Hydroxychloroquine-induced hyperpigmentation in systemic diseases: prevalence, clinical features and risk factors: a cross-sectional study of 41 cases

Dermatologists' and Rheumatologists' Adherence to the Latest Recommendations for Screening of Hydroxychloroquine Retinopathy in Saudi Arabia: A Cross-Sectional Study

INTRODUCTION

 Hydroxychloroquine (HCQ) is used to manage the symptoms of inflammatory rheumatic and dermatologic disorders. However, HCQ retinopathy is a serious side effect because even after the drug is discontinued, irreversible vision loss may occur and may continue to progress. According to the American Academy of Ophthalmology (AAO), the recent recommendation for HCQ dosing is ≤5 mg/kg of real body weight, with baseline ophthalmologic screening during the first year of HCQ treatment and yearly screening after five years of continuous use of HCQ medication, unless the patient is at high risk or symptoms have developed. Nonetheless, this study aims to assess dermatologists' and rheumatologists' adherence in Saudi Arabia to the 2016 AAO HCQ retinal toxicity guidelines.

METHODS

 A questionnaire-based cross-sectional study was conducted on dermatologists and rheumatologists in Saudi Arabia. It was conducted between August and September 2022 and questionnaires were sent to dermatologists and rheumatologists via their professional emails or accounts.

RESULTS

The collected sample consisted of 635 participants; males and females represented 54% and 46%, respectively; 47.6% were consultants; 50.1% were rheumatologists; and 49.9% were dermatologists. Approximately 28.2% of the participants reported treating one to three patients with HCQ in the previous year. Only 45.4% of the respondents stated that the ideal recommended HCQ dose for reducing the risk of retinopathy is "≤ 5 mg/kg of the real body weight." More than 50% of the respondents stated that systemic lupus erythematosus was the most common disease for which they used HCQ. Additionally, 36.5% of the physicians screened patients during the first year of HCQ treatment. We found significant associations between practice levels and specialty practice-related questions with a p-value of less than 0.05, except for the specialty practice-related question, "What is the most common disease for which you use HCQ?" with a p-value of 0.074. Also, we found significant associations between all demographic variables and screening-related variables with a p-value of less than 0.05, with two exceptions: no significant associations were found between specialty area and the screening-related question, "Do you recommend screening tests for all patients starting treatment with HCQ?" at p = 0.270, and gender and the screening-related question, "When would you recommend screening tests for a patient without risk?" at p = 0.142.

CONCLUSIONS

 Dermatologists and rheumatologists in Saudi Arabia have shown poor adherence to the most recent AAO recommendations. Educating physicians and patients about the AAO guidelines is needed for HCQ to be used in a way that is both effective and safe.

Thiazolopyrimidine derivatives as novel class of small molecule tyrosinase inhibitor

Tyrosinase, the rate-limiting enzyme of melanogenesis, plays a crucial role in hyperpigmentation. As a result, in this study, a novel class of thiazolopyrimidine derivatives was developed and synthesized as tyrosinase inhibitor. The structure of derivatives was characterized using various spectroscopy techniques, including FTIR, Mass, 1H-NMR, and 13C-NMR. Next, the inhibitory activities of all derivatives were examined against tyrosinase, and, 6a as the most potent compound, exhibited an IC50 value of 28.50 µM. Furthermore, the kinetic study of 6a was performed to better understand the inhibitory mechanism and its type of inhibition. The UV/Vis spectra analysis was also executed to provide valuable evidence supporting the inhibitory mechanism of compound 6a in the context of tyrosinase inhibition. Also, molecular docking and dynamic molecular study of 6a were executed to study its interactions within the enzyme's binding site.

Clinical features of acute generalized exanthematous pustulosis caused by hydroxychloroquine in rheumatology patients and exploration of CARD14 gene mutations

Introduction

Acute generalized exanthematous pustulosis (AGEP) is a rare condition characterized by superficial pustules following drug ingestion or infection. Currently, there is no clear link between rheumatism and AGEP. It has been described that hydroxychloroquine (HCQ) is a rare cause of acute generalized epidermal necrolysis (AGEP). Presently, there are limited studies on HCQ-induced AGEP. We aimed to explore the clinical features and associated gene expression of AGEP induced after HCQ treatment exposure in rheumatology patients.

Methods

We assessed patients with HCQ-induced AGEP diagnosed at the Second Affiliated Hospital of Guizhou University of Chinese Medicine between January 1, 2017, and May 1, 2022. We also reviewed similar cases reported in specific databases.

Results

The study included five females (mean age, 40.2 years), and the mean time from initiation of HCQ treatment to symptom onset was 12.2 d. All patients received steroids and allergy medications after HCQ discontinuation, and the rash completely resolved within an average of 25.2 d. We performed whole exome sequencing and Sanger validation in our patient sample. CARD14 gene mutations were detected in three patients. Additionally, seven mutation sites were detected.

Discussion

HCQ-induced AGEP may have a longer latency period and regression time than AGEP induced by other drugs. Our patients all experienced CARD14 gene mutations. AGEP often resolves with topical therapy and drug discontinuation, although some cases require systemic steroid therapy. In the future, patients with rheumatism should pay attention to the effectiveness of HCQ during treatment and be aware of the associated skin toxicity.

