Topical Moisturizer Meaningfully Reduces Disease Severity in Atopic Patients With Xerosis

BACKGROUND

Repairing the epidermal barrier is critically important in atopic dermatitis (AD), but the effect of moisturizer on quality of life (QOL) is not well characterized.  Objective: To assess whether the use of a moisturizer improves QOL in atopic patients with xerosis.  Methods: Thirty-five (35) adults with xerosis and AD received a moisturizer designed for AD to apply daily for three months. Adherence was assessed with electronic monitors. Quality of life (QOL) was assessed with the Dermatology Life Quality Index (DLQI) at baseline and follow-up.  Results: Mean adherence to the moisturizer was 46%. Dryness improved from 1.9 at baseline to 1.4 at follow-up (P=0.02). DLQI improved from 3.3 at baseline to 1.5 at 3 months (P=0.005). The "feeling self-conscious or embarrassed due to their skin condition" DLQI item improved from 0.79 at baseline to 0.14 at 3 months (P=0.0009).  Conclusion: Moisturizers are the foundation of AD treatment. Even non-medicated topical emollients can improve QOL in patients with AD.  J Drugs Dermatol. 2023;22(12):e51-e52.     doi:10.36849/JDD.7036e.

Topical Ivermectin Is Associated With Improved Erythematotelangiectatic, Papulopustular, and Phymatous Rosacea in a Secondary Analysis

Rosacea has variable clinical presentation consisting of four overlapping phenotypes: erythematotelangiectatic, papulopustular, phymatous, and ocular.1 Rosacea's pathogenesis involves increased cutaneous density of Demodex folliculorum mites, which drive inflammation through activation of Toll-like receptor-2.1,2 Thus, topical ivermectin (IVM) 1.0% cream's anti-inflammatory and acaricidal activity provides an effective and targeted treatment for moderate-to-severe rosacea. However, literature assessing IVM is limited to efficacy in treating the papulopustular presentation, limiting generalizability.1,3,4 Although our primary endpoint was to assess patient adherence, the objective of this secondary analysis was to assess IVM efficacy in rosacea, regardless of clinical presentation.

The Patient-Physician Relationship and Adherence: Observations From a Clinical Study

Improved patient-physician relationships (PPR) are associated with better patient satisfaction and disease outcomes, however, there is limited literature assessing how PPR affects adherence in dermatology. We recruited 30 subjects with a clinical diagnosis of rosacea. Subjects were instructed to use ivermectin 1% cream once daily for 3 months and adherence was measured using the Medication Event Monitoring System cap. The Patient-Doctor Relationship Questionnaire (PDRQ-9), a validated questionnaire assessing patients’ perceived strength of the relationship with their doctor, was completed. Mean adherence for all subjects over three months of the study was 62%. PDRQ-9 scores positively correlated with adherence rates for 3 months of treatment (r(26)=0.52; P=0.006). The perceived strength of the PPR may have a role in patients’ adherence to their medications. Improving the PPR, through empathy and effective communication, may facilitate better medication adherence and treatment outcomes. Perche PO, Singh R, Cook MK, et al. The patient-physician relationship and adherence: observations from a clinical study. J Drugs Dermatol. 2023;22(8):838-839. doi:10.36849/JDD.7103.

Oversight of in-office dispensing and samples in dermatology

The provision of samples and in-office dispensing of products and medications to patients are important, yet often controversial, practices in dermatology. Opinions on the practices of sampling and in-office dispensing vary greatly among dermatologists. Ultimately, there are several advantages and disadvantages associated with each practice, and common topics of discussion include ethics, costs, safety, and adherence. Many of the concerns associated with the practices of sampling and dispensing in dermatology may be mitigated by careful consideration and action by prescribers. Providers should be aware of their current practices surrounding these issues and, if used, methods by which these practices can be improved to optimize patient care. With careful consideration, it may be possible to practice sampling and dispensing of products and medications safely, ethically, and to the patients' advantage as an integral part of the dermatology practice.

