Crohn’s disease skin lesions

10 Skin Rashes Linked to Ulcerative Colitis

1. Erythema nodosum

Erythema nodosum is the most common skin issue for people with IBD. Erythema nodosum are tender red nodules that usually appear on the skin of your legs or arms. The nodules may also look like a bruise on your skin.

Erythema nodosum affects anywhere from 3 to 10 percent of people with UC. It’s seen more in women than men.

This condition tends to coincide with flare-ups, sometimes occurring just before a flare starts. Once your UC is under control again, the erythema nodosum will likely go away.

2. Pyoderma gangrenosum

Pyoderma gangrenosum is the second most common skin issue in people with IBD. One large study of 950 adults with IBD found that pyoderma gangrenosum affected 2 percent of people with UC.

Pyoderma gangrenosum starts as a cluster of small blisters that can spread and combine to create deep ulcers. It’s usually seen on your shins and ankles, but it may also appear on your arms. It can be very painful and cause scarring. The ulcers could become infected if they’re not kept clean.

Pyoderma gangrenosum is thought to be caused by immune system disorders, which may also contribute to UC. Treatment involves high doses of corticosteroids and drugs that suppress your immune system. If the wounds are severe, your doctor may also prescribe pain medication for you to take.

3. Sweet’s syndrome

Sweet’s syndrome is a rare skin condition characterized by painful skin lesions. These lesions start as small, tender red or purple bumps that spread into painful clusters. They’re usually found on your face, neck, or upper limbs. Sweet’s syndrome is linked to active flare-ups of UC.

Sweet’s syndrome is often treated with corticosteroids in either pill or injection form. The lesions may go away on their own, but recurrence is common, and they can result in scars.

4. Bowel-associated dermatosis-arthritis syndrome

Bowel-associated dermatosis-arthritis syndrome (BADAS) is also known as bowel bypass syndrome or blind loop syndrome. People with the following are at risk:

  • a recent intestinal surgery
  • diverticulitis
  • appendicitis
  • IBD

Doctors think that it may be caused by overgrown bacteria, leading to inflammation.

BADAS causes small, painful bumps that may form into pustules over the course of one to two days. These lesions are usually found on your upper chest and arms. It can also cause lesions that look like bruises on your legs, similar to erythema nodosum.

The lesions usually go away on their own but may come back if your UC flares up again. Treatment may include corticosteroids and antibiotics.

5. Psoriasis

Psoriasis, an immune disorder, is also associated with IBD. In a study from 1982, 5.7 percent of people with UC also had psoriasis.

Psoriasis results in a buildup of skin cells that form white or silver-looking scales in raised, red patches of skin. Treatment may include topical corticosteroids or retinoids.

6. Vitiligo

Vitiligo occurs more often in people with UC and Crohn’s than in the overall population. In vitiligo, the cells that are responsible for producing the pigment of your skin are destroyed, leading to white patches of skin. These white patches of skin can develop anywhere on your body.

Researchers think that vitiligo is also an immune disorder. An estimated 20 percent of people with vitiligo have another immune disorder as well, such as UC.

Treatment can include topical corticosteroids or a combination pill and light treatment known as psoralen and ultraviolet A (PUVA) therapy.

Learn more: What does vitiligo look like? “

7. Pyodermatitis-pyostomatitis vegetans

Pyodermatitis vegetans is a rash with red pustules that can rupture and form raised scaly patches of skin known as plaques. It’s usually found in the skin folds of your armpit or groin. It’s linked to a similar skin condition known as pyostomatitis vegetans, in which pustules form in your mouth. The two conditions are collectively known as pyodermatitis-pyostomatitis vegetans (PPV).

PPV is so closely linked to UC that some people are only diagnosed with UC after one or both forms of PPV develop. The pustules usually appear after UC has been active for several years.

8. Leukocytoclastic vasculitis

Leukocytoclastic vasculitis is also known as hypersensitivity vasculitis. In leukocytoclastic vasculitis, inflammation causes small blood vessels to burst and blood to pool under your skin. This leads to purple-colored spots known as purpura. The spots can be small or large patches and are usually found on your ankles or legs.

In most cases of leukocytoclastic vasculitis, the skin lesions go away once the underlying UC is treated.

9. Acne

Ulcerative colitis is also linked to cystic acne in some people. Cystic acne is a painful type of acne that develops under your skin. Cystic acne can be treated with topical prescriptions like retinol or benzoyl peroxide.

If you have cystic acne and either have UC or are at high risk of developing it, you shouldn’t use the prescription drug Accutane. Accutane has been linked to UC and other IBDs.

Read more: Acne treatment types and side effects “

10. Hives

Hives are red and often itchy skin rashes that can appear on any part of your body. UC is linked to cases of chronic hives. They may occur as a reaction to medications you take to manage your UC.

If you start a new medication and experience persistent hives, contact your doctor about alternatives.

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Medications

Crohn’s disease involves periods of ‘relapse’ when the inflammation in the bowel flares up, and periods of ‘remission’ when the inflammation calms down. The aim of treatment is to treat relapses when they occur and give the bowel a chance to heal. Medications are also used to help maintain remission, improve general wellbeing and prevent complications from developing.

Medications commonly used to control inflammation in Crohn’s disease include:

  • steroids
  • aminosalicylates to control the frequency of relapses
  • medicines that supress the immune system
  • antibiotics

You may also be advised to take medicines that control diarrhoea, relieve pain and supplement your diet (for example, to boost your iron levels, vitamin D and calcium).

Surgery

Surgery for Crohn’s disease can remove or widen sections of the bowel that are badly affected by disease. The healthy ends of the bowel are usually re-joined to each other.

Sometimes, a stoma (an artificial opening in the stomach that diverts faeces or urine into a bag) is required if the disease is very severe. It’s normal to feel uneasy about the idea of living with a stoma, but it often greatly improves a person’s quality of life.

Living with Crohn’s disease

With careful management, most people with Crohn’s are able to enjoy life, including work, travel, recreation, sex and having children.

To keep healthy, consider:

  • keeping a food diary to check if there are any foods that make your symptoms worse during a flare-up
  • asking your doctor about supplements if you think you may be malnourished
  • quitting cigarettes, if you have Crohn’s disease and smoke. There is evidence that smoking can make Crohn’s disease more severe and harder to control.
  • exercising regularly to lift your mood and help relieve stress
  • learning some relaxation techniques to help manage stress

Complications of Crohn’s disease

A small number of people with Crohn’s can develop inflammation in other parts of the body, such as the liver, skin, joints and eyes.

Regular monitoring by a gastroenterologist, as well as colonoscopies, may help prevent complications from developing. But medications, including steroids and drugs designed to prevent inflammation – and occasionally surgery – may be needed.

Osteoporosis (thinning of the bones) can develop as a side effect of long-term corticosteroid use.

Crohn’s disease can cause bowel obstruction. When this happens, symptoms include increasing abdominal pain and cramping, vomiting and bloating. This is a medical emergency that requires a trip to hospital.

