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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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2
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Manzo Margiotta F, Michelucci A, Fidanzi C, Granieri G, Salvia G, Bevilacqua M, Janowska A, Dini V, Romanelli M. Monoclonal Antibodies in the Management of Inflammation in Wound Healing: An Updated Literature Review. J Clin Med 2024; 13:4089. [PMID: 39064129 PMCID: PMC11278249 DOI: 10.3390/jcm13144089] [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: 05/25/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
Chronic wounds pose a significant clinical challenge due to their complex pathophysiology and the burden of long-term management. Monoclonal antibodies (mAbs) are emerging as a novel therapeutic option in managing difficult wounds, although comprehensive data on their use in wound care are lacking. This study aimed to explore existing scientific knowledge of mAbs in treating chronic wounds based on a rationale of direct inhibition of the main molecules involved in the underlying inflammatory pathophysiology. We performed a literature review excluding primary inflammatory conditions with potential ulcerative outcomes (e.g., hidradenitis suppurativa). mAbs were effective in treating wounds from 16 different etiologies. The most commonly treated conditions were pyoderma gangrenosum (treated with 12 different mAbs), lipoid necrobiosis, and cutaneous vasculitis (each treated with 3 different mAbs). Fourteen mAbs were analyzed in total. Rituximab was effective in 43.75% of cases (7/16 diseases), followed by tocilizumab (25%, 4/16 diseases), and both etanercept and adalimumab (18.75%, 3/16 conditions each). mAbs offer therapeutic potential for chronic wounds unresponsive to standard treatments. However, due to the complex molecular nature of wound healing, no single target molecule can be identified. Therefore, the use of mAbs should be considered as a translational approach for limited cases of multi-resistant conditions.
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Affiliation(s)
- Flavia Manzo Margiotta
- Department of Dermatology, University of Pisa, 56126 Pisa, Italy; (F.M.M.); (A.M.); (G.G.); (G.S.); (M.B.); (A.J.); (V.D.)
- Interdisciplinary Center of Health Science, Sant’Anna School of Advanced Studies of Pisa, 56127 Pisa, Italy
| | - Alessandra Michelucci
- Department of Dermatology, University of Pisa, 56126 Pisa, Italy; (F.M.M.); (A.M.); (G.G.); (G.S.); (M.B.); (A.J.); (V.D.)
- Interdisciplinary Center of Health Science, Sant’Anna School of Advanced Studies of Pisa, 56127 Pisa, Italy
| | | | - Giammarco Granieri
- Department of Dermatology, University of Pisa, 56126 Pisa, Italy; (F.M.M.); (A.M.); (G.G.); (G.S.); (M.B.); (A.J.); (V.D.)
| | - Giorgia Salvia
- Department of Dermatology, University of Pisa, 56126 Pisa, Italy; (F.M.M.); (A.M.); (G.G.); (G.S.); (M.B.); (A.J.); (V.D.)
| | - Matteo Bevilacqua
- Department of Dermatology, University of Pisa, 56126 Pisa, Italy; (F.M.M.); (A.M.); (G.G.); (G.S.); (M.B.); (A.J.); (V.D.)
| | - Agata Janowska
- Department of Dermatology, University of Pisa, 56126 Pisa, Italy; (F.M.M.); (A.M.); (G.G.); (G.S.); (M.B.); (A.J.); (V.D.)
| | - Valentina Dini
- Department of Dermatology, University of Pisa, 56126 Pisa, Italy; (F.M.M.); (A.M.); (G.G.); (G.S.); (M.B.); (A.J.); (V.D.)
| | - Marco Romanelli
- Department of Dermatology, University of Pisa, 56126 Pisa, Italy; (F.M.M.); (A.M.); (G.G.); (G.S.); (M.B.); (A.J.); (V.D.)
