Dermatological and Rheumatological Complications in IBD

From 30% to 50% of patients with inflammatory bowel disease (IBD) are diagnosed with extraintestinal manifestations (EIMs), including dermatological and rheumatological disorders, according to Hans Herfarth, MD, who discussed the topic at the virtual Advances in Inflammatory Bowel Diseases regional meeting on September 12.

Dr Herfarth is a professor of medicine at the Inflammatory Bowel Disease Center at the University of North Carolina School of Medicine.

In some cases, EIMs are independent of IBD activity, such as ankylosing spondylitis and type 2 arthropathy, he explained. The longer the course of the disease, the more likely it is for patients to present with EIMs. He noted that within 30 years of diagnosis of IBD, 50% of patients had developed an EIM.

The most frequent EIM found in a large Swiss cohort study was arthritis, which developed in 33% of patients with Crohn disease and 21% of patients with ulcerative colitis. Peripheral arthropathy in patients with IBD are classified as Type 1 (Pauciarticular) and Type 2 (Polyarticular). In Type 1, IBD activity is parallel, affecting fewer than 5 joints and mainly large joints. It tends to be self-limiting, resolving within 10 weeks, and the primary treatment recommended is control of the underlying IBD.

Type 2 arthropathy, Dr Herfarth explained, is independent of IBD disease activity, meaning it can occur even when IBD is in remission. It usually affects more than 5 joints and smaller joints, can continue for years, and may be treated with sulfasalazine, COX-2 inhibitors, anti-tumor necrosis factor therapeutics, methotrexate, and physical therapy.

He noted that lupus-like reactions in patients with IBD taking anti-TNFs can involve both skin and joints, causing arthralgia and arthritis, myalgias, fever, fatigue, and skin rashes. The prevalence of lupus-like reactions was less than 1% in clinical trials and 1% to 2% in retrospective cohort studies. The underlying mechanism of such reactions is not known, but risk factors for these EIMs include being a woman, smoking, having a high level of C-reactive protein, and being autoantibody positive.

Dr Herfarth said that radiological evidence of sacroiliitis is found in 20% to 50% of patients with IBD, but only between 1% and 10% have progressive spondylitis. Although the human leukocyte antigen B27 (HLA-B27) is associated with axial arthritis, significant numbers of patients with IBD are negative for this marker, making it unreliable as a diagnostic test for these conditions in patients with IBD. For such EIMs, anti-TNF therapeutics are the preferred agents. Physical therapy and cox-2 inhibitors can also be used.

Dermatological complications present in up to 20% of patients with IBD. The most common is erythema nodosum. Pyoderma gangrenosum occurs in 1% to 2% of patients with IBD and can be treated with a variety of agents used as therapy for IBD, including topical or systemic steroids, methotrexate, thiopurines, and biologics. “Infliximab is the only agent with proven efficacy in a small, randomized, placebo-controlled study,” Dr Herfarth said. "Treatment is essentially trial-and-error."

Parastomal pyoderma is a rare complication, "which unfortunately is increasing," in which necrotic ulcerations appear in the area around an abdominal stoma. Systemic therapy with steroids, anti-TNFs, or methotrexate can be administered, as well as a local steroid injection, Dr Herfarth said. Topical tacrolimus, becalmethasone inhaler therapy, and hyperbaric oxygen therapy are among other options. In some cases, surgical therapy is required. Treatment can be challenging, Dr Herfarth said. 

Hidradenitis suppurativa is not specific to IBD, but patients with IBD have a 9-fold risk of developing this rare disease compared with the general population, he noted. Painful nodules and abscesses appear most often in the axilla, groin, and anogenital areas. It can be treated with antibiotics and anti-TNF therapeutics, and by surgical procedures. It can look like Crohn disease, Dr Herfarth said, so it is important to check the axilla. Treatment should be coordinated with colleagues in dermatology, he stated.

Lesions that resemble psoriasis and eczema may occur in some patients with IBD who are taking anti-TNF therapies. “Paradoxical inflammatory complications of the skin have been mainly observed after anti-TNF therapies, but preliminary reports show that it can also occur with other biologics, such as vedolizumab and ustekinumab,” Dr Herfarth said.

In one cohort of more than 900 patients with IBD with a median follow-up of 3.5 years, 31% of patients developed eczematous psoriasis and 24% developed eczema, while a combined 20% developed other forms of paradoxical skin inflammation.

“Most of these cases can be controlled with topical treatment, and the anti-TNF treatment for IBD can be maintained,” Dr Herfarth explained. “You may consider switching the patient to an anti-IL 23 therapy such as ustekinumab in severe or resistant cases.” 

Noting that treatment for dermatologic and rheumatologic EIMs “is often experimental and does not follow established algorithms,” Dr Herfarth suggested that consultation with colleagues in rheumatology and dermatology is necessary to ensure the best possible patient care and can be particularly helpful “if the colleague is somewhat experienced in IBD.”

—Rebecca Mashaw

Reference:

Herfarth, H. Dermatological and rheumatological complications. Talk presented at: Advances in Inflammatory Bowel Disease 2020 regional meeting; September 12, 2020; virtual.