Currently,
tumor necrosis factor alpha (
TNF-alpha) inhibitors are widely used for many autoimmune disorders. However, they cause an immunocompromised status that sometimes leads to many cutaneous side effects including atypical
infections. Herein, we report the first case of
adalimumab-related
Majocchi's granuloma.A 43-year-old Taiwanese male patient with chronic plaque-type
psoriasis developed numerous tender nodules 1 month after
adalimumab injection. The nodules responded poorly to bacterial
folliculitis treatment. After repeated skin biopsies for pathology and tissue fungal culture,
Majocchi's granuloma was confirmed.
Adalimumab was withheld, and 12 weeks of
terbinafine treatment was given. On completion of treatment, the nodular skin lesions and dystrophic nail lesions improved dramatically.The information, including time span, clinical features, histological findings, and improvement following withdrawal of
adalimumab and treatment with an oral
antifungal agent, indicates that
Majocchi's granuloma was
adalimumab-related.
Psoriasis patients are more susceptible to
dermatophyte infection due to local and systemic
immunosuppressant therapy. It is important to perform a thorough examination for latent
dermatophyte infection, including skin and nail lesions, before treatment with
TNF-alpha inhibitors and during traditional
psoriasis treatment. When atypical presentation together with treatment failure is noted in
psoriasis patients prescribed biologics, clinicians should investigate evidence of
dermatophyte infection and provide proper treatment. Sometimes, multiple skin biopsies and tissue fungal cultures are required to establish a correct diagnosis.