment in Lung Function preservation

The research, led by Dr. Manal Hassanien from Assiut University, Egypt, showed that after one year, the difference in the annual rate of decline in FVC between the upadacitinib and mycophenolate groups was 20.9 mL/year, favoring upadacitinib (P = .05).This suggests a meaningful benefit in preserving lung function for patients treated with upadacitinib.

Did You Know? Forced vital capacity (FVC) is the maximum amount of air a person can exhale after a maximum inhalation. It’s a key indicator of lung function.

The double-blinded, randomized study involved 57 patients with SSc, with disease onset of more than 3 years. All participants had an FVC less than 75% of the predicted normal value and evidence of lung fibrosis. Patients were administered either 15 mg of upadacitinib daily or 2000 mg of mycophenolate daily.

Detailed Study Results: FVC and DLCO Improvements

After 52 weeks, a decline of โ‰ฅ 5% in FVC from baseline was observed in 20.6% of the upadacitinib group, compared to 37.5% in the mycophenolate group. Furthermore,a 10% drop in FVC from baseline at 1 year was more common in patients taking mycophenolate (17.9%) than in those taking upadacitinib (6.8%).

Changes in diffusing capacity of the lungs for carbon monoxide (DLCO) at 52 weeks were also more favorable in the upadacitinib group (-62.7 mL) compared to the mycophenolate group (-93.3 mL). DLCO measures how well the lungs transfer gas from inhaled air to the bloodstream, providing another critical measure of lung health according to the american Thoracic Society.

Pro tip: Monitoring FVC and DLCO regularly can definitely help track the progression of SSc-ILD and assess the effectiveness of treatments.

Expert Commentary and Future Considerations

Dr. Iulia Szabo, a rheumatologist at “Iuliu Haลฃieganu” University of Medicine and Pharmacy, Romania, commented on the study, calling the results “really promising.” she noted that previous studies have shown encouraging evidence using other JAK inhibitors in SSc-ILD treatment, although the data were mostly experimental.

Szabo also cautioned that the younger age of participants in the study may mean that older patients could experience a higher risk of adverse events associated with JAK inhibitors.”The problem we might have will be with older patients as we certainly know all the adverse effects that JAK inhibitors have, and probably we should be a bit more cautious,” she said.

Current Treatment Landscape and Upadacitinib’s Potential Role

Currently, upadacitinib is FDA-approved for various conditions, including rheumatoid arthritis, psoriatic arthritis, and Crohn’s disease. However,for SSc-ILD,nintedanib and tocilizumab remain the only FDA-approved treatments. The findings from this study suggest that upadacitinib could potentially become another valuable option for managing this challenging condition.

Key metrics: Upadacitinib vs. Mycophenolate in SSc-ILD Treatment
Metric Upadacitinib Mycophenolate
Annual FVC decline Difference Favored Upadacitinib (20.9 mL/year) –
โ‰ฅ 5% FVC Decline at 52 Weeks 20.6% 37.5%
10% FVC Drop at 1 Year 6.8% 17.9%
DLCO Change at 52 Weeks -62.7 mL -93.3 mL

What are your thoughts on the potential of upadacitinib for treating SSc-ILD?

How might these findings impact treatment strategies for patients with systemic sclerosis?

Evergreen Insights on Systemic Sclerosis-Associated Interstitial Lung Disease

Systemic sclerosis (SSc), also known as scleroderma, is a chronic autoimmune disease characterized by hardening and tightening of the skin and connective tissues. Interstitial lung disease (ILD) is a common and serious complication of SSc, affecting a significant proportion of patients. SSc-ILD can lead to progressive scarring of the lungs, resulting in shortness of breath, reduced exercise capacity, and ultimately, respiratory failure.

The management of SSc-ILD typically involves immunosuppressive medications aimed at reducing inflammation and slowing the progression of lung damage.however, current treatments have limitations, and new therapeutic options are needed to improve outcomes for patients with this debilitating condition. The emergence of JAK inhibitors like upadacitinib offers a promising avenue for future treatment strategies.

Frequently Asked Questions About Upadacitinib and SSc-ILD

Is upadacitinib a cure for systemic sclerosis-associated interstitial lung disease?
No, upadacitinib is not a cure for SSc-ILD. However, it may help to slow the progression of the disease and improve lung function.
How long does it take to see results with upadacitinib for SSc-ILD?
The clinical trial showed improvements in lung function within 52 weeks of treatment. Individual results may vary.
Are there any side effects associated with upadacitinib?
Yes,like all medications,upadacitinib can cause side effects. Common side effects may include infections, nausea, and headache. It is indeed critically important to discuss potential side effects with your healthcare provider.
Can upadacitinib be used in combination with other treatments for SSc-ILD?
The safety and efficacy of upadacitinib in combination with other treatments for SSc-ILD have not been fully established. Your healthcare provider can determine the best treatment approach for your individual situation.
Where can I find more information about systemic sclerosis-associated interstitial lung disease?
You can find more information about SSc-ILD from reputable sources such as the Scleroderma Foundation and the American Lung Association.

Disclaimer: This article provides information for general knowledge and awareness only. It does not constitute medical advice and should not be substituted for professional consultation with a qualified healthcare provider.

Share this article and join the conversation! What other advancements in autoimmune disease treatments are you excited about?

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