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Hajizadeh N, Heidari A, Sadeghi S, Goodarzi A. Tumor necrosis factor inhibitors and janus kinase inhibitors in the treatment of cicatricial alopecia: A systematic review. PLoS One 2024; 19:e0293433. [PMID: 38335182 PMCID: PMC10857607 DOI: 10.1371/journal.pone.0293433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/12/2023] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Cicatricial alopecia (CA) refers to various conditions that result in permanent hair loss. Treatment of CA has always been challenging. Regarding immune-mediated pathophysiology for many CA subtypes, the administration of Janus kinase (JAK) and tumor necrosis factor (TNF) inhibitors have potentiated the treatments of CA. METHODS After a thorough systematic search in PubMed/Medline, Embase, Web of Science, Scopus, Google Scholar, ClinicalTrials.gov, and WHO ICTRP, a total of 3,532 relevant records were retrieved and screened. Accordingly, 56 studies met the eligibility criteria and entered the review. RESULTS Among JAK inhibitors, oral tofacitinib was the most frequently reported and the most effective treatment in improving signs and symptoms of CA with minimal adverse effects (AEs). Baricitinib was another JAK inhibitor with sustained improvement while causing mild AEs. As a TNF inhibitor, adalimumab induced a rapid and stable improvement in signs and symptoms in most patients with rare, tolerable AEs. Thalidomide was the other frequently reported yet controversial TNF inhibitor, which caused a rapid and significant improvement in the condition. However, it may result in mild to severe AEs, particularly neuropathies. Infliximab is a TNF inhibitor with mostly favorable results, albeit in a few patients caused treatable dermatological AEs. Apremilast and certolizumab pegol caused an incomplete amelioration of signs and symptoms with no AEs. Lenalidomide is another TNF inhibitor that can induce temporary improvement in CA with probable AEs. It is noteworthy that utilizing adalimumab, infliximab, etanercept, golimumab, and an anonymous TNF inhibitor has induced paradoxical CA and other A.E.s in some patients. CONCLUSION Recent studies have recommended JAK and TNF inhibitors, especially oral tofacitinib and adalimumab, as a new modality or adjuvant therapy to previous medications for primary CA. Nonetheless, monitoring AEs on a regular basis is suggested, and further extensive studies are required before definitive recommendations.
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Affiliation(s)
- Nima Hajizadeh
- School of Medicine, Iran University of Medical Sciences, Tehran, Iran
- Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
| | - Amirhossein Heidari
- Faculty of Medicine, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Sara Sadeghi
- Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
- Department of Medicine, New York Health System, South Brooklyn Hospital, New York, NY, United States of America
| | - Azadeh Goodarzi
- Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), Iran University of Medical Sciences, Tehran, Iran
- Department of Dermatology, Faculty of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center (RCRDC), School of Medicine, Iran University of Medical Sciences, Tehran, Iran
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2
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Verdelli A, Corrà A, Mariotti EB, Aimo C, Ruffo di Calabria V, Volpi W, Quintarelli L, Caproni M. An update on the management of refractory cutaneous lupus erythematosus. Front Med (Lausanne) 2022; 9:941003. [PMID: 36213629 PMCID: PMC9537468 DOI: 10.3389/fmed.2022.941003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/29/2022] [Indexed: 11/15/2022] Open
Abstract
Management of cutaneous lupus erythematosus (CLE) involves a combination of preventive measures, topical and systemic drugs, fairly similar for the different subtypes. Although guidelines exist, to date, no specific drugs have been specifically licensed for CLE. Antimalarials remain the first-line systemic treatment, but many patients do not respond, making refractory lupus a challenge for clinicians. The choice of alternative medication should be based on effectiveness, safety and cost. Most of the available drugs for CLE have been adapted from systemic lupus erythematosus (SLE) treatment but the existing literature is limited to small studies and evidence often lacks. As knowledge of pathogenesis of both CLE and SLE is improving, promising new therapies are emerging. In this review, we discuss the available medications, focusing on the novelties under development for CLE.
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Affiliation(s)
- Alice Verdelli
- Section of Dermatology, Azienda USL Toscana Centro, Florence, Italy
| | - Alberto Corrà
- Section of Dermatology, University of Florence, Florence, Italy
| | | | - Cristina Aimo
- Section of Dermatology, University of Florence, Florence, Italy
| | | | - Walter Volpi
- Section of Dermatology, Azienda USL Toscana Centro, Florence, Italy
| | - Lavinia Quintarelli
- Rare Dermatological Diseases Unit, Department of Health Sciences, Azienda USL Toscana Centro, University of Florence, Florence, Italy
| | - Marzia Caproni
- Rare Dermatological Diseases Unit, Department of Health Sciences, Azienda USL Toscana Centro, University of Florence, Florence, Italy
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3
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Wagner C, Chasset F, Francès C, Lipsker D. [Ungual lesions in lupus erythematosus: A retrospective study of 14 patients]. Ann Dermatol Venereol 2020; 147:823-832. [PMID: 32763004 DOI: 10.1016/j.annder.2020.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/12/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION There are few studies focusing on ungual lesions in patients with lupus erythematosus (LE). The aim of this study is to describe our experience with ungual lesions in LE patients. MATERIALS AND METHODS A multicentric retrospective descriptive study was performed at the dermatology departments of the university hospitals in Strasbourg and at the Tenon hospital in Paris and involved reviewing the medical records and photographs of patients with ungual lesions. RESULTS Fourteen patients were included: 12 (86 %) were women with a median age of 38 years (28-78 years). All patients had cutaneous LE presenting as follows: 3 isolated forms (21 %), and associated with systemic LE (LES) for remaining 11 patients (79 %). The most frequent ungual or peri-ungual lesions were longitudinal ridging (12 patients, 86 %), onycholysis and cuticular alterations (8 patients each, 57 %), pterygium (7 patients, 50 %), melanonychia, onychoschizia and subungual hyperkeratosis (5 patients with each, 36 %). Among patients with pterygium and onychoschizia, respectively 6 (86 %) and 5 (100 %) presented the discoid LE subtype, while respectively 6 (86 %) and 4 (80 %) had multisystemic involvement. DISCUSSION Ungual lesions do not appear specific and do not in themselves allow diagnosis of LE. They can in fact occur in other diseases such as connective tissue disorders. However, their diagnosis is important because certain of them, such as pterygium, can lead to severe ungual dystrophia, with functional consequences. In our study, pterygium and onychoschizia appeared to be associated with cutaneous discoid lupus erythematosus and multisystemic involvement. The coexistence of peri-ungual lesions related to cutaneous lupus erythematosus and/or multisystemic involvement does not out differentiation of lupus ungual lesions and post-inflammatory lesions.
