Rediscovering hydroxyurea: its role in recalcitrant psoriasis

Unconventional treatment options in psoriasis: A review

Psoriasis is a common skin disease that affects 1-3% of the general population. The treatment depends on body surface area involved, quality of life impairment and associated comorbidities. The treatment options include topical therapy, phototherapy, conventional systemic therapy (methotrexate, cyclosporine and acitretin), biologics and oral small molecules (apremilast and tofacitinib). Despite the availability of newer therapies such as biologics and oral small molecules, many a time, there is a paucity of treatment options due to the chronic nature of the disease, end-organ toxicity of the conventional drugs or high cost of newer drugs. In these scenarios, unconventional treatment options may be utilized as stand-alone or adjuvant therapy. In this review, we have discussed these uncommonly used treatment options in the management of psoriasis.

Management of psoriasis in patients with inflammatory bowel disease: From the Medical Board of the National Psoriasis Foundation

BACKGROUND

There is a significant association between psoriasis and inflammatory bowel disease (IBD). Many treatments for psoriasis and psoriatic arthritis are also used for IBD.

OBJECTIVE

To assess therapeutic options for patients with psoriasis and concurrent IBD.

METHODS

A systematic literature search was performed for clinical studies of biologic and systemic psoriasis medications in psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease, for the period from January 1, 1947, to February 14, 2017. Randomized, controlled, double-blinded studies were selected if available. If not, the next highest level of available evidence was selected.

RESULTS

Of the 2282 articles identified, 132 were selected. Infliximab and adalimumab have demonstrated efficacy in psoriasis, psoriatic arthritis, ulcerative; colitis, and Crohn's disease. Ustekinumab has demonstrated efficacy in psoriasis, psoriatic arthritis, and Crohn's disease. Certolizumab has demonstrated efficacy in psoriatic arthritis and Crohn's disease. Etanercept, secukinumab, brodalumab, and ixekizumab have demonstrated efficacy in psoriasis and psoriatic arthritis but may exacerbate or induce IBD. Guselkumab has demonstrated efficacy in psoriasis.

LIMITATIONS

There are no known clinical trials of treatment specifically for concurrent psoriasis and IBD.

CONCLUSIONS

Infliximab and adalimumab have demonstrated efficacy in psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease; other agents have demonstrated efficacy for some, but not all, of these indications.

Hydroxyurea for the Treatment of Psoriasis with an Emphasis on HIV-Infected Psoriasis Patients: A Review

Hydroxyurea is a drug that has been long forgotten for the treatment of psoriasis. In addition to its anti-psoriatic effects, it has also been shown to have antiviral effects. This dual effect makes it a drug that dermatologists may want to consider when treating psoriasis in HIV-infected patients. Currently, no studies are available that discuss the safety and efficacy of hydroxyurea in the treatment of psoriasis in this immunocompromised group; however, numerous reports discuss the safety and efficacy of hydroxyurea in psoriasis and HIV separately. This review suggests that hydroxyurea is generally safe and effective. The main risk involves the hematologic adverse events (anemia, leukopenia, thrombocytopenia, and macrocytosis), which appear to be dose dependent. Because of the common hematologic adverse events, hydroxyurea may be considered a viable therapeutic option for patients with generalized psoriasis that is inadequately responsive to other safer options, whether or not the patient is HIV positive.

A multidisciplinary team approach to hydroxyurea-associated chronic wound with squamous cell carcinoma

Hydroxyurea (HU) has been shown to induce a variety of cutaneous adverse reactions, including severe leg ulcers. This report shows a successful treatment of a HU-induced chronic wound associated with squamous cell carcinomas (SCC). A 62-year-old patient affected with polycythemia vera and treated with HU for 10 years, presented with a non healing ulcer on a left heel. The patient gave a history of suffering from the wound for over 2 years. Biopsy showed evidence of invasive SCC. The patient underwent Mohs surgery and a greater saphenous vein ablation for polycythemia vera-associated vascular complications. The wound consistently decreased in size following successive debridements and coverage with human skin equivalent. The wound healed completely after a 6-month period. A multidisciplinary team approach to the treatment proved to be effective resulting in healing of this multifactorial chronic ulcer.

Hydroxyurea in the management of thalassemia intermedia

Hydroxyurea (HU) is an antineoplastic agent that enhances fetal hemoglobin. The clinical significance induced by this compound is well known in sickle cell disease. This clinical significance could also be expected in beta-thalassemia patients. Although studies on beta-thalassemia major patients showed significant results, but these clinical responses are expected to be more in thalassemia intermedia (TI) patients because of lesser alpha/beta globin imbalance. Studies showed that HU therapy in TI patients has significant effects on increasing Hb levels that can cause reducing blood transfusion dependency and transfusion free in some patients, decreasing skeletal deformities and splenomegaly and increasing energy state. So HU therapy could be a useful alternative to blood transfusion in some TI patients.

