Clinical pharmacokinetics and pharmacodynamics of topical non-biological therapies for psoriasis patients.

INTRODUCTION: Psoriasis is a chronic inflammatory cutaneous disease that causes patients psychosocial distress. Topical therapies are utilized for mild-to-moderate disease and for more severe disease in conjunction with systemic therapies. Topical corticosteroids are a cornerstone of treatment for psoriasis, but long-term use can cause stria and cutaneous atrophy and as well as systemic side effects such as topical steroid withdrawal. Non-steroidal topical therapies tend to be safer than topical corticosteroids for long-term use. AREAS COVERED: We conducted a literature review on the pharmacokinetic (PK) and pharmacodynamic (PD) properties of topical therapies for psoriasis. We discuss how the PK and PD characteristics of these therapies inform clinicians on efficacy and toxicity when prescribing for patients. EXPERT OPINION: Topical corticosteroids, used intermittently, are very safe and effective. Long-term, continuous use of topical corticosteroids can cause systemic side effects. Several generic and newly approved non-steroidal options are available, but no head-to-head studies compare the effectiveness of the generics (vitamin D analogs, tacrolimus, pimecrolimus) against the newer therapies (roflumilast, tapinarof). Patients often do not respond to topical therapies due to poor adherence to treatment regimens. For patients resistant to topical treatment, phototherapy or systemic therapy may be an option.

Patients' and caregivers' perspectives of the atopic dermatitis journey.

BACKGROUND: Understanding the patient journey is important to optimize care for patients with atopic dermatitis (AD) and overcome challenges in diagnosis and management. OBJECTIVE: To explore patient and caregiver perspectives regarding their experience with AD. METHODS: Patients and caregivers of patients with AD completed a pre-meeting survey and were invited to join an advisory board meeting in their country (China, Hong Kong, Ireland, Japan and Lebanon) to discuss the survey results. Data were analyzed descriptively. RESULTS: The survey included 31 participants (patients and caregivers) from Hong Kong (n = 7), China (n = 7), Ireland (n = 6), Japan (n = 6) and Lebanon (n = 5). The most challenging factors in the AD journey were management of symptoms before a confirmed diagnosis (68%), sudden recurrence of flares or worsening of symptoms (68%) and lifestyle changes (52%). In terms of overall AD management, 35% of participants indicated that AD was managed well, 23% had a clear treatment plan and 19% were generally satisfied with disease management. A collaborative relationship with healthcare professionals was favored. CONCLUSION: A holistic assessment of AD includes understanding patient and caregiver preferences, needs, experiences and disease perceptions. Addressing the identified gaps may improve the management of AD.

Non-Systemic Medication for the Treatment of Prurigo Nodularis: A Systematic Review.

Prurigo nodularis (PN) is a skin disease characterized by firm, itchy, erythematous lesions. Treatment consists of systemic and non-systemic modes of therapy. Non-systemic forms of treatment are first-line and include topical corticosteroids, topical steroid-sparing agents, and phototherapy. The objective was to review the efficacy of non-systemic treatment used to treat PN. A systematic search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with PROSPERO (CRD42023412012). The search consisted of keywords and Medical Subject Heading (MeSH) terms and translated to Ovid MEDLINE, Embase, and Scopus. Google Scholar was also searched for the first 200 articles. Article quality of evidence was scored using GRADE criteria. The search yielded 1151 results; 37 met criteria for inclusion. There were 14 studies on phototherapy, and 11 studies on topical corticosteroids, most of which were also combined with topical antihistamines, antipruritics, and/or phototherapy. There were 2 studies each on topical antipruritics used in isolation, vitamin D analogues, and intralesional triamcinolone acetonide. There was 1 study each on topical pimecrolimus, tacrolimus, 2% dinitrochlorobenzene, cryotherapy, acupuncture, and the Paul Gerson Unna boot. Most were case reports and case series, although 2 randomized controlled trials on phototherapy and topical pimecrolimus were included. Corticosteroids had varying levels of positive response in patients and appeared more effective when used in combination or under occlusive dressing. Phototherapy is likely effective, but the risk of relapse is high. Cryotherapy may also be a lesion-directed agent to circumvent challenges to adherence and avoidance of systemic medication.

