Radiation Recall Dermatitis With Bruton Tyrosine Kinase Inhibitor Therapy

This case report describes a woman in her 70s with a history of breast cancer and chronic lymphocytic leukemia who presented with a painful rash of the bilateral chest extending onto the flanks.

Efficacy and safety of subcutaneous spesolimab for the prevention of generalised pustular psoriasis flares (Effisayil 2): an international, multicentre, randomised, placebo-controlled trial

BACKGROUND

Spesolimab is an anti-interleukin-36 receptor monoclonal antibody approved to treat generalised pustular psoriasis (GPP) flares. We aimed to assess the efficacy and safety of spesolimab for GPP flare prevention.

METHODS

This multicentre, randomised, placebo-controlled, phase 2b trial was done at 60 hospitals and clinics in 20 countries. Eligible study participants were aged between 12 and 75 years with a documented history of GPP as per the European Rare and Severe Psoriasis Expert Network criteria, with a history of at least two past GPP flares, and a GPP Physician Global Assessment (GPPGA) score of 0 or 1 at screening and random assignment. Patients were randomly assigned (1:1:1:1) to receive subcutaneous placebo, subcutaneous low-dose spesolimab (300 mg loading dose followed by 150 mg every 12 weeks), subcutaneous medium-dose spesolimab (600 mg loading dose followed by 300 mg every 12 weeks), or subcutaneous high-dose spesolimab (600 mg loading dose followed by 300 mg every 4 weeks) over 48 weeks. The primary objective was to demonstrate a non-flat dose-response curve on the primary endpoint, time to first GPP flare.

FINDINGS

From June 8, 2020, to Nov 23, 2022, 157 patients were screened, of whom 123 were randomly assigned. 92 were assigned to receive spesolimab (30 high dose, 31 medium dose, and 31 low dose) and 31 to placebo. All patients were either Asian (79 [64%] of 123) or White (44 [36%]). Patient groups were similar in sex distribution (76 [62%] female and 47 [38%] male), age (mean 40·4 years, SD 15·8), and GPP Physician Global Assessment score. A non-flat dose-response relationship was established on the primary endpoint. By week 48, 35 patients had GPP flares; seven (23%) of 31 patients in the low-dose spesolimab group, nine (29%) of 31 patients in the medium-dose spesolimab group, three (10%) of 30 patients in the high-dose spesolimab group, and 16 (52%) of 31 patients in the placebo group. High-dose spesolimab was significantly superior versus placebo on the primary outcome of time to GPP flare (hazard ratio [HR]=0·16, 95% CI 0·05-0·54; p=0·0005) endpoint. HRs were 0·35 (95% CI 0·14-0·86, nominal p=0·0057) in the low-dose spesolimab group and 0·47 (0·21-1·06, p=0·027) in the medium-dose spesolimab group. We established a non-flat dose-response relationship for spesolimab compared with placebo, with statistically significant p values for each predefined model (linear p=0·0022, emax1 p=0·0024, emax2 p=0·0023, and exponential p=0·0034). Infection rates were similar across treatment arms; there were no deaths and no hypersensitivity reactions leading to discontinuation.

INTERPRETATION

High-dose spesolimab was superior to placebo in GPP flare prevention, significantly reducing the risk of a GPP flare and flare occurrence over 48 weeks. Given the chronic nature of GPP, a treatment for flare prevention is a significant shift in the clinical approach, and could ultimately lead to improvements in patient morbidity and quality of life.

FUNDING

Boehringer Ingelheim.

Rapid and sustained improvements in Generalized Pustular Psoriasis Physician Global Assessment scores with spesolimab for treatment of generalized pustular psoriasis flares in the randomized, placebo-controlled Effisayil 1 study

BACKGROUND

Effisayil 1 was a randomized, placebo-controlled study of spesolimab, which is an anti-IL-36 receptor antibody, in patients presenting with a generalized pustular psoriasis flare.

OBJECTIVE

To assess the effects of spesolimab over the 12-week study.

METHODS

The primary endpoint of the study was Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) pustulation subscore of 0 at week 1. Patients (N = 53) were randomized (2:1) to receive a single intravenous dose of 900 mg spesolimab or placebo on day 1. Patients could receive open-label spesolimab for persistent flare symptoms on day 8.

RESULTS

Most patients receiving spesolimab achieved a GPPGA pustulation subscore of 0 (60.0%) and GPPGA total score of 0 or 1 (60.0%) by week 12. In patients randomized to placebo who received open-label spesolimab on day 8, the proportion with GPPGA pustulation subscore of 0 increased from 5.6% at day 8 to 83.3% at week 2. No factors predictive of spesolimab response were identified in patient demographics or clinical characteristics.

LIMITATIONS

The effect of initial randomization was not determined conventionally beyond week 1 due to patients receiving open-label spesolimab.

CONCLUSION

Rapid control of generalized pustular psoriasis flare symptoms with spesolimab was sustained over 12 weeks, further supporting its potential use as a therapeutic option for patients.

The Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) score: online assessment and validation study of a specific measure of GPP disease activity

Generalized pustular psoriasis (GPP), a rare and potentially life-threatening neutrophilic skin disease, is characterised by recurrent flares of pustulation on non-acral skin with associated erythema, crusting and scaling.1,2 There are no agreed or validated measurements for assessing GPP severity or symptom improvement; clinically validated endpoints that incorporate key manifestations of GPP, and are meaningful and reliable for the evaluation of treatment response, are needed.

