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Zhou T, Al Muqrin A, Abu-Hilal M. Updates on Pityriasis Rubra Pilaris: A Scoping Review. J Cutan Med Surg 2024; 28:158-166. [PMID: 38174859 PMCID: PMC11015718 DOI: 10.1177/12034754231223159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Pityriasis rubra pilaris (PRP) is a rare, inflammatory papulosquamous skin disease with unknown exact etiology. Historically, PRP has been challenging to diagnose, especially during the acute phase, and to treat, due to its unclear pathogenesis. To better inform clinical practice, a literature review was conducted employing a broad search strategy to capture PRP-related published studies between January 1, 2012 to October 31, 2022. Two hundred twenty-one studies were identified, which were categorized into 9 themes: (1) potential causes and triggering factors, (2) comorbidities, (3) diagnostic difficulties, (4) genetics, (5) clinical manifestations and laboratory values, (6) treatment, (7) treatment-related adverse events, (8) quality of life, and (9) other. COVID-19 infection, COVID-19 vaccination, and malignancy were the most commonly reported potential triggering factors. Misdiagnosis is very common during the early acute stages. Pathogenesis and genetic studies have further implicated caspase recruitment domain family member 14 (CARD14) mutations in the development of familial PRP (Type V) and have underlined the overlap between psoriasis and PRP. To date, there are currently no specific and validated scoring systems or tools to assess the severity of PRP. While large, randomized trials are still lacking, biologic agents remain the most effective therapy.
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Affiliation(s)
- Ted Zhou
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Abdullah Al Muqrin
- Division of Dermatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mohannad Abu-Hilal
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Division of Dermatology, Department of Medicine, McMaster University, Hamilton, ON, Canada
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2
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Fydanaki O, Rezq H, Sepetis AE, Joganathan V. Resolution of Pityriasis rubra pilaris induced ectropion with oral dexamethasone. A case report. Orbit 2024:1-3. [PMID: 38319642 DOI: 10.1080/01676830.2024.2311657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/24/2024] [Indexed: 02/07/2024]
Abstract
An 82-year-old male presented with generalised Pityriasis rubra pilaris (PRP) managed initially by dermatology team. The patient did not respond to first- and second-line treatment, including oral acitretin, steroid creams, and methotrexate, and developed bilateral cicatricial ectropion, for which he was referred to oculoplastic team for surgical management. A head injury resulting in subacute subdural haematoma, managed with a week course of low dose oral dexamethasone, resulted in the improvement of his skin condition and complete resolution of the cicatricial ectropion within a few weeks. Thus, systemic treatment of PRP with oral dexamethasone may be considered sooner in the treatment of cicatricial ectropion in similar cases.
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Affiliation(s)
- Ourania Fydanaki
- Ophthalmology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Haytham Rezq
- Ophthalmology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Anastasios E Sepetis
- Ophthalmology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Varajini Joganathan
- Ophthalmology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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3
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Smyk J, Kamińska A, Borowy P, Major P, Gołojuch K, Batko B. Pityriasis Rubra Pilaris - a difficult path to optimal treatment. Case report. POLSKI MERKURIUSZ LEKARSKI : ORGAN POLSKIEGO TOWARZYSTWA LEKARSKIEGO 2024; 52:363-367. [PMID: 39007476 DOI: 10.36740/merkur202403114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Abstract
Pityriasis Rubra Pilaris is a rare, chronic inflammatory dermatosis of unknown etiology, presenting with erythema and papular eruptions. Treatment is difficult due to the lack of causal therapy, guidelines and requires an individualized approach. The most common treatments are systemic retinoids, immunosuppressants, phototherapy and biological therapy. This article presents the case of a 73-year-old man suffering from type 1 pityriasis rubra pilaris. The patient was initially treated with acitretin, which was discontinued due to hypogammaglobulinemia. This rare side effect of acitretin has not been previously published. As a second-line treatment, the patient received methotrexate, but with no clinical improvement after 3 months and an increase in skin pruritus. Finally, the use of isotretinoin resulted in significant clinical improvement and was well tolerated.
