Adalimumab-Associated Pemphigoid
Yes, adalimumab has been definitively associated with bullous pemphigoid (BP), with multiple case reports documenting drug-induced BP following adalimumab therapy, though this remains a rare adverse event. 1
Evidence for Association
The British Association of Dermatologists' 2012 guidelines for bullous pemphigoid management explicitly acknowledge this association, stating there is "conflicting evidence as to whether these agents treat or induce BP." 1 The guidelines document two specific case reports of adalimumab-induced BP, including one case with features overlapping with mucous membrane pemphigoid. 1
Documented Cases
Multiple case reports confirm this association:
An 81-year-old patient receiving adalimumab for ulcerative colitis developed BP, with other causes (tumors, other drugs, viral infections) excluded; symptoms resolved after stopping adalimumab and initiating corticosteroid therapy. 2
A patient with psoriasis developed simultaneous BP and vitiligo after adalimumab treatment, representing the first reported case of dual autoimmune manifestations from this agent. 3
A 43-year-old man with psoriasis and pemphigus experienced dramatic exacerbation of disease one day after receiving adalimumab 80 mg injection. 4
Clinical Context and Mechanism
This paradoxical autoimmune phenomenon occurs despite TNF-alpha inhibitors theoretically having immunosuppressive properties. 1 The British Association of Dermatologists notes that while some reports describe successful treatment of BP with etanercept (another TNF-alpha inhibitor), other reports document TNF-alpha inhibitors inducing BP, creating a clinical paradox. 1
The mechanism remains unclear, but this represents part of a broader pattern of autoimmune complications associated with TNF inhibition, including lupus-like syndromes (15 cases reported with adalimumab) and vasculitis (5 cases reported). 5, 6
Clinical Implications
Clinicians should maintain high vigilance for new-onset blistering or autoimmune phenomena in patients receiving adalimumab. 2, 3 The importance of monitoring for autoimmune events during TNF inhibition cannot be overstated, as patients may develop more than one autoimmune condition simultaneously. 3
Management Approach
When adalimumab-induced BP is suspected:
- Discontinue adalimumab immediately 2
- Initiate topical and/or systemic corticosteroid therapy (prednisolone 1 mg/kg/day has been effective) 2
- Exclude other BP triggers including malignancy, other medications, and infections 2
- Symptoms typically resolve quickly after drug discontinuation and appropriate treatment 2
Frequency and Risk Assessment
While the association is established, adalimumab-induced BP remains a rare complication. 1 The British Association of Dermatologists classifies evidence for this association as strength of recommendation D with level of evidence 3, reflecting the limited number of case reports rather than controlled studies. 1
Common adalimumab adverse events (injection site reactions 15%, infections, headaches, gastrointestinal upset) occur far more frequently than autoimmune blistering diseases. 1, 5