Hair Loss and Red Scalp and TNF Inhibitors
TNF inhibitor induced psoriasis: An Important Consideration in Patients with Refractory Red Scalp Issues Following TNF Inhibitors
I’ve selected this question below for this week’s question of the week. It allows us to review some concepts in TNF inhibitor triggered psoriasis.
Question
I am 19 and have been battling a red scalp and hair loss since starting a TNF inhibitor for my Crohn’s disease. No one can figure out what’s going on and I’ve been diagnosed with psoriasis, seborrheic dermatitis, allergy and telogen effluvium and genetic hair loss.
Do you think it’s related to my hair loss is related to this drug? Do I need to stop this drug?
Answer
Thank you so much for reaching out!
I am concerned in this case that what we might be dealing with is TNF inhibitor induced psoriasis. She could have AGA as well …..but until we aggressively treat the psoriasis, I’m not sure we can say just how much AGA she actually has. Of course, we’d want to make sure there is no telogen effluvium here so blood tests for ferritin, TSH are important.
The ability of TNF inhibitors to cause psoriasis rather than be used to treat psoriasis is called “paradoxical psoriasis”. The terms TNF inhibitor induced Psoriasis and paradoxical psoriasis can be used interchangeably. The prevalence of anti-TNF-induced psoriasis ranges from 1-7 %. In the pediatric literature, Cyrenne et al identified 210 patients with TNF induced psoriasis out of 4564 pediatric patients treated with these drugs. That put the frequency of the condition at 4.6 %.
Many authors have shown that females comprised a greater number of cases. It ranges from just a slightly greater proportion of females than males to upwards of 70 % females affected by the phenomenon. The time from initiation of treatment to onset of lesions is around 8-11 months on average. Most cases therefore develop within the first year of treatment.
You might consider if this timing is related. Of course some cases of TNF inhibitor induced psoriasis are also a worsening of existing psoriasis so even if she had psoriasis before the question is really whether it got worse.
Patients with paradoxical psoriasis can have many underlying conditions. However, rheumatoid arthritis, ankylosing spondylitis, and Crohn's disease account for the vast majority of background disease states in patients who develop TNF Inhibitor Induced Psoriasis.
Most cases of TNF Inhibitor-induced psoriasis are linked to infliximab, with fewer cases described with adalimumab, certolizumab, and etanercept. In 2009, Ko et al evaluated 127 cases of TNF Inhibitor-induced psoriasis. Inflixmimab topped the list of TNF inhibitors implicated. There were 70 in patients on infliximab (55.1%), 35 using etanercept (27.6%), and 22 with adalimumab (17.3%). Infliximab also stands out in the pediatric literature as also being the number one cause of paradoxical psoriasis from TNF inhibitor use. In 2021, Cyrenne et al showed that infliximab was the drug most likely to induce psoriasis in pediatric patients followed by adalimumab.
In pediatric patients, Cyrenne et al found that the scalp was the most commonly affected area in TNF Inhibitor induced psoriasis (47.5%), followed by the ears (30.8%).
How should this be treated?
The options for treating of this patient is to aim to eradicate the psoriasis and then see how much hair loss is left over. That would then guide how aggressively to treat the AGA.
There are three options for treatment of TNF inhibitor induced psoriasis. Option 1 is to “treat through” the TNF inhibitor - in other words, one has the option to continue the TNF inhibitor and try to aggressively treat the psoriasis. Option 2 involves switching to a different TNF inhibitor and option 3 is to completely abandon the TNF inhibitor therapy altogether.
Option 1: Continuing the Same TNF I and Treating the Psoriasis (Treating through)
Continuing the TNF inhibitor and trying to aggressively treat the skin disease is among the top option. This is often worth trying first as some patients with TNF inhibitor induced psoriasis respond well to basic psoriasis treatments.
That might be the preference here although I don’t know how well the patient is responding to IBD treatments with adalimumab. I would recommend starting a topical steroid and aggressive shampooing regimen with tar, salicylic acid and anti-dandruff ingredients. She may tolerate some low concentration steroid injections such as triamcinolone acetonide 2 mg per mL at 3-4 cc every 3 months. Sometimes, steroid injections just ‘melt’ psoriasis as the expression goes
In 2022, Lian et al described 10 patients who developed paradoxical psoriasis on TNF inhibitors. 8 of the 10 patients regained control of their skin disease despite continuing the TNF Inhibitor. In other words, 80 % of patients did well using option 1.
A 2020 study by Mazloom et al showed that topical medications alone improved or resolved TNFI-induced psoriasis in 63.5% of adult patients. Cyclosporine and methotrexate (>10 mg weekly) were often effective if topicals failed.
In a systematic review of pediatric patients by Cyrenne et al, it was found that the majority of patients continued the TNF inhibitor and treated the psoriasis they had with psoriasis-directed therapies.
Option 2: Switching to a New TNF Inhibitor
Changing to another TNF inhibitor is rarely a good option as it often does not clear psoriasis lesions. Nevertheless, it is an option.
in 2009, Ko et al showed that switching to a different anti-TNF agent led to resolution in only 15.4% of cases.
Among pediatric patients, a 2021 study by Cyrenne et al found in a systematic review that only 32.0% of those who switched to a new TNF inhibitor had complete clearance of their skin lesions.
