Tofacitinib as the potent treatment for refractory pemphigus: A possible alternative treatment for pemphigus

Efficacy and safety of Bruton's tyrosine kinase inhibitors in the treatment of pemphigus: A comprehensive literature review and future perspective

Bruton's tyrosine kinase (BTK) is a protein involved in B-cell-receptor signaling and B-cell proliferation. The pathophysiology of several autoimmune diseases, such as pemphigus disorder, relies on the BTK signaling pathway. Therefore, BTK inhibitors were found to be beneficial alternatives to conventional treatmentsThe current study aimed to assess the efficacy and safety of BTK inhibitors in treating pemphigus. A complete search was performed on databases including PubMed/MedLine, Scopus, Web of Science, as well as Google Scholar search engine for studies published by September 20th, 2023. The current review indicates that BTK inhibitors alone or in combination with conventional treatments are promising options in the management of pemphigus. The overall safety profile of BTK inhibitors has been acceptable, and the reported adverse reactions were not severe or life-threatening.

Concurrent bullous pemphigoid and psoriasis vulgaris successfully treated with Janus kinase inhibitor tofacitinib: A case report and review of the literature

Bullous pemphigoid (BP) and psoriasis are both immune-related skin diseases. Still, the comorbidities between the two are rare, and there is no consensus on the optimal treatment strategy for BP combined with psoriasis. JAK inhibitors are emerging, molecularly targeted therapeutic agents that target the molecule of Janus kinase, a signal transducer and activator of transcription (JAK/STAT). JAK inhibitors block intracellular signaling pathways by blocking the gene transcription of key pro-inflammatory cytokines that play a central role in the pathogenesis of many inflammatory and autoimmune diseases. Tofacitinib is a first-generation JAK inhibitor. The purpose of this article is to describe the first report of the use of tofacitinib in treating BP combined with psoriasis vulgaris with significant results. According to our findings, tofacitinib may be a safe and effective treatment option for patients suffering from BP and psoriasis together. The implications of this are substantial for the guidance of treatment strategies for both comorbid conditions.

Janus kinase inhibitors in autoimmune bullous diseases

Autoimmune bullous disease (AIBD) is a severe skin disorder caused by autoantibodies that target intercellular or cell-matrix adhesion proteins. Currently, the preferred treatment for AIBD involves the use of glucocorticoids or traditional immunosuppressants. Additionally, the utilization of biological agents such as rituximab, omalizumab, and dupilumab is on the rise. However, effectively managing AIBD remains a challenge. The Janus kinase/signal transducers and activators of transcription (JAK/STAT) pathway has been implicated in various inflammatory diseases. In recent years, a range of drugs known as JAK inhibitors, which target this pathway, have been developed. Several studies have explored the efficacy and safety of JAK inhibitors for treating AIBD. Consequently, this review begins by examining the role of the JAK/STAT pathway in AIBD, summarizing the application of different JAK inhibitors in AIBD treatment, and emphasizing the importance of disease management in treating AIBD with JAK inhibitors. Furthermore, it highlights the need for a better understanding of the JAK/STAT pathway's role in AIBD, as well as the effectiveness and safety of JAK inhibitors for treating this disease.

Concurrent bullous pemphigoid and plaque psoriasis successfully treated with Janus kinase inhibitor Baricitinib

We report a case of aggressive bullous pemphigoid (BP) concurrent with plaque psoriasis successfully treated with Janus kinase inhibitor Baricitinib. The 83-year-old Chinese man suffered ten years of psoriasis and developed bullous pemphigoid with typical intense blisters and significantly elevated serum anti-BP180 autoantibodies. Due to concerns on his poor health conditions including stage III hypertension and potential serious side effects of standard treatment with systematic steroid, he was given Baricitinib orally 4mg/day. Significant improvement in skin lesions and pruritus was noted following treatment for 12falseweeks, from which the dose of Baricitinib was halved and continued for an additional 12falseweeks. He showed a complete remission of both bullous and psoriatic lesions without any adverse effects at the 24-week follow-up visit. Our observation suggests a potential of Baricitinib as a new alternative therapeutic option for concurrent plaque psoriasis and bullous pemphigoid or either of them. This article is protected by copyright. All rights reserved.