Disorders of hyperpigmentation. Part I. Pathogenesis and clinical features of common pigmentary disorders

Disorders of hyperpigmentation are common and, depending on the extent and location of involvement, can affect the quality of life and pose a significant psychologic burden for patients. Given the similarities in presentation of the various causes of hyperpigmentation, it is often difficult to elucidate the etiology of these conditions, which is important to guide management. Furthermore, certain disorders, such as lichen planus pigmentosus and ashy dermatosis, have similar clinical and/or histologic presentations, and their classification as distinct entities has been debated upon, leading to additional confusion. In this review, the authors selected commonly encountered disorders of hyperpigmentation of the skin, subdivided into epidermal, dermal, or mixed epidermal-dermal disorders based on the location of pigment deposition, along with disorders of hyperpigmentation of the mucosa and nails. Melanocytic nevi, genetic disorders, and systemic causes of hyperpigmentation were largely excluded and considered to be outside the scope of this review. We discussed the pathogenesis of hyperpigmentation as well as the clinical and histologic features of these conditions, along with challenges encountered in their diagnosis and classification. The second article in this 2-part continuing medical education series focuses on the medical and procedural treatments of hyperpigmentation.

Oral pigmentation as an adverse effect of chloroquine and hydroxychloroquine use: A scoping review

BACKGROUND

Chloroquine and hydroxychloroquine are 2 medications used to treat some systemic diseases.

OBJECTIVE

The aim of this scoping review was to assess the occurrence of oral pigmentation induced by chloroquine or hydroxychloroquine and to understand the pathogenic mechanism behind this phenomenon.

METHODS

The review was performed according to the list of PRISMA SrC recommendations and the JBI Manual for Evidence Synthesis for Scoping Reviews. MEDLINE (PubMed), Scopus, EMBASE, SciELO, Web of Science, Lilacs, and LIVIVO were primary sources, and "gray literature" was searched in OpenThesis and Open Access Thesis and Dissertations (OATD). Studies that screened the occurrence of oral pigmentation associated to the use of chloroquine or hydroxychloroquine were considered eligible. No restrictions of year and language of publication were applied. Study selection and data extraction were performed by 2 independent reviewers. The risk of bias was assessed through the JBI tool, depending on the design of the selected studies.

RESULTS

The initial search resulted in 2238 studies, of which 19 were eligible. Sixteen studies were case reports, 2 had case-control design and 1 was cross-sectional. Throughout the studies, 44 cases of oral pigmentation were reported. The hard palate was the anatomic region most affected with pigmentation (66%). According to the case reports, most of the lesions (44%) were bluish-gray. The minimum time from the beginning of treatment (chloroquine or hydroxychloroquine) to the occurrence of pigmentation was 6 months. The mean treatment time with the medications was 4.9 years, and the mean drug dosage was 244 mg. Most of the studies (63.1%) had low risk of bias (high methodological quality).

CONCLUSIONS

The outcomes of this study suggest that hyperpigmentation depend on drug dosage and treatment length. Hyperpigmentation was detected after a long period of treatment with chloroquine or hydroxychloroquine.

Hydroxychloroquine in systemic lupus erythematosus: overview of current knowledge

The antimalarial hydroxychloroquine (HCQ) has demonstrated several crucial properties for the treatment of systemic lupus erythematosus (SLE). Herein, we reviewed the main HCQ pharmacologic features, detailed its mechanism of action, and summarized the existing guidelines and recommendations for HCQ use in rheumatology with a systematic literature search for the randomized controlled trials focused on lupus. HCQ has been shown to decrease SLE activity, especially in mild and moderate disease, to prevent disease flare and to lower the long-term glucocorticoid need. The numerous benefits of HCQ are extended to pregnancy and breastfeeding period. Based on cohort studies, antithrombotic and metabolic HCQ’s effects were shown, including lipid-lowering properties, which might contribute to an improved cardiovascular risk. Moreover, early HCQ use in antinuclear antibodies positive individuals might delay the progression to SLE. Finally, HCQ has a significant favorable impact on long-term outcomes such as damage accrual and mortality in SLE. Based on these multiple benefits, HCQ is now the mainstay long-term treatment in SLE, recommended by current guidelines in all patients unless contraindications or side effects. The daily dose associated with the best compromise between efficacy and safety is matter of debate. The concern regarding retinal toxicity rather than proper efficacy data is the one that dictated the daily dosage of ⩽5 mg/kg/day actual body weight currently agreed upon.

Systematic review and meta-analysis of the safety of chloroquine and hydroxychloroquine from randomized controlled trials on malarial and non-malarial conditions

BACKGROUND

Despite the expectations regarding the effectiveness of chloroquine (CQ) and hydroxychloroquine (HCQ) for coronavirus disease (COVID-19) management, concerns about their adverse events have remained.

OBJECTIVES

The objective of this systematic review was to evaluate the safety of CQ and HCQ from malarial and non-malarial randomized clinical trials (RCTs).

METHODS

The primary outcomes were the frequencies of serious adverse events (SAEs), retinopathy, and cardiac complications. Search strategies were applied to MEDLINE, EMBASE, LILACS, CENTRAL, Scopus, and Trip databases. We used a random-effects model to pool results across studies and Peto's one-step odds ratio (OR) for event rates below 1%. Both-armed zero-event studies were excluded from the meta-analyses. We used the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate the certainty of evidence.

