Off-Label Uses of Biologic Agents in Dermatology: A 2006 Update

The Use of TNFα Inhibitors in Treating Pediatric Skin Disorders

Tumor necrosis factor alpha (TNF) inhibitors have had a significant impact in medicine since the approval of the first drug of its class by the US FDA in 1998. New clinical data and indications have emerged for TNF inhibitors in recent years. Currently, four TNF inhibitors have been approved by the US FDA for dermatology, two of which include US FDA-approved pediatric use. In particular, growing evidence supports the use of etanercept and adalimumab as attractive therapies for pediatric psoriasis. Data for use of etanercept in treating toxic epidermal necrolysis and either etanercept or infliximab for Kawasaki disease is expanding. In addition, there have been clinical reports on the use of TNF inhibitors to treat a variety of other pediatric dermatologic conditions. To help clinicians keep pace with the new data provided by many pediatric dermatology studies involving TNF inhibitors, this review provides an overview of the use of TNF inhibitors in the treatment of pediatric plaque psoriasis, hidradenitis suppurativa, atopic dermatitis, pyoderma gangrenosum, toxic epidermal necrolysis, and Kawasaki disease. For TNF inhibitors with little data in the pediatric population, data on adult use is discussed. Furthermore, the review summarizes available clinical data on efficacy, safety, and tolerability of agents currently available.

Off-label uses of anti-TNF therapy in three frequent disorders: Behçet's disease, sarcoidosis, and noninfectious uveitis

Tumoral necrosis factor α plays a central role in both the inflammatory response and that of the immune system. Thus, its blockade with the so-called anti-TNF agents (infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab) has turned into the most important tool in the management of a variety of disorders, such as rheumatoid arthritis, spondyloarthropatties, inflammatory bowel disease, and psoriasis. Nonetheless, theoretically, some other autoimmune disorders may benefit from these agents. Our aim is to review these off-label uses of anti-TNF blockers in three common conditions: Behçet's disease, sarcoidosis, and noninfectious uveitis. Due to the insufficient number of adequate clinical trials and consequently to their lower prevalence compared to other immune disorders, this review is mainly based on case reports and case series.

Ten common questions (and their answers) about off-label drug use

The term off-label drug use (OLDU) is used extensively in the medical literature, continuing medical education exercises, and the media. Yet, we propose that many health care professionals have an underappreciation of its definition, prevalence, and implications. This article introduces and answers 10 questions regarding OLDU in an effort to clarify the practice's meaning, breadth of application, acceptance, and liabilities. Off-label drug use involves prescribing medications for indications, or using a dosage or dosage form, that have not been approved by the US Food and Drug Administration. Since the Food and Drug Administration does not regulate the practice of medicine, OLDU has become common. It occurs in every specialty of medicine, but it may be more common in areas of medicine in which the patient population is less likely to be included in clinical trials (eg, pediatric, pregnant, or psychiatric patients). Pharmaceutical companies are not allowed to promote their medications for an off-label use, which has lead to several large settlements for illegal marketing. To limit liability, physicians should prescribe medications only for indications that they believe are in the best interest of the patient. In addition, health care professionals should educate themselves about OLDU to weigh the risks and benefits and provide the best possible care for their patients.

Iatrogenic skin injury in hospitalized patients

Iatrogenic skin injuries in hospitalized patients range from drug-related complications to those related to procedures. Common drug complications include drug reaction with eosinophilia and systemic symptoms (DRESS), linear immunoglobulin (Ig) A bullous dermatosis, Stevens-Johnson syndrome/toxic epidermal necrolysis, and acute generalized exanthematous pustulosis. Contact dermatitis can result from surgical preparations of chlorhexidine and povidone-iodine, medical adhesives, topical postsurgical ointments, most commonly neomycin and bacitracin, and internal prostheses, including coronary stents, pacemakers, and metal joints. Complications arising from procedures include thrombosis caused by placement of peripherally inserted central catheters, pyoderma gangrenosum from sites of dermal trauma, and anetoderma of prematurity from cutaneous monitoring devices in neonates. Calcinosis cutis and decubitus ulcers are also hospital problems.

Biosimilars: the 'future' of biologic therapy?

The introduction of a number of biologic therapies to the market has revolutionized therapeutics in dermatology. However, the patents protecting their manufacture are about to lapse, and follow-on generic products, known as biosimilars, are about to flood the pharmaceutical market. The 'biosimilars' are different from the generic products of conventional drugs in terms of efficacy, safety and immunogenicity. This awareness is essential for their proper prescription and the safety of patients. This article intends to serve as a primer for dermatologists in their understanding of biosimilars.

Pyoderma gangrenosum: a review and update on new therapies

Pyoderma gangrenosum is a rare and often painful skin disease that can be unpredictable in its response to treatment. There is currently no gold standard of treatment or published algorithm for choice of therapy. The majority of data comes from case studies that lack a standard protocol not only for treatment administration but also for the objective assessment of lesion response to a specific therapy. This review provides an update to the treatment of pyoderma gangrenosum with a particular focus on new systemic therapies.