NOVA-II: Part 2 study to evaluate the safety and efficacy of OQL011 on VEGF inhibitor-associated hand-foot skin reaction in patients with cancer

TPS741

Background: Hand-foot skin reaction (HFSR) is associated with the use of multi-targeted tyrosine kinase inhibitors sharing vascular endothelial growth factor receptor inhibitor (VEGFRi) activity (e.g., cabozantinib, regorafenib, sorafenib, sunitinib). HFSR results from impaired vascular repair mechanisms from inhibition of VEGF signaling and is characterized by painful palmoplantar lesions that may impact the quality of life and consistent dosing of anticancer agents. NOVA-II is a two-part, double-blind, randomized controlled trial evaluating OQL011, a nitroglycerin (NTG) topical ointment. Part 1 enrolled 31 subjects and studied OQL011 0.2% NTG for Grade ≥2 NCI CTCAE v5.0 palmar-plantar erythrodysesthesia (PPE). Part 1 safety and pharmacokinetic data support the continuance of NOVA-II, Part 2 dose-ranging study. The Part 1 inclusion criteria and primary endpoint were based on NCI CTCAE PPE. A unique investigator global assessment (IGA) was evaluated in Part 1 for HFSR severity (Grades 0-4) and has been revised utilizing Part 1 data for use as the primary endpoint for Part 2. We hypothesize that OQL011 containing NTG, a nitric oxide donor releasing free nitric oxide and activating guanylate cyclase in skin vessels, will mitigate HFSR symptoms and disease severity via local upregulation of the VEGF/VEGFR signaling pathways. Methods: NOVA-II Part 2 is a global, dose-ranging phase 2, double-blind, randomized controlled trial to evaluate the safety and efficacy of 3 doses of OQL011 (0.1%, 0.2%, and 0.5% NTG) compared to vehicle control for the treatment of moderate to severe VEGFRi associated HFSR. Part 2 will enroll up to 140 patients (randomized 1:1:1:1; vehicle: OQL011@ 0.1%: 0.2%: 0.5% NTG) with IGA Grade ≥3 (IGA scale 0-4). Subjects will apply the study drug (i.e., OQL011 or vehicle) to palmar and plantar surfaces TID and will be evaluated at Visit 1 (Day 0), Visit 2 (Day 14), and Visit 3 (Day 28). The primary endpoint is the proportion of patients achieving an IGA Grade ≤1 at Visit 2 (Day 14). A superiority test will be performed to compare each of the OQL011 doses to the vehicle, and the study drug exposure-response relationship will be explored. The correlation between IGA and NCI CTCAE v5.0 PPE, patient-reported outcomes including a numerical pain rating scale (NPRS), and Hand-foot Quality of Life (HF-QoL) questionnaire will be measured. Pharmacokinetics will be evaluated in a subset of subjects randomized 2:2:2:1, with 6 patients in each of the 3 OQL011 dose level groups and 3 patients in the vehicle group. PK samples will be collected on Day 0 at pre-dose, 5 min, 15 min, 30 min, 45 min, 1 h, 1.5 h, 2 h, 4 h, 6 h, and 8 h, after the first application of investigational drugs. Study enrollment for Part 2 is currently ongoing in the United States, India, and China. (NCT04088318) Clinical trial information: NCT04088318 .

Expert guidance on prophylaxis and treatment of dermatologic adverse events with Tumor Treating Fields (TTFields) therapy in the thoracic region

Tumor Treating Fields (TTFields) are electric fields, delivered via wearable arrays placed on or near the tumor site, that exert physical forces to disrupt cellular processes critical for cancer cell viability and tumor progression. As a first-in-class treatment, TTFields therapy is approved for use in newly diagnosed glioblastoma, recurrent glioblastoma, and pleural mesothelioma. Additionally, TTFields therapy is being investigated in non-small cell lung cancer (NSCLC), brain metastases from NSCLC, pancreatic cancer, ovarian cancer, hepatocellular carcinoma, and gastric adenocarcinoma. Because TTFields therapy is well tolerated and delivery is locoregional, there is low risk of additive systemic adverse events (AEs) when used with other cancer treatment modalities. The most common AE associated with TTFields therapy is mild-to-moderate skin events, which can be treated with topical agents and may be managed without significant treatment interruptions. Currently, there are no guidelines for oncologists regarding the management of TTFields therapy-related skin AEs in the thoracic region, applicable for patients with pleural mesothelioma or NSCLC. This publication aims to provide guidance on preventing, minimizing, and managing dermatologic AEs in the thoracic region to help improve patient quality of life and reduce treatment interruptions that may impact outcomes with TTFields therapy.

Factors Associated With Dermatologic Follow-up vs Emergency Department Return in Patients With Hidradenitis Suppurativa After an Initial Emergency Department Visit

Importance

Emergency department (ED) visitation is common for the treatment of hidradenitis suppurativa (HS), whereas dermatology outpatient care is low. The reasons underlying this differential follow-up have not been elucidated.

Objective

To assess the interventions and patient factors associated with ED return following an initial ED visit for HS.

Design, Setting, and Participants

This retrospective cohort study used data from the IBM® MarketScan® Commercial and Multi-State Medicaid databases (trademark symbols retained per database owner requirement). An HS cohort was formed from patients who had 2 or more claims for HS during the study period of 2010 to 2019 and with at least 1 ED visit for their HS or a defined proxy. Data were analyzed from November 2021 to May 2022.

Exposures

Factors analyzed included those associated with the ED visit and patient characteristics.

Main Outcomes and Measures

Primary outcomes were return to the ED or dermatology outpatient follow-up for HS or related proxy within 30 or 180 days of index ED visit.

Results

This retrospective cohort study included 20 269 patients with HS (median [IQR] age, 32 [25-41] years; 16 804 [82.9%] female patients), of which 7455 (36.8%) had commercial insurance and 12 814 (63.2%) had Medicaid. A total of 9737 (48.0%) patients had incision and drainage performed at the index ED visit, 14 725 (72.6%) received an oral antibiotic prescription, and 9913 (48.9%) received an opioid medication prescription. A total of 3484 (17.2%) patients had at least 1 return ED visit for HS or proxy within 30 days, in contrast with 483 (2.4%) who had a dermatology visit (P < .001). Likewise, 6893 (34.0%) patients had a return ED visit for HS or proxy within 180 days, as opposed to 1374 (6.8%) with a dermatology visit (P < .001). Patients with Medicaid and patients who had an opioid prescribed were more likely to return to the ED for treatment of their disease (odds ratio [OR], 1.48; 95% CI, 1.38-1.58; and OR, 1.48; 95% CI, 1.39-1.58, respectively, within 180 days) and, conversely, less likely to have dermatology follow-up (OR, 0.16; 95% CI, 0.14-0.18; and OR, 0.81; 95% CI, 0.71-0.91, respectively, within 180 days).

