Kaitlyn Bader

In her session, “What’s New and Hot in Alopecia Areata Management,” Natasha A. Mesinkovska, MD, PhD, vice chair of clinical research in the department of dermatology at the University of California, Irvine, shares the latest pearls in alopecia areata management.

 Mesinkovska is very involved in alopecia areata research, as she was the chief scientific officer of the National Alopecia Areata Foundation from 2015 to 2022 and is currently part of their clinical research advisory council.

Mesinkovska’s session covered hot topics in alopecia areata management, including vaccines and viruses, JAK inhibitors, dupilumab, minoxidil, and what is coming down the pipeline.

Mesinkovska began by discussing the correlation between alopecia areata and COVID-19, as well as the COVID-19 vaccine and boosters. In some examples, many of Mesinkovska’s patients experienced alopecia areata totalis after mild cases of COVID-19. Additionally, in a few patient examples, patients who previously had alopecia areata, but were stable or making progress, began to lose their hair again after the COVID-19 vaccine. Mesinkovska stressed that she does not believe this should be a reason not to receive a COVID-19 vaccine or booster, but that clinicians should consider the effects and talk with their patients.

Regarding JAK inhibitors, clinicians have a new JAK to choose from, baricitinib (Olumiant; Eli Lily) for the treatment of alopecia areata in adults. Current alopecia areata clinical trials include deuruxolitinibCTP 543, ritlecitinib, and delgotcitinib. Mesinkovska cautioned clinicians to be aware of black box warnings of JAK inhibitors and to discuss adverse events with patients.

Dupilumab also shows promising potential for alopecia areata treatment. Dupilumab is an IL-4 and IL-13 antagonist currently approved to treat atopic dermatitis in children and adults.

Minoxidil is still a viable option for patients with alopecia areata, especially for those hesitant to start JAK inhibitors, or for pediatric patients. Possible adverse effects of minoxidil include hypertrichosis, postural hypotension, and lower limb edema.

Finally, an alopecia areata drug coming down the pipeline is etrasimod, a sphingosine 1-phosphate receptor modulator. It is an oral pill taken once daily, and has previous indications of ulcerative colitis, Crohn’s disease, and eosinophilic esophagitis.

This article originally appeared on Dermatology Times.

Mesinkovska A. What’s new and hot in alopecia areata management. Presented at the 2023 Winter Clinical Hawaii Dermatology Conference; January 13-18, 2023; Kohala Coast, Hawaii.

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Natasha A. Mesinkovska, MD, PhD, shares what’s new in alopecia areata management.

What's New in Alopecia Areata Management

The patient journey and the relationship between psoriasis and psoriatic arthritis were key points in a presentation by Bruce E. Strober, MD, PhD, at the 2022 Fall Clinical Dermatology Conference, held in Las Vegas, Nevada.

Strober began by giving a quick review of psoriasis as a systemic inflammatory disease that is not just limited to the skin. “Most patients have a lot of inflammation affecting other tissues, and that’s important because we need to control systemic inflammation for patients with psoriasis,” said Strober, a clinical professor of dermatology at Yale University School of Medicine in New Haven, Connecticut, and scientific codirector of the CorEvitas Psoriasis Registry. In psoriatic arthritis, the ligaments and tendons are affected just as much as the joints. Stiffness, pain, and achiness are other common symptoms of the disease. In addition, it is important to consider whether the arthritis is peripheral or axial psoriatic arthritis. Axial diseases affect up to half of patients with psoriatic arthritis and are associated with neck and lower back pain.

Once of the main goals of treating psoriasis or psoriatic arthritis is to achieve skin clearance, according to Strober. If providers can completely clear a patient’s skin, it is much easier to manage symptoms than if only 80% to 90% of the skin is cleared. Complete clearance also means patients are more likely to benefit from no psoriasis symptoms and no impairment to their health-related quality of life.

Over 30% of patients with psoriasis will also develop psoriatic arthritis. For those patients, the time to the onset of psoriatic arthritis is between 7 and 12 years, and the prevalence of psoriatic arthritis increases with psoriasis duration. One of Strober’s most important takeaways from the session was that axial disease is an important consideration for individuals with psoriasis and psoriatic arthritis. Axial disease is present in 20% to 50% of patients with psoriatic arthritis and may involve the spine, and it often goes undiagnosed.

