Roflumilast foam 0.3% for adolescent and adult patients with seborrheic dermatitis: A randomized, double-blinded, vehicle-controlled, phase 3 trial

BACKGROUND

The topical phosphodiesterase 4 inhibitor roflumilast has been studied in several dermatologic conditions.

OBJECTIVE

Roflumilast foam 0.3% is being investigated as a topical treatment for seborrheic dermatitis (SD).

METHODS

In this phase 3, double-blinded trial, patients with SD were randomly assigned (2:1 ratio) to once-daily roflumilast foam 0.3% or vehicle foam for 8 weeks. The primary efficacy outcome was Investigator Global Assessment (IGA) Success at week 8, defined as IGA of 0 (Clear) or 1 (Almost Clear) plus ≥2-point improvement from baseline. Safety was also assessed.

RESULTS

79.5% of roflumilast-treated and 58.0% of vehicle-treated patients met the primary endpoint (P < .001); statistically significant differences in IGA Success also favored roflumilast at week 2 (roflumilast: 43.0%; vehicle: 25.7%; P < .001) and week 4 (roflumilast: 73.1%; vehicle: 47.1%; P < .001). Roflumilast was well-tolerated with a low rate of treatment-emergent adverse events.

LIMITATIONS

Study limitations include the 8-week treatment period for this chronic condition.

CONCLUSIONS

Once-daily roflumilast foam was superior to vehicle in leading to IGA of Clear or Almost Clear plus ≥2-point improvement from baseline at 8 weeks in patients with SD. Longer trials are needed to determine durability and safety of roflumilast foam in SD.

Efficacy of Roflumilast Foam, 0.3%, in Patients With Seborrheic Dermatitis: A Double-blind, Vehicle-Controlled Phase 2a Randomized Clinical Trial

Importance

Current topical treatment options for seborrheic dermatitis are limited by efficacy and/or safety.

Objective

To assess safety and efficacy of roflumilast foam, 0.3%, in adult patients with seborrheic dermatitis affecting the scalp, face, and/or trunk.

Design, Setting, and Participants

This multicenter (24 sites in the US and Canada) phase 2a, parallel group, double-blind, vehicle-controlled clinical trial was conducted between November 12, 2019, and August 21, 2020. Participants were adult (aged ≥18 years) patients with a clinical diagnosis of seborrheic dermatitis for a 3-month or longer duration and Investigator Global Assessment (IGA) score of 3 or greater (at least moderate), affecting 20% or less body surface area, including scalp, face, trunk, and/or intertriginous areas. Data analysis was performed from September to October 2020.

Interventions

Once-daily roflumilast foam, 0.3% (n = 154), or vehicle foam (n = 72) for 8 weeks.

Main Outcomes and Measures

The main outcome was IGA success, defined as achievement of IGA score of clear or almost clear plus 2-grade improvement from baseline, at week 8. Secondary outcomes included IGA success at weeks 2 and 4; achievement of erythema score of 0 or 1 plus 2-grade improvement from baseline at weeks 2, 4, and 8; achievement of scaling score of 0 or 1 plus 2-grade improvement from baseline at weeks 2, 4, and 8; change in Worst Itch Numeric Rating Scale (WI-NRS) score from baseline; and WI-NRS success, defined as achievement of 4-point or greater WI-NRS score improvement in patients with baseline WI-NRS score of 4 or greater. Safety and tolerability were also assessed.

Results

A total of 226 patients (mean [SD] age, 44.9 [16.8] years; 116 men, 110 women) were randomized to roflumilast foam (n = 154) or vehicle foam (n = 72). At week 8, 104 (73.8%) roflumilast-treated patients achieved IGA success compared with 27 (40.9%) in the vehicle group (P < .001). Roflumilast-treated patients had statistically significantly higher rates of IGA success vs vehicle at week 2, the first time point assessed. Mean (SD) reductions (improvements) on the WI-NRS at week 8 were 59.3% (52.5%) vs 36.6% (42.2%) in the roflumilast and vehicle groups, respectively (P < .001). Roflumilast was well tolerated, with the rate of adverse events similar to that of the vehicle foam.

Conclusions and Relevance

The results from this phase 2a randomized clinical trial of once-daily roflumilast foam, 0.3%, demonstrated favorable efficacy, safety, and local tolerability in the treatment of erythema, scaling, and itch caused by seborrheic dermatitis, supporting further investigation as a nonsteroidal topical treatment.

Trial Registration

ClinicalTrials.gov Identifier: NCT04091646.