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3
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Li Pomi F, Motolese A, Paganelli A, Vaccaro M, Motolese A, Borgia F. Shedding Light on Photodynamic Therapy in the Treatment of Necrobiosis Lipoidica: A Multicenter Real-Life Experience. Int J Mol Sci 2024; 25:3608. [PMID: 38612420 PMCID: PMC11011432 DOI: 10.3390/ijms25073608] [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: 02/21/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 04/14/2024] Open
Abstract
Necrobiosis Lipoidica (NL) is a dermatological condition characterized by the development of granulomatous inflammation leading to the degeneration of collagen and subsequent formation of yellowish-brown telangiectatic plaques usually localized on the pretibial skin of middle-aged females. Due to its rarity and unclear etiopathogenesis, therapeutic options for NL are not well-standardized. Among them, photodynamic therapy (PDT) is an emerging tool, although its efficacy has primarily been evaluated in single case reports or small case series. This study reports the real-life experience of a cohort of NL patients treated with PDT at the Section of Dermatology of the University Hospital of Messina and Reggio-Emilia. From 2013 to 2023, 17 patients were enrolled -5 males (29%) and 12 females (71%) aged between 16 and 56 years (mean age: 42 ± 13 years), with a median duration of NL of 8 years. The overall complete clearance (>75% lesion reduction) was 29%, while the partial clearance (25-75% lesion reduction) was 59%, with 12% being non-responders. This study adds to the little amount of evidence present in the literature regarding the effectiveness of PDT in the treatment of NL. Variability in treatment responses among patients underscores the need for personalized protocols, optimizing photosensitizers, light sources, and dosimetry. The standardization of treatment protocols and consensus guidelines are essential to ensure reproducibility and comparability across studies.
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Affiliation(s)
- Federica Li Pomi
- Department of Precision Medicine in Medical, Surgical and Critical Care (Me.Pre.C.C.), University of Palermo, 90127 Palermo, Italy;
| | - Alfonso Motolese
- Dermatology Unit, Department of Surgery, Infermi Hospital, AUSL Romagna, 47923 Rimini, Italy;
| | - Alessia Paganelli
- Dermatology Unit, Santa Maria Nuova Hospital IRCCS, 42123 Reggio Emilia, Italy; (A.P.); (A.M.)
| | - Mario Vaccaro
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy;
| | - Alberico Motolese
- Dermatology Unit, Santa Maria Nuova Hospital IRCCS, 42123 Reggio Emilia, Italy; (A.P.); (A.M.)
| | - Francesco Borgia
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, 98125 Messina, Italy;
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4
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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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5
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Necrobiosis lipoidica of the breast associated with Crohn's disease: a case report. J Med Case Rep 2023; 17:1. [PMID: 36597169 PMCID: PMC9811805 DOI: 10.1186/s13256-022-03698-9] [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: 03/29/2021] [Accepted: 11/25/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Necrobiosis lipoidica located to the breast; without evidence of glucose intolerance, is extremely rare, and its association to Crohn's disease is not usual. CASE PRESENTATION We report an interesting case of an association of necrobiosis lipoidica of the breast and Crohn's disease in a 54-year-old Moroccan woman. Skin necrobiotic changes are a characteristic feature in necrobiosis lipoidica, but they are exceptional in metastatic Crohn's disease, since there are only three published cases of necrobiotic skin lesions on the lower leg resembling erythema nodosum in metastatic Crohn's disease. CONCLUSIONS On the basis of this rare observation, necrobiosis lipoidica without evidence of glucose intolerance should be recognized as a possible cutaneous manifestation or association of Crohn's disease.