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Affiliation(s)
- Jakub Smyk
- DEPARTMENT OF RHEUMATOLOGY AND IMMUNOLOGY, ANDRZEJ FRYCZ-MODRZEWSKI CRAKOW UNIVERSITY, CRAKOW, POLAND
| | - Alicja Kamińska
- DEPARTMENT OF RHEUMATOLOGY AND IMMUNOLOGY, ANDRZEJ FRYCZ-MODRZEWSKI CRAKOW UNIVERSITY, CRAKOW, POLAND
| | - Przemysław Borowy
- DEPARTMENT OF RHEUMATOLOGY AND IMMUNOLOGY, J. DIETL HOSPITAL, CRACOW, POLAND
| | - Patrycja Major
- DEPARTMENT OF RHEUMATOLOGY AND IMMUNOLOGY, ANDRZEJ FRYCZ-MODRZEWSKI CRAKOW UNIVERSITY, CRAKOW, POLAND
| | - Katarzyna Gołojuch
- DEPARTMENT OF RHEUMATOLOGY AND IMMUNOLOGY, ANDRZEJ FRYCZ-MODRZEWSKI CRAKOW UNIVERSITY, CRAKOW, POLAND
| | - Bogdan Batko
- DEPARTMENT OF RHEUMATOLOGY AND IMMUNOLOGY, J. DIETL HOSPITAL, CRACOW, POLAND
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Heidemeyer K, Seyed Jafari SM, Farnina L, Bossart S, Feldmeyer L, Yawalkar N. Case report: Area of focus of management of severe pityriasis rubra pilaris by dose optimization of adalimumab biosimilar in combination with acitretin and montelukast. Front Med (Lausanne) 2023; 10:1295777. [PMID: 38098840 PMCID: PMC10720432 DOI: 10.3389/fmed.2023.1295777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/17/2023] [Indexed: 12/17/2023] Open
Abstract
Pityriasis rubra pilaris (PRP) is a rare inflammatory skin disorder characterized by hyperkeratotic follicular papules, orange-red scaling plaques with islands of sparing and palmoplantar keratoderma. While spontaneous resolution occurs in some cases, treatment can be challenging for others. The use of biologics in PRP management has gained attention in recent studies, although their high costs and potential side effects present limitations. We present a case of a 71-year-old patient with treatment-resistant PRP who showed significant improvement through optimized adalimumab treatment. Considering the emerging role of phospholipase A2 in PRP pathogenesis, montelukast was added, further enhancing the therapeutic response. By maintaining montelukast and prolonging the adalimumab interval to 3 and 4 weeks, effective dose optimization was achieved without PRP relapse. This case report highlights the potential for adalimumab dose optimization by shortening the initial treatment interval for increased effectiveness and lengthening the interval during the maintenance phase to conserve medication doses. Montelukast appears to assist in sustaining clinical outcomes during interval prolongation, necessitating further investigation through additional studies.
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Affiliation(s)
- Kristine Heidemeyer
- Department of Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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5
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Guenther JS, Ahronowitz I, Worswick S. Kaposi's Varicelliform Eruption After Treatment With Ixekizumab in a Patient With Pityriasis Rubra Pilaris. Cureus 2023; 15:e38395. [PMID: 37265883 PMCID: PMC10231903 DOI: 10.7759/cureus.38395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/03/2023] Open
Abstract
Pityriasis rubra pilaris (PRP) is a rare condition characterized by red-orange plaques with islands of sparing with follicular and palmoplantar hyperkeratosis. The disease can be difficult to treat and often requires patients to trial multiple therapeutic options. In recent years, targeted biologic therapies have increasingly been trialed due to their relative efficacy and favorable safety profile. Ixekizumab, an interleukin-17 inhibitor, is one such therapy that has demonstrated efficacy in PRP with few reported adverse events. We present a PRP patient who developed Kaposi's varicelliform eruption followed by a pseudomonal superinfection three months after initiation of ixekizumab.
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Affiliation(s)
- Jana S Guenther
- Department of Dermatology, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Iris Ahronowitz
- Department of Dermatology, University of Southern California Keck School of Medicine, Los Angeles, USA
| | - Scott Worswick
- Department of Dermatology, University of Southern California Keck School of Medicine, Los Angeles, USA
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Guenther J, Novack D, Kamath S, Worswick S. Treatment Options for Juvenile Pityriasis Rubra Pilaris. Paediatr Drugs 2023; 25:151-164. [PMID: 36529810 DOI: 10.1007/s40272-022-00549-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 12/23/2022]
Abstract
Pityriasis rubra pilaris represents a group of familial and acquired disorders of cornification that affect both adult and pediatric patients. Treatment options are difficult to assess through clinical trials, given the rarity of the disorder and its tendency for spontaneous remission. Case reports and case series are therefore the primary means of assessment. Because of the heterogeneity of the disease, there is no universal approach to treatment, and multiple agents may need to be trialed to achieve disease control. At present, topicals are used for most pediatric patients, though monotherapy with topicals is only effective for less severe disease. Despite concerns over their side-effect profiles, oral retinoids are generally accepted as a first-line systemic therapy. However, interleukin-17 inhibitors and ustekinumab, an interleukin-12 and interleukin-23 inhibitor, may soon become first-line systemic treatment as well, given their efficacy and relative safety in trials thus far. Ustekinumab, in particular, is emerging as a first-line agent for patients with pityriasis rubra pilaris with CARD14 gene variations. When these therapies fail, second-line and adjunctive therapies to consider include tumor necrosis factor-alpha inhibitors, methotrexate, and phototherapy. However, further investigation is necessary to assess the safety and efficacy of many of these agents in juvenile pityriasis rubra pilaris.
