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Hwang AS, Kechter JA, Li X, Hughes A, Severson KJ, Boudreaux B, Bhullar P, Nassir S, Yousif M, Zhang N, Butterfield RJ, Nelson S, Xing X, Tsoi LC, Zunich S, Sekulic A, Pittelkow M, Gudjonsson JE, Mangold A. Topical Ruxolitinib in the Treatment of Necrobiosis Lipoidica: A Prospective, Open-Label Study. J Invest Dermatol 2024; 144:1994-2001.e4. [PMID: 38417541 DOI: 10.1016/j.jid.2023.11.027] [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] [Received: 10/10/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 03/01/2024]
Abstract
Necrobiosis lipoidica (NL) is a rare granulomatous disease. There are few effective treatments for NL. We sought to investigate the efficacy and safety of the Jak1/2 inhibitor, ruxolitnib, in the treatment of NL and identify the biomarkers associated with the disease and treatment response. We conducted an open-label, phase 2 study of ruxolitinib in 12 patients with NL. We performed transcriptomic analysis of tissue samples before and after treatment. At week 12, the mean NL lesion score decreased by 58.2% (SD = 28.7%, P = .003). Transcriptomic analysis demonstrated enrichment of type I and type II IFN pathways in baseline disease. Weighted gene coexpression network analysis demonstrated post-treatment changes in IFN pathways with key hub genes IFNG and signal transducer and activator of transcription 1 gene STAT1. Limitations include small sample size and a study group limited to patients with <10% body surface area. In conclusion, ruxolitinib is an effective treatment for NL and targets the key pathogenic mediators of the disease.
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Affiliation(s)
- Angelina S Hwang
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Jacob A Kechter
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Xing Li
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Alysia Hughes
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Kevin J Severson
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Blake Boudreaux
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Puneet Bhullar
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Shams Nassir
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Miranda Yousif
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Steven Nelson
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Xianying Xing
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lam C Tsoi
- Department of Dermatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Samantha Zunich
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Mark Pittelkow
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Aaron Mangold
- Department of Dermatology, Mayo Clinic, Scottsdale, Arizona, USA.
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Ionescu C, Petca A, Dumitrașcu MC, Petca RC, Ionescu (Miron) AI, Șandru F. The Intersection of Dermatological Dilemmas and Endocrinological Complexities: Understanding Necrobiosis Lipoidica-A Comprehensive Review. Biomedicines 2024; 12:337. [PMID: 38397939 PMCID: PMC10887100 DOI: 10.3390/biomedicines12020337] [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: 01/08/2024] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Necrobiosis lipoidica (NL) is a rare granulomatous skin disorder with a predilection for females, often associated with diabetes mellitus (DM). This paper aims to comprehensively review the literature on NL, focusing on its association with DM, thyroid disorders, and the metabolic syndrome. METHODS A systematic search was conducted in English-language literature from inception to October 2023, utilizing PubMed. We identified 530 studies and selected 19 based on clinical significance, statistical support, and relevance to the paper's goals. RESULTS The coexistence of NL and DM is prevalent, with rates ranging from 11% to 65.71%. NL may precede DM diagnosis and a correlation between NL and increased daily insulin requirements has been observed in such patients. NL is suggested as a potential prognostic marker for DM complications; however, recent studies question this association, highlighting the need for further research. Studies in the context of NL and Thyroid Disease indicate a correlation, especially with autoimmune thyroiditis. Regarding NL and Metabolic Syndrome, the prevalence of metabolic syndrome among NL patients is notably higher than in the general population. Additionally, DM patients with ulcerated NL commonly exhibit hypertension or obesity, raising questions about the potential influence of hypertension and obesity on NL ulcerations. CONCLUSION Additional research is required to untangle the complex connections between NL and various comorbidities.
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Affiliation(s)
- Corina Ionescu
- Department of Dermatovenerology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.I.); (F.Ș.)
- Dermatology Department, “Elias” University Emergency Hospital, 011461 Bucharest, Romania
| | - Aida Petca
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.P.); (M.C.D.)
- Department of Obstetrics and Gynecology, Elias Emergency University Hospital, 011461 Bucharest, Romania
| | - Mihai Cristian Dumitrașcu
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (A.P.); (M.C.D.)
- Department of Obstetrics and Gynecology, University Emergency Hospital of Bucharest, 050098 Bucharest, Romania
| | - Răzvan-Cosmin Petca
- Department of Urology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Urology, “Prof. Dr. Th. Burghele” Clinical Hospital, 050659 Bucharest, Romania
| | - Andreea Iuliana Ionescu (Miron)
- Department of Oncological Radiotherapy and Medical Imaging, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Medical Oncology, Colțea Clinical Hospital, 030167 Bucharest, Romania
| | - Florica Șandru
- Department of Dermatovenerology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.I.); (F.Ș.)