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Seivright JR, Villa NM, De DR, Hsiao JL, Shi VY. Intralesional biologics for inflammatory dermatoses: A systematic review. Dermatol Ther 2021; 35:e15234. [PMID: 34825744 DOI: 10.1111/dth.15234] [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: 09/06/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/28/2022]
Abstract
Biologic medications are systemic therapeutic options for inflammatory dermatoses. Local forms of administration are less well-studied. To provide a summary of intralesional (IL) administration of biologics for various non-malignant inflammatory dermatologic conditions reported in the literature. A systematic review was performed in the PubMed and Embase databases from 2000 to 2020. Inclusion criteria included the local use of biologic medications for non-malignant cutaneous conditions. Quality was assessed with the modified Oxford Centre for Evidence-Based Medicine ratings. A total of 19 articles describing the use of 5 biologic medications in 9 dermatologic conditions were identified, comprising 172 patients. Conditions successfully treated with intralesional biologics included pemphigus vulgaris (rituximab), granuloma faciale (rituximab), perianal Crohn's disease (infliximab), lichen sclerosus (adalimumab), and necrobiosis lipoidica (etanercept and infliximab). Intralesional etanercept reduced pruritus associated with keloids. A case report of the use of infliximab for pyoderma gangrenosum did not demonstrate any efficacy. There was no consistent effect noted with treatments for sarcoidosis (infliximab) or cutaneous lymphoid hyperplasia (rituximab). Local administration of biologic medications may offer an additional method of treating refractory inflammatory dermatoses, but further study is needed to develop standardized dosing protocols, clarify efficacy rates, and identify optimal treatment candidates.
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Affiliation(s)
- Justine R Seivright
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Natalie M Villa
- Department of Dermatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Devea R De
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Jennifer L Hsiao
- Department of Medicine, Division of Dermatology, University of California Los Angeles, Los Angeles, California, USA
| | - Vivian Y Shi
- Department of Dermatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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7
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Petrova E, Hovnanian A. Advances in understanding of Netherton syndrome and therapeutic implications. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1857724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Evgeniya Petrova
- Laboratory of genetic skin diseases, Université de Paris, Imagine Institute, INSERM UMR1163, Paris, France
| | - Alain Hovnanian
- Laboratory of genetic skin diseases, Université de Paris, Imagine Institute, INSERM UMR1163, Paris, France
- Departement of Genetics, AP-HP, Hôpital Necker-Enfants Malades, Paris, France
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8
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Sandhu VK, Alavi A. The role of anti-tumour necrosis factor in wound healing: A case report of refractory ulcerated necrobiosis lipoidica treated with adalimumab and review of the literature. SAGE Open Med Case Rep 2019; 7:2050313X19881594. [PMID: 31666953 PMCID: PMC6801891 DOI: 10.1177/2050313x19881594] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Necrobiosis lipoidica is a chronic granulomatous disease historically associated
with diabetes. Necrobiosis lipoidica commonly presents with erythematous papules
or plaques on the anterior lower extremities, which can be ulcerated in up to
30% of patients. The pathophysiology of necrobiosis lipoidica is unknown but
proposed to be predominantly linked to microangiopathy. No treatment option for
necrobiosis lipoidica has shown consistent efficacy. Previous case reports have
shown immune-modulating agents to be reasonable treatment options for ulcerative
necrobiosis lipoidica. However, evidence for the tumour necrosis factor-alpha
inhibitor, adalimumab, is limited and contradictory. We report a case of a
74-year-old type 2 diabetic female with a 2-year history of multiple ulcerated
necrobiosis lipoidica plaques resistant to topical and systemic therapy.
Treatment with adalimumab showed complete re-epithelization of all ulcers by
week 28. Adalimumab may be an effective treatment option for ulcerated
necrobiosis lipoidica that has failed traditional therapies. Further reports of
adalimumab treatment of necrobiosis lipoidica and other chronic inflammatory
wounds are needed.
