Immunosuppressive Agents in Skin Disorders

Mycophenolate Mofetil (CellCept®) for Psoriasis: A Two-Center, Prospective, Open-Label Clinical Trial

Background:

Mycophenolate mofetil (MMF) is an immune suppressant that selectively inhibits activated lymphocytes. Its usefulness in treating psoriasis has not been systematically investigated.

Objective:

To evaluate efficacy and safety of MMF as a monotherapy for psoriasis.

Methods:

This is a two-center, prospective, open-label clinical trial.

Results:

Twenty-three patients with moderate to severe psoriasis [mean psoriasis area and severity index (PASI) of 21.7] were treated with MMF 2–3 g/day for 12 weeks. Eighteen patients completed the study. The PASI was reduced by 24% ( p < 0.001) at 6 weeks, and by 47% ( p < 0.001) at 12 weeks. At the end of the treatment phase, 77% of the patients had significant reduction of PASI while 22% did not respond. The treatment was well tolerated. Five patients experienced mild nausea. One patient each had periorbital edema and pruritus. One patient had transient leukopenia.

Conclusion:

In this noncontrolled trial, the majority of patients with moderate to severe psoriasis responded to mycophenolate mofetil monotherapy with few adverse events. A randomized, controlled trial should be considered to confirm the usefulness of MMF as a monotherapy for psoriasis.

Safety of Conventional Systemic Agents and Biologic Agents in the Treatment of Psoriasis

For many years, the mainstays of psoriasis therapy were conventional oral immunosuppressants (eg, cyclosporine and methotrexate) and retinoids. Recently, six biologic agents were approved for the treatment of psoriasis in Canada and the United States: alefacept, efalizumab, etanercept, infliximab, adalimumab, and ustekinumab. Biologic agents exert their therapeutic effect in psoriasis through inhibition of various pathways. Although these treatments are new to the management of psoriasis, many have been used in other disease states, such as rheumatoid arthritis, psoriatic arthritis, and Crohn's disease. Long-term safety data are available from the treatment of these diseases. Both conventional and biologic treatments are effective in the treatment of psoriasis, but they are associated with serious adverse events, ranging from organ toxicity to serious infections, birth defects, and malignancies. This article reviews the safety profiles of both classes of treatments.

The Use of Systemic Immune Moderators in Dermatology: An Update

In addition to corticosteroids, dermatologists have access to an array of immunomodulatory therapies. Azathioprine, cyclophosphamide, methotrexate, cyclosporine, and mycophenolate mofetil are the systemic immunosuppressive agents most commonly used by dermatologists. In addition, new developments in biotechnology have spurred the development of immunobiologic agents that are able to target the immunologic process of many inflammatory disorders at specific points along the inflammatory cascade. Alefacept, efalizumab, etanercept, and infliximab are the immunobiologic agents that are currently the most well known and most commonly used by dermatologists. This article reviews the pharmacology, mechanism of action, side effects, and clinical applications of these therapies.

Immunosuppressive agents in dermatology. An update

Azathioprine, cyclophosphamide, methotrexate, and cyclosporine are the immunosuppressive agents most commonly used by dermatologists. Azathioprine has a relatively good safety profile and is therefore often preferred for the treatment of chronic eczematous dermatitides and bullous disorders. Awareness of the role of genetic polymorphisms in its metabolism can increase the efficacy and safety of this drug. Cyclophosphamide is an antimetabolite that has a more rapid onset of immunosuppressive effect than azathioprine, but has significant short-term and long-term toxicity. It is of use in fulminant, life-threatening cutaneous disease. Methotrexate is an antimetabolite that has significant anti-inflammatory activity. Despite its hepatotoxicity, its role in inflammatory dermatoses is broadening. Likewise, the role of cyclosporine is being expanded. This drug has potent T-cell inhibitory effects secondary to interference with intracellular signal transduction. Given the evidence for cumulative renal toxicity, it currently has a role in the short-term treatment of refractory psoriasis and atopic dermatitis, as well as in select inflammatory dermatoses. Familiarity with disease-specific clinical efficacy, side-effect profile, and dosage allows the successful and judicious use of these drugs in dermatologic disorders.