Long-Term Safety and Disease Control With Ruxolitinib Cream in Atopic Dermatitis: Results From Two Phase 3 Studies

BACKGROUND

Ruxolitinib cream demonstrated safety and efficacy over 8 weeks in two double-blind phase 3 atopic dermatitis studies (NCT03745638/NCT03745651).

OBJECTIVE

Evaluate long-term safety (LTS) and disease control with ruxolitinib cream.

METHODS

Patients initially randomized to twice-daily 0.75%/1.5% ruxolitinib cream maintained their regimen during the 44-week LTS period (as-needed treatment). Patients on vehicle were rerandomized (1:1) at Week 8 to either ruxolitinib cream strength. Safety and disease control (Investigator's Global Assessment [IGA] score 0/1 and affected body surface area [BSA]) were assessed.

RESULTS

Over 52 weeks, adverse events (AEs) were reported in 67.4%/62.6%/53.5%/57.6% of patients in 0.75%/1.5% ruxolitinib cream/vehicle to 0.75% ruxolitinib cream/vehicle to 1.5% ruxolitinib cream groups (n=426/446/101/99). Most common AEs were upper respiratory tract infection (10.3%/11.4%/5.9%/7.1%) and nasopharyngitis (8.9%/9.9%/7.9%/14.1%). Most AEs were considered unrelated to treatment. Application site reactions were infrequent (3.8%/1.8%/1.0%/1.0%). Disease control was achieved throughout the LTS; 74.1%-77.8% of patients had IGA 0/1 at Week 52, and mean affected BSA was low (1.4%-1.8%).

LIMITATIONS

LTS had no control treatment.

CONCLUSION

During 44 weeks of as-needed treatment, ruxolitinib cream demonstrated effective disease control and tolerability; low ruxolitinib plasma concentrations alongside safety findings reflecting known risk factors suggest physiologically meaningful systemic Janus kinase inhibition is highly unlikely.

Insights into adult atopic dermatitis heterogeneity derived from circulating biomarker profiling in patients with moderate-to-severe disease

Atopic dermatitis (AD) is a heterogeneous systemic inflammatory skin disease associated with dysregulated immune responses, barrier dysfunction and activated sensory nerves. To characterize circulating inflammatory profiles and underlying systemic disease heterogeneity within AD patients, blood samples from adult patients (N = 123) with moderate‐to‐severe AD in a phase 2 study of baricitinib (JAHG) were analysed. Baseline levels of 131 markers were evaluated using high‐throughput and ultrasensitive proteomic platforms, patient clusters were generated based on these peripheral markers. We implemented a novel cluster reproducibility method to validate cluster outcomes within our study and used publicly available AD biomarker data set (73 markers, N = 58 patients) to validate our findings. Cluster reproducibility analysis demonstrated best consistency for 2 clusters by k‐means, reproducibility of this clustering outcome was validated in an independent patient cohort. These unique JAHG patient subgroups either possessed elevated pro‐inflammatory mediators, notably TNFβ, MCP‐3 and IL‐13, among a variety of immune responses (high inflammatory) or lower levels of inflammatory biomarkers (low inflammatory). The high inflammatory subgroup was associated with greater baseline disease severity, demonstrated by greater EASI, SCORAD Index, Itch NRS and DLQI scores, compared with low inflammatory subgroup. African‐American patients were predominantly associated with the high inflammatory subgroup and increased baseline disease severity. In patients with moderate‐to‐severe AD, heterogeneity was identified by the detection of 2 disease subgroups, differential clustering amongst ethnic groups and elevated pro‐inflammatory mediators extending beyond traditional polarized immune responses. Therapeutic strategies targeting multiple pro‐inflammatory cytokines may be needed to address this heterogeneity.

Efficacy and Safety of Oral Janus Kinase 1 Inhibitor Abrocitinib for Patients With Atopic Dermatitis: A Phase 2 Randomized Clinical Trial

Question

Does the oral Janus kinase 1 selective inhibitor abrocitinib improve atopic dermatitis signs and symptoms in adults with moderate to severe atopic dermatitis at doses that are well tolerated?

Findings

In this randomized, double-blinded, phase 2b clinical trial including 267 participants, the proportion of patients achieving substantial improvement from baseline was significantly greater for those receiving 200 mg and 100 mg of abrocitinib compared with placebo. Dose-related decreases in platelet count were observed for all doses greater than 10 mg, but platelet values trended upward toward baseline after the maximum decrease at week 4 and despite ongoing treatment with abrocitinib; most adverse events were mild and considered unrelated to treatment.

Meaning

The findings of this study show that 12 weeks of once-daily treatment with 200 mg or 100 mg of oral abrocitinib resulted in significant improvement in the signs and symptoms of atopic dermatitis.