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Affiliation(s)
| | - Afsaneh Alavi
- Department of Dermatology, University of Toronto, Toronto, ON, Canada.,York Dermatology Center, Richmond Hill, ON, Canada
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Abstract
A 56-year-old woman presented with periocular nodules that were clinically suspected to be neurofibromas. Histopathologic examination of excised nodules revealed a pronounced granulomatous reaction to a foreign material that was composed of glossy polygonal palely eosinophilic fragments. These fragments were outlined in red with Masson trichrome, stained gray with the elastic stain, and were uniformly red with Gomori methenamine silver staining. The histopathologic appearance was consistent with a granulomatous reaction to Dermalive facial filler. Postoperatively the patient admitted that she had filler injections many years earlier in another country, and that nodules appeared 1 year after injection. Treatment with steroids, intralesional immunosuppressive agents and surgery had been previously attempted to eradicate the nodules. The literature pertaining to granulomatous reactions to Dermalive and related hybrid facial fillers is reviewed and treatment options are discussed. This report is the first to illustrate the unique histopathologic staining characteristics of Dermalive, which may be useful to ophthalmic pathologists in identifying this uncommon foreign material.
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10
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Peckruhn M, Tittelbach J, Elsner P. Update: Treatment of necrobiosis lipoidica. J Dtsch Dermatol Ges 2017; 15:151-157. [PMID: 28214312 DOI: 10.1111/ddg.13186] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 10/18/2016] [Indexed: 11/30/2022]
Abstract
Necrobiosis lipoidica (NL) is a rare granulomatous disease of hitherto unclear etiology frequently seen in patients with diabetes. Characterized by its potential for ulcerations, it often presents a serious burden for those affected. There are currently neither German nor European guidelines for the treatment of NL. At the same time, standard treatment with topical or intralesional corticosteroids does not always show satisfactory results. We therefore set out to evaluate whether the various treatment regimens published since 2000 have actually expanded the therapeutic armamentarium in a relevant manner. Included were all publications that described more than one patient being treated with any given therapeutic modality. Overall, we analyzed data for 16 different treatment regimens reported in 49 publications. The largest amount of data exists for topical PUVA therapy, photodynamic therapy (PDT), and systemic treatment with fumaric acid esters. Remarkably, our analysis showed that with an increase in the number of documented patients treated with a given therapeutic modality, the proportion of those achieving a complete or partial response actually decreased. This was interpreted as publication bias. Thus, no clear recommendation can be given for second-line therapy in case topical or intralesional corticosteroids fail.
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Affiliation(s)
| | - Jörg Tittelbach
- Department of Dermatology, University Hospital, Jena, Germany
| | - Peter Elsner
- Department of Dermatology, University Hospital, Jena, Germany
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11
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Peckruhn M, Tittelbach J, Elsner P. Update: Therapie der Necrobiosis lipoidica. J Dtsch Dermatol Ges 2017; 15:151-158. [PMID: 28214306 DOI: 10.1111/ddg.13186_g] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 10/18/2016] [Indexed: 11/28/2022]
Abstract
Die Necrobiosis lipoidica ist eine seltene granulomatöse Erkrankung von bisher unzureichend geklärter Ätiologie. Häufig stellt die bei Diabetikern gehäuft zu beobachtende und zur Ulzeration neigende Dermatose eine starke Belastung für die Patienten dar. Bezüglich der Therapie existieren aktuell keine deutschen oder europäischen Leitlinien. Gleichzeitig lässt sich unter der aktuellen Standardtherapie, der lokalen oder intraläsionalen Anwendung von Glukokortikoiden, nicht immer ein zufriedenstellendes Ansprechen beobachten. Daher wurde untersucht, ob seit dem Jahr 2000 publizierte Therapiemodalitäten das Therapiespektrum relevant und erfolgversprechend erweitern. Es erfolgte eine Betrachtung aller Arbeiten im oben genannten Zeitraum, bei denen mehr als ein Einzelfallbericht je Therapiemodalität publiziert wurde. Insgesamt wurden in einem systematischen Review die Daten von 16 verschiedenen, seit 2000 publizierten Therapieverfahren in 49 Publikationen analysiert. Im Ergebnis zeigte sich, dass die meisten Erfahrungen bezüglich der topischen PUVA-Therapie, der photodynamischen Therapie (PDT) und der systemischen Therapie mit Fumarsäureestern vorliegen. Allerdings ist auffällig, dass mit steigender Zahl der pro Behandlungsmodalität behandelten Patienten der Anteil der Patienten, bei denen eine Abheilung bzw. eine teilweise Abheilung berichtet wurde, sinkt. Wir interpretieren diese Beobachtung als Publikationsbias. Daher kann für keines der besprochenen Verfahren eine klare Empfehlung als Therapie der zweiten Wahl nach Versagen der lokalen bzw. intraläsionalen Steroidtherapie gegeben werden.