Choosing Systemic Agents for Psoriasis.

Treatment options for moderate-to-severe psoriasis depend on drug efficacy and safety, patient preferences, comorbidities, and cost-no drug dominates across all dimensions. Interleukin (IL)-17 inhibitors may be preferred for fast-acting treatment, while the 3-month schedule of risankizumab, ustekinumab, or tildrakizumab may be attractive for patients who prioritize fewer injections. Phototherapy is suitable for patients who wish to avoid systemic agents or when cost is a concern. For patients with poor adherence, infliximab or tildrakizumab may be well suited as they require in-office administration. Dermatologists can educate patients on available therapies to find a regimen best suited to their needs.

A Review of Topical Tapinarof for the Treatment of Plaque Psoriasis.

OBJECTIVE: This article reviews the efficacy and safety of 1% tapinarof cream for plaque psoriasis. DATA SOURCES: A literature search was conducted from August 2022 to February 2023. The terms tapinarof, VTAMA, benvitimod, GSK2894512, DMVT-505, and WBI-1001 were queried in PubMed. ClinicalTrials.gov was searched to identify ongoing or unpublished studies. STUDY SELECTION AND DATA EXTRACTION: All clinical trials written in English and relevant to pharmacology, efficacy, and safety were included. DATA SYNTHESIS: In two 12-week phase III clinical trials, disease severity assessed by a Physician's Global Assessment (PGA) score of clear or almost clear and a 2-point PGA improvement was 35.4% and 40.2% at week 12 in the 2 trials, respectively. In the 40-week, open-label extension trial, the efficacy and safety results were similar: 40.9% of patients achieved a PGA of 0 at least once during the trial, and 58.2% of patients with PGA ≥ 2 achieved PGA 0/1 at least once. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS: Tapinarof is a topical aryl hydrocarbon receptor agonist and a first-in-class, potentially promising treatment for plaque psoriasis recently approved by the U.S. Food and Drug Administration. CONCLUSION: Compared with placebo, tapinarof may be an effective and safe topical treatment for mild to severe plaque psoriasis. Head-to-head trials to compare the efficacy and adverse effect profile of tapinarof to other topical treatments are still needed, as are investigation in patients with recent or current use of phototherapy or biologic or nonbiologic systemics. Cost and adherence to treatment may be barriers for treatment efficacy.

A Case Series on the Use of Brentuximab Vedotin for the Treatment of Mycosis Fungoides.

BACKGROUND: Brentuximab vedotin (BV) is an anti-CD30 monoclonal antibody that appears to be more effective against CD30-expressing cutaneous T-cell lymphoma (CTCL) compared to current standard-of-care treatments.   Objective: To determine the real-world efficacy and adverse effects of BV use in patients with mycosis fungoides (MF) who were treated with BV at Atrium Health Wake Forest Baptist Medical Center. METHODS: Study staff performed a retrospective chart review of patients diagnosed with MF who were prescribed BV at Atrium Health Wake Forest Baptist Comprehensive Cancer Center. RESULTS:   Regardless of their response to BV, all patients in our cohort had higher CD30 positivity on subsequent biopsies compared to their initial skin biopsy.  Conclusions: Improved understanding of appropriate CD30 testing and evaluation will allow for quicker invention of patients with BV responsive CTCL.  J Drugs Dermatol. 2023;22(12):e33-e34.    doi:10.36849/JDD.6981e.

Concurrent Atopic Dermatitis and Psoriasis Successfully Treated With Dual Biologic Therapy.