Importance

Atopic dermatitis is associated with substantial patient and caregiver burden. Currently available treatments for atopic dermatitis are inadequate or contraindicated for some patients. Abrocitinib (PF-04965842) is an oral Janus kinase 1 selective inhibitor under investigation for the treatment of atopic dermatitis.

Objective

To investigate the efficacy and safety of abrocitinib for patients with moderate to severe atopic dermatitis.

Design, Setting, and Participants

A phase 2b, randomized, double-blinded, placebo-controlled, parallel-group trial was conducted from April 15, 2016, to April 4, 2017, at 58 centers in Australia, Canada, Germany, Hungary, and the United States among 267 patients 18 to 75 years of age with a clinical diagnosis of moderate to severe atopic dermatitis for 1 year or more and inadequate response or contraindication to topical medications for 4 weeks or more within 12 months. Efficacy was assessed in the full analysis set, which was a modified intention-to-treat population that included all patients who received 1 dose or more of the study drug except for 4 patients from 1 site.

Interventions

Participants were randomly assigned 1:1:1:1:1 to receive abrocitinib (200 mg, 100 mg, 30 mg, or 10 mg) or placebo once daily for 12 weeks.

Main Outcomes and Measures

The primary outcome was the proportion of patients achieving an Investigator’s Global Assessment of clear (0) or almost clear (1) with an improvement from baseline of 2 grades or more at week 12. The secondary outcome was the percentage change from baseline in the Eczema Area and Severity Index at week 12.

Results

Of the 267 participants, 144 were women (mean [SD] age, 40.8 [16.1] years). At week 12, 21 of 48 patients receiving 200 mg of abrocitinib (43.8%; P < .001, 2-sided), 16 of 54 patients receiving 100 mg of abrocitinib (29.6%; P < .001), and 3 of 52 patients receiving placebo (5.8%) achieved grades of clear or almost clear on the Investigator’s Global Assessment scale with improvement of 2 grades or more; these rates correspond to maximum effect model-based estimates of 44.5% (95% CI, 26.7%-62.3%) for those receiving 200 mg of abrocitinib, 27.8% (95% CI, 14.8%-40.9%) for those receiving 100 mg of abrocitinib, and 6.3% (95% CI, −0.2% to 12.9%) for those receiving placebo. Reductions in the Eczema Area and Severity Index were 82.6% (90% CI, 72.4%-92.8%; P < .001) for those receiving 200 mg of abrocitinib, 59.0% (90% CI, 48.8%-69.3%; P = .009) for those receiving 100 mg of abrocitinib, and 35.2% (90% CI, 24.4%-46.1%) for those receiving placebo. Adverse events were observed in 184 of 267 patients (68.9%); the most frequently reported adverse events (in ≥3 patients in any group) were dermatitis atopic, upper respiratory tract infection, headache, nausea, and diarrhea. Dose-dependent decreases in platelet count were observed but trended upward toward baseline levels after week 4.

Conclusions and Relevance

Once-daily oral abrocitinib was effective and well tolerated for short-term use in adults with moderate to severe atopic dermatitis. Additional trials are necessary to evaluate long-term efficacy and safety.

Trial Registration

ClinicalTrials.gov identifier: NCT02780167

TYK2/JAK1 Inhibitor PF-06700841 in Patients with Plaque Psoriasis: Phase IIa, Randomized, Double-Blind, Placebo-Controlled Trial

TRIAL DESIGN

We report results from a phase IIa study of efficacy and safety of PF-06700841, an oral TYK2/Jak1 inhibitor, in patients with moderate-to-severe plaque psoriasis (NCT02969018).

METHODS

Patients were randomized to PF-06700841 30 mg once daily (QD), 60 mg QD, or placebo (4-week induction), followed by 10 mg QD, 30 mg QD, 100 mg once weekly, or placebo (8-week maintenance). The primary endpoint was week 12 change from baseline in PASI score. Secondary endpoints were the proportion of patients achieving 75% and 90% reduction from baseline PASI at week 12.

RESULTS

In total, 212 patients in 35 sites were treated; mean (SD) baseline PASI score was 20.8 (7.68). Decreases in PASI at week 12 were statistically significant compared with placebo in five treatment groups. The greatest change from baseline (least squares mean change -17.3 [95% confidence interval, -20.0 to -14.6]) was observed in the 30-mg QD continuous treatment group. Overall, 136 patients experienced treatment-emergent adverse events, including six serious adverse events in five patients and 13 discontinuations in treatment groups because of adverse events. No herpes zoster cases or major adverse cardiac events including thromboembolic events occurred.

