From the Guidelines
The development of asthma and atopic dermatitis in a patient with previously well-controlled psoriasis on etanercept is likely due to an immune dysregulation phenomenon, and the best management approach is to continue etanercept while adding targeted therapy for the atopic conditions, as recommended by the joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics 1. The situation likely represents the "atopic march" or an immunological shift from Th1/Th17 (psoriasis) to Th2 (atopic conditions) dominance following TNF-α inhibition. Some key points to consider in management include:
- Continuing etanercept if psoriasis remains controlled, as it is recommended as a monotherapy treatment option in adult patients with moderate-to-severe plaque psoriasis 1
- Adding targeted therapy for the atopic conditions, such as a medium-potency topical corticosteroid (such as triamcinolone 0.1% cream) for atopic dermatitis lesions twice daily for 2 weeks, followed by maintenance with tacrolimus 0.1% ointment
- Starting with an inhaled corticosteroid like fluticasone (250mcg twice daily) plus a long-acting beta-agonist if needed for asthma
- Considering dupilumab (300mg subcutaneously every 2 weeks after 600mg loading dose) as it targets both atopic dermatitis and asthma through IL-4/IL-13 inhibition while not worsening psoriasis Regular monitoring for all conditions is essential, with pulmonary function tests every 3-6 months. This approach addresses the immunological paradox where blocking TNF-α may have permitted emergence of Th2-mediated conditions, requiring a multi-targeted treatment strategy to manage all concurrent conditions. Key treatment considerations include:
- Etanercept dose: the recommended maintenance dose of etanercept after the initial 12 weeks is 50 mg once weekly, although 50 mg twice weekly may be required for better disease control in some patients 1
- Combination therapy: combination of etanercept and topicals, such as high-potency corticosteroids with or without a vitamin D analogue, is recommended as a treatment option to augment efficacy for the treatment of moderate-to-severe plaque psoriasis 1
From the Research
Explanation for Developing Asthma and Atopic Dermatitis
- The development of asthma and atopic dermatitis in a patient with severe chronic plaque psoriasis who achieved complete remission with etanercept (Tumor Necrosis Factor-alpha inhibitor) can be attributed to the complex interplay of immune system pathways 2, 3, 4.
- Etanercept, as a TNF-alpha inhibitor, may have altered the balance of the immune system, potentially leading to an increased risk of developing other immune-related conditions such as asthma and atopic dermatitis 3, 4.
- The exact mechanisms behind this phenomenon are not fully understood and require further research to determine the causal relationships between TNF-alpha inhibition and the development of asthma and atopic dermatitis 2, 5.
Management Approach
- For patients who develop asthma and atopic dermatitis while on etanercept, a personalized approach to management is necessary, taking into account the patient's individual risk profile and medical history 2, 5.
- Ustekinumab, an IL-12 and IL-23 inhibitor, has shown efficacy in treating moderate-to-severe atopic dermatitis and may be considered as an alternative treatment option for patients who develop asthma and atopic dermatitis while on etanercept 6.
- Close monitoring of the patient's condition and adjustment of the treatment plan as needed is crucial to ensure optimal management of both psoriasis and the newly developed conditions 3, 4.
- Further research is needed to fully understand the safety and efficacy of biologic agents in treating psoriasis and other immune-related conditions, particularly in pediatric populations 5.