An update to the 2013-2014 American Academy of Dermatology (AAD) guidelines for the pharmacological management of atopic dermatitis

INTRODUCTION

Atopic dermatitis is a common dermatologic condition that affects millions of people worldwide, and a standardized approach to treatment was published by the American Academy of Dermatology (AAD) in 2013-14. Since 2014, new FDA-approved treatment options such as dupilumab and crisaborole have changed the landscape of AD management, and future therapies such as JAK inhibitors and anti-interleukin 13 and 31 antibodies appear effective, emphasizing the need for a comprehensive review to give clinicians an updated toolbox to aid in pharmacologic management.

AREAS COVERED

In this review, the authors explore the updated efficacy and safety data on established therapeutic options for AD including topical corticosteroids, topical calcineurin inhibitors, cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil. In addition, the authors also explore trial data and studies on dupilumab, crisaborole, omalizumab, tofacitinib, ruxolinitib, abrocitinib, baricitinib, upadacitinib, delgocitinib, nemoliuzumab, and tralokinumab.

EXPERT OPINION

The AAD guidelines must be updated in the future to include several new treatment modalities that have revolutionized the pharmacologic management of patients with AD, including dupilumab and crisaborole. The future of AD treatment is also extremely bright, as JAK inhibitors and Il-13/31 antibodies have shown convincing results in the improvement of AD patients' lives in various trials and studies that have been examined in this paper.

Learning from disease registries during a pandemic: Moving toward an international federation of patient registries

High-quality dermatology patient registries often require considerable time to develop and produce meaningful data. Development time is influenced by registry complexity and regulatory hurdles that vary significantly nationally and institutionally. The rapid emergence of the coronavirus disease 2019 (COVID-19) global pandemic has challenged health services in an unprecedented manner. Mobilization of the dermatology community in response has included rapid development and deployment of multiple, partially harmonized, international patient registries, reinventing established patient registry timelines. Partnership with patient organizations has demonstrated the critical nature of inclusive patient involvement. This global effort has demonstrated the value, capacity, and necessity for the dermatology community to adopt a more cohesive approach to patient registry development and data sharing that can lead to myriad benefits. These include improved utilization of limited resources, increased data interoperability, improved ability to rapidly collect meaningful data, and shortened response times to generate real-world evidence. We call on the global dermatology community to support the development of an international federation of patient registries to consolidate and operationalize the lessons learned during this pandemic. This will provide an enduring means of applying this knowledge to the maintenance and development of sustainable, coherent, and impactful patient registries of benefit now and in the future.

Morgellons disease etiology and therapeutic approach: a systematic review

Morgellons disease is characterized by patient reports of fibers embedded in and protruding from the skin. Etiologies from infection to delusion have been endorsed, and treatment guidelines are not well-defined. The objective of this manuscript is to evaluate the existing evidence regarding the etiology and treatment of Morgellons disease in an effort to better inform clinical management. A PubMed search including key words "Morgellons," "delusional parasitosis and fibers," "delusions of parasitosis and fibers," or "delusional infestation and fibers" was completed. Original publications directly assessing etiology or treatment methods of Morgellons disease published between January, 2010 and the time of manuscript preparation were reviewed and evaluated. Sixteen articles regarding etiology were reviewed. All studies were correlative in nature with various limitations. Support for a psychiatric etiology was more widespread than support for an infectious etiology. Eleven articles regarding treatment efficacy were reviewed. Antipsychotic regimens have the most evidence of efficacy. Existing data regarding Morgellons disease suggests a psychiatric etiology and supports treatment with a low-dose antipsychotic agent once non-psychiatric causes have been excluded.

1% Tirbanibulin Ointment for the Treatment of Actinic Keratoses

Objective

Actinic keratoses (AKs) are cutaneous lesions that arise in sun-damaged skin. AKs may transform into squamous cell carcinoma in situ. Tirbanibulin 1% ointment is a new topical treatment for AKs, recently approved by the Food and Drug Administration.

Data Sources

The PubMed database was searched for articles published from 1960 to March 31, 2021, using the keywords tirbanibulin and Klisyri.

Data Extraction

Phase 2 and phase 3 clinical trials were reviewed.