- Dermatology Department, “Elias” University Emergency Hospital, 011461 Bucharest, Romania
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Arnet L, Erfurt-Berge C. Effect of abrocitinib in a patient with extensive necrobiosis lipoidica. J Eur Acad Dermatol Venereol 2023; 37:e1208-e1210. [PMID: 37170953 DOI: 10.1111/jdv.19189] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Affiliation(s)
- L Arnet
- Department of Dermatology, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - C Erfurt-Berge
- Department of Dermatology, Uniklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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Hwang E, Abdelghaffar M, Shields BE, Damsky W. Molecularly Targeted Therapies for Inflammatory Cutaneous Granulomatous Disorders: A Review of the Evidence and Implications for Understanding Disease Pathogenesis. JID INNOVATIONS 2023; 3:100220. [PMID: 37719661 PMCID: PMC10500476 DOI: 10.1016/j.xjidi.2023.100220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/21/2023] [Accepted: 07/28/2023] [Indexed: 09/19/2023] Open
Abstract
Inflammatory cutaneous granulomatous diseases, including granuloma annulare, cutaneous sarcoidosis, and necrobiosis lipoidica, are distinct diseases unified by the hallmark of macrophage accumulation and activation in the skin. There are currently no Food and Drug Administration-approved therapies for these conditions except prednisone and repository corticotropin injection for pulmonary sarcoidosis. Treatment of these diseases has generally been guided by low-quality evidence and may involve broadly immunomodulatory medications. Development of new treatments has in part been limited by an incomplete understanding of disease pathogenesis. Recently, there has been substantial progress in better understanding the molecular pathogenesis of these disorders, opening the door for therapeutic innovation. Likewise, reported outcomes of treatment with immunologically targeted therapies may offer insights into disease pathogenesis. In this systematic review, we summarize progress in deciphering the pathomechanisms of these disorders and discuss this in the context of emerging evidence on the use of molecularly targeted therapies in treatment of these diseases.
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Affiliation(s)
- Erica Hwang
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mariam Abdelghaffar
- School of Medicine, Royal College of Surgeons in Ireland, Busaiteen, Bahrain
| | - Bridget E. Shields
- Department of Dermatology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - William Damsky
- Department of Dermatology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
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Palomares SJ, Farberg AS. Nonulcerated Necrobiosis Lipoidica Successfully Treated with Tapinarof: A Case Report. Clin Cosmet Investig Dermatol 2023; 16:1373-1376. [PMID: 37275215 PMCID: PMC10237186 DOI: 10.2147/ccid.s408070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 05/25/2023] [Indexed: 06/07/2023]
Abstract
Necrobiosis lipoidica (NL) is a chronic granulomatous disorder of the skin which usually presents with red papules and plaques on the lower extremities. Diabetes mellitus has been found to be associated with NL, but the pathophysiology of the disease is unknown. Based on a Doppler flowmetry study showing increased blood flow at NL lesions and the macrophage upregulation of granulomatous disorders, it is reasonable to conclude that there is an inflammatory component to it. NL is extremely challenging to manage. The initial treatment of choice is usually topical or intralesional corticosteroids, and if this fails to work, many dermatologists depend on the small number of case reports for more treatment options. We present a pre-diabetic patient with nonulcerative NL who was successfully treated with the first-in-class therapeutic aryl hydrocarbon receptor (AHR)-modulating agent tapinarof cream (VTAMA, Dermavant). Following the case presentation is a discussion of this topical novel agent and its unique anti-inflammatory mechanism of action. Tapinarof specifically binds to and activates AHR leading to downregulation of TNF-α/IL-23/IL-17 and inhibition of IL-4/IL-13 mediated STAT6 activation. Anti-TNF-α agents and JAK-inhibitors have also been found to be beneficial in treating NL; tapinarof seems to target both these pathways without the risk of their serious adverse reactions.
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Uzuncakmak TK, Durdu M, Karadag AS. Granulomatous annular diseases. Clin Dermatol 2023; 41:355-367. [PMID: 37467899 DOI: 10.1016/j.clindermatol.2023.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Granulomatous skin disorders comprise a large group of diseases that are typically characterized by granuloma formation both in the skin and in many other tissues. Cutaneous lesions are usually seen as erythematous papules and plaques that may occasionally be arranged in an annular, ringlike configuration. The etiopathogenesis is unclear in most cases, and granuloma formation may be associated with various systemic, infectious, and metabolic disorders, foreign bodies, environmental antigens, or malignancies. Treatment options are dependent on the etiology, extent, and severity of the lesions. This review includes the clinical, histopathologic, and dermatoscopy findings, differentials, and treatment options for noninfectious granulomatous annular skin disorders.
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Affiliation(s)
| | - Murat Durdu
- Department of Dermatology, Başkent University Faculty of Medicine, Adana Dr. Turgut Noyan Application and Research Center, Adana, Turkey
| | - Ayse Serap Karadag
- Department of Dermatology, Istanbul Arel University Medical Faculty, Istanbul, Turkey.
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Nugent S, Coromilas AJ, English JC, Rosenbach M. Improvement of necrobiosis lipoidica with topical ruxolitinib cream after prior nonresponse to compounded topical tofacitinib cream. JAAD Case Rep 2022; 29:25-26. [PMID: 36186415 PMCID: PMC9522866 DOI: 10.1016/j.jdcr.2022.08.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Shannon Nugent
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Alexandra J. Coromilas
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph C. English
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Misha Rosenbach
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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