Dermatologic therapeutics: thalidomide. A practical guide

Influence of Cytokine-Related genetic variants in TNF, IL6, IL1β, and IFNγ genes in the thalidomide treatment for Erythema nodosum leprosum in a Brazilian population sample

Erythema nodosum leprosum (ENL), an inflammatory reaction in leprosy, causes painful nodules, fever, and malaise due to immune system activation. Thalidomide is an effective treatment, although associated with important adverse effects. We aimed to evaluate the association of genetic variants in genes encoding tumor necrosis factor alpha (TNF-α), interleukin-1 beta (IL-1β) and interleukin-6 (IL-6) with the response to treatment of ENL with thalidomide. 148 patients from the South and Northeast regions of Brazil were included. Genomic DNA was isolated from blood and/or saliva samples using commercial kits, and genetic variants in TNF, IL6, IL1β, and IFNγ genes were genotyped by TaqMan system. We identified an association between polymorphisms in TNF (rs1799964C, rs1800630A, rs1799724T and rs1800629A) IL1β (rs4848306G, rs1143623G, rs16944A, and rs1143627A), IL6 (rs2069840C and rs2069845G) and IFNγ (rs2430561T) with thalidomide dose variation in a time-dependent manner. Associations of IL6 and TNF haplotypes with thalidomide dosage variation over the time of treatment were also observed. Polymorphisms in TNF, IL6, IL1β, and IFNγ genes may modulate their expression levels, potentially impacting the required dosage of thalidomide in the treatment of ENL. Our findings should be confirmed in further studies to estimate the size effect of these polymorphisms on ENL treatment with thalidomide.

Erythema Nodosum Leprosum: Update and challenges on the treatment of a neglected condition

Erythema Nodosum Leprosum (ENL) occurs due to the immunological complication of multibacillary leprosy and is characterized by painful nodules and systemic compromising. It is usually recurrent and/or chronic and has both physical and economic impact on the patient, being a very important cause of disability. In addition, ENL is a major health problem in countries where leprosy is endemic. Therefore, adequate control of this condition is important. The management of ENL aims to control acute inflammation and neuritis and prevent the onset of new episodes. However, all currently available treatment modalities have one or two drawbacks and are not effective for all patients. Corticosteroid is the anti-inflammatory of choice in ENL but may cause dependence, especially for chronic patients. Thalidomide has a rapid action but its use is limited due the teratogenicity and neurotoxicity. Clofazimine and pentoxifylline have slow action and have important adverse effects. Finally, there is no pattern or guidelines for treating these patients, becoming more difficult to evaluate and to control this condition. This review aims to show the main drugs used in the treatment of ENL and the challenges in the management of the reaction.

Serendipity in Cancer Drug Discovery: Rational or Coincidence?

Novel drug development leading to final approval by the US FDA can cost as much as two billion dollars. Why the cost of novel drug discovery is so expensive is unclear, but high failure rates at the preclinical and clinical stages are major reasons. Although therapies targeting a given cell signaling pathway or a protein have become prominent in drug discovery, such treatments have done little in preventing or treating any disease alone because most chronic diseases have been found to be multigenic. A review of the discovery of numerous drugs currently being used for various diseases including cancer, diabetes, cardiovascular, pulmonary, and autoimmune diseases indicates that serendipity has played a major role in the discovery. In this review we provide evidence that rational drug discovery and targeted therapies have minimal roles in drug discovery, and that serendipity and coincidence have played and continue to play major roles. The primary focus in this review is on cancer-related drug discovery.

Thalidomide: Still an important second-line treatment in refractory cutaneous lupus erythematosus?

BACKGROUND

Cutaneous lupus erythematosus (CLE) can be a severe disease, characterized by extensive, disfiguring lesions and a relapsing course. Thalidomide is known as an effective treatment for CLE, however, its use is restricted by its potential side-effects. Nevertheless, it remains a valuable option to consider. Therefore, it is important to report new clinical experiences.

METHODS

The data of 30 patients with refractory CLE, who were treated with thalidomide, were retrospectively analyzed. The response rate was categorized as complete, partial or no response. The relapse rate and the occurrence of side-effects were registered.

RESULTS

Six patients prematurely discontinued treatment because of side-effects. The response rate was 100% in the remaining 24 patients, including 20 patients (83%) with complete response and 4 (27%) with partial response. Clinical relapse was frequent (73%) and occurred between 3 and 24 weeks after withdrawal of thalidomide. Nine patients (30%) developed peripheral neuropathy. In the majority, there was no complete resolution of the neuropathy-associated symptoms after stopping thalidomide. One patient developed a thrombosis in an artery stent.

CONCLUSION

Because of high risk of polyneuropathy, low-dose thalidomide should be used and long-term therapy should be avoided. Therefore, it should be recommended to combine thalidomide with other treatments for CLE.