If you suspect that you are having a life-threating medical emergency, call triple zero (000) immediately and ask for an ambulance.

Crohn’s disease can also cause complications anywhere in the gut, from the mouth to the anus. Complications around the anus can include abscesses (boils), flaps of thickened skin, and fissures

Fistulas occur in up to 1 in 3 people with Crohn’s disease; they are tunnels, or ‘tracks’, that connect the intestines to other organs or to the outer skin surface. They usually develop in areas of severe scarring and ulceration. A large fistula may require surgery to flush out any contents and promote healing.

Where to get more help

  • Speak to your doctor or gastroenterologist. To find a health professional near you, use the healthdirect service finder.
  • For information and support, visit Crohn’s and Colitis Australia or call the IBD helpline on 1800 138 029.
  • For more information about living with a stoma, visit the Australian Council of Stoma Associations.
  • To find an accredited practising dietitian, who may be able to help manage your Crohn’s disease with diet, visit the Dietitians Association of Australia.

Crohn’s Disease

Original Editors – Sarah Bailey from Bellarmine University’s Pathophysiology of Complex Patient Problems project.

Top Contributors – Sarah Bailey, Laura Ritchie, Kim Jackson, Dave Pariser and Elaine Lonnemann

Definition/Description

Gastrointestinal Tract in which Crohn’s Disease affects Crohn’s disease is a form of inflammatory bowel disease (IBD) that causes inflammation to the lining of the digestive or gastrointestinal (GI) tract and may be a result of an immune system malfunction. The immune system sees the bacteria and organisms that lie within the GI tract and intestines and mistakes them for outside invaders to the body. In response to this, the body produces extra white blood cells to the GI tract to fight off the invaders, which creates inflammation within the lining of the tract. Chronic inflammation may result in ulcerations within the layers of the tract . The inflammation can occur to any portion of the GI tract, from mouth to anus and can affect all layers of the intestinal tract while healthy bowel layers may be interspaced between the diseased portions of the bowel.

The most commonly affected portion of GI tract affected is the lower portion of the small intestine, or ileum . Due to the inflammation, abdominal pain, diarrhea and malnutrition can be a result . Crohn’s disease is also referred to as granulomatous enteritis or colitis, ileitis, regional enteritis, or terminal ileitis. This disease is similar in some aspects to ulcerative colitis, but the difference lies in the fact that ulcerative colitis produces inflammation only within the colon or rectum while Crohn’s disease produces inflammation within the colon, rectum, small intestine, stomach, mouth and esophagus. The inflammation caused by Crohn’s disease has the potential to affect the deeper layers more than ulcerative colitis . While these two conditions are very similar, approximately 10 percent of individuals are unable to pinpoint whether the disease process is ulcerative colitis or Crohn’s disease. For these individuals, they are then diagnosed with indeterminate colitis .

Prevalence

Geographic Distribution of Crohn’s Disease) Crohn’s disease affects approximately 500,000 to two million people in the United States, equally affecting men and women . This disease may occur in individuals of all age, but has characteristically affected adolescents and young adults between 15-35 of age. It is estimated that 10 percent of individuals affected are under the age of 18. Crohn’s has been found to affect American Jews of European descent four to five times more than the general population. The prevalence among whites is 149 per 100,000 with a steady increase in incidence among African Americans. Hispanics and Asian have a lower prevalence than do African Americans and whites. There has been a potential link between living environment and the incidence of Crohn’s disease, where there are more reports amongst urban and northern climates than rural and southern climates. Similarly, this disease tends to be more predominant in the US and Europe .

Characteristics/Clinical Presentation

There is no cure for this condition and Crohn’s disease alters between periods of remission and relapse. Crohn’s typically appears around adolescence and early adulthood and there is potential of Crohn’s disease to run in families . About 20-25% of individuals affected with Crohn’s disease have a close relative who is affected with ulcerative colitis or Crohn’s disease. If an individual has a relative with Crohn’s, the risk of this individual is 10 times higher than the general population, while a brother or sister link increases the risk to 30 times higher than the general population. Current researchers have identified an abnormal genetic mutation on gene NOD2/CARD 15 which reduces the ability of the body to distinguish harmful bacteria. This mutation is found twice as often in individuals affected with Crohn’s versus the general population .

Symptoms of Crohn’s Disease

While Crohn’s is a chronic disease, the patients will experience bouts of flare ups and remission with the absence of symptoms . About 50% of individuals with Crohn’s Disease will have mild symptoms. The other half may experience more severe symptoms and pain that appears to come and go. These patients undergo painful exacerbations and potentially symptom free remissions. The remissions might last for months to years but the symptoms will eventually return. This unpredictable nature is part of what makes Crohn’s so complicating. Typical symptoms include:

  • Diarrhea
  • Abdominal cramping generally in the right lower quadrant
  • Fever
  • Potential rectal bleeding. The rectal bleeding is potentially due to tears or fissures within the anus lining.
  • Fistulas or tunnels leading from the intestines to the bladder, vagina or skin may also occur, while most occur around the anal area. The fistula has potential to produce drainage, pus, mucus or stool being excreted from the opening. These symptoms may vary between individuals and may not all be present at the same time.
  • Weight loss
  • Fatigue
  • Perianal lesions
  • Stunted growth in children
  • Extraintestinal manifestations

Types of Crohn’s Disease

Distribution of Crohn’s Disease within the Gastrointestinal tract There are different types of Crohn’s Disease dependent upon the location and disease pattern within the GI tract. The different locations of Crohn’s Disease include:

Gastroduodenal Crohn’s Disease

Located in the upper gastrointenstinal tract and affects the stomach and first part of the small intestine (duodenum). This is uncommon and symptoms occur in 5% of those diagnosed with Crohn’s. Associated symptoms include:

  • Nausea
  • Loss of appetite
  • Weight loss
  • Vomiting
  • Pain in upper abdomen

Jejunoileitis

This is also uncommon in the general population of those diagnosed with Crohn’s disease. Inflammation is located in the Jejunum or Second part of small intestines. Associated symptoms include:

  • Diarrhoea
  • Abdominal pain (after eating)
  • Malnutrition due to malabsoprtion of nutrients
  • Weight loss

Ileitis

Inflammation located in the last part of small intestine or ileum and affects 30% of individuals diagnosed with Crohn’s disease. Associated symptoms include:

  • Diarrhoea

Ileocolitis

This is the most common form of Crohn’s disease and affects 50% of those diagnosed with inflammation located in the ileum and colon. Associated symptoms include:

  • Diarrhoea
  • Abdominal pain (right lower quadrant)
  • Weight loss

Crohn’s Colitis

This affects 20% of individuals diagnosed with Crohn’s disease with inflammation located in the colon. The perianal disease and extraintestinal complications are more commonly associated in these individuals. Associated symptoms include:

  • Diarrhoea
  • Rectal bleeding
  • Abdominal pain

Perianal Disease

This occurs in 1/3 of individuals diagnosed with Crohn’s disease. These individuals can have fistulae, fissures, abscesses or skin tags (fleshy growths outside the anus)

Associated Co-morbidities

While commonly Crohn’s disease affects the GI tract, there have been instances where additional complications include arthritis, skin conditions, inflammation of the eyes and/or mouth, joints, kidney stones, gallstones and liver/biliary conditions were also reported. The most common associated comorbidity is a blockage of the intestines. Continual blockage tends to thicken the walls of the intestine with scar tissue which further reduces the size of the passageway . Fistulas are also common due to sores or ulcers that develop into deep ulcers or tracts connecting into the bladder, vagina, skin or anal area. These fistulas are then exposed to infection.

