Interferon in the treatment of cutaneous T-cell lymphoma

Interferons are polypeptides with a broad range of in vivo effects that have shown efficacy in cutaneous T-cell lymphoma (CTCL). Particularly useful is alfa interferon (IFN) which, as a single agent, has shown partial remission rates of > 50% and complete responses of > 20%. Side-effects are predictable, generally well tolerated and dose-related. The efficacy of IFN has increased with combination therapy without any significant increase in attendant side-effects. An update on the specifics of the different IFN subtypes, their inherent biologic activity, pharmacokinetics, efficacy and safety in CTCL is presented in this paper.

Cytokine therapy of cutaneous T-cell lymphoma: interferons, interleukin-12, and interleukin-2

It is well accepted that cutaneous T-cell lymphomas (CTCL), including mycosis fungoides and Sézary syndrome, represent lymphomas that are highly responsive to immune modifying agents. Furthermore, the recent emphasis on the use of cytokine-related therapeutics is based upon the exceedingly important role of the host immune response in effecting progression of disease. In this article we discuss the data that support the importance of the host immune response in the control of progression of CTCL and the role that cytokine therapy has in supporting the host immune response and the effects of this approach to induce regression of skin and systemic disease.

Efficacy and tolerability of finasteride 1 mg in men aged 41 to 60 years with male pattern hair loss

A 24-month double-blind, randomized, placebo-controlled, parallel-group, multicenter study of 424 men was conducted to determine the efficacy and tolerability of finasteride 1 mg on hair growth/loss in men aged 41 to 60 years with mild-to-moderate, predominantly vertex male pattern hair loss. Efficacy was evaluated by review of global photographs of the vertex scalp taken at baseline and at Months 6, 12, 18, and 24 and by patient self-assessments and investigator clinical assessments of change from baseline in hair growth/loss collected at Months 6, 12, 18, and 24. Safety analyses included assessment of clinical and laboratory adverse experiences, including sexual adverse experiences. Analysis of global photographic assessment data showed significant improvement in hair growth for men in the finasteride group compared with those taking placebo beginning at Month 6 (p < 0.001) and maintained through Month 24 (p < 0.001). Results of the patient self-assessment and investigator assessments were consistent with those from the global photographic assessment. Finasteride 1 mg improved scalp hair growth in men aged 41 to 60 years with predominantly vertex male pattern hair loss compared with results seen with placebo. Improvement was evident by 6 months of treatment and continued through 24 months. Treatment with finasteride 1 mg was generally well tolerated.

A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men

BACKGROUND

Topical minoxidil solution 2% stimulates new hair growth and helps stop the loss of hair in individuals with androgenetic alopecia (AGA). Results can be variable, and historical experience suggests that higher concentrations of topical minoxidil may enhance efficacy.

OBJECTIVE

The purpose of this 48-week, double-blind, placebo-controlled, randomized, multicenter trial was to compare 5% topical minoxidil with 2% topical minoxidil and placebo in the treatment of men with AGA.

METHODS

A total of 393 men (18-49 years old) with AGA applied 5% topical minoxidil solution (n = 157), 2% topical minoxidil solution (n = 158), or placebo (vehicle for 5% solution; n = 78) twice daily. Efficacy was evaluated by scalp target area hair counts and patient and investigator assessments of change in scalp coverage and benefit of treatment.

RESULTS

After 48 weeks of therapy, 5% topical minoxidil was significantly superior to 2% topical minoxidil and placebo in terms of change from baseline in nonvellus hair count, patient rating of scalp coverage and treatment benefit, and investigator rating of scalp coverage. Hair count data indicate that response to treatment occurred earlier with 5% compared with 2% topical minoxidil. Additionally, data from a patient questionnaire on quality of life, global benefit, hair growth, and hair styling demonstrated that 5% topical minoxidil helped improve patients' psychosocial perceptions of hair loss. An increased occurrence of pruritus and local irritation was observed with 5% topical minoxidil compared with 2% topical minoxidil.

CONCLUSION

In men with AGA, 5% topical minoxidil was clearly superior to 2% topical minoxidil and placebo in increasing hair regrowth, and the magnitude of its effect was marked (45% more hair regrowth than 2% topical minoxidil at week 48). Men who used 5% topical minoxidil also had an earlier response to treatment than those who used 2% topical minoxidil. Psychosocial perceptions of hair loss in men with AGA were also improved. Topical minoxidil (5% and 2%) was well tolerated by the men in this trial without evidence of systemic effects.