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Affiliation(s)
- C Wagner
- Clinique dermatologique, université de Strasbourg, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - F Chasset
- Service de dermatologie et allergologie, faculté de médecine Sorbonne université, Sorbonne université, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris cedex 20, France
| | - C Francès
- Service de dermatologie et allergologie, faculté de médecine Sorbonne université, Sorbonne université, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris cedex 20, France
| | - D Lipsker
- Clinique dermatologique, université de Strasbourg, hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France.
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Reymann V, Bessis D, Bergeret B, Lipsker D, Du-Thanh A, Terrail N, Dandurand M, Dereure O. Efficacy and safety of low-dose oral lenalidomide in refractory cutaneous lupus erythematosus: an open series of 19 cases. J Eur Acad Dermatol Venereol 2020; 35:e113-e115. [PMID: 32730681 DOI: 10.1111/jdv.16839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- V Reymann
- Department of Dermatology and INSERM U1058 Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, Montpellier, France
| | - D Bessis
- Department of Dermatology and INSERM U1058 Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, Montpellier, France
| | - B Bergeret
- Department of Dermatology, University Hospital of Nimes, Nimes, France
| | - D Lipsker
- Department of Dermatology, University Hospital of Strasbourg, Strasbourg, France
| | - A Du-Thanh
- Department of Dermatology and INSERM U1058 Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, Montpellier, France
| | - N Terrail
- Outpatient Delivery Unit, Pharmacy, University Hospital of Montpellier, Montpellier, France
| | - M Dandurand
- Department of Dermatology, University Hospital of Nimes, Nimes, France
| | - O Dereure
- Department of Dermatology and INSERM U1058 Pathogenesis and Control of Chronic and Emerging Infections, University of Montpellier, Montpellier, France
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Drug-Induced Neutropenia During Treatment of Non-Neoplastic Dermatologic Diseases: A Review. Clin Drug Investig 2020; 40:915-926. [PMID: 32691244 DOI: 10.1007/s40261-020-00956-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Idiosyncratic drug-induced neutropenia (DIN) is a rare, potentially fatal adverse reaction. A literature search was performed on Pubmed and Embase, targeting articles indicating neutropenia as a complication during the treatment of non-neoplastic dermatological disorders. In 66 identified articles, the common incriminated drugs included conventional oral immunomodulators, topical cytotoxic agents, antibacterials, antifungals, biologics and targeted synthetic disease-modifying antirheumatic drugs, non-steroidal anti-inflammatory drugs, and retinoids, with dapsone being reported most often. The duration of drug exposure before the diagnosis of neutropenia varied, but mostly ranged from days to weeks. The majority of patients recovered after drug discontinuation and supportive management including antibiotics and granulocyte colony-stimulating factor, but fatal cases were reported. The proposed pathogenesis of DIN consists of direct drug toxicity and immune-mediated reaction. Certain genetic variants, individual variability in enzyme efficiency, and concomitant use of other drugs may increase the risk of DIN. Being familiar with the most commonly implicated agents and risk factors helps early identification and prompt management of this potentially fatal complication.
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6
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Domingo S, Solé C, Moliné T, Ferrer B, Ordi-Ros J, Cortés-Hernández J. Efficacy of Thalidomide in Discoid Lupus Erythematosus: Insights into the Molecular Mechanisms. Dermatology 2020; 236:467-476. [PMID: 32659758 DOI: 10.1159/000508672] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/11/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Thalidomide has been used successfully in a variety of chronic refractory inflammatory dermatological conditions with underlying autoimmune or infectious pathogenesis. It was first used for refractory discoid lupus erythematosus (DLE) in 1983 and has steadily grown since then. METHOD In this review, we describe the therapeutic benefits of thalidomide for DLE treatment and its biological properties. We explain how new discoveries in DLE pathogenesis are relevant to understand thalidomide's mechanism of action and the need to find an alternative safe drug with similar therapeutic effects. SUMMARY Thalidomide's efficacy in DLE patients is significant, with 80-90% reaching clinical remission according to different studies. However, thalidomide's use is still limited by serious adverse effects such as teratogenicity, neurotoxicity, and thrombosis. In addition, there is a frequent rate of relapse and many patients require a long-term low dose of thalidomide as maintenance. The achievement of clinical response within weeks is key to avoid irreversible DLE fibrotic sequelae, making it critical to introduce thalidomide earlier in the DLE treatment algorithm. Recently, microarray and miRNA screenings demonstrated a significant CD4+ T enrichment and T-helper 1 response predom-inance with a dysregulation of regulatory T cell (Treg) expression in DLE lesions that induced high levels of proinflammatory, chemotaxis, and apoptotic proteins that induce the chronic inflammation response. Thalidomide's anti-inflammatory, antiangiogenic, and T-cell co-stimulatory effects may be beneficial for DLE since it promotes cytokine inhibition, inhibits macrophage activation, regulates Treg responses, inhibits angiogenesis, modulates T cells, and promotes NK cell-mediated cytotoxicity.
