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Guenther J, Novack D, Kamath S, Worswick S. Treatment Options for Juvenile Pityriasis Rubra Pilaris. Paediatr Drugs 2023; 25:151-164. [PMID: 36529810 DOI: 10.1007/s40272-022-00549-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 12/23/2022]
Abstract
Pityriasis rubra pilaris represents a group of familial and acquired disorders of cornification that affect both adult and pediatric patients. Treatment options are difficult to assess through clinical trials, given the rarity of the disorder and its tendency for spontaneous remission. Case reports and case series are therefore the primary means of assessment. Because of the heterogeneity of the disease, there is no universal approach to treatment, and multiple agents may need to be trialed to achieve disease control. At present, topicals are used for most pediatric patients, though monotherapy with topicals is only effective for less severe disease. Despite concerns over their side-effect profiles, oral retinoids are generally accepted as a first-line systemic therapy. However, interleukin-17 inhibitors and ustekinumab, an interleukin-12 and interleukin-23 inhibitor, may soon become first-line systemic treatment as well, given their efficacy and relative safety in trials thus far. Ustekinumab, in particular, is emerging as a first-line agent for patients with pityriasis rubra pilaris with CARD14 gene variations. When these therapies fail, second-line and adjunctive therapies to consider include tumor necrosis factor-alpha inhibitors, methotrexate, and phototherapy. However, further investigation is necessary to assess the safety and efficacy of many of these agents in juvenile pityriasis rubra pilaris.
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Affiliation(s)
- Jana Guenther
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Sonia Kamath
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Scott Worswick
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Kromer C, Sabat R, Celis D, Mössner R. Systemische Therapien bei Pityriasis rubra pilaris: eine systematische Übersicht. J Dtsch Dermatol Ges 2019; 17:243-260. [DOI: 10.1111/ddg.13718_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Christian Kromer
- Klinik für DermatologieVenerologie und AllergologieUniversitätsmedizin Göttingen Göttingen Deutschland
| | - Robert Sabat
- Interdisiplinäre Gruppe für Molekulare Immunpathologie, Dermatologie/Medizinische Immunologie, Charité – Universitätsmedizin Berlin Berlin Deutschland
- Psoriasis Forschungs‐ und BehandlungsCentrum, Klinik für Dermatologie, Venerologie und Allergologie und Institut für Medizinische Immunologie, Charité – Universitätsmedizin Berlin Berlin Deutschland
| | - Daniel Celis
- Wirtschaftswissenschaftliche Fakultät, Universität Göttingen Göttingen Deutschland
| | - Rotraut Mössner
- Klinik für DermatologieVenerologie und AllergologieUniversitätsmedizin Göttingen Göttingen Deutschland
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Kromer C, Sabat R, Celis D, Mössner R. Systemic therapies of pityriasis rubra pilaris: a systematic review. J Dtsch Dermatol Ges 2018; 17:243-259. [PMID: 30520557 DOI: 10.1111/ddg.13718] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 06/29/2018] [Indexed: 02/03/2023]
Abstract
Pityriasis rubra pilaris (PRP) is a rare papulosquamous disorder. Treatment is challenging; the armamentarium consists of topical corticosteroids, phototherapy, classic systemic treatments such as retinoids or immunosuppressive drugs, and most recently biologicals. However, the relative effectiveness of therapies is unclear. Our objective was to review the published literature on systemic treatment of PRP. A systematic review was conducted on PubMed and the Cochrane Library up to 5 September 2017. Studies evaluating any systemic treatments of PRP (except for historical treatments) were included. Overall, 182 studies met the predefined inclusion criteria, and reported on 475 patients and 652 courses of treatment. 42.0 % (225/514) of all patients treated with retinoids achieved an excellent response (isotretinoin: 61.1 % [102/167], etretinate: 47 % [54/115], and acitretin: 24.7 % [43/174]) compared to an excellent response rate of 33.1 % (53/160) with methotrexate. Therapy with biologicals was successful in 51.0 % of patients (71/133) (ustekinumab: 62.5 % [10/16], infliximab: 57.1 % [28/49], etanercept: 53.3 % [16/30], and adalimumab: 46.4 % [13/28]). This review balances effectiveness, side effects, experience, and drug costs in order to suggest a treatment regimen starting with isotretinoin as first-line, methotrexate as second-line and biologicals as third-line treatment for this difficult-to-treat dermatosis.