It has been discovered that individuals with Crohn’s disease have referred pain to the low back. Approximately 25% of individuals with Crohn’s and/or irritable bowel disease have sacroilitis, polyarthritis, monarthritis of ankle, knee, elbows and/or wrists , as well as migratory arthralgias. At times, these joint conditions may even present initially before the other GI related symptoms.

Since this disease affects the absorption of nutrients, chronically involved individuals commonly have deficiencies of protein, calories and vitamins. This may be due to the malabsorption or overall inadequate dietary intake secondary to the patient’s attempt to limit the pain produced with eating .

There is a risk of colorectal cancer that tends to increase with an increased length of time with the disease. There is a 2% incidence of colorectal cancer after 10 years diagnosis, 9% incidence after 20 years diagnosis, and 19% incidence after 30 years of diagnosis of Crohn’s disease. A 20% mortality rate lies within the first 10 years of diagnosis in the presence of complications. Surgical removal of the Crohn’s bowel does not prevent colorectal cancer, thus putting importance on prevention and screening for early detection of colorectal cancer.

Osteopenia can occur in 50% of patients diagnosed with Crohn’s Disease and osteoporosis can occur in 15% of those diagnosed. It is thought these complications may be due to the steroid therapy , smokers, those with a more active disease as well as those individuals with low calcium and vitamin D intake. Due to this, all patients diagnosed with Crohn’s Disease should be informed of this potential complication and should be advised to take supplemental calcium and vitamin D.

Stones of the kidney and gallbladder are potential comorbidities. Kidney stones may occur due to the fat malabsorption and diarrhea in individuals with Crohn’s Disease. These patients may experience extreme flank or lower lateral back pain as well as blood in the urine. Gallstones may occur due to the bile acid malabsoprtion. These patients may experience right sided abdominal pain.

Diagnostic Tests/Lab Tests/Lab Values

The diagnosis of Crohn’s disease is made by ruling out other potential causes to explain the patient’s signs and symptoms. Some of the tests include blood tests, fecal occult blood test (FOBT), colonoscopy, flexible sigmoidoscopy, barium enema or small bowel imaging, CT of the GI tract, or a capsule endoscopy.

The blood tests are used to check for anemia which would indicate inflammation within the body, infection, and antibodies that might be present with individuals with inflammatory bowel disease.

The FOBT assesses an individual’s stool sample for the presence of blood.

Normal small bowel and Crohn’s Disease small bowel through colonoscopy A colonoscopy allows the doctor to take a biopsy or tissue sample to determine if there is a presence of any granulomas which are common with Crohn’s disease and not ulcerative colitis. The flexible sigmoidoscopy allows the doctor to assess the last portion of the colon for any biopsy samples. This allows the doctor to determine if there is any inflammation or bleeding amongst the intestines.Barium enema study showing (arrows) narrowing in the small bowel from Crohn’s Disease Barium enemas allow the doctors to assess the intestines via x-ray. The barium coats the inner lining of the GI tract to allow the lining to be visible on the x-ray.

A CT of the GI tract allows a quick look at the entire bowel in a way that cannot be seen in other diagnostic tests. This helps to assess for blockages, abscesses or fistulas.

The capsule endoscopy consists of a capsule with a small camera inside that is swallowed by the individual. The camera takes pictures every second as it travels along your GI tract. The pictures are then sent to a wireless computer belt worn by the patient that can then be taken into the doctor and downloaded for view.

Causes

The initial cause of Crohn’s disease is unknown, but was previously thought to be caused by a person’s stress and diet. Now, it is believed that factors such as these are just aggravating components while hereditary and a malfunctioning immune system may be a part of the development of Crohn’s disease. The immunological explanation believes that immune system attempts to fight off organisms while inflaming the GI tract. In those affected with Crohn’s disease, there may be an abnormal response to the bacteria that produces the large extent of inflammation. The hereditary explanation believes there is a genetic mutation that has been found in those individuals affected with Crohn’s. Crohn’s disease produces small, shallow, scattered and crater-like erosion along the inner surface of the GI tract. As this disease progresses, the erosions become deeper and larger ulcerations that will eventually scar and create stiffness along the tract. With this stiffness, the bowel can easily become obstructed. Along the deep ulcerations, the bacterium that travels along the GI tract is diffused into adjacent organs and abdominal cavity.

Some research has indicated that Crohn’s disease is very similar to a condition called Johne’s disease that occurs in cattle. The difference between the two is that Johne’s disease has a known etiology which is a bacterium called Mycobacterium avium subspecies paratuberculosis or MAP. It is believed that MAP’s presence in the intestines of individuals with Crohn’s disease could be a common characteristic. It is believed that the MAP comes from the pasteurized milk consumed from cows that are infected with Johne’s disease. The pasteurization does not remove this organism and potentially is reasoning for the connection. Individuals with Crohn’s disease do not have high amounts of MAP, so the direct cause of inflammation is still unknown if the bacterium directly influences the inflammation. Some theorize that the elimination of MAP may help to improve Crohn’s disease.

Systemic Involvement

Erythema Nodosum

Crohn’s disease may have extraintestinal symptoms, or symptoms that occur outside of the intestines. This can occur in up to 25% of patients diagnosed with Crohn’s Disease. These can include any or all of the following:

Musculoskeletal

  • Osteoporosis
  • Arthritis (most commonly peripheral joints)
  • Low back pain

Integumentary

  • Erythema nodosum or painful red bumps on the skin surface
  • Pyoderma gangrenosum or skin ulcerations

Extraintestinal manifestations of Crohn’s disease

Genitourinary

  • Kidney stones
  • Liver involvement:
    • Hepatitis
    • Cirrhosis Primary sclerosing cholangitis (PSC) or inflammation of liver ducts

Oral

  • Sores within the mouth

Ophthalamic

  • Redness and itching of the eyes
  • uveitis, eye pain and/or vision changes

Psychiatric

  • Emotional distress

Medical Management

The main goal of medical therapy is to better regulate the patient’s immune system. Additional goals for treatment in Crohn’s Disease include: inducing remission, maintain remission, improve the patient’s quality of life and minimize toxicity. The specific treatment of Crohn’s Disease is dependent upon several factors, including the location, severity of disease, type of disease, complications of Crohn’s and the individual’s response to prior medical treatments. There is a current “step up” therapy that is used for individuals with Crohn’s disease.