Conclusions and Relevance

This cohort study suggests that many patients with HS frequent the ED for their disease but are not subsequently seen in the dermatology clinic for ongoing care. The findings in this study raise the opportunity for cross-specialty interventions that could be implemented to better connect patients with HS to longitudinal care.

Design of Effisayil™ 2: A Randomized, Double-Blind, Placebo-Controlled Study of Spesolimab in Preventing Flares in Patients with Generalized Pustular Psoriasis

INTRODUCTION

Generalized pustular psoriasis (GPP) is a rare autoinflammatory skin disease characterized by flares of widespread erythema with sterile pustules, and can be relapsing with recurrent flares, or persistent with intermittent flares. Spesolimab, a humanized anti-interleukin-36 (IL-36) receptor monoclonal antibody, targets the key IL-36 pathogenetic pathway in GPP. A previous study showed that spesolimab treatment led to rapid pustular and skin clearance in patients with GPP flares, which was sustained for up to 12 weeks. This study investigates the long-term effects of spesolimab on GPP flares, for which no specific treatments are currently available. The Effisayil™ 2 study will assess whether maintenance treatment with subcutaneous spesolimab prevents the occurrence of GPP flares and determine the optimal dosing regimen to achieve this aim.

METHODS

Patients will have a documented history of GPP with a Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) score of 0 or 1 (clear or almost clear) at screening and randomization. Patients will be randomized 1:1:1:1 to three groups receiving a 600-mg subcutaneous loading dose of spesolimab followed by a 300-mg maintenance dose administered every 4 or 12 weeks, or a 300-mg loading dose followed by a 150-mg maintenance dose administered every 12 weeks, and one group receiving placebo, for 48 weeks. The primary endpoint is time to first GPP flare. If a patient experiences a GPP flare during the randomized maintenance treatment period, an open-label intravenous dose of 900-mg spesolimab will be administered, with an option for a second intravenous dose after 1 week.

CONCLUSIONS

Effisayil™ 2 is the first placebo-controlled study in patients with GPP to investigate whether maintenance treatment with spesolimab can prevent flares and provide sustained disease control. This study will provide valuable insights on the long-term management of patients with this potentially life-threatening skin disease.

TRIAL REGISTRATION NUMBER

NCT04399837.

A survey study of prevention and treatment patterns by academic and community oncologists for papulopustular, acneiform skin rash associated with epidermal growth factor receptor inhibitor (EGFRi) therapy

e24083

Background: EGFRi’s are associated with dermatologic AEs that include an acneiform skin rash. This rash occurs in up to 80% for all grades and 18% for grades ≥3. Treatments are based on grade and include topical antibiotics or corticosteroids for grades 1 and 2, and EGFRi dose interruption and/or oral corticosteroids for severe grades (i.e., ≥ grade 3). For prevention, topical corticosteroids or oral antibiotics are recommended. This survey was conducted to assess current toxicity management patterns and treatment gaps for EGFRi associated skin rash. Methods: An online survey (MedSurvey) with 5 eligibility & 8 questions related to EGFRi practice patterns was conducted (April 2021). Fifty-one practicing oncologists completed the survey. Results: Among the 51 oncologists, 86% have been practicing ≥ 11 yrs with 37% from an academic and 63% from a community setting. They (percent of respondents) prescribed cytotoxic chemotherapy (91%) and targeted agents (84%) > 10x/week. Prevention of EGFRi skin rash with topical antibiotics (33%), topical steroids (45%), and oral antibiotics (45%) were commonly administered prophylactic treatments, while 26% do not treat prophylactically. EGFRi’s were started at a lower dose always 6%, frequently (≥50%) 26%, sometimes (< 50%) 24%, and never 45% of the time. Skin rash treatment is started by 47% at Grade 1, 33% at Grade 2, and 2% ≥Grade 3, while 18% start treatment prophylactically. The majority (57%) would use a novel agent to treat skin rash, while 26% would use it for patients with a previous occurrence, 13% for those not responding to the standard of care and 2% would use this agent for selected EGFR inhibitors. For Grade 1 skin rash (multiple choices allowed), 33% used observation only for management, whereas 55% prescribed topical antibiotics, 35% prescribed oral antibiotics, and 55% used topical steroids. Dose reduction was implemented 4% of the time. For Grade 2 skin rash (multiple choices allowed) 51% used topical antibiotics, 63% prescribed an oral antibiotic, and 77% used topical steroids. Dose reduction was used 35% of the time. For patients not responding to standard therapy 6% switched to a different anti-cancer regimen, 16% changed to another EGFRi, while 77% interrupted the EGFRi therapy. Conclusions: Treating EGFRi-associated skin rash continues to be a significant challenge with Grade 2/3 toxicity or patients not responding to standard treatment. This often requires a therapeutic dose reduction or interruption that may impact the efficacy of anti-cancer treatment. Effective management (prevention and treatment) for skin toxicities associated with EGFRi inhibitors remains an unmet need for many patients and a treatment challenge for oncologists.

