Penn State College of Medicine, Department of Family and Community Medicine, Hershey (Drs. Clebak and L. Helm); Penn State College of Medicine, Department of Dermatology (Dr. M. Helm); Maine Medical Center, Department of Dermatology, Portland (Dr. Seiverling). kclebak@pennstatehealth.psu.edu
The authors reported no potential conflict of interest relevant to this article.
Individualize therapy according to the severity of disease, location of the lesions, involvement of joints, and comorbidities.
Other systemic agents—for individuals who cannot tolerate the biologic agents—include acitretin, azathioprine, mycophenolate mofetil, and cyclosporine.15,17
Paradoxical psoriatic reactions
When a psoriatic condition develops during biologic drug therapy, it is known as a paradoxical psoriatic reaction. The onset of de novo psoriasis has been documented during TNF-α inhibitor therapy for individuals with underlying rheumatoid arthritis.23 Skin biopsy reveals the same findings as common plaque psoriasis.
Using immunosuppressive Tx? Screen for tuberculosis
Testing to exclude a diagnosis of latent or undiagnosed tuberculosis must be performed prior to initiating immunosuppressive therapy with methotrexate or a biologic agent. Tuberculin skin testing, QuantiFERON-TB gold test, and the T-SPOT.TB test are accepted screening modalities. Discordance between tuberculin skin tests and the interferon gamma release assays in latent TB highlights the need for further study using the available QuantiFERON-TB gold test and the T-SPOT.TB test.24
CORRESPONDENCE Karl T. Clebak, MD, FAAFP, Penn State Health Milton S. Hershey Medical Center, Department of Family and Community Medicine, 500 University Drive, Hershey, PA 17033; kclebak@pennstatehealth.psu.edu.