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Affiliation(s)
- Christian Kromer
- Department of Dermatology, Venereology, and Allergology, University Medical Centre, Göttingen, Germany
| | - Robert Sabat
- Interdisciplinary Group of Molecular Immunopathology, Dermatology/Medical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Psoriasis Research and Treatment Center, Department of Dermatology and Allergy and Institute of Medical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Daniel Celis
- Faculty of Economic Sciences, Göttingen University, Göttingen, Germany
| | - Rotraut Mössner
- Department of Dermatology, Venereology, and Allergology, University Medical Centre, Göttingen, Germany
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Abstract
Pityriasis rubra pilaris (PRP) is an idiopathic, papulosquamous inflammatory dermatosis. It is characterized by hyperkeratotic follicular papules coalescing into orange-red scaly plaques, islands of sparing, and palmoplantar keratoderma. PRP can be subdivided into six clinical subtypes according to Griffiths' classification, based on age of onset, disease extent, prognosis, and other associated features. The sixth subtype of PRP occurs in individuals affected by HIV infection, and retroviral screening in all de novo cases of PRP is advised. Other reported associations include various infections, autoimmunity, drugs, and malignancies, although the true significance of these is still unclear. The genetic basis for familial cases, most commonly categorized under the fifth subtype, has been mapped to gain of function mutations in the caspase recruitment domain family, member 14 (CARD14) gene. Treatment of PRP remains a challenge to this day due to a paucity of high-quality evidence. Therapeutic regimens have been guided mostly by case reports and case series, with the mainstay of treatment being oral retinoids. Recently, biologics have emerged as a promising treatment for PRP. We present a review of the clinicopathologic features, pathogenesis, associated disorders, and treatment of PRP, with an emphasis and critical appraisal of the existing literature on the latter.
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Roenneberg S, Biedermann T. Pityriasis rubra pilaris: algorithms for diagnosis and treatment. J Eur Acad Dermatol Venereol 2018; 32:889-898. [DOI: 10.1111/jdv.14761] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/30/2017] [Indexed: 12/11/2022]
Affiliation(s)
- S. Roenneberg
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Germany Munich
| | - T. Biedermann
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Germany Munich
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Moretta G, De Luca EV, Di Stefani A. Management of refractory pityriasis rubra pilaris: challenges and solutions. Clin Cosmet Investig Dermatol 2017; 10:451-457. [PMID: 29184428 PMCID: PMC5687447 DOI: 10.2147/ccid.s124351] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pityriasis rubra pilaris (PRP) is a rare chronic inflammatory papulosquamous skin disease. Its clinical presentation and evolution is very variable. The most frequent clinical features are follicular papules, progressing to yellow-orange erythroderma with round small areas of normal skin and the well-demarcated palmoplantar keratoderma. Actually, six different types of PRP have been described based on clinical characteristics, age of onset, and prognosis. The pathogenesis is still unknown, and treatment can be challenging. Available treatments are mainly based on case reports or case series of clinical experience because no controlled randomized trials have never been performed because of the rarity of the condition. Traditional systemic treatment consists in retinoids, which are actually considered as first-line therapy, but refractory cases that do not respond or relapse after drug interruption do exist. In recent years, numerous reports have demonstrated the efficacy of new agents such as biological drugs. This article is an overview on available therapeutic options, in particular for refractory forms of PRP.