A survey study of prevention and treatment patterns by academic and community oncologists for hand-foot skin reaction associated with vascular endothelial growth factor receptor inhibitor (VEGFRi) therapy

322

Background: VEGFRi therapies are associated with hand-foot skin reaction (HFSR) that affects up to 69% of patients depending on the VEGFRi administered. The incidence and severity of HFSR are dose-dependent and have been associated with improved clinical outcomes suggesting a direct toxicity mechanism. HFSR significantly diminishes patients’ quality of life and effects optimal treatment. Current HFSR treatments focus on managing symptoms since there are no effective therapies that address the underlying cause of HFSR. Small studies and expert opinion have suggested treating HFSR with topical corticosteroids or urea-based creams. However, the most effective management remains dose reduction/interruption or treatment discontinuation. This survey was conducted to assess current toxicity management patterns and treatment gaps for VEGFRi associated HFSR. Methods: An online survey (MedSurvey) with 5 eligibility & 8 questions related to VEGFRi practice patterns was conducted (April 27 to 30, 2021). Fifty-one (51) practicing oncologists completed the survey. Results: Among the 51 oncologists, 86% have been practicing ≥ 11 yrs with 37% from an academic setting and 63% from a community setting. They (percent of respondents) prescribed cytotoxic chemotherapy (91%) and targeted agents (84%) more than 10 times per week. Prevention of VEGFRi-induced HFSR with urea (57%) or topical steroids (75%) were the commonly administered prophylactic treatments. The majority (53%) would prophylactically use a novel agent to prevent HFSR, while 33% would use it for HFSR prevention in a patient with a previous occurrence, and 12% would use this agent for selected VEGFR inhibitors. Many oncologists (4% always, 61% sometime/frequently) start a VEGFRi at a lower dose and titrate up to prevent HFSR. For grade 1 HFSR (multiple choices allowed), 37% used observation only for management, whereas 51% prescribed urea ointment, and 63% used a topical steroid. Dose reduction was implemented 20% of the time. For grade 2 HFSR (multiple choices allowed) 53% used urea ointment, 84% prescribed a topical steroid and 59% considered dose reduction as a treatment strategy. For patients not responding to standard therapy 2% switched to a different anti-cancer regimen, 18% changed the VEGFRi, while 78% interrupted the VEGFRi therapy. Conclusions: Treating VEGFRi-associated HFSR continues to be a significant challenge with grade 2/3 toxicity or patients not responding to standard treatment. This often requires a therapeutic dose reduction or interruption that may impact the efficacy of anti-cancer treatment. Effective management (prevention and treatment) for skin toxicities associated with targeted-multikinase/VEGFRi inhibitors remains an unmet need for many patients and a treatment challenge for oncologists.

Part 1 results from NOVA-II, a randomized, double-blind, vehicle-controlled phase II study evaluating the safety and efficacy of OQL011 on VEGFR inhibitor associated hand-foot skin reaction in cancer patients

TPS396

Background: Hand-foot skin reaction (HFSR) is associated with the use of multi-targeted tyrosine kinase inhibitors sharing vascular endothelial growth factor receptor inhibitory (VEGFRi) activity (e.g., cabozantinib, regorafenib, sorafenib, sunitinib). HFSR affects the palms and soles with edema, erythema, hyperkeratosis, pain, and bullae/blisters impacting quality-of-life, activities of daily living, and consistent VEGFRi dosing. HFSR incidence differs among VEGFRi, ranging from 5-69% (all grades) and 1-19% (grade 3). Topical urea has marginal benefit, and to date, there are no regulatory authority approved HFSR treatments. The pathogenesis of HFSR has been partially associated with impaired vascular repair mechanisms resulting from inhibition of VEGF signaling. Nitric oxide (NO) has been reported to induce VEGF upregulation at a moderate concentration. We hypothesized that topical stimulation of VEGF signaling through OQL011, an NO donor, will safely and effectively mitigate HFSR. Methods: NOVA-II is a phase 2, double-blind, randomized vehicle-controlled trial evaluating the safety and efficacy of OQL011 for the treatment of moderate to severe HFSR. Subjects receiving a VEGFRi (either mono- or combination therapy) and have Grade ≥2 HFSR per NCI CTCAE v5.0 for palmar plantar erythrodysesthesia (PPE) were eligible. For Part 1, 31 subjects were randomized (2:1) and received 0.2% OQL011 topical ointment or vehicle TID for 6 weeks. The primary endpoint is the proportion of patients who achieve an NCI CTCAE v5.0 for PPE Grade 0 or 1 by Week 3. An investigator global assessment (IGA) scale is being developed to assess HFSR recovery, and a secondary endpoint will measure the proportion of patients who have improvement in HFSR severity and achieve an IGA score of clear (0) or almost clear (1) by Week 3 and/or Week 6. A Chi-square test will be used to detect a difference between the treatment arm and the vehicle-control arm. Additionally, the IGA score will be validated by assessing the inter- & intra-rater reliability. The correlation between IGA, NCI CTCAE v5.0 for PPE, and patient outcomes including Visual Analog Scale of Pain, HFSR Quality of Life questionnaire will also be reported. This study began enrolling patients in December 2019 and completed the last patient Visit in August 2021. Data lock, unblinding and data analysis will be completed by mid-November. Clinical trial information: NCT04088318.

Recurrent Onychomadesis of the Toenails in Children and Adults: A Case Series

INTRODUCTION

Onychomadesis occurs when the nail plate separates from the nail matrix and nail bed, eventually leading to shedding of the nail. This condition has been attributed to viral infections, autoimmune disorders, drug side effects, and physical trauma. A subset of patients has a recurrent form of onychomadesis without a clear trigger; this phenomenon is not well characterized in the literature.

CASE PRESENTATION

We present a case series of pediatric and adult patients with recurrent toenail onychomadesis in order to better characterize the disorder and explore possible etiologies, risk factors, and treatments.

DISCUSSION/CONCLUSION

For the cases herein, we propose microtrauma associated with footwear as the underlying etiology given the periodicity of nail shedding, exclusion of other etiological factors, and presence of predisposing risk factors in certain patients. Many patients saw improvement with application of urea 40% cream, suggesting this can be a valuable part of a treatment strategy, in addition to minimizing injury to involved digits.

Trial of Spesolimab for Generalized Pustular Psoriasis

BACKGROUND

Generalized pustular psoriasis (GPP) is a rare, life-threatening, inflammatory skin disease characterized by widespread eruption of sterile pustules. Interleukin-36 signaling is involved in the pathogenesis of this disorder. Spesolimab, a humanized anti-interleukin-36 receptor monoclonal antibody, is being studied for the treatment of GPP flares.