This approach involves:

  • Patients first treated with medications with fewer side effects that may not be as effective as the stronger medications
  • As the disease progresses, the treatment becomes more intense involving medications that are more powerful with potentially more toxicity levels.

Traditional Crohn’s treatment pyramid

Medications

There are a few classifications of drugs that can be used to help relieve the symptoms of Crohn’s disease. These include anti-inflammatory, cortisone or steroids, immune system suppressors, Infliximab (Remicade), antibiotics and anti-diarrheal/fluid replacements.

Anti-inflammatory drugs are generally the initial step in relieving the symptoms, which can include Sulfasalazine, which is better for conditions within the colon and is the most common. An additional type includes 5-ASA agents such as Mesalamine which has fewer side effects but is not as effective at treating the small intestine.

Cortisone or corticosteroids can be very effective by reducing inflammation within the body, but their side effects are vast including night sweats, high blood pressure, osteoporosis, bone fractures, excessive facial hair, increased susceptibility for infection and cataracts. Prednisone is typically prescribed when the disease is beginning and typically worse.

Immune system suppressors suppress the immune system which targets the immune system to reduce the inflammation within the body. Some types include Imuran or Azathioprine and Purinethol which are the most commonly used for IBD and conditions. These may also help to heal the fistulas . It should be noted that the use of immunosuppressive drugs may increase the effectiveness of corticosteroids.

Infliximab (Remicade) is the first medication to block the inflammation response by the body. This was approved by the FDA for the treatment of moderate to severe Crohn’s disease that has failed to respond to prior conservative treatments. This medication is an anti-TNF substance or anti-tumor necrosis factor and neutralizes this protein that is produced by the immune system. The TNF is targeted and removed before there is the chance for inflammation to occur in the GI tract. The FDA has declared a warning to children and adolescents taking this medication or other TNF inhibitors are at an increased risk for developing cancer.

Antibioticsare used to treat and heal fistulas and abscesses associated with Crohn’s disease. Medications such as these may also reduce the amount of harmful bacteria within the GI tract that suppresses the intestinal immune system. Common antibiotics include Flagyl and Cipro.

Additional medications that are used to help relieve symptoms in individuals with Crohn’s disease include: anti-diarrheals to relieve the diarrhea, laxatives, pain relievers, iron supplements, vitamin B-12 shots, calcium and vitamin D. Nutrition supplements are also very important, especially in children whose growth may be slowed. This nutrition might be in the form of high-calorie liquid formulas, feedings tube or parenteral nutrition injected into the vein. This will help to overall improve the nutrition of the individual and allow their bowel to rest which may reduce inflammation for a short period of time.

It is estimated that 2/3 of individuals affected with Crohn’s will need surgery at some point within their lives. This becomes a necessary treatment plan when medications and conservative treatment has failed. The surgery is used either to relieve the symptoms or correct complications secondary to perforation, abscess, blockage, or bleeding into the intestines. The surgery can often times improve the symptoms but may never treat or heal the condition. Crohn’s disease often reoccurs after surgery, so the benefits and complications should be weighed appropriately by the patient when choosing the course of action.

Surgical Intervention

Some indications for surgery include:

  • Perforation of intestines
  • Fistula that cannot be medically managed
  • Abcess
  • Uncontrollable bleeding from intestine
  • Cancer or precancer
  • Toxic magacolon – a potentially lethal form of acute colitis
  • Failure of medical therapy

There are multiple surgical processes that can be used for individuals with Crohn’s Disease. These include:

  • Bowel resection in which the affected parts of the intestines are removed and the healthier portions are then reattached.
  • Proctocolectomy and Ostomy where the individual may need the whole colon and rectum removed. These patients will need a stoma where the stool can then exit the body via pouch or bag.
  • Stricturoplasty is the removal of the strictures or scarred narrowing of the intestines. This will widen the portions and will allow intestinal contents to pass through.

Physical Therapy Management

Crohn’s disease is associated with periumbilical pain and referred low back pain. Individuals may also experience pain in the lower right quadrant and potential associated iliopsoas abscess due to an inflammatory mass that may create hip, buttock, thigh, or knee pain. When a patient presents to physical therapy with unknown origin of low back, sacroiliac or hip pain, it is vital for the therapist to screen for potential organic sources of the pain and is even more important in patients with a history of inflammatory bowel disease.

Since individuals with Crohn’s disease might also have associated low bone mineral content and a high potential for osteoporosis, it is important for the therapist to provide education on osteoporosis and its prevention.

Hydration is very important in patient’s with Crohn’s disease so the therapist should be aware of signs of dehydration, including headache, dry lips, brittle nails and hair, dry hands and disorientation.

Due to the complexity of Crohn’s Disease, patients might be predisposed to emotional stress that could exacerbate the prior symptoms. In knowing this, the therapist has the availability to accept the patient’s feelings, validate the disease to the patient as well as prescribing an exercise program to better the outcome for the patient. These exercises have the ability to boost the immune system, reduce depression, and improve the body image of the patient. In addition to providing this exercise program, therapists can better create coping mechanisms as well as techniques to manage the unexpectedness of Crohn’s Disease.

Outcome Measures

An outcome measure has been created to track the progress or lack of progress for individuals affected with Crohn’s disease called Crohn’s Disease Activity Index (CDAI). A score below 150 indicates a better prognosis than higher scores. This measure helps to track an individual’s progress from week to week to determine if the symptoms are better or worse. This is more of a gauge of progress and not a prognosis tool.

Dietary Management

An elemental diet that includes food broken down into basic components like amino acids, vitamins, sugars, etc can help improve the symptoms associated with Crohn’s disease. There has also been improvements found in individuals who are placed on diets free of dairy, gluten and yeast products. Herbs have also been studied to determine effectiveness of relief of symptoms.

Additional ways to better manage the symptoms may include changes to your diet. Some key points include:

  • Eating smaller meals and at more frequent intervals
  • Reducing the amount of greasy, fatty foods that may produce diarrhoea and gas
  • Limit consumption of milk and dairy products
  • Reduce the amount of carbohydrates that are poorly digested that may cause diarrhoea, gas, bloating, cramps
  • Restrict the intake of high-fiber foods such as nuts, seeds, corn, and popcorn.

