Tuberculosis-Related Outcomes in Dermatologic Patients Receiving Systemic Therapy

Importance: Biologic agents are commonly used with conventional immunosuppressants for treatment of immune-mediated dermatologic diseases, raising concerns about tuberculosis (TB) risk, particularly in high-burden geographic regions. Previous studies have shown inconsistent results across biologic classes, with most focusing on active TB and limited data on latent TB infection (LTBI) conversion. Objectives: To evaluate the incidence of active TB and LTBI conversion in dermatologic patients receiving systemic therapy and to explore differences by biologic class and regional TB burden. Data Sources: PubMed/MEDLINE, Embase, Web of Science Core Collection, and the Cochrane Library were searched from database inception to October 1, 2025. Controlled vocabulary and free-text terms were used for dermatologic diseases, systemic therapies, and tuberculosis-related outcomes. Clinical trial registries and reference lists were also screened. Study Selection: Randomized clinical trials, cohort studies, case-control studies, and cross-sectional studies reporting active TB or LTBI conversion in dermatologic patients receiving systemic therapy were included. Two reviewers independently screened records and performed full-text assessment. Data Extraction and Synthesis: Data extraction and risk-of-bias assessment (Newcastle-Ottawa Scale and Cochrane Risk of Bias tool) were conducted independently by 2 reviewers following PRISMA guidelines. Single-arm incidence rates were pooled using random-effects models with logit transformation. Prespecified subgroup analyses were conducted by biologic class and regional TB burden. Main Outcomes and Measures: Primary outcomes were incidence of LTBI conversion (among patients with negative baseline results of tuberculin skin test or interferon-gamma release assay) and active TB during follow-up. Results: Of 4726 records identified, 31 studies comprising a total of 15 005 patients met inclusion criteria and were included in the analysis. The pooled incidence of LTBI conversion was 4.3%, highest with tumor necrosis factor inhibitors, followed by interleukin (IL)-17 and ustekinumab (IL-12/23 p40 inhibitor). The overall incidence of active TB was 1.0% and it was more frequent in high-burden regions. Conclusions and Relevance: In this systematic review and meta-analysis, TB-related risk varied by biologic mechanism and epidemiologic context. Risk assessment and monitoring should integrate dermatologic treatment class and regional TB burden to guide clinical decision-making.