RESULTS

One hundred and six RCTs were included. We found no significant difference between CQ/HCQ and control (placebo or non-CQ/HCQ) in the frequency of SAEs (OR: 0.98, 95% confidence interval [CI]: 0.76-1.26, 33 trials, 15,942 participants, moderate certainty of evidence). However, there was a moderate certainty of evidence that CQ/HCQ increases the incidence of cardiac complications (RR: 1.62, 95% CI: 1.10-2.38, 16 trials, 9908 participants). No clear relationship was observed between CQ/HCQ and retinopathy (OR: 1.63, 95% CI: - 0.4-6.57, 5 trials, 344 participants, very low certainty of evidence).

CONCLUSIONS

CQ and HCQ probably do not increase SAEs, with low frequency of these adverse events on malarial and non-malarial conditions. However, they may increase cardiac complications especially in patients with COVID-19. No clear effect of their use on the incidence of retinopathy was observed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020177818.

An Open-Label Study Assessing the Efficacy and Tolerability of a Skincare Regimen in Subjects of Different Ethnicities with Moderate-to-Severe Hyperpigmentation

Background

Hyperpigmentation is a common cosmetic concern that significantly impacts self‐esteem. A skincare regimen has been developed to improve the appearance, tone, texture, and luminosity of subjects with facial hyperpigmentation (Even Up^® Hyperpigmentation Regimen; Colorescience, Inc., Carlsbad, CA).

Aims

The objective of this open‐label trial was to assess the efficacy and tolerability of this regimen for treating facial hyperpigmentation.

Patients/Methods

Subjects with moderate‐to‐severe facial hyperpigmentation (N = 33) were randomized to those not using prescription, advanced or physician‐dispensed skin care products (Group A, n = 23) and those currently using prescription, advanced or physician‐dispensed skincare products for facial hyperpigmentation (Group B, n = 10). Both groups were provided three skincare products comprising the hyperpigmentation regimen and instructions for use. Subjects were evaluated at baseline and Weeks 2, 4, 8 and 12.

Results

The overall median (range) baseline MASI score at baseline was 9.0 (2, 31), decreasing by 0.0 (−7, 0) points at Week 2 (p = 0.002), 0.6 (−8, 0) points at Week 4 (p < 0.0001), 1.5 (−16, 0) points by Week 8 (p < 0.0001) and 2.4 (−20, 0) points at Week 12 (p < 0.0001). At Week 12, the overall median improvement in MASI score was 26% and higher for Group B (32% vs. 22%). By Week 2, subjects reported lighter, less noticeable brown spots (76%), brighter, more luminous skin (88%), more even skin tone (67%), and healthier look and feel (85%). Improvements continued throughout the study. No adverse events were observed or reported.

Conclusions

This regimen addresses facial hyperpigmentation and protects skin against the damaging effects of ultraviolet and high energy visible light (HEV). It is safe to use on all skin types and tones.

Dermatological manifestations associated with COVID-19: A comprehensive review of the current knowledge

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has become a significant health problem globally. The virus has spread widely and become a global pandemic. The pathophysiology for SARS-CoV-2 has not been explained clearly. It has been associated with several multiorgan symptoms, among which its dermatological manifestations are of great interest. Primarily, there has been no report of skin features among COVID-19 patients. Nevertheless, recently there have been several reports regarding COVID-19 patients who presented with cutaneous manifestations. In the current review, we focus on the various cutaneous manifestations of COVID-19 infection.

Superficial X-ray-induced hyperpigmentation in postoperative keloid radiotherapy: A study of 70 keloids to identify clinical features and risk factors

BACKGROUND

Postoperative radiation is one of the most effective treatments for keloid. Radiation-induced hyperpigmentation is, however, a concern for both patients and dermatologists.

AIMS

To identify clinical features and risk factors of superficial X-ray-induced hyperpigmentation in postoperative keloid radiotherapy.

PATIENTS/METHODS

From November 2019 to November 2020, 70 keloids in 55 patients were treated with superficial X-ray after surgery. Patient data and treatment-related parameters were collected. Follow-up photographs were taken one month after radiotherapy. Three independent dermatologists assessed photographs for pigmentation. The clinical characteristics and severity of pigmentation were summarized. Logistic regression was used to analyze the risk factors associated with occurrence and severity of hyperpigmentation.

RESULTS

The pigmentation was a well-defined rectangular brown macule consistent with the unprotected area that involves normal skin, and 82.9% of keloids displayed pigmentation induced by superficial X-ray at one month after treatment. All keloids of trunk appeared to be mild-to-moderately hyperpigmented (100%); 92.89% of limb keloids displayed mainly severe pigmentation. Keloid location was an independent risk factor for the incidence and severity of pigmentation. Longer incision length was also predictive of increased hyperpigmentation severity.

CONCLUSIONS

Superficial X-ray-induced hyperpigmentation was common and severe in postoperative keloid radiotherapy. The incidence and severity of pigmentation can be predicted by the location and incision length of the keloid.