Differential Diagnosis

The symptoms above are not specific to Crohn’s disease and have potential to be seen in other conditions. Differential diagnoses can include the following:

  • Infectious causes – bacterial, viral, or parasitic infection.
  • Ischemia – low blood flow to the small intestine or colon, usually seen in older patients
  • Medication – non-steroidal anti-inflammatories, antibiotics, birth control pills
  • Diverticulitis – infection of a diverticulum (outpouching of colon) that can present with left lower quadrant pain and fever
  • Appendicitis – usually presents with right lower quadrant abdominal pain and fever
  • Irritable bowel syndrome – can cause severe diarrhea and abdominal pain
  • Lactose intolerance – can cause diarrhea, bloating, and abdominal pain. Patients with Crohn’s disease can also have lactose intolerance.
  • Celiac disease – sensitivity to gluten (wheat) which can cause diarrhea and bloating.
  • Gallstones
  • Cancer, lymphoma
  • Diseases that affect other organs in the abdomen also need to be considered such as:
  • Endometriosis, pelvic inflammatory disease, ectopic pregnancy, ruptured ovarian cyst
  • Kidney stones, bladder or kidney infections

Case Reports

  • Crohn’s Disease Case Study
  • Barlow S. Case study: A 16 year old male with bone density losses resulting from Crohn’s disease. Synergy . January 2003;21. Available from: ProQuest Nursing & Allied Health Source. Accessed April 6, 2010, Document ID: 347682641. Case study:A 16 year old male with bone density losses resulting from Crohn’s disease
  • Arumugam R, Brandt ML, Jaksic T, Gilger M. Crohn’s disease presenting as chronic constipation: A case report. Clinical Pediatrics . 2000;39:369-71. Available from: Health Module. Accessed April 6, 2010, Document ID: 55518839. Crohn’s disease presenting as chronic constipation: A case report
  • Holaday M, Smith KE, Robertson S, Dallas J. An atypical eating disorder with Crohn’s disease in a fifteen-year-old male: A case study. Adolescence . 1994;29:865-73. Available from: Research Library Core. Accessed April 6, 2010, Document ID: 1499994.An atypical eating disorder with Crohn’s disease in a fifteen-year-old male: A case study
  • Ogram AE, Sobanko JF, Nigra TP. Metastatic cutaneous Crohn’s disease of the face: a case report and review of the literature. Cutis. 2010;85:25-7. Available from: Pubmed. Acessed April 6, 2010. Metastatic cutaneous Crohn’s disease of the face: a case report and review of the literature

Resources

Crohn’s & Colitis Foundation of America: Crohn’s & Colitis Foundation of America

Living with Crohn’s Disease: Living with Crohn’s Disease

National Digestive Diseases Information Clearinghouse (NDDIC): Crohn’s Disease

CDAI Calculator: Crohn’s Disease Activity Index Calculator

Presentations

How Crohn’s Disease Affects Your Skin

Other Skin Problems Related to Crohn’s

Localized skin conditions around the anal area of a person with Crohn’s disease include skin tags and skin cracks called anal fissures. These result from the swelling and irritation caused by Crohn’s. You can best prevent and manage them with good hygiene, warm baths, and soothing ointments.

Other rare skin problems associated with Crohn’s include:

  • Acrodermatitis enteropathica, a Crohn’s complication caused by a zinc deficiency. Zinc is important for optimal nutrition, but people with Crohn’s may lose some of the mineral due to bouts of diarrhea. “This skin condition causes a pink, scaly rash that usually appears around the mouth or anal area,” says Winterfield. Replacing zinc in the diet makes the rash go away.
  • Epidermolysis bullosa acquisita, a complication of Crohn’s that can happen to people who have had Crohn’s for a long time. It causes blisters on the knees, elbows, and feet. (It also occurs in other diseases of the immune system.) Good skin care helps to prevent it. Treatment may require steroids and immune-suppression drugs.

RELATED: Essential Resources for Living With Crohn’s Disease or Ulcerative Colitis

Crohn’s Skin Conditions Caused by Medications

Beyond skin conditions that stem from the condition itself, some Crohn’s medications may lead to adverse skin reactions.

  • Sulfasalazine, a drug used to block inflammation in Crohn’s, may cause an allergic skin rash, hives, or itching. “In most cases this medication can be replaced with another that does not contain sulfa,” says Winterfield.
  • Steroids are important medications used to block inflammation in Crohn’s. Long-term steroid use can cause stretch marks on the skin, thinning of the skin, and aggravation of acne.
  • Anti-tumor necrosis factor (TNF) drugs, a relatively new class of medication used for Crohn’s disease, may cause a skin rash at the injection site. “Psoriasis is another immune disease that may be linked with Crohn’s, and anti-TNF drugs may trigger psoriasis in some people,” notes Winterfield. Indeed, in a study published in June 2014 in Digestion, the authors described 13 people with Crohn’s who had developed the skin condition while receiving this kind of therapy. Their skin symptoms improved once their anti-TNF treatment was discontinued. Other research, published in January 2016 in the Scandinavian Journal of Gastroenterology, suggested that some patients with Crohn’s who use such drugs might also develop eczema, which makes the skin itchy and red.

“It is important to remember that many of these skin conditions occur in people who don’t have Crohn’s disease, and also that people with Crohn’s disease can have skin conditions that aren’t caused by Crohn’s,” says Winterfield.

Learning as much as you can about Crohn’s and working closely with your doctor to keep Crohn’s under control is the best way to prevent complications. Always check in with your doctor if you develop any new symptoms, including ones that have nothing to do with tummy troubles.

Additional reporting by Agata Blaszczak-Boxe

10 rashes caused by ulcerative colitis

There is a range of different skin conditions that are associated with UC. These are explored below.

Share on PinterestThere are a number of different skin conditions associated with ulcerative colitis.

Erythema nodosum is the most common skin issue for people who also have UC. Up to 10 percent of people with UC may develop erythema nodosum.

Erythema nodosum causes tender red nodules to appear on a person’s arms or legs. These nodules may look like bruises.

In people with UC, this skin rash tends to come up during a flare-up and go away when UC is in remission.

According to this 2012 review, pyoderma gangrenosum is the second most common skin problem that may affect people with UC.

This skin rash begins as a cluster of blisters on the shins, ankles, or arms. It often spreads and can form deep ulcers. If not kept clean, this may become infected.

Researchers believe this condition is caused by a problem with the immune system that may be linked to the cause of UC.

3. Psoriasis

Psoriasis is a skin condition caused by a problem with the immune system. It leads to red, patchy skin, covered with a build-up of dead skin cells.

Many people with UC and other types of IBD are also affected by psoriasis.

This 2015 study found that there were some genetic links between the genes that cause IBD and those that cause psoriasis. More research is needed to understand these connections fully.

4. Hives

Hives are red raised spots that may appear as a rash anywhere on the body. They form due to a reaction in the immune system.

Sometimes people react to the medication they are taking for UC, which can cause chronic hives.

5. Acne

A 2011 study found a link between taking a drug intended to treat cystic acne (isotretinoin) and developing UC. More research is needed to understand this link better.

6. Bowel-associated dermatosis-arthritis syndrome

Bowel-associated dermatosis-arthritis syndrome (BADAS) is a condition where small bumps form on the upper chest and arms, in addition to other symptoms. These bumps can then form pustules, causing discomfort. BADAS may also cause lesions on the legs.

Researchers do not fully understand the cause, but they think it may relate to inflammation as a result of bacteria in the gut. Having IBD makes it more likely a person will develop BADAS.

Pyodermatitis vegetans and pyostomatitis vegetans are two skin conditions that are linked.

The former causes red pustules that burst and form scaly patches in the armpit or groin. The latter involves pustules in the mouth.