A literature review on Janus kinase (JAK) inhibitors for the treatment of immunobullous disorders

Janus kinases (JAKs) are a group of intracytoplasmic tyrosine kinase proteins that bind to the cytoplasmic part of the transmembrane cytokine receptors and regulate signaling. The pathophysiology of various autoimmune and autoinflammatory conditions relies on JAK/STAT signaling and therefore, the inhibition of JAK/STAT pathways can be a promising treatment for such diseases, especially inflammatory skin conditions. The current study aimed to evaluate the efficacy of JAK inhibitors in the treatment of immunobullous diseases, including pemphigus, pemphigoid, dermatitis herpetiformis, and epidermolysis bullosa. The databases used to identify the studies were Web of Science, Scopus, and PubMed/Medline for studies published until 2/3/2022. The current review suggests that JAK inhibitors may be revolutionary for the future treatments of dermatologic conditions, especially autoimmune bullous disease. Results also indicated the effectiveness of JAK inhibitors for the treatment of immunobullous diseases.

Comprehensive Phytochemical Profiling of Polyherbal Divya-Kayakalp-Vati and Divya-Kayakalp-Oil and Their Combined Efficacy in Mouse Model of Atopic Dermatitis-Like Inflammation Through Regulation of Cytokines

Purpose

Atopic dermatitis (AD) is a chronic inflammatory disease that varies in signs and symptoms in different individuals. General symptoms include dryness of the skin, itching, and development of red to brownish-gray patches. Divya-Kayakalp-Vati (DKV) and -Oil (DKO) are Indian polyherbal compositions prescribed for treating inflammatory skin diseases. In the present study, we evaluated the anti-inflammatory efficacy of DKV and DKO co-treatment (DKV-O) in ameliorating Oxazolone (OXA)-stimulated AD-like inflammation and pro-inflammatory cytokine release in a Swiss albino mouse model.

Methods

Phytochemical profiling of the DKV and DKO were done using Liquid Chromatography-Mass Spectroscopy (LC-MS) QToF. Swiss albino mice were sensitized for 7 days and treated with OXA in their ear region. Stimulated and control animals were orally treated with DKV and topically with DKO. Anti-inflammatory efficacy of DKV-O was determined in OXA-treated animals through physiological, histopathological, and biochemical parameter analysis.

Results

DKV and DKO formulations individually contained 39 and 59 phytochemicals, respectively. Many of the phytochemicals have been reported to have anti-inflammatory activities. In the OXA-sensitized Swiss albino mice, combined treatment with DKV-O, and separately with Dexamethasone (positive control) significantly reduced the OXA-stimulated ear edema, biopsy weight, and epidermal thickness. DKV-O further reduced OXA-stimulated induction of inflammatory lesions, neutrophil influx, and release of Interleukin (IL)-1β, IL-6, tumor necrosis factor-α, and myeloperoxidase.

Conclusion

Finally, DKV-O co-treatment showed good pharmacological effects in ameliorating AD-like inflammation through the modulation of inflammatory cell influx and release of soluble mediators. Therefore, DKV-O treatment can be used as a suitable polyherbal therapeutic against AD-like inflammatory diseases.