“Axial disease affects the vertebra, specifically the neck, lower back, and the sacroiliac. It’s different [from] a disease that affects the periphery, such as the ankles. The reason why we know that is because certain therapeutics preferentially treat only a peripheral but not an axial [disease],” Strober said.

Moving on to therapeutic options, Strober believes the current targeted therapeutics and targeted immunosuppressants on the market for psoriasis and psoriatic arthritis are safe and tolerable. He mentioned that dermatologists are aware that some biologics are not intended for certain patients. Those with inflammatory bowel disease, for example, should not receive IL-17 inhibitors, and patients with certain forms of cancer should avoid JAK inhibitors. However, most patients with psoriatic disease can receive agents from the different drug classes. Rheumatologists strongly recommend IL-17 inhibitors and tumor necrosis factor (TNF) inhibitors for patients with axial disease; however, IL-23 inhibitors are not recommended for those with axial disease. Strober emphasized that patients with axial psoriatic arthritis need to receive an IL-17 or TNF inhibitor to effectively treat their symptoms and prevent severe disease progression.

1. Strober B. Psoriatic disease: defining a new era for patients and physicians. Presented at: 2022 Fall Clinical Dermatology Conference; October 20-23, 2022; Las Vegas, NV.

Understanding the relationship between psoriasis and psoriatic arthritis can help.

New Approaches in Psoriasis and Psoriatic Arthritis Treatment 

In another ASDS presentation, Charles Puza, MD, a postgraduate dermatology resident at the University of Texas Southwestern in Dallas, shared research data on safety and complications of immune checkpoint inhibitors with dermatologic procedures during an oral abstract session.

 The objective of the study was to determine postoperative complications in patients undergoing dermatologic procedures while receiving immune checkpoint inhibitors.

“[I]n 2011, ipilimumab [Yervoy] was the first medication in this class granted FDA approval for metastatic melanoma. Since then, immune checkpoint inhibitors have continued to expand, [as well as] the indications, including squamous cell carcinoma, Merkel cell carcinoma, lung cancer, hepatocellular carcinoma, renal cell cancer, urogenital cancer, and many other rare conditions,” Puza said.

The adverse effects related to this class of medications are related to immune system activation and include colitis, hepatitis, and pneumonitis, according to the study. The safety of dermatologic procedures and postoperative complications in these patients has yet to be studied.

The current study was single center and retrospective, and it examined patients from January 2015 through June 2021, allowing for a 6-month follow-up period. All patients were actively receiving immune checkpoint inhibitors at the time of dermatologic surgery, including Mohs surgery and excisions. Biopsies or intralesional injections were not included. Puza and his colleagues continually reviewed the indications for immune checkpoint inhibitor therapy, patient demographics, and postoperative complications.

Twenty-five patients fit the criteria of the study; most were men, and the mean age was 64.3 years. Overall, the 25 patients underwent 48 dermatologic procedures ranging from excision with immediate closure to electrodesiccation and curettage. The indications for immune checkpoint inhibitors primarily included melanoma, lung cancer, bladder cancer, and bile duct cancer. Regarding procedural locations, approximately half of the patients received a procedure on the head or neck, with the other half of patients in the extremity and trunk group.

Nivolumab (Opdivo) was the most common immune checkpoint inhibitor used by patients in this study, received by 16 patients. Pembrolizumab (Keytruda) was the second most common therapy, used in 5 patients, and 3  patients received a combination of ipilimumab and nivolumab.

“Overall, complications were rare in this cohort. Again, this [study] is extremely small, but infection was identified in 2 patients and treated with oral antibiotics without complication. One patient had significant enough pain to require an emergency department visit. Neither recurrence nor postoperative bleeding [were] reported in the follow-up period,” Puza said.

“To conclude, immune checkpoint inhibitor therapy does not appear to dramatically increase the rates of complications in patients undergoing dermatologic procedures,” Puzasaid. “Although this was a small study, dermatologic surgery, including Mohs micrographic surgery, was safe and well tolerated in this small sampling of patients.”

