1
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Cho SK, Vazquez T, Werth VP. Litifilimab (BIIB059), a promising investigational drug for cutaneous lupus erythematosus. Expert Opin Investig Drugs 2023:1-9. [PMID: 37148249 DOI: 10.1080/13543784.2023.2212154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
INTRODUCTION There are no U.S. Food and Drug Administration (FDA) approved therapies for cutaneous lupus erythematosus (CLE). Litifilimab is a monoclonal antibody against BDCA2, a plasmacytoid dendritic cell specific antigen, currently under investigation for systemic lupus erythematosus (SLE) and CLE. The LILAC study, published in the New England Journal of Medicine, is a phase II randomized controlled trial for CLE which demonstrated superiority of Litifilimab over placebo using a skin directed outcome measure. AREAS COVERED This review identifies challenges that have hindered the development of any approved treatments for CLE, recent SLE trials that include skin disease data, and the pharmacological properties of litifilimab. We review the clinical efficacy and safety of litifilimab for both SLE and CLE in the phase I and II clinical trials. This review aims to highlight the need for more CLE specific clinical trials and examine the potential of litifilimab as the first FDA approved therapy for CLE. (Clinical trial registration: www.clinicaltrials.gov identifier is NCT02847598.). EXPERT OPINION Litifilimab demonstrated efficacy in a randomized phase II clinical trial as a standalone CLE trial using validated skin specific outcome measures, making it the first successful clinical trial for a CLE targeted therapy. If approved, litifilimab will be a pivotal change in the landscape of CLE management especially for severe and refractory disease.
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Affiliation(s)
- Sung Kyung Cho
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Thomas Vazquez
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Victoria P Werth
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Department of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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2
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Elmgren J, Nyberg F. Clinical aspects of cutaneous lupus erythematosus. Front Med (Lausanne) 2023; 9:984229. [PMID: 36698816 PMCID: PMC9868707 DOI: 10.3389/fmed.2022.984229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 12/16/2022] [Indexed: 01/11/2023] Open
Abstract
Lupus erythematosus (LE) is an autoimmune inflammatory disease with a wide clinical spectrum from life-threatening multi-organ inflammation in systemic lupus erythematosus (SLE) to limited skin disease in cutaneous LE (CLE). The etiology of CLE is still not fully understood but a multifactorial genesis with genetic predisposition and certain environmental factors as triggers for the development are generally accepted features. Lesions can be induced and aggravated by UV-irradiation and smoking is linked to more severe forms of skin disease and to co-morbidity. Drugs, including many common medicines like antihypertensives, are known to induce subacute CLE (SCLE). The mechanisms involved have recently been shown to be part of the IFN-I pathway and new, specific treatments are currently in clinical trials. CLE is currently classified in subtypes based on clinical presentation and duration into acute CLE (ACLE), SCLE, and chronic CLE (CCLE). Distinct subtypes can be seen in individual patients or coexist within the same patient. Because of the confluent and overlapping picture between these subsets, serology, and histopathology constitute an important role guiding towards correct diagnose and there is ongoing work to update the classification. The Cutaneous Lupus Area Severity Index (CLASI) is a validated tool to measure activity and damage both in clinical trials but also for the clinician to evaluate treatment and follow the course of the disease among patients. CLE is known to have substantial impact on the life of those affected. Several tools have been proposed to measure QoL in these patients, currently Skindex-29 is probably the most used. Patient education is an important part of prevention of flares, including UV-protection and smoking cessation. First-line treatment includes topical corticosteroids as well as topical calcineurin inhibitors with the addition of systemic treatment with antimalarials in more severe or therapy resistant cases. Treatment specifically targeting CLE has been lacking, however novel potential therapies are in later phase clinical trials. In this review we aim to describe the different subsets of the cutaneous form in LE with focus on clinical aspects.
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Affiliation(s)
- Julia Elmgren
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden,Department of Dermatology, Karolinska University Hospital, Stockholm, Sweden,*Correspondence: Julia Elmgren,
| | - Filippa Nyberg
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden,Department of Dermatology, Karolinska University Hospital, Stockholm, Sweden
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3
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Kristensen JK, Nielsen C, Haloob N. Patient reported outcome measures (PROMS) for body image in dermatology: A systematic review. SKIN HEALTH AND DISEASE 2022; 2:e167. [PMID: 36479261 PMCID: PMC9720198 DOI: 10.1002/ski2.167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 06/17/2023]
Abstract
INTRODUCTION It is widely acknowledged that negative body image perception is linked to anxiety, depression, and body dysmorphic disorder. However, there is no gold standard, body image related patient reported outcome measure in use, specific for dermatologic disease, despite evidence to suggest a high prevalence of mental health problems relating to body image in this group of patients. AIM The aim of this study was to perform a review of body image Patient Reported Outcome Measures (PROMs) used in dermatology and to evaluate their effectiveness. METHODS Searches were performed in the major databases. Two investigators independently performed full text evaluation by applying an established checklist to evaluate the conceptual model, content validity, reliability, construct validity, scoring and interpretability and respondent burden. RESULTS Six different PROMs were identified of which only one was fully validated. There was a significant lack of patient involvement in the development of PROMs in this context. CONCLUSIONS We therefore encourage further research in this field to improve the quality of evidence to better understand the relationship between mental health and dermatologic disease.