Systemic toxicity of chloroquine and hydroxychloroquine: prevalence, mechanisms, risk factors, prognostic and screening possibilities

Chloroquine (CQ) and its hydroxylated analog, hydroxychloroquine (HCQ), are 4-aminoquinoline initially used as an antimalarial treatment. CQ and HCQ (4-aminoquinoline, 4-AQ) are today used in rheumatology, especially to treat rheumatoid arthritis and systemic lupus erythematosus. Their mechanism of action revolves around a singular triptych: 4-AQ acts as alkalizing agents, ionized amphiphilic molecules, and by binding to numerous targets. 4-AQ have so pleiotropic and original mechanisms of action, providing them an effect at the heart of the regulation of several physiological functions. However, this broad spectrum of action is also at the origin of various and original side effects, notably a remarkable chronic systemic toxicity. We describe here the 4-AQ-induced lesions on the eye, the heart, muscle, the nerves, the inner ear, and the kidney. We also describe their prevalence, their pathophysiological mechanisms, their risk factors, their potential severity, and the means to detect them early. Most of these side effects are reversible if treatment is stopped promptly. This 4-AQ-induced toxicity must be known to prescribing physicians, to closely monitor its appearance and stop treatment in time if necessary.

Hydroxychloroquine-induced acute generalized exanthematous pustulosis: a series of seven patients and review of the literature

BACKGROUND

Hydroxychloroquine (HCQ)-induced acute generalized exanthematous pustulosis (AGEP) is poorly described in the literature. The aim of our study was to characterize the clinical, laboratory, allergological, and genetic features of HCQ-induced AGEP.

METHODS

We conducted a retrospective study of patients with HCQ-induced AGEP diagnosed between 2011 and 2019. We performed molecular analysis to identify variations in the IL36RN gene. We also reviewed similar cases reported between 1991 and March 2020.

RESULTS

Seven female patients were included. The mean age was 47 years old, and the average time from HCQ start to onset of symptoms was 40 days. All patients received topical steroids with a full resolution of the rash within an average of 39 days after HCQ withdrawal. Patch tests were performed for three patients with positive results in one case. Genetic analyses were performed for three patients, and no mutation in the IL36RN gene was identified.

CONCLUSION

The latent period and the duration for resolution of HCQ-induced AGEP may be longer than with other drugs due to the metabolic characteristics of HCQ. Mutations in the IL36RN gene were not identified in our patients.

Safety management in treatment with antimalarials in rheumatology. Interdisciplinary recommendations on the basis of a systematic literature review

BACKGROUND

Antimalarial medication (AM) plays an important role in the treatment of rheumatic diseases.

OBJECTIVE

Updated evidence-based recommendations on the safety management of rheumatological treatment with AM are presented.

METHODS

A systematic literature search in the databases Medline (PubMed) and Cochrane identified 1160 studies on the safety of treatment with AM in rheumatology. In addition, a manual search was carried out and 67 publications considered to be particularly relevant by the authors were analyzed in more detail. These publications served as a basis for consensus-based recommendations.

RESULTS

Treatment with AM in rheumatology should be carried out with hydroxychloroquine (HCQ) with a dosage not exceeding 5 mg/kg body weight/day. Patients should undergo a basic ophthalmological examination within the first 6 months of AM treatment. Pre-existing maculopathy, renal insufficiency (glomerular filtration rate, GFR <60 ml/min), tamoxifen comedication, a daily dose of >5 mg/kg HCQ or treatment with chloroquine (CQ) show an increased risk for AM-induced retinopathy. These patients should undergo an annual ophthalmological check from the beginning of the treatment, whereas patients with no risk factors are recommended to start this only after 5 years of taking the medication. The ophthalmological examination should comprise at least both an appropriate subjective and an objective method and these are usually an automated visual field test and optical coherence tomography (OCT). A visual field test revealing a parafoveal sensitivity loss and an OCT showing a parafoveal circumscribed loss of the photoreceptor layer or focal interruptions of the structural line of the outer segment are signs of a possible AM retinopathy. Determination of creatine kinase (CK) and lactate dehydrogenase (LDH) in blood is appropriate to screen for cardiomyopathy and myopathy and should be checked before starting the treatment and then ca. every 3 months. The use of cardiac biomarkers, such as brain natriuretic peptide (BNP) or troponin in serum, electrocardiograph (ECG) or cardiac imaging should be considered depending on the situation. An intake of HCQ is safe during pregnancy and breastfeeding according to the current state of knowledge and is protective for mother and child in patients with systemic lupus erythematosus.

CONCLUSION

The updated recommendations on AM treatment in rheumatology in particular include a more rigorous measuring of doses, risk stratification in monitoring and defined ophthalmological examination methods to detect a possible retinopathy.

Safety of hydroxychloroquine in COVID-19 and other diseases: a systematic review and meta-analysis of 53 randomized trials

INTRODUCTION

Many concerns still exist regarding the safety of hydroxychloroquine (HCQ) in the treatment of Coronavirus Disease 2019 (COVID-19).

OBJECTIVES

The purpose of this study was to evaluate the safety of HCQ in the treatment of COVID-19 and other diseases by performing a systematic review and meta-analysis.

METHODS

Randomized controlled trials (RCTs) reporting the safety of HCQ in PubMed, Embase, and Cochrane Library were retrieved starting from the establishment of the database till June 5, 2020. Literature screening, data extraction, and assessment of risk bias were performed independently by two reviewers.

RESULTS

We identified 53 eligible studies involving 5496 patients. The meta-analysis indicated that the risk of adverse effects (AEs) in the HCQ group was significantly increased compared with that in the control group (RD 0.05, 95%CI, 0.02 to 0.07, P = 0.0002), and the difference was also statistically significant in the COVID-19 subgroup (RD 0.15, 95%CI, 0.07 to 0.23, P = 0.0002) as well as in the subgroup for other diseases (RD 0.03, 95%CI, 0.01 to 0.04, P = 0.003).