Adverse effects of hydroxyurea in beta-thalassemia intermedia patients: 10 years' experience

The aim of this study was to evaluate the tolerance and adverse effects of hydroxyurea (HU) in thalassemia intermedia (TI) patients who had been treated by HU for a period of 10 years. One hundred forty-three TI patients, including 78 male and 65 female, median age 21 years old (range: 5-37 years old), who were treated by HU were investigated as a case study, and 106 TI, including 63 male and 43 female, median age 22 years old (range: 5-39 years old), who were not treated by any HU as a control group. Mean dose of HU treatment was 10.74 mg/kg/day (range: 8-12 mg/kg/day) and adverse effects of HU were recorded in 44 (30.7%) patients. Dermatologic side effects were most commonly seen, followed by neurological and gastrointestinal adverse effects. There were not any reports of hematologic toxicity or any signs of bone marrow suppression during HU treatment. Statistical analysis showed a positive correlation between advancing age and the presence of adverse effects during HU treatment (P < .001). But there were not any significant relations among gender, HU dose, and duration of HU treatment and the presence of adverse effects (P > .05). It was also observed that splenectomized patients more frequently experienced adverse effects of HU (P < .05). According to these results, it seems that most of adverse effects in low-dose HU therapy in patients with TI, at least in short and medium terms, are minor and can be tolerated without needs of discontinuation of treatment.

Synthesis, antitumor evaluation and crystal structure of hydroxyurea derivatives

A series of hydroxyurea derivatives have been synthesized and elucidated by means of FT-IR, (1)H-, (13)C-NMR and MS. The exact stereostructures of representative compounds have been determined by X-ray crystal structure analysis. In the crystals, inversion dimers linked by pairs of N-H...O hydrogen bonds occurred, and further N-H...O links led to chains of molecules. In vitro antitumor activities against Tca8113 human tongue cancer cells and L1210 murine leukemia cells were evaluated. A total of 8 of the 12 compounds had higher inhibitory activities than hydroxyurea against L1210 cells. Among them, the most promising compounds were 3e, 3d, 3a and 2d.

Psoriasis in patients with HIV infection: from the medical board of the National Psoriasis Foundation

BACKGROUND

Patients with psoriasis and HIV infection often present with more severe and treatment-refractory cutaneous disease. In addition, many of these patients have significant psoriatic arthritis. Many effective drugs for psoriasis and psoriatic arthritis are immunosuppressive. Therefore, therapy for the HIV-infected patient is more challenging, requiring both careful consideration of the potential risks and benefits of treatment and more fastidious monitoring for potential adverse events.

OBJECTIVE

A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options. Our aim was to arrive at a consensus on therapy for psoriasis in patients with HIV.

METHODS

A MEDLINE search of the terms "psoriasis," "psoriatic arthritis," "human immunodeficiency virus (HIV)," and "HIV skin diseases" was performed and literature relevant to HIV-associated psoriasis and the treatment of HIV-associated psoriasis were reviewed.

RESULTS

Based on a review of the literature, 29 reports were included as evidence in this review. Topical therapy is the first-line recommended treatment for mild to moderate disease. For moderate to severe disease, phototherapy and antiretrovirals are the recommended first-line therapeutic agents. Oral retinoids may be used as second-line treatment. For more refractory, severe disease, cautious use of cyclosporine, methotrexate, hydroxyurea, and tumor necrosis factor-alpha inhibitors may also be considered.

LIMITATIONS

There are no randomized, placebo-controlled trials evaluating the therapeutic efficacy or safety of treatments for patients with HIV-associated psoriasis; consequently, the evidence supporting this review consists mainly of case reports or case series.

CONCLUSIONS

HIV-associated psoriasis is often refractory to traditional treatments. Treatment is challenging and requires careful consideration and should be tailored to patients based on disease severity and the input from an infectious disease specialist. Close monitoring for potential adverse events is necessary.

Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this fourth of 6 sections of the guidelines of care for psoriasis, we discuss the use of traditional systemic medications for the treatment of patients with psoriasis. Treatment should be tailored to meet individual patients' needs. We will discuss in detail the efficacy and safety, and offer recommendations for the use of the 3 most commonly used, and approved, traditional systemic agents: methotrexate, cyclosporine, and acitretin. We will also briefly discuss the available data for the use of azathioprine, fumaric acid esters, hydroxyurea, leflunomide, mycophenolate mofetil, sulfasalazine, tacrolimus, and 6-thioguanine in psoriasis.

