Effect of dosing frequency on the safety and efficacy of imiquimod 5% cream for treatment of actinic keratosis on the forearms and hands: a phase II, randomized placebo-controlled trial

BACKGROUND

Clinical studies in cutaneous conditions other than actinic keratosis (AK) have revealed that the safety and efficacy profile of imiquimod is influenced by dosing frequency.

OBJECTIVES

To evaluate dosing frequency response of imiquimod 5% for treatment of AK.

METHODS

This was a phase II, multicentre, randomized, double-blind, placebo-controlled study. Adults with > or = 10 but < or = 50 clinical AKs, one of which was histologically confirmed, were randomized (4:1) to 2-6 packets of imiquimod or placebo cream applied to the dorsum of the forearms and hands once daily 2, 3, 5 or 7 times per week for 8 weeks. The primary endpoint was complete clearance of AKs in the treatment area at 8 weeks post-treatment.

RESULTS

One hundred and forty-nine (94 men and 54 women) white subjects, with a mean +/- SD age of 71 +/- 10.2 years, were enrolled. Twenty-eight subjects (18.8%) discontinued from study: 0%, 3.1%, 6.9%, 30.0% and 33.3% withdrew for local skin reactions or adverse events in the combined placebo, and in the imiquimod 2, 3, 5 or 7 times per week groups, respectively. Seven serious adverse events occurred; none was related to the study drug. Median baseline lesions ranged from 38 to 40 for the treatment groups. Complete clearance was achieved in 0%, 3.2%, 6.9%, 3.3% and 6.7% of subjects, and partial clearance (> or = 75% lesion reduction) in 0%, 22.6%, 24.1%, 20.0% and 36.7% of subjects for the placebo and imiquimod 2, 3, 5 or 7 times per week regimens, respectively.

CONCLUSIONS

Imiquimod 5% applied more frequently than 3 times per week to AKs was not well tolerated. Complete clearance rates were low; however, partial clearance rates increased with increased dosing frequency (P = 0.002).

Oral retinoids for chemoprevention of skin cancers in organ transplant recipients: results of a survey

Systemic retinoid therapy is thought to be beneficial for chemosuppression of skin cancers in solid organ transplant recipients. We present the results of a survey of 28 dermatologists with experience managing transplant recipients to clarify when and how systemic retinoids are used in this population. Almost 80% of respondents use retinoids in some transplant recipients. Factors influencing the use of retinoids include the incidence and aggressiveness of cutaneous squamous cell carcinomas and the extent of concomitant actinic keratoses. Patients are monitored more closely during periods of dose adjustment than during the maintenance phase of therapy. Adverse effects are variably managed symptomatically, with dose adjustment, by discontinuation of retinoids, or by referral to another specialist for further evaluation. In the absence of large randomized controlled trials, the practice habits of experienced physicians serve as a useful guide for the use of oral retinoids in transplant recipients.

CLinical experience acquired with the efalizumab (Raptiva® ) (CLEAR) trial in patients with moderate-to-severe plaque psoriasis: results from a phase III international randomized, placebo-controlled trial

BACKGROUND

Efalizumab (anti-CD11a), a humanized monoclonal antibody, blocks multiple T-cell-dependent functions implicated in the pathogenesis of psoriasis, including T-cell activation, migration to the skin, reactivation in psoriatic skin and interactions with keratinocytes.

OBJECTIVES

This multinational, randomized, double-blind, placebo-controlled, parallel-group trial was designed to evaluate the safety and efficacy of subcutaneous efalizumab 1.0 mg kg-1 once weekly for 12 weeks compared with placebo in a population that included high-need patients, defined as those for whom at least two systemic therapies were unsuitable because of lack of efficacy, intolerance or contraindication.

PATIENTS/METHODS

Patients with moderate-to-severe plaque psoriasis [involvement of >or=10% of total body surface area and Psoriasis Area and Severity Index (PASI)>or=12.0 at screening] were randomized in a 2:1 ratio to receive efalizumab or placebo. The primary efficacy endpoint was the proportion of patients achieving >or=75% PASI improvement (PASI-75 response) at week 12 in the intention-to-treat population; secondary endpoints included changes in PASI, static Physician's Global Assessment, Physician's Global Assessment of change from baseline and percentage of body surface area affected. Results We enrolled 793 patients (529 received efalizumab and 264 placebo), including 526 high-need patients (342 received efalizumab and 184 placebo). Week 12 PASI-75 rates were 29.5% for efalizumab compared with 2.7% for placebo among high-need patients (P<0.0001) and 31.4% for efalizumab compared with 4.2% for placebo in the full study population (P<0.0001).

