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Basal vacuolar change with superficial perivascular lymphocytic infiltrate and presence of red blood cell extravasation
Source publication
Background
We present a rare case of TNF-α inhibitor induced pigmented purpuric dermatoses (PPD) and explore its mechanisms and management.
Case presentation
A 44-year-old woman presented with non-pruritic non-tender petechial rash on bilateral lower limbs after being started on Adalimumab, with the rash progressing to worsen on Golimumab, both us...
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Methods
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Citations
... Although the exact cause of Schamberg disease is not well understood, certain medications have been implicated in the development or exacerbation of the disease, including amlodipine [23,24], raloxifene [25], dupilumab [26], and TNF-alfa inhibitors [27]. Alcohol [28], physical exercise [29], and odontogenic infection [30] have been attributed a possible pathogenic role in SD as well. ...
Pigmented purpuric dermatoses (PPD) encompass a group of chronic skin conditions characterized by the presence of petechiae, purpura, and pigmentation changes. While generally benign, these dermatoses can be persistent and aesthetically bothersome. Key clinical features include red to brownish patches with a distinctive “cayenne pepper” appearance, predominantly localized on the lower extremities, particularly the shins. Subtypes include Schamberg disease, Majocchi’s disease, Gougerot–Blum disease, Ducas and Kapetanakis pigmented purpura, and lichen aureus. Diagnosis relies primarily on clinical evaluation of skin lesions, with biopsy as a confirmatory tool. Although the exact cause of PPD remains unclear, capillary fragility and red blood cell extravasation are implicated. Treatment strategies for PPD aim to alleviate symptoms, considering the generally benign and chronic nature of the condition. As there is no standardized treatment, various methods with varying efficacy are employed. After searching SCOPUS and PubMed databases, we assessed 42 original articles to present current knowledge regarding therapy of PPD. This review will compare treatment approaches specifically in Schamberg disease and other manifestations of pigmented purpuric dermatoses.
Tumor necrosis factor alpha (TNFα) inhibitors are now widely used to treat immune-mediated inflammatory diseases. Although they have a good safety profile, they are also associated with adverse cutaneous events. Pigmented purpuric dermatoses (PPD) include a variety of skin diseases characterized by multiple petechial hemorrhages due to capillaritis. Five major clinical types of PPD have been described and purpura annularis telangiectodes of Majocchi (PATM) is a rare subtype of PPD. The cause of PPD is unknown, but drugs are implicated in a minority of cases. There are very few cases in the literature triggered by TNFα inhibitors. We present a case of PATM induced by certolizumab pegol and perform a review including 4 articles in the literature reporting 5 PPD cases induced by TNFα inhibitors. When purpuric eruptions develop in patients treated with TNFα inhibitors, PPD and vasculitis should be differentiated. Thus, patients are not exposed to unnecessary evaluations and treatments.
