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Novel Therapies for Inflammatory Dermatologic Conditions
by Ronald D. Wise, MD, FAAD



INTRODUCTION
We frequently encounter patients with chronic inflammatory dermatoses and treat them with various medications to control their diseases. Maintenance therapies may have side effects, and we are faced with the challenge of prescribing minimal dosages to avoid possible sequelae. The following are examples of new approaches for the treatment of some of these common ailments.

ATOPIC DERMATITIS
Atopic dermatitis is a chronic, relapsing eczematous disease that is typically manifested at an early age. Fifty percent of the cases are diagnosed between the ages of 0 and 1 year, 30% are diagnosed between 1 and 5 years, and 20% are diagnosed at an age older than 5 years. This disease is usually intensely pruritic and has been described as the itch that rashes. Patients respond to this symptom with vigorous scratching, which induces the release of proinflammatory substances that exacerbate the eczematous process and thus induces the patient to enter a vicious cycle of itching and scratching. Type 2 T helper lymphocyte (Th2)-related cytokines have been implicated in the pathogenesis of acute atopic dermatitis, and as the disease becomes chronic, type 1 T helper lymphocytes (Th1) mediate the disease.

Conventional therapies for atopic dermatitis include application of astringents to acute, weeping lesions and moisturization of xerotic areas. Antibiotics are prescribed for secondary pyodermas, and sedating antihistamines alleviate pruritus. Corticosteroids, both topical and systemic, are widely used to rapidly decrease inflammation.

Topical corticosteroids penetrate the skin well and bind to glucocorticoid receptors on T cells to inhibit the formation of the proinflammatory interleukins IL-1, IL-2, and IL-6; interferon alpha (IFN-a); and tumor necrosis alpha (TNF-a) within the dermis. They act quickly and are very effective in the short term. However, corticosteroids also bind to receptors on fibrocytes and inhibit the production of collagen to potentially result in the unwanted sequelae of cutaneous atrophy and telangiectasias. Striae, acneiform, and rosacea-like eruptions are additional side effects of topical corticosteroid therapy. Such adverse events occur most frequently with topical steroids in the high potency categories and those that are halogenated. Systemic reactions include growth retardation, Cushing's syndrome, ocular toxicity, and suppression of the hypothalamic-pituitary-adrenal axis.

TARGET AUDIENCE
This activity is intended for dermatologists, skin specialists, primary care physicians, and other physicians who manage and treat patients with inflammatory dermatologic conditions.

STATEMENT OF NEED
Chronic inflammatory dermatoses, including psoriasis, acne, rosacea, and perioral dermatitis are commonly encountered in both the dermatology and primary care settings. Various therapies, both topical and systemic, are used to treat these conditions. However, the use of maintenance therapies is often accompanied by side effects; in the case of antibiotics, the generation of resistance is a serious and growing concern. Clinicians may be able to overcome these challenges by prescribing minimal dosages. A thorough review of recent clinical studies and reports examining new and effective approaches to treatment may help clinicians determine the safest and most effective therapeutic regimens for patients suffering from these conditions.

LEARNING OBJECTIVES
Upon completion of this educational activity, participants should be able to:
  • Describe the pathogenesis of several common chronic inflammatory dermatoses
  • Discuss the advantages and disadvantages of the available treatments for these conditions
  • Discuss the rationale for the use of subantimicrobial doses of doxycycline for the treatment of inflammatory conditions
ACCREDITATION STATEMENT
This continuing medical education activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of The Dulaney Foundation and Advanstar Communications Inc, publisher of Dermatology Times. The Dulaney Foundation is accredited by the ACCME to provide continuing medical education for physicians.

DESIGNATION STATEMENT
The Dulaney Foundation designates this educational activity for a maximum of 0.5 category 1 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

FACULTY DISCLOSURE
Ronald D. Wise, MD, FAAD
Associate Professor of Dermatology
Scholl College of Podiatric Medicine
at Rosalind Franklin University of Medicine and Science
Chicago, Illinois
Associate Professor of Medicine
College of Osteopathic Medicine
Midwestern University
Downers Grove, Illinois

Dr. Wise has a financial interest/relationship or affiliation in the form of: Consultant: CollaGenex Pharmaceuticals Inc. Speakers Bureau: Novartis Pharmaceuticals Corporation, 3M Pharmaceuticals, and CollaGenex Pharmaceuticals Inc.

DISCLOSURE OF UNLABELED USE
This educational activity contains discussion of published and/or investigational uses of agents that are not indicated by the US Food and Drug Administration. The Dulaney Foundation, Dermatology Times, and CollaGenex Pharmaceuticals Inc do not recommend the use of any agent outside of the labeled indications. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

DISCLAIMER
Participants have an implied responsibility to use newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients' conditions and possible contraindications or dangers in use, review of any applicable manufacturer's product information, and comparison with recommendations of other authorities. The views and opinions expressed in this monograph are those of the faculty and do not necessarily reflect the views of The Dulaney Foundation, Dermatology Times, or CollaGenex Pharmaceuticals Inc.



For more information about psoriasis, contact the National Psoriasis Foundation
at 800-723-9166 or visit their website at www.psoriasis.org




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