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Valido K, Murphy MJ, Leventhal JS, Damsky W. Successful treatment of pityriasis rubra pilaris with brodalumab after nonresponse to IL-17A inhibition: A role for the innate cytokine IL-17C. JAAD Case Rep 2024; 48:85-87. [PMID: 38783931 PMCID: PMC11111584 DOI: 10.1016/j.jdcr.2024.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024] Open
Affiliation(s)
- Kailyn Valido
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | - Michael J. Murphy
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
| | | | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
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Chandy RJ, Chokshi A, Tan I, Feldman SR. Biologics for Treatment of Pityriasis Rubra Pilaris: A Literature Review. J Cutan Med Surg 2024; 28:269-275. [PMID: 38549359 DOI: 10.1177/12034754241238735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
OBJECTIVE To describe the published efficacy and adverse event rates associated with existing biologics for the treatment of pityriasis rubra pilaris (PRP). DATA SOURCES A literature review using the PubMed database (January 1990-July 2023) was conducted. Multiple search combinations were conducted using "pityriasis rubra pilaris" and various biologics as keywords to identify relevant articles. STUDY SELECTION AND DATA EXTRACTION Inclusion criteria included all study types that were published within the past 30 years in English and mentioned at least one biologic and PRP. A preliminary search yielded a total of 499 results. After screening using inclusion and exclusion criteria, 77 relevant articles (69 case reports, 5 case series, 2 clinical trials, and 1 retrospective analysis) were analyzed. DATA SYNTHESIS TNF-α inhibitors have been evaluated and are effective in treating PRP. However, recent treatment with anti-interleukin (IL)-17 and anti-IL-23 therapies such as ustekinumab, secukinumab, and ixekizumab are emerging as new treatment options with a mean improvement in PRP Area and Severity Index scores, change in severity of erythema, scaling, and thickness of PRP lesions. From initial clinical trials, secukinumab and ixekizumab are promising treatment options for achieving remission. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review compares the efficacy for numerous biologics and a discussion to guide clinicians on benefits and risks in choosing a biologic for PRP patients. CONCLUSIONS Biologics may be a favourable treatment option leading to greater patient adherence due to reduced dosing frequencies, improvement in quality of life, and reduction in frequency and severity of flares.
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Affiliation(s)
- Rithi J Chandy
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Aditi Chokshi
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Isabella Tan
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Social Sciences and Health Policy, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Dermatology, University of Southern Denmark, Odense, Denmark
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Chen MKY, Flanagan AL, Sebaratnam DF, Gu Y. Biologics for inherited disorders of keratinisation: A systematic review. Australas J Dermatol 2024; 65:185-214. [PMID: 38126177 DOI: 10.1111/ajd.14197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/13/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND/OBJECTIVES Recent literature highlights the potential of biologics in the management of inherited disorders of keratinisation. In this study, we conducted a systematic review of existing literature on treatment outcomes of inherited keratinisation disorders treated with biologics. METHODS Eligible records were retrieved through searches of the electronic databases MEDLINE, Embase, PubMed and Scopus. Databases were searched from inception to July 2023 for eligible records. A snowballing method was employed to search the references of the retrieved records for the identification of potentially relevant articles. RESULTS One hundred and four eligible studies consisting of a total of 166 patients with an inherited disorder of keratinisation were included. Patients had a median age of 19 years (range: 0.5 to 70 years). The most common disorders were Netherton syndrome (n = 63; 38%), autosomal recessive congenital ichthyoses (n = 27; 16%), CARD14-associated papulosquamous eruptions (n = 17; 10%) and familial pityriasis rubra pilaris (PRP) (n = 15; 9%).Of the 207 times biologics were employed, the three most frequently employed biologics were secukinumab (n = 47; 23%), dupilumab (n = 44; 21%) and ustekinumab (n = 37; 18%). Complete remission was observed in 10 (5%) instances, partial remission in 129 (62%), no or limited response to biologic therapy in 68 (32%) cases, and results are still pending in one case. A total of 33 adverse events were reported. CONCLUSIONS Whilst biologics may be considered in cases of inherited keratinisation disorders recalcitrant to standard therapy, definitive conclusions are prohibited by the low-level of evidence and substantial heterogeneity in methodology across the included studies. Establishment of consensus definitions, and randomised clinical trials may help ascertain the efficacy and safety of biologic therapy in this context and establish the best agent and dosing protocol for each disorder.