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Affiliation(s)
- Jana Guenther
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Sonia Kamath
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Scott Worswick
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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Haynes D, Strunck JL, Topham CA, Ortega-Loayza AG, Kent G, Cassidy PB, Hu R, Choate K, Wang Z, Liu Y, Greiling TM. Evaluation of Ixekizumab Treatment for Patients With Pityriasis Rubra Pilaris: A Single-Arm Trial. JAMA Dermatol 2021; 156:668-675. [PMID: 32293641 DOI: 10.1001/jamadermatol.2020.0932] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Pityriasis rubra pilaris is a rare and disabling cutaneous disease that is frequently recalcitrant to conventional therapies and appears to involve interleukin (IL)-17 overexpression. Objective To investigate the clinical response and safety of ixekizumab in treating pityriasis rubra pilaris. Design, Setting, and Participants Single-arm, investigator-initiated trial conducted in adult patients with moderate to severe pityriasis rubra pilaris at a single-center academic university from June 2018 to January 2020. A total of 41 patients were screened, 12 were enrolled, and 11 completed the full duration of therapy. A referred, consecutive sample was used during participant selection. The treatment period and primary outcome occurred over 24 weeks with additional patient follow-up through 36 weeks. Intervention Subcutaneous administration of ixekizumab, a humanized IgG4 antibody that binds IL-17A, at the US Food and Drug Administration-approved dosing schedule for treatment of psoriasis for 24 weeks. Main Outcomes and Measures The primary outcome was the mean change in Psoriasis Area and Severity Index at 24 weeks. Secondary outcomes included change in affected body surface area, quality of life, induction of sustained remission, and association of improvement with CARD14 genetic variations and cutaneous cytokine expression. Results A total of 12 white patients (mean [SD] age, 49.8 [15.1] years; 8 male [67%]) were enrolled between June 2018 and April 2019, with 11 completing the full course of intervention. The mean (SEM) improvements in Psoriasis Area and Severity Index, affected body surface area, and Dermatology Life Quality Index were 15.2 (2.1) (P < .0001), 29.8% (9.3%) (P = .009), and 9.5 (2.5) (P = .004), respectively. The 4 participants with the most improvement in Psoriasis Area and Severity Index at week 24 stayed in remission at week 36 (defined as lack of increase in Psoriasis Area and Severity Index from week 24 through week 36), off therapy. Relative dermal IL-17A expression decreased by a 1.9 log-fold change. No participants had known pathogenic CARD14 variations. There were no serious adverse events. Conclusions and Relevance In this single-armed trial, ixekizumab was associated with reduced clinical signs and symptoms of pityriasis rubra pilaris in a subset of patients, including those in whom other systemic therapies have failed. Trial Registration ClinicalTrials.gov Identifier: NCT03485976.
