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SAT0433 Anti-tnf treatment in rheumatoid arthritis and ankylosing spondylitis patients is associated with a strong increase of palmoplantar pustulosis but not of psoriasis vulgaris
  1. J Ruwaard1,
  2. E van der Vlugt1,
  3. M Nurmohamed1,
  4. T Rispens2,
  5. GJ Wolbink1,2
  1. 1Amsterdam Rheumatology and immunology Center | Reade
  2. 2Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Centre, Amsterdam, Netherlands


Background The prevalence of paradoxical psoriasis developed with biological use is already studied. However, none of these studies discriminate between psoriasis vulgaris (PV) and palmoplantar pustulosis (PPP), while these might be different entities (1). The prevalence in general population is 2–4% for PV and 0.01–0.05% for PPP (1–3). Moreover, most reports in the literature imply only a role for anti-Tumor necrosis factors (anti-TNF), although, a few cases described paradoxical psoriasis in patients treated with biologicals other than anti-TNF.

Objectives To study the prevalence and incidence density of paradoxical psoriasis and palmoplantar pustulosis in patients with rheumatoid arthritis (RA) and ankylosing spondylitis (AS) treated with biological therapy. Second to investigate differences between paradoxical psoriasis and palmoplantar pustulosis.

Methods Data were collected from the observational cohorts of AS and RA patients. 1499 consecutive patients were included for calculating prevalence and incidence density. Incidence density is calculated per 1000 person years. For calculating differences, only biological naïve patients (n=830) were included. Kaplan Meier curve was used to show the difference in time in onset.

Results In all, 13 cases of PPP and 16 cases of PV were observed in both the RA as AS cohorts. In AS patients 1.73% developed PPP and 1.38% PV. In RA patients respectively 0.66% and 0.99%.

The incidence density of PPP in RA was 2.1 (95% CI 0.7–3.6), for PV 3.2 (95% CI 1.4–5.0). In AS, 4.7 (95% CI 0.6–8.8) for PPP and 3.7 (95% CI 2.3–12.7) for PV. Although not statistically significant, PPP was more prevalent in adalimumab (0.94%) compared to etanercept (0.34%). In contrast, PV occurs in 0.53% in adalimumab and 0.92% in etanercept treated patients. PPP was only observed in anti-TNF, PV was also observed in 1 patient treated with tocilizumab and 1 with abatacept.

A difference was observed in the time to event, with a median of 6 months (IQR 4–16 months) for PPP and 50 months (IQR 11–67 months) for PV; p=0.003 (figure 1). Discontinuation of biological treatment was indicated in 80% of the PPP patients and 18.2% PV patients.

Conclusions Our findings show that biological therapy in patients with RA or AS is associated with a 13 to 35 fold increase in prevalence of PPP. While the prevalence of biological-associated PV is lower than the prevalence of PV in the general population. In this study PV and PPP are different from each other regarding prevalence, time to onset and consequences for biological treatment, and therefore should be considered as separate entities.


  1. J Dermatolog Treat 2011 Apr;22(2):102–5.

  2. Lancet 2015 Sep 5;386(9997):983–94.

  3. Acta Derm Venereol 1971;51(4):284–8.


Disclosure of Interest None declared

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