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Biologics in autoimmune bullous diseases: Current scenario

Autoimmune bullous diseases can be intraepidermal (pemphigus group of disorders) or subepidermal (pemphigoid group of disorders). The treatment of these disorders chiefly comprises corticosteroids and immunosuppressant adjuvants like azathioprine and mycophenolate mofetil. Autoantibodies are the main mediators of these diseases. Rituximab, a chimeric anti-CD20 monoclonal antibody targeting B-cells, has emerged as an excellent treatment option for refractory pemphigus vulgaris in the last decade. Since then, many new biologics have been proposed/explored for managing autoimmune bullous diseases. These hold potential for greater efficacy and lesser adverse effects than conventional immunosuppressants. In this review, we discuss the role of various biologics in the treatment of autoimmune bullous diseases, followed by a brief discussion on the drawbacks to their use and new developments in this area.

MicroRNAs in pemphigus and pemphigoid diseases

Autoimmune blistering diseases are a heterogenous group of dermatological disorders characterized by blisters and erosions of the skin and/or mucous membranes induced by autoantibodies against structural proteins of the desmosome or the dermal-epidermal adhesion complex including the hemidesmosome. They consist of the two major disease groups, pemphigus and pemphigoid diseases (PPDs). The diagnosis is based on clinical findings, histopathology, direct immunofluorescence, and detection of circulating autoantibodies. The pathogenesis is not fully elucidated, prognostic factors are lacking, and to date, there is no cure for PPDs. MicroRNAs (miRNAs) represent small, non-coding RNAs that play a pivotal role in the posttranscriptional regulation of gene expression. Their dysfunction was highlighted to play a significant role in the pathogenesis of various diseases. Even though a link between miRNAs and autoimmune blistering diseases had been suggested, the research of their involvement in the pathogenesis of PPDs is still in its infancy. miRNAs hold promise for uncovering new layers in the pathogenesis of PPDs, in order to improve diagnosis and also to develop potential therapeutic options. In the current article, we provide an overview regarding current knowledge of miRNAs in terms of complex pathogenesis of PPDs, and, also, their potential role as biomarkers, predictive factors and therapeutic targets.

The Next Frontier of Regulatory T Cells: Promising Immunotherapy for Autoimmune Diseases and Organ Transplantations

Regulatory T cells (Tregs) are crucial in maintaining tolerance. Hence, Treg immunotherapy is an attractive therapeutic option in autoimmune diseases and organ transplantations. Currently, autoimmune diseases do not have a curative treatment and transplant recipients require life-long immunosuppression to prevent graft rejection. There has been significant progress in understanding polyclonal and antigen-specific Treg biology over the last decade. Clinical trials with good manufacturing practice (GMP) Treg cells have demonstrated safety and early efficacy of Treg therapy. GMP Treg cells can also be tracked following infusion. In order to improve efficacy of Tregs immunotherapy, it is necessary that Tregs migrate, survive and function at the specific target tissue. Application of antigen specific Tregs and maintaining cells' suppressive function and survival with low dose interleukin-2 (IL-2) will enhance the efficacy and longevity of infused GMP-grade Tregs. Notably, stability of Tregs in the local tissue can be manipulated by understanding the microenvironment. With the recent advances in GMP-grade Tregs isolation and antigen-specific chimeric antigen receptor (CAR)-Tregs development will allow functionally superior cells to migrate to the target organ. Thus, Tregs immunotherapy may be a promising option for patients with autoimmune diseases and organ transplantations in near future.

Emerging Topical and Systemic JAK Inhibitors in Dermatology

Accumulating data on cellular and molecular pathways help to develop novel therapeutic strategies in skin inflammation and autoimmunity. Examples are psoriasis and atopic dermatitis, two clinically and immunologically well-defined disorders. Here, the elucidation of key pathogenic factors such as IL-17A/IL-23 on the one hand and IL-4/IL-13 on the other hand profoundly changed our therapeutic practice. The knowledge on intracellular pathways and governing factors is shifting our attention to new druggable molecules. Multiple cytokine receptors signal through Janus kinases (JAKs) and associated signal transducer and activators of transcription (STATs). Inhibition of JAKs can simultaneously block the function of multiple cytokines. Therefore, JAK inhibitors (JAKi) are emerging as a new class of drugs, which in dermatology can either be used systemically as oral drugs or locally in topical formulations. Inhibition of JAKs has been shown to be effective in various skin disorders. The first oral JAKi have been recently approved for the treatment of rheumatoid arthritis and psoriatic arthritis. Currently, multiple inhibitors of the JAK/STAT pathway are being investigated for skin diseases like alopecia areata, atopic dermatitis, dermatomyositis, graft-versus-host-disease, hidradenitis suppurativa, lichen planus, lupus erythematosus, psoriasis, and vitiligo. Here, we aim to discuss the immunological basis and current stage of development of JAKi in dermatology.