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Affiliation(s)
- Dylan Haynes
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Jennifer L Strunck
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Christina A Topham
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | | | - Gail Kent
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Pamela B Cassidy
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Ronghua Hu
- Department of Dermatology, Yale University, New Haven, Connecticut
| | - Keith Choate
- Department of Dermatology, Yale University, New Haven, Connecticut
| | - Zhiping Wang
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Yuangang Liu
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
| | - Teri M Greiling
- Department of Dermatology, Oregon Health & Science University, Portland, Oregon
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Bagatin E, Costa CS, Rocha MADD, Picosse FR, Kamamoto CSL, Pirmez R, Ianhez M, Miot HA. Consensus on the use of oral isotretinoin in dermatology - Brazilian Society of Dermatology. An Bras Dermatol 2020; 95 Suppl 1:19-38. [PMID: 33036809 PMCID: PMC7772596 DOI: 10.1016/j.abd.2020.09.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/11/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Isotretinoin is a synthetic retinoid, derived from vitamin A, with multiple mechanisms of action and highly effective in the treatment of acne, despite common adverse events, manageable and dose-dependent. Dose-independent teratogenicity is the most serious. Therefore, off-label prescriptions require strict criteria. OBJECTIVE To communicate the experience and recommendation of Brazilian dermatologists on oral use of the drug in dermatology. METHODS Eight experts from five universities were appointed by the Brazilian Society of Dermatology to develop a consensus on indications for this drug. Through the adapted DELPHI methodology, relevant elements were listed and an extensive analysis of the literature was carried out. The consensus was defined with the approval of at least 70% of the experts. RESULTS With 100% approval from the authors, there was no doubt about the efficacy of oral isotretinoin in the treatment of acne, including as an adjunct in the correction of scars. Common and manageable common adverse events are mucocutaneous in nature. Others, such as growth retardation, abnormal healing, depression, and inflammatory bowel disease have been thoroughly investigated, and there is no evidence of a causal association; they are rare, individual, and should not contraindicate the use of the drug. Regarding unapproved indications, it may represent an option in cases of refractory rosacea, severe seborrheic dermatitis, stabilization of field cancerization with advanced photoaging and, although incipient, frontal fibrosing alopecia. For keratinization disorders, acitretin performs better. In the opinion of the authors, indications for purely esthetic purposes or oil control are not recommended, particularly for women of childbearing age. CONCLUSIONS Approved and non-approved indications, efficacy and adverse effects of oral isotretinoin in dermatology were presented and critically evaluated.
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Affiliation(s)
- Ediléia Bagatin
- Department of Dermatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | | | - Fabíola Rosa Picosse
- Department of Dermatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | | | - Rodrigo Pirmez
- Centro de Estudos dos Cabelos, Instituto de Dermatologia Professor Rubem David Azulay, Santa Casa da Misericórdia do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Mayra Ianhez
- Department of Tropical Medicine and Dermatology, Universidade Federal de Goiás, Goiânia, GO, Brazil
| | - Hélio Amante Miot
- Department of Dermatology, Faculdade de Ciências Médicas e Biológicas de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil.
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Kalogeropoulos CI, Papathanasiou KA, Tsagkaraki I, Giannopoulos G, Bamias A, Boutati EI. A Case of Meningococcal and HSV-2 Meningitis in a Patient Being Treated with Ustekinumab for Pityriasis Rubra Pilaris. Eur J Case Rep Intern Med 2020; 7:001615. [PMID: 32789127 PMCID: PMC7417051 DOI: 10.12890/2020_001615] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/11/2020] [Indexed: 12/03/2022] Open
Abstract
Pityriasis rubra pilaris (PRP) is a rare chronic inflammatory papulosquamous dermatosis affecting both adults and children. Six subtypes of PRP have been described. Recently, the management of PRP with biologic immunosuppressive agents regularly used in psoriasis has been supported by several case reports and series. Ustekinumab is an anti-IL12/23 IgG1 kappa human monoclonal antibody. It has been approved for the treatment of Crohn’s disease, plaque psoriasis, psoriatic arthritis and ulcerative colitis. It has also been reported to be effective as an off-label treatment for PRP. Current data are equivocal regarding infectious disease risk with ustekinumab administration. We describe a case of meningococcal and HSV-2 infection of the central nervous system in a patient being treated with ustekinumab for PRP.
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Affiliation(s)
- Charalampos I Kalogeropoulos
- Second Propaedeutic Department of Internal Medicine and Research Institute, University General Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Konstantinos A Papathanasiou
- Second Propaedeutic Department of Internal Medicine and Research Institute, University General Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Ismini Tsagkaraki
- Second Propaedeutic Department of Internal Medicine and Research Institute, University General Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgios Giannopoulos
- Second Propaedeutic Department of Internal Medicine and Research Institute, University General Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Aristotelis Bamias
- Second Propaedeutic Department of Internal Medicine and Research Institute, University General Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni I Boutati
- Second Propaedeutic Department of Internal Medicine and Research Institute, University General Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
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Abstract
Pityriasis rubra pilaris is a rare papulosquamous chronic skin disease. The disease often exists for years and is difficult to treat. Not only is it clinically similar to psoriasis vulgaris, but both diseases also have a similar cytokine profile. The successful use of biologicals is frequently reported in case reports. Studies with large numbers of cases are lacking.
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Affiliation(s)
- D Kohn
- Klinik für Dermatologie, Dermatochirurgie und Allergologie, Asklepios Klinik Weißenfels, Naumburger Str. 76, 06667, Weißenfels, Deutschland.
| | - T Wetzig
- Klinik für Dermatologie, Dermatochirurgie und Allergologie, Asklepios Klinik Weißenfels, Naumburger Str. 76, 06667, Weißenfels, Deutschland
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