10.5826/dpc.1401a13
text/xml
2160-9381
3350
en
Iria Neri
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Paradoxical Psoriasis: A Dermoscopic and Histopathologic Teaching Points
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Image Letter
2024-01-31
2023-03-18
2024-01-31
2024-02-21
e2024013
Dermatol Pract Concept
Iria Neri
2024/01/31
10.5826/dpc.1401a13
e2024013
Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
2160-9381
en
e2024013
Pugliese, D. et al. Paradoxical psoriasis in a large cohort of patients with inflammatory bowel disease receiving treatment with anti-TNF alpha: 5-year follow-up study. Aliment. Pharmacol. Ther.42, 880–888 (2015).
Paradoxical Psoriasis: A Dermoscopic and Histopathologic Teaching Points
https://dpcj.org/index.php/dpc/article/download/3350/2534
                    Paradoxical Psoriasis: A Dermoscopic
                     and Histopathologic Teaching Point
         Marco Adriano Chessa1,2, Luca Rapparini1,2, Federica Filippi1, Carlotta Baraldi1,
                             Bianca Maria Piraccini1, Iria Neri1


1 Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
2 Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Italy



Citation: Chessa MA, Rapparini L, Filippi F, Baraldi C, Piraccini BM, Neri I. Paradoxical psoriasis: A Dermoscopic and Histopathologic
Teaching Point. Dermatol Pract Concept. 2024;14(1):e2024013. DOI: https://doi.org/10.5826/dpc.1401a13
Accepted: June 12, 2023; Published: January 2024
Copyright: ©2024 Chessa et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing Interests: None.
Authorship: All authors have contributed significantly to this publication.
Corresponding Author: Luca Rapparini, MD, Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of
Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Via Massarenti 1, 40138 Bologna, Italy. ORCID 0000-0002-
4029-941X. Phone: +390512144838 E-mail: luca.rapparini2@studio.unibo.it




Case Presentation                                                        dipropionate ointment was started. At 3 months of ­follow-
                                                                         up, the plantar lesions were completely resolved, without
A 50-year-old woman presented an erythematous desquama-                  Crohn’s disease relapses.
tive plantar eruption occurred 6 months prior to the visit
(Figure 1A). Several treatments with topical potent cortico-
                                                                         Teaching Point
steroids and antimycotics were given in the clinical suspect
of dyshidrotic eczema, without improvement.                              Paradoxical psoriasis is a well-documented manifestation
    Dermoscopy showed white scales and regularly dis-                    in patients with inflammatory bowel disease treated with
tributed red dots, a pattern usually detected in psoriasis               anti-TNF-α agents [2]. The pathological mechanism of the
(Figure 1B) [1].                                                         onset of psoriasis due to anti-TNF-α seems related to the
    Histological examination showed parakeratosis, hy-                   migration of T cells to the skin induced by IFN-α produced
pogranulosis     and    psoriasiform     epidermal     hyperplasia       by plasmacytoid dendritic cells.
and neutrophils in the stratum corneum, forming Munro                         Dermoscopy in palmoplantar localization could be
micro-abscesses, confirming the diagnosis of psoriasis                   crucial for a differential diagnosis: in chronic dyshidrotic
(Figure 1C).                                                             ­eczema yellow scales and brownish dots/globules are u
                                                                                                                              ­ sually
    A further investigation of medical history revealed that             detected (Figure 1D) corresponding to tiny spongiotic vesi-
the patient was affected by Crohn disease, and successfully              cles; while psoriasis is characterized by white scales and reg-
treated with adalimumab in the last 5 years. A diagnosis                 ular distributed red dots.
of paradoxical psoriasis was proposed, and in agreement                       In these cases, the withdrawal from anti-TNF-α usually
with the gastroenterologist, biological therapy was switched             induces a complete remission of the skin lesions, thus con-
to ustekinumab. In addition, calcipotriol/betamethasone                  firming a reversible and drug-related side effect.




Image Letter | Dermatol Pract Concept. 2024;14(1):e2024013                                                                               1
Figure 1. (A) Erythematous desquamative plantar eruption with rhagades. (B) Dermoscopy of palmoplantar psoriasis: white scales (white
arrows) and regular distributed red dots (red arrows). (C) Histology of palmoplantar psoriasis: parakeratosis, hypogranulosis, psoriasiform
epidermal hyperplasia, neutrophil in the stratum corneum, dilated capillaries and perivascular lymphocytes in the dermis (H&E, 10x).
(D) Dermoscopy of dyshidrotic eczema: yellow scales (yellow arrows) and brownish dots/globules (brown arrows).


    In our case, given the personal history of Crohn disease, a            A prospective, comparative study of 90 patients. J Dermatol.
switch to a biological drug of another class was successfully              2020;47(10):1157-1165. DOI: 10.1111/1346-8138.15487.
                                                                           PMID: 32691449.
undertaken.
                                                                        2. Pugliese D, Guidi L, Ferraro PM, et al. Paradoxical psoriasis in
                                                                           a large cohort of patients with inflammatory bowel disease re-
Patient Consent: Informed consent for the use of informa-                   ceiving treatment with anti-TNF alpha: 5-year follow-up study.
tion and images has been obtained from the patient.                         Aliment Pharmacol Ther. 2015;42(7):880-888. DOI: 10.1111
                                                                            /apt.13352. PMID: 26235565.


References
 1. Çetinarslan T, Türel Ermertcan A, Temiz P. Dermoscopic clues of
    palmoplantar hyperkeratotic eczema and palmoplantar psoriasis:




2                                                                             Image Letter | Dermatol Pract Concept. 2024;14(1):e2024013