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Affiliation(s)
- Michelle K Y Chen
- School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Alice L Flanagan
- School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Deshan F Sebaratnam
- School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Yaron Gu
- School of Clinical Medicine, UNSW Medicine & Health, Sydney, New South Wales, Australia
- Department of Dermatology, Liverpool Hospital, Liverpool, New South Wales, Australia
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Joshi TP, Duvic M. Pityriasis Rubra Pilaris: An Updated Review of Clinical Presentation, Etiopathogenesis, and Treatment Options. Am J Clin Dermatol 2024; 25:243-259. [PMID: 38159213 DOI: 10.1007/s40257-023-00836-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2023] [Indexed: 01/03/2024]
Abstract
Pityriasis rubra pilaris (PRP) is a rare papulosquamous reaction pattern with a significant impact on quality of life. Type I PRP is the most common PRP variant, presenting as erythematous papules emerging in a follicular distribution and later coalescing into plaques with characteristic islands of sparing; histologically, an alternating pattern of orthokeratosis and parakeratosis is considered the hallmark of PRP (checkerboard hyperkeratosis). Other PRP variants (types II-V) differ in their age of onset and clinical presentation. Type VI PRP is a rare PRP subtype associated with human immunodeficiency virus infection and is occasionally associated with diseases of the follicular occlusion tetrad. Caspase recruitment domain family, member 14 (CARD14)-associated papulosquamous eruption and facial discoid dermatitis are newly described disease states that have an important clinical overlap with PRP, creating shared conundrums with respect to diagnosis and treatment. The etiology inciting PRP often remains uncertain; PRP has been suggested to be associated with infection, malignancy, or drug/vaccine administration in some cases, although these are based on case reports and causality has not been established. Type V PRP is often due to inborn CARD14 mutations. Furthermore, recent literature has identified interleukin-23/T-helper-17 cell axis dysregulation to be a major mediator of PRP pathogenesis, paving the way for mechanism-directed therapy. At present, high-dose isotretinoin, ixekizumab, and secukinumab are systemic agents supported by single-arm prospective studies; numerous other agents have also been trialed for PRP, with variable success rates. Here, we discuss updates on clinical manifestations, present new insights into etiopathogenesis, and offer a survey of recently described therapeutic options.
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Affiliation(s)
- Tejas P Joshi
- School of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
| | - Madeleine Duvic
- Department of Dermatology, University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Boudreaux BW, Pincelli TP, Bhullar PK, Patel MH, Brumfiel CM, Li X, Heckman MG, Pittelkow MR, Mangold AR, Sluzevich JC. Secukinumab for the treatment of adult-onset pityriasis rubra pilaris: a single-arm clinical trial with transcriptomic analysis. Br J Dermatol 2022; 187:650-658. [PMID: 35701384 DOI: 10.1111/bjd.21708] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/04/2022] [Accepted: 06/11/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND The pathogenesis of pityriasis rubra pilaris (PRP) is not completely understood, but interleukin (IL)-17 has been shown to play a critical role. There are no reliable immunomodulatory agents to treat PRP. We conducted an open-label, single-arm clinical trial of secukinumab, a monoclonal antibody that inhibits IL-17A, for the treatment of PRP. OBJECTIVES To evaluate the clinical efficacy of secukinumab and define the transcriptomic landscape of PRP and its response to IL-17A blockade. METHODS Twelve patients with PRP were recruited for an open-label trial of secukinumab. Patients received a 24-week course of secukinumab. The primary endpoint was a ≥ 75% reduction in Psoriasis Area and Severity Index (PASI 75) from baseline to week 28. Secondary endpoints included PASI 90, change in Physician's Global Assessment (PGA), and change in Dermatology Life Quality Index (DLQI). RNA sequencing was performed on lesional and nonlesional skin biopsies obtained at baseline and week 2. Sample groups were compared to identify differential gene expression and pathway enrichment. This trial was registered with ClinicalTrials.gov: 'Cosentyx (secukinumab) for the treatment of adult onset pityriasis rubra pilaris' - NCT03342573. RESULTS At week 28, six of 11 patients (55%) achieved PASI 75, and three patients (27%) achieved PASI 90. PGA (P = 0.008) and DLQI scores (P = 0.010) showed significant improvement with treatment. No serious treatment-related adverse events were encountered. Treatment with secukinumab normalized transcriptional differences between lesional and nonlesional skin. Transcriptomic data from nonresponsive patients suggest that overactivity of innate immune pathways may be driving resistance to secukinumab. CONCLUSIONS Secukinumab appears to be an effective treatment for PRP and warrants further investigation. PRP is a transcriptionally heterogeneous disease, reflecting its variable response to therapy. Agents targeting other IL-17 isoforms and innate immune mediators should be considered for future clinical trials. What is already known about this topic? The pathogenesis of pityriasis rubra pilaris is incompletely understood. Successful treatment has been reported with a variety of immunomodulatory agents, but disease is often refractory to therapy. Interleukin (IL)-17 is thought to drive keratinocyte proliferation and vascular dysfunction in this disease. A previous trial demonstrated efficacy of the anti-IL-17A drug ixekizumab for pityriasis rubra pilaris. What does this study add? Herein we describe the findings of a clinical trial of secukinumab, an anti-IL-17A monoclonal antibody, for the treatment of pityriasis rubra pilaris. Secukinumab was effective in treating pityriasis rubra pilaris. Our transcriptomic data give new insight into the expressional changes that occur in response to secukinumab and suggest mechanisms of treatment resistance.