METHODS

In a phase 2 trial, we randomly assigned patients with a GPP flare in a 2:1 ratio to receive a single 900-mg intravenous dose of spesolimab or placebo. Patients in both groups could receive an open-label dose of spesolimab on day 8, an open-label dose of spesolimab as a rescue medication after day 8, or both and were followed to week 12. The primary end point was a Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) pustulation subscore of 0 (range, 0 [no visible pustules] to 4 [severe pustulation]) at the end of week 1. The key secondary end point was a GPPGA total score of 0 or 1 (clear or almost clear skin) at the end of week 1; scores range from 0 to 4, with higher scores indicating greater disease severity.

RESULTS

A total of 53 patients were enrolled: 35 were assigned to receive spesolimab and 18 to receive placebo. At baseline, 46% of the patients in the spesolimab group and 39% of those in the placebo group had a GPPGA pustulation subscore of 3, and 37% and 33%, respectively, had a pustulation subscore of 4. At the end of week 1, a total of 19 of 35 patients (54%) in the spesolimab group had a pustulation subscore of 0, as compared with 1 of 18 patients (6%) in the placebo group (difference, 49 percentage points; 95% confidence interval [CI], 21 to 67; P<0.001). A total of 15 of 35 patients (43%) had a GPPGA total score of 0 or 1, as compared with 2 of 18 patients (11%) in the placebo group (difference, 32 percentage points; 95% CI, 2 to 53; P = 0.02). Drug reactions were reported in 2 patients who received spesolimab, in 1 of them concurrently with a drug-induced hepatic injury. Among patients assigned to the spesolimab group, infections occurred in 6 of 35 (17%) through the first week; among patients who received spesolimab at any time in the trial, infections had occurred in 24 of 51 (47%) at week 12. Antidrug antibodies were detected in 23 of 50 patients (46%) who received at least one dose of spesolimab.

CONCLUSIONS

In a phase 2 randomized trial involving patients with GPP, the interleukin-36 receptor inhibitor spesolimab resulted in a higher incidence of lesion clearance at 1 week than placebo but was associated with infections and systemic drug reactions. Longer and larger trials are warranted to determine the effect and risks of spesolimab in patients with pustular psoriasis. (Funded by Boehringer Ingelheim; Effisayil 1 ClinicalTrials.gov number, NCT03782792.).

Reducing Skin Toxicities from EGFR Inhibitors with Topical BRAF Inhibitor Therapy

Treatment of cancer with EGFR inhibitors is limited by on-target skin toxicities induced by inhibition of the MAPK pathway. BRAF inhibitors are known to paradoxically activate the MAPK downstream of EGFR, which we confirmed using human skin keratinocytes. We then conducted a phase I clinical trial testing the hypothesis that topical therapy with the BRAF inhibitor LUT014 could improve skin toxicities induced by EGFR inhibitors. Ten patients with metastatic colorectal cancer who had developed acneiform rash while being treated with cetuximab or panitumumab were enrolled in three cohorts. LUT014 was well tolerated, and there were no dose-limiting toxicities. The acneiform rash improved in the 6 patients who started with grade 2 rash in the low and intermediate cohorts. We conclude that topical LUT014 is safe and efficacious in improving rash from EGFR inhibitors, consistent with the mechanism of action inducting paradoxical MAPK activation. SIGNIFICANCE: BRAF inhibitor topical therapy could avoid dose reductions of EGFR inhibitors, locally treating the main dose-limiting skin toxicity of this class of agents.This article is highlighted in the In This Issue feature, p. 2113.

A phase II study to evaluate the safety and efficacy of OQL011 on VEGFR inhibitor-associated hand-foot-skin reaction in cancer patients

TPS12132

Background: Hand-Foot Skin Reaction (HFSR) is frequently associated with the use of multi-targeted tyrosine kinase inhibitors of the vascular endothelial growth factor receptor (VEGFRi) such as cabozantinib, regorafenib, sunitinib, and lenvatinib. HFSR affects the skin on the palms and soles and is manifested as edema, erythema, hyperkeratosis, and bullae, leading to a decrease in quality of life and interruptions in dosing. The incidence of HFSR differs among VEGFRi, ranging from 5-60% (all grades) and 1-18% (grade 3). To date, there is no FDA approved treatment for HFSR, and marginal benefit has been shown with topical urea or steroids. Although not fully elucidated, the pathogenesis of HFSR has been associated with impaired vascular repair mechanisms, caused by inhibition of VEGF signaling pathways. We hypothesize that topical stimulation of VEGFR through OQL011 will decrease the severity of HFSR symptoms via local upregulation of the VEGF/VEGFR related signaling pathways. Methods: NCT04088318 is a phase 2, double-blind, randomized controlled trial to evaluate the safety and efficacy of OQL011 compared to vehicle control in the treatment of moderate to severe HFSR in patients on VEGFRi therapy. Eligible patients will have ≥ grade 2 palmar plantar erythrodysesthesia (PPE). The study is expected to enroll 112 patients in two parts. In the first part, 42 patients will apply 0.2% OQL011 topical ointment or vehicle control (2:1 randomization) TID for six weeks. In Part 2, 70 subjects will be randomized into two additional dose levels or vehicle control in a 2:2:1 ratio. The two dose levels selected will be based on the efficacy and safety results of Part 1. The primary efficacy endpoint is improvement of NCI CTCAE v5.0 PPE to grade ≤1 by week 3. Photographs of the affected areas will be taken at Day 0, 7, 14, 21 and 42 timepoints. Superiority test will be performed to compare treatment groups, and the exposure-response relationship will be explored. In addition, an investigator global assessment (IGA) for HFSR will be used in this trial to specifically assess skin recovery and is proposed to be a new evaluation tool. The validity of IGA criteria will be evaluated by assessing the inter-rater and intra-rater reliability. The correlation between IGA, NCI CTCAE v5.0 for PPE, and patient reported outcomes including Visual Analog Scale of Pain, Hand-foot Quality of Life questionnaire will also be evaluated. This study began enrolling patients in December 2019 and is ongoing. Clinical trial information: NCT04088318.

