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What's new in dermatology

What's new in dermatology
Authors:
Abena O Ofori, MD
Rosamaria Corona, MD, DSc
Literature review current through: Feb 2022. | This topic last updated: Feb 12, 2022.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

ATOPIC DERMATITIS AND OTHER DERMATITIS

Tralokinumab for atopic dermatitis (February 2022)

Adults with persistent, moderate-to-severe atopic dermatitis (AD) despite optimal topical therapy may require systemic immunomodulatory therapy to achieve adequate disease control. In a recent randomized trial of 380 adults with moderate-to-severe AD, more patients assigned to subcutaneous tralokinumab, a fully human monoclonal anti-interleukin-13 antibody, achieved a 75 percent improvement in the Eczema Area and Severity Index at 16 weeks compared with placebo (56 versus 36 percent, respectively) [1]. All patients were allowed to use a midpotency topical corticosteroid as needed. Treatment was general well tolerated. Conjunctivitis was more common in patients receiving tralokinumab than in those receiving placebo. These findings support the efficacy of tralokinumab for adults with AD; this and other studies were the basis for US Food and Drug Administration approval of tralokinumab for this indication. However, long-term studies are needed before its use becomes routine. (See "Treatment of atopic dermatitis (eczema)", section on 'Tralokinumab'.)

Topical ruxolitinib for atopic dermatitis (October 2021)

Topical ruxolitinib, a Janus kinase (JAK) inhibitor, is a new short-term therapy for atopic dermatitis (AD). In two randomized trials that enrolled over 1200 adolescents and adults with mild to moderate AD (<20 percent of body surface area affected) not controlled by topical prescription medications, more individuals assigned to ruxolitinib cream (0.75% or 1.5%) achieved clear or almost clear skin and reduced pruritis with no increase in adverse effects compared with vehicle [2]. Based on these findings, topical ruxolitinib has been approved by the US Food and Drug Administration for the short-term treatment of mild to moderate AD in immunocompetent individuals with the characteristics of the study participants. Although topical ruxolitinib appears promising, more data are needed regarding its systemic absorption and long-term safety before its use becomes routine. (See "Treatment of atopic dermatitis (eczema)", section on 'Topical ruxolitinib'.)

Oral upadacitinib versus subcutaneous dupilumab for atopic dermatitis (October 2021)

Evidence continues to mount that upadacitinib, an oral selective Janus kinase (JAK) inhibitor, is effective for moderate to severe atopic dermatitis (AD). In a recent randomized trial of nearly 700 adults with moderate to severe AD, more individuals assigned to oral upadacitinib achieved a 75 percent improvement in the eczema area and severity index at 16 weeks compared with subcutaneous dupilumab (71 versus 61 percent, respectively) [3]. Adverse events including rare but serious infections such as herpes zoster and eczema herpeticum were more common in individuals receiving upadacitinib. These findings are encouraging regarding the efficacy of upadacitinib. However, pending results of long-term studies and more detail on adverse effects of upadacitinib, we suggest use of dupilumab for selected patients with moderate to severe atopic dermatitis. (See "Treatment of atopic dermatitis (eczema)", section on 'JAK inhibitors'.)

INFECTIONS AND INFESTATIONS

Topical spinosad for scabies (September 2021)

Spinosad is an insecticide derived from fermentation of a soil actinobacterium and causes fatal neuronal excitation in insects, including the parasites responsible for scabies. In the combined results from two phase 3 randomized trials (551 adults and children with scabies), 78 percent of patients treated with a single application of spinosad 0.9% topical suspension achieved complete cure compared with only 40 percent of patients in the vehicle group [4]. Treatment was well tolerated. These findings support spinosad as a topical therapy for scabies and contributed to the US Food and Drug Administration (FDA) approval of spinosad for this indication. The efficacy of spinosad has not been directly compared with the currently preferred therapies (topical permethrin or oral ivermectin). (See "Scabies: Management".)

PEDIATRIC DERMATOLOGY

Atenolol for complicated infantile hemangiomas (November 2021)

Evidence from small studies suggest that oral atenolol, a selective beta-1 blocker, may be as effective as propranolol for the treatment of complicated infantile hemangiomas, with the potential for a lower risk of serious adverse effects (eg, bronchospasm, bradycardia, hypoglycemia). In a randomized, open-label trial of nearly 400 infants with problematic hemangiomas treated with atenolol (1 mg/kg per day in a single dose) or propranolol (2 mg/kg per day in three divided doses), the rate of complete/nearly complete response at 96 weeks was similar in the two groups (80 versus 82 percent, respectively) [5]. Adverse events, including sleep disturbance, cold extremities, and bradycardia, were more frequent in the propranolol group than in the atenolol group (70 versus 44 percent). These findings indicate that atenolol has similar efficacy as propranolol for the treatment of complicated infantile hemangiomas with a better safety profile. Atenolol also has the advantage of once-daily administration. However, an oral formulation suitable for infants is not widely available. (See "Infantile hemangiomas: Management", section on 'Other beta blockers'.)

