Review Article

Paradoxical Psoriasis as a Consequence of Tumour Necrosis Factor Antagonists in Patients With Inflammatory Bowel Disease

Cassandra Marie Townsend; Fiona Lovegrove; Reena Khanna; Aze Suzanne Wilson


Aliment Pharmacol Ther. 2022;55(11):1379-1388. 

In This Article

Abstract and Introduction


Background: Tumour necrosis factor (TNF) antagonists are an efficacious therapy used in the management of several immune-mediated inflammatory diseases, including inflammatory bowel disease (IBD) and psoriasis. However, since being prescribed more widely, reports of new-onset psoriatic lesions have began to emerge in the literature and are known as paradoxical psoriasis.

Aim: To review the evidence available in both the dermatology and gastroenterology literature pertaining to the entity known as paradoxical psoriasis as it relates to IBD and to create a comprehensive guide to assist clinicians who treat this challenging patient population.

Methods: A literature search was conducted in PubMed to identify manuscripts that presented, discussed or summarised data pertaining to paradoxical psoriasis presenting in individuals with IBD.

Results: Paradoxical psoriasis is now thought to be a contradictory effect of TNF antagonist therapy leading to psoriatic lesions often within the first year of treatment. The underlying pathogenesis, although not completely understood, is likely related to an imbalance of inflammatory cytokines. The histological appearance, while similar to classical psoriasis, does have unique features. The clinical presentation can vary among patients but often presents during maintenance therapy for inflammatory bowel disease. Treatment options should be determined based upon the severity of the skin lesion, activity of the underlying inflammatory bowel disease and the patient's unique clinical history.

Conclusions: The approach to paradoxical psoriasis in IBD should be discussed with a multidisciplinary team to optimise and preserve intestinal disease remission and to ensure the resolution of debilitating skin lesions.


Inflammatory bowel disease (IBD) is a relatively common condition that includes both Crohn's disease (CD) and ulcerative colitis (UC). The mainstay of treatment in both of these conditions is immunomodulatory therapy. Many different biologic agents are now approved for the treatment of IBD and target different points in the inflammatory cascade that are known to be upregulated during periods of disease activity.[1] Tumour necrosis factor (TNF) antagonists are one class of biologic agents that are available. In IBD therapeutics, this class includes infliximab, adalimumab, golimumab and certolizumab pegol.[1]

Paradoxical psoriasis (PP) is an established side effect of TNF antagonist therapy[2] that was initially described in patients with rheumatologic conditions.[3,4] PP is defined as the onset of new psoriatic lesions following the initiation of TNF antagonist therapy in patients without a prior diagnosis of psoriasis.[4,5] It is considered to be paradoxical because the cytokine, TNF is linked to the pathogenesis of de novo psoriatic lesions and TNF antagonists are approved for the treatment of psoriasis.[6]

While PP associated with TNF antagonist therapy has been previously described in both the IBD and dermatology literature, we feel a collaborative review from the perspective of both specialities will help to guide busy clinicians in the management of PP. The aim of this review is to provide a practical overview of PP as it pertains to patients with IBD, bridging the gaps that exist in the IBD and dermatological literature.