Quality-of-life improvements in cutaneous T-cell lymphoma patients treated with denileukin diftitox (ONTAK)

Cutaneous T-cell lymphoma (CTCL) can be associated with painful, pruritic, disfiguring lesions. As part of a multicenter, randomized phase III trial in patients with heavily pretreated advanced and/or recurrent CTCL, the effects of an interleukin-2 receptor-targeted fusion protein, denileukin diftitox (DAB389IL-2, ONTAK), on patient-rated overall quality of life (QOL), skin appearance, and pruritus severity were evaluated. A total of 71 patients with stage IB-IVA CTCL received intravenous denileukin diftitox 9 microg/kg/day or 18 microg/kg/day over 15-60 minutes for 5 consecutive days on an outpatient basis; cycles were planned for every 21 days for a total of 8 cycles over 6 months. Prior to each treatment cycle, patients were evaluated for disease response and were asked to self-rate their overall QOL via the Functional Assessment of Cancer Therapy-General (FACT-G) questionnaire, skin appearance (7-point scale), and pruritus severity (10-cm visual analogue scale). Composite FACT-G and most individual subscale scores (physical, social/family, emotional, and functional well being) in documented responders (n = 21) gradually increased during the study period, generally reaching statistical significance (P < 0.05) by cycle 3, and were significantly (P < or = 0.041) higher than the scores of nonresponders at endpoint. Additionally for responders, assessments of skin severity and pruritus severity showed significant (P < or = 0.05) improvements at study endpoint compared with baseline. Adverse transfusion-related events (eg, hypersensitivity reactions, flu-like syndrome) were common during cycles 1 and 2, and vascular-leak syndrome occurred in 25% of patients. Denileukin diftitox was not associated with any clinically significant myelosuppression. Heavily pretreated patients with advanced and/or recurrent CTCL who responded to denileukin diftitox therapy showed significant improvements in self-rated overall QOL, skin appearance, and pruritus severity.

The role for interleukin-12 therapy of cutaneous T cell lymphoma

Recent phase I and phase II trials using recombinant human interleukin-12 (rhIL-12) for cutaneous T cell lymphoma (CTCL) have been completed. Observations on 32 evaluable patients revealed an overall response rate approaching 50 percent. Biopsy of regressing lesions revealed an increase in numbers of CD8+ and/or TIA-1+ T cells. These results suggest that rhIL-12 may induce lesion regression by augmenting antitumor cytotoxic T cell responses. Future trials will be focused on strategies for further immune enhancement by the concomitant use of additional immune augmenting cytokines with rhIL-12.

A phase III, randomized, double-blind, placebo-controlled study of peldesine (BCX-34) cream as topical therapy for cutaneous T-cell lymphoma

BACKGROUND

The purine nucleoside phosphorylase inhibitor peldesine is a new agent being evaluated as a T-cell inhibitor.

OBJECTIVE

We attempted to determine the efficacy of peldesine (BCX-34) in a 1% dermal cream formulation as a treatment for cutaneous T-cell lymphoma (CTCL).

METHODS

Ninety patients with patch and plaque phase CTCL, histologically confirmed by a referee dermatopathologist, were enrolled in a randomized, double-blind, placebo-controlled study. BCX-34 dermal cream 1% or the vehicle cream (as a placebo control) was applied twice daily to the entire skin surface for up to 24 weeks. Efficacy of the topical therapy was assessed in terms of complete or partial (> or = 50%) clearing of patches and plaques.

RESULTS

Of the 89 patients able to be examined, 43 received BCX-34 and 46 received the placebo vehicle cream. One patient withdrew early and was not analyzed. The two groups were well balanced for potential prognostic factors. A total of 28% (12/43) of the patients treated with BCX-34 showed a response, but 24% (11/46) of patients who received vehicle also responded (P =.677).

CONCLUSION

Although BCX-34 dermal cream 1% was not significantly better than the control as therapy for patch and plaque-phase CTCL, this appears to be the first published placebo-controlled trial evaluating treatment for CTCL. Whether the vehicle cream has more than a placebo therapeutic effect is unclear. The relatively high (24%) placebo response rate should be kept in mind in assessing other treatments for early-stage CTCL.

Lack of efficacy of finasteride in postmenopausal women with androgenetic alopecia

BACKGROUND

Finasteride, an inhibitor of type 2 5alpha-reductase, decreases serum and scalp dihydrotestosterone (DHT) by inhibiting conversion of testosterone to DHT and has been shown to be effective in men with androgenetic alopecia (AGA). The effects of finasteride in women with AGA have not been evaluated.