Dermatologic Adverse Events Associated with Selective Fibroblast Growth Factor Receptor Inhibitors: Overview, Prevention, and Management Guidelines

Fibroblast growth factor receptor (FGFR) tyrosine kinases, which are expressed on the cell membrane, are involved in a wide range of biological functions such as cell proliferation, survival, migration, and differentiation. The identification of FGFR fusions and other alterations in a wide range of solid tumors, including cholangiocarcinoma and bladder cancer, has resulted in the development of several selective FGFR inhibitors for use in these indications, for example, infigratinib, erdafitinib, derazantinib, pemigatinib, and futibatinib. In addition to the typical adverse events associated with tyrosine kinases, the FGFR inhibitors appear to give rise to a number of adverse events affecting the skin. Here we describe these skin events, which include the more common nail adverse events (e.g., onycholysis), palmar-plantar erythrodysesthesia syndrome, and stomatitis, as well as less common reactions such as calciphylaxis. This review aims to provide oncologists with an understanding of these dermatologic events and proposes guidelines for the management of treatment-emergent dermatologic adverse events. Awareness of possible adverse events associated with specific drugs should allow physicians to educate patients as to what to expect and implement effective management plans at the earliest possible opportunity, thereby preventing premature discontinuation while maintaining patient quality of life. IMPLICATIONS FOR PRACTICE: Identification of fibroblast growth factor receptor (FGFR) aberrations in cholangiocarcinoma and bladder cancer led to development of selective FGFR inhibitors for these indications, based on clinical benefit and safety profiles. The most frequent adverse events (AEs) include those affecting skin, hair, and nails, a unique class effect of these agents. These are usually mild to moderate in severity. This work reviewed skin AEs reported with FGFR inhibitors and provides management guidelines for physicians, aiming to increase awareness of skin events and provide effective treatment strategies. Early intervention and effective management may improve treatment adherence, optimize outcomes, and improve quality of life.

Navigating immunosuppression in a pandemic: A guide for the dermatologist from the COVID Task Force of the Medical Dermatology Society and Society of Dermatology Hospitalists

Dermatologists treating immune-mediated skin disease must now contend with the uncertainties associated with immunosuppressive use in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Although the risk of infection with many commonly used immunosuppressive agents remains low, direct data evaluating the safety of such agents in coronavirus disease 2019 (COVID-19) are scarce. This article reviews and offers guidance based on currently available safety data and the most recent COVID-19 outcome data in patients with immune-mediated dermatologic disease. The interdisciplinary panel of experts emphasizes a stepwise, shared decision-making approach in the management of immunosuppressive therapy. The goal of this article is to help providers minimize the risk of disease flares while simultaneously minimizing the risk of iatrogenic harm during an evolving pandemic.

Prevention and Management of Dermatologic Adverse Events Associated With Tumor Treating Fields in Patients With Glioblastoma

Importance: Tumor Treating Fields (TTFields) are an anti-mitotic treatment approved for treating newly diagnosed and recurrent glioblastoma, and mesothelioma. TTFields in glioblastoma comprise alternating electric fields (200 kHz) delivered continuously, ideally for ≥18 h/day, to the tumor bed via transducer arrays placed on the shaved scalp. When applied locoregionally to the tumor bed and combined with systemic temozolomide chemotherapy, TTFields improved overall survival vs. temozolomide alone in patients with newly diagnosed glioblastoma. Improved efficacy outcomes with TTFields were demonstrated, while maintaining a well-tolerated and manageable safety profile. The most commonly-reported TTFields–associated adverse events (AEs) are beneath-array dermatologic events. Since survival benefit from TTFields increases with duration-of-use, prevention and management of skin AEs are critical to maximize adherence. This paper describes TTFields-associated dermatological AEs and recommends prevention and management strategies based on clinical trial evidence and real-world clinical experience.

Observations: TTFields–associated skin reactions include contact dermatitis (irritant/allergic), hyperhidrosis, xerosis or pruritus, and more rarely, skin erosions/ulcers and infections. Skin AEs may be prevented through skin-care and shifting (~2 cm) of array position during changes. TTFields–related skin AE management should be based on clinical phenotype and severity. Depending on diagnosis, recommended treatments include antibiotics, skin barrier films, moisturizers, topical corticosteroids, and antiperspirants. Water-based lotions, soaps, foams, and solutions with minimal impact on electrical impedance are preferred with TTFields use over petroleum-based ointments, which increase impedance.

Conclusions: Early identification, prophylactic measures, and symptomatic skin AE management help patients maximize TTFields usage, while maintaining quality-of-life and optimizing therapeutic benefit.

Implications for practice: TTFields confer a survival benefit in patients with glioblastoma that correlates positively with duration of daily use. Skin events (rash) are the primary treatment-related AE that can limit duration of use. The recommendations described here will help healthcare professionals to recognize, prevent, and manage dermatologic AEs associated with TTFields treatment. These recommendations may improve cutaneous health and support adherence to therapy, both of which would maximize treatment outcomes.

Pemphigus foliaceus in a patient with gastrointestinal stromal tumor treated with adjuvant imatinib mesylate

Pemphigus is an autoimmune bullous disease with a number of described associations, including medications, which have been grouped into three structural categories - thiol drugs, phenol drugs, and drugs with neither functional group [1]. Discontinuation of the offending medication is considered a mainstay of therapy. We report a patient in whom the onset of pemphigus foliaceus was associated with initiation of imatinib mesylate adjuvant therapy in a patient with resected gastrointestinal stromal tumor (GIST). Imatinib was continued because of the survival benefit to the patient with a resected, high risk GIST. Treatment with rituximab resulted in near resolution of his blistering rash and follow up enzyme-linked immunosorbent assay (ELISA) demonstrated reference range immunoreactivity for both desmoglein 1 and desmoglein 3. After dose increase of imatinib therapy owing to tumor growth, the patient subsequently again developed a similar eruption. Re-biopsy and ELISA were consistent with recurrence of pemphigus. In conclusion, although the patient's pemphigus was cleared with a single cycle of rituximab infusions while continuing imatinib therapy, the disease returned after imatinib dose was increased a year later, suggesting a dose-response relationship.