PSORIASIS AND OTHER PAPULOSQUAMOUS DISORDERS

Spesolimab for generalized pustular psoriasis (January 2022)

Generalized pustular psoriasis (GPP) is a rare, potentially life-threatening disorder in which the interleukin-36 pathway plays a role. A phase 2 randomized trial (n = 53) that assessed the efficacy of spesolimab, an investigational monoclonal antibody targeting the IL-36 receptor, found patients assigned to spesolimab more likely to achieve resolution of visible pustules within one week than patients assigned to placebo (54 versus 6 percent) [6]. Adverse events associated with spesolimab included infections and some serious adverse events, such as drug reaction with eosinophilia and systemic symptoms (DRESS). These findings support a potential role for IL-36 receptor inhibition in the treatment of GPP. However, larger trials with longer-term follow-up are needed to confirm these findings. (See "Pustular psoriasis: Management", section on 'Other therapies'.)

Apremilast for mild to moderate plaque psoriasis in adults (January 2022)

Although apremilast, an oral phosphodiesterase 4 inhibitor, is an established therapy for moderate to severe plaque psoriasis, the role of apremilast in the treatment of mild psoriasis has been less clear. In the first randomized trial to assess apremilast for mild to moderate plaque psoriasis (n = 595), more patients assigned to apremilast achieved the specified level of response (clear or almost clear by the Physician Global Assessment with prespecified improvement parameters) compared with patients in the placebo group (22 versus 4 percent) [7]. Diarrhea, headache, nausea, nasopharyngitis, and upper respiratory tract infection were among the most commonly reported adverse events in the apremilast group. These findings support use of apremilast for mild to moderate plaque psoriasis that cannot be managed with topical treatments. (See "Treatment of psoriasis in adults", section on 'Apremilast'.)

Topical tapinarof for psoriasis (December 2021)

Topical therapies play an important role in the treatment of psoriasis. In two identical phase 3 trials of tapinarof, an investigational topical aryl hydrocarbon receptor-modulating agent, a total of 1025 adults with chronic plaque psoriasis involving 3 to 20 percent of the total body surface area were randomly assigned to either tapinarof 1% cream or vehicle [8]. At week 12, patients treated with tapinarof were more likely to achieve the specified level of response (clear or almost clear by the Physician Global Assessment with pre-specified improvement parameters) than patients in the vehicle groups (35 versus 6 percent in trial 1 and 40 versus 6 percent in trial 2). Adverse events of folliculitis, contact dermatitis, and headache occurred more frequently in the tapinarof groups. These findings support efficacy of tapinarof; however, additional study is necessary to confirm long-term efficacy and safety. (See "Treatment of psoriasis in adults", section on 'Emerging therapies'.)

Bimekizumab versus adalimumab and secukinumab for plaque psoriasis (August 2021)

In phase 3 trials, bimekizumab, an investigational monoclonal IgG1 antibody that inhibits interleukin (IL) 17A and IL-17F, has demonstrated clinical efficacy for moderate to severe plaque psoriasis in adults and superiority over ustekinumab. Two new phase 3 trials also support greater efficacy of bimekizumab compared with adalimumab and secukinumab for this indication. In the BE SURE trial (n = 478), 86 percent of adults treated with bimekizumab had at least 90 percent improvement in the Psoriasis Area and Severity Index score (PASI 90) at week 16, compared with 47 percent of adults treated with adalimumab [9]. In the BE RADIANT trial (n = 743), 62 percent of adults in the bimekizumab group achieved complete skin clearance (PASI 100) compared with 49 percent in the secukinumab group [10]. These findings offer further support for combined inhibition of IL-17A and IL-17F as a therapeutic strategy for moderate to severe plaque psoriasis. (See "Treatment of psoriasis in adults", section on 'Emerging therapies'.)

URTICARIA AND ANGIOEDEMA

Impact of pregnancy on chronic urticaria (November 2021)

The impact of pregnancy on disease activity in chronic urticaria has been largely unstudied. In an international study of 288 pregnancies, patients with either chronic spontaneous urticaria (the majority) or chronic inducible urticaria completed questionnaires. During pregnancy, 51 percent reported improved symptoms, 29 percent reported worsening symptoms, and 20 percent noticed no change [11]. Patients with more than one pregnancy reported similar changes during each pregnancy. These findings inform counseling of patients with chronic urticaria regarding their likely disease course during pregnancy. (See "Chronic spontaneous urticaria: Clinical manifestations, diagnosis, pathogenesis, and natural history", section on 'Impact of pregnancy'.)