OBJECTIVE

The purpose of this study was to evaluate the efficacy of finasteride in postmenopausal women with AGA.

METHODS

In this 1-year, double-blind, placebo-controlled, randomized, multicenter trial, 137 postmenopausal women (41-60 years of age) with AGA received finasteride 1 mg/day or placebo. Efficacy was evaluated by scalp hair counts, patient and investigator assessments, assessment of global photographs by a blinded expert panel, and histologic analysis of scalp biopsy specimens.

RESULTS

After 1 year of therapy, there was no significant difference in the change in hair count between the finasteride and placebo groups. Both treatment groups had significant decreases in hair count in the frontal/parietal (anterior/mid) scalp during the 1-year study period. Similarly, patient, investigator, and photographic assessments as well as scalp biopsy analysis did not demonstrate any improvement in slowing hair thinning, increasing hair growth, or improving the appearance of the hair in finasteride-treated subjects compared with the placebo group. Finasteride was generally well tolerated.

CONCLUSION

In postmenopausal women with AGA, finasteride 1 mg/day taken for 12 months did not not increase hair growth or slow the progression of hair thinning.

The presence of loose anagen hairs obtained by hair pull in the normal population

To help determine the specificity of "loose anagen" (LA) hairs in Loose Anagen Syndrome, the presence or absence of LA hairs on a gentle but firm hair pull was evaluated in 110 normal subjects from a 0.5 to 83 y old. In children < or =10 y old, 61% had LA hairs on hair pull evaluation and 73% of all hairs obtained were LA hairs. In contrast, LA hairs were found in only two of 87 (2%) normal postpubescent subjects. The number of LA hairs was small in normal children (1-2 per hair pull) and a maximum of one out of every 6-7 hair pulls in adults, far less than that reported with Loose Anagen Syndrome. Although the mere presence of LA hairs on a hair pull test is thus not specific for LAS in children, the number per hair pull may have diagnostic significance. Correlation of these findings with the various hair disorder phenotypes currently termed Loose Anagen Syndrome will be important.

Pityriasis amiantacea: a report of two cases in adults

Pityriasis amiantacea is a scaly condition of the scalp that is usually seen in children. It is most often associated with an underlying primary dermatosis. We describe two adult patients who did not present with concomitant scalp or cutaneous diseases.

Methods of hair removal

The methods of hair removal vary between simple inexpensive means of home treatment (shaving, plucking, depilatories) to expensive and potentially time-consuming means used by paraprofessionals, nurses, and/or physicians (electrolysis, lasers, x-ray). The ways in which these different methods induce hair removal, the duration of such removal, and the nuances between devices within the same category of methods are discussed.

Finasteride in the treatment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group

BACKGROUND

Androgenetic alopecia (male pattern hair loss) is caused by androgen-dependent miniaturization of scalp hair follicles, with scalp dihydrotestosterone (DHT) implicated as a contributing cause. Finasteride, an inhibitor of type II 5alpha-reductase, decreases serum and scalp DHT by inhibiting conversion of testosterone to DHT.

OBJECTIVE

Our purpose was to determine whether finasteride treatment leads to clinical improvement in men with male pattern hair loss.

METHODS

In two 1-year trials, 1553 men (18 to 41 years of age) with male pattern hair loss received oral finasteride 1 mg/d or placebo, and 1215 men continued in blinded extension studies for a second year. Efficacy was evaluated by scalp hair counts, patient and investigator assessments, and review of photographs by an expert panel.

RESULTS

Finasteride treatment improved scalp hair by all evaluation techniques at 1 and 2 years (P < .001 vs placebo, all comparisons). Clinically significant increases in hair count (baseline = 876 hairs), measured in a 1-inch diameter circular area (5.1 cm2) of balding vertex scalp, were observed with finasteride treatment (107 and 138 hairs vs placebo at 1 and 2 years, respectively; P < .001). Treatment with placebo resulted in progressive hair loss. Patients' self-assessment demonstrated that finasteride treatment slowed hair loss, increased hair growth, and improved appearance of hair. These improvements were corroborated by investigator assessments and assessments of photographs. Adverse effects were minimal.

CONCLUSION

In men with male pattern hair loss, finasteride 1 mg/d slowed the progression of hair loss and increased hair growth in clinical trials over 2 years.

Tretinoin emollient cream for photodamaged skin: results of 48-week, multicenter, double-blind studies

BACKGROUND

The ability of topical tretinoin to improve certain signs of skin photodamage has been shown previously.