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Affiliation(s)
- Gaia Moretta
- Institute of Dermatology, Fondazione Policlinico Universitario A. Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Erika V De Luca
- Institute of Dermatology, Fondazione Policlinico Universitario A. Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandro Di Stefani
- Institute of Dermatology, Fondazione Policlinico Universitario A. Gemelli, Catholic University of the Sacred Heart, Rome, Italy
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Photosensitive pityriasis rubra pilaris. Postepy Dermatol Alergol 2016; 33:239-42. [PMID: 27512362 PMCID: PMC4969422 DOI: 10.5114/ada.2016.60619] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 09/19/2015] [Indexed: 11/17/2022] Open
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Giménez-Arnau A. A public danger induces common action: contact allergy epidemic to dimethylfumarate in Europe. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.11.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Di Stefani A, Galluzzo M, Talamonti M, Chiricozzi A, Costanzo A, Chimenti S. Long-term ustekinumab treatment for refractory type I pityriasis rubra pilaris. J Dermatol Case Rep 2013; 7:5-9. [PMID: 23580907 DOI: 10.3315/jdcr.2013.1127] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Accepted: 12/01/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Pityriasis rubra pilaris is a rare, chronic erythematous squamous disorder of unknown etiology. The disease is characterized initially by small follicular papules that coalesce into yellowish pink scaly plaques, palmoplantar keratoderma, diffuse furfuraceous scale of the scalp, and frequent progression to exfoliative erythroderma. Generally it is difficult to discern pityriasis rubra pilaris from other skin conditions but key-clinical features help in the diagnosis such as "islands" of spared skin within generalized erythroderma, follicular keratotic plugs, and an orange hue of the involved skin. Treatment options include topical vitamin D analogues, keratolytics, systemic acitretin, methotrexate, cyclosporine, azathioprine, fumaric acid esters, phototherapy, and anti-TNFα agents. Cases, of pityriasis rubra pilaris, successfully treated with a short-course ustekinumab therapy, have been reported. MAIN OBSERVATIONS We report a 31-year-old man with pityriasis rubra pilaris, refractory to conventional treatments, successfully treated with ustekinumab monotherapy for over 64 weeks. After failing conventional systemic agents (cyclosporine, aciretin and methotrexate), ustekinumab 45 mg has been prescribed, with the same dosing regimen as in psoriasis. The patient improved dramatically within 4 weeks of the first injection, with markedly less erythema and pruritus. Long-term control of the disease of the disease was achieved (64 weeks of treatment). CONCLUSION We report this case in order to show the striking and rapid efficacy of ustekinumab in reducing the signs and symptoms of the disease. Complete remission was achieved after the third injection, but also a long-term control of the disease. The therapy was well-tolerated in our patient and no adverse events occurred.
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Abstract
Pityriasis rubra pilaris (PRP) is a rare inflammatory dermatosis of unknown etiology, and finding a successful therapy can be challenging. PRP occurs equally in men and women. In some patients, associated autoimmune diseases, infections, or malignancies are possible trigger factors. PRP shows a bimodal age distribution, peaking in the first as well as in the fifth to sixth decade. Its classification into five subgroups is based on age at onset, clinical course, morphologic features, and prognosis. More than 50% of patients are best classified as type I with adult-onset PRP. This form is also characterized by high spontaneous remission rates (80%) within 1-3 years. Clinically, the classical adult (type I) and classical juvenile (type III) forms appear to be the same except for the patient's age. Recently, the designation of a new category of PRP (type VI) has been proposed that is characterized by the presence of HIV infection with different clinical features and a poorer prognosis. Typical morphologic features of PRP are erythematosquamous salmon-colored plaques with well demarcated islands of unaffected skin. Often, keratoderma of the palms and soles is present. In patients with extensive disease, ectropion is a dreaded complication. Histology shows hyperkeratosis, alternating orthokeratosis and parakeratosis in a checkerboard pattern, and focal acantholytic dyskeratosis. Descriptions and therapeutic experiences are mainly based on case reports. Mostly, systemic retinoids, methotrexate, and other immunosuppressive agents as well as UV light therapy are applied, with varying response rates. In recent years, treatment with so-called 'biologics' is becoming more and more popular for treating recalcitrant PRP. We present a review of the clinical features, histopathologic findings, classification, differential diagnoses, and treatment of PRP.
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Affiliation(s)
- Annette Klein
- Department of Dermatology, University of Regensburg, Regensburg, Germany.