Data Synthesis

In phase 2 clinical trials, 43% of patients treated with tirbanibulin experienced complete clearance by day 57 (43% [95% CI = 32, 54]). Across two phase 3 clinical trials (pooled data), complete (100%) clearance occurred in 49% of patients in tirbanibulin groups and in only 9% of the vehicle groups (difference, 41% points; 95% CI = 35 to 47; P < 0.001). Although no comparative studies are available, tirbanibulin is applied for a shorter duration (5 days) compared with diclofenac 3% gel, fluorouracil 5% cream, and imiquimod 3.75% cream. Adverse events were mild and included pruritus, application site pain, and local skin reactions. Systemic adverse events such as necrosis and angioedema, observed with other AK treatments such as fluorouracil and imiquimod, were not observed with tirbanibulin, thus giving tirbanibulin a favorable safety profile.

Relevance to Patient Care and Clinical Practice

Tirbanibulin effectively reduces AK burden and recurrence and has a favorable safety profile with mild adverse events. In comparison, imiquimod, 5-flourouracil, and diclofenac can result in necrosis, angioedema, and arthralgias.

Conclusion

With a favorable safety profile and short regimen, tirbanibulin is an efficacious treatment for clinicians to utilize in their treatment toolbox when treating AKs on the face and scalp.

New and Emerging Systemic Treatments for Atopic Dermatitis

Atopic dermatitis (AD) is a prevalent inflammatory skin condition that, depending on its severity, can cause enormous morbidity. Corticosteroids and systemic immunosuppression, traditionally standard of care for difficult-to-treat disease, have many undesirable side effects. The desire for targeted treatments along with an improved understanding of the pathophysiology of AD has spurred the development of novel treatments. In this article, we review promising new treatments and discuss how their targets—IL-13, IL-31, OX40 (CD134), and the Janus kinase family of proteins—participate in the pathogenesis of AD. We review the published phase II and III data for dupilumab, tralokinumab, lebrikizumab, nemolizumab, anti-OX40 antibody, baricitinib, abrocitinib, and upadacitinib. The introduction of new agents may offer new options, but it remains to be seen how narrow-acting agents, like single interleukin inhibitors, will compare in safety and efficacy to broad-acting agents such as JAK inhibitors.

Topical calcipotriol plus betamethasone dipropionate for the treatment of plaque psoriasis: a drug evaluation

Introduction: Psoriasis is an inflammatory skin disease affecting approximately 3.2% of adults in the United States. The mainstay treatment for mild-to-moderate plaque psoriasis (the most common subtype and severity) is topical therapy.Areas covered:The fixed combination calcipotriol plus betamethasone dipropionate (BD) is an effective topical treatment for plaque psoriasis. Two therapies with separate actions - a Vitamin D analog and a high-potency topical corticosteroid - combined into a single medication allows for better efficacy and patient adherence. The treatment is available in ointment, gel, suspension, foam, and cream formulations. The authors elaborate on this and provide their expert perspectives.Expert opinion: Combination calcipotriol/BD offers several advantages over its separate product monotherapies, including better efficacy, safety, and ease of use. Newer calcipotriol/BD formulations include less messy vehicles, thus promoting improved adherence. Further data are needed on whether combination calcipotriol/BD will be cost-effective and whether insurers will place it in the treatment coverage algorithm. Due to its higher price, calcipotriol/BD will likely remain a second-line treatment option after generic topical corticosteroids.

Immunogenicity of Biologic and Biosimilar Therapies for Psoriasis and Impact of Novel Immunoassays for Immunogenicity Detection

Anti-drug antibodies (ADAs) may develop against originator biologic and biosimilar therapies used for the treatment of psoriasis and may be the cause of initial therapeutic non-response or diminished therapeutic response over time. Comparing immunogenicity between therapeutic agents is challenging owing to the variation in assays used for detection, among other reasons. Using the results of a PubMed search for psoriasis clinical trials disclosing the rates of ADAs for originator biologic and biosimilar therapies approved for the treatment of psoriasis within the last 5 years, this review discusses the rates and potential clinical impact of ADA formation in patients with psoriasis managed with originator biologic and biosimilar therapies, along with novel methods of ADA testing. Anti-drug antibodies are detectable in all biologic and biosimilar therapies approved for the treatment of psoriasis in the last 5 years, and the effect of ADAs on clinical response varies by agent. Novel immunoassays used for the detection of ADAs may have increased sensitivity compared with traditional assays, although the increased rate of detection may not correlate with decreased clinical response and the decision to test for the presence of ADAs may vary from patient to patient. Though ADA formation seems ubiquitous with the use of biologic agents for the treatment of psoriasis, the increased rates of ADAs detected by novel immunoassays may not necessarily correlate with decreased treatment efficacy.