Atopic dermatitis (AD) and psoriasis are chronic inflammatory skin conditions with clinical and histopathologic features that often overlap, representing an underlying immunopathological spectrum of disease that can complicate the proper diagnosis and treatment of both conditions. We report the case of a patient with longstanding concurrent, treatment-resistant AD and psoriasis who was successfully treated with dual biologic therapy with dupilumab and guselkumab. Our case highlights the importance of considering coexisting AD and psoriasis in patients with treatment-resistant disease and the utility of dual biologic therapy. We also review an established but rare incidence of overlap between AD and psoriasis and highlight diagnostic challenges and the importance of assessing patients comprehensively. Our case also demonstrates the utility of patch testing and tissue diagnosis in patients with concurrent AD and psoriasis, as well as the importance of considering both diagnostic testing and clinical response in clinical decision-making.

Could red and near-infrared emitting fabric technology improve the severity of psoriasis, polymorphous light eruption, and alopecia areata?

AIM: Low-level light therapy (LLLT) may offer an adjunctive therapeutic tool for inflammatory skin conditions. This pilot study assessed the efficacy of a red/near-infrared (NIR)-emitting fabric for psoriasis, polymorphous light eruption (PMLE), and alopecia areata (AA). METHODS: Fourteen patients (five with psoriasis, five with PMLE, and four with AA) were instructed to wear a red/NIR-emitting (Lumiton®) garment during the 12-week study. Efficacy was assessed subjectively by patient-reported improvement and objectively by the redness, thickness, and scale of elbow psoriasis plaques, the frequency of PMLE flares, and the Severity of Alopecia Tool (SALT) score. RESULTS: Three patients with psoriasis completed the study while two self-discontinued. The three patients who completed the study noted improvement and two had improvements in lesion redness, thickness, or scale, while one was clinically stable. Three patients with PMLE completed the study, and none had a disease flare during the study period. Three patients with AA completed the study: two reported disease improvement and all three had an improved SALT score. CONCLUSION: Use of a wellness apparel that emits red and NIR light may be associated with improved disease severity in patients with mild elbow psoriasis, PMLE, and limited AA. Limitations of this study include continuation on topical, intralesional, or systemic medications and small sample size.

New synthetic pharmacotherapeutic approaches to the treatment of moderate-to-severe plaque psoriasis in adults.

INTRODUCTION: Psoriasis is a chronic inflammatory and immune-mediated condition affecting 3.2% of the United States population. There are many options for psoriasis treatment including topicals, oral systemic agents, and biologics. A greater understanding of the pathophysiology of psoriasis has led to an increase in the therapeutic options for treatment. AREAS COVERED: In this review, we outline the novel synthetic agents for moderate-to-severe plaque psoriasis and discuss a strategy for implementing these agents in clinical practice. A literature search was performed using PubMed to identify articles relevant to the topic published before October 2022. EXPERT OPINION: Topicals are first-line for the treatment of moderate-to-severe plaque psoriasis, most commonly including topical steroids, vitamin D analogs, and topical calcineurin inhibitors. While new topical agents have favorable properties, they are not always effective and adherence to topical agents is poor. Biologics are safe and effective, but patients often prefer oral therapy as opposed to injectable medications. Additionally, anti-drug antibodies can reduce effectiveness of biologics over time. Oral medications are preferred, but we now have a high bar for efficacy and safety. Cost is also a barrier for many patients. Recent development of new synthetic treatment options is promising, and we recommend that providers consider these agents as they develop holistic and individualized treatment plans for their patients.

Reducing costs in atopic dermatitis.