RESULTS

for all secondary efficacy endpoints showed superiority of efalizumab over placebo in both the high-need and the full populations. Efalizumab demonstrated a favourable safety profile, without evidence of systemic toxicity, in both the high-need group and the overall study population.

CONCLUSIONS

The efficacy and safety of efalizumab therapy were comparable between high-need patients and the more general moderate-to-severe psoriasis patient population. In view of its demonstrated efficacy and safety profile, efalizumab represents a valuable option for the treatment of adult patients with moderate-to-severe plaque psoriasis, including high-need patients.

Oral retinoids for the prevention of skin cancers in solid organ transplant recipients: a systematic review of randomized controlled trials

BACKGROUND

The increased incidence of skin cancers after solid organ transplantation is well recognized. Skin cancers developing in transplant recipients are more aggressive in behaviour. Therapeutic options to reduce and/or delay the development of cutaneous neoplasms are therefore of interest.

OBJECTIVES

The objective of this review was to summarize the available medical literature from randomized controlled trials on the use of oral retinoids as a preventive agent for skin cancers in the solid organ transplant population.

METHODS

Three electronic databases were searched for relevant trials: MEDLINE (1966-October 2003), EMBASE (1980-week 44, 2003) and the Cochrane Controlled Trials Register (third quarter 2003). Randomized or quasi-randomized controlled clinical trials on subjects of any age or ethnic background who had received a solid organ transplant (cardiac, renal, liver, etc.) were evaluated. All titles and abstracts found by the search strategy were independently reviewed by two researchers for inclusion into the review.

RESULTS

Eighty-one abstracts were identified through the electronic databases for consideration. Review of the abstracts identified three eligible trials. One cross-over trial involving 23 subjects treated with acitretin 25 mg daily for 12 months reported 46 squamous cell carcinomas (SCCs) developing in six subjects during acitretin treatment vs. 65 SCCs developing in 15 subjects during the drug-free period. Another trial involving 44 subjects treated with acitretin 30 mg daily or placebo for 6 months reported two of 19 subjects developing two SCCs in the treatment group vs. nine of 19 subjects developing 18 new skin cancers (15 SCCs, one Bowen's disease, two basal cell carcinomas) in the placebo group. One dose comparison trial involving 26 renal transplant recipients treated with acitretin did not find a significant difference in numbers of skin cancers developing at the doses examined. The major limitation to the use of acitretin was poor tolerance due to adverse events. Headaches, rash, musculoskeletal symptoms and hyperlipidaemia were the most common causes of withdrawal from treatment. No alterations in renal or liver function were detected during the periods of treatment or follow-up.

CONCLUSIONS

The available data from a small number of randomized controlled trials suggest that acitretin may have a role in the management of solid organ transplant recipients with skin cancers. Tolerability of the drug is a major factor limiting its use. Appropriate selection of patients may help improve the risk-benefit ratio.

Summary of actinic keratosis studies with imiquimod 5% cream

Imiquimod is being investigated as a therapeutic option for the management of actinic keratosis. Three recent clinical trials have demonstrated a reasonable efficacy rate and high safety profile. 'Cycle' therapy may improve the safety profile while maintaining efficacy. 'Field' treatment with imiquimod may uncover and treat 'subclinical' actinic keratoses, which in turn may potentially result in fewer recurrences. Longer follow-up studies are required to investigate this possibility.

Epidemiology and aetiology of basal cell carcinoma

Basal cell carcinoma is the most common malignancy among caucasians worldwide. Accurate epidemiological data can be difficult to obtain, but does suggest that the overall incidence is increasing. Risk factors include skin type, prior skin cancers and immunosuppression. Research in free radical-mediated cellular injury and innate defence mechanisms, and ultraviolet radiation-induced genetic mutations have improved our understanding of the development of this disorder.

Treatment of Bowen's disease using a cycle regimen of imiquimod 5% cream

Bowen's disease (BD; intraepithelial squamous cell carcinoma) is a challenging condition to treat because lesions, which can be multiple, are often located at sites that heal poorly, such as the shin. The disease is usually persistent and progressive and appears as an enlarging, demarcated erythematous plaque. Two elderly female patients with Bowen's disease of the lower leg are presented. Imiquimod 5% cream was applied in a cycle of three times weekly for 3 weeks followed by a 4-week rest period. The treatment was successful after a second cycle of therapy, with both cases clinically clear at 2- and 3-month follow-up visits.

Imiquimod 5% cream in the treatment of superficial basal cell carcinoma: results of a multicenter 6-week dose-response trial

BACKGROUND

Superficial basal cell carcinoma (sBCC) is an increasingly common tumor in fair-skinned populations throughout the world. Imiquimod, an immune response modifier that induces cytokines including interferons, has been shown in preliminary studies to have an effect when applied topically to BCC.

