Rheumatology International

, Volume 39, Issue 1, pp 161–166 | Cite as

Tocilizumab-induced psoriasis-like eruption resolved by shortening the dose interval in a patient with rheumatoid arthritis: a case-based review

  • Michitaro Hayakawa
  • Keisuke IzumiEmail author
  • Misako Higashida-Konishi
  • Mari Ushikubo
  • Masako Tsukamoto
  • Kumiko Akiya
  • Kazuhiro Araki
  • Hisaji Oshima
Case Based Review


Tocilizumab (TCZ) is a humanized antihuman interleukin-6 (IL-6) receptor antibody used for the treatment of inflammatory diseases such as rheumatoid arthritis (RA). While TCZ could act as a therapeutic agent, it has a potential for inducing adverse drug events including psoriasis-like eruption. Seven cases with specific reference to TCZ-induced psoriasis eruption have been reported worldwide so far. In these cases, treatments with the same dosage of TCZ were either maintained or discontinued. Herein, we report a case involving a 74-year-old man diagnosed with rheumatoid factor-positive and anti-citrullinated protein antibody-positive RA with comorbidity of atopic dermatitis. TCZ was administered intravenously with oral methotrexate. After the third infusion, the patient developed TCZ-induced psoriasis-like eruptions, which were resolved by shortening the dose interval. Eruption recurrence was not observed after frequent TCZ subcutaneous injection. Our case may help physicians manage TCZ-induced psoriasis-like eruption.


Rheumatoid arthritis Tocilizumab Psoriasis Interleukin-6 receptors Adverse drug reaction Atopic dermatitis 


Authors’ contributions

MH designed the study, and wrote the initial draft of the manuscript. KI contributed to the design of the study, the collection and interpretation of data, and the assistance of the preparation of the manuscript. All other authors contributed to the data collection and interpretation, and critically reviewed the manuscript. All authors approved the final version of the manuscript, and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Written informed consent was obtained from the patient described in the case report. The patient has also agreed on publishing the pictures included in this manuscript.


