Ann Dermatol.  2010 May;22(2):212-215. 10.5021/ad.2010.22.2.212.

A Case of Tumor Necrosis Factor-alpha Inhibitors-induced Pustular Psoriasis

  • 1Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea.


Anti-tumor necrosis factor (TNF)-alpha agents promise better disease control for the treatment of ankylosing spondylitis resistant to classical disease-modifying treatments. Etanercept, a recombinant human TNF receptor fusion protein, is used to treat a variety of TNF-alpha-mediated diseases by inhibiting the biological activity of TNF-alpha. We experienced a case of pustular psoriasis in a 32-year-old man during anti-TNF-alpha therapy with etanercept. He had a history of ankylosing spondylitis for 2 years. Two years after treatment of etanercept, erythematous pustules developed on his palms and soles. He had no previous history of pustular psoriasis. The skin lesion improved as the etanercept therapy was stopped, but pustular skin eruption recurred as adalimumab, a different TNF-alpha inhibitor, was administered to manage his ankylosing spondylitis. Several TNF-alpha inhibitors have different molecular structures, but these inhibitors might have a similar potency to induce pustular psoriasis from this case.


Adalimumab; Etanercept; Pustular psoriasis; TNF-alpha inhibitors

MeSH Terms

Antibodies, Monoclonal, Humanized
Immunoglobulin G
Molecular Structure
Receptors, Tumor Necrosis Factor
Spondylitis, Ankylosing
Tumor Necrosis Factor-alpha
Antibodies, Monoclonal, Humanized
Immunoglobulin G
Receptors, Tumor Necrosis Factor
Tumor Necrosis Factor-alpha


  • Fig. 1 After 2 years of etanercept therapy for ankylosing spondylitis, erythematous scaly pustular lesions arose on both palms (A) and soles (B).

  • Fig. 2 Epidermal hyperplasia with hyperkeratosis and parakeratosis are shown on horny layer; granular layer has disappeared (A, B). Capillaries in the papillary dermis associated with perivascular lymphocytic infiltration (B). Munro microabscess was shown. Intraepidermal pustule formation was shown (C) (H&E, A: ×40, B: ×100, C: ×200).

  • Fig. 3 Erythematous scaly patches on both palms (A) and soles (B) have improved following etanercept discontinuation.

  • Fig. 4 After 4 months of adalimumab therapy for ankylosing spondylitis, erythematous scaly pustular lesion arose on both palms (A) and soles (B).

Cited by  2 articles

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