Atopic dermatitis (AD) is a common relapsing inflammatory skin condition associated with a high economic burden due to its chronicity and multitude of direct and indirect treatment costs. AD disproportionately impacts children and minority populations, and treatment choices are cost-prohibitive for many patients. Our objective was to describe the treatment and management of AD from a cost-conscious perspective. A review of the literature was conducted with PubMed using the following keywords: AD, cost, medications, treatment, management, efficacy, adherence, education, and prophylactic. The use of moisturizers prophylactically in high-risk infants who have yet to develop AD may reduce incidence of disease and associated costs. Increasing patient medication adherence and moisturizing between flares also reduces costs in AD. The use of corticosteroids as the first-line treatment is efficacious and cost-effective for mild cases of AD, however, in severe cases of AD corticosteroids alone are not sufficient. Systemic biologics are necessary in some patients with severe cases of AD; however, they are associated with high costs. Phototherapy, through portable home units, tanning beds, and natural sunlight are cost-effective alternatives. Effective management of AD improves with education programs for both the patient and their family, reducing long-term costs in the management of this disease. Reducing AD treatment costs requires consideration of prophylactic therapies, patient education, and should differ based on the severity of disease. A multifaceted approach to AD treatment reduces costs and health-care barriers.

Comparing available JAK inhibitors for treating patients with psoriasis.

INTRODUCTION: Cytokine blockers have revolutionized the management of psoriasis. While efficacious, not all patients respond, and treatment may lose efficacy over time. Janus kinase (JAK) inhibitors target the Janus Kinase/Signal Transducer and Activator of Transcription (JAK/STAT) transduction cascade from transmitting cytokine signals in psoriasis. AREAS COVERED: A PubMed search of phase I, II, and III clinical trials published between 2012 and 2021 utilizing the key terms: Janus kinase and psoriasis. Our search was expanded from clinical trials to further investigate the pathophysiology, standard of care, and safety and efficacy of JAK inhibitors in psoriasis. EXPERT OPINION: Current treatments for psoriasis include topicals, phototherapy, and systemic therapy. The subcutaneous or intravenous route of biologic administration presents a challenge as patients often prefer oral medications over injections and because of anti-drug antibody development. Tofacitinib is effective and has an overall mild-to-moderate safety profile but includes an FDA black box warning for increased risk of cardiovascular events and malignancy. Other JAK inhibitors have an acceptable safety profile and are effective in early clinical trials. Poor topical medication adherence should be considered when evaluating JAK inhibitors. Oral JAK inhibitors may provide a preferable route of administration and improved clinical outcomes.

Views and Beliefs of Vitiligo Patients in Online Discussion Forums: A Qualitative Study.

Individuals with chronic illnesses turn to online communities to engage in asynchronous peer-to-peer exchanges to better understand and manage their disease. Messages and advice exchanged by online users with vitiligo are not well characterized. We conducted a qualitative study to explore the content exchanged by individuals with vitiligo in online forums. An interpretive research paradigm was utilized to assess public online forum content. A systematic search using the phrases online forum vitiligo support, vitiligo online message board, and vitiligo forums identified 39 relevant forums; 9 of them met inclusion criteria, with 382 total anonymous users. Major themes and subthemes included vitiligo disease management, homeopathy/home remedies, psychosocial impact, public perceptions, and camouflage/concealment.

Review of the holistic management of pediatric atopic dermatitis.