CONCLUSIONS

HCQ is associated with a high total risk of AEs compared with the placebo or no intervention in the overall population. Given the small number of COVID-19 participants included, we should be cautious regarding the conclusion stating that HCQ is linked with an increase incidence of AEs in patients with COVID-19, which we hope to confirm in the future through well-designed and larger sample size studies.

Review of adverse cutaneous reactions of pharmacologic interventions for COVID-19: A guide for the dermatologist

The new coronavirus, severe acute respiratory syndrome coronavirus 2, is associated with a wide variety of cutaneous manifestations. Although new skin manifestations caused by COVID-19 are continuously being described, other cutaneous entities should also be considered in the differential diagnosis, including adverse cutaneous reactions to drugs used in the treatment of COVID-19 infections. The aim of this review is to provide dermatologists with an overview of the cutaneous adverse effects associated with the most frequently prescribed drugs in patients with COVID-19. The skin reactions of antimalarials (chloroquine and hydroxychloroquine), antivirals (lopinavir/ritonavir, ribavirin with or without interferon, oseltamivir, remdesivir, favipiravir, and darunavir), and treatments for complications (imatinib, tocilizumab, anakinra, immunoglobulins, corticosteroids, colchicine and low molecular weight heparins) are analyzed. Information regarding possible skin reactions, their frequency, management, and key points for differential diagnosis are presented.

A multiscale absorption and transit model for oral delivery of hydroxychloroquine: Pharmacokinetic modeling and intestinal concentration prediction to assess toxicity and drug-induced damage in healthy subjects

Hydroxychloroquine (HCQ) is commonly used in the treatment of malaria and rheumatic diseases. Recently it has also been identified as possible therapeutic option in combating COVID-19. However, the use of HCQ is known to induce cytotoxicity. In 2020, we developed a multiscale absorption and transit (MAT) toolkit to simulate the dissolution, transport, absorption, distribution, metabolism, and elimination of orally administered drugs in the human GIT at multiple levels. MAT was constructed by integrating the spatially accurate first-principles driven high-fidelity drug transport, dissolution, and absorption model in the human stomach and GIT using the recently published Quasi-3D framework. The computational results showed that MAT was able to match the experimental concentration results better than the traditional compartmental models. In this study, we adapted MAT, to predict the pharmacokinetics of orally delivered HCQ in healthy subjects. The computational results matched the experimental concentration results. The simulated stomach and intestinal fluid and enterocyte concentrations were compared with the in vitro CC50 values. While the peak enterocyte concentrations were several orders lower than the in vitro CC50 values, the peak stomach and the intestinal fluid concentrations were only one order smaller than the in vitro CC50 values. In particular, the peak stomach and the duodenum fluid concentrations were just 3× smaller than the in vitro CC50 values. This implies that the lumen walls are much more susceptible to cytotoxicity-based damage than the enterocyte layers. We envision that MAT can be used to optimize the dosing regimen of HCQ by maximizing its bioavailability, while simultaneously minimizing the cytotoxic damage.

Chloroquine and hydroxychloroquine in the treatment of malaria and repurposing in treating COVID-19

Chloroquine (CQ) and Hydroxychloroquine (HCQ) have been commonly used for the treatment and prevention of malaria, and the treatment of autoimmune diseases for several decades. As their new mechanisms of actions are identified in recent years, CQ and HCQ have wider therapeutic applications, one of which is to treat viral infectious diseases. Since the pandemic of the coronavirus disease 2019 (COVID-19), CQ and HCQ have been subjected to a number of in vitro and in vivo tests, and their therapeutic prospects for COVID-19 have been proposed. In this article, the applications and mechanisms of action of CQ and HCQ in their conventional fields of anti-malaria and anti-rheumatism, as well as their repurposing prospects in anti-virus are reviewed. The current trials and future potential of CQ and HCQ in combating COVID-19 are discussed.

Cytotoxicity Evaluation of Chloroquine and Hydroxychloroquine in Multiple Cell Lines and Tissues by Dynamic Imaging System and Physiologically Based Pharmacokinetic Model

Chloroquine (CQ) and hydroxychloroquine (HCQ) have been challenged in treating COVID-19 patients and still under debate due to the uncertainty regarding the effectiveness and safety, and there is still lack of the systematic study on the toxicity of these two drugs. To further uncover the toxicity profile of CQ and HCQ in different tissues, we evaluated the cytotoxicity of them in eight cell lines and further adopted the physiologically based pharmacokinetic models to predict the tissue risk, respectively. Retina, myocardium, lung, liver, kidney, vascular endothelium, and intestinal epithelium originated cells were included in the toxicity evaluation of CQ and HCQ, respectively. The proliferation pattern was monitored in 0–72 h by IncuCyte S3. CC50 and the ratio of tissue trough concentrations to CC50 (R_TTCC) were brought into predicted toxicity profiles. Compared to CQ, HCQ was found to be less toxic in six cell types except Hep3B and Vero cells. In addition, R_TTCC was significantly higher in CQ treatment group compared to HCQ group, which indicates relative safety of HCQ. To further simulate the situation of the COVID-19 patients who suffered the dyspnea and hypoxemia, we also tested the cytotoxicity upon hypoxia and normoxia (1, 5 vs. 21% O₂). It was found that the cytotoxicity of CQ was more sensitive to hypoxia compared with that of HCQ, particularly in liver originated cells. Both CQ and HCQ showed cytotoxicity in time-dependent manner which indicates the necessity of short period administration clinically.