JAK inhibitors for the treatment of autoimmune and inflammatory diseases

Cytokines play a central role in the pathophysiology of autoimmune and inflammatory diseases. Several cytokines signal through the JAK-STAT pathway, which is now recognized as a major target to inhibit the effect of a wide array of cytokines. JAK inhibitors are increasingly used in the setting of inflammatory and autoimmune diseases. While the currently approved drugs are panJAK inhibitors, more selective small molecules are being developed and tested in various rheumatic disorders. In this extensive review, we present evidence- or hypothesis-based perspectives for these drugs in various rheumatologic conditions, such as rheumatoid arthritis, systemic lupus erythematosus, giant cell arteritis, and autoinflammatory diseases.

Tyrosine Kinases in Autoimmune and Inflammatory Skin Diseases

Tyrosine kinases relay signals from diverse leukocyte antigen receptors, innate immune receptors, and cytokine receptors, and therefore mediate the recruitment and activation of various leukocyte populations. Non-receptor tyrosine kinases of the Jak, Src, Syk, and Btk families play major roles in various immune-mediated disorders, and small-molecule tyrosine kinase inhibitors are emerging novel therapeutics in a number of those diseases. Autoimmune and inflammatory skin diseases represent a broad spectrum of immune-mediated diseases. Genetic and pharmacological studies in humans and mice support the role of tyrosine kinases in several inflammatory skin diseases. Atopic dermatitis and psoriasis are characterized by an inflammatory microenvironment which activates cytokine receptors coupled to the Jak-Stat signaling pathway. Jak kinases are also implicated in alopecia areata and vitiligo, skin disorders mediated by cytotoxic T lymphocytes. Genetic studies indicate a critical role for Src-family kinases and Syk in animal models of autoantibody-mediated blistering skin diseases. Here, we review the various tyrosine kinase signaling pathways and their role in various autoimmune and inflammatory skin diseases. Special emphasis will be placed on identification of potential therapeutic targets, as well as on ongoing preclinical and clinical studies for the treatment of inflammatory skin diseases by small-molecule tyrosine kinase inhibitors.

Pemphigus: Current and Future Therapeutic Strategies

Pemphigus encompasses a heterogeneous group of autoimmune blistering diseases, which affect both mucous membranes and the skin. The disease usually runs a chronic-relapsing course, with a potentially devastating impact on the patients' quality of life. Pemphigus pathogenesis is related to IgG autoantibodies targeting various adhesion molecules in the epidermis, including desmoglein (Dsg) 1 and 3, major components of desmosomes. The pathogenic relevance of such autoantibodies has been largely demonstrated experimentally. IgG autoantibody binding to Dsg results in loss of epidermal keratinocyte adhesion, a phenomenon referred to as acantholysis. This in turn causes intra-epidermal blistering and the clinical appearance of flaccid blisters and erosions at involved sites. Since the advent of glucocorticoids, the overall prognosis of pemphigus has largely improved. However, mortality persists elevated, since long-term use of high dose corticosteroids and adjuvant steroid-sparing immunosuppressants portend a high risk of serious adverse events, especially infections. Recently, rituximab, a chimeric anti CD20 monoclonal antibody which induces B-cell depletion, has been shown to improve patients' survival, as early rituximab use results in higher disease remission rates, long term clinical response and faster prednisone tapering compared to conventional immunosuppressive therapies, leading to its approval as a first line therapy in pemphigus. Other anti B-cell therapies targeting B-cell receptor or downstream molecules are currently tried in clinical studies. More intriguingly, a preliminary study in a preclinical mouse model of pemphigus has shown promise regarding future therapeutic application of Chimeric Autoantibody Receptor T-cells engineered using Dsg domains to selectively target autoreactive B-cells. Conversely, previous studies from our group have demonstrated that B-cell depletion in pemphigus resulted in secondary impairment of T-cell function; this may account for the observed long-term remission following B-cell recovery in rituximab treated patients. Likewise, our data support the critical role of Dsg-specific T-cell clones in orchestrating the inflammatory response and B-cell activation in pemphigus. Monitoring autoreactive T-cells in patients may indeed provide further information on the role of these cells, and would be the starting point for designating therapies aimed at restoring the lost immune tolerance against Dsg. The present review focuses on current advances, unmet challenges and future perspectives of pemphigus management.

