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Abatacept-Induced Disseminated Superficial Porokeratosis.

CLINICAL IMAGE Disseminated superficial porokeratosis (DSP) presents as atrophic papules with a keratotic ridge. Drug-induced porokeratosis has been reported in association with several classes of medications, most notably immunosuppressants. To our knowledge, we report the first case of abatacept-induced DSP. A 66-year-old woman with rheumatoid arthritis was treated with abatacept after partial response and loss of efficacy over time to hydroxychloroquine, methotrexate, golimumab, certolizumab pegol, and adalimumab. After her fourth dose of abatacept, she developed a pruritic, scaly rash that worsened with subsequent injections. The patient denied recent changes to other medications, which included low-dose aspirin, calcium carbonate–vitamin D3, dexlansoprazole, and ergocalciferol. On physical examination, scattered pink papuleswith a double-ridged border of peripheral scale limited to the bilateral upper and lower extremities were observed (Fig. 1). A skin biopsy revealed cornoid lamella in a follicular infundibulum, characteristic of porokeratosis (Fig. 2). Abatacept was discontinued and the patient began both systemic and topical corticosteroids with continual improvement 4 months after her last dose of abatacept. The keratinocyte abnormalities characteristic of porokeratosis are thought to be related to either faulty maturation of keratinocytes or an acceleration of epidermopoiesis. A gene locus identified for DSP, for instance, has been mapped to the same susceptibility locus as psoriasis. It is hypothesized that immunosuppression causes porokeratosis due to restricted immune surveillance that allows keratinocyte clones to persist. Tumor necrosis factor inhibitor (TNFi) biologic therapies have been mostly associated with biologic-induced porokeratosis. Like TNFi's, there are reports of abatacept-associated skin eruptions that may mimic porokeratosis, including early psoriasis, requiring biopsy for diagnosis. Porokeratosis has also been associated with malignant transformation, particularly to squamous cell carcinoma (SCC). In addition, patients treated with immunemodulators including abatacept have been reported to develop SCCs. Clinicians should continue to closely follow patients on abatacept and TNFi's for development of biologic-induced porokeratosis and SCCs.