Rheumatol Int (2012) 32:3779–3783 DOI 10.1007/s00296-011-2265-4 123 ORIGINAL ARTICLE Psoriasis and psoriasiform lesions induced by TNF antagonists: the experience of a tertiary care hospital from northern Spain Alejandra López-Robles · Rubén Queiro · Mercedes Alperi · Sara Alonso · José L. Riestra · Javier Ballina Received: 29 May 2011 / Accepted: 8 December 2011 / Published online: 21 December 2011  Springer-Verlag 2011 Abstract The aim of this study was to investigate the cumulated incidence and clinical characteristics of the pso- riasiform lesions seen in a wide cohort of rheumatic patients exposed to anti-TNF drugs in a tertiary care hos- pital from northern Spain. The study population included 450 patients exposed to anti-TNF agents from 2001 to 2007 and treated in a university hospital in northern Spain. Two hundred patients were exposed to inXiximab (44%), 129 (29%) to etanercept, and 121 (27%) to adalimumab. The cumulated incidence (CI) of this skin reaction was cal- culated for each of the three agents studied. Psoriasis and psoriasiform lesions were documented in 7 patients diag- nosed with diVerent rheumatic inXammatory conditions (1.56%). Cases of this adverse eVect were identiWed with all three anti-TNF agents available at that time, but less frequently with inXiximab (CI: 0.5%) compared with eta- nercept (CI: 2.3%) or adalimumab (CI: 2.5%). The most common lesion was palmoplantar pustulosis (71.3% of the cases), and the latency period to the development of the lesions ranged from 4 to 38 months (mean 9 months). In four of the 7 patients, treatment was suspended, while in the remaining three patients treatment was continued. The CI of this skin reaction in our setting is similar to that pub- lished by others. InXiximab was found to be less frequently associated with this adverse event. In our experience, it is not always necessary to stop anti-TNF therapy for the skin lesions to improve. Keywords Anti-TNF drugs · Psoriasis · Palmoplantar pustulosis · Cumulated incidence Introduction Tumor necrosis factor-alpha (TNF) is a proinXammatory cytokine that plays an important role in diVerent inXamma- tory diseases, including skin psoriasis. This cytokine has a key role in the pathogenesis of psoriasis, since it is involved in the skin immune response, stimulating epidermal growth and vascular proliferation and thus favoring plaque forma- tion. There is suYcient evidence of the eYcacy of treatment with TNF antagonists in diseases such as rheumatoid arthritis (RA), spondyloarthropathies, juvenile idiopathic arthritis, inXammatory bowel disease, and skin psoriasis. Despite the eYcacy of anti-TNF drugs in application to psoriasis, as demonstrated by diVerent clinical trials, in recent years, there have been a growing number of reports of exacerbation, worsening, or the appearance of new psori- asiform conditions [1, 2]. There are over 200 cases in the literature of psoriasis, psoriasiform lesions, and worsening of prior psoriasis after starting treatment with anti-TNF drugs [3]. The etiopathogenesis of this phenomenon is not known, though it appears to be related to an imbalance between TNF and interferon- activity [4]. The present study evaluated the cumulated incidence (CI) of skin lesions of this kind among the patients with rheumatic inXammatory diseases receiving treatment with TNF antagonists in a university hospital in northern Spain. After reviewing the histories of the Wrst 450 patients receiv- ing anti-TNF therapy in our department, we identiWed 7 cases, which were described below. Patients and methods This cohort study included 450 patients diagnosed with several rheumatic conditions exposed to anti-TNF drugs A. López-Robles · R. Queiro (&) · M. Alperi · S. Alonso · J. L. Riestra · J. Ballina Rheumatology Service, Hospital Universitario Central de Asturias (HUCA), C/Celestino Villamil s/n, 33006 Oviedo, Spain e-mail: rubenque7@yahoo.es