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Affiliation(s)
| | | | - Nora Haloob
- Imperial College HealthcareNHS TrustLondonUK
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4
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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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5
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Guo LN, Perez-Chada LM, Borucki R, Nambudiri VE, Werth VP, Merola JF. Development of a working core outcome set for cutaneous lupus erythematosus: a practical approach to an urgent unmet need. Lupus Sci Med 2022; 8:8/1/e000529. [PMID: 34969875 PMCID: PMC8718411 DOI: 10.1136/lupus-2021-000529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/05/2021] [Indexed: 11/23/2022]
Abstract
Objective The lack of standardised outcomes and outcome measures for cutaneous lupus erythematosus (CLE) represents a substantial barrier to clinical trial design, comparative analysis and approval of novel investigative treatments. We aimed to develop a working core outcome set (COS) for CLE randomised controlled trials and longitudinal observational studies. Methods We conducted a multistage literature review of CLE and SLE studies to generate candidate domains and outcome measures. Domains were narrowed to a working core domain set. Outcome measures for core domains were identified and examined. Results Proposed core domains include skin-specific disease activity and damage, investigator global assessment (IGA) of disease activity, symptoms (encompassing itch, pain and photosensitivity), health-related quality of life (HRQoL) and patient global assessment (PtGA) of disease activity. Recommended physician-reported outcome measures include the Cutaneous Lupus Erythematous Disease Area and Severity Index (CLASI) and Cutaneous Lupus Activity IGA (CLA-IGA). For the domains of symptoms, HRQoL and PtGA of disease activity, we were unable to recommend one clearly superior instrument. Conclusion This work represents a starting point for further refinement pending formal consensus activities and more rigorous evaluations of outcome measure quality. In the interim, the proposed working COS can serve as a much-needed guide for upcoming CLE clinical trials.
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Affiliation(s)
- Lisa N Guo
- Dermatology and Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Lourdes M Perez-Chada
- Harvard Medical School, Boston, Massachusetts, USA.,Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Robert Borucki
- Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Vinod E Nambudiri
- Harvard Medical School, Boston, Massachusetts, USA.,Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Victoria P Werth
- Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph F Merola
- Harvard Medical School, Boston, Massachusetts, USA.,Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Dermatology and Medicine, Division of Rheumatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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6
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Chong BF, Werth V. Cutaneous Lupus Erythematosus and Dermatomyositis: Utilizing Assessment Tools for Treatment Efficacy. J Invest Dermatol 2021; 142:936-943. [PMID: 34952717 DOI: 10.1016/j.jid.2021.09.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 09/06/2021] [Accepted: 09/17/2021] [Indexed: 12/19/2022]
Abstract
There have been important developments in defining cutaneous lupus erythematosus and dermatomyositis. The skin manifestations of these two diseases have a profound impact on QOL, with both emotional and symptomatic impacts that are important to address. The proliferation of potential therapeutic targets has made it important to make sure that these diseases are defined in a way that they can be included in translational and clinical studies of both localized and systemic forms of the diseases. There are now validated disease tools and QOL studies that are facilitating current and future scientific and therapeutic developments.
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Affiliation(s)
- Benjamin F Chong
- Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Victoria Werth
- Department of Dermatology, Penn Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.
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7
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Yuki EFN, Silva CA, Aikawa NE, Romiti R, Heise CO, Bonfa E, Pasoto SG. Thalidomide and Lenalidomide for Refractory Systemic/Cutaneous Lupus Erythematosus Treatment: A Narrative Review of Literature for Clinical Practice. J Clin Rheumatol 2021; 27:248-259. [PMID: 31693649 DOI: 10.1097/rhu.0000000000001160] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Thalidomide has shown exceptional results in systemic/cutaneous lupus erythematosus(SLE/CLE). Recently, lenalidomide has been also prescribed for SLE/CLE treatment. Literature regarding efficacy/adverse events for these drugs is scarce with a single systematic review and meta-analysis focused solely on thalidomide for refractory cutaneous lupus subtypes. OBJECTIVE We, therefore, addressed in this narrative review the efficacy/adverse effects of thalidomide and lenalidomide for SLE and CLE. In addition, we provide a specialist approach for clinical practice based on the available evidence. RESULTS Efficacy of thalidomide for refractory cutaneous lupus treatment was demonstrated by several studies, mostly retrospective with small sample size(≤20). The frequency of peripheral polyneuropathy is controversial varying from 15-80% with no consistent data regarding cumulative dose and length of use. Drug withdrawn results in clinical partial/complete reversibility for most cases (70%). For lenalidomide, seven studies (small sample sizes) reported its efficacy for SLE/CLE with complete/partial response in all patients with a mean time to response of 3 months. Flare rate varied from 25-75% occurring 0.5-10 months after drug withdrawn. There were no reports of polyneuropathy/worsening of previous thalidomide-induced neuropathy, but most of them did not perform nerve conduction studies. Teratogenicity risk exist for both drugs and strict precautions are required. CONCLUSIONS Thalidomide is very efficacious as an induction therapy for patients with severe/refractory cutaneous lupus with high risk of scarring, but its longstanding use should be avoided due to neurotoxicity. Lenalidomide is a promising drug for skin lupus treatment, particularly regarding the apparent lower frequency of nerve side effects.
