Intraepidermal and subepidermal blistering with skin necrosis, possibly caused by etanercept in treatment of a patient with psoriasis

Abstract

Background: Etanercept is often used for treating patients with plaque psoriasis and psoriatic arthritis. Case report: A 78 year old Caucasian female recently treated with Etanercept for plaque psoriasis developed necrotic patches and plaques on several areas of the body. Skin biopsies for hematoxylin and eosin (H&E) histology and immunohistochemistry(IHC), as well as direct immunofluorescence (DIF) were taken. Results: H&E review revealed necrotic areas in the epidermis, with both intraepidermal and subepidermal blisters. Dilated dermal blood vessels with a perivascular infiltrate of lymphocytes, histiocytes and neutrophils were seen. DIF revealed anti-stratum corneum reactivity involving multiple immunoglobulins and complement factors, as well as deposits of fibrinogen and complement/C3c complexes at the basement membrane zone and in upper and intermediate dermal neurovascular areas. IHC review demonstrated an overexpression of von Willembrand factor, positive CEA in the stratum corneum. Focal BCL-10 and P53 overexpression on the basaloid and spinous layers of the epidermis was also noted. CD15 and myeloperoxidase expression were noted in the blisters as well as CD8 and CD45 expression around the upper dermal blood vessels. Conclusions: We present a case of intraepidermal and subepidermal blistering with skin necrosis and document the presence of multiple immunoreactants in these lesions, possibly clinically linked to Etanercept.

Keywords

• Etanercept
• blistering diseases
• medication adverse events
• severe adverse events
• autoimmunity
• necrosis
• von Willembrand factor
• vascular degeneration.