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Affiliation(s)
- Sandra Domingo
- Rheumatology Research Group, Lupus Unit, Vall d'Hebron University Hospital, Vall d´Hebron Research Institute (VHIR), Barcelona, Spain
| | - Cristina Solé
- Rheumatology Research Group, Lupus Unit, Vall d'Hebron University Hospital, Vall d´Hebron Research Institute (VHIR), Barcelona, Spain,
| | - Teresa Moliné
- Departament of Pathology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Berta Ferrer
- Departament of Pathology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Josep Ordi-Ros
- Department of Internal Medicine, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Josefina Cortés-Hernández
- Rheumatology Research Group, Lupus Unit, Vall d'Hebron University Hospital, Vall d´Hebron Research Institute (VHIR), Barcelona, Spain
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7
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Company-Quiroga J, Alique-García S, Romero-Maté A. Current Insights Into The Management Of Discoid Lupus Erythematosus. Clin Cosmet Investig Dermatol 2019; 12:721-732. [PMID: 31632120 PMCID: PMC6781736 DOI: 10.2147/ccid.s184824] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 09/18/2019] [Indexed: 12/18/2022]
Abstract
Discoid lupus erythematosus is the most disfiguring and common presentation of chronic cutaneous lupus erythematosus. Although most patients will respond to lifestyle measures and topical treatment, a non-negligible number of patients will require systemic and physical therapy, either alone or in combination. We performed a review of the available evidence on the discoid lupus erythematosus treatment. Lifestyle measures and topical treatment (corticosteroids and topical calcineurin inhibitors) remain the therapeutic strategies with the highest evidence level. Within systemic treatment approaches, antimalarial drugs are still the first-line therapy, while other systemic and physical therapies have highly variable evidence. Hence, we propose a therapeutic algorithm based on the strength of recommendations of the different treatment modalities, focusing on the refractory disease.
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8
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Chen KL, Krain RL, Werth VP. Advancing understanding, diagnosis, and therapies for cutaneous lupus erythematosus within the broader context of systemic lupus erythematosus. F1000Res 2019; 8:F1000 Faculty Rev-332. [PMID: 30984372 PMCID: PMC6436187 DOI: 10.12688/f1000research.17787.1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2019] [Indexed: 01/19/2023] Open
Abstract
Cutaneous lupus erythematosus (CLE) is an autoimmune disease that can be associated with systemic lupus erythematosus (SLE) symptoms. The pathogenesis of both CLE and SLE is multifactorial, involving genetic susceptibility, environmental factors, and innate and adaptive immune responses. Despite the efficacy of current medications, many patients remain refractory, highlighting the necessity for new treatment options. Unfortunately, owing to challenges related in part to trial design and disease heterogeneity, only one new biologic in the last 50 years has been approved by the US Food and Drug Administration for the treatment of SLE. Thus, although SLE and CLE have a similar pathogenesis, patients with CLE who do not meet criteria for SLE cannot benefit from this advancement. This article discusses the recent trials and emphasizes the need to include patients with single-organ lupus, such as CLE, in SLE trials.
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Affiliation(s)
- Kristen L. Chen
- Department of Dermatology, Corporal Michael J. Crescenz VAMC, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
- Department of Dermatology, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Suite 1-330A, Philadelphia, PA 19104, USA
| | - Rebecca L. Krain
- Department of Dermatology, Corporal Michael J. Crescenz VAMC, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
- Department of Dermatology, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Suite 1-330A, Philadelphia, PA 19104, USA
| | - Victoria P. Werth
- Department of Dermatology, Corporal Michael J. Crescenz VAMC, 3900 Woodland Avenue, Philadelphia, PA 19104, USA
- Department of Dermatology, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, Suite 1-330A, Philadelphia, PA 19104, USA
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9
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Nutan F, Ortega-Loayza AG. Cutaneous Lupus: A Brief Review of Old and New Medical Therapeutic Options. J Investig Dermatol Symp Proc 2018; 18:S64-S68. [PMID: 28941497 DOI: 10.1016/j.jisp.2017.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Accepted: 11/07/2016] [Indexed: 11/27/2022]
Abstract
Systemic lupus erythematosus is a chronic inflammatory condition which affects predominantly women in their 30s. It has several clinical manifestations, including skin lesions that can be classified as acute cutaneous lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus erythematosus. A multifaceted approach to treating cutaneous lupus is advocated.
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Affiliation(s)
- Fnu Nutan
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia, USA.
| | - Alex G Ortega-Loayza
- Department of Dermatology, Virginia Commonwealth University, Richmond, Virginia, USA
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Nakae Y, Hyuga M, Terada Y, Kishimoto W, Fukunaga A, Tabata S, Maesako Y, Komatsu K, Higuchi O, Nakane T, Arima N. Multiple Myeloma Presenting with Autoimmune Autonomic Ganglionopathy. Intern Med 2017; 56:3347-3351. [PMID: 29021436 PMCID: PMC5790725 DOI: 10.2169/internalmedicine.9096-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Autoimmune autonomic ganglionopathy is an autonomic disorder that occurs as a symptom of paraneoplastic neurological syndrome. To date, there have been no reports on multiple myeloma with autoimmune autonomic ganglionopathy. A 37-year-old Japanese woman suffered from orthostatic hypotension was diagnosed with multiple myeloma (IgG kappa type), and a serological examination revealed the presence of anti-ganglionic nicotinic acetylcholine receptor (anti-gAChR) antibodies. She was treated for multiple myeloma, as a result, the autonomic disturbance improved and her anti-gAChR antibody titer decreased to undetectable levels, despite the fact that she only achieved a partial remission of multiple myeloma. Treatment for multiple myeloma may improve autoimmune autonomic ganglionopathy.
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Affiliation(s)
- Yoshiki Nakae
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Mizuki Hyuga
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Yuta Terada
- Department of Neurology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Wataru Kishimoto
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Akiko Fukunaga
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Sumie Tabata
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Yoshitomo Maesako
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Kenichi Komatsu
- Department of Neurology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
| | - Osamu Higuchi
- Department of Clinical Research, National Hospital Organization Nagasaki Kawatana Medical Center, Japan
| | | | - Nobuyoshi Arima
- Department of Hematology, Kitano Hospital, The Tazuke Kofukai Medical Research Institute, Japan
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Wu EY, Schanberg LE, Wershba EC, Rabinovich CE. Lenalidomide for refractory cutaneous manifestations of pediatric systemic lupus erythematosus. Lupus 2017; 26:646-649. [PMID: 27837194 PMCID: PMC5388573 DOI: 10.1177/0961203316676377] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Objective Cutaneous manifestations of pediatric systemic lupus erythematosus cause significant morbidity. Lenalidomide, a thalidomide analogue, has shown promise treating cutaneous lupus erythematosus in adults. Our objective was to evaluate lenalidomide's efficacy and safety in treating refractory cutaneous manifestations of pediatric systemic lupus erythematosus. Methods We performed a retrospective chart review of 10 adolescents who received lenalidomide for recalcitrant cutaneous lupus erythematosus. Information was gathered at drug initiation and 6-month follow-up. The Wilcoxon matched-pairs signed-rank test was used to assess change in quantitative parameters of disease activity. Results Nine subjects were girls and six were African-American. Indications for lenalidomide treatment included alopecia, nasal and oral ulcers, extensive malar rash, discoid lesions, bullous lesions, panniculitis, cutaneous vasculitis, and Raynaud's phenomenon with digital ulcerations. Within 6 months, all patients demonstrated complete or near resolution based on physician report. Prednisone dose decreased from a mean 23.5 mg (SD± 13.3) to 12.25 mg (SD± 9.2) ( P= 0.008). Sedimentation rate decreased from a mean 29 mm/hour (SD± 31.5) to 17 mm/hour (SD± 18.1) ( P= 0.004). Lenalidomide was well tolerated. Conclusion Lenalidomide is an effective and safe treatment for a spectrum of dermatological conditions in pediatric systemic lupus erythematosus. Its use may allow a reduction in prednisone dose and decreased disfigurement. Prospective study is needed to clarify lenalidomide's role in treating cutaneous manifestations of systemic lupus erythematosus.
