Anti-TNFα therapy and microvascular changes: a case-based review of the potential association with early scleroderma pattern development.

Tumor necrosis factor-alpha (TNFα) inhibitors have profoundly transformed the therapeutic landscape of psoriatic arthritis (PsA), offering effective control of synovitis, enthesitis, and axial disease, while preventing progressive joint destruction. However, emerging evidence suggests that TNFα blockade may be temporally associated with autoimmune phenomena, including vasculitis, drug-induced lupus erythematosus, and systemic sclerosis-like manifestations. The potential impact of vascular homeostasis and endothelial function changes secondary to TNFα inhibition has emerged as a topic of considerable clinical interest. Through a detailed case presentation and comprehensive literature review, we examine the case of a 30-year-old male with PsA who, during maintenance therapy with adalimumab, developed a capillaroscopic pattern characterized by megacapillaries and microhemorrhages, consistent with early systemic sclerosis (SSc) features, despite the absence of overt connective tissue disease manifestations. Comprehensive immunological screening excluded specific autoantibodies typically associated with SSc, and extensive instrumental evaluations ruled out internal organ involvement. This clinical observation, analyzed within the context of current literature, highlights the need for understanding the potential temporal relationship between long-term TNFα inhibition and microvascular changes, while supporting the prospective use of nailfold videocapillaroscopy (NVC) as a valuable surveillance tool in biologic-treated cohorts. Early recognition of subclinical vascular abnormalities may enhance risk stratification and guide tailored monitoring strategies in selected patients.