Nonstandard and off-label therapies for psoriasis

Although most psoriasis patients respond to standard therapies, many circumstances warrant the use of nonstandard or off-label treatments. For instance, patients with treatment-resistant psoriasis or those who have had multiple adverse effects to other therapies may be good candidates for off-label treatments. Similarly, patients with unusual and hard-to-treat forms of psoriasis such as pustular psoriasis and palmoplantar psoriasis or specific comorbidities may benefit from certain nonstandard therapies. Drugs that may be used as alternatives to standard therapies include mycophenolate mofetil, tacrolimus or pimecrolimus, isotretinoin, colchicine, sulfasalazine, paclitaxel, dapsone, azathioprine, and hydroxyurea. Other unconventional therapies include climatotherapy at the Dead Sea and grenz ray therapy.

Methotrexate versus hydroxycarbamide (hydroxyurea) as a weekly dose to treat moderate-to-severe chronic plaque psoriasis: a comparative study

BACKGROUND

Literature is replete with reports on the therapeutic efficacy and toxicity of methotrexate or hydroxycarbamide for treating chronic plaque psoriasis but no comparative study on their efficacy/safety has been carried out. While methotrexate has long been used in weekly doses in the treatment of psoriasis, the efficacy of hydroxycarbamide as a weekly therapy remains universally unexplored.

METHODS

Two groups of 15 patients each having moderate-to-severe chronic plaque psoriasis were given weekly doses of methotrexate (15-20 mg/week) or hydroxycarbamide (3-4.5 g/week). The clinical response was assessed by the percentage reduction in the baseline PASI scores for the next 12 weeks.

RESULTS

At the end of 12 weeks, the mean percentage reduction in the PASI score was 77.28+/-18.80 in the methotrexate group and 48.47+/-26.53 in the hydroxycarbamide group. Ten (66.66%) patients in the methotrexate group achieved >75% reduction in the PASI score, while in the hydroxycarbamide group only two (13.33%) patients showed similar results, signifying that methotrexate leads to a faster clearance of the disease. The methotrexate-related side effects, however, were also higher.

CONCLUSIONS

Weekly doses of hydroxycarbamide can be used as an alternative to methotrexate in patients who either experience intolerable methotrexate side effects or have achieved its recommended cumulative dose.

The effect of various methods of psoriasis treatment on somatotrophin axis hormones in serum

OBJECTIVE

To investigate the effect of pharmacotherapy and phototherapy on the concentration of hormones of the somatotrophin axis [growth hormone (GH), insulin-like growth factor-I (IGF-I) and insulin-like growth factor binding protein-3 (IGFBP-3)] in the serum of patients with psoriasis in exacerbation and remission.

METHODS

GH and IGFBP-3 in serum were determined by immunoradiometric assay (IRMA), and IGF-I concentrations - by radioimmunological assay (RIA). The dermatological state was assessed by the psoriasis area and severity index (PASI).

RESULTS

There was no significant difference in the GH concentrations in patients both in exacerbation and remission, irrespective of therapy applied. However, in the group treated by phototherapy a significant increase in IGFBP-3 secretion was observed, whereas in the group treated with cyclosporin A - a significant increase in IGF-I secretion was observed in remission.

CONCLUSION

Different methods of treatment have different effects on the secretion of somatotrophin axis hormones, but generally the hormone concentrations do not return to the values observed in healthy people. The therapeutic actions of the drugs concerned are not fully known and require further investigations.

Current systemic therapies for psoriasis: where are we now?

Many systemic agents are used in the treatment of psoriasis. They provide good control of psoriasis in the majority of patients and have improved their life quality indices. Frequently, combination therapy is utilized to synergize the efficacy of these medications. Many dermatologists are hesitant in prescribing systemic agents because of their adverse effects. However, such potential toxicities arising from these medications can largely be avoided if proper patient selection and close monitoring are performed.

