{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,14]],"date-time":"2026-03-14T21:22:45Z","timestamp":1773523365363,"version":"3.50.1"},"reference-count":13,"publisher":"BMJ","issue":"12","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2025,12,12]]},"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:p>We report the case of a woman in her 70s who developed generalised granuloma annulare (GA) after 3 years of successful ustekinumab therapy for severe palmoplantar psoriasis. Ustekinumab, an interleukin (IL)-12\/23 inhibitor, was ceased as the most likely trigger. GA remained persistent despite multiple treatments but resolved gradually over 5 years. This resolution was followed by a severe flare of her psoriasis, requiring initiation of guselkumab, an IL-23 inhibitor. This case illustrates a probable paradoxical T-helper (Th)1-mediated granulomatous reaction to ustekinumab, likely due to immune dysregulation between Th1 and Th17 pathways. It adds to the limited but growing body of evidence suggesting ustekinumab may trigger delayed granulomatous inflammation via phenotypic switching, including GA. Clinicians should be aware of this potential complication, even after long-term stable use of ustekinumab. Managing biologically induced paradoxical inflammation is complex and may require switching to an alternative biological agent, particularly when cessation leads to rebound flare of the underlying condition.<\/jats:p>","DOI":"10.1136\/bcr-2025-268668","type":"journal-article","created":{"date-parts":[[2025,12,31]],"date-time":"2025-12-31T11:35:34Z","timestamp":1767180934000},"page":"e268668","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Generalised granuloma annulare following ustekinumab therapy for palmoplantar psoriasis"],"prefix":"10.1136","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4186-7391","authenticated-orcid":false,"given":"Samuel","family":"Morriss","sequence":"first","affiliation":[{"name":"Department of Dermatology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jenny","family":"Nicolopoulos","sequence":"additional","affiliation":[{"name":"Department of Dermatology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Con","family":"Dolianitis","sequence":"additional","affiliation":[{"name":"Department of Dermatology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2025,12,31]]},"reference":[{"key":"2025123106151472000_18.12.e268668.1","doi-asserted-by":"crossref","first-page":"1594","DOI":"10.1016\/j.jaad.2020.11.053","article-title":"Development of granuloma annulare in patients on biologic therapies: A systematic review","volume":"85","author":"Lytvyn","year":"2021","journal-title":"J Am Acad Dermatol"},{"key":"2025123106151472000_18.12.e268668.2","first-page":"606","article-title":"A Case of Generalized Granuloma Annulare Development in a Psoriasis Patient Treated with Interleukin-12\/23 Blockers","volume":"60","author":"Kim","year":"2022","journal-title":"Korean J Dermatol"},{"key":"2025123106151472000_18.12.e268668.3","article-title":"Interstitial Granulomatous Drug Reaction to Ustekinumab","volume":"2022","author":"Walker","year":"2022","journal-title":"Case Rep Dermatol Med"},{"key":"2025123106151472000_18.12.e268668.4","doi-asserted-by":"crossref","first-page":"1231","DOI":"10.1002\/jvc2.369","article-title":"Paradoxical granulomatous reaction to ustekinumab","volume":"3","author":"Obijiofor","year":"2024","journal-title":"JEADV Clinical Practice"},{"key":"2025123106151472000_18.12.e268668.5","doi-asserted-by":"crossref","DOI":"10.1186\/s13256-019-2137-1","article-title":"Sarcoid- like Phenomenon - ustekinumab induced granulomatous reaction mimicking diffuse metastatic disease: a case report and review of the literature","volume":"13","author":"Gad","year":"2019","journal-title":"J Med Case Rep"},{"key":"2025123106151472000_18.12.e268668.6","doi-asserted-by":"crossref","first-page":"163","DOI":"10.2174\/1574886315666200316113312","article-title":"Ustekinumab-induced Sarcoidosis in a Patient with Psoriatic Arthritis","volume":"15","author":"Kobak","year":"2020","journal-title":"Curr Drug Saf"},{"key":"2025123106151472000_18.12.e268668.7","unstructured":"Adverse drug reaction probability scale (naranjo) in drug induced liver injury. livertox: clinical and research information on drug-induced liver injury. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases, 2012."},{"key":"2025123106151472000_18.12.e268668.8","unstructured":"World Health Organization . The use of the WHO-UMC system for standardised case causality assessment, Available: https:\/\/www.who.int\/docs\/default-source\/medicines\/pharmacovigilance\/whocausality-assessment.pdf"},{"key":"2025123106151472000_18.12.e268668.9","doi-asserted-by":"crossref","first-page":"e501","DOI":"10.1097\/MJT.0000000000001103","article-title":"Granuloma Annulare Induced by Pregabalin","volume":"28","author":"Fernandez-Nieto","year":"2019","journal-title":"Am J Ther"},{"key":"2025123106151472000_18.12.e268668.10","doi-asserted-by":"crossref","first-page":"53","DOI":"10.2165\/00063030-200923010-00006","article-title":"Ustekinumab","volume":"23","author":"Weber","year":"2009","journal-title":"BioDrugs"},{"key":"2025123106151472000_18.12.e268668.11","doi-asserted-by":"crossref","first-page":"63","DOI":"10.1016\/j.jaad.2019.12.028","article-title":"Granuloma annulare skin profile shows activation of T-helper cell type 1, T-helper cell type 2, and Janus kinase pathways","volume":"83","author":"Min","year":"2020","journal-title":"J Am Acad Dermatol"},{"key":"2025123106151472000_18.12.e268668.12","doi-asserted-by":"crossref","DOI":"10.3389\/fimmu.2018.02746","article-title":"Psoriasis: Classical vs. Paradoxical. 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