By Clelland, Susan; Hunek, Jeffrey R
The “Clinical Snapshot” series provides a concise examination of a clinical presentation including history, treatment, patient education, and nursing measures. Using the format here, you are invited to submit your “Clinical Snapshot” to Dermatology Nursing.
History: A 20-year-old female presented with a history of psoriasis and psoriatic arthritis since childhood. She started treatment with etanercept (Enbrel) 1 month previously. One day after a subcutaneous injection into the left thigh, she developed a mildly pruritic eruption on the right thigh, at the site of a previous injection.
Description of Skin Lesion: There is an erythematous, slightly indurated plaque on the anterior right thigh. There is adjacent ecchymosis (see Figure 1).
Hallmark of the Disease: Etanercept (Enbrel) is an injectable fusion protein that competitively inhibits the pro-inflammatory cytokine TNF-α. It is approved for use in rheumatoid arthritis, juvenile rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis, and adults with chronic moderate-to-severe plaque psoriasis. In clinical trials, the most common adverse effect of this treatment was injection site reaction (ISR). This can occur in up to 49% of patients and usually presents as erythema, pruritus, pain, or edema. At least 7% of patients develop “recall ISR,” or reaction at a prior treatment site with subsequent injections.
Normal Course: Injection site reactions to etanercept usually occur within the first month of treatment. They most commonly occur 1 to 2 days after an injection, and the duration is usually 3 to 5 days. ISRs decrease in frequency with continued treatment in the vast majority of patients, although a persistent or worsening reaction has been described.
Treatment: Most ISRs resolve without treatment, but symptomatic eruptions can be treated with cold compresses, topical corticosteroids, oral antihistamines, or acetaminophen. Discontinuing treatment with etanercept is rarely indicated.
Patient Education: Instruct patients to avoid administering etanercept to the area of ISR. Future injections should be given at least one inch from the periphery of the ISR. Rotation of injection sites should also be encouraged. Recommended sites include the anterior thighs, outer upper arms, and the abdomen two or more inches from the navel. Injections should not be administered into psoriasis skin lesions. Signs and symptoms of infection should be reviewed with the patient.
Figure 1.
An erythematous, slightly indurated plaque on the anterior right thigh with adjacent ecchymosis.
Nursing Measures: Make sure patients understand that an ISR will resolve and that it is not related to the disease process. The proper injection technique should be reviewed, and patients should be instructed to contact their physician if they exhibit severe itching, pain, swelling, or signs of infection.
References
Edwards, K.R., Mowad, C.M., & Tyler, W.B. (2003). Worsening injection site reactions with continued use of etanercept. Journal of Drugs in Dermatology, 2(2), 184-187.
Immunex Corporation. (2005). ENBREL prescribing information. Thousand Oaks, CA: Immunex Corporation.
Murphy, F.T., Enzenauer, RJ., Battafarano, D.F., & David-Bajar, K. (2000). Etanercept-associated injection site reactions. Archives in Dermatology, 136, 556-557.
Werth, V.P., & Levinson, A.I. (2001). Etanercept-induced injection site reactions: Mechanistic insights from clinical findings and immunohistochemistry. Archives in Dermatology, 737, 953- 955.
Zeltser, R., Valle, E, Tanck, C, Hoylst, M.M., Ritchlin, C., & Gaspari, A.A. (2001). Clinical, histological, and immunophenotypic characteristics of injection site reactions associated with etanercept. Archives in Dermatology, 137, 893-899.
Susan Clelland, BSN, RN, is a Nurse Supervisor, Henry Ford Hospital, Detroit, MI.
Jeffrey R. Hunek, MD, is a Dermatology Resident, Henry Ford Hospital, Detroit, MI.
Copyright Anthony J. Jannetti, Inc. Oct 2005
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