This systematic review and meta-analysis evaluated the incidence of active TB and LTBI conversion in dermatologic patients receiving systemic therapy (biologics, glucocorticoids, conventional immunosuppressants), spanning 31 studies with 15,005 patients searched through October 2025, with subgroup analyses by biologic class (TNF inhibitors, IL-17, IL-12/23) and regional TB burden.
Pooled LTBI conversion rate was 4.3% overall, highest with TNF inhibitors, followed by IL-17 inhibitors and ustekinumab (IL-12/23 p40 inhibitor). Active TB incidence was 1.0% overall, with markedly higher rates in high-burden regions (e.g., 30.2% in India with high-dose glucocorticoids, 14.1% in South Africa with SLE) versus very low rates in low-burden regions (e.g., 0.095% in the UK). Biologic-only LTBI conversion analyses showed substantial heterogeneity (I² = 81%).
High heterogeneity across studies (I² = 81% for biologic LTBI conversion) limits precision of pooled estimates. LTBI testing methods varied (TST vs. IGRA) and baseline screening protocols differed. Most included studies were observational cohorts with variable prophylaxis use, follow-up duration, and risk-of-bias scores (NOS 4–8/9).
Screen all dermatologic patients for LTBI before starting biologics—especially TNF inhibitors—and factor in regional TB burden when deciding on prophylaxis and monitoring intensity. In high-burden regions, even conventional immunosuppressants (glucocorticoids) carry substantial active TB risk and warrant close vigilance.
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