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Affiliation(s)
- E Y Wu
- 1 Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - L E Schanberg
- 2 Department of Pediatrics, Duke University Medical Center, Durham, USA
| | - E C Wershba
- 3 Phoenix Children's Medical Group, Phoenix, USA
| | - C E Rabinovich
- 2 Department of Pediatrics, Duke University Medical Center, Durham, USA
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12
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Fennira F, Chasset F, Soubrier M, Cordel N, Petit A, Francès C. Lenalidomide for refractory chronic and subacute cutaneous lupus erythematosus: 16 patients. J Am Acad Dermatol 2017; 74:1248-51. [PMID: 27185425 DOI: 10.1016/j.jaad.2016.01.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 01/20/2016] [Accepted: 01/25/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Feriel Fennira
- Université Paris 6, AP-HP, Service de Dermatologie-Allergologie, Hôpital Tenon, France
| | - François Chasset
- Université Paris 6, AP-HP, Service de Dermatologie-Allergologie, Hôpital Tenon, France
| | - Martin Soubrier
- Université de Clermont-Ferrand, Service de Rhumatologie, Hôpital G-Montpied, France
| | - Nadège Cordel
- Unité de Dermatologie et Médicine Interne, CHU de Pointe à Pitre, Université des Antilles, Guadeloupe
| | - Antoine Petit
- Université Paris VII, APHP, Service de Dermatologie, Hôpital Saint Louis, France
| | - Camille Francès
- Université Paris 6, AP-HP, Service de Dermatologie-Allergologie, Hôpital Tenon, France.
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13
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Werth VP, Fiorentino D, Sullivan BA, Boedigheimer MJ, Chiu K, Wang C, Arnold GE, Damore MA, Bigler J, Welcher AA, Russell CB, Martin DA, Chung JB. Brief Report: Pharmacodynamics, Safety, and Clinical Efficacy of AMG 811, a Human Anti-Interferon-γ Antibody, in Patients With Discoid Lupus Erythematosus. Arthritis Rheumatol 2017; 69:1028-1034. [PMID: 28118537 PMCID: PMC5434930 DOI: 10.1002/art.40052] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 01/17/2017] [Indexed: 01/22/2023]
Abstract
Objective Interferon‐γ (IFNγ) is implicated in the pathogenesis of discoid lupus erythematosus (DLE). This study sought to evaluate a single dose of AMG 811, an anti‐IFNγ antibody, in patients with DLE. Methods The study was designed as a phase I randomized, double‐blind, placebo‐controlled crossover study of the pharmacodynamics, safety, and clinical efficacy of AMG 811 in patients with DLE. Patients received a single subcutaneous dose of AMG 811 (180 mg) or placebo. The patients in sequence 1 received AMG 811 followed by placebo, while those in sequence 2 received placebo followed by AMG 811. Pharmacodynamic end points included global transcriptional analyses of lesional and nonlesional skin, IFNγ blockade signature (IGBS) transcriptional scores in the skin and blood, keratinocyte IFNγ RNA scores, and serum levels of CXCL10 protein. Additional end points were efficacy outcome measures, including the Cutaneous Lupus Erythematosus Disease Area and Severity Index, and safety outcome measures. Results Sixteen patients with DLE were enrolled in the study (9 in sequence 1 and 7 in sequence 2). AMG 811 treatment reduced the IGBS score (which was elevated in DLE patients at baseline) in both the blood and lesional skin. The keratinocyte IFNγ RNA score was not affected by administration of AMG 811. Serum CXCL10 protein levels (which were elevated in the blood of DLE patients) were reduced with AMG 811 treatment. The AMG 811 treatment was well tolerated but did not lead to statistically significant improvements in any of the efficacy outcome measures. Conclusion AMG 811 treatment led to changes in IFNγ‐associated biomarkers and was well tolerated, but no significant clinical benefit was observed in patients with DLE.
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Affiliation(s)
- Victoria P Werth
- University of Pennsylvania and Corporal Michael J. Crescenz Veterans Administration Medical Center, Philadelphia, Pennsylvania
| | | | | | | | - Kit Chiu
- Amgen Inc., Thousand Oaks, California
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14
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Kuhn A, Aberer E, Bata-Csörgő Z, Caproni M, Dreher A, Frances C, Gläser R, Klötgen HW, Landmann A, Marinovic B, Nyberg F, Olteanu R, Ranki A, Szepietowski JC, Volc-Platzer B. S2k guideline for treatment of cutaneous lupus erythematosus - guided by the European Dermatology Forum (EDF) in cooperation with the European Academy of Dermatology and Venereology (EADV). J Eur Acad Dermatol Venereol 2016; 31:389-404. [PMID: 27859683 DOI: 10.1111/jdv.14053] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 10/26/2016] [Indexed: 12/31/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is a rare inflammatory autoimmune disease with heterogeneous clinical manifestations. To date, no therapeutic agents have been licensed specifically for patients with this disease entity, and topical and systemic drugs are mostly used 'off-label'. The aim of the present guideline was to achieve a broad consensus on treatment strategies for patients with CLE by a European subcommittee, guided by the European Dermatology Forum (EDF) and supported by the European Academy of Dermatology and Venereology (EADV). In total, 16 European participants were included in this project and agreed on all recommendations. Topical corticosteroids remain the mainstay of treatment for localized CLE, and further topical agents, such as calcineurin inhibitors, are listed as alternative first-line or second-line topical therapeutic option. Antimalarials are recommended as first-line and long-term systemic treatment in all CLE patients with severe and/or widespread skin lesions, particularly in patients with a high risk of scarring and/or the development of systemic disease. In addition to antimalarials, systemic corticosteroids are recommended as first-line treatment in highly active and/or severe CLE. Second- and third-line systemic treatments include methotrexate, retinoids, dapsone and mycophenolate mofetil or mycophenolate acid, respectively. Thalidomide should only be used in selected therapy-refractory CLE patients, preferably in addition to antimalarials. Several new therapeutic options, such as B-cell- or interferon α-targeted agents, need to be further evaluated in clinical trials to assess their efficacy and safety in the treatment of patients with CLE.
