Biologics May be Effective for Erythrodermic Psoriasis
Some biologics, such as ustekinumab (Stelara) and infliximab (Remicade), were found to be safe and effective for patients with erythrodermic psoriasis in a recent study published in Journal of the American Academy of Dermatology.
In the systemic review, researchers analyzed treatment response and tolerability of biologic medications in 43 studies with a total of 179 patients with erythrodermic psoriasis. Baseline Psoriasis Area Severity Index (PASI) score, PASI improvement score, and adverse events were reported, and adequate treatment was defined as PASI ≥50.
Most patients responded at some point during treatment, the researchers said. They found a higher level of evidence supported the effectiveness of infliximab, ustekinumab, ixekizumab (Taltz), and guselkumab (Tremfya). The most commonly reported adverse event was infection (n=35), the researchers noted.
“Patients with erythrodermic psoriasis treated with biologics demonstrated positive responses and treatment was well-tolerated with a weak recommendation and limited quality of evidence in favor of infliximab, ustekinumab, ixekizumab, and guselkumab,” they concluded.
Reference
Carrasquillo OY, Pabón-Cartagena G, Falto-Aizpurua LA, et al. Treatment of erythrodermic psoriasis with biologics: a systematic review. J Am Acad Dermatol. Published online April 2, 2020. doi:10.1016/j.jaad.2020.03.073
Is Mycophenolate an Effective Option for Morphea?
A recent study in JAMA Dermatology found mycophenolate was a well-tolerated, effective treatment for patients with recalcitrant, severe morphea.
The current first-line therapy for morphea is methotrexate with or without systemic corticosteroids, but for patients who are unresponsive, intolerant, or contraindicated to that treatment, mycophenolate (either mycophenolate mofetil or mycophenolic acid), is recommended. However, evidence to support this recommendation is weak, the researchers said.
To evaluate the effectiveness of mycophenolate on morphea disease activity, the researchers conducted a retrospective cohort study. The study consisted of 77 patients with morphea (61 [79%] female) from eight institutions over a 20-year period. The median age of disease onset was 36 years and median diagnostic delay was 8 months. Disease activity, severity, and response at 0, 3 to 6, and 9 to 12 months of mycophenolate treatment were assessed as the primary outcomes, and tolerance of mycophenolate was assessed as the secondary outcome.
The most common subtypes of disease were generalized morphea (37 [48%]), pansclerotic morphea (12 [16%]), and linear morphea of the trunk and/or extremities (9 [12%]). Of the patient cohort, 41 (53%) had an associated functional impairment and 49 (64%) had severe disease.
Further, 12 of the 77 patients were initially treated with mycophenolate as monotherapy or combination therapy. The other 65 patients received mycophenolate after the initial therapy was ineffective (50/65 [77%]) or poorly tolerated (21/65 [32%]). Methotrexate (48/65 [74%]), systemic corticosteroids (42/65 [65%]), hydroxychloroquine (20/65 [31%]), and/or phototherapy (14/65 [22%]) were the most common initial therapies used.
The researchers observed stable or improved disease among 22 and 44 patients, respectively, after 3 to 6 months of treatment with mycophenolate. Following 9 to 12 months of treatment, the researchers found 14 patients had stable and 33 had improved disease. By the end of the study, 27 (35%) patients achieved disease remission.
“Treatments received in conjunction with mycophenolate were frequent,” the researchers said, noting that mycophenolate was well tolerated. The most common adverse events were gastrointestinal (24 [31%]), while cytopenia (3 [4%]) and infection (2 [3%]) were the less frequent.
“This study suggests that mycophenolate is a well-tolerated and beneficial treatment of recalcitrant, severe morphea,” the researchers concluded.
Reference
Arthur M, Fett NM, Latour E, et al. Evaluation of the effectiveness and tolerability of mycophenolate mofetil and mycophenolic acid for the treatment of morphea. JAMA Dermatol. Published online April 1, 2020. doi:10.1001/jamadermatol.2020.0035
NCCN Releases Advisory Statement for NMSC During Pandemic
On March 30, 2020, the National Comprehensive Cancer Network released a second version of their advisory statement on the management of non-melanoma skin cancer (NMSC) during the coronavirus disease (COVID-19) pandemic.