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Affiliation(s)
| | | | | | | | - Carlos Otto Heise
- Neurology Department, Hospital das Clinicas, Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), Sao Paulo, Brazil
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8
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Annapureddy N, Jolly M. Patient-Reported Outcomes in Lupus. Rheum Dis Clin North Am 2021; 47:351-378. [PMID: 34215368 DOI: 10.1016/j.rdc.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Patient-reported outcome (PRO) was identified as a core systemic lupus erythematosus (SLE) outcome in 1999. More than 20 years later, however, generic PRO measures evaluating impact in SLE are used mainly for research. Generic and disease-targeted PRO tools have unique advantages. Significant progress in identification of patient disease-relevant PRO concepts and development of new PRO tools for SLE has occurred over the past 20 years. Further research needs to focus on responsiveness and minimally important differences of existing, promising PRO tools to facilitate their use in SLE patient care and research.
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Affiliation(s)
- Narender Annapureddy
- Department of Medicine, Vanderbilt University, 1160 21st Avenue, Suite T3113 MCN, Nashville, TN 37232, USA
| | - Meenakshi Jolly
- Department of Medicine, Rush University, 1611 West Harrison Street, Suite 510, Chicago, IL 60615, USA.
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9
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Proteome study of cutaneous lupus erythematosus (CLE) and dermatomyositis skin lesions reveals IL-16 is differentially upregulated in CLE. Arthritis Res Ther 2021; 23:132. [PMID: 33931094 PMCID: PMC8086067 DOI: 10.1186/s13075-021-02511-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/12/2021] [Indexed: 11/30/2022] Open
Abstract
Background The objective of the study was to explore the disease pathways activated in the inflammatory foci of skin lesions in cutaneous lupus erythematosus (CLE) and dermatomyositis (DM). Methods Skin biopsies acquired from active CLE and DM lesions, patient (PC), and also healthy controls (HC) were investigated. Biopsy sections were examined by a pathologist, inflammatory foci were laser micro-dissected and captured, and proteins within captured tissue were detected in an unbiased manner by mass spectrometry. Protein pathway analysis was performed by the string-db.org platform. Findings of interest were confirmed by immunohistochemistry (IHC). Results Proteome investigation identified abundant expression of interferon-regulated proteins (IRP) as a common feature of CLE and DM. Interleukin (IL)-16 was the only abundant cytokine differentially expressed in CLE compared to DM. Caspase-3, an enzyme that cleaves IL-16 into its active form, was detected in low levels. Significantly higher proportion of IL-16- and caspase-3-positive cells was identified in CLE lesions in comparison with DM, PC, and HC. Proteomic results indicate more abundant complement deposition in CLE skin lesions. Conclusions Using unbiased mass spectrometry investigation of CLE and DM inflammatory infiltrates, we confirmed that high IRP expression is a common feature of both CLE and DM, while IL-16 is the only differentially expressed cytokine in CLE. IHC confirmed high expression of IL-16 and caspase-3 in CLE. Our novel molecular findings indicate that IL-16 detection could be useful in differential diagnostics between the two conditions that can display similar histopathological appearance. IL-16 could be of interest as a future therapeutic target for CLE.
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10
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Chakka S, Krain RL, Concha JSS, Chong BF, Merola JF, Werth VP. The CLASI, a validated tool for the evaluation of skin disease in lupus erythematosus: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:431. [PMID: 33842652 PMCID: PMC8033342 DOI: 10.21037/atm-20-5048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Cutaneous lupus erythematosus (CLE) can present with or without features of systemic lupus erythematosus (SLE), with estimates of the incidence of isolated skin disease almost equaling the incidence of those with systemic disease. However, despite the impact CLE has on a patient’s quality of life (QoL), there has been no US Food and Drug Administration (FDA) approved treatment for the disease in the past 50 years. In addition, patients with skin predominant LE are often excluded from clinical SLE trials. In the rare trials that include patients with skin predominant LE, disease activity and progression in the skin are often difficult to evaluate using multi-organ outcome measures. The need for new therapies for CLE and the lack of focus on skin outcomes has led to the development of the Cutaneous Lupus Disease Area and Severity Index (CLASI), a validated organ-specific outcome measure that is not only responsive to change in disease activity and damage but also correlated to changes in a patient’s QoL. This paper will emphasize the extensive validation studies performed in developing the CLASI, as well as the importance of clinical trials using the CLASI to address the need for improved therapies for patients with lupus skin manifestations.
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Affiliation(s)
- Srita Chakka
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca L Krain
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Josef Symon S Concha
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin F Chong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Joseph F Merola
- Department of Dermatology and Department of Medicine, Division of Rheumatology, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA.,Department of Dermatology, University of Pennsylvania, Philadelphia, PA, USA
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11
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Arora S, Isenberg DA, Castrejon I. Measures of Adult Systemic Lupus Erythematosus: Disease Activity and Damage. Arthritis Care Res (Hoboken) 2020; 72 Suppl 10:27-46. [PMID: 33091256 DOI: 10.1002/acr.24221] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/09/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Shilpa Arora
- Rush University Medical Center, Chicago, Illinois
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12
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Goulden B, Isenberg D. Anti-IFNαR Mabs for the treatment of systemic lupus erythematosus. Expert Opin Biol Ther 2020; 21:519-528. [PMID: 33085537 DOI: 10.1080/14712598.2021.1841164] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The type 1 interferon pathway is known to play a role in the immunopathology of systemic lupus erythematosus (SLE). As a result, biologic agents targeting this pathway have been developed and are currently being investigated in clinical trials. AREAS COVERED We review the biologic agents which have been developed to antagonize type I interferons in SLE. We focus on anifrolumab, a type I interferon receptor antagonist, and consider the complexities of defining efficacy in SLE clinical trials. EXPERT OPINION Anifrolumab shows promise as an addition to the SLE therapeutic armamentarium. Despite discordant results between its two phase III studies, there is a convincing suggestion of benefit in both trials to encourage the view that this approach might be effective. Data acquired thus far look particularly useful for cutaneous disease. We await data on its effect on renal, pulmonary, cardiac, and central nervous system involvement, on patient reported outcomes, and its safety and efficacy with long-term use.
