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In a study encompassing more than 80,000 patient-years, people with psoriasis taking IL-23 inhibitors saw the lowest risk of paradoxical atopic dermatitis (AD) compared with patients taking other biologics.

That's according to a report appearing recently in . Older age, female sex, history of AD, and a history of hay fever all were associated with higher risk of paradoxical eczema.

Using data from the British Association of Dermatologists Biologics and Immunomodulators Register (BADBIR), researchers examined 24,997 drug exposures from 13,699 participants (median age 46 years [IQR 36-55 years]; 57% male), encompassing 81,441 total patient-years. Of these, 273 exposures were associated with paradoxical eczema.

Adjusted incidence rates were 1.22 per 100,000 person-years for IL-17 inhibitors, 0.94 per 100,000 person-years for TNF inhibitors, 0.80 per 100,000 person-years for IL-12/23 inhibitors, and 0.56 per 100,000 person-years for IL-23 inhibitors.

First study author, Ali Al-Janabi, MBBChir, MRCP, MA, is a physician and investigator in the division of musculoskeletal and dermatological sciences at The University of Manchester Faculty of Biology Medicine and Health in England. Al-Janabi's discussion of the study findings with the Reading Room has been edited for length and clarity.

What was the impetus or "statement of need" for this project?

Al-Janabi: While biologics are usually effective in patients with psoriasis, a proportion develop AD, or paradoxical eczema. From our experience, this can be highly problematic and may require the patient to stop taking their biologic.

There is a need to understand which patients are at risk of this phenomenon, and whether certain drug classes carry a lower risk of paradoxical eczema than others.

Would you summarize your key finding?

Al-Janabi: The risk appeared lowest in patients receiving biologics targeting IL-23. A history of AD or hay fever also increased risk of paradoxical eczema, as did increasing age and female sex.

Did anything surprise you about your findings?

Al-Janabi: We were surprised that there was not a greater increase in risk with IL-17 inhibitors, as we suspected from our clinical experience. We were also surprised to find an apparent association between cyclosporin use at the point of biologic initiation and subsequent development of paradoxical eczema, though it is possible that these patients had a pre-existing eczema phenotype that was masked by cyclosporin treatment.

What are the take-home messages?

Al-Janabi: The main clinical message would be to consider IL-23 blockers in patients with previous AD or paradoxical eczema.

Is there anything else you would like to add?

Al-Janabi: Before firm recommendations can be made, this work needs to be replicated to validate our findings. Ideally, we would like to accurately predict treatment response and adverse events to select the right treatment for our patients the first time.

It is important to know that paradoxical reactions can present many months after initiating biologic therapy. I encourage clinicians to report such cases, including to registries such as BADBIR, as this enables research that can improve outcomes.