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Affiliation(s)
| | | | - Peter Elsner
- Klinik für Hautkrankheiten, Universitätsklinikum Jena
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12
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Basoulis D, Fragiadaki K, Tentolouris N, Sfikakis PP, Kokkinos A. Anti-TNFα treatment for recalcitrant ulcerative necrobiosis lipoidica diabeticorum: A case report and review of the literature. Metabolism 2016; 65:569-73. [PMID: 26975548 DOI: 10.1016/j.metabol.2015.12.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 12/29/2015] [Accepted: 12/30/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Necrobiosis lipoidica diabeticorum (NLD) is a rare degenerative connective tissue disorder associated with diabetes mellitus, which usually presents with red papules or plaques with raised edges and occasional ulceration. Ulcerating NLD is notoriously difficult to treat. We present a young patient with ulcerative NLD who was successfully treated with the anti-TNFα agent infliximab. Case presentation is followed by a review of therapeutic TNFα blockade in NLD. CASE PRESENTATION A 17-year old woman with type 1 diabetes since the age of 8, presented with a long-standing and extensively ulcerated and infected NLD lesion on her left shin. After achieving better glycemic control and treating her for infection of the wound, several NLD treatments failed to help, including corticosteroids and hyperbaric oxygen. She was treated successfully with 4 monthly sessions of 5mg/kg body weight intravenous infliximab, achieving complete resolution of ulceration. DISCUSSION A multitude of available treatments have been suggested for NLD over the past decades, based on two axes, one through wound healing and the other through immunosuppression. Anti-TNFα agents are relatively new drugs that brought a revolution in chronic inflammatory diseases and have been on the rise as novel potential treatments for NLD. Three out of the five available anti-TNFα agents have been safely tested so far, both topically and systematically, with mostly favorable results. CONCLUSION Intravenous infliximab was successful in the treatment of recalcitrant ulcerating NLD in our patient. Taken together with an increasing number of similar reports revealing a pathogenetic role of TNFα in NLD, we suggest that anti-TNFα agents are promising drugs in the management of this condition.
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Affiliation(s)
- Dimitrios Basoulis
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
| | - Kalliopi Fragiadaki
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
| | - Nicholas Tentolouris
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
| | - Petros P Sfikakis
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
| | - Alexander Kokkinos
- First Department of Propaedeutic Medicine, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma St, Goudi, Athens, Greece.
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13
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Abstract
Necrobiosis lipoidica is a granulomatous condition presenting as indolent atrophic plaques, often on the lower extremities. There is a multitude of case reports suggesting possible associations and documenting different therapeutic alternatives with varied success. Important complications include ulceration and the development of squamous cell carcinoma. The disease course is often indolent and recurrent despite treatment. This article reviews the etiopathogenesis, clinical presentations, and evidence for treatment alternatives of this condition.
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Affiliation(s)
- Cathryn Sibbald
- Department of Medicine (Dermatology), University of Toronto, Toronto, Ontario, Canada
| | - Sophia Reid
- Department of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Afsaneh Alavi
- Department of Medicine (Dermatology), University of Toronto, Toronto, Ontario, Canada.