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Affiliation(s)
- Bethan Goulden
- Rheumatology Department, University College London, London, UK
| | - David Isenberg
- Rheumatology Department, University College London, London, UK
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13
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Petty AJ, Floyd L, Henderson C, Nicholas MW. Cutaneous Lupus Erythematosus: Progress and Challenges. Curr Allergy Asthma Rep 2020; 20:12. [PMID: 32248318 DOI: 10.1007/s11882-020-00906-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW The review provides an update on the diagnosis, pathogenesis, and treatment of cutaneous lupus erythematosus (CLE). RECENT FINDINGS Diagnostic challenges exist in better defining CLE as an independent disease distinct from systemic lupus erythematosus with cutaneous features and further classifying CLE based on clinical, histological, and laboratory features. Recent mechanistic studies revealed more genetic variations, environmental triggers, and immunologic dysfunctions that are associated with CLE. Drug induction specifically has emerged as one of the most important triggers for CLE. Treatment options include topical agents and systemic therapies, including newer biologics such as belimumab, rituximab, ustekinumab, anifrolumab, and BIIB059 that have shown good clinical efficacy in trials. CLE is a group of complex and heterogenous diseases. Future studies are warranted to better define CLE within the spectrum of lupus erythematosus. Better insight into the pathogenesis of CLE could facilitate the design of more targeted therapies.
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Affiliation(s)
- Amy J Petty
- School of Medicine, Duke University, Durham, NC, 27710, USA
| | - Lauren Floyd
- Department of Dermatology, Duke University, Durham, NC, 27710, USA
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14
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Nanes BA, Zhu JL, Chong BF. Robust measurement of clinical improvement in patients with cutaneous lupus erythematosus. Lupus Sci Med 2020; 7:e000364. [PMID: 32095249 PMCID: PMC7008708 DOI: 10.1136/lupus-2019-000364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/05/2019] [Accepted: 01/05/2020] [Indexed: 11/08/2022]
Abstract
Objective The severity and disease course of cutaneous lupus erythematosus (CLE) are highly variable. Consequently, outcome measures for CLE clinical improvement are heterogeneous, complicating treatment decisions and therapeutic development. This study characterises CLE outcome measures and identifies the influence of clinical improvement thresholds on strengths of associations with patient demographic and clinical factors. Methods In this pilot cohort study, multivariable models identified factors associated with CLE activity and skin damage improvement, defined as relative decreases in Cutaneous Lupus Activity and Severity Index (CLASI) activity (CLASI-A) and damage (CLASI-D) scores, over ranges of response thresholds. Results 66 patients with 119 visit-pairs were included in the CLASI-A analysis. 74 patients with 177 visit-pairs were included in the CLASI-D analysis. Factors associated with CLE activity and damage improvement depended on the response threshold. Some associations were stronger at more stringent thresholds, including subacute CLE predominance with increased likelihood of CLASI-A improvement (R2=0.73; 50% reduction: OR 1.724 (95% CI 0.537 to 5.536); 75%: 5.67 (95% CI 1.56 to 20.5)) and African-American race with decreased likelihood of CLASI-D improvement (R2=0.80; 20%: 0.40 (95% CI 0.17 to 0.93); 40%: 0.25 (95% CI 0.08 to 0.82)). Other associations were stable across multiple thresholds, including older age of CLE development with increased likelihood of CLASI-A improvement (R2=0.25; 50%: 1.05 (95% CI 1.01 to 1.09]; 75%: 1.05 (95% CI 1.00 to 1.10)) and higher initial disease activity with decreased likelihood of CLASI-D improvement (R2=0.55; 20%: 0.91 (95% CI 0.84 to 0.98); 40%: 0.88 (95% CI 0.79 to 0.97)). Conclusions Examining a range of CLASI threshold outcomes can comprehensively characterise changes in disease course in patients with CLE. Insufficiently stringent thresholds may fail to distinguish meaningful clinical change from natural fluctuation in disease activity.
