Summer AAD Advice From Experts: Advanced Systemic Therapeutics—Systemic Treatment of Granulomatous Diseases
SYM S001–Advanced Systemic Therapeutics
Noninfectious granulomatous skin diseases represent a spectrum of cutaneous reactions which can challenge any dermatologist. First and foremost, some granulomatous reactions may represent a skin sign of systemic disease, warranting thorough workup, with treatment focused on the underlying systemic process. Second, granulomatous reactions may themselves cause significant morbidity to patients and warrant treatment—often with little high-quality evidence to guide the clinician. In the Advanced Systemic Therapeutics session devoted to granulomatous diseases, we reviewed the data and presented some algorithmic approaches to managing these entities.
Treatment options generally include topical therapies, phototherapy, immunomodulatory/anti-inflammatory agents, and immunosuppressive agents. Topical steroids can be beneficial in some cases (such as fine papular granuloma annulare or thin patches of necrobiosis lipoidica). Intralesional triamcinolone can be quite helpful in treating isolated lesions. Phototherapy can be particularly helpful in widespread granuloma annulare (while there is more evidence for PUVA, narrowband UVB can be helpful and may be a simpler starting point). Immunomodulatory/anti-inflammatory agents include tetracycline class antibiotics (minocycline being the most effective), antimalarial agents (with more data for chloroquine, but hydroxychloroquine being easier to obtain and administer), and phosphodiesterase inhibitors (pentoxiphylline or apremilast). Immunosuppressive agents (particularly corticosteroids and methotrexate) are quite effective in treating most granulomatous reactions. Finally, the TNF inhibitors are rapidly coming to the fore as some of the most effective anti-granulomatous agents in our arsenal.
Focusing on granuloma annulare, while intralesional injections can help when there are limited, localized lesions, most widespread cases warrant consideration for systemic treatment. The best data available is for PUVA or chloroquine; we suggest starting with either narrowband UVB or hydroxychloroquine for ease of use and fewer side effects. Antimalarials in particular seem to be highly effective, with some of the best available data. When those agents fail, treatment decisions are based on isolated case reports for the most part. Tetracycline class antibiotics, retinoids, dapsone, or even methotrexate may be considered; but, in severe, recalcitrant cases, there are emerging reports demonstrating efficacy with a number of TNF inhibitors.
One critical point to keep in mind is that granulomatous inflammation is slow; slow to develop, and slow to resolve. All therapies take months to demonstrate efficacy, and patience is essential—which should be carefully explained to patients, less the lack of patience from impatient patients leads you to abandon a treatment before it has a chance to work.
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