1. Puza C, Pyle H, Srivastava D, Nijhawan R. Immune checkpoint inhibitors and dermatologic procedures: a retrospective review of safety and complications. Presented at: American Society for Dermatologic Surgery Annual Meeting; October 6-10, 2022; Denver, CO.

Immune checkpoint inhibitor therapy does not appear to increase complication
rates in patients undergoing dermatologic procedures.

A Study of Immune Checkpoint Inhibitors and Complication Rates 

According to its quarterly earnings report, Eli Lilly and Company has submitted its Biologics License Application (BLA) to the US Food and Drug Administration (FDA) for lebrikizumab, an interleukin (IL)-13 inhibitor for moderate-to-severe atopic dermatitis (AD). The BLA submission is based on results from 3 phase 3 trials evaluating the safety and efficacy of lebrikizumab, a monotherapy, in combination with standard-of-care topical corticosteroids in adults and adolescents aged 12 years and older.

Lebrikizumab monotherapy was successful in improving AD in 80% of patients at the end of the first year, according to results from the 52-week, randomized, double-blind, placebo-controlled, parallel-group phase 3 ADvocate 1 and 2 trials. Patients first received 500 mg of lebrikizumab and another dose at 2 weeks, followed by 250 mg or placebo every 2 weeks during a 16-week treatment period.

After week 16, patients who achieved a clinical response, defined as the Eczema Area and Severity Index (EASI) score of 75, were randomly selected to receive lebrikizumab every 2 or every 4 weeks or the placebo for an additional 36 weeks.

In the ADvocate 1 trial, 79% of patients who received lebrikizumab every 4 weeks and 79% of patients who received lebrikizumab every 2 weeks maintained EASI75 throughout the first year. In the ADvocate 2 trials, 85% of patients who received lebrikizumab every 4 weeks and 77% of patients who received it every 2 weeks maintained EASI75.

The FDA granted lebrikizumab Fast Track designation in AD in December 2019. The lebrikizumab phase 3 program includes 5 key global studies evaluating more than 2000 patients, including 2 monotherapy studies (ADvocate 1 and 2), a combination study with topical corticosteroids (ADhere), and long-term extension (ADjoin) and adolescent open-label (ADore) studies.

According to Eli Lilly, lebrikizumab is a novel, investigational, monoclonal antibody developed to bind IL-13 with high affinity, slow disassociation rate, and high potency to prevent the formation of the IL-13Rα1/IL-4Rα heterodimer complex and subsequent signaling to inhibit the biological effects of IL-13. AD is an IL-13 dominant disease, and IL-13 is responsible for skin barrier dysfunction, itch, skin thickening, and susceptibility to infection.

Eli Lilly submits biologics license application to FDA for lebrikizumab. Healio. Published November 4, 2022. Accessed November 7, 2022.

Lebrikizumab dosed every four weeks maintained durable skin clearance in Lilly’s phase 3 monotherapy atopic dermatitis trials. Eli Lilly and Company. Published September 8, 2022. Accessed November 8, 2022.

BLA submission is based on phase 3 trial results evaluating the safety and efficacy of lebrikizumab.

BLA Submitted for Lebrikizumab Atopic Dermatitis Treatment

Journal of Clinical and Aesthetic Dermatology

 aimed to evaluate the safety and efficacy of combining oral zinc with low-dose isotretinoin in patients with acne vulgaris (AV). Overall results found that oral since plus low-dose isotretinoin resulted in satisfactory improvement in patients with AV and with fewer adverse effects. The study author believes further studies are recommended to compare the efficacy of other zinc preparations if combined with systemic isotretinoin at different concentrations.

The study enrolled 60 patients with moderate-to-severe AV, according to the Global Acne Grading System (GAGS). Patients were divided into 2 groups; Group A received oral zinc sulfate plus low-dose isotretinoin and Group B received the standard isotretinoin dosage. Acne severity, photos, adverse effects, and patient-reported satisfaction were recorded at each visit.

In the 2 groups, there was no significant difference in the reduction of lesion count and GAGS scores. The frequency of treatment-related side effects was 20% in Group A and 76.7% in Group B. There was no difference regarding the relapse rates between both groups (p>0.05). Finally, the patient’s satisfaction rates did not differ between the 2 groups.

