Quick Shot #4 Answer
Answer: Refer to dermatology for treatment with topical steroids and phototherapy
This patient’s rash is consistent with psoriasis. This can be an idiopathic skin condition or can be associated with medications including anti-TNF therapies. In this patient with the new development of psoriasis after initiating anti-therapy, this is most consistent with a drug induced condition. There is some evidence that Il-23 and Th-17 cells may play a role in this paradoxical response and provides an explanation for why ustekinumab can be very effective at managing these patients. Management is differentiated based on the severity of the skin reaction (mild in this patient’s condition) and the effectiveness of therapy (very effective in this patient). In this patient with a mild case of psoriasis and responding to his TNF therapy, it would be reasonable to treat through with continuing infliximab and starting topical therapies. If that was not effective, he could be switched to a different TNF or a IBD directed therapy in a different class.