Figure 2.

(a–d) Patient 5, a 61‐year‐old man with an 11‐year history of psoriasis previously treated with ciclosporin, methotrexate and etanercept, developed paradoxical eczema (PE) on three different biologic classes. The first episode presented with an eczematous reaction on the face 238 days after starting ustekinumab. The patient subsequently developed generalized eczema 25 days after starting secukinumab. Apremilast was ineffective in controlling the psoriasis. Both episodes of PE resolved with ciclosporin. PE recurred rapidly after starting guselkumab; the drug cleared the psoriasis completely and the PE is currently being managed with topical corticosteroids and antihistamines only. All episodes of PE were associated with eosinophilia, which was not present otherwise. (a,b) Severe plaque psoriasis affecting the back and legs 8 weeks after initiation of guselkumab; (c,d) significant improvement in psoriasis and the presence of hypopigmented atrophic scars from resolved pruriginous nodules 2 years after initiation of guselkumab. [Colour figure can be viewed at wileyonlinelibrary.com]