Hair whitening in psoriatic patient during adalimumab failur
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The role of TNFα inhibitors in the development of vitiligo is controversial. There have been several case reports that have revealed a therapeutic benefit in patients affected by vitiligo receiving anti-TNFα therapy for other diseases. The therapeutic effect of anti-TNFα agents on vitiligo might result from contrasting the inhibition of TNFα on melanogenesis. Indeed, it has been demonstrated that TNFα exerts a melanocytotoxic effect, reducing the level of tyrosinase in vitro. On the other hand, anti-TNFα therapies have been associated with the development of a considerable number of autoimmune diseases, including vitiligo.

Authors report the case of a 40-year-old male, with 18-years history of psoriasis and psoriatic arthritis, positive family history (father), and lack of comorbidity. Previously, he had been treated with cycles of cyclosporine A (up to 4 years, from 2008), withdrawn for transient and mild efficacy. In 2015, a biological therapy with an anti-TNFα agent, adalimumab, was started, according to the posology scheme. At baseline the patient reported PASI 21, BSA 30%, and DLQI 7. After 12 weeks PASI 1, BSA 3% (minimal manifestations at forearms) and DLQI 0 were recorded, and this excellent result was maintained for about 3 years.

However, at follow-up visits in November 2018 a loss of efficacy of adalimumab therapy was recorded (loss of 50% of clinical improvement; PASI 12, BSA 25%, and DLQI 6). Moreover, the patient reported a hair and facial hair whitening, including beard, sideburns and eyebrows, normally black pigmented before psoriasis worsening during the use of adalimumab. Surprisingly, cutaneous manifestations of vitiligo were not recorded. Wood lamp examination of vitiligo affected areas showed depigmented hair with a bright-white fluorescence, confirming the diagnosis. In addition, laboratory tests were performed to check for other autoimmune conditions, which revealed high levels of circulating thyroid autoantibodies (anti-thyroglobulin and anti-thyroid peroxidase) didn’t present before adalimumab’ failure.

For all these reasons the biologic therapy was interrupted, and a topical therapy based on corticosteroid and vitamin D derived was prescribed. However, in January 2019, while the whitening described above persisted, the patient presented with total remission of autoimmune thyroiditis, but with worsening of psoriasis and psoriatic arthritis (PASI 16,5, BSA 35%, and DLQI 12; flare of joint pain). A new biologic therapy with an anti-IL17A agent (ixekizumab) was started. The patient rapidly improved (after 1 month PASI90), and after 3 months he achieved PASI100.

A good control of the psoriatic disease has been kept to date, after nearly two years of treatment. Interestingly, a re pigmentation of vitiligo affected areas was shown after 3 months, with a progressive improvement 9 months and 18 months later treatment with ixekizumab.