OBJECTIVE

Our purpose was to assess the effectiveness of tretinoin emollient cream in maintaining or further improving photodamaged skin during extended use.

METHODS

Photodamaged subjects who completed 24 weeks of once-daily use of tretinoin emollient cream 0.05% (n = 149) or 0.01% (n = 149) continued to use the same strength formulation in a 24-week double-blind extension.

RESULTS

Maintenance of improvement or continued reduction in signs of photodamage was noted in both investigators' and subjects' evaluations of the 0.05% and 0.01% preparations; these results were confirmed by skin replica analyses. Cutaneous side effects were less common during the extension study than during the first 24 weeks of therapy.

CONCLUSION

Both strengths of tretinoin emollient cream (0.05% and 0.01%) appeared safe and effective in the treatment of photodamaged skin during a 48-week treatment period.

Sustained improvement in photodamaged skin with reduced tretinoin emollient cream treatment regimen: effect of once-weekly and three-times-weekly applications

BACKGROUND

Previous studies have documented reversal of long-term photodamage with once-daily applications of topical tretinoin.

OBJECTIVE

Our purpose was to assess the effectiveness of tretinoin emollient cream in maintaining improvement in photodamage with a reduced frequency of applications.

METHODS

A total of 126 subjects who completed 48 weeks of once-daily treatment with tretinoin emollient cream 0.05% were enrolled for an additional 24 weeks of tretinoin once weekly, three times weekly, or no therapy.

RESULTS

The clinical improvement observed during 48 weeks of once-daily treatment was sustained with three-times weekly applications and to a lesser extent with once-weekly dosing, whereas effects tended to regress in subjects off therapy. The overall incidence of adverse events in the skin and subcutaneous tissues appeared to vary with dose frequency.

CONCLUSION

After 48 weeks of once-daily treatment, the continued use of tretinoin emollient cream 0.05% at a dose of three times per week maintains and, in some cases, may further enhance improvement in photodamage. Discontinuation of therapy results in some reversal of beneficial effects.

Pentostatin (2'-deoxycoformycin) in the treatment of cutaneous T-cell lymphoma

BACKGROUND

The treatment of patients with advanced or therapy-refractory cutaneous T-cell lymphoma (CTCL) remains a challenge. Pentostatin is a potent inhibitor of adenosine deaminase and is selectively toxic to lymphocytes. In a small number of patients with CTCL, it previously has been shown to be effective.

OBJECTIVE

Our purpose was to evaluate the efficacy and safety of pentostatin in the treatment of patients with advanced and/or therapy-refractory CTCL.

METHODS

Eighteen patients with stage I to IVb CTCL were treated with 4 to 5 mg/m2 of intravenous pentostatin every 1 to 4 weeks.

RESULTS

Two patients (11%) had complete responses of 4 months and 6 years, respectively. These patients had stage III and IVa CTCL and had previously received many different external or systemic treatments. Partial remission (50% to 99% clearing) lasting for 1.5 to 6 months occurred in five patients (28%) with stage IIa (n = 3), stage IIb, and stage IVa CTCL. These patients had received a median of three prior external or systemic treatments. No major side effects were observed, and bone marrow suppression was mild.

CONCLUSION

Single-agent pentostatin in intravenous doses of 4 to 5 mg/m2 is an effective systemic treatment of CTCL (39% objective response rate) with little toxicity.

Eccrine gland infiltration by mycosis fungoides

After identifying prominent eccrine infiltration by atypical lymphocytes in a biopsy of tumor stage mycosis fungoides (MF), we sought to determine the pattern of eccrine epithelial infiltration in MF. The frequency, intensity, and distribution of infiltration of eccrine gland structures, including acrosyringium, duct and coil epithelium, was studied by examining 71 biopsy specimens from 42 patients with MF in which eccrine structures were present. These were obtained from a retrospective review of pathologic specimens from Duke University Medical Center from 1992 and 1993. At least focal eccrine infiltration was noted in 23 of the 71 biopsy specimens (32%). Immunohistochemical confirmation of T-lymphocyte phenotype was performed in the 23 cases with positive reaction to antibodies CD3 and CD45RO and negative reaction with CD20. Folliculosebaceous units were present in 22 of the 71 biopsy specimens and were at least focally involved by MF in 11 (50%) in this series. A control group of biopsy specimens of reactive dermatoses were characterized by more superficial location of lymphocytes, with more spongiosis and epithelial degenerative changes. These findings further illustrate the epitheliotropic behavior of MF.