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Affiliation(s)
- A Kuhn
- Interdisciplinary Center for Clinical Trials (IZKS), University Medical Center Mainz, Mainz, Germany.,Division of Immunogenetics, Tumor Immunology Program, German Cancer Research Center, Heidelberg, Germany
| | - E Aberer
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - Z Bata-Csörgő
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - M Caproni
- Department of Medical and Surgical Critical Care Section of Dermatology, University of Florence, Florence, Italy
| | - A Dreher
- Evidence-Based Medicine Frankfurt, Institute for General Practice, Goethe-University Frankfurt, Frankfurt, Germany
| | - C Frances
- Department of Dermatology and Allergology, Hôpital Tenon, Paris, France
| | - R Gläser
- Department of Dermatology, Venerology and Allergology, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - H-W Klötgen
- Department of Dermatology, Inselspital Bern - University Hospital, Bern, Switzerland
| | - A Landmann
- Division of Immunogenetics, Tumor Immunology Program, German Cancer Research Center, Heidelberg, Germany
| | - B Marinovic
- Department of Dermatology and Venereology, University Hospital Center Zagreb and School of Medicine University of Zagreb, Zagreb, Croatia
| | - F Nyberg
- Institution for Clinical Sciences, Unit for Dermatology, Karolinska Institutet at Danderyd Hospital (KIDS), Stockholm, Sweden
| | - R Olteanu
- Department of Dermatology, Colentina Clinical Hospital, Bucharest, Romania
| | - A Ranki
- Department of Skin and allergic diseases, Inflammation Center, Helsinki University Central Hospital, Helsinki, Finland
| | - J C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - B Volc-Platzer
- Department of Dermatology, Donauspital, University affiliated Hospital, Vienna, Austria
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Kindle SA, Wetter DA, Davis MDP, Pittelkow MR, Sciallis GF. Lenalidomide treatment of cutaneous lupus erythematosus: the Mayo Clinic experience. Int J Dermatol 2016; 55:e431-9. [PMID: 26873674 DOI: 10.1111/ijd.13226] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 10/13/2015] [Accepted: 10/19/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Published case series describe lenalidomide as an effective treatment of refractory cutaneous lupus erythematosus (CLE). OBJECTIVES The present study aimed to further characterize lenalidomide use in the treatment of CLE. METHODS A retrospective review of patients treated with lenalidomide for CLE from January 1, 2000, to December 17, 2014, was conducted. RESULTS Eight of the nine patients (89%) were women. Their median age at initiation of lenalidomide was 62 years (range: 41-86 years). Subtypes of CLE included discoid lupus erythematosus (DLE) (n = 6), lupus panniculitis (n = 2), and subacute CLE (n = 1). Before the initiation of lenalidomide, all patients had been previously treated unsuccessfully or were intolerant to at least one antimalarial and one immunosuppressive agent. With lenalidomide, five patients achieved a complete response (CR), two a partial response, and two had no response (lupus panniculitis). Time to initial response (dose range: 2.5-10.0 mg/d) varied from 2 weeks to 3 months; the median time to CR in five patients was 3 months (range: 3-6 months). The median duration of lenalidomide therapy was 12 months (range: 2-67 months). The median duration of follow-up was 48 months (range: 20-103 months). Adverse effects included mild leukopenia; one patient had deep vein thrombosis of unclear etiology during a hospitalization. No patients developed or showed progression of systemic LE while receiving lenalidomide. CONCLUSIONS Lenalidomide was effective for the treatment of CLE (particularly DLE) but not for the treatment of lupus panniculitis in this series.
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Affiliation(s)
- Scott A Kindle
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - David A Wetter
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
| | - Mark D P Davis
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
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Frankel HC, Sharon VR, Vleugels RA, Merola JF, Qureshi AA. Lower-dose thalidomide therapy effectively treats cutaneous lupus erythematosus but is limited by neuropathic toxicity. Int J Dermatol 2014; 52:1407-9. [PMID: 24164159 DOI: 10.1111/j.1365-4632.2011.05200.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Hillary C Frankel
- Department of Dermatology and Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USADepartment of Dermatology, University of California Davis, Sacramento, CA, USADepartment of Dermatology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USADepartment of Dermatology and Department of Rheumatology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USADepartment of Dermatology and Channing Laboratory, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Baret I, De Haes P. Thalidomide: Still an important second-line treatment in refractory cutaneous lupus erythematosus? J DERMATOL TREAT 2014; 26:173-7. [PMID: 24731053 DOI: 10.3109/09546634.2014.906036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cutaneous lupus erythematosus (CLE) can be a severe disease, characterized by extensive, disfiguring lesions and a relapsing course. Thalidomide is known as an effective treatment for CLE, however, its use is restricted by its potential side-effects. Nevertheless, it remains a valuable option to consider. Therefore, it is important to report new clinical experiences. METHODS The data of 30 patients with refractory CLE, who were treated with thalidomide, were retrospectively analyzed. The response rate was categorized as complete, partial or no response. The relapse rate and the occurrence of side-effects were registered. RESULTS Six patients prematurely discontinued treatment because of side-effects. The response rate was 100% in the remaining 24 patients, including 20 patients (83%) with complete response and 4 (27%) with partial response. Clinical relapse was frequent (73%) and occurred between 3 and 24 weeks after withdrawal of thalidomide. Nine patients (30%) developed peripheral neuropathy. In the majority, there was no complete resolution of the neuropathy-associated symptoms after stopping thalidomide. One patient developed a thrombosis in an artery stent. CONCLUSION Because of high risk of polyneuropathy, low-dose thalidomide should be used and long-term therapy should be avoided. Therefore, it should be recommended to combine thalidomide with other treatments for CLE.
