Infliximab for refractory oral ulcers

SER recommendations on treatment of refractory Behçet's syndrome

OBJECTIVE

To develop multidisciplinary recommendations based on available evidence and expert consensus for the therapeutic management of patients with refractory Behçet's syndrome (BS) (difficult to treat, severe resistant, severe relapse) to conventional treatment.

METHODS

A group of experts identified clinical research questions relevant to the objective of the document. These questions were reformulated in PICO format (patient, intervention, comparison and outcome). Systematic reviews of the evidence were conducted, the quality of the evidence was evaluated following the methodology of the international working group Grading of Recommendations Assessment, Development, and Evaluation (GRADE). After that, the multidisciplinary panel formulated the specific recommendations.

RESULTS

4 PICO questions were selected regarding the efficacy and safety of systemic pharmacological treatments in patients with BS with clinical manifestations refractory to conventional therapy related to mucocutaneous and/or articular, vascular, neurological parenchymal and gastrointestinal phenotypes. A total of 7 recommendations were made, structured by question, based on the identified evidence and expert consensus.

CONCLUSIONS

The treatment of most severe clinical manifestations of BS lacks solid scientific evidence and, besides, there are no specific recommendation documents for patients with refractory disease. With the aim of providing a response to this need, here we present the first official Recommendations of the Spanish Society of Rheumatology for the management of these patients. They are devised as a tool for assistance in clinical decision making, therapeutic homogenisation and to reduce variability in the care of these patients.

Follicular lymphoma manifests as multiple erosive and proliferative lesions of the oral mucosa: case report and brief literature review

Background

Erosion is one of the most common and basic lesions of oral mucosal diseases. Long-term refractory oral erosions, induced by autoimmune blistering diseases, infectious diseases, malignant diseases, and some rare conditions, may substantially reduce the quality of life of patients or even constitute a life-threatening condition, resulting in a clinical dilemma regarding the accurate diagnosis and precise management of these diseases. As a special type of malignant lymphoma, most lesions of follicular lymphoma (FL) in the oral mucosa present as masses or swelling of the oral mucosa, while emerging novel presentations lead to intractable diagnoses. Hence, diagnostic algorithms for such diseases are clinically required. 

Case presentation

A 55-year-old female patient presented to the clinic with long-lasting oral mucosal erosions and proliferative lesions. Blood tests, pathological examinations of oral lesions including haematoxylin–eosin (HE) staining, and direct immunofluorescence precluded all of the potential diagnoses described previously. Unexpectedly, positron emission tomography/computed tomography (PET/CT) and abdominal CT of the patient revealed a dense mass in the retroperitoneal area, and the final diagnosis of the retroperitoneal mass was FL. After three courses of chemotherapy conducted by the haematologist, the erosion and proliferative lesions in the patient's oral mucosa had significantly improved. HE and immunohistochemical staining results of intraoral lesions also confirmed it as oral FL. The successful diagnosis of FL in this case is of great clinical significance, as the oral and abdominal FL were treated in a timely manner to avoid unfavourable outcomes.

Conclusions

To the best of our knowledge, this is the first case of FL that exhibited widespread erosions interspersed with proliferative lesions. Clinicians should be aware of oral FL or seek systemic factors in the presence of similar refractory oral erosions when treatment is non-responsive and the diagnosis is intractable.

Tumor necrosis factor alpha (TNF-α) blockage reduces acute inflammation and delayed wound healing in oral ulcer of rats

Oral traumatic ulcers (OTU) are common in dental routine, and the control of proinflammatory cytokines, such as the tumor necrosis factor-alpha (TNF-α), may interfere with OTU repair. Our aim was to evaluate the role of TNF-α in the healing process of OTU in rats. Wistar male rats were divided into six groups: a control-group (treated with 0.1 mL/kg of saline) and five groups treated with anti-TNF-α infliximab (INF) at 1, 3, 5, 7, and 10 mg/kg immediately before OTU production. The animals were weighed (day 0) and euthanized on days 1, 3, 7, 14 and 21 after ulceration. The ulcers were clinically measured, and the mucosa samples were histologically (scores 0-4), histochemically (collagen assay (pircrosirius)), histomorphometrically (cell counting), and immunohistochemically (TNF-α, α-smooth-muscle-actin (α-SMA), monocyte-chemoattractive-protein-1 (MCP-1), interleukin-8 (IL-8), and fibroblast-growth-factor (FGF)) analyzed. The Evans blue assay was used to measure the vascular permeability. ANOVA-1-2-way/Bonferroni, Kruskal-Wallis/Dunn, and correlation analyses were performed (GraphPad Prism 5.0, p < 0.05). High doses of INF reduced the OTU area (p = 0.043), body mass loss (p = 0.023), vascular permeability (p < 0.001), and reduced delayed histologic scores (p < 0.05), polymorphonuclear (p < 0.001) and mononuclear (p < 0.001) cells, blood vessel counting (p = 0.006), and total (p < 0.001), type-I (p = 0.018), and type-III (p < 0.001) collagen. INF treatment reduced TNF-α immunostaining and delayed MPC-1, FGF, and α-SMA expression, with little/none influence in IL-8 immunostaining. TNF-α blockage by INF reduced acute inflammation in OTU but delayed cell migration and wound healing.

Neutrophilic Dermatosis and Management Strategies for the Inpatient Dermatologist

Purpose of Review

Neutrophilic dermatoses are a heterogeneous group of disorders with significant overlap in associated conditions, clinical presentation, and histopathologic features. This review provides a structural overview of neutrophilic dermatoses that may present in the inpatient setting along with diagnostic work-up and management strategies.