Thalidomide improves clinical symptoms of primary cutaneous amyloidosis: report of familiar and sporadic cases

Primary cutaneous amyloidosis (PCA), either familial or sporadic, poses a therapeutic challenge. We conducted an open trial using thalidomide to treat three cases of familial and three cases of sporadic PCA, at initial dose of 100 mg/day. Dosage adjustment was made according to improvement of symptoms or patient's own choice. All except one sporadic case experienced moderate to significant relief on the symptoms of itching, over an observational period of 8 weeks by visual analog score (from 8.08 ± 0.88 to 1.60 ± 0.68, on average) as well as clinical amelioration of symptoms. Side effects included fatigue, drowsiness, numbness, and facial and leg edema in some of the patients. From the present observation, it seems that thalidomide is a promising drug to treat PCA.

Innovative uses of thalidomide

Thalidomide is approved for treating erythema nodosum leprosum and multiple myeloma, but it has also emerged as a useful treatment option for many refractory dermatologic disorders. Some of the innovative but off-label uses of thalidomide include aphthous stomatitis, Behçet's disease, lupus erythematosus, prurigo nodularis, sarcoidosis, actinic prurigo, graft-versus-host disease, Langerhans cell histiocytosis, erythema multiforme, lichen planus, Kaposi sarcoma, Jessner lymphocytic infiltrate, uremic pruritus, pyoderma gangrenosum, scleroderma, scleromyxedema, and necrobiosis lipoidica. This article reviews the background, pharmacology, and innovative uses of thalidomide in dermatology.

Nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology: understanding the gap between guidelines and practice

BACKGROUND

Clinical decision making in dermatology is a complex process and might be influenced by a wide range of nonclinical factors.

OBJECTIVES

The aim of this study was to explore the role of nonclinical influences, beyond diagnosis and severity, on clinical decision making in dermatology.

METHODS

Semi-structured qualitative interviews were conducted with 46 clinicians working in departments of dermatology of nine different hospitals in Wales. Interviews were audio-recorded and later transcribed and their contents analysed.

RESULTS

Nonclinical factors influencing patient management decisions in dermatology that were identified related to patients, clinicians and practice characteristics. Patient-related factors included place of residence, socioeconomic circumstances, education and intelligence, ethnicity, age, treatment adherence, expectations from treatment, quality of life, concerns and worries, difficult patients, and family members or friends. Clinician-related factors included time constraints in clinic, clinicians' personal circumstances, relationship with colleagues, and relationship with pharmaceutical companies. Practice-related factors included working in private practice, cost of treatment to the National Health Service (NHS), prescribing bureaucracy, and availability of treatment service in the work place. There was a difference between the consultants' views and those of the other clinicians over the impact of pharmaceutical companies on clinicians' prescribing and the awareness of treatment costs to the NHS. Most of the factors identified could potentially influence the clinicians' decision-making process subconsciously. Some clinicians highlighted that these factors are untaught in the medical curriculum, and are usually ignored in clinical guidelines, and therefore represent a challenge to the practice of evidence-based medicine.

CONCLUSIONS

This study has described one aspect of the reality of medical decision making beyond the conventional evidence-based guidelines approach. Proper understanding of nonclinical influences on decision making is of paramount importance for the best patient-centred treatment outcomes.

Angiogenesis in cutaneous disease: part I

Angiogenesis is an important process in normal physiology and disease pathogenesis. Angiogenesis is controlled in a healthy body by a system of angiogenic growth factors and angiogenesis inhibitors. When angiogenic growth factors are predominantly expressed, blood vessel growth occurs and disease may result. Successful therapies have been developed that target growth factors, their receptors, or the cascade pathways that are activated by growth factor/receptor interactions. There is good evidence that angiogenesis plays an important role in a wide range of cutaneous maladies, and angiogenesis-targeting therapies are playing an increasing role in the management of dermatologic disease. Cutaneous angiogenesis offers an exciting new arena for targeted dermatologic therapeutics.

LEARNING OBJECTIVES

After completing this learning activity, participants should be able to distinguish angiogenic growth factors and inhibitors, recognize angiogenic mediating agents and compare their mechanisms of action, and apply the use of angiogenic mediating agents in clinical and research situations.

Treatment of scleromyxedema and the dermatoneuro syndrome with intravenous immunoglobulin

Scleromyxedema is a rare disease characterized by extensive mucin deposition with fibrosis, and is associated with a monoclonal gammopathy. Currently there is no consensus on optimal treatment of this potentially fatal disease because of the lack of randomized controlled trials and limited number of case reports. At the time of this writing, 24 cases were published reporting clinical improvement of scleromyxedema with intravenous immunoglobulin. Herein we report a case showing dramatic improvement of scleromyxedema symptoms, both cutaneous and extracutaneous (including the dermatoneuro syndrome), and review the use of intravenous immunoglobulin in the treatment of scleromyxedema. This is a single case. The rarity of scleromyxedema, especially the dermatoneuro syndrome, precludes impedes large trials. In conclusion, increasing evidence supports intravenous immunoglobulin as an effective and relatively safe treatment for both cutaneous and extracutaneous manifestations of scleromyxedema, including the dermatoneuro syndrome.