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Affiliation(s)
- Benjamin A Nanes
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Jane L Zhu
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Benjamin F Chong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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15
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Dresco F, Puzenat E, Delobeau M, Salard D, Lihoreau T, Pelletier F, Aubin F. [Resistant and progressive cutaneous lupus erythematosus treated with belimumab: A retrospective monocentric study]. Rev Med Interne 2020; 41:152-159. [PMID: 31980188 DOI: 10.1016/j.revmed.2019.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/25/2019] [Accepted: 12/08/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Belimumab is currently approved for the treatment of active systemic lupus erythematosus (SLE). The aim of our study was to evaluate the efficacy of belimumab in the treatment of cutaneous lupus erythematosus (CLE), resistant to conventional therapy. PATIENTS AND METHODS Seven patients with resistant and progressive LEC and treated with belimumab were retrospectively analyzed. The efficacy and safety of belimumab were evaluated with the CLASI, RCLASI and DLQI scores, after 6 to 12 months of treatment. RESULTS Eighty-three percent of patients demonstrated a significant clinical improvement based on the CLASI and RCLASI activity scores, including 1 complete and 4 partial responses, without worsening of CLASI and RCLASI damage scores. Eighty percent of patients also showed an improvement of their quality of life (DLQI). Oral corticosteroids were discontinued in all patients. Tolerance was acceptable with only one serious adverse event (bacteriema). CONCLUSION Our study suggests the clinical efficiency of belimumab in a series of 7 patients presenting a resistant and progressive CLE.
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Affiliation(s)
- F Dresco
- Service de dermatologie, UMR Inserm 1098, CHU et université de Franche Comté, Besançon, France
| | - E Puzenat
- Service de dermatologie, UMR Inserm 1098, CHU et université de Franche Comté, Besançon, France
| | - M Delobeau
- Service de dermatologie, centre hospitalier de Haute Comté, Pontarlier, France
| | - D Salard
- Service de dermatologie, centre hospitalier de Haute Comté, Pontarlier, France
| | | | - F Pelletier
- Service de dermatologie, UMR Inserm 1098, CHU et université de Franche Comté, Besançon, France
| | - F Aubin
- Service de dermatologie, UMR Inserm 1098, CHU et université de Franche Comté, Besançon, France.
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Blake SC, Daniel BS. Cutaneous lupus erythematosus: A review of the literature. Int J Womens Dermatol 2019; 5:320-329. [PMID: 31909151 PMCID: PMC6938925 DOI: 10.1016/j.ijwd.2019.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 07/04/2019] [Accepted: 07/20/2019] [Indexed: 02/06/2023] Open
Abstract
Knowledge with regard to the pathogenesis of lupus erythematosus has progressed rapidly over the past decade, and with it has come promising new agents for the treatment of cutaneous lupus erythematous (CLE). Classification of CLE is performed using clinical features and histopathologic findings, and is crucial for determining prognosis and choosing therapeutic options. Preventative therapy is critical in achieving optimal disease control, and patients should be counseled on sun-safe behavior and smoking cessation. First-line therapy includes topical corticosteroids and calcineurin inhibitors, with antimalarial therapy. Traditionally, refractory disease was treated with oral retinoids, dapsone, and other oral immunosuppressive drugs, but new therapies are emerging with improved side effect profiles and efficacy. Biologic agents, such as belimumab and ustekinumab, have been promising in case studies but will require larger trials to establish their role in routine therapy. Other novel therapies that have been trialed successfully include spleen tyrosine kinase inhibitors and fumaric acid esters. Finally, new evidence has been published recently that describes safer dosing regimens in thalidomide and lenalidomide, both effective medications for CLE. Given the chronic disease course of CLE, long-term treatment-related side effects must be minimized, and the introduction of new steroid-sparing agents is encouraging in this regard.
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Affiliation(s)
- Stephanie Clare Blake
- University of New South Wales, Sydney, Australia.,St. George Department of Dermatology, Sydney, Australia
| | - Benjamin Silas Daniel
- University of New South Wales, Sydney, Australia.,St. George Department of Dermatology, Sydney, Australia.,St Vincent's Hospital, Melbourne, Australia
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Clinical characteristics and health related quality of life (HRQoL) in Egyptian patients with systemic lupus erythematosus. THE EGYPTIAN RHEUMATOLOGIST 2019. [DOI: 10.1016/j.ejr.2018.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Concha JSS, Patsatsi A, Marshak-Rothstein A, Liu ML, Sinha AA, Lee LA, Merola JF, Jabbari A, Gudjonsson JE, Chasset F, Jarrett P, Chong B, Arkin L, Fernandez AP, Caproni M, Greenberg SA, Kim HJ, Pearson DR, Femia A, Vleugels RA, Fiorentino D, Fujimoto M, Wenzel J, Werth VP. Advances in Cutaneous Lupus Erythematosus and Dermatomyositis: A Report from the 4th International Conference on Cutaneous Lupus Erythematosus-An Ongoing Need for International Consensus and Collaborations. J Invest Dermatol 2018; 139:270-276. [PMID: 30243657 DOI: 10.1016/j.jid.2018.08.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 08/28/2018] [Accepted: 08/28/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Josef Symon S Concha
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aikaterini Patsatsi
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ann Marshak-Rothstein
- Division of Rheumatology, Department of Medicine, University of Massachusetts School of Medicine, Worcester, Massachusetts, USA
| | - Ming-Lin Liu
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Animesh A Sinha
- Department of Dermatology, Jacobs School of Medicine & Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Lela A Lee