Tofacitinib for the treatment of rheumatoid arthritis: an update

INTRODUCTION

Tofacitinib inhibits the Janus kinases, tyrosine kinases that are activated by cytokines involved in the pathophysiology of rheumatoid arthritis. Areas covered: Clinical trials have revealed an anti-rheumatic effect of monotherapy and combination therapy with methotrexate (MTX). Post-hoc analysis of those clinical trials and real-world experiences will be reviewed to explore efficacy and safety. Expert commentary: The efficacy of tofacitinib monotherapy has garnered much attention and has been initiated in large number of patients. However, combination therapy with MTX is necessary in order to achieve the maximum effect. Combination therapy can be transferred to monotherapy by tapering and/or discontinuing MTX. The discontinuation of tofacitinib should be avoided and tapering should be investigated. There has been no new safety signal although venous thrombotic events (VTEs) have been raised and would require long-term follow-up. Increased events of Herpes zoster were observed and the use of a subunit vaccination is expected to become an effective tool for prevention. Post-hoc analysis of the clinical trials and real-world experience is revealing further usefulness of tofacitinib not only in rheumatoid arthritis but also other diseases. Additional experience and data from the real world are required to help improve the use of tofacitinib..

Frontal fibrosing alopecia: An update on the hypothesis of pathogenesis and treatment

Frontal fibrosing alopecia (FFA) is a relatively new scarring alopecia that is considered a variant of lichen planopilaris (LPP) with no recognized promising treatments. In this study, we tried to clarify the underlying signaling pathways and their roles in the pathogenesis and progression of FFA. Because of several differences in clinical manifestations, response to treatments, and pathological findings, these two conditions could be differentiated from each other. Taking into account the already discussed signaling pathways and involved players such as T cells, mast cells, and sebaceous glands, different possible therapeutic options could be suggested. In addition to treatments supported by clinical evidence, such as 5 alpha-reductase inhibitors, topical calcineurin inhibitors, hydroxychloroquine, peroxisome proliferator-activated receptor gamma agonists, and oral retinoid agents, various other treatment strategies and drugs, such as phototherapy, Janus kinase inhibitors, dehydroepiandrosterone, sirolimus, cetirizine, and rituximab, could be suggested to mitigate disease progression. Of course, such lines of treatment need further evaluation in clinical trials.

What's new in the treatment of atopic dermatitis?

Atopic dermatitis (AD) is a pruritic, chronic and inflammatory skin disease, with an usual onset in the pediatric age. Several drugs are used in the treatment of this skin disease. Drugs as steroid, calcineurin inhibitors, and moisturizing creams are widely used in the treatment of this disease but often patients are not satisfied with the obtained results. New drugs like dupilumab or crisaborole seem to be a promising option for moderate and severe forms of AD. This article analyzes the newest therapy available today for the treatment of AD.