Atopic Dermatitis (AD) is a chronic inflammatory skin disease that is broadly characterized by eczematous lesions and pruritus. This condition is detrimental in a multitude of ways, including patient quality of life (QOL), family QOL, economic burden, and psychosocial afflictions. Current management needs to incorporate a holistic approach which considers the financial, emotional, and physical limitations of both the treatments and the provider. A non-systematic search was conducted on the holistic management of pediatric AD. Various search queries were used such as the key terms of "atopic dermatitis," "pediatric," "eczema," "management," and more to encompass treatments, adherence, and comorbidities. There is an association with AD and depression in children, and its prevalence should be screened for routinely in children with AD. Collaboration with other specialties may prove to be prudent in addressing this comorbidity. Objective quality of life scores can open the door to much needed conversation with patients to get them the help they need. In expanding our scope, we find the extended consequences of AD have a ripple effect on families of pediatric patients. Lastly, we introduce a model for improving treatment adherence. CONCLUSION: Patient quality-of-life can be negatively affected by the symptoms, expense, stigma, and time commitment, and inconvenience imposed by complicated treatment regimens. To ensure proper, holistic management of pediatric AD, multiple factors must be considered; seasonal changes, lifestyle modifications, and the psychosocial impact are just a couple of factors that require monitoring. WHAT IS KNOWN: • Atopic dermatitis impacts patients and their families in quality of life, economically, and psychosocially. • Current treatment revolves largely around treating physical manifestation of disease with first line measures such as topical steroids. WHAT IS NEW: • The holistic management of AD incorporates a good physician-patient relationship, frequent follow-up, and providing structured written plans. • We introduce the house building model for improving treatment adherence. KEY POINTS: Pediatric AD can be managed in a more holistic manner which incorporates several factors from the lives of patients and their families. Pediatric patients suffer from many physical and mental comorbidities which should be screened for. Adherence with treatment may be improved by following a model which emphasizes establishing a good physician-patient relationship, frequent follow-up, and providing structured written plans.

Treatment of keratosis pilaris and its variants: a systematic review.

INTRODUCTION: Keratosis pilaris (KP) is a common, benign skin condition of follicular hyperkeratosis. Although KP is asymptomatic, the cosmetic appearance of KP can lead to psychosocial distress among patients. New emerging treatments are increasingly being utilized. Yet, there is little to no summative data on the treatments of KP and its subtypes. OBJECTIVE: To summarize existing literature on treatments for KP and its subtypes. METHODS: A comprehensive search was performed using Pubmed/MEDLINE, Embase and Web of Science databases. The search identified 1150 non-duplicated articles, and 47 articles were included in the review. The primary outcomes measured were KP treatment type and the degree of improvement following therapy. FINDINGS: Our findings demonstrate that the most supported form of treatment for KP is laser therapy, particularly the QS:Nd YAG laser. Topical treatments - including Mineral Oil-Hydrophil Petrolat, tacrolimus, azelaic acid, and salicylic acid - are also effective at least for improving the appearance of KP. CONCLUSION: While the measured treatment outcomes varied among studies, laser therapy appears to be the most effective form of treatment. Use of topicals also improved KP lesions.

Factors Influencing Patient Preferences for Phototherapy: A Survey Study.

There is limited literature regarding patient preferences for phototherapy. Patients may consider different forms of phototherapy depending on a multitude of factors important to them, including safety, cost, efficacy, insurance issues, and convenience. This study aimed to determine which form of phototherapy-in-office UVB, at-home UVB, home tanning, salon tanning, and sunbathing-was preferred by survey participants and the reasons for their preferences. Additionally, participants were asked which forms of phototherapy they considered safest and most efficacious, cost-effective, and convenient.

Chromate-Induced Allergic Contact Dermatitis Treated With Dupilumab.

Chromate causes persistent, difficult to treat irritant and allergic contact dermatitis in cement-handling occupational workers. When therapeutics such as topical corticosteroids, topical calcineurin inhibitors, phototherapy and immune-modulating treatments like methotrexate fail, many patients are advised that avoidance may be the only remaining option – an option that may be particularly challenging if the patient’s occupation necessitates chromate exposure. We report a case of severe chromate-induced allergic contact dermatitis in a 55-year-old cement mason that presented to the outpatient dermatology clinic with multiple scaly, erythematous, >5 cm plaques scattered over the skin of his hands, head and neck. After a prior failed course of treatment with high potency topical corticosteroid, this patient was successfully treated with dupilumab. Given the success of dupilumab in our patient, we propose the consideration of dupilumab as an alternative treatment option for those suffering from chromate-induced allergic contact dermatitis that is refractory to ultra-high potency topical corticosteroids. J Drugs Dermatol. 2021;20(12):1340-1342. doi:10.36849/JDD.6246.