Group A was comprised of 15 males and 15 females with a median age of 23.5 years. Group B was comprised of 15 males and 15 females with a median age of 25 years. There was no statistically significant difference between the 2 studied groups regarding the reduction of comedonal and non-comedonal lesions count, as well as GAGS assessment at both bassline baseline and monthly follow-up visits except at the fourth visit. At the fourth follow-up visit, Group B showed a more significant improvement in GAGS than Group A, however, the difference became insignificant by the fifth visit.

In this study, oral zinc combined with low-dose isotretinoin demonstrated satisfactory improvement in patients with AV with fewer adverse effects. Another benefit of this combination is the treatment cost, as systemic isotretinoin products are known to be expensive in comparison to oral overthe counter zinc supplementations.

Oral zinc is an inexpensive, adjuvant, and sparing therapy to systemic isotretinoin in AV. Additionally, oral zinc minimizes isotretinoin’s adverse effects. However, the rate of treatment relapse is similar to higher dose isotretinoin monotherapy. Further studies are recommended to assess using other zinc preparations and higher zinc doses with different isotretinoin regimens to determine the best combination.

Salah E. Oral Zinc as a Novel Adjuvant and Sparing Therapy for Systemic Isotretinoin in Acne Vulgaris: A Preliminary Comparative Study. J Clin Aesthet Dermatol. 2022;15(10):58–61.

https://jcadonline.com/zinc-therapy-systemic-isotretinoin-acne/

Numerous adverse effects are associated with standard-dose isotretinoin.

Examining the Safety and Efficacy of Oral Zinc and Low-Dose Isotretinoin for Acne Vulgaris

Aveeno recently revealed results from its first-ever State of Skin Sensitivity report that examined the causes of sensitive skin and the connection between the body, mind, and skin.

Results show that 71% of adults identify as having sensitive skin, which is a 55% increase in the last 2 decades. In a time of body positivity across mainstream culture, sensitive skin affects how adults view their skin and themselves. Aveeno’s report also focused on how common skin conditions can influence the quality of life and emotional well-being of adults with sensitive skin.

1/3 of patients with skin diseases like acne, atopic dermatitis, psoriasis, and rosacea are estimated to struggle with emotional disorders, including anxiety and depression

Approximately 50% of adults with moderate-to-severe atopic dermatitis reported that it affects social functions, sleep, work productivity, leisure activities, and family relationships

90% of patients with rosacea report that their condition lowers their self-esteem

Sensitive skin is equally common across all ethnicities

More of Fitzpatrick phototypes I and III report having sensitive skin than having non-sensitive skin, and phototypes IV, V, and VI more frequently identify as having non-sensitive skin

Current smokers more frequently identify as having sensitive skin, whereas more nonsmokers report having non-sensitive skin

The State of Skin Sensitivity Report was an online survey distributed to 1000 participants (800 females, 200 males, aged 18-65 years old) with self-declared sensitive skin consumers of varying ethnicities.

After participating in the study, consumers believe stress and ingredients cause the majority of skin reactions. Those who identified as extremely sensitive were 200% more likely to have been diagnosed with eczema, rosacea, acne, or allergies than those who identified as slightly sensitive. Itch is the most commonly reported symptom of sensitive skin, followed by redness and dryness. Out of the study participants, 79% reported that their sensitive skin remained constant or worsened over time, and 65% reported they had sensitive skin before the age of 30.

To encourage more discussions of sensitive skin, Aveeno is asking consumers to share their sensitive skin journeys on social media and use the hashtag: #ProudlySensitiveSkin to highlight consumer experiences with skin conditions.

Aveeno releases new report revealing that 71% of adults have sensitive skin. Aveeno. Published October 25, 2022. Accessed October 26, 2022. 

https://www.prnewswire.com/news-releases/aveeno-releases-new-report-revealing-that-71-of-adults-have-sensitive-skin-301658252.html?tc=eml_cleartime

State of Skin Sensitivity Report raises awareness of the causes of skin sensitivity and its effect on the mind.