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Affiliation(s)
| | | | - Puneet K Bhullar
- Department of Dermatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Meera H Patel
- Department of Dermatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | | | - Xing Li
- Department of Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL, USA
| | - Mark R Pittelkow
- Department of Dermatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
| | - Aaron R Mangold
- Department of Dermatology, Mayo Clinic Arizona, Scottsdale, AZ, USA
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Iznardo H, Puig L. Beyond plaque psoriasis - pathogenesis and treatment of other psoriasis phenotypes. Curr Opin Rheumatol 2022; 34:225-234. [PMID: 35699337 DOI: 10.1097/bor.0000000000000882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Psoriasis vulgaris is the commonest presentation of psoriatic disease, but morphologic variants such as pustular psoriasis (PP) and a closely related disease, pityriasis rubra pilaris (PRP), have been known for a long time, have been associated with rheumatologic manifestations indistinguishable from psoriatic arthritis (PsA) that may go unrecognized, and often represent a therapeutic conundrum. There is recent evidence that underlying genetic and pathogenetic differences may provide the basis for newer therapeutic approaches. RECENT FINDINGS This narrative review highlights the clinical, genetic and pathogenetic characteristics of PP and PRP, their association with PsA and recent developments in their treatment, especially with biologic agents targeting IL-36 and other cytokines of pathogenic relevance. SUMMARY The clinical manifestations of PP and PRP are less well known to rheumatologists than those of psoriasis, and recent advances in our insight on their pathogenesis may eventually overcome the therapeutic difficulties faced by dermatologists and rheumatologists in the management of these diseases and their rheumatologic manifestations.
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Affiliation(s)
- Helena Iznardo
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma, Barcelona, Spain
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Morren MA, Legius E, Giuliano F, Hadj-Rabia S, Hohl D, Bodemer C. Challenges in Treating Genodermatoses: New Therapies at the Horizon. Front Pharmacol 2022; 12:746664. [PMID: 35069188 PMCID: PMC8766835 DOI: 10.3389/fphar.2021.746664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/29/2021] [Indexed: 01/28/2023] Open
Abstract
Genodermatoses are rare inherited skin diseases that frequently affect other organs. They often have marked effects on wellbeing and may cause early death. Progress in molecular genetics and translational research has unravelled many underlying pathological mechanisms, and in several disorders with high unmet need, has opened the way for the introduction of innovative treatments. One approach is to intervene where cell-signaling pathways are dysregulated, in the case of overactive pathways by the use of selective inhibitors, or when the activity of an essential factor is decreased by augmenting a molecular component to correct disequilibrium in the pathway. Where inflammatory reactions have been induced by a genetically altered protein, another possible approach is to suppress the inflammation directly. Depending on the nature of the genodermatosis, the implicated protein or even on the particular mutation, to correct the consequences or the genetic defect, may require a highly personalised stratagem. Repurposed drugs, can be used to bring about a "read through" strategy especially where the genetic defect induces premature termination codons. Sometimes the defective protein can be replaced by a normal functioning one. Cell therapies with allogeneic normal keratinocytes or fibroblasts may restore the integrity of diseased skin and allogeneic bone marrow or mesenchymal cells may additionally rescue other affected organs. Genetic engineering is expanding rapidly. The insertion of a normal functioning gene into cells of the recipient is since long explored. More recently, genome editing, allows reframing, insertion or deletion of exons or disruption of aberrantly functioning genes. There are now several examples where these stratagems are being explored in the (pre)clinical phase of therapeutic trial programmes. Another stratagem, designed to reduce the severity of a given disease involves the use of RNAi to attenuate expression of a harmful protein by decreasing abundance of the cognate transcript. Most of these strategies are short-lasting and will thus require intermittent life-long administration. In contrast, insertion of healthy copies of the relevant gene or editing the disease locus in the genome to correct harmful mutations in stem cells is more likely to induce a permanent cure. Here we discuss the potential advantages and drawbacks of applying these technologies in patients with these genetic conditions. Given the severity of many genodermatoses, prevention of transmission to future generations remains an important goal including offering reproductive choices, such as preimplantation genetic testing, which can allow selection of an unaffected embryo for transfer to the uterus.