OTHER DERMATOLOGY

Bimekizumab for hidradenitis suppurativa (November 2021)

Uncontrolled studies suggest benefit of IL-17 inhibition for hidradenitis suppurativa (HS). In a phase 2 trial of bimekizumab, an investigational inhibitor of IL-17A and IL-17F, 90 patients were randomly assigned to bimekizumab, placebo, or adalimumab (as a reference arm) [12]. At week 12, 57 percent of patients in the bimekizumab group achieved the specified level of clinical response, compared with 26 percent of patients in the placebo group. The incidence of treatment-emergent adverse effects was similar among the treatment groups, with infections as the most common adverse effects in the bimekizumab group. This is the first randomized trial to show efficacy of an IL-17 inhibitor for HS. It provides additional support for IL-17 inhibition for the treatment of HS pending results of phase 3 trials. (See "Hidradenitis suppurativa: Management", section on 'Medical therapies'.)

REFERENCES

  1. Silverberg JI, Toth D, Bieber T, et al. Tralokinumab plus topical corticosteroids for the treatment of moderate-to-severe atopic dermatitis: results from the double-blind, randomized, multicentre, placebo-controlled phase III ECZTRA 3 trial. Br J Dermatol 2021; 184:450.
  2. Papp K, Szepietowski JC, Kircik L, et al. Efficacy and safety of ruxolitinib cream for the treatment of atopic dermatitis: Results from 2 phase 3, randomized, double-blind studies. J Am Acad Dermatol 2021; 85:863.
  3. Blauvelt A, Teixeira HD, Simpson EL, et al. Efficacy and Safety of Upadacitinib vs Dupilumab in Adults With Moderate-to-Severe Atopic Dermatitis: A Randomized Clinical Trial. JAMA Dermatol 2021; 157:1047.
  4. Seiler JC, Keech RC, Aker JL, et al. Spinosad at 0.9% in the treatment of scabies: Efficacy results from 2 multicenter, randomized, double-blind, vehicle-controlled studies. J Am Acad Dermatol 2022; 86:97.
  5. Ji Y, Chen S, Yang K, et al. Efficacy and Safety of Propranolol vs Atenolol in Infants With Problematic Infantile Hemangiomas: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2021; 147:599.
  6. Bachelez H, Choon SE, Marrakchi S, et al. Trial of Spesolimab for Generalized Pustular Psoriasis. N Engl J Med 2021; 385:2431.
  7. Stein Gold L, Papp K, Pariser D, et al. Efficacy and safety of apremilast in patients with mild-to-moderate plaque psoriasis: Results of a phase 3, multicenter, randomized, double-blind, placebo-controlled trial. J Am Acad Dermatol 2022; 86:77.
  8. Lebwohl MG, Stein Gold L, Strober B, et al. Phase 3 Trials of Tapinarof Cream for Plaque Psoriasis. N Engl J Med 2021; 385:2219.
  9. Warren RB, Blauvelt A, Bagel J, et al. Bimekizumab versus Adalimumab in Plaque Psoriasis. N Engl J Med 2021; 385:130.
  10. Reich K, Warren RB, Lebwohl M, et al. Bimekizumab versus Secukinumab in Plaque Psoriasis. N Engl J Med 2021; 385:142.
  11. Kocatürk E, Al-Ahmad M, Krause K, et al. Effects of pregnancy on chronic urticaria: Results of the PREG-CU UCARE study. Allergy 2021; 76:3133.
  12. Glatt S, Jemec GBE, Forman S, et al. Efficacy and Safety of Bimekizumab in Moderate to Severe Hidradenitis Suppurativa: A Phase 2, Double-blind, Placebo-Controlled Randomized Clinical Trial. JAMA Dermatol 2021; 157:1279.
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References

1 : Tralokinumab plus topical corticosteroids for the treatment of moderate-to-severe atopic dermatitis: results from the double-blind, randomized, multicentre, placebo-controlled phase III ECZTRA 3 trial.

2 : Efficacy and safety of ruxolitinib cream for the treatment of atopic dermatitis: Results from 2 phase 3, randomized, double-blind studies.

3 : Efficacy and Safety of Upadacitinib vs Dupilumab in Adults With Moderate-to-Severe Atopic Dermatitis: A Randomized Clinical Trial.

4 : Spinosad at 0.9% in the treatment of scabies: Efficacy results from 2 multicenter, randomized, double-blind, vehicle-controlled studies.

5 : Efficacy and Safety of Propranolol vs Atenolol in Infants With Problematic Infantile Hemangiomas: A Randomized Clinical Trial.

6 : Trial of Spesolimab for Generalized Pustular Psoriasis.

7 : Efficacy and safety of apremilast in patients with mild-to-moderate plaque psoriasis: Results of a phase 3, multicenter, randomized, double-blind, placebo-controlled trial.

8 : Phase 3 Trials of Tapinarof Cream for Plaque Psoriasis.

9 : Bimekizumab versus Adalimumab in Plaque Psoriasis.

10 : Bimekizumab versus Secukinumab in Plaque Psoriasis.

11 : Effects of pregnancy on chronic urticaria: Results of the PREG-CU UCARE study.

12 : Efficacy and Safety of Bimekizumab in Moderate to Severe Hidradenitis Suppurativa: A Phase 2, Double-blind, Placebo-Controlled Randomized Clinical Trial.