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Infliximab/mercaptopurine Psoriasis, elevated liver function test and pancytopenia: case report

A 10-year-old girl developed psoriasis during treatment with infliximab and elevated liver function test and pancytopenia during treatment with mercaptopurine for Crohn’s disease [routes and dosages not stated; not all outcome stated]. The girl presented with rash on her scalp and trunk and associated hair loss for several months. She had a significant history of Crohn’s disease. She applied over the counter ketoconazole shampoo, salicylic-acid shampoo and topical corticosteroids without improvement. She was diagnosed with Crohn’s disease at the age of 6 years. Initially, she had received prednisone as a bridge to mercaptopurine. After 1 year from treatment, she developed elevated liver function test and pancytopenia secondary to mercaptopurine. Therefore, the girl’s treatment with mercaptopurine was changed to infliximab with good control of her gastrointestinal symptoms. Twelve months after starting infliximab, she developed rashes. At presentation, physical examination showed erythematous scaly plaques on the scalp, upper chest and back. She also had patches of alopecia on her posterior scalp. Based on this examination, she was diagnosed with psoriasis secondary to infliximab. As corrective measures, she applied fluocinonide solution on her scalp and triamcinolone ointment on the trunk. After 2 weeks of treatment, her symptoms improved. Therefore, she started receiving methotrexate therapy with the other treatment regimen. However, after 4 weeks of methotrexate, her skin disease deteriorated with new psoriatic plaques on the face, ears, neck, trunk and bilateral upper and lower extremities and worsening of alopecia. Hence, her treatment with infliximab was switched to ustekinumab to managed Crohn’s disease and psoriasis. She received off-label induction dose of IV ustekinumab 260mg. At the same time, she started receiving narrowband ultraviolet (NBUVB) phototherapy. Following the induction dose, she started receiving a maintenance dose of subcutaneous ustekinumab 90mg every 8 weeks with methotrexate and NBUVB phototherapy. Within 8 weeks, the psoriatic plaques on her trunk and extremities completely recovered with a few patches remaining on her elbows and umbilicus. The psoriatic plaques on her scalp also improved and regrowth of hair was observed. Additionally, following ustekinumab therapy, her Crohn’s disease remained asymptomatic with complete mucosal healing of the gastrointestinal tract. She continued to have mild erythematous scaly patches on the scalp and ears, but these areas under good control with topical corticosteroids. Thereafter, the frequency of ustekinumab decreased to every 6 weeks. Her skin patches completely resolved without any other medication. Bonomo L, et al. Tumor necrosis factor inhibitor-induced psoriasis in a pediatric Crohn’s disease patient successfully treated with ustekinumab. Journal of Drugs in Dermatology 19: 328-331, No. 3, Mar 2020. Available from: URL: http://doi.org/10.3684