Tolerability of and Adherence to Topical Treatments in Atopic Dermatitis: A Narrative Review

Atopic dermatitis (AD) is a common, chronic inflammatory skin disease that oftentimes requires complex therapy. Poor adherence is a major barrier to AD treatment success. An interspecialty, virtual roundtable panel was held, through which clinical dermatologists, allergists, and behavioral and social psychologists discussed AD management and adherence. Relevant literature was reviewed, and the content of this article was organized based on the roundtable discussion. Current guidelines for AD treatment include maintenance and acute therapy for mild-to-severe AD. Therapy is often complex and requires significant patient involvement, which may contribute to poor treatment adherence. Behavioral and social psychology strategies that may help improve adherence include scheduling timely follow-up appointments, using a clearly written eczema action plan (EAP), reducing perceived treatment burden, utilizing anchoring techniques, sharing anecdotes, and rewarding children using positive reinforcement and stickers. There are multiple practical ways by which providers can improve both the management and treatment adherence of patients with AD.

Clascoterone: How the Novel Androgen Receptor Inhibitor Fits Into the Acne Treatment Paradigm

Many patients with acne remain unsatisfied with results from the various topical treatments available and often do not improve, because of poor adherence. Even if topical clascoterone, a safe and effective treatment, were more potent than existing topicals, it could face the same poor adherence hurdle as existing treatments. Real-life efficacy will likely not reflect trial results because, for several reasons, adherence is better in trials than in real-life practice. Although topical clascoterone may be exciting initially for its promise to improve acne outcomes, the long-term place in therapy may be another topical option that minimally enhances patients' treatment outcomes.

Factors associated with adverse COVID-19 outcomes in patients with psoriasis-insights from a global registry-based study

BACKGROUND

The multimorbid burden and use of systemic immunosuppressants in people with psoriasis may confer greater risk of adverse outcomes of coronavirus disease 2019 (COVID-19), but the data are limited.

OBJECTIVE

Our aim was to characterize the course of COVID-19 in patients with psoriasis and identify factors associated with hospitalization.

METHODS

Clinicians reported patients with psoriasis with confirmed/suspected COVID-19 via an international registry, Psoriasis Patient Registry for Outcomes, Therapy and Epidemiology of COVID-19 Infection. Multiple logistic regression was used to assess the association between clinical and/or demographic characteristics and hospitalization. A separate patient-facing registry characterized risk-mitigating behaviors.

RESULTS

Of 374 clinician-reported patients from 25 countries, 71% were receiving a biologic, 18% were receiving a nonbiologic, and 10% were not receiving any systemic treatment for psoriasis. In all, 348 patients (93%) were fully recovered from COVID-19, 77 (21%) were hospitalized, and 9 (2%) died. Increased hospitalization risk was associated with older age (multivariable-adjusted odds ratio [OR] = 1.59 per 10 years; 95% CI = 1.19-2.13), male sex (OR = 2.51; 95% CI = 1.23-5.12), nonwhite ethnicity (OR = 3.15; 95% CI = 1.24-8.03), and comorbid chronic lung disease (OR = 3.87; 95% CI = 1.52-9.83). Hospitalization was more frequent in patients using nonbiologic systemic therapy than in those using biologics (OR = 2.84; 95% CI = 1.31-6.18). No significant differences were found between classes of biologics. Independent patient-reported data (n = 1626 across 48 countries) suggested lower levels of social isolation in individuals receiving nonbiologic systemic therapy than in those receiving biologics (OR = 0.68; 95% CI = 0.50-0.94).

