Mark Lebwohl, MD: ‘One of the remarkable things is that so many of the new treatments that have come out in all of medicine have come from work done in dermatology.’

Great advances have been made recently in developing biologic treatments for basal cell carcinoma, actinic keratoses, melanoma, psoriasis, and urticaria, as well as systemic and topical treatments for vitiligo, eczema, rosacea, and toenail fungus. Mark Lebwohl, MD, presented an update on these treatments during Friday’s Everett C. Fox, MD, Lectureship, “Dermatologic Therapy: A Bright Future.”

“One of the remarkable things is that so many of the new treatments that have come out in all of medicine have come from work done in dermatology,” said Dr. Lebwohl, professor and chair of dermatology at Mount Sinai Hospital, New York. “We have been at the forefront of biologic therapies, which are taking over all of medicine. There are many other treatments that were recently introduced to dermatology or are on the horizon for dermatology that make the therapeutic outlook for our specialty very good.” Listen to Dr. Lebwohl’s podcast about new treatments for several dermatologic conditions.

Skin cancer and AKs

Vismodegib, the hedgehog inhibitor, is a dramatic therapy that can “melt away” tumors, he said. It has been approved for the treatment of catastrophic basal cell carcinoma and metastatic basal cell carcinoma.

Several drugs are effective in treating precancerous skin lesions, but ingenol mebutate is a new topical therapy that only needs to be applied for two or three days. Other advantages are that it has a high response rate and is linked to long remissions. Several older drugs, such as imiquimod, also harness the immune system to provide durable remissions.

Four new BRAF inhibitors have been approved for treating melanoma — ipilimumab, vemurafenib, dabrafenib, and trametinib. A fifth treatment — nivolumab — is expected to be approved in the near future.

“The data show that they work, but the tumors can become resistant, so they only prolong life for a limited amount of time, but it is the first shot,” Dr. Lebwohl said. “Now we are going to use them in combination to figure out ways of making them work better. There is a lot of promise in melanoma in the near future.”

Psoriasis

Three new biologics that block IL-17 or its receptor to treat psoriasis are expected to be approved beginning in 2014. Brodalumab, secukinumab, and ixekizumab have been “phenomenally effective” and so far appear to have few side effects.

“The clearing is much greater than we have seen with other drugs we used in the past,” Dr. Lebwohl said. “With these drugs, we are talking about PASI (psoriasis area and severity index) scores in the 90s and PASI 100, which means not a dot of psoriasis is left. So, we are seeing a whole change in our ability to treat psoriasis.”

Two oral therapies, apremilast and tofacitinib, may be approved, the first as early as this year’s end. Tofacitinib already has been approved for the treatment of rheumatoid arthritis.

Urticaria

Omalizumab is a new biologic used in asthma that also works for chronic urticaria. It is dramatically effective, Dr. Lebwohl said, calling it a “life-changing drug” for one of his patients who has battled severe hives for years.

Several other treatments have been developed for a variety of conditions:

• Vitiligo: Afamelanotide is implanted in the skin in combination with narrowband ultraviolet B treatment
• Hand eczema: Alitretinoin has been tested under daily practice conditions in the TOCCATA study
• Atopic dermatitis: Sodium hypochlorite (NaOCl), a component of bleach, is helpful adjunctive therapy
• Rosacea: Brimonidine, a vasoconstritive agent is being incorporated into a cream to treat moderate to severe facial erythema
• Onychomycosis: Efinaconazole is in phase III trials and may be introduced this year
• Psoriasis and atopic dermatitis: Two topical anti-inflammatories, WBI-1001 and tofacitinib, are being evaluated in trials
• Atopic dermatitis: Several new biologic therapies are being tested and one, dupilumab, has been “dramatically effective”