The two conditions are typically grouped together and called pyodermatitis-pyostomatitis vegetans (PPV).

This condition is associated with UC, though it is rare. Symptoms will typically occur after a person has had UC for a few years. Often, however, people are not diagnosed with UC until after a doctor has diagnosed PPV.

8. Sweet’s syndrome

Sweet’s syndrome is another condition that is linked to UC flare-ups.

When a person has Sweet’s syndrome, small red or purple bumps on the skin develop into painful lesions. They often form on the upper limbs, face, and neck.

9. Vitiligo

Vitiligo is a skin condition that destroys the pigment-producing cells in the skin. Vitiligo may lead to white patches forming anywhere on the body.

Researchers think that vitiligo is caused by an immune disorder. According to the National Institute of Health (NIH), around 20 percent of people with vitiligo also have another immune disorder, such as UC.

10. Leukocytoclastic vasculitis

Leukocytoclastic vasculitis (hypersensitivity vasculitis) occurs when small blood vessels under the skin become inflamed and die. The inflammatory reaction leads to the development of purple spots on the skin of the legs or ankles, called purpura.

The condition results from inflammation and is linked to UC flare-ups. Leukocytoclastic vasculitis typically goes away when UC is in remission

PMC

Skin lesions induced by anti-TNF therapy

An emerging problem in the course of CD is represented by the occurrence of skin lesions during anti-TNF therapy. Skin adverse events in patients treated with anti-TNF agents are classified as: a) local or systemic manifestations related to treatment such as diffused skin rash following drug administration or skin reaction at the injection site; b) skin infection; c) malignancy; d) autoimmune-related skin disease.8

Anti-TNF agents, which are approved for the treatment of moderate to severe psoriasis, may paradoxically cause psoriasiform skin lesions in patients with IBD.9 An incidence of psoriasiform lesions of 1.6%–8.8%, which is consistent with data derived from anti-TNF-treated patients with rheumatoid arthritis.7,10,11 has been reported. Psoriasiform lesions during anti-TNF therapy occur more frequently in patients with CD than in those with UC (i.e. 90%–96% vs 4%–10%, respectively).7,12 The main risk factors for developing psoriasiform skin lesions are: smoking (past or active), increased body mass index (BMI), female sex, familial history of inflammatory skin disease and short disease duration.7 The most frequent localisation of psoriasiform lesions is hand palm or feet plant, scalp and flexures (Figure 2). The pathogenic mechanism of anti-TNF agents-related psoriasiform skin lesions is still an object of debate. Tillack et al. reported that psoriasiform lesions induced by anti-TNF therapy were characterised by infiltrates of IL-17/IL-22-expressing Th17 cells and interferon (IFN)-γ-expressing Th1 cells, the severity of lesions being correlated with the density of Th17 cell infiltrates. This suggests that Th1 and Th17 cells may play a pathogenic role in development of these lesions and indicates that anti-TNF-induced psoriasiform lesions and non-anti-TNF-related psoriasis may have a common pathogenic mechanism. In fact, in both conditions, an increased expression of the Th17-derived cytokines IL-17 and IL-22 has been demonstrated.7,13,14 Also, a role for over-production of IFN-α by plasmacytoid dendritic cells (pDCs) has been suggested.7,15 In fact, TNFα inhibits pDC maturation from haematopoietic progenitor cells and consequently inhibits IFN-α production.7,16 Therefore, anti-TNF treatment may result in unlimited IFNα production by pDCs, which might in turn favour the formation of psoriasiform lesions. In agreement with this hypothesis, Tillack et al. found increased IFNα protein expression in skin biopsy of patients with anti-TNF-associated psoriasiform lesions.7 Other studies suggested that altered lymphocyte migration caused by anti-TNF therapy may also contribute to skin lesions through the expression of CXCR3 ligands which, by interacting with their receptor, regulate leucocyte trafficking.7,17,18 Finally, Scaldaferri et al. hypothesised that anti-TNF agents may induce a ‘patchy cutaneous’ immune suppression leading to the development of psoriasis-like lesions.19

Palmar (a) and perianal (b) psoriasis in a Crohn’s disease patient on anti-TNF therapy.

There are no clear guidelines for management of anti-TNF-induced psoriasiform lesions. Paradoxical psoriasis can be treated with topical corticosteroids, vitamin D analogues, phototherapy, methotrexate or cyclosporine, but it is occasionally refractory to conventional treatments.20,21 In the case of localised lesions, topical corticosteroids or vitamin D analogues are indicated. In the case of diffuse lesions, there is an indication for systemic treatment with steroids or methotrexate or cyclosporine. Discontinuation of anti-TNF therapy may be required in about 30% of patients with severe lesions or in those who do not respond to conventional therapy leading to an improvement of skin lesions in 24% to 88%. After the resolution of skin lesions, the reintroduction of anti-TNF therapy should be considered. If anti-TNF therapy does no longer represent an option, alternative therapies for IBD have to be considered. Some studies reported efficacy of ustekinumab, an anti-IL-12/IL-23 p40 antibody, in patients non-responsive to local therapy after stopping anti-TNF therapy.7 Whether switching from one anti-TNF to another may have a positive impact on skin lesions is not completely clear. Tillack et al.7 in a large prospective study found that in 21/434 (4.8%) patients on anti-TNF therapy who developed psoriasiform lesions the switching strategy resulted in no significant improvement. Afzali et al.12 in a retrospective study including 1004 IBD patients on anti-TNF therapy found that 27 patients (i.e. 2.7%) developed psoriasiform skin lesions. In particular, skin lesions developed in eight of 620 (i.e. 1.3%) patients on infliximab, in 10/243 (i.e 4.1%) on adalimumab and in nine of 141 (i.e. 6.4%) on certolizumab. Of these 27 patients, six were managed by switching to another anti-TNF agent and four of these six patients showed a significant improvement in skin lesions. Therefore, therapeutic approach for paradoxical psoriasis must be discussed properly with patients because it may have a negative impact on the underlying intestinal disease and must be based on psoriasis severity, response to the standard therapy, and possibility of using alternative therapies for IBD.7,22

Anti-TNF therapy is associated with the development of skin lesions other than psoriasiform lesions with an incidence of approximately 18%. The most common non-psoriasiform skin disorders associated with anti-TNF therapy are infusion reactions to infliximab with skin erythema (5.8%), followed by viral skin infections (2.5%), eczematiform skin lesions (2.1%), xerosis cutis (2.1%) and bacterial skin infections (1.4%).7 SLE is an uncommon phenomenon with most cases reported in rheumatological series with an incidence of about 1%. Ninety-four per cent of the cases responded to interruption of therapy.23,24

