Novel concepts in inflammatory bowel disease.

INTRODUCTION: Clinical management in inflammatory bowel disease (IBD) is constantly changing. Although improvement in symptoms is of paramount importance, using this as the only surrogate marker of disease activity might underestimate disease burden. SOURCES OF DATA: New data from randomized clinical trials are now available. Treatment paradigms are constantly changing leading to an evolution in the therapeutic approach in routine IBD practice. AREAS OF AGREEMENT: Patients with an aggressive disease phenotype should be identified at the onset and treated more intensely in order to achieve long-lasting mucosal remission. AREAS OF CONTROVERSY: Patients who have mild and indolent disease need to be identified and not over treated. GROWING POINTS: The primary endpoint in IBD management should ideally be mucosal healing. Ample data are now available that correlates mucosal healing with surgical-free outcomes with minimal intestinal damage and patient disability. However, the exact degree of mucosal healing that will lead to improved long-term remission, decreased hospital and surgical rates remains unknown. AREAS TIMELY FOR DEVELOPING RESEARCH: Clinical translational work is needed to identify novel pathways in IBD pathogenesis that sub-select patients who would benefit by specific-cytokine pathway modulation.

Review article: dermatological complications of immunosuppressive and anti-TNF therapy in inflammatory bowel disease.

BACKGROUND: With the expanding list of medications available to treat patients with inflammatory bowel disease (IBD), it is important to recognise adverse events, including those involving the skin. Dermatological adverse events may be confused with extra-intestinal manifestations of IBD. AIM: To review drug-related dermatological manifestations associated with immunosuppressive and anti-tumour necrosis factor (anti-TNF) therapy. METHODS: The literature was searched on PubMed for dermatological adverse events in IBD. RESULTS: Present thiopurine exposure was associated with a 5.9-fold [95% confidence interval (CI), 2.1-16.4] increased risk of developing non-melanoma skin cancer (NMSC). The peak incidence is highest in Caucasians over the age of 65 years with crude incidence rates of 4.0 and 5.7/1000 patient-years for present and previous use. In anti-TNF-exposed subjects, drug-induced lupus was reported in 1% of the cases and a psoriatic rash in up to 3% of the cases. Anti-TNF monotherapy increases the risk of NMSC ~2-fold to a rate of 0.5 cases per 1000 person-years. Cutaneous lymphomas have been rarely reported in subjects on thiopurine or anti-TNF drug monotherapy. Combination therapy seems to have an additive effect on the risk of developing NMSC and lymphoma. CONCLUSIONS: Physicians need to be aware of the wide spectrum of dermatological complications of immunosuppressive and anti-TNF therapy in IBD, especially psoriasis and non-melanoma skin cancer. Vigilance and regular screening for non-melanoma skin cancer is recommended. Case discussions between gastroenterologists and dermatologists should be undertaken to best manage dermatological adverse events.