- Departments of Dermatology and Medicine, University of Colorado School of Medicine, Denver, Colorado, USA
| | - Joseph F Merola
- Department of Dermatology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Jabbari
- Department of Dermatology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Interdisciplinary Program in Immunology, University of Iowa, Iowa City, Iowa, USA
| | - Johann E Gudjonsson
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - François Chasset
- Sorbonne Université, Faculté de Médecine Sorbonne Université, AP-HP, Service de Dermatologie et Allergologie, Hôpital Tenon, Paris, France
| | - Paul Jarrett
- Department of Medicine, The University of Auckland, Auckland, New Zealand
| | - Benjamin Chong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Lisa Arkin
- Departments of Dermatology and Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Anthony P Fernandez
- Departments of Dermatology and Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marzia Caproni
- Dermatologic Rare Diseases and Skin Immunopathology Unit, USL Toscana Centro-University of Florence, Florence, Italy
| | - Steven A Greenberg
- Department of Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hee Joo Kim
- Department of Dermatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - David R Pearson
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alisa Femia
- Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA
| | - Ruth Ann Vleugels
- Department of Dermatology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - David Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Manabu Fujimoto
- Department of Dermatology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Joerg Wenzel
- Department of Dermatology, University of Bonn, Bonn, Germany
| | - Victoria P Werth
- Corporal Michael J. Crescenz VAMC, Philadelphia, Pennsylvania, USA; Department of Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Presto JK, Okon LG, Feng R, Wallace DJ, Furie R, Fiorentino D, Werth VP. Computerized planimetry to assess clinical responsiveness in a phase II randomized trial of topical R333 for discoid lupus erythematosus. Br J Dermatol 2018; 178:1308-1314. [PMID: 29336019 DOI: 10.1111/bjd.16337] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND R333 is a topical janus kinase and spleen tyrosine kinase inhibitor being evaluated for discoid lupus erythematosus (DLE) treatment. There is no validated measure to assess the area of active DLE lesions. OBJECTIVES To evaluate R333 efficacy and assess a technique to measure responsiveness. METHODS Fifty-four patients with DLE were randomized in a double-blind design to R333 or placebo. Primary end point was the proportion of patients achieving ≥ 50% decrease in erythema and scale based on lesional Cutaneous Lupus Erythematosus Disease Area and Severity IndexTM for all treated lesions at week 4. Two-dimensional (2D) area measurements for each lesion were recorded at baseline and weeks 1-6. Eighty-eight photographs (44 pre- and 44 post-treatment) were obtained from the trial and change in size of active areas was analysed by computerized planimetry and physician-assessed area change (PAAC). RESULTS Thirty-six patients were randomized to R333 and 18 patients were randomized to placebo. Primary end point was not achieved. There was a strong association between lesion activity and physician global assessment (P < 0·001). Photos of 42 patients assessed by computerized planimetry demonstrated excellent inter- and intra-rater reliability. Area change by computerized planimetry showed a strong correlation with PAAC (Spearman r = 0·72). Area change by 2D measurements showed a weak correlation with PAAC (Spearman r = 0·29). CONCLUSIONS Four weeks of R333 treatment did not result in significant improvement in lesion activity. Lesion activity and area change using computerized planimetry are better determinants of responsiveness than area change using 2D measurements.
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Affiliation(s)
- J K Presto
- Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A.,Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, U.S.A
| | - L G Okon
- Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A.,Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, U.S.A
| | - R Feng
- Biostatistics and Epidemiology at the Hospital of the University of Pennsylvania, Pennsylvania, PA, U.S.A
| | - D J Wallace
- Division of Rheumatology, Cedars-Sinai Medical Center, Los Angeles, CA, U.S.A
| | - R Furie
- Division of Rheumatology, Northwell Health, Great Neck, NY, U.S.A
| | - D Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Stanford, CA, U.S.A
| | - V P Werth
- Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), Philadelphia, PA, U.S.A.,Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, Pennsylvania, PA, U.S.A
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Merrill JT, Manzi S, Aranow C, Askanase A, Bruce I, Chakravarty E, Chong B, Costenbader K, Dall'Era M, Ginzler E, Hanrahan L, Kalunian K, Merola J, Raymond S, Rovin B, Saxena A, Werth VP. Lupus community panel proposals for optimising clinical trials: 2018. Lupus Sci Med 2018; 5:e000258. [PMID: 29657738 PMCID: PMC5894527 DOI: 10.1136/lupus-2018-000258] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 02/06/2018] [Accepted: 02/12/2018] [Indexed: 12/14/2022]
Abstract
Formidable impediments stand in the way of treatment development for lupus. These include the unwieldy size of current trials, international competition for scarce patients, complex outcome measures and a poor understanding of these outcomes in the world at large. The heterogeneity of the disease itself coupled to superimposition of variegated background polypharmacy has created enough immunological noise to virtually ensure the failure of lupus treatment trials, leaving an understandable suspicion that at least some of the results in testing failed drugs over the years may not have been negative, but merely uninterpretable. The authors have consulted with many clinical trial investigators, biopharmaceutical developers and stakeholders from government and voluntary sectors. This paper examines the available evidence that supports workable trial designs and proposes approaches to improve the odds of completing interpretable treatment development programs for lupus.