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Affiliation(s)
- Marie-Anne Morren
- Pediatric Dermatology Unit, Departments of Dermatology and Venereology and Pediatrics, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Eric Legius
- Department for Human Genetics, University Hospitals Leuven, KU Leuven, ERN Genturis and ERN Skin, Leuven, Belgium
| | - Fabienne Giuliano
- Department of Medical Genetics, University Hospital Lausanne, Lausanne, Switzerland
| | - Smail Hadj-Rabia
- Department of Pediatric Dermatology and Dermatology, National Reference Centre for Genodermatosis and Rare Diseases of the Skin (MAGEC), Hôpital Necker-Enfants Malades, and Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, ERN Skin, Paris, France
| | - Daniel Hohl
- Department of Dermatology and Venereology, University Hospital Lausanne, University of Lausanne, Lausanne, Switzerland
| | - Christine Bodemer
- Department of Pediatric Dermatology and Dermatology, National Reference Centre for Genodermatosis and Rare Diseases of the Skin (MAGEC), Hôpital Necker-Enfants Malades, and Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, ERN Skin, Paris, France
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Frare CP, Blumstein AJ, Paller AS, Pieretti L, Choate KA, Bowcock AM, Larralde M. CARD14-associated papulosquamous eruption (CAPE) in pediatric patients: Three additional cases and review of the literature. Pediatr Dermatol 2021; 38:1237-1242. [PMID: 34448248 PMCID: PMC8578307 DOI: 10.1111/pde.14779] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
CARD14-associated papulosquamous eruption (CAPE) is a proposed term that encompasses features ranging from psoriasis to pityriasis rubra pilaris (PRP) in association with CARD14 mutations. The early onset of the disease, prominent facial involvement, family history of an autosomal dominant trait, and poor response to conventional treatment are characteristics of CAPE that distinguish it from classical psoriasis and PRP. We describe the clinical features, family history, and response to therapy in three unrelated children with CAPE and compare these characteristics with those of previously described pediatric patients. Testing for CARD14 mutations in children with early onset of features of psoriasis or pityriasis rubra pilaris and resistance to conventional therapy should be considered.
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Affiliation(s)
- Cindy P Frare
- Department of Dermatology, Hospital Alemán, Buenos Aires, Argentina
| | - Alli J Blumstein
- Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy S Paller
- Departments of Dermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lia Pieretti
- Dr Úraga Private Center for Skin Diseases, Guayaquil, Ecuador
| | - Keith A Choate
- Department of Genetics, Yale University School of Medicine, New Haven, CT, USA
| | - Anne M Bowcock
- Dermatology, Oncological Sciences and Genetics & Genomics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Margarita Larralde
- Department of Dermatology, Hospital Alemán, Buenos Aires, Argentina.,Department of Pediatric Dermatology, Ramos Mejía Hospital, Buenos Aires, Argentina
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Amat-Samaranch V, Cubiró X, Tubau C, Garcia-Melendo C, Puig L. Response of pityriasis rubra pilaris to brodalumab after primary failure to ustekinumab. Int J Dermatol 2020; 60:e112-e114. [PMID: 33128453 DOI: 10.1111/ijd.15219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 09/02/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Victoria Amat-Samaranch
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Xavier Cubiró
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carla Tubau
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Cristina Garcia-Melendo
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luis Puig
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Camela E, Miano C, Di Caterino P, Lo Presti M, De Fata Salvatores G, Fabbrocini G, Megna M. Erythrodermic pityriasis rubra pilaris treatment: Two case reports and literature review. Dermatol Ther 2020; 33:e14223. [PMID: 32820849 DOI: 10.1111/dth.14223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/07/2020] [Accepted: 08/17/2020] [Indexed: 01/16/2023]
Abstract
Pityriasis rubra pilaris (PRP) is a rare inflammatory dermatosis characterized by hyperkeratotic follicular papules and erythematous-desquamative plaques that tend to progressively evolve into erythroderma. Treatment is challenging given that international guidelines are not available and large-scale trials do not exist. Traditionally, many topical and systemic drugs had been used as consolidated agents; recently, biologicals are gaining increasing importance, promisingly dominating the therapeutic scenario ahead. Herein, we present a case series showing the "past" and the "future" therapeutic approaches to erythrodermic PRP, one case treated with acitretin and nb-UVB phototherapy combination, while the other with ustekinumab, performing also a throughout literature review.
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Affiliation(s)
- Elisa Camela
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Chiara Miano
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Paola Di Caterino
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Maurizio Lo Presti
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gaia De Fata Salvatores
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Matteo Megna
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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