OBJECTIVE

We conducted a multicenter, randomized, open-label dose-response trial of imiquimod 5% cream in the treatment of primary sBCC assessing efficacy and safety of different dose regimens.

METHODS

Ninety-nine patients were randomized to 6 weeks' application of imiquimod in 1 of 4 treatment regimens: twice every day, once every day, twice daily 3 times/week, once daily 3 times/week. The treatment site was excised and examined histologically 6 weeks after cessation of imiquimod.

RESULTS

Intention-to-treat analysis revealed 100% (3/3) histologic clearance in the twice-daily regimen, 87.9% (29/33) clearance in the once every day regimen, 73.3% (22/30) clearance in the twice-daily 3 times/week regimen, and 69.7% (23/33) clearance in the once-daily 3 times/week regimen. Dose-related inflammatory skin reactions at the site of application were common. The majority were well tolerated and only 1 patient withdrew from the trial as a result of a medication-related skin reaction.

CONCLUSION

Imiquimod 5% cream appears to have potential as a patient-administered treatment option in sBCC.

Pemphigoid gestationis occurring in a patient with HELLP syndrome

A case of pemphigoid gestationis occurring in a 40 year old female who developed HELLP syndrome during her fourth pregnancy is reported. Seven days after emergency Caesarean section for pre-eclampsia, she developed a pruritic blistering eruption which clinically resembled pemphigoid gestationis. The diagnosis was supported by skin histology and immunofluorescence. She responded rapidly to oral corticosteroids, with no evidence of recurrence after 12 weeks of follow up. In the current case report, the previously unreported simultaneous occurrence of two uncommon conditions is described.

Managing HIV. Part 5: Treating secondary outcomes. 5.1 HIV and skin disease

The skin is the largest and most visible organ of the body, and a perception of good health depends on its appearance as well as its function. As about 90% of HIV-infected patients develop cutaneous signs and symptoms, diagnosis and management are vital in recognising progression of HIV infection.

Disseminated superficial actinic porokeratosis. A histological review of 61 cases with particular reference to lymphocytic inflammation

The pathology of 61 cases of disseminated superficial actinic porokeratosis was reviewed and the relative frequency of the histological features associated with the cornoid lamella and the pathology within and outside the porokeratotic rim were assessed. Papillary dermal lymphocytic infiltrate (97%), spinous layer vacuolar changes (90%), dyskeratotic cells in the epidermis (77%), and liquefaction degeneration of the basal layer (67%) were frequently seen under the cornoid lamella. Papillary lymphocytic infiltration was seen more frequently inside the porokeratotic ring in comparison to the outer skin. Lymphocyte marker studies in nine cases showed a predominance of activated T lymphocytes with positive LN3 and UCHL-1 staining. Together with the finding of a lichenoid reaction pattern, these results lend support to the hypothesis that actinic porokeratosis represents a migrating clone of abnormal keratinocytes with an associated immunological host response.

Australian trial of topical minoxidil and placebo in early male pattern baldness

One hundred and sixty nine men with early male pattern baldness (androgenic alopecia) were treated in a random, double-blind fashion with either 2% minoxidil solution or placebo vehicle for 24 weeks, one ml applied twice daily. After 24 weeks all patients received the active solution until week 48. After 24 weeks the minoxidil treated patients had increased their non-vellus hair counts significantly more than the placebo treated group; means were 37.6 and 8.8 hairs per reference area, 95% C.I. for difference = 10.85 to 60.75. The rate of non-vellus hair regrowth was also greater among minoxidil treated patients than placebo treated patients. Nine (12.5%) evaluable minoxidil treated patients compared with 2 (2.7%) evaluable placebo treated patients reported moderate or dense hair regrowth at week 24. Minimal regrowth was reported by 18 (25%) active group and 15 (20%) placebo group patients. The investigators considered that 3 (2%) of the minoxidil group and none of the placebo group had moderate hair regrowth and that none had dense regrowth. After 48 weeks treatment 28 (23%) patients considered that they had moderate hair regrowth and the investigators considered that 14 (12%) patients had moderate regrowth. None had dense growth. No serious adverse reactions or deaths were reported. Minoxidil solution appeared to be an efficacious and safe treatment for early androgenic alopecia.

Oysters, iron overload and Vibrio vulnificus septicaemia

A case of Vibrio vulnificus septicaemia complicated by cutaneous leg ulceration is described. A 74 year old man with haemochromatosis and sideroblastic anaemia developed an acute febrile illness with cutaneous manifestations 24 hours after ingesting raw oysters. The presence of blistering should be considered an important clue to the diagnosis of Vibrio vulnificus septicaemia, and this can facilitate prompt effective antimicrobial therapy. Clinicians should be aware of this infection because of its high case fatality rate, especially in patients with iron overload states.