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Affiliation(s)
- Joan T Merrill
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Susan Manzi
- Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Cynthia Aranow
- Autoimmune and Musculoskeletal Disease, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Anca Askanase
- Columbia University Medical Center, New York City, New York, USA
| | - Ian Bruce
- University of Manchester, Manchester, England, UK
| | - Eliza Chakravarty
- Arthritis & Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Ben Chong
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Karen Costenbader
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Ellen Ginzler
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, New York, USA
| | - Leslie Hanrahan
- Research and Education, Lupus Foundation of America, Washington, District of Columbia, USA
| | - Ken Kalunian
- Rheumatology, University of California, San Diego, San Diego, USA
| | - Joseph Merola
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sandra Raymond
- Lupus Foundation of America, Washington, District of Columbia, USA
| | - Brad Rovin
- Internal Medicine/Nephrology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Amit Saxena
- Rheumatology, New York University, New York City, New York, USA
| | - Victoria P Werth
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Presto JK, Hejazi EZ, Werth VP. Biological therapies in the treatment of cutaneous lupus erythematosus. Lupus 2016; 26:115-118. [PMID: 27687023 DOI: 10.1177/0961203316670731] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cutaneous lupus erythematosus (CLE) is an autoimmune skin disease occurring in association with or without systemic lupus erythematosus (SLE). Although antimalarials are widely used as the first-line systemic agent, refractory cases may benefit from additional immunomodulators, immunosuppressives, and biologics. An interest in biological therapies for CLE has emerged in recent years due to novel insight into the pathogenesis of CLE. These targets include B cells, T cells, and cytokines that are involved in immune system pathways. Currently belimumab is the only biological therapy approved for SLE and no biologic has been approved for CLE. While there is a paucity of high quality evidence with regard to biologics in CLE management, trials are currently being performed to determine their role.
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Affiliation(s)
- J K Presto
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), USA.,2 Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, USA
| | - E Z Hejazi
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), USA.,2 Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, USA
| | - V P Werth
- 1 Corporal Michael J. Crescenz Veterans Affairs Medical Center (Philadelphia), USA.,2 Department of Dermatology at the Perelman School of Medicine at the University of Pennsylvania, USA
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Chang J, Werth VP. Therapeutic options for cutaneous lupus erythematosus: recent advances and future prospects. Expert Rev Clin Immunol 2016; 12:1109-21. [PMID: 27249209 DOI: 10.1080/1744666x.2016.1188006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Treatment and prevention are of critical importance in patients with cutaneous lupus erythematosus (CLE), as the disease can have a devastating effect on patient well-being and quality of life. AREAS COVERED We conducted a selective search of the PubMed database for articles published between December 2010 and November 2015. This review encompasses both non-pharmaceutical (photoprotection, smoking cessation, drug withdrawal, and vitamin D replacement) and pharmaceutical (topicals, antimalarials, immunosuppressives, biologics, etc.) interventions used in the treatment of CLE. Expert Commentary: Recent work has expanded our understanding of established therapies as well as introduced new treatments for consideration, though existing medications still prove inadequate for a subset of patients. Changes in trial design may help to alleviate this issue.
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Affiliation(s)
- Joshua Chang
- a Dermatology Section, Corporal Michael J. Crescenz Philadelphia VA Medical Center , Philadelphia , PA , USA.,b Department of Dermatology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
| | - Victoria P Werth
- a Dermatology Section, Corporal Michael J. Crescenz Philadelphia VA Medical Center , Philadelphia , PA , USA.,b Department of Dermatology , Perelman School of Medicine at the University of Pennsylvania , Philadelphia , PA , USA
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23
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Garza-Mayers AC, McClurkin M, Smith GP. Review of treatment for discoid lupus erythematosus. Dermatol Ther 2016; 29:274-83. [DOI: 10.1111/dth.12358] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Anna Cristina Garza-Mayers
- Harvard Medical School; Boston Massachusetts
- Massachusetts General Hospital, Department of Dermatology; Boston Massachusetts
| | | | - Gideon P. Smith
- Harvard Medical School; Boston Massachusetts
- Massachusetts General Hospital, Department of Dermatology; Boston Massachusetts
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Hejazi EZ, Werth VP. Cutaneous Lupus Erythematosus: An Update on Pathogenesis, Diagnosis and Treatment. Am J Clin Dermatol 2016; 17:135-46. [PMID: 26872954 DOI: 10.1007/s40257-016-0173-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Cutaneous lupus erythematosus (CLE) includes a broad range of dermatologic manifestations, which may or may not be associated with systemic disease. Recent studies in this area continue to shape our understanding of this disease and treatment options. Epidemiologic studies have found an incidence of CLE of 4.30 per 100,000, which approaches similar analysis for systemic lupus erythematosus (SLE). Although there have been extensive efforts to define SLE, the classification of CLE and its subgroups remains a challenge. Currently, diagnosis relies on clinical and laboratory findings as well as skin histology. The Cutaneous Lupus Area and Severity Index™ (CLASI™) is a validated measure of disease activity and damage. CLE pathogenesis is multifactorial and includes genetic contributions as well as effects of ultraviolet (UV) light. Immune dysregulation and aberrant cell signaling pathways through cytokine cascades are also implicated. Patient education and avoidance of triggers are key to disease prevention. Antimalarials and topical steroids continue to be the standard of care; however, immunosuppressants, thalidomide analogs and monoclonal antibodies are possible systemic therapies for the treatment of recalcitrant disease.