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Affiliation(s)
- Isabelle Baret
- Department of Dermatology, University Hospital Leuven , Leuven , Belgium
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Anyanwu C, Langenhan J, Werth VP. Measurement of disease severity in cutaneous autoimmune diseases. F1000PRIME REPORTS 2013; 5:19. [PMID: 23755366 PMCID: PMC3673224 DOI: 10.12703/p5-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of disease-specific outcome instruments for several autoimmune skin diseases including cutaneous lupus erythematosus (CLE), dermatomyositis, vitiligo, pemphigus and alopecia areata has facilitated the objective assessment of disease in clinical trials. Validation of these instruments provides reliable tools to measure disease severity and therapeutic effect in clinical studies. However, the existence of multiple outcome measures for each disease and the lack of uniformity between studies has created a challenge in comparing results across trials. Efforts to address this issue include the Core Outcome Measures in Effectiveness Trials (COMET) initiative and international meetings directed at reaching a consensus. Other challenges with the use of outcome measures include difficulties measuring change in mild disease, measuring response in topical studies, and capturing disease activity in skin with extensive post-inflammatory hyperpigmentation.
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Affiliation(s)
- Cynthia Anyanwu
- Philadelphia VA Medical CenterPhiladelphia, PA
- Department of Dermatology, University of Pennsylvania School of MedicinePhiladelphia, PA
| | - Jamie Langenhan
- Philadelphia VA Medical CenterPhiladelphia, PA
- Department of Dermatology, University of Pennsylvania School of MedicinePhiladelphia, PA
| | - Victoria P. Werth
- Philadelphia VA Medical CenterPhiladelphia, PA
- Department of Dermatology, University of Pennsylvania School of MedicinePhiladelphia, PA
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Abstract
Cutaneous lupus erythematosus (CLE) encompasses a wide range of dermatologic manifestations, which may or may not be associated with the development of systemic disease. Cutaneous lupus is divided into several sub-types, including acute CLE (ACLE), sub-acute CLE (SCLE) and chronic CLE (CCLE). CCLE includes discoid lupus erythematosus (DLE), LE profundus (LEP), chilblain cutaneous lupus and lupus tumidus. The diagnosis of these diseases requires proper classification of the sub-type, through a combination of physical examination, laboratory studies, histology, antibody serology and occasionally direct immunofluorescence, while ensuring to exclude systemic disease. The treatment of cutaneous lupus consists of patient education on proper sun protection along with appropriate topical and systemic agents. Systemic agents are indicated in cases of widespread, scarring or treatment-refractory disease. In this chapter, we discuss issues in classification and diagnosis of the various sub-types of CLE, as well as provide an update on therapeutic management.
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Affiliation(s)
- Lauren G. Okon
- Department of Dermatology Perelman Center for Advanced Medicine Suite 1-330A 3400 Civic Center Boulevard Philadelphia, PA 19104 Tel. 215-823-4208 Fax 866-755-0625
| | - Victoria P. Werth
- Department of Dermatology Perelman Center for Advanced Medicine Suite 1-330A 3400 Civic Center Boulevard Philadelphia, PA 19104
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Chang YC, Werth VP. Update on Epidemiology and Clinical Assessment Tools of Cutaneous Lupus Erythematosus and Dermatomyositis. CURRENT DERMATOLOGY REPORTS 2013; 2:48-57. [PMID: 33585073 PMCID: PMC7880122 DOI: 10.1007/s13671-012-0037-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cutaneous Lupus Erythematosus (CLE) and Dermatomyositis (DM) are cutaneous autoimmune diseases that have been among the least systematically studied, due in part to the lack of validated outcome instruments in the past. More recent epidemiologic studies have elucidated the incidence and prevalence of these diseases and their subtypes. In addition, the advent of validated clinical outcome measures, including the Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) and the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI), has led to an objective means of measuring activity and damage of the disease. These outcome measures have established the framework for evaluating responsiveness and therapeutic efficacy in clinical trials as well as longitudinal studies to study disease course.
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Affiliation(s)
- Yunyoung C Chang
- Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Victoria P Werth
- Philadelphia Veterans Affairs Medical Center, Philadelphia, PA, USA
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Cortés-Hernández J, Ávila G, Vilardell-Tarrés M, Ordi-Ros J. Efficacy and safety of lenalidomide for refractory cutaneous lupus erythematosus. Arthritis Res Ther 2012; 14:R265. [PMID: 23217273 PMCID: PMC3674591 DOI: 10.1186/ar4111] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 11/12/2012] [Indexed: 01/08/2023] Open
Abstract
Introduction Cutaneous lupus erythematosus (CLE) is a chronic disease characterized by disfigurement and a relapsing course. Thalidomide has proven its efficacy in refractory cutaneous lupus disease, although it is not exempt from significant side effects and frequent relapses after withdrawal. New thalidomide analogues have been developed but lack clinical experience. The aim of this preliminary phase II study was to evaluate the efficacy and safety of lenalidomide in patients with refractory CLE. Methods Fifteen patients with refractory cutaneous lupus disease were enrolled in this single-center, open-label, non-comparative pilot trial between January 2009 and December 2010. Oral lenalidomide (5 to 10 mg/day) was administered and tapered according to clinical response. Patients were followed up for a mean of 15 months (range: 7 to 30). Primary efficacy endpoint was the proportion of patients achieving complete response, defined by a Cutaneous Lupus Erythematosus Disease Area and Severity index (CLASI) activity score of 0. Other secondary endpoints included development of side effects, evaluation of cutaneous and systemic flares, and impact on the immunological parameters. Results One patient discontinued treatment due to side effects. All remaining patients saw clinical improvement and this was already noticeable after 2 weeks of treatment. Twelve of those patients (86%) achieved complete response but clinical relapse was frequent (75%), usually occurring 2 to 8 weeks after lenalidomide's withdrawal. No influence on systemic disease, immunological parameters or CLASI damage score was observed. Side effects including insomnia, grade 2 neutropenia and gastrointestinal symptoms, were minor (13%). These resolved after withdrawing medication. Neither polyneuropathy nor thrombosis was observed. Conclusion Lenalidomide appears to be efficacious and safe in patients with refractory CLE, but clinical relapse is frequent after its withdrawal. Trial registration ClinicalTrials.gov: NCT01408199.
