ArticleClinical rheumatology2026
Paradoxical psoriasis in axial spondyloarthritis and rheumatoid arthritis treated with b/tsDMARDs: a retrospective cohort study.
Article in Clinical rheumatology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
INTRODUCTION/
objectivesTo determine the incidence of paradoxical psoriasis (PP) across multiple b/tsDMARD classes, identify independent risk factors, and characterise the clinical features and treatment outcomes of PP in axial spondyloarthritis (axSpA) and rheumatoid arthritis (RA).
methodsSingle-centre retrospective cohort study of 1588 adult patients with axSpA or RA receiving at least one b/tsDMARD between January 2019 and December 2024. PP was defined as de novo psoriasiform skin lesions confirmed by dermatological evaluation. Incidence rates were calculated per 100 person-years. Risk factors were assessed by multivariable Firth penalised logistic regression and Kaplan-Meier analysis.
resultsPP developed in 32 patients (2.0%) over 2795.7 person-years (incidence rate 1.14/100 PY; 95% CI 0.78-1.62). Thirty cases (93.8%) occurred with TNF inhibitors. No PP was observed with JAK inhibitors, rituximab, or tocilizumab. The predominant phenotype was palmoplantar pustular psoriasis (65.6%); median time to onset was 12.0 months (IQR 5.2-25.2). Ever-smoking was the sole independent predictor of PP (adjusted OR 2.15; p = 0.043); TNF inhibitor use and family history showed borderline associations. Kaplan-Meier analysis confirmed higher cumulative PP incidence in ever-smokers (log-rank p = 0.031). The causative b/tsDMARD was discontinued in 27 patients (84.4%); complete remission was achieved in 15 (55.6%).
conclusionsPP occurs predominantly with TNF inhibitor therapy and is independently predicted by ever-smoking status. Palmoplantar pustular psoriasis is the predominant phenotype. Drug discontinuation leads to complete remission in the majority of patients, and non-TNF b/tsDMARDs may be considered as alternatives following PP development. Key Points • Paradoxical psoriasis occurs in 2% of axSpA and RA patients on b/tsDMARDs, almost exclusively with TNF inhibitors. • Ever-smoking is the sole independent predictor; smokers initiating TNF inhibitors warrant proactive skin monitoring. • Drug discontinuation achieves complete remission in most patients; non-TNF b/tsDMARDs are effective alternatives.
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