Association of Leukemia Cutis With Survival in Acute Myeloid Leukemia

Importance

Leukemia cutis (LC) is an important yet understudied extramedullary manifestation of leukemia. Previous reports have suggested poor prognosis for patients with LC, but these reports have largely consisted of descriptive studies with a limited number of patients.

Objectives

To identify patient factors associated with LC and characterize the association of LC with the course of acute myeloid leukemia (AML).

Design, Setting, and Participants

This retrospective, matched-cohort study included 1683 patients with AML diagnosed from January 1, 2005, to April 1, 2017, with and without biopsy-proven LC seen at a single-center, tertiary care hospital in St Louis, Missouri. To specifically evaluate differences in survival, propensity scoring was used to match patients with AML with LC to patients with AML without LC off the logit of propensity score based on age, race/ethnicity, sex, and leukemia type. Kaplan-Meier methods were used to compare cumulative probability survival. Matched survival analysis was performed with extended Cox regression to determine factors associated with leukemia-specific and overall survival.

Main Outcomes and Measures

Leukemia-specific survival and overall survival.

Results

A total of 1683 patients were reviewed, including 78 patients with biopsy-proven LC of the AML type and 1605 patients with AML without LC. A total of 62 of the patients with AML and LC (mean [SD] age, 58.2 [11.7] years; 33 [53.2%] male) were matched in a 1:3 ratio to 186 patients with AML without LC (mean [SD] age, 58.2 [13.5] years; 103 [55.4%] male). The 5-year survival among the 62 patients with AML with LC was 8.6%, shorter than the 28.3% among the 186 matched patients with AML without LC. Matched survival analysis revealed that patients with AML and LC compared with those without LC had hazard ratios of 2.06 (95% CI, 1.26-3.38; P = .004) for leukemia-specific death and of 1.66 (95% CI, 1.06-2.60; P = .03) for all-cause death. In addition, matched patients with LC had greater odds of extramedullary organ burden (odds ratio, 3.48; 95% CI, 1.72-7.05; P < .001).

Conclusions and Relevance

The results suggest that the presentation of LC in patients with AML is associated with decreased overall survival and leukemia-specific survival. Patients with AML presenting with LC may require more intensive treatment and monitoring of their leukemic disease.

Psoriasis and mortality in the United States: Data from the National Health and Nutrition Examination Survey

BACKGROUND

Psoriasis is a multifactorial disease that has been associated with multiple systemic disorders. Despite its role in mediating cardiovascular, metabolic, and pulmonary disorders, few studies have examined the independent mortality risk associated with psoriasis.

OBJECTIVE

To determine the independent relationship between psoriasis and all-cause mortality in a nationally representative sample of the US population.

METHODS

Retrospective population-based cohort study of adults and adolescents older than 10 years (N = 13 031) who participated in National Health and Nutrition Examination Surveys (2003-2006 and 2009-2010). Psoriasis status was determined from a self-reported medical history questionnaire. Mortality data are linked from national databases.

RESULTS

Psoriasis was present in 2.7% of the study population. Over an average median follow-up of 52.3 months, psoriasis was significantly associated with increased mortality risk (HR, 1.99; 95% CI, 1.01-3.93; P = .047) with adjustment for demographics, smoking, and comorbidities including cardiovascular disease, diabetes, chronic obstructive pulmonary disease, cancer, chronic kidney disease, and stroke. These comorbidities mediated 15.5%, 5.9%, 8.7%, 11.7%, 4.2%, and 4.7% of the association between psoriasis and mortality, respectively.

CONCLUSION

Psoriasis is independently associated with an increased risk of mortality. This relationship is partially mediated by an increased prevalence of the cardiovascular, infectious, and neoplastic disorders seen among patients with psoriasis.

Association Between Psoriasis with Arthritis and Hearing Impairment in US Adults: Data from the National Health and Nutrition Examination Survey

Objective.

Emerging data has linked inflammatory arthritis with hearing impairment (HI). The objective of this study was to investigate the relationship between psoriasis with arthritis (PsA) and HI in the US population. Given the known association of HI and depression, a secondary aim is to investigate the effect of PsA on mental well-being.

Methods.

Cross-sectional study using the National Health and Nutrition Examination Survey for adults aged ≥ 20 years (n = 10,747). Association of PsA with above outcomes was examined using multivariable generalized linear and ordinal logistic regression models, adjusted for demographics and medical comorbidities. Structural equation models examined the extent to which HI mediated the effect of PsA on mental health.

Results.

Individuals with PsA were more likely to report hearing difficulties (OR 1.50, p = 0.043), visit a mental health provider (OR 1.62, p = 0.084), have 1.62 more days of poor mental health over the previous month (p = 0.033), and have depression (OR 2.01, p = 0.015) compared to controls. HI mediated 6.5%, 8.3%, and 5.0% of the effect of PsA on the above mental health outcomes, respectively.

Conclusion.

PsA is independently associated with a significantly increased risk of HI, which partially mediates an association with worsened psychiatric outcomes.

Chronic Inflammation Promotes Skin Carcinogenesis in Cancer-Prone Discoid Lupus Erythematosus

High-risk skin cancer is a rare, but severe, complication associated with discoid lupus erythematosus (DLE). Chronic scar, inflammation, UVR, and immunosuppressive medications are proposed explanations for this heightened skin cancer risk; however, the exact mechanism driving skin carcinogenesis in DLE is unknown. The distinct co-localization of multiple independent skin cancers with areas of active inflammation in two DLE patients followed over 8 years strongly suggested that lupus inflammation promotes skin carcinogenesis in DLE. To investigate this clinical observation, we subjected lupus-prone MRL/lpr and control (MRL/n) mice to a skin carcinogenesis protocol. Skin tumors developed preferentially within the cutaneous lupus inflammation without scarring in MRL/lpr mice (P < 0.01). The inflammation in MRL/lpr skin was characterized by the accumulation of regulatory T cells, mast cells, M2 macrophages, and markedly elevated transforming growth factor-β1 and IL-6 levels, which have been linked to tumor promotion. Tacrolimus treatment reduced skin inflammation and blocked cancer development in MRL/lpr mice (P = 0.0195). A similar tumor-promoting immune environment was detected in SCCs and the perilesional skin of cancer-prone DLE patients. Therefore, discoid lupus inflammation promotes skin cancer in high-risk DLE patients, and blocking the inflammation may be critical for preventing this life-threatening complication of DLE.

