Study: IL-23 Inhibitors Associated With Lowest Risk of Paradoxical Eczema in Patients With Plaque Psoriasis


Biologics for plaque psoriasis has been associated with an atopic dermatitis phenotype, paradoxical eczema, but the risk factors are not well known.

IL-23 inhibitors could be considered to treat patients with psoriasis that is associated with paradoxical eczema, according to the results of a study published in JAMA Dermatology. In the study, investigators aimed to determine if biologics could be used for this patient population.

Acute psoriasis on the elbows is an autoimmune incurable dermatological skin disease | Image Credit: SNAB -


According to the study authors, biologics for plaque psoriasis has been associated with an atopic dermatitis phenotype, paradoxical eczema, but the risk factors are unknown. The investigators wanted to determine the risk of paradoxical eczema among those who used biologics as well as identify the factors associated with paradoxical eczema.

From September 2007 to December 2022, investigators included adults aged 18 years or older who had plaque psoriasis and were exposed to a biologic product, including biosimilars, TNF inhibitors, IL-17, IL-12/23, or IL-23. Individuals were identified using data from the British Association of Dermatologists Biologics and Immunomodulators Register. Data were collected at baseline, every 6 months for the first 3 years, then annually after the 3 years. Information on therapy start and stop dates, baseline comorbidities, adverse event data, and demographics were collected by investigators.

Investigators included 24,997 biologic exposures from 13,699 adults aged 18 years and older with plaque psoriasis. Patients were 57% male, with a median age of 46 years and 92% were White, 0.6% Black, 0.7% Chinese, and 6% South Asian. For the biologics, 47% were TNF inhibitors, 26% were IL-12/23 inhibitors, 19% were IL-17 inhibitors, and 8% were IL-23 inhibitors. There was a total of 265 paradoxical eczema events that the study authors attributed to 273 biologic exposures. The adjusted incidence rates included 1.22 per 100,000 person-years for IL-17 inhibitors, 0.94 per 100,000 for TNF inhibitors, 0.80 per 100,000 for IL-12/23 inhibitors, and 0.56 per 100,000 for IL-23 inhibitors, according to the study.

The study authors reported that the median onset from biologic initiation was 294 days, but the events were skewed towards initiation of the biologic. The commonly affected areas included eczema on the face and neck, limbs, trunk, and hands or feet, with the most common symptoms being pruritus, redness, and dryness. Of the 21 biopsies, all showed a feature of eczema with 1 biopsy overlapping with features of psoriasis. Topical treatment was most common, followed by oral antibiotics, stopping or switching biologic therapy, and systemic corticosteroids, according to the results.

Further, the study authors stated that of the 241 individuals affected by paradoxical eczema, 20 had more than 1 event, with 5 occurring after receiving the same biologic for the index event, 6 after receiving a different biologic in the same class, and 13 from a biologic in another class. They found that TNF inhibitors were most used for the index event in the multiple-event cohort compared to those with 1 event at 80% and 50%, followed by IL-17 at 10% and 19%, IL-12/23 at 10% and 28%, and IL-23 at 0% and 3%, respectively. Furthermore, individuals with multiple events also had a higher rate of hay fever at 20%, psoriatic arthritis at 40%, or receiving cyclosporine at biologic initiation at 25% compared with 1%, 30%, and 8%, respectively, for those with only 1 event.

The study authors concluded that IL-23 inhibitors were associated with a lower risk of paradoxical eczema compared with TNF inhibitors, according to the study results. However, they stated that the risk was highest for IL-17 inhibitors, followed by TNF and IL-12/23 inhibitors.


Al-Janabi A, Alabas OA, Yiu ZZN, et al. Risk of Paradoxical Eczema in Patients Receiving Biologics for Psoriasis. JAMA Dermatol. Published online December 06, 2023. doi:10.1001/jamadermatol.2023.4846

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