Psoriasis flare confused with drug allergy: A collaborative effort is required to treat tuberculosis in the setting of severe psoriasis.

Background: Psoriasis is a chronic autoimmune disorder. Severe psoriasis is treated with systemic immunosuppressive agents. Systemic immunosuppression increases the risk of tuberculosis (TB) disease. Sudden cessation of immunosuppression seems logical in a TB patient but can lead to psoriasis flares. And when a new rash occurs during TB therapy, drug reaction is usually suspected. This can result in untreated TB disease or intermittent therapy, thus increasing the risk for acquired drug resistance. Methods: We describe two patients who developed TB disease during immunosuppressive therapy for psoriasis. When the immunosuppressive therapy was stopped, due to TB disease, both patients experienced significant worsening of psoriasis. The skin changes were confused with drug reaction to TB medications. Significant treatment interruptions resulted. A single team of TB physicians and one dermatologist, worked in conjunction to formulate a psoriasis and TB treatment plan. The patients were treated with acitretin and cyclosporine systemically along with topical agents to achieve psoriasis control. Then both were sequentially challenged with one TB medication at a time to ensure no drug reaction occurred while monitored at Texas Center for Infectious Disease. Cyclosporine was then tapered off. Results: Both patients tolerated the alternative psoriasis regimen and TB therapy well. Both demonstrated clinical, bacteriologic, and radiographic improvement. Conclusion: Treatment of TB disease in patients with severe psoriasis requires a collaborative effort between the TB treatment team and dermatology. A balanced approach, including treatment of both diseases, is necessary to avoid confusion of psoriasis flare versus drug induced skin reactions from TB medications.