CONCLUSIONS

PF-06700841 was generally effective and well tolerated in patients with moderate-to-severe plaque psoriasis.

Adalimumab medium-term dosing strategy in moderate-to-severe hidradenitis suppurativa: integrated results from the phase III randomized placebo-controlled PIONEER trials

Background

Weekly adalimumab (Humira^®) is approved for the treatment of hidradenitis suppurativa (HS) based on the 12‐week placebo‐controlled periods of the two phase III PIONEER trials.

Objectives

Using PIONEER integrated trial results, we aimed to evaluate the optimal medium‐term adalimumab maintenance dosing strategy for moderate‐to‐severe HS.

Methods

Each trial had two double‐blind periods; 12‐week Period A and 24‐week Period B. Patients randomized to adalimumab 40 mg every week (ADAew) (Period A), were rerandomized in Period B to ADAew (ADAew/ew), ADA every other week (ADAew/eow), or placebo (ADAew/pbo). Placebo‐randomized patients were reassigned in Period B to ADAew (PIONEER I) or placebo (PIONEER II). The primary outcome was HS Clinical Response (HiSCR). Patients who lost response during Period B were discontinued from the study and offered an option to enter the open‐label extension (OLE) to receive ADAew. Results are reported across the two study periods, and data were combined from the two study periods and the OLE.

Results

For week‐12 HiSCR achievers, the HiSCR week‐36 rate was 48·1% (ADAew/ew) vs. 46·2% (ADAew/eow) and 32·1% (ADAew/pbo). Combining (post hoc) these patients with week‐12 partial responders further differentiated outcomes in Period B (ADAew/ew 55·7% vs. ADAew/eow 40·0% and ADAew/pbo 30·1%). Period‐B adverse‐event rates were ADAew/ew 59·6% vs. ADAew/eow 57·4% and ADAew/pbo 65·0%. One patient (ADAew/ew) reported a serious infection.

Conclusions

Weekly adalimumab treatment, effective throughout 36 weeks, was the optimal maintenance medium‐term dosing regimen for this population. At least partial response after 12 weeks with continued weekly dosing had better outcomes than dose reduction or interruption. Patients who do not show at least a partial response to weekly adalimumab by week 12 are unlikely to benefit from continued therapy. No new safety risks were identified.

What's already known about this topic?

Hidradenitis suppurativa (HS) is a chronic inflammatory disease, commonly misinterpreted as an infection and treated with long‐term antibiotic regimens or surgical incisions.

Based on the chronicity of HS and the lack of evidence for efficacious and safe long‐term HS treatments, it is important to evaluate medium‐ to long‐term therapies for HS.

Weekly adalimumab (Humira^®) is approved for the treatment of moderate‐to‐severe HS based on the two phase III PIONEER trials.

What does this study add?

This study pooled data from the two PIONEER trials, providing a more robust assessment of outcomes.

After at least partial treatment success with weekly adalimumab short‐term therapy (12 weeks), continuing weekly dosing during the subsequent 24 weeks had better outcomes than dose reduction or treatment interruption.

Patients who do not show at least a partial response to weekly adalimumab by week 12 are unlikely to benefit from continued therapy.

Linked Comment: https://doi.org/10.1111/bjd.18437.

https://www.bjdonline.com/article/adalimumab-medium-term-dosing-strategy-in-moderate-to-severe-hidradenitis-suppurativa-integrated-results-from-the-phase-iii-randomized-placebo-controlled-pioneer-t/

Two Phase 3 Trials of Adalimumab for Hidradenitis Suppurativa

BACKGROUND

Hidradenitis suppurativa is a painful, chronic inflammatory skin disease with few options for effective treatment. In a phase 2 trial, adalimumab, an antibody against tumor necrosis factor α, showed efficacy against hidradenitis suppurativa.

METHODS

PIONEER I and II were similarly designed, phase 3 multicenter trials of adalimumab for hidradenitis suppurativa, with two double-blind, placebo-controlled periods. In period 1, patients were randomly assigned in a 1:1 ratio to 40 mg of adalimumab weekly or matching placebo for 12 weeks. In period 2, patients were reassigned to adalimumab at a weekly or every-other-week dose or to placebo for 24 weeks. The primary end point was a clinical response, defined as at least a 50% reduction from baseline in the abscess and inflammatory-nodule count, with no increase in abscess or draining-fistula counts, at week 12.