HIV-associated pruritus: etiology and management

With the advent of highly active antiretroviral therapy (HAART), life-threatening opportunistic infection has become less common in patients with HIV infection and longevity has increased dramatically. With increased longevity, the problems of living with a chronic disease have become more prominent in this patient population. Disorders such as fat redistribution and metabolic abnormalities can result from antiviral medications and from HIV disease itself. Pruritus is one of the most common symptoms encountered in patients with HIV. The spectrum of skin diseases in such patients encompasses dermatoses of diverse etiologies; a few are peculiar to patients with HIV while others are not. Some of these conditions may cause severe and sometimes intractable pruritus that provokes scratching, picking, disfigurement, sleep loss, and significant psychological stress. Moreover, the expense of ongoing medical treatments can be daunting. Skin rash can sometimes be the initial presentation of HIV infection or serve as a harbinger of disease progression. Causes of pruritus include skin infections, infestations, papulosquamous disorders, photodermatitis, xerosis, drug reactions, and occasionally lymphoproliferative disorders. Drug eruptions are particularly common in patients who are HIV positive, presumably as a result of immune dysregulation, altered drug metabolism, and polypharmacy. Itching can also result from systemic diseases such as chronic renal failure, liver disease, or systemic lymphoma. Workup of pruritus should include a careful examination of the skin, hair, nails, and mucous membranes to establish a primary dermatologic diagnosis. If no dermatologic cause is found, a systemic cause or medication-related etiology should be sought. Idiopathic HIV pruritus is a diagnosis of exclusion and should only be considered when a specific diagnosis cannot be established. The management of HIV-associated pruritus should be directed at the underlying condition. Phototherapy has been found to be useful in the treatment of several HIV-associated dermatoses and idiopathic pruritus as well. Unfortunately, some of the treatments that have been suggested for patients with HIV are anecdotal or based on small uncontrolled studies. The last decade has seen a surge in the utilization of HAART which, to some degree, reconstitutes the immune system and ameliorates some dermatologic diseases. On the other hand, some skin diseases flare temporarily when HAART is started. Unless frank drug allergy is suspected, HAART does not need to be stopped.

Traditional therapies: glucocorticoids, azathioprine, methotrexate, hydroxyurea

The 'old favourites' used for treatment of inflammatory diseases, and hence, the original immunomodulators, include the glucocorticoids, azathioprine, methotrexate and hydroxyurea. Glucocorticoids are still one of the most effective anti-inflammatory agents because they work on several different intracellular processes and hence, block many components that contribute to inflammatory and immune responses. They bind to intracellular glucocorticoid receptors which transport them into the nucleus. Here the receptor/steroid complex may bind to many genes that interact with transcription factors including NFkappaB and AP-1, to inhibit their activation, thereby preventing activation of many genes encoding immune effector and pro-inflammatory cytokines. Also, protein kinases involved in intracellular signalling, are directly activated resulting in phosphorylation of various targets of which Annexin (AXA)-1 is critical in inhibiting biosynthesis of both purines and DNA. This results in reduced proliferation of B and T lymphocytes, reduced immune effector mechanisms and reduced recruitment of mononuclear cells including monocytes into sites of immune inflammation. Methotrexate also blocks DNA synthesis and hence cellular proliferation but also induces release of adenosine. This inhibits chemotaxis of polymorph neutrophils and release of critical cytokines such as TNF-alpha and Interleukins 6 and 8. Hydroxyurea also inhibits DNA synthesis with inhibitory effects on proliferation of lymphocytes and possibly kerationcytes. Even though many new agents with much greater selectivity are coming through into clinical use, this group of old agents still have an absolutely central position in the therapeutic armamentarium. Their value lies in the fact that they are not 'clean' drugs with narrow effects but they inhibit a wide range of mechanisms involved in immune and inflammatory processes.

Short-term methotrexate therapy in psoriasis: a study of 197 patients

Methotrexate (MTX) is one of the most effective antipsoriatic drugs available. Although it is undeniably hepatotoxic, it can be used safely in most patients with severe psoriasis if established guidelines are followed. Current opinion on the monitoring of hepatic damage is divided, however, and the need for repeated liver biopsies during MTX therapy is being re-examined. We have used MTX in a short-term protocol in our patients with psoriasis for the past 20 years, and have recently attempted to minimize or eliminate the need for liver biopsies using this regimen. Data on 244 psoriatics who were given MTX from 1981 to 2000 have been reviewed. Our protocol entailed the use of weekly oral MTX at the full therapeutic dose during episodes of peak disease activity, with tapering off of MTX when the disease subsided in response to treatment combined with natural/seasonal remission. Intensive topical and heliotherapy were encouraged throughout to facilitate the earliest possible drug withdrawal and the longest possible drug-free interval before the next relapse. Strict inclusion criteria were applied before starting MTX. A total of 243 cycles of MTX therapy have been given to 197 evaluable patients. More than 75% improvement occurred in 88% of patients in 8.5 +/- 5.1 weeks. The mean cumulative dose was 709.3 +/- 369.2 mg and the mean duration of follow-up was 16.5 +/- 9.1 months. Fifteen (6.1%) patients had serious adverse effects requiring the cessation of therapy. Only three patients had deranged liver function tests. Thirty-four pre-MTX and 13 post-MTX liver biopsies were taken, which revealed grade I or II changes that were nonprogressive. Our experience with short-term MTX therapy has enabled us to safely administer MTX to our patients with minimal recourse to liver biopsy. In developing countries, where advanced noninvasive methods for the assessment of liver damage are unaffordable or unavailable, this interrupted, short-term regimen may present an acceptable and safe method of using MTX in carefully selected patients with severe psoriasis.