From the Guidelines
The relationship between shifting immunity in patients with concomitant plaque psoriasis and eczema (atopic dermatitis) is complex, and treatment with immunomodulatory therapies can sometimes unmask or trigger the other condition through immune pathway shifting, as seen with TNF-α inhibitors and dupilumab 1. When treating patients with both conditions, it is essential to consider the "Th1-Th2 paradigm" that explains the immunological relationship between psoriasis and atopic dermatitis. Psoriasis is predominantly a Th1/Th17-mediated disease, while atopic dermatitis is primarily Th2-driven. The concomitant presence of both conditions in the same patient may represent shared genetic susceptibility factors or common inflammatory pathways involving IL-23/IL-17 axis dysregulation.
Treatment Considerations
- Combination therapies that address both pathways, such as methotrexate (7.5-15mg weekly) or cyclosporine (3-5mg/kg/day), may be effective in managing patients with both conditions 1.
- Careful monitoring for paradoxical reactions is essential when using targeted biologics, and treatment may need adjustment based on which condition becomes predominant during the disease course.
- Adalimumab, a human anti-TNF-a monoclonal antibody, has been shown to be effective in treating moderate-to-severe plaque psoriasis, with a recommended starting dose of 80 mg taken as 2 self-administered subcutaneous 40-mg injections of the initial dose, followed by a 40-mg self-administered subcutaneous injection 1 wk later, followed by 40 mg self-administered every 2 wk thereafter 1.
Key Takeaways
- The treatment of patients with concomitant plaque psoriasis and eczema (atopic dermatitis) requires careful consideration of the immunological relationship between the two conditions.
- Combination therapies that address both pathways may be effective in managing patients with both conditions.
- Careful monitoring for paradoxical reactions is essential when using targeted biologics, and treatment may need adjustment based on which condition becomes predominant during the disease course.
From the Research
Relationship Between Shifting Immunity in Patients with Concomitant Plaque Psoriasis and Eczema
- The relationship between shifting immunity in patients with concomitant plaque psoriasis and eczema is complex and not fully understood 2.
- Studies have shown that the use of biologic therapies for the treatment of chronic plaque psoriasis can be linked to the development of atopic eczema, amongst other cutaneous adverse events 2.
- A systematic review found that 92 patients developed eczema, including atopic eczema, while being treated with biologics for chronic plaque psoriasis, with some patients having a prior history of atopy, eosinophilia, or raised serum immunoglobulin E 2.
Coexistence of Plaque Psoriasis and Eczema in the Same Patient
- The coexistence of plaque psoriasis and eczema in the same patient can create diagnostic confusion and difficulty in management 2.
- Treatment strategies for patients with both conditions include topical or oral corticosteroids, and treatment with alternative systemic agents such as ciclosporin or apremilast 2.
- Switching biologic agents can significantly improve outcomes for patients with moderate-to-severe plaque psoriasis who have failed to respond to their first biologic agent 3.
Treatment Course and Immunity Shift
- The treatment course for patients with concomitant plaque psoriasis and eczema may involve a shift in immunity, with some patients experiencing a phenotypic switch to eczema while receiving biologics for plaque psoriasis 2.
- The use of topical corticosteroids, such as clobetasol propionate, can be effective in improving the signs and symptoms of plaque psoriasis, but may not address the underlying immune mechanisms contributing to the coexistence of eczema 4, 5, 6.
- Further research is needed to elucidate the mechanisms and risk factors contributing to the shift in immunity and the development of eczema in patients with plaque psoriasis 2.