Recent Findings

Sweet’s syndrome has been found in patients with coronavirus disease 2019 (COVID-19). Pyoderma gangrenosum (PG) has been shown to be equally associated with ulcerative colitis and Crohn’s disease. A clinical trial shows that cyclosporine is equally effective as prednisone in treating PG. Neutrophilic eccrine hidradenitis has been found in the setting of newer antineoplastic medications, such as BRAF inhibitors, as well as in the setting of malignancy without chemotherapy exposure.

Summary

Neutrophilic dermatoses are a rare and complex group of dermatoses with varying and overlapping clinical presentations. Physicians should be aware of the growing list of associated diseases in order to build a better differential diagnosis or to potentially investigate for co-existing disease.

Role of biologics in refractory recurrent aphthous stomatitis

Refractory recurrent aphthous stomatitis (RRAS) manifests as severe ulcerative lesions of the oral mucosa with poor healing and a poor response to conventional therapy, with or without systemic diseases. Its treatment remains a clinical challenge owing to the lack of effective therapies. Recently, biologics have emerged as promising targeted therapies for RRAS. The biologics targeting specific inflammatory pathways involved in the pathogenesis of RRAS, including tumor necrosis factor-alpha inhibitors and interleukin inhibitors, offer a more precise and promising therapeutic approach for RRAS. These targeted therapies have been shown to promote healing and decrease recurrence frequency in, and improve the quality of life of patients with RRAS. Herein, the types and mechanisms of biologics currently used to treat RRAS have been reviewed; furthermore, the dose, duration, therapeutic efficacy, and adverse effects of RRAS with or without certain associated systemic diseases, and the current problems and future directions have been discussed.

Refractory Oral Ulcer Responsive to Infliximab: A Case Report

PURPOSE

Some oral ulcers are refractory to treatment. Recently, anti-tumor necrosis factor-alpha (anti-TNF-α) agents have been shown to induce relatively long remissions of refractory oral ulcers.

METHODS

A 69-year man presented with a sore throat caused by a pharyngeal ulcer in the soft palate and subsequently repeatedly developed oropharyngolaryngeal ulcers and an ulcer in the ileocecal region. Intestinal Behçet disease was suspected, but he did not meet the diagnostic criteria for this condition. Seven months after the initial presentation, he developed a lingual ulcer that did not resolve despite treatment with prednisolone. Given the suspicion of intestinal Behçet disease, 300 mg of infliximab was administered intravenously.

RESULTS

After the third dose of infliximab with prednisolone, the ulcer began to improve. He received infliximab every 8 weeks thereafter and developed no new oropharyngolaryngeal ulcers during the 17 months after the first infusion of infliximab.

CONCLUSIONS

When a patient has refractory oral ulcers, attention must be paid to digestive symptoms and whether the patient has a systemic disease such as Behçet disease investigated. Furthermore, administration of infliximab to patients with refractory ulcers can be considered even when they do not fulfill the clinical criteria for a systemic disease.

Neutrophilic dermatoses: Pathogenesis, Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease

Neutrophilic dermatoses are a heterogeneous group of inflammatory skin disorders that present with unique clinical features but are unified by the presence of a sterile, predominantly neutrophilic infiltrate on histopathology. The morphology of cutaneous lesions associated with these disorders is heterogeneous, which renders diagnosis challenging. Moreover, a thorough evaluation is required to exclude diseases that mimic these disorders and to diagnose potential associated infectious, inflammatory, and neoplastic processes. While some neutrophilic dermatoses may resolve spontaneously, most require treatment to achieve remission. Delays in diagnosis and treatment can lead to significant patient morbidity and even mortality. Therapeutic modalities range from systemic corticosteroids to novel biologic agents, and the treatment literature is rapidly expanding. The first article in this continuing medical education series explores the pathogenesis of neutrophilic dermatoses and reviews the epidemiology, clinical and histopathologic features, diagnosis, and management of Sweet syndrome, neutrophilic eccrine hidradenitis, and Behçet disease.

Is Optimal Management of Recurrent Aphthous Stomatitis Possible? A Reality Check

Recurrent Aphthous Stomatitis (RAS) is a condition in which aphthous ulcers repeatedly occur in the oral cavity. It is prevalent in developed countries, occurring in all ages, geographic regions and races and about 80% of people have one episode of oral aphthous ulcers before the age of 30 years. With no laboratory procedures to confirm the diagnosis, treatment is mainly empirical in nature and focuses on short-term symptomatic management. Although numerous treatment modalities have been recommended, only a few are evidence based and can be considered for the optimal management of RAS. Biologic agents are a new category of drugs which acts by blocking specific pathways associated with the pathophysiology of neoplastic or immune-mediated diseases. These agents have targeted immunosuppressive or anti-inflammatory actions. In patients of RAS who were not responding to standard therapy, etanercept, adalimumab, infliximab and Interferon-Alpha (INF-α) were found to be useful. The objective of this review was to propose and review a treatment protocol to be followed for the optimal management of RAS. We reviewed several evidence-based studies and through this review we recommend topical interventions as the first-line of therapy since they are associated with low risk of systemic side effects. Due to limitations in the number of evidence-based trials and the insufficient data to support or refute the efficacy of the therapies prescribed, larger evidence-based clinical studies and literature reviews are needed to further improvise the optimal methodology for the effective management of RAS.