Medication-Induced Oral Hyperpigmentation: A Systematic Review

BACKGROUND

Medication-induced oral hyperpigmentation is an oral condition that impacts patients' quality of life and has been linked to many systemic therapeutic agents. The exact pathogenesis of tissue pigmentation varies greatly and is not completely known. This systematic review aimed to present data on the causal association between medications and the development of oral/mucosal pigmentation as an adverse drug reaction.

METHODS

A systematic review and analysis of literature were conducted using the following databases: PubMed, Science Direct, ProQuest, Web of Science, and Scopus. The systematic review included original articles written in English and published between January 1982 and June 2020. Following the PRISMA statement, eligible articles were systematically reviewed, and data were extracted from eligible studies and analyzed.

RESULTS

A total of 235 articles were identified, of which 57 met the inclusion criteria and were included in this review. The mean age of included patients was 46.2±16.38 years (range: 10-90 years) with a male to female ratio of 1:1.45. Oral mucosal hyperpigmentation was reported following the use of several classes of medications such as antiviral (eg, zidovudine), antibiotic (eg, minocycline), antimalarial (eg, chloroquine), anti-fungal (eg, ketoconazole), antileprotic (eg, clofazimine), antihypertensive (eg, amlodipine), chemotherapeutic, and antineoplastic drugs. The risk of developing oral pigmentation was significantly higher with antimalarial medications, antibiotics, antineoplastic and chemotherapeutic agents. Medication-induced oral hyperpigmentation was most frequent among women and in the hard palate.

CONCLUSION

Future research is warranted to better understand the pathogenesis and risk factors for medication-induced oral hyperpigmentation in order to reassure patients during prescription and management.

Vitiligo, From Physiopathology to Emerging Treatments: A Review

Vitiligo is a chronic inflammatory skin disease leading to the loss of epidermal melanocytes. To date, treatment options for vitiligo patients are limited, lack sustained efficacy, and are mainly based on off-label use of immunosuppressive agents, such as systemic or topical steroids or topical calcineurin inhibitors, in association with the use of ultraviolet light. However, recent insights into the understanding of the immune pathogenesis of the disease have led to the identification of several therapeutic targets and the development of targeted therapies that are now being tested in clinical trials. In this review, based on the physiopathology of the disease, we summarize emerging targets that could be developed for the treatment of vitiligo and discuss recent and ongoing developments of drugs for the management of the disease.

[Safety management of the treatment with antimalarial drugs in rheumatology. Interdisciplinary recommendations based on a systematic literature search]

BACKGROUND

Antimalarial medication (AM) plays an important role in the treatment of rheumatic diseases.

OBJECTIVE

Updated evidence-based recommendations on the safety management of rheumatological treatment with AM are presented.

METHODS

A systematic literature search in the databases Medline (PubMed) and Cochrane identified 1160 studies on the safety of treatment with AM in rheumatology. In addition, a manual search was carried out and 67 publications considered to be particularly relevant by the authors were analyzed in more detail. These publications served as a basis for consensus-based recommendations.

RESULTS

Treatment with AM in rheumatology should be carried out with hydroxychloroquine (HCQ) with a dosage not exceeding 5 mg/kg body weight/day. Patients should undergo a basic ophthalmological examination within the first 6 months of AM treatment. Pre-existing maculopathy, renal insufficiency (glomerular filtration rate, GFR <60 ml/min), tamoxifen comedication, a daily dose of >5 mg/kg HCQ or treatment with chloroquine (CQ) show an increased risk for AM-induced retinopathy. These patients should undergo an annual ophthalmological check from the beginning of the treatment, whereas patients with no risk factors are recommended to start this only after 5 years of taking the medication. The ophthalmological examination should comprise at least both an appropriate subjective and an objective method and these are usually an automated visual field test and optical coherence tomography (OCT). A visual field test revealing a parafoveal sensitivity loss and an OCT showing a parafoveal circumscribed loss of the photoreceptor layer or focal interruptions of the structural line of the outer segment are signs of a possible AM retinopathy. Determination of creatine kinase (CK) and lactate dehydrogenase (LDH) in blood is appropriate to screen for cardiomyopathy and myopathy and should be checked before starting the treatment and then ca. every 3 months. The use of cardiac biomarkers, such as brain natriuretic peptide (BNP) or troponin in serum, electrocardiograph (ECG) or cardiac imaging should be considered depending on the situation. An intake of HCQ is safe during pregnancy and breastfeeding according to the current state of knowledge and is protective for mother and child in patients with systemic lupus erythematosus.

CONCLUSION

The updated recommendations on AM treatment in rheumatology in particular include a more rigorous measuring of doses, risk stratification in monitoring and defined ophthalmological examination methods to detect a possible retinopathy.