RESULTS

We enrolled 307 patients in PIONEER I and 326 in PIONEER II. Clinical response rates at week 12 were significantly higher for the groups receiving adalimumab weekly than for the placebo groups: 41.8% versus 26.0% in PIONEER I (P=0.003) and 58.9% versus 27.6% in PIONEER II (P<0.001). Patients receiving adalimumab had significantly greater improvement than the placebo groups in rank-ordered secondary outcomes (lesions, pain, and the modified Sartorius score for disease severity) at week 12 in PIONEER II only. Serious adverse events in period 1 (excluding worsening of underlying disease) occurred in 1.3% of patients receiving adalimumab and 1.3% of those receiving placebo in PIONEER I and in 1.8% and 3.7% of patients, respectively, in PIONEER II. In period 2, the rates of serious adverse events were 4.6% or less in all the groups in both studies, with no significant between-group differences.

CONCLUSIONS

Treatment with adalimumab (40 mg weekly), as compared with placebo, resulted in significantly higher clinical response rates in both trials at 12 weeks; rates of serious adverse events were similar in the study groups. (Funded by AbbVie; ClinicalTrials.gov numbers, NCT01468207 and NCT01468233 for PIONEER I and PIONEER II, respectively.).

Success of oxandrelone in the treatment of decubitus ulcers

A case of pressure ulcer in a 25-year-old male patient with the neurodegenerative disorder giant axonal neuropathy (GAN) was safely and effectively treated with an eight-week regimen of oxandrolone and nutritional supplementation. An initial dose of 5 mg twice daily was begun for the first two weeks of therapy, followed by six weeks of treatment with 10 mg twice daily. This therapy was supported with protein supplementation and adequate caloric intake. The patient's liver function tests were monitored weekly and remained within the normal range. His pressure ulcer was completely resolved at the conclusion of the eight weeks of therapy.

Psoriasis and psoriatic arthritis in a patient with HIV: response to mycophenolate mofetil treatment

A case of psoriasis and psoriatic arthritis in a 38-year-old white male patient infected with human immunodeficiency virus (HIV) treated safely and effectively with mycophenolate mofetil (MMF) is reported. Treatments for psoriasis and psoriatic arthritis are manifold, including topical, oral, intramuscular, intravenous, and subcutaneous therapies. These indicated treatments for psoriasis and psoriatic arthritis result in suppression of the immune system.

Collision tumor composed of Merkel cell carcinoma and lentigo maligna melanoma

We report the case of an immunocompetent 79-year-old white man with a history of melanoma in situ on the back with a collision tumor composed of a Merkel cell carcinoma (MCC) and lentigo maligna melanoma on the left cheek. The cells of the MCC expressed cytokeratin 20 (CK 20) in a diffuse cytoplasmic pattern, AE1 and AE3 in a perinuclear dot-like pattern and diffusely with neuron-specific enolase. The tumor cells of the MCC failed to express thyroid transcription factor-1. The atypical melanocytes of lentigo maligna melanoma expressed Melan-A and S-100. At the same visit, a lentigo maligna was diagnosed by excisional biopsy on the right cheek. The variability in expression of CK 20, AE1 and AE3 in MCC are reviewed. Prior reports of MCC in collision with non-melanoma skin cancers are reviewed. Additionally, the role of immunosuppression in the development of MCC is considered.

Success of omalizumab as monotherapy in adult atopic dermatitis: case report and discussion of the high-affinity immunoglobulin E receptor, FcepsilonRI

We report a case of a 41-year-old black man who presented with chronic severe atopic dermatitis that only responded to oral corticosteroids. Failed treatments for this patient included topical corticosteroids, topical pimecrolimus, oral prednisone, oral antihistamines, azathioprine, and narrowband UV light therapy. Only oral corticosteroids provided significant relief. The patient had an immunoglobulin E (IgE) level of 7340 IU/mL (reference range, 0-100 IU/mL). He responded to a 12-week course of omalizumab, a humanized monoclonal anti-LgE antibody currently indicated for patients 12 years and older with moderate to severe persistent asthma. Our patient experienced no adverse events throughout the course of treatment. We suggest that omalizumab may have a role in the treatment of isolated atopic dermatitis in the adult population.

Basal cell carcinoma of the nail unit

We report a case of a 70-year-old white male with a basal cell carcinoma of the left thumb nail unit. Excision of the tumor via Mohs micrographic surgery was completed in 2 stages. The defect was repaired with a full thickness skin graft. Five months later the nail unit healed without complications. Prior to this report, 21 cases of basal cell carcinoma have been reported in the world literature. This case, as well as the prior reports, are reviewed with a focus on time to diagnosis, location, excisional technique, and method of repair.