“The advisory should be interpreted in the context of the practitioners’ local situations,” the authors said. “Physicians are encouraged to work with local authorities to comply with institutional and local guidelines, as well as be prepared to suspend excisional surgery if insufficient space, equipment or personnel are available to proceed safely.”
The general recommendations include:
- Multidisciplinary teleconferences should be used whenever possible for developing care plans for high-risk NMSCs, including merkel cell carcinoma (MCC), that require treatment beyond office-based excision for local disease. These complex decisions should be made on a case-by-case basis using available resources and considering patient risk factors.
- Teleconference, using video and photographic evaluation, are encouraged for evaluating new tumors if possible.
- Follow-up using teleconference and/or photographs is encouraged for small lesions suspected of NMSC. Biopsies should be reserved for growing lesions or those that are highly concerning.
- If a small lesion is undergoing biopsy, physicians should obtain photographs with landmarks, such as tattoos, or have patients re-mark the site daily to facilitate accurate site location in case there is a delay.
Recommendations for NMSC, not including MCC:
- All excisions should be postponed during the COVID-19 pandemic.
- If NMSC poses a risk for metastasis or debilitating progression within 3 months, as estimated by the physician, excision may be considered. The risks posed by the tumor should be weighed against the risk of COVID-19 infection or asymptomatic transmission of infection to health care workers during care.
- Adjuvant therapy after surgical clearance of local excision is not recommended to be undertaken during this time due to the multiple visits needed and increased risk of COVID-19 transmissions. Exceptions to this recommendation are patients with extensive or multifocal invasion of large caliber nerves, clinical trials, and N2 disease (eg, multiple nodes involved, extranodal extension, a nodal disease focus >3 cm) based on the eighth edition of the AJCC Cancer Staging Manual.
Recommendations for MCC include:
- Excisions are not recommended to be deferred during the COVID-19 pandemic, except for elderly or frail patients with tumors of < 1 cm.
- If operating rooms are not available, office-based excisions using wide local excision with standard margins or Mohs surgery can be performed with deferral of sentinel lymph node biopsy (SLNB). Excisions should be allowed to granulate or closed primarily with cerclage or linear closure without undermining to facilitate SLNB at a later date.
- Multidisciplinary decision-making is recommended for patients with clinical stage III disease, and these decisions should be based on each patient’s medical comorbidities, degree of tumor burden, and scarcity of hospital resources.
In addition, the statement recommends the use of dissolving sutures to avoid return visits, telemedicine for postoperative care, and N95 masks for patients with facial lesions undergoing surgery, especially for those on the nose or lips, along with eye protection, to prevent the risk of contracting or transmitting COVID-19.
Reference
National Comprehensive Cancer Network. Advisory statement for non-melanoma skin cancer care during the COVID-19 pandemic. Published March 30, 2020. Accessed April 2, 2020. https://www.nccn.org/covid-19/pdf/NCCN-NMSC.pdf
Topical AD Therapy Not Associated With Cancer in Children
Tacrolimus, a topical calcineurin inhibitor, does not appear to increase the risk of cancer among pediatric patients with atopic dermatitis (AD), according to the findings of a recent study in Journal of the American Academy of Dermatology.
Using data from APPLES (A Prospective Pediatric Longitudinal Evaluation to Assess the Long-term Safety of Tacrolimus Ointment for the Treatment of AD), the researchers assessed the incident of malignancies over 10 years among children with AD treated with topical tacrolimus for 6 weeks or more.
The researchers calculated standardized incidence ratios for cancer events compared with sex-, age-, and race-matched controls using data from national cancer registries. A total of 7954 patients enrolled at 314 sites were included in the study.
Six confirmed cancer cases occurred over 44,629 person-years, the researchers said, but there was no diagnosis of lymphoma.
“This finding provides no support for the hypothesis that topical tacrolimus increases long-term cancer risk in children with AD,” the researchers concluded.
Reference
Paller AS, Fölster-Holst R, No Chen SC, et al. Evidence of increased cancer incidence in children using topical tacrolimus for atopic dermatitis. J Am Acad Dermatol. Published online April 1, 2020. doi:10.1016/j.jaad.2020.03.075