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14
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Feily A, Mehraban S. Treatment Modalities of Necrobiosis Lipoidica: A Concise Systematic Review. Dermatol Reports 2015; 7:5749. [PMID: 26236446 PMCID: PMC4500868 DOI: 10.4081/dr.2015.5749] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Revised: 04/14/2015] [Accepted: 04/26/2015] [Indexed: 11/22/2022] Open
Abstract
Necrobiosis lipoidica (NL) is a rare inflammatory granulomatous skin disorder closely associated with diabetes mellitus. The aim of this paper is to review and discuss all the treatment modalities proposed and tested for this disease. A systematic review of the existing literature was conducted to investigate all the available data and summarize all the clinical trials, case reports and original articles on NL. Two major databases (PubMed and Google Scholar) were used. We have examined about 70 articles. Numerous treatment modalities have been currently investigated to compare recalcitrant NL. Being rare, most of the studies regarding this disease are case reports or small-scale clinical trials. We have found that, in spite of plentiful investigations carried out during the years, there is no treatment modality that has proved to be utterly satisfactory in treating NL.
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Affiliation(s)
- Amir Feily
- Department of Dermatology, Jahrom University of Medical Sciences , Iran
| | - Shadi Mehraban
- Department of Dermatology, Jahrom University of Medical Sciences , Iran
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15
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Jones RGA, Martino A. Targeted localized use of therapeutic antibodies: a review of non-systemic, topical and oral applications. Crit Rev Biotechnol 2015; 36:506-20. [PMID: 25600465 DOI: 10.3109/07388551.2014.992388] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Therapeutic antibodies provide important tools in the "medicine chest" of today's clinician for the treatment of a range of disorders. Typically monoclonal or polyclonal antibodies are administered in large doses, either directly or indirectly into the circulation, via a systemic route which is well suited for disseminated ailments. Diseases confined within a specific localized tissue, however, may be treated more effectively and at reduced cost by a delivery system which targets directly the affected area. To explore the advantages of the local administration of antibodies, we reviewed current alternative, non-systemic delivery approaches which are in clinical use, being trialed or developed. These less conventional approaches comprise: (a) local injections, (b) topical and (c) peroral administration routes. Local delivery includes intra-ocular injections into the vitreal humor (i.e. Ranibizumab for age-related macular degeneration), subconjunctival injections (e.g. Bevacizumab for corneal neovascularization), intra-articular joint injections (i.e. anti-TNF alpha antibody for persistent inflammatory monoarthritis) and intratumoral or peritumoral injections (e.g. Ipilimumab for cancer). A range of other strategies, such as the local use of antibacterial antibodies, are also presented. Local injections of antibodies utilize doses which range from 1/10th to 1/100th of the required systemic dose therefore reducing both side-effects and treatment costs. In addition, any therapeutic antibody escaping from the local site of disease into the systemic circulation is immediately diluted within the large blood volume, further lowering the potential for unwanted effects. Needle-free topical application routes become an option when the condition is restricted locally to an external surface. The topical route may potentially be utilized in the form of eye drops for infections or corneal neovascularization or be applied to diseased skin for psoriasis, dermatitis, pyoderma gangrenosum, antibiotic resistant bacterial infections or ulcerated wounds. Diseases confined to the gastrointestinal tract can be targeted directly by applying antibody via the injection-free peroral route. The gastrointestinal tract is unusual in that its natural immuno-tolerant nature ensures the long-term safety of repeatedly ingesting heterologous antiserum or antibody materials. Without the stringent regulatory, purity and clean room requirements of manufacturing parenteral (injectable) antibodies, production costs are minimal, with the potential for more direct low-cost targeting of gastrointestinal diseases, especially with those caused by problematic antibiotic resistant or toxigenic bacteria (e.g. Clostridium difficile, Helicobacter pylori), viruses (e.g. rotavirus, norovirus) or inflammatory bowel disease (e.g. ulcerative colitis, Crohn's disease). Use of the oral route has previously been hindered by excessive antibody digestion within the gastrointestinal tract; however, this limitation may be overcome by intelligently applying one or more strategies (i.e. decoy proteins, masking therapeutic antibody cleavage sites, pH modulation, enzyme inhibition or encapsulation). These aspects are additionally discussed in this review and novel insights also provided. With the development of new applications via local injections, topical and peroral routes, it is envisaged that an extended range of ailments will increasingly fall within the clinical scope of therapeutic antibodies further expanding this market.