A case of hyperpigmentation induced by hydroxychloroquine and quinacrine in a patient with systemic lupus erythematosus and review of the literature

Hydroxychloroquine (HQ) and quinacrine are widely used antimalarials for systemic lupus erythematosus (SLE) and other autoimmune diseases. We report a case of antimalarial-induced hyperpigmentation in a 57-year old African-American woman. The patient had a long-standing history of SLE that was treated with HQ and quinacrine in varying doses for 16 years. The disease improved considerably and entered remission; however, the patient subsequently developed severe, disseminated hyperpigmentation on her face, trunk, upper and lower extremities. A malar facial biopsy revealed numerous perivascular and scattered interstitial, heavily pigment laden dark brown to black macrophages. The Fontana Masson staining was positive for melanin, and Perl’s stain for iron was negative. This staining pattern, to our knowledge, has only been reported once before in the literature. Our patient represents a rare case of severe recalcitrant hyperpigmentation induced by combination HQ and quinacrine therapy for SLE.

[Ungual lesions in lupus erythematosus: A retrospective study of 14 patients]

INTRODUCTION

There are few studies focusing on ungual lesions in patients with lupus erythematosus (LE). The aim of this study is to describe our experience with ungual lesions in LE patients.

MATERIALS AND METHODS

A multicentric retrospective descriptive study was performed at the dermatology departments of the university hospitals in Strasbourg and at the Tenon hospital in Paris and involved reviewing the medical records and photographs of patients with ungual lesions.

RESULTS

Fourteen patients were included: 12 (86 %) were women with a median age of 38 years (28-78 years). All patients had cutaneous LE presenting as follows: 3 isolated forms (21 %), and associated with systemic LE (LES) for remaining 11 patients (79 %). The most frequent ungual or peri-ungual lesions were longitudinal ridging (12 patients, 86 %), onycholysis and cuticular alterations (8 patients each, 57 %), pterygium (7 patients, 50 %), melanonychia, onychoschizia and subungual hyperkeratosis (5 patients with each, 36 %). Among patients with pterygium and onychoschizia, respectively 6 (86 %) and 5 (100 %) presented the discoid LE subtype, while respectively 6 (86 %) and 4 (80 %) had multisystemic involvement.

DISCUSSION

Ungual lesions do not appear specific and do not in themselves allow diagnosis of LE. They can in fact occur in other diseases such as connective tissue disorders. However, their diagnosis is important because certain of them, such as pterygium, can lead to severe ungual dystrophia, with functional consequences. In our study, pterygium and onychoschizia appeared to be associated with cutaneous discoid lupus erythematosus and multisystemic involvement. The coexistence of peri-ungual lesions related to cutaneous lupus erythematosus and/or multisystemic involvement does not out differentiation of lupus ungual lesions and post-inflammatory lesions.

Hydroxychloroquine-induced hyperpigmentation in a 14-year-old female with systemic lupus erythematosus

Hydroxychloroquine (HCQ)-induced hyperpigmentation is uncommon but is increasingly recognized. To our knowledge, HCQ-induced hyperpigmentation has not been reported in the pediatric age group. Herein, we present the case of a 14-year-old girl with systemic lupus erythematosus, who developed hyperpigmentation on her shins and dorsum of the left foot, approximately 3 years after initiating treatment with HCQ. Physicians who treat children with HCQ for reasons such as rheumatologic disorders, dermatologic disorders and, more recently, coronavirus disease-19 should be aware of this less-known side effect of HCQ.

Hydroxychloroquine safety: A meta-analysis of randomized controlled trials

Background

Hydroxychloroquine (HCQ) is currently being examined for COVID-19. No previous meta-analysis has evaluated its side effects versus placebo. We conducted this meta-analysis to compare the safety of HCQ versus placebo.

Methods

Two authors independently searched PubMed and EMBASE databases for randomized controlled trials (RCTs) of adults comparing the adverse events (AEs) of HCQ versus placebo for any indication. Peto odds ratios (Peto ORs) and 95% confidence intervals (CIs) were calculated based on random-effects models. The heterogeneity (I²) was assessed using Cochran's Q test.

Results

Nine RCTs (eight were double-blind) with a total of 916 patients were included. HCQ caused significantly more skin pigmentation than placebo (Peto OR, 4.64; 95% CI, 1.13 to 19.00; P-value = 0.033; I² = 0%). The increase in other AEs did not reach statistical significance: rash (Peto OR, 1.11; 95% CI, 0.3 to 3.77; P-value = 0.03; I² = 0%); gastrointestinal AEs (Peto OR, 1.43; 95% CI, 0.55 to 3.72; P-value = 0.46; I² = 15.17%); headache (Peto OR, 1.94; 95% CI, 0.65 to 5.78; P-value = 0.23; I² = 9.99%); dizziness (Peto OR, 1.32; 95% CI, 0.49 to 3.52; P-value = 0.58; I² = 0%); fatigue (Peto OR, 2.13; 95% CI, 0.76 to 5.98; P-value = 0.15; I² = 0%); and visual AEs (Peto OR, 1.61; 95% CI, 0.76 to 3.41; P-value = 0.22; I² = 0%). Cardiac toxicity was not reported.

Conclusions

This meta-analysis of RCTs found a significantly higher risk of skin pigmentation in HCQ users versus placebo. More data are needed to evaluate HCQ in the context of COVID-19 treatment.

