Granuloma annulare development in a patient with rheumatoid arthritis treated with tocilizumab: case-based review

Granuloma annulare (GA) is the most common non-infectious disease. Despite the fact that it is a benign disease, it can be associated with a variety of disorders and certain drugs including biological disease-modifying anti-rheumatic drugs (bDMARDs). A 50-year-old man with a history of rheumatoid arthritis refractory to methotrexate, hydroxychloroquine and infliximab was treated with tocilizumab (TCZ), an interleukin-6 receptor antagonist, 162 mg subcutaneously every week. The patient responded very well to TCZ treatment with a decrease of acute phase reactants and reduction of disease activity score for 28-joints count. However, 3 months later he developed erythematous polycyclic eruptions affecting the lower extremities consistent with a diagnosis of GA which was confirmed by a skin biopsy. TCZ has been discontinued and the patient was treated with prednisone presenting complete resolution of skin manifestations after 4 weeks. This is the first case of GA development during TCZ treatment. Thus, we review the literature and discuss the relevant cases of GA development in patients treated with bDMARDs. When dealing with patients treated with these agents, all physicians should be aware of possible adverse events and the potential development of such complications.