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Duarte I, Lazzarini R, Rotter A. Dermatological drugs, topical agents, and cosmetics. SIDE EFFECTS OF DRUGS ANNUAL 2010. [DOI: 10.1016/s0378-6080(10)32014-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Juvenile pityriasis rubra pilaris: Report of 28 cases in Taiwan. J Am Acad Dermatol 2008; 59:943-8. [DOI: 10.1016/j.jaad.2008.07.054] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2007] [Revised: 07/26/2008] [Accepted: 07/27/2008] [Indexed: 11/23/2022]
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Seckin D, Tula E, Ergun T. Successful use of etanercept in type I pityriasis rubra pilaris. Br J Dermatol 2007; 158:642-4. [DOI: 10.1111/j.1365-2133.2007.08379.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Klein A, Szeimies RM, Landthaler M, Karrer S. Exacerbation of Pityriasis Rubra Pilaris under Efalizumab Therapy. Dermatology 2007; 215:72-5. [PMID: 17587845 DOI: 10.1159/000102039] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2006] [Accepted: 02/02/2007] [Indexed: 11/19/2022] Open
Abstract
A 60-year-old woman, diagnosed as having psoriasis vulgaris in 2004 and unresponsive to standard therapies, received weekly subcutaneous injections with efalizumab. Within 9 weeks of treatment a massive aggravation of skin lesions occurred with widespread orange-tinged erythroderma, islands of normal skin on the back and the inner side of the forearms and palmoplantar hyperkeratosis. A biopsy confirmed the clinical diagnosis of pityriasis rubra pilaris. After discontinuation of efalizumab and treatment with oral corticosteroids, acitretin (30 mg/day) and PUVA therapy, the skin lesions continuously improved. Efalizumab, a fully humanized monoclonal antibody against CD11a, inhibits various T cell processes important in the pathogenesis of psoriasis. Efalizumab has been approved for the treatment of moderate to severe psoriasis, but there are no reports in the literature on the use of efalizumab for pityriasis rubra pilaris.
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Affiliation(s)
- A Klein
- Department of Dermatology, University of Regensburg, Regensburg, Germany
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Kerr AC, Ferguson J. Type II adult-onset pityriasis rubra pilaris successfully treated with intravenous immunoglobulin. Br J Dermatol 2007; 156:1055-6. [PMID: 17313492 DOI: 10.1111/j.1365-2133.2007.07773.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Martinez Calixto LE, Suresh L, Matsumura E, Aguirre A, Radfar L. Oral pityriasis rubra pilaris. ACTA ACUST UNITED AC 2006; 101:604-7. [PMID: 16632271 DOI: 10.1016/j.tripleo.2005.08.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2005] [Revised: 08/09/2005] [Accepted: 08/22/2005] [Indexed: 11/18/2022]
Abstract
Pityriasis rubra pilaris is a chronic, papulosquamous dermatosis of unknown etiology. Oral mucosal involvement of this condition is rare with only 3 previously reported cases in the English literature. A case of a 68-year-old man with pityriasis rubra pilaris with involvement of tongue and palate is presented. Clinical features, histopathologic features, and management of pityriasis rubra pilaris are discussed. We hereby present an additional case, the fourth worldwide, and review the literature.
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Affiliation(s)
- Luis Edmundo Martinez Calixto
- Advanced Oral and Maxillofacial Pathology, Department of Oral Diagnostic Sciences, School of Dental Medicine, State University of New York at Buffalo, NY 14214, USA
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Manoharan S, White S, Gumparthy K. Successful treatment of type I adult-onset pityriasis rubra pilaris with infliximab. Australas J Dermatol 2006; 47:124-9. [PMID: 16637810 DOI: 10.1111/j.1440-0960.2006.00247.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 59-year-old woman presented with a painful, pruritic eruption that had commenced as an erythematous, dry patch on the upper back but progressed to erythroderma. Examination revealed orange-tinged erythroderma, scalp scaling, ectropion, palmoplantar keratoderma and nail changes. A diagnosis of type I adult-onset pityriasis rubra pilaris was made, and a subsequent skin biopsy was consistent with this. She was treated with a number of topical and systemic agents with minimal improvement or major side-effects. The patient was then treated with intravenous infliximab 5 mg/kg. She improved dramatically within 2 weeks and was no longer erythrodermic. Five further infusions resulted in additional improvement. Methotrexate was briefly added to the regime, but was ceased owing to nausea. Topical tar and keratolytics were used on the scalp. The patient was left with minimal disease activity and was maintained on emollients.
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Affiliation(s)
- Shobhan Manoharan
- Department of Dermatology, Wirral Hospital NHS Trust, Clatterbridge Hospital, Bebington Wirral, England, UK.
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