Revisiting hydroxychloroquine and chloroquine for patients with chronic immunity-mediated inflammatory rheumatic diseases

Hydroxychloroquine and chloroquine, also known as antimalarial drugs, are widely used in the treatment of rheumatic diseases and have recently become the focus of attention because of the ongoing COVID-19 pandemic. Rheumatologists have been using antimalarials to manage patients with chronic immune-mediated inflammatory rheumatic diseases for decades. It is an appropriate time to review their immunomodulatory and anti-inflammatory mechanisms impact on disease activity and survival of systemic lupus erythematosus patient, including antiplatelet effect, metabolic and lipid benefits. We also discuss possible adverse effects, adding a practical and comprehensive approach to monitoring rheumatic patients during treatment with these drugs.

Orofacial manifestations and dental management of systemic lupus erythematosus: A review

Systemic lupus erythematosus (SLE) is an autoimmune multisystem disease with numerous clinical manifestations. There is no consensus about the ideal oral management for this group of patients to date. This review aimed to describe the broad spectrum of orofacial and clinical manifestations and their therapeutic approaches. Studies concerning orofacial manifestations of SLE and dental treatment modalities were selected by a literature search (1978-2019) using Google Scholar, PubMed/MEDLINE electronic databases. The initial search strategy provided a total of 129 articles, and of these, 30 were included for qualitative synthesis. The reviewed studies revealed that SLE patients are more at risk of compromised oral and dental health exhibiting increased risk of periodontal diseases and temporomandibular joint disorders. The use of systemic drugs especially immunosuppressive and anticoagulants in SLE patients may also influence their oral management. Results emphasize the need to carry out, at an early stage of the disease, an appropriate oral management of these patients to improve oral health-related quality of life and to prevent the need of more invasive therapeutics. A multidisciplinary approach is needed for dental and medical management of such patients.

The color of skin: brown diseases of the skin, nails, and mucosa

Brown diseases comprise disorders leading to hyperpigmentation in skin and nails. Melasma is an acquired skin disorder that is characterized by brownish macules that typically occur on the face. Schamberg disease, also known as progressive pigmented purpura, is characterized by brown pigmentation with pepper spots on their edges. We summarize the epidemiology, pathogenesis, histologic features, and treatment choices for additional brown diseases, including melasma, pigmented purpuric dermatoses, postinflammatory hyperpigmentation, drug-induced hyperpigmentation, and pigmentations due to systemic or physiologic conditions.

Cytotoxicity Evaluation of Chloroquine and Hydroxychloroquine in Multiple Cell Lines and Tissues by Dynamic Imaging System and Physiologically Based Pharmacokinetic Model

Chloroquine (CQ) and hydroxychloroquine (HCQ) have been challenged in treating COVID-19 patients and still under debate due to the uncertainty regarding the effectiveness and safety, and there is still lack of the systematic study on the toxicity of these two drugs. To further uncover the toxicity profile of CQ and HCQ in different tissues, we evaluated the cytotoxicity of them in eight cell lines and further adopted the physiologically based pharmacokinetic models to predict the tissue risk, respectively. Retina, myocardium, lung, liver, kidney, vascular endothelium, and intestinal epithelium originated cells were included in the toxicity evaluation of CQ and HCQ, respectively. The proliferation pattern was monitored in 0-72 h by IncuCyte S3. CC50 and the ratio of tissue trough concentrations to CC50 (R_TTCC) were brought into predicted toxicity profiles. Compared to CQ, HCQ was found to be less toxic in six cell types except Hep3B and Vero cells. In addition, R_TTCC was significantly higher in CQ treatment group compared to HCQ group, which indicates relative safety of HCQ. To further simulate the situation of the COVID-19 patients who suffered the dyspnea and hypoxemia, we also tested the cytotoxicity upon hypoxia and normoxia (1, 5 vs. 21% O₂). It was found that the cytotoxicity of CQ was more sensitive to hypoxia compared with that of HCQ, particularly in liver originated cells. Both CQ and HCQ showed cytotoxicity in time-dependent manner which indicates the necessity of short period administration clinically.

An Update on Drug-Induced Pigmentation

Drug-induced pigmentation accounts for up to 20% of all cases of acquired pigmentation. A thorough review of medical history and previous and ongoing medications as well as a complete skin examination can guide diagnosis. Implicated agents include alkylating/cytotoxic agents, analgesics, antiarrhythmics, anticoagulants, antiepileptics, antimalarials, antimicrobials, antiretrovirals, metals, prostaglandin analogs, and psychotropic agents, among others. Confirming true drug associations can be challenging, especially in the setting of delayed onset of pigmentation and coexisting polypharmacy.

Longitudinal melanonychia and subungual hemorrhage in a patient with systemic lupus erythematosus treated with hydroxychloroquine

Hydroxychloroquine is an antimalarial agent, most commonly prescribed in the treatment of several rheumatic diseases. Although generally well tolerated, a variety of mucocutaneous adverse effects have been reported. Besides the familiar adverse effects, longitudinal melanonychia is rarely seen. Although the incidence is extremely low, systemic lupus erythematosus may also cause nail pigmentation in its own right. We report the case of a 55-year-old woman who was diagnosed with systemic lupus erythematosus and presented with longitudinal melanonychia of all 10 fingernails after 3 years of treatment with hydroxychloroquine, without mucocutaneous hyperpigmentation. The pigment of the nail lasted for more than 15 years. To the best of our knowledge, this is first published report of hydroxychloroquine-induced melanonychia without mucocutaneous hyperpigmentation. This case demonstrates that hydroxychloroquine treatment and the primary disease should be considered in the case of multiple nail changes in patients with systemic lupus erythematosus.