First-in-human phase 1 clinical study of the IL-15 superagonist complex ALT-803 to treat relapse after transplantation

New therapies for patients with hematologic malignancies who relapse after allogeneic hematopoietic cell transplantation (allo-HCT) are needed. Interleukin 15 (IL-15) is a cytokine that stimulates CD8+ T-cell and natural killer (NK) cell antitumor responses, and we hypothesized this cytokine may augment antileukemia/antilymphoma immunity in vivo. To test this, we performed a first-in-human multicenter phase 1 trial of the IL-15 superagonist complex ALT-803 in patients who relapsed >60 days after allo-HCT. ALT-803 was administered to 33 patients via the IV or subcutaneous (SQ) routes once weekly for 4 doses (dose levels of 1, 3, 6, and 10 μg/kg). ALT-803 was well tolerated, and no dose-limiting toxicities or treatment-emergent graft-versus-host disease requiring systemic therapy was observed in this clinical setting. Adverse events following IV administration included constitutional symptoms temporally related to increased serum IL-6 and interferon-γ. To mitigate these effects, the SQ route was tested. SQ delivery resulted in self-limited injection site rashes infiltrated with lymphocytes without acute constitutional symptoms. Pharmacokinetic analysis revealed prolonged (>96 hour) serum concentrations following SQ, but not IV, injection. ALT-803 stimulated the activation, proliferation, and expansion of NK cells and CD8+ T cells without increasing regulatory T cells. Responses were observed in 19% of evaluable patients, including 1 complete remission lasting 7 months. Thus, ALT-803 is a safe, well-tolerated agent that significantly increased NK and CD8+ T cell numbers and function. This immunostimulatory IL-15 superagonist warrants further investigation to augment antitumor immunity alone and combined with other immunotherapies. This trial was registered at www.clinicaltrials.gov as #NCT01885897.

Acute graft-versus-host disease following lung transplantation in a patient with a novel TERT mutation

Familial pulmonary fibrosis is associated with loss-of-function mutations in telomerase reverse transcriptase (TERT) and short telomeres. Interstitial lung diseases have become the leading indication for lung transplantation in the USA, and recent data indicate that pathogenic mutations in telomerase may cause unfavourable outcomes following lung transplantation. Although a rare occurrence, solid organ transplant recipients who develop acute graft-versus-host disease (GVHD) have very poor survival. This case report describes the detection of a novel mutation in TERT in a patient who had lung transplantation for familial pulmonary fibrosis and died from complications of acute GVHD.

The effect of smoking and age on the response to first-line therapy of hidradenitis suppurativa: An institutional retrospective cohort study

BACKGROUND

Treatment for hidradenitis suppurativa is often empiric and inadequate, and determining which patients will respond is difficult.

OBJECTIVE

We sought to determine which patient factors are associated with a positive response to first-line medical therapy.

METHODS

A single-center retrospective cohort study of all patients with hidradenitis suppurativa seen between January 1, 1992, and October 1, 2014, was conducted. Response to first-line medical therapy (oral/topical antibiotics, intralesional corticosteroids, and topical washes) was examined at follow-up within 6 months of initiating therapy. A multivariate binary logistic regression model was built examining response to treatment and the interplay of patient factors and treatment initiated.

RESULTS

In all, 198 patients were included in the final model. Nonsmokers (odds ratio 2.634, 95% confidence interval 1.301-5.332, P = .007) and older individuals (odds ratio 1.046 for each additional year, 95% confidence interval 1.020-1.072, P < .001) were more likely to have improvement at follow-up. In addition, current smokers differed significantly from nonsmokers in several regards.

LIMITATIONS

The retrospective nature of this study is a limitation, as is relying on classification of disease severity from physical examination findings in some patients.

CONCLUSIONS

The results of this study suggest that clinicians may be able to more accurately predict which patients with hidradenitis suppurativa will respond to first-line medical therapy, and which patients may require therapy escalation.

Dermatologic adverse events to chemotherapeutic agents, part 1: cytotoxics, epidermal growth factor receptors, multikinase inhibitors, and proteasome inhibitors

Dermatologic toxicities have profound effects on patients receiving chemotherapy for cancer treatment. Cytotoxic chemotherapies are associated with a number of nonspecific dermatologic adverse events including alopecia, mucositis, and onychodystrophy. Targeted therapies including epidermal growth factor inhibitors, multikinase inhibitors, and proteasome inhibitors are associated with different skin reactions that are class-specific. In Part 1 of this review, we examine the presentations of the most common dermatologic adverse events associated with the above drugs and discuss the strategies used for their prevention and treatment.

Palmoplantar pustules and osteoarticular pain in a 42-year-old woman

Key teaching points • Synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome is characterized by distinctive osteoarticular manifestations and a spectrum of neutrophilic dermatoses. • The most common dermatologic manifestations include palmoplantar pustulosis, acne conglobata, and acne fulminans. • SAPHO syndrome should be considered in patients presenting osteoarticular pain, particularly involving the anterior chest wall and/or spine, and neutrophilic skin lesions.

Fever, eosinophilia, and death: a case of minocycline hypersensitivity

Minocycline (MCN) is a member of the tetracycline family that is commonly used to treat dermatologic conditions such as acne and perioral dermatitis; however, it also has been associated with a number of adverse effects, including drug reaction with eosinophilia and systemic symptoms (DRESS). We report the case of a 46-year-old woman who developed a rash, fever, and eosinophilia during treatment with MCN for perioral dermatitis. Although MCN was discontinued and the patient was administered oral corticosteroids for several months, she subsequently died from multiorgan failure with giant cell myocardi-tis (GCM) and eosinophilic myocarditis found on autopsy. This article highlights a rare consequence of hypersensitivity to a commonly used drug and illustrates the importance of rapid recognition and aggressive management of MCN-induced DRESS.