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Affiliation(s)
| | - Angela Martino
- a Department of Chemistry , University of Warwick , Coventry , UK
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16
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Abstract
The advent of biologics in dermatologic treatment armentarium has added refreshing dimensions, for it is a major breakthrough. Several agents are now available for use. It is therefore imperative to succinctly comprehend their pharmacokinetics for their apt use. A concerted endeavor has been made to delve on this subject. The major groups of biologics have been covered and include: Drugs acting against TNF-α, Alefacept, Ustekinumab, Rituximab, IVIG and Omalizumab. The relevant pharmacokinetic characteristics have been detailed. Their respective label (approved) and off-label (unapproved) indications have been defined, highlighting their dosage protocol, availability and mode of administration. The evidence level of each indication has also been discussed to apprise the clinician of their current and prospective uses. Individual anti-TNF drugs are not identical in their actions and often one is superior to the other in a particular disease. Hence, the section on anti-TNF agents mentions the literature on each drug separately, and not as a group. The limitations for their use have also been clearly brought out.
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Affiliation(s)
- Virendra N Sehgal
- Dermato-Venereology (Skin/VD) Center, Sehgal Nursing Home, Delhi, India
| | - Deepika Pandhi
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
| | - Ananta Khurana
- Department of Dermatology and STD, University College of Medical Sciences and Associated Guru Teg Bahadur Hospital, Delhi, India
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17
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Murphy-Chutorian B, Han G, Cohen SR. Dermatologic manifestations of diabetes mellitus: a review. Endocrinol Metab Clin North Am 2013; 42:869-98. [PMID: 24286954 DOI: 10.1016/j.ecl.2013.07.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Diabetes mellitus affects every organ of the body including the skin. Certain skin manifestations of diabetes are considered cutaneous markers of the disease, whereas others are nonspecific conditions that occur more frequently among individuals with diabetes compared with the general population. Diabetic patients have an increased susceptibility to some bacterial and fungal skin infections, which account, in part, for poor healing. Skin complications of diabetes provide clues to current and past metabolic status. Recognition of cutaneous markers may slow disease progression and ultimately improve the overall prognosis by enabling earlier diagnosis and treatment.
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18
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Reid SD, Ladizinski B, Lee K, Baibergenova A, Alavi A. Update on necrobiosis lipoidica: A review of etiology, diagnosis, and treatment options. J Am Acad Dermatol 2013; 69:783-791. [DOI: 10.1016/j.jaad.2013.05.034] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 05/23/2013] [Accepted: 05/30/2013] [Indexed: 11/16/2022]
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19
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[Off-label use of infliximab]. Hautarzt 2013; 64:757-61. [PMID: 24150825 DOI: 10.1007/s00105-013-2596-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Tumor necrosis factor α (TNFα) is a pro-inflammatory cytokine and a key mediator of inflammation. Several TNFα antagonists have been used therapeutically. One of them, infliximab, is a chimeric monoclonal antibody with anti-TNFα activity. Numerous studies have shown TNFα antagonists to be effective in treating psoriasis--particularly severe resistant forms--and arthritis. Additionally, several case reports and studies showing the effects of TNFα on new dermatologic indications have been published. The intention of this review is to summarize the new off-label uses of infliximab according to published data.
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20
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Leister L, Körber A, Dissemond J. Erfolgreiche Behandlung einer Patientin mit therapierefraktärer, exulzerierter Necrobiosis lipoidica non diabeticorum mit Adalimumab. Hautarzt 2013; 64:509-11. [PMID: 23595890 DOI: 10.1007/s00105-013-2535-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- L Leister
- Klinik und Poliklinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Essen, Hufelandstr. 55, 45122, Essen, Deutschland
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