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Abstract
Cutaneous lupus erythematosus is a heterogeneous autoimmune condition that can significantly impact quality of life. Treatment is focused on reducing clinical inflammation and preventing scarring. The choice of treatment should be guided based on the severity of disease. Mild or localized disease can be treated with sun protection and topical agents. Antimalarials are the initial treatment of choice if systemic therapy is required. Patients with severe or unresponsive disease can also be treated with a number of other immunomodulating or immunosuppressive agents. Clinicians should be aware of their potential adverse effects and appropriate dosing.
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Affiliation(s)
- Christopher B Hansen
- Department of Dermatology, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA.
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24
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Kuhn A, Ruland V, Bonsmann G. Cutaneous lupus erythematosus: Update of therapeutic options. J Am Acad Dermatol 2011; 65:e195-213. [DOI: 10.1016/j.jaad.2010.06.017] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 05/28/2010] [Accepted: 06/04/2010] [Indexed: 12/23/2022]
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Abstract
Cutaneous lupus erythematosus (CLE) is an autoimmune inflammatory skin disease seen in patients with or without systemic lupus erythematosus. The management of CLE includes treatment and prevention of lesions as well as routine assessment for systemic disease. Treatment options include topical and systemic therapies. Topical therapies include corticosteroids and calcineurin inhibitors. Systemic therapies generally fall under one of three categories: antimalarials, immunomodulators (eg, dapsone and thalidomide), and immunosuppressives (eg, methotrexate and mycophenolate). Evidence for the treatment of CLE has been limited by few prospective studies and the lack of a validated outcome measure (until recently). There is good evidence to support the use of topical steroids and calcineurin inhibitors, although most of these trials have not used placebo or vehicle controls. There have been no randomized, placebo-controlled trials evaluating systemic therapies in the treatment of CLE.
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Affiliation(s)
- Aileen Y Chang
- Department of Dermatology, Perelman Center for Advanced Medicine, University of Pennsylvania School of Medicine, Philadelphia, USA.
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26
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Lenalidomide-induced purpuric eruption: A new adverse cutaneous reaction. J Am Acad Dermatol 2011; 65:654-656. [DOI: 10.1016/j.jaad.2010.04.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2010] [Revised: 03/17/2010] [Accepted: 04/22/2010] [Indexed: 11/24/2022]
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Lenalidomide therapy in treatment-refractory cutaneous lupus erythematosus: histologic and circulating leukocyte profile and potential risk of a systemic lupus flare. J Am Acad Dermatol 2011; 66:571-82. [PMID: 21821308 DOI: 10.1016/j.jaad.2011.01.015] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2010] [Revised: 10/11/2010] [Accepted: 01/19/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND Lenalidomide is a thalidomide analogue that may serve as an adjunctive therapy for treatment-refractory cutaneous lupus erythematosus (CLE). OBJECTIVES We evaluate the use of lenalidomide in CLE and describe the skin and circulating leukocyte profile of treatment-refractory patients before and after treatment. METHODS Five subjects were treated with lenalidomide in an unblinded open-label study. Immunohistochemistry of skin was performed for T-cell markers, glycosaminoglycans, and CXCL10, an interferon-inducible chemokine, before and after treatment. Immunophenotyping and measurement of interferon-inducible genes from peripheral blood mononuclear cells was also performed before and after treatment. RESULTS Four subjects demonstrated clinical improvement of their skin, however one of these responders subsequently developed symptoms of systemic lupus erythematosus. Small changes in rare circulating leukocyte subsets, plasmacytoid dendritic cells, and regulatory T cells were observed with treatment and may correlate with clinical response. Treatment was associated with increased circulating HLA-DR expression and decreased markers of interferon-mediated pathways, regardless of clinical response. LIMITATIONS Our results are limited by small sample size and the measurement of rare populations of circulating cell subsets. CONCLUSIONS Lenalidomide may have usefulness as therapy for severe, treatment-refractory CLE. However, our preliminary data suggest that lenalidomide may activate T cells and trigger systemic disease in some patients with CLE. We also saw a different histologic and circulating leukocyte phenotype in the nonresponding subject. Further characterization of the skin and circulating leukocyte profile of treatment-refractory patients will improve our understanding of CLE.
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Chang AY, Piette EW, Foering KP, Tenhave TR, Okawa J, Werth VP. Response to antimalarial agents in cutaneous lupus erythematosus: a prospective analysis. ACTA ACUST UNITED AC 2011; 147:1261-7. [PMID: 21768444 DOI: 10.1001/archdermatol.2011.191] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To demonstrate response to antimalarial agents in patients with cutaneous lupus erythematosus (CLE) using activity scores from the Cutaneous Lupus Erythematosus Disease Area and Severity Index, a validated outcome measure. DESIGN Prospective, longitudinal cohort study. SETTING University cutaneous autoimmune disease clinic. PARTICIPANTS A total of 128 patients with CLE who presented from January 2007 to July 2010 and had at least 2 visits with activity scores. INTERVENTION Administration of antimalarial agents. MAIN OUTCOME MEASURES Response was defined by a 4-point or 20% decrease in activity score. Response to initiation was determined by the difference between the scores before treatment and at the first visit at least 2 months after treatment. Response to continuation was determined by the difference between the scores at the first visit and the most recent visit while undergoing treatment. RESULTS Of 11 patients who initiated treatment with hydroxychloroquine, 55% were responders (n = 6), showing a decrease in median (interquartile range [IQR]) activity score from 8.0 (3.5-13.0) to 3.0 (1.8-7.3) (P = .03). Of 15 patients for whom hydroxychloroquine failed, 67% were responders to initiation of hydroxychloroquine-quinacrine therapy (n = 10), showing a decrease in median (IQR) activity score from 6.0 (4.8-8.3) to 3.0 (0.75-5.0) (P = .004). Nine of 21 patients who continued hydroxychloroquine treatment (43%), and 9 of 21 patients who continued hydroxychloroquine-quinacrine (43%) were responders, showing a decrease in median (IQR) activity score from 6.0 (1.5-9.5) to 1.0 (0.0-4.5) (P = .01) and 8.5 (4.25-17.5) to 5.0 (0.5-11.5) (P = .01), respectively. CONCLUSIONS The use of quinacrine with hydroxychloroquine is associated with response in patients for whom hydroxychloroquine monotherapy fails. Further reduction in disease activity can be associated with continuation of treatment with antimalarial agents.