Cutaneous malignancies have also been reported in patients treated with anti-TNF agents or thiopurines. Askling et al., in a meta-analysis including 74 randomised controlled trials using anti-TNF therapy with over 22,000 patients reported a relative risk of NMSC (Figure 3) associated with all anti-TNF monotherapies equal to 2.02 (95% confidence interval (CI) 1.11–3.95).25 Data from the Therapy, Resource, Evaluation, and Assessment Tool (TREAT) registry including 6273 patients, 3420 treated with anti-TNF agents and 2853 non-anti-TNF-treated, with a mean follow-up/patient of 5.2 years, show that there is no statistically significant difference in the incidence of NMSC between patients treated with anti-TNF and those treated differently (0.16 vs 0.18 events per 100 patient-years, respectively).26 Biancone et al., showed that patients treated with anti-TNF agents have an increased risk of lymphoma and NMSC.27 However, it has been questioned whether IBD by itself may carry an increased risk of NMSC. In this respect, Long et al. demonstrated that IBD patients have an increased risk of NMSC independently of anti-TNF therapy compared to non-IBD controls with an incidence rate ratio (IRR) equal to 1.64 (95% CI 1.51–1.78). Moreover, persistent use (>365 days) of both thiopurine (6 MP/azathioprine) and anti-TNF is associated to an increased risk of developing NMSC with an adjusted odds ratio (OR) equal to 2.18 (95% CI 1.07–4.46).28 More recently, Long et al.29 in a retrospective case-control study of administrative data including108,579 patients with IBD (50,920 CD, 56,390 ulcerative colitis and 1269 IBD of undefined type) demonstrated that IBD was associated with an increased incidence of MM (IRR, 1.29; 95% CI, 1.09–1.53). Risk was greatest among individuals with CD (IRR, 1.45; 95% CI, 1.13–1.85; adjusted hazard ratio (HR), 1.28; 95% CI, 1.00–1.64). The incidence of NMSC also increased among patients with IBD (IRR, 1.46; 95% CI, 1.40–1.53) and was greatest among those with CD (IRR, 1.64; 95% CI, 1.54–1.74). In this study, therapy with anti-TNF appeared to increase the risk of MM (OR 1.88; 95% CI, 1.08–3.29). Patients who had been treated with thiopurines had an increased risk of NMSC (OR, 1.85; 95% CI, 1.66–2.05).25 Therefore, based on this study, use of biologics increases the risk of MM whereas the use of thiopurines increases the risk of NMSC. However, the absolute risk of developing MM or NMSC in IBD patients is as low as 57/100,000 person-years and 912/100,000 person-years, respectively. Therefore, taking into account the benefits of anti-TNF agents or thiopurines, the mildly increased relative risk of developing skin malignancies should not deter the use of these efficacious therapeutical agents. Avoidance of the sun, use of sun-protective agents or clothing may represent a valuable option for primary prevention of both MM and NMSC.

Bowen’s disease (i.e. squamous cell carcinoma in situ) on the extensor aspect of the arm in a Crohn’s disease patient on anti-TNF therapy.

While thiopurine-associated increase in the risk of NMSC may be linked to the activation of thiopurine into a mutagenic DNA-reactive moiety after exposure to ultraviolet light,30 the mechanism whereby anti-TNF agents may increase the risk of skin malignancies is not fully understood. However, an alteration in immune surveillance due to anti-TNF may contribute.24,25 TNF-α has a complex effect on carcinogenesis and, depending on doses, promotes cell proliferation and thus tumour growth or induces apoptosis and inhibits angiogenesis, thus suppressing the development of a number of cancers.31–33 No causal association between anti-TNF agents and cancer has been demonstrated so far and caution is required when the available data are interpreted, because the follow-up of IBD patients treated with anti-TNF drugs is quite short. Multicentre studies in large populations with long-term follow-up are needed to address the issue of anti-TNF therapy and cancer development.

Is Crohn’s Disease Causing Your Skin Woes?

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Tasha Weinstein has been through the ringer since she was diagnosed with Crohn’s disease at the age of 11. Now 23, her experience with the inflammatory bowel disease has not only included the most common symptoms—such as persistent diarrhea, cramping, and other gastrointestinal symptoms—but also a memorable bout of erythema nodosum, the term for painful red bumps that appear on the legs of some people with Crohn’s.

“I didn’t know what they were at first, but they looked like massive spider bites,” the New York City-based sales executive says. “I couldn’t walk because it was so painful.”

Weinstein is not alone. About 5 percent of people with an inflammatory bowel disease such as Crohn’s will develop some skin complications, according to the Crohn’s and Colitis Foundation of America (CCFA). Exactly who will develop skin issues with Crohn’s is not fully understood, but risks do include being female, being diagnosed with Crohn’s at a young age, and experiencing other non-digestive symptoms, called extraintestinal manifestations, according to a study published in the February 2014 issue of the Journal of Gastroenterology and Hepatology.

“Some skin issues are due to the underlying inflammation that causes Crohn’s disease, and some are due to its treatment,” says Misha Rosenbach, MD, an assistant professor of dermatology and internal medicine, director of the Dermatology Inpatient Consult Service, and the director of the Dermatology Urgent Care Clinic at the University of Pennsylvania in Philadelphia. “But regardless of the cause, skin disorders can be devastating to the patient. If you have Crohn’s and you see something new develop on your skin, it is worth questioning whether it is related to Crohn’s.” In many cases, more aggressive treatment of the Crohn’s disease can help clear your skin, Dr. Rosenbach adds.

Some of the more common skin issues that can occur with Crohn’s disease include:

Erythema nodosum. As Weinstein experienced, these red bumps can be tender, painful, and uncomfortable. “They form from inflammation in the fat and can be the first Crohn’s disease symptom to emerge or appear in conjunction with a flare,” Rosenbach says. The good news is that these bumps tend to get better with tighter control of Crohn’s, he adds.

Pyoderma gangrenosum (PG). “These are big red blisters that can expand to painful ulcers that ooze pus,” says James Marion, MD, a professor of gastroenterology at the Icahn School of Medicine and a physician at the Susan and Leonard Feinstein Inflammatory Bowel Disease Clinical Center at Mount Sinai Hospital in New York City. About 1 percent of people with Crohn’s will develop PG, according to the CCFA. Complicating the situation even more, this serious condition is often misdiagnosed and treated as an infection. “We try to optimize treatment of Crohn’s in the face of PG as it can be a warning sign of a coming flare,” Dr. Marion says.

Skin tags. These are abnormal, typically small growths of skin. When they occur with Crohn’s disease, however, they often appear on the buttocks and tend to be larger and more painful than others, Marion says, adding that “they can really interfere with quality of life.” Skin tags develop from inflammation around the anal canal and tend to be worse during periods of heavy diarrhea. “We typically don’t remove them. Instead, we just dial up Crohn’s treatment,” he says.

Sores and fissures. “Crohn’s is a disease that affects the entire gastrointestinal tract, from the mouth to the anus,” Rosenbach says. This means there can be lip swelling, ulcers, or fissures (cuts or tears) in the mouth as well as in the anal area. “They are usually seen during severe flares and tend to get better when Crohn’s disease is under control,” he adds.