CONCLUSION

In this international case series of patients with moderate-to-severe psoriasis, biologic use was associated with lower risk of COVID-19-related hospitalization than with use of nonbiologic systemic therapies; however, further investigation is warranted on account of potential selection bias and unmeasured confounding. Established risk factors (being older, being male, being of nonwhite ethnicity, and having comorbidities) were associated with higher hospitalization rates.

Comparing prescribing patterns for topical corticosteroids based on their FDA indication by age

BACKGROUND/OBJECTIVES

Atopic dermatitis (AD) affects up to 20% of the pediatric population, with a growing prevalence over the past 30 years. Topical corticosteroids (TCS) are commonly used as a first-line topical therapy for AD and are prescribed in 59% of all AD visits. However, some topical corticosteroids are prescribed outside of their age range indications. This paper aims to explore the frequency with which topical corticosteroids are prescribed for AD outside of their FDA-approved age range.

METHODS

Data on prescribing patterns for AD were obtained from the National Ambulatory Medical Care Survey (NAMCS). We assessed the frequency of off-label use of topical corticosteroids with respect to age indications in four specific age-groups, as delineated in the data (0-1, 2-7, 8-18, and 19+ years).

RESULTS

All prescribed topical corticosteroids found in the NAMCS database have an indication for AD or other inflammatory dermatoses or pruritic dermatoses. However, some medications were prescribed outside of their FDA-approved age indications. These off-label prescription rates ranged from 52% for desoximetasone to 0% for halobetasol and alclometasone, or rates lower than could be detected by our study.

CONCLUSIONS

Much like other medications for AD treatment, TCS are sometimes used off-label. The off-label use of topical corticosteroids to treat pediatric AD highlights a gap between clinical practice and regulating guidelines. Additional pediatric studies would offer a greater body of evidence to maintain or expand label indications for the use of TCS in younger patients.

A review of secukinumab in psoriasis treatment

Psoriasis is a systemic immunologic disorder associated with decreased quality of life and numerous co-morbidities, including psoriatic arthritis and cardiovascular disease. Secukinumab, a fully human IgG1 monoclonal antibody, selectively binds IL-17A and is approved by the US FDA and European Medicines Agency for moderate-to-severe plaque psoriasis and psoriatic arthritis. This review examines the efficacy and safety of secukinumab for the treatment of psoriasis using the literature retrieved from the PubMed database. In clinical trials, treatment with secukinumab led to rapid and sustained improvement in Psoriasis Area and Severity Index (PASI) scores, with PASI 90 response rates up to 68.5% at 5 years. Long-term clinical trial and real-world data have established secukinumab as a safe and effective treatment for psoriasis.

An update on the impact of depression on the treatment of psoriasis

Introduction: Estimates of the prevalence of comorbid depression vary, ranging from 9 and 62%. Deterioration of mental health may emerge as a result of psoriasis; however, it is theorized that depression alone may independently predispose patients to new-onset psoriasis.Areas covered: The aim of this brief review is to explore the impact of depression on psoriasis treatment.Expert opinion: The two studies that directly assess the role of depression in psoriasis treatment outcomes are important, as unaddressed depression can undermine the success of a given treatment. This may reflect the notion that depressed individuals are less likely to be adherent. Thus, it may be valuable for clinicians to not only screen for depression, but to ensure that it is adequately treated. Our knowledge of treatment preferences in psoriasis patients with comorbid depression is limited. Expanding our understanding of preferences may allow providers to better align their recommendations to ultimately increase adherence. Additionally, given that many psoriasis treatments have an impact on depression, it may be beneficial for clinicians to evaluate patients for psychiatric risk factors to optimize the treatment regimen.

Current and emerging biologics for the treatment of pediatric atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory skin condition characterized by erythematous lesions, pruritus, and a skin barrier defect. Long-term treatment in children is challenging, as there is only one Food and Drug Administration-approved systemic medication. Current treatments may have limited efficacy or serious side effects in children. With a deeper understanding of AD pathogenesis and the advent of target-specific medications, several biologics are undergoing clinical trials for future use in pediatric AD.

AREAS COVERED

This article reviews the current and emerging biologic therapies for treatment of pediatric AD. It allows for comprehensive comparison of medications and their clinical trials to help providers optimize patient treatment plans while providing expert insight into upcoming advancements in the treatment of pediatric AD.