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Affiliation(s)
- Aileen Y Chang
- Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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Abstract
In patients with cutaneous lupus erythematosus (CLE) and mild skin involvement, local therapy consisting of topically applied pharmacological agents, e.g., topical/intralesional steroids, may be sufficient. Recent reports have also shown efficacy of topical calcineurin inhibitors in patients with CLE, particularly on the face. Special attention receives consistent sun protection through photoresistant clothing and application of light-shielding substances with highly potent chemical or physical UVA- and UVB-protective filters. These substances should be applied in sufficient amount (ca. 2 mg/cm(2)) at least 20-30 minutes before sun exposure in order to avoid induction and exacerbation of cutaneous lesions. The mainstay of treatment for disfiguring and widespread skin manifestations in patients with CLE, irrespective of the subtype of the disease, is antimalarial agents. Our understanding of the use of combinations of antimalarials and proper dosing according to the ideal bodyweight limits problems with toxicity. Further therapies, such as methotrexate, or retinoids, dapsone, mycophenolate mofetil, and thalidomide in selected cases, can be helpful for patients with resistant disease; however, side effects need to be taken into consideration. Recent advances in biotechnology resulted in the development of novel systemic agents, but randomized controlled trials are necessary for the approval of new therapeutic strategies in CLE.
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Affiliation(s)
- A Kuhn
- Department of Dermatology, University of Münster, Münster, Germany.
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30
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Abstract
This article focuses on the management of discoid lupus erythematosus, subacute cutaneous lupus erythematosus, and systemic lupus erythematosus when the usual therapeutic arsenal such as oral antimalarial drugs and topical/oral steroids fail or provide insufficient treatment efficacy. Many of the treatments listed are the same or similar to each other because of similarities in the pathogenesis of various subtypes of cutaneous lupus. The clinical challenge is to determine the indications for topical versus systemic therapy, and to also identify the scenarios when combined therapy is necessary.
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Affiliation(s)
- Haydee M Knott
- Department of Dermatology, Cleveland Clinic, 9500 Euclid Avenue, A-61, Cleveland, OH 44195, USA
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Klein RS, Morganroth PA, Werth VP. Cutaneous lupus and the Cutaneous Lupus Erythematosus Disease Area and Severity Index instrument. Rheum Dis Clin North Am 2010; 36:33-51, vii. [PMID: 20202590 DOI: 10.1016/j.rdc.2009.12.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article provides an overview of cutaneous lupus erythematosus, including classification schemes, disease subtypes, and therapy. It also describes the Cutaneous Lupus Erythematosus Disease Area and Severity Index, a novel clinical outcome instrument that quantifies cutaneous activity and damage in cutaneous lupus erythematosus.
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Rottman JB, Willis CR. Mouse Models of Systemic Lupus Erythematosus Reveal a Complex Pathogenesis. Vet Pathol 2010; 47:664-76. [DOI: 10.1177/0300985810370005] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The mammalian immune system is remarkable in that it can respond to an essentially infinite number of foreign antigens. The ability to mount a long-lasting (adaptive) immune response against foreign antigen requires the participation of cells selected from an enormously diverse population of B and T cells. Because the B and T cell receptors expressed by these cells are generated at random, a significant percentage of B and T cells are invariably directed against self-antigen. Under normal circumstances, autoreactive B and T cells are eliminated, reprogrammed, or inactivated in the primary and secondary lymphoid organs. Despite these checks and balances, a small but significant number of people and animals still develop autoimmune disease. One such autoimmune disease—systemic lupus erythematosus—is characterized by the loss of B- and T-cell tolerance to self-antigens (principally nuclear), culminating in multisystemic inflammation. Multiple genetic defects, drug exposure, infectious agents, and environmental factors can contribute to the pathogenesis of the disease. Loss of B- and T-cell tolerance precipitates activation of plasmacytoid and myeloid dendritic cells; collectively, these cells cooperate to form a complex positive feedback loop, continually stimulated by the persistence of self-antigen. Novel treatment strategies now focus on specific inhibition of various aspects of the feedback loop. These specific inhibitors have the potential to be more effective and lack the side effects associated with generalized immunosuppression.
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Affiliation(s)
- J. B. Rottman
- Pathology Department, Amgen Inc, Cambridge, Massachusetts
| | - C. R. Willis
- Inflammation Research, Amgen Inc, Seattle, Washington
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Abstract
PURPOSE OF REVIEW There is an increasing interest in improving the understanding of pathophysiology, outcome measures, and therapies of rheumatic skin disease. Increasingly, studies are using the skin as a primary endpoint for evaluating therapies. This will review the current state of the art for the most common rheumatic skin diseases. RECENT FINDINGS A number of medications, including biologics such as tumor necrosis factor alpha and interferon, have been associated with onset of cutaneous lupus. The cutaneous lupus erythematosus area and severity index has been further validated and utilized in a number of studies. Smoking continues to be associated both with presence and refractoriness of cutaneous lupus erythematosus to therapy. There are several tools now available for evaluating the skin disease of dermatomyositis, but there is a need for new effective therapies. Measurement of skin disease in scleroderma continues to be a challenge, and there is a need for more effective therapies. Several studies show efficacy of intravenous iloprost for severe Raynaud's and skin ulcers, and of bosentan for digital ulcers. SUMMARY The present review covers new outcome measures, treatments, and unusual manifestations of cutaneous lupus, dermatomyositis, scleroderma, and rheumatoid arthritis. There have been a number of new studies related to validation of disease activity measures, as well as their use in evaluation of new therapies for these conditions. Validated outcome measures are required to perform meaningful studies, and will facilitate organized epidemiologic, quality of life, and therapeutic studies.
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Quoi de neuf en thérapeutique dermatologique ? Ann Dermatol Venereol 2009; 136 Suppl 7:S445-59. [DOI: 10.1016/s0151-9638(09)73386-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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