Skin issues related to Crohn’s treatment or surgery. Some Crohn’s disease skin problems are related to treatment, such as steroids that are used to get a flare under control, says Gary Goldenberg, MD, an assistant clinical professor of dermatology at the Icahn School of Medicine. “Steroids can thin the skin, causing stretch marks, and they can also affect hormone levels, which can cause breakouts,” he explains.

Crohn’s surgery that involves creating an alternate means of collecting stool outside the body can lead to various skin issues, too. “You may get a rash from the tape at the site of the pouch or an irritation from the stool’s passage,” Dr. Goldenberg says. “Or some people may be allergic to the adhesion material.” Working with a dermatologist can help you manage these issues.

Skin cancer. Immune-modulating drugs used to treat Crohn’s disease have been linked to some types of skin cancer, according to the CCFA. “If you have Crohn’s and are treated with an immune-modulating drug, see a dermatologist for a yearly skin check, be vigilant about checking your own skin, and always call if you see something suspicious,” Goldenberg says. It’s also important to apply broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or higher to help lower this risk, he adds.

“People with Crohn’s should consult a dermatologist along with their gastroenterologist to stay on top of all Crohn’s disease symptoms,” Goldenberg stresses. Weinstein agrees: “I see my dermatologist regularly and call every time I notice something new on my skin.”

An Unusual Cause of Skin Rash in Crohn’s Disease

A skin biopsy was performed to confirm the diagnosis. The biopsy was negative for bacterial and fungal organisms, acid-fast bacilli, and viral inclusion bodies. In the dermis, a superficial and perivascular inflammatory pattern predominantly composed of neutrophils and a variable number of eosinophils was observed. Additionally, neutrophil degeneration forming nuclear dust, erythrocyte extravasation, and fibrinoid necrosis of the vessels is present. (FigureFigure B). Findings were consistent with leukocytoclastic vasculitis. The patient was started on prednisone (40 mg/d), and the anti-tumor necrosis factor (TNF) agent was discontinued. A notable improvement of their skin lesions was noticed 8 weeks later (FigureFigure C). She had full resolution of the lesions at follow-up and was subsequently started on ustekinumab for maintenance therapy of the Crohn’s disease.

Anti-TNF therapy has been linked to the development of autoimmune diseases, especially psoriasis, lupus-like syndrome, demyelinating central nervous system disease, and interstitial lung disease.1x1Ramos-Casals, M., Brito-Zeron, P., Munoz, S. et al. Autoimmune diseases induced by TNF-targeted therapies: analysis of 233 cases. Medicine. 2007; 86: 242–251
Crossref | PubMed | Scopus (499) | Google ScholarSee all References Leukocytoclastic vasculitis associated with anti-TNF therapy is uncommon and has been reported mainly in rheumatoid arthritis patients.2x2Moustou, A.E., Matekovits, A., Dessinioti, C. et al. Cutaneous side effects of anti-tumor necrosis factor biologic therapy: a clinical review. J Am Acad Dermatol. 2009; 61: 486–504
Abstract | Full Text | Full Text PDF | PubMed | Scopus (126) | Google ScholarSee all References The skin is the leading affected organ, with the most common cutaneous manifestation being a palpable purpura.3x3Sokumbi, O., Wetter, D.A., Makol, A. et al. Vasculitis associated with tumor necrosis factor-α inhibitors. Mayo Clin Proc. 2012; 87: 739–745
Abstract | Full Text | Full Text PDF | PubMed | Scopus (81) | Google ScholarSee all References Nonetheless, one-fourth of the patients with cutaneous vasculitis can present extracutaneous manifestations, particularly peripheral neuropathy and renal vasculitis.1x1Ramos-Casals, M., Brito-Zeron, P., Munoz, S. et al. Autoimmune diseases induced by TNF-targeted therapies: analysis of 233 cases. Medicine. 2007; 86: 242–251
Crossref | PubMed | Scopus (499) | Google ScholarSee all References The pathogenesis remains unclear, although it is thought that the development of antibodies against anti-TNF agents could lead to an immune complex–mediated hypersensitivity vasculitis.3x3Sokumbi, O., Wetter, D.A., Makol, A. et al. Vasculitis associated with tumor necrosis factor-α inhibitors. Mayo Clin Proc. 2012; 87: 739–745
Abstract | Full Text | Full Text PDF | PubMed | Scopus (81) | Google ScholarSee all References

It can be difficult to establish causality in cases of vasculitis associated with anti-TNF therapy. Active inflammatory bowel disease, medications, underlying infection, collagen vascular disorders, or malignancy can be associated with vasculitis in this setting.1x1Ramos-Casals, M., Brito-Zeron, P., Munoz, S. et al. Autoimmune diseases induced by TNF-targeted therapies: analysis of 233 cases. Medicine. 2007; 86: 242–251
Crossref | PubMed | Scopus (499) | Google ScholarSee all References, 2x2Moustou, A.E., Matekovits, A., Dessinioti, C. et al. Cutaneous side effects of anti-tumor necrosis factor biologic therapy: a clinical review. J Am Acad Dermatol. 2009; 61: 486–504
Abstract | Full Text | Full Text PDF | PubMed | Scopus (126) | Google ScholarSee all References, 3x3Sokumbi, O., Wetter, D.A., Makol, A. et al. Vasculitis associated with tumor necrosis factor-α inhibitors. Mayo Clin Proc. 2012; 87: 739–745
Abstract | Full Text | Full Text PDF | PubMed | Scopus (81) | Google ScholarSee all References However, in our patient, these conditions were reasonably excluded from clinical data, unremarkable laboratory results, and the resolution of the vasculitis after anti-TNF discontinuation and steroid treatment. In the absence of systemic involvement, the prognosis is excellent, with the majority of cases resolving within weeks to months after discontinuation of the anti-TNF agent.3x3Sokumbi, O., Wetter, D.A., Makol, A. et al. Vasculitis associated with tumor necrosis factor-α inhibitors. Mayo Clin Proc. 2012; 87: 739–745
Abstract | Full Text | Full Text PDF | PubMed | Scopus (81) | Google ScholarSee all References Patients with persistent lesions or systemic manifestations may require additional therapy, such as systemic corticosteroids and immunosuppressants.1x1Ramos-Casals, M., Brito-Zeron, P., Munoz, S. et al. Autoimmune diseases induced by TNF-targeted therapies: analysis of 233 cases. Medicine. 2007; 86: 242–251
Crossref | PubMed | Scopus (499) | Google ScholarSee all References, 3x3Sokumbi, O., Wetter, D.A., Makol, A. et al. Vasculitis associated with tumor necrosis factor-α inhibitors. Mayo Clin Proc. 2012; 87: 739–745
Abstract | Full Text | Full Text PDF | PubMed | Scopus (81) | Google ScholarSee all References For patients presenting cutaneous rash during anti-TNF therapy clinicians need to consider leukocytoclastic vasculitis diagnosis. In this setting, skin biopsy and extensive investigations for systemic involvement must be engaged. The resolution of leukocytoclastic vasculitis may be achieved by discontinuing use of the anti-TNF agent and initiating adjuvant treatment.

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