EXPERT OPINION

Treating pediatric AD is complicated given the variety of disease severity, psychosocial impact, and relative lack of approved medications for severe disease. Given the safety data on dupilumab, newer biologics will likely be second-line. We do not yet understand the long-term impact of newer biologics on an immature immune system, nor do we fully understand their risks and toxicities. We should proceed optimistically, yet cautiously, with the study of biologics in children.

Examining recommendations for the use of biologics and other systemic therapies during COVID-19: a review and comparison of available dermatology guidelines and patient registries

BACKGROUND

The novel coronavirus (COVID-19) has an affinity for almost every organ system, including the skin. This review article will compile and compare dermatology guidelines related to the dermatologic care of patients during the COVID-19 pandemic.

OBJECTIVE

To review and compare the available guidelines and recommendations on use of biologics and other systemic therapies in dermatology patients.

METHODS

We conducted a search for guidelines and recommendations for dermatology providers, with specific attention to the management of biologics and non-biologic systemic agents during COVID-19. International and United States-based guidelines specific to the field of dermatology and guidance for healthcare providers were used as inclusion criteria. Available registries were included as well.

CONCLUSION

The guidelines stress a shared decision-making approach with risk-benefit analysis and treatment strategy modifications tailored to each unique patient case. The guidelines were all concordant with one another in highlighting the importance that patients should not discontinue their medications without first speaking with their providers.

An evaluation of baricitinib as a therapeutic option for adult patients with moderate to severe atopic dermatitis

INTRODUCTION

Moderate-to-severe AD burdens a large proportion of AD patients and may represent an inadequacy of treatment options available for resistant disease.

AREAS COVERED

This review provides an overview of the therapies for moderate-to-severe AD in late-stage development and in the clinic, and focuses on baricitinib as an emerging therapeutic option. Baricitinib is an orally available selective JAK1/JAK2 inhibitor that is approved for use in the treatment of moderate-to-severe rheumatoid arthritis (RA). Baricitinib decreases AD lesions, disease severity, and improves quality of life. Overall, the small molecule inhibitor is well tolerated. However, its black-box warnings in the RA population raise a concern for its long-term safety.

EXPERT OPINION

Baricitinib is a promising treatment modality for moderate-to-severe AD. Its primary advantage over dupilumab, the revolutionary biologic agent approved for AD, is that patients prefer an oral medication over an injection. However, providers will likely prescribe an injectable over an oral medication if baricitinib has an unfavorable safety profile. Insurance coverage of baricitinib will also have a major role in clinical use. Baricitinib will likely face competition from other JAK inhibitors in the future; however, it will have an advantage if it becomes the first FDA-approved medication of its kind for resistant AD.

Emerging systemic drugs in the treatment of plaque psoriasis

INTRODUCTION

Psoriasis is a common, chronic inflammatory skin condition that affects 2-3% of the US population and represents a large psychosocial burden for patients. Over the last decade, highly effective targeted therapies for psoriasis have been developed - namely, those targeting interleukin (IL)-17 and IL-23. The success of biologic agents targeting IL-17 and IL-23 underscores the importance of the IL-23/T helper (Th)17 cell axis in psoriasis pathogenesis. Oral small molecule drugs - such as Janus kinase (JAK) inhibitors, tyrosine kinase 2 (TYK2) inhibitors, and fumaric acid esters (FAEs) - are also being investigated for the treatment of psoriasis.

AREAS COVERED

This article reviews systemic biologic and oral small molecule drugs currently undergoing clinical trials for the treatment of plaque psoriasis.

EXPERT OPINION

Many patients with psoriasis have mild disease, and many with mild disease do not seek medical care for their condition. Many patients with mild disease could be adequately treated with topical treatments and phototherapy; however, adherence and feasibility have often been an issue with these treatment types. There seems to be limited room for development of novel biologics, as the existing ones are extraordinarily safe, effective, and convenient with few injections. Patients would prefer a safe, effective oral treatment; however, JAK inhibitors seem unlikely to fill this role completely.