Option 3: Stopping TNF Inhibitor Therapy
Stopping the TNF inhibitor group of drugs altogether is probably the option with the best chance of helping. Of course, that may not be the first step but it is one with a good chance of helping. In fact, many researchers have the view that TNF inhibitor psoriasis is different from regular psoriasis in that psoriasis caused by TNF inhibitors is not really a de novo type of psoriasis but simply a type of psoriasis that is maintained by blocking TNF signalling. For this reason, stopping TNF inhibitor therapy often proves extremely helpful in challenging cases of paradoxical psoriasis.
This is by no means a guarantee and in mild cases one may still consider option 1 (treating through). Ko et al suggested that cessation of anti-TNF therapy with systemic therapy led to resolution in 64.3% of cases. A 2020 study by showed that discontinuation of the TNFI with or without other interventions improved or resolved TNFI-induced psoriasis in 67% of refractory cases.
In a series of 125 patients by Guerra et al, 37 % of patients with TNF Inhibitor Induced Psoriasis ultimately needed to stop their TNF inhibitors.
In the pediatric age group, stopping TNF inhibitors frequently helps a great deal as well. For example, Cyrenne et al found that among patients who were switched to another drug rather than a TNF inhibitor, 81% had complete clearance of their paradoxical psoriasis.
Final Comment
It’s possible here that Adalimumab is involved – especially if it developed (or worsened) within a year or so of starting.
In my view, the red scalp issues warrant aggressive treatment before deciding on how much AGA to treat. Certainly spironolactone or topical minoxidil or oral minoxidil are good options but I’d really like to see the psoriasis gone before aggressively treating the AGA (if indeed there is much AGA).
Thinning” of this kind can trick you into thinking there is more AGA than there is
For my typical patient with similar situation I might
1. Start a salicylic acid – tar shampoo twice weekly.
2. Start fluocinolone acetonide oil once weekly and night followed by shampooing out the next morning with zinc pyrithione or ketoconazole shampoo. Once things improve, we can get rid of the fluocinolone acetonide oil. It’s not so elegant but it can work great to lift scales
3. Steroid injections every 3 months and low doses (2 mg per mL) not 5 and not 10 mg per mL
4. Add 2.5 to 5 mg of methotrexate once weekly if we need to (if the psoriasis does not disappear)
5. Stop adalimumab if it seems we are not really winning here.
6. Starting 0.625 mg of oral minoxidil (after counseling) and then increasing to 1.25 mg after 3 months is well tolerated. 50 to 100 mg of oral spironolactone can be added after 9 months if the response is not as good as hoped.. In situations like this I often avoid topical minoxidil but there is nothing wrong per se in starting topical minoxidil. I just find it sometimes irritates.
References
Alessia Nidegger et al. [Paradoxical psoriasis induced by anti-TNF - a clinical challenge]. Rev Med Suisse. 2019 Mar 27;15(644):668-671.
Boggs J et al. Paradoxical psoriasis caused by tumour necrosis factor inhibitor therapy. Clin Exp Dermatol. 2021 Apr;46(3):580-582.
Brown G, Wang E, Leon A, et al. Tumor necrosis factor-alpha inhibitor-induced psoriasis: systematic review of clinical features, histopathological findings, and management experience. J Am Acad Dermatol. 2017;76(2):334–341.
Cyrenne et al. Paradoxical psoriasis in pediatric patients: A systematic review. Pediatr Dermatol . 2021 Sep;38(5):1086-1093.
Guerra I, Perez-Jeldres T, Iborra M, et al. Incidence, clinical characteristics, and management of psoriasis induced by anti-TNF therapy in patients with inflammatory bowel disease: a nationwide cohort study. Inflamm Bowel Dis. 2016;22(4):894–901.
Ko J et al. Induction and exacerbation of psoriasis with TNF-blockade therapy: a review and analysis of 127 cases. J Dermatolog Treat . 2009;20(2):100-8.
Lian N et al. Tumor necrosis factors-α inhibition-induced paradoxical psoriasis: A case series and literature review. Dermatol Ther . 2020 Nov;33(6):e14225.
Jun et al Antitumor necrosis factor treatment in patients with inflammatory bowel disease does not promote psoriasis development: A meta-analysis. Medicine (Baltimore). 2022 Jul 8;101(27):e29872.
Mazloom et al. TNF-α inhibitor-induced psoriasis: A decade of experience at the Cleveland Clinic. J Am Acad Dermatol . 2020 Dec;83(6):1590-1598.
Olteanu R, Zota A. Paradoxical reactions induced by tumor necrosis factor-alpha antagonists: a literature review based on 46 cases. Indian J Dermatol Venereol Leprol. 2016;82(1):7–12.
Pugliese D, Guidi L, Ferraro PM, et al. Paradoxical psoriasis in a large cohort of patients with inflammatory bowel disease receiving treatment with anti-TNF alpha: 5-year follow-up study. Aliment Pharmacol Ther. 2015;42(7):880–888.
Ya et al. Family history of psoriasis, psychological stressors, and tobacco use are associated with the development of tumor necrosis factor-α inhibitor-induced psoriasis: A case-control study. J Am Acad Dermatol . 2020 Dec;83(6):1599-1605.
Thank you again