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26
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Volc-Platzer B. Measuring cutaneous symptoms of dermatomyositis: an important step towards objective monitoring of disease course and treatment response as a basis for clinical trials. Br J Dermatol 2015; 173:890-1. [DOI: 10.1111/bjd.14094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- B. Volc-Platzer
- Department of Dermatology; Donauspital/SMZ Ost; Langobardenstrasse 122 A-1220 Vienna Austria
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Mikdashi J, Nived O. Measuring disease activity in adults with systemic lupus erythematosus: the challenges of administrative burden and responsiveness to patient concerns in clinical research. Arthritis Res Ther 2015; 17:183. [PMID: 26189728 PMCID: PMC4507322 DOI: 10.1186/s13075-015-0702-6] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Measuring lupus disease activity accurately remains a challenging and demanding task given the complex multi-system nature of lupus, an illness known for its variability between patients and within the same patient over time. Many have attempted to define what disease activity means and how it should be measured, and several instruments were devised for a standardized assessment of disease activity and outcome domains in clinical research. Several of these measuring tools have been able to detect clinical improvement and have demonstrated adequate reliability, validity, and sensitivity to change in observational studies, and some were found to be useful in randomized controlled trials. However, several failed clinical trials have confronted these metrics, as they were not intended for clinical trials. The Outcome Measures Rheumatology group and the US Food and Drug Administration have recommended using measures of disease activity, cumulative organ damage, health-related quality of life, and adverse events as outcomes of interest. Composite responder indices that determine disease global improvement, ensure no significant worsening in unaffected organ systems, and include a physician’s global assessment have been used in randomized clinical trials. Yet unmet therapeutic needs were further challenged by the complex content and psychometric information of the updated instruments, including increased administrative burden associated with demanding training and cost of instruments, and small effect size associated with responsiveness to patient concerns. Nevertheless, with the progress of novel targeted therapy, refining the disease activity metrics is essential. Selection of the disease activity endpoints which is a defining aspect of clinical trial design must be tailored to the outcome of interest and measured by a reliably rated scale characterized by minimal administrative burden. An optimal scale should be simple and practical and incorporate elements of patient concerns.
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Affiliation(s)
- Jamal Mikdashi
- Division of Rheumatology and Clinical Immunology, University of Maryland School of Medicine, 10 South Pine Street, Suite 834, Baltimore, MD, 21201, USA.
| | - Ola Nived
- Department of Rheumatology, Institution of Clinical Sciences, Lund University Hosptial, SE-221 85, Lund, Sweden
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Abstract
PURPOSE OF REVIEW Cutaneous Lupus Erythematous (CLE) is an autoimmune disease in which patients may present with isolated skin findings or have CLE associated with underlying systemic disease. The most significant recent studies on its pathogenesis and therapeutic management are reviewed here. RECENT FINDINGS Patients with subacute and Discoid Lupus Erythematous had elevated Interferon score, about a third of all cases of SCLE could be attributed to previous drug exposure, and smoking may be more closely associated with CLE than Systemic Lupus Erythematous (SLE). An underlying genetic defect in some subsets of CLE patients may also be shared with SLE. Efficacy of antimalarial therapy is enhanced by increasing treatment duration or maintaining higher blood drug concentrations. Combination antimalarials that include quinacrine, thalidomide analogs, and Mycophenalate Mofetil may also be effective in refractory CLE. SUMMARY The pathogenesis of CLE remains unclear, and is likely multifactorial. Identified associations with subsets of CLE suggest future research questions in CLE pathogenesis. Subsets of CLE associated with interface dermatitis may share an underlying genetic defect in interferon signaling with SLE. The Cutaneous Lupus Disease Area and Severity Index is a valuable and widely used tool allowing standardized assessment and reporting of cutaneous disease activity and damage. More evidence is available to guide treatment of refractory CLE, but larger studies are needed. VIDEO ABSTRACT http://links.lww.com/COR/A4.
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Ishiguro M, Hashizume H, Ikeda T, Yamamoto Y, Furukawa F. Evaluation of the quality of life of lupus erythematosus patients with cutaneous lesions in Japan. Lupus 2013; 23:93-101. [DOI: 10.1177/0961203313509293] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The quality of life (QOL) of lupus erythematosus (LE) patients with skin manifestations is impaired, but little is known about Japanese patients. We assessed whether the skin symptoms in LE are associated with the QOL using the Japanese versions of the Skindex-29 and Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI). In all, 54 LE patients with cutaneous lesions completed the Japanese version of the Skindex-29, and physicians assessed the severity of their eruptions using the CLASI before and after treatment. The QOL of the LE patients was better after the therapeutic intervention using the Skindex-29 questionnaire. We tested several factors for an independent association with the QOL. A significant risk factor for a poor QOL was a female gender in “Functioning” before treatment. In addition, a poor QOL tended to be correlated with a female gender in “Emotions” and older current age in “Symptoms” before treatment, and with a longer duration of SLE in “Functioning” after treatment. In the CLASI analysis, skin manifestation activity in the acute phase correlated with a poor emotional and functional QOL rather than a symptomatic QOL. To the best of our knowledge, this is the first report evaluating the QOL of Japanese LE patients, despite the small cohort.
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Affiliation(s)
- M Ishiguro
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - H Hashizume
- Department of Dermatology, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - T Ikeda
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - Y Yamamoto
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
| | - F Furukawa
- Department of Dermatology, Wakayama Medical University, Wakayama, Japan
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30
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Dua AB, Touma Z, Toloza S, Jolly M. Top 10 Recent Developments in Health-Related Quality of Life in Patients with Systemic Lupus Erythematosus. Curr Rheumatol Rep 2013; 15:380. [DOI: 10.1007/s11926-013-0380-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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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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