  1. 1.
    Brulhart L, Nissen MJ, Chevallier P, Gabay C (2010) Tocilizumab in a patient with ankylosing spondylitis and Crohn’s disease refractory to TNF antagonists. Jt Bone Spine 77:625–626CrossRefGoogle Scholar
  2. 2.
    Shimizu M, Hamaguchi Y, Ishikawa S, Ueno K, Yachie A (2015) Successful treatment with tocilizumab of a psoriasiform skin lesion induced by etanercept in a patient with juvenile idiopathic arthritis. Mod Rheumatol 25:972–973CrossRefGoogle Scholar
  3. 3.
    Chugai Pharmaceutical Co (2017) Guide for appropriate use of medication ACTEMRA®. Accessed 3 Mar 2018
  4. 4.
    de Benedetti F, Massa M, Robbioni P, Ravelli A, Burgio GR, Martini A (1991) Correlation of serum interleukin-6 levels with joint involvement and thrombocytosis in systemic juvenile rheumatoid arthritis. Arthritis Rheumatol 34:1158–1163CrossRefGoogle Scholar
  5. 5.
    Costa L, Caso F, Cantarini L, Del Puente A, Scarpa R, Atteno M (2014) Efficacy of tocilizumab in a patient with refractory psoriatic arthritis. Clin Rheumatol 33:1355–1357CrossRefGoogle Scholar
  6. 6.
    Hughes M, Chinoy H (2013) Successful use of tocilizumab in a patient with psoriatic arthritis. Rheumatology 52:1728–1729CrossRefGoogle Scholar
  7. 7.
    Laurent S, Le Parc JM, Clérici T, Bréban M, Mahé E (2010) Onset of psoriasis following treatment with tocilizumab. Br J Dermatol 163:1364–1365CrossRefGoogle Scholar
  8. 8.
    Wendling D, Letho-Gyselinck H, Guillot X, Prati C (2012) Psoriasis onset with tocilizumab treatment for rheumatoid arthritis. J Rheumatol 39:657CrossRefGoogle Scholar
  9. 9.
    Suzuki S, Miyamoto A, Tada Y, Ichikawa M, Yamamoto G, Kurokawa M, Sato S (2012) Case reports: psoriatic lesions appearing in a patient under tocilizumab therapy. Hihu Rinsho 54:981–984Google Scholar
  10. 10.
    Grasland A, Mahé E, Raynaud E, Mahé I (2013) Psoriasis onset with tocilizumab. Jt Bone Spine 80:541–542CrossRefGoogle Scholar
  11. 11.
    Palmou-Fontana N, Sánchez Gaviño JA, McGonagle D, García-Martinez E, de Onzoño Martín LI (2014) Tocilizumab-induced psoriasiform rash in rheumatoid arthritis. Dermatology 228:311–313CrossRefGoogle Scholar
  12. 12.
    Sparsa L, Afif N, Bularca S, Fricker A, Thiebault S, Dahan E, Wendling D, Sibilia J, Ardizzone M (2014) Paradoxical cutaneous reactions associated with tocilizumab therapy. Rev Med Interne 35:613–616CrossRefGoogle Scholar
  13. 13.
    Taylor W, Gladman D, Helliwell P, Marchesoni A, Mease P, Mielants H, CASPAR Study Group (2006) Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum 54:2665–2673CrossRefGoogle Scholar
  14. 14.
    Gottlieb A, Korman NJ, Gordon KB, Feldman SR, Lebwohl M, Koo JY, Van Voorhees AS, Elmets CA, Leonardi CL, Beutner KR, Bhushan R, Menter A (2008) Guidelines of care for the management of psoriasis and psoriatic arthritis: Sect. 2. Psoriatic arthritis: overview and guidelines of care for treatment with an emphasis on the biologics. J Am Acad Dermatol 58:851–864CrossRefGoogle Scholar
  15. 15.
    Nishimoto N, Terao K, Mima T, Nakahara H, Takagi N, Kakehi T (2008) Mechanisms and pathologic significances in increase in serum interleukin-6 (IL-6) and soluble IL-6 receptor after administration of an anti-IL-6 receptor antibody, tocilizumab, in patients with rheumatoid arthritis and castleman disease. Blood 112:3959–3964CrossRefGoogle Scholar
  16. 16.
    Diaz-Torne C, Ortiz MDA, Moya P, Hernandez MV, Reina D, Castellvi I, De Agustin JJ, Fuente D, Corominas H, Sanmarti R, Zamora C, Cantó E, Vidal S (2018) The combination of IL-6 and its soluble receptor is associated with the response of rheumatoid arthritis patients to tocilizumab. Semin Arthritis Rheum 47:757–764CrossRefGoogle Scholar
  17. 17.
    Chalaris A, Rabe B, Paliga K, Lange H, Laskay T, Fielding CA, Jones SA, Rose-John S, Scheller J (2007) Apoptosis is a natural stimulus of IL6R shedding and contributes to the proinflammatory trans-signaling function of neutrophils. Blood 110:1748–1755CrossRefGoogle Scholar
  18. 18.
    Jones SA, Horiuchi S, Topley N, Yamamoto N, Fuller GM (2001) The soluble interleukin 6 receptor: mechanisms of production and implications in disease. FASEB J 15:43–58CrossRefGoogle Scholar
  19. 19.
    Di Cesare A, Di Meglio P, Nestle FO (2009) The IL-23/Th17 axis in the immunopathogenesis of psoriasis. J Investig Dermatol 129:1339–1350CrossRefGoogle Scholar
  20. 20.
    Tesmer LA, Lundy SK, Sarkar S, Fox DA (2008) Th17 cells in human disease. Immunol Rev 223:87–113CrossRefGoogle Scholar
  21. 21.
    Wilson NJ, Boniface K, Chan JR, McKenzie BS, Blumenschein WM, Mattson JD, Basham B, Smith K, Chen T, Morel F, Lecron JC, Kastelein RA, Cua DJ, McClanahan TK, Bowman EP, de Waal Malefyt R (2007) Development, cytokine profile and function of human interleukin 17-producing helper T cells. Nat Immunol 8:950–957CrossRefGoogle Scholar
  22. 22.
    Nograles KE, Zaba LC, Shemer A, Fuentes-Duculan J, Cardinale I, Kikuchi T, Ramon M, Bergman R, Krueger JG, Guttman-Yassky E (2009) IL-22-producing “T22” T cells account for upregulated IL-22 in atopic dermatitis despite reduced IL-17-producing TH17 T cells. J Allergy Clin Immunol 123:1244–1252CrossRefGoogle Scholar
  23. 23.
    Nishina N, Kikuchi J, Hashizume M, Yoshimoto K, Kameda H, Takeuchi T (2014) Baseline levels of soluble interleukin-6 receptor predict clinical remission in patients with rheumatoid arthritis treated with tocilizumab: implications for molecular targeted therapy. Ann Rheum Dis 73:945–947CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Connective Tissue DiseasesNational Hospital Organization Tokyo Medical CenterTokyoJapan
  2. 2.Division of Rheumatology, Department of Internal MedicineKeio University School of MedicineTokyoJapan

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