Therapy explosion

"These cutting-edge therapies also offer new opportunities for off-label uses of the biologic drugs," says Michael Heffernan, M.D., a Washington University dermatologist at Barnes-Jewish Hospital here. "The best part is that the safety and efficacy of these drugs are far superior to what we used previously, so many of the new treatments are replacing older treatments."

Nonetheless, he adds, many of the older systemic therapies are still very effective. "I anticipate that we will use more combination therapy, much like our friends in rheumatology do," he says. "I think we will be using some of these older drugs at lower - and therefore safer - doses, but with increased effectiveness, because we'll be using them along with other medications."

The biologic therapies now available for psoriasis are: the T-cell drugs Raptiva (efalizumab, Biogen) and Amevive (alefacept, Genentech), or the anti-tumor necrosis factor drugs Enbrel (etanercept, Amgen/Wyeth), Remicade (infliximab, Centocor), which was just recently approved for psoriatic arthritis, and Humira (adalimumab, Abbott), which is expected to be approved soon. Beyond psoriasis, a number of new uses for tumor necrosis-blocking drugs in dermatology have been reported, including granuloma annulare, pyoderma gangrenosum, vasculitis, sarcoidosis, hidradenitis suppurativa, pemphigus, pemphigoid and graft versus host disease.

"We're finding out that one of the reasons these newer drugs are being used so frequently in psoriasis is because of their improved safety profile over the other systemic agents," Dr. Heffernan says. "Now I think that dermatologists are also finding new uses for these drugs in other diseases where we may not have tried systemic therapy before because we didn't think it was worth the risk-benefit ratio. I've been very proud to see dermatologists step up in the treatment of psoriasis, and I'd like to see us continue to step up in the treatment of other diseases, too."

Other uses

A number of new drugs are showing some efficacy in other disorders, too. The use of Raptiva has proven effective for psoriasis, but now its use in treating granuloma annulare, lichen planus, alopecia areata and atopic dermatitis reportedly is showing promise as well.

In addition, Rituxan (rituximab, IDEC), an anti-CD20 monoclonal antibody currently used in treating lymphoma, also has been found effective for B-cell lymphoma of the skin, as well as pemphigus, dermatomyositis and lupus.

Another new biologic therapy is intravenous gammaglobulin, which has shown effectiveness in treating autoimmune blistering diseases, chronic urticaria, scleromyxedema and, most importantly, toxic epidermal necrolysis.

Combos offer benefits

Combining therapies - sometimes older, proven drugs with newer, off-label medications - will allow dermatologists to tailor treatment plans for each patient, according to Dr. Heffernan. "We will be able to achieve greater degrees of clearance more easily, and, hopefully, faster and more safely," he says. "We will be able to combine two, three or four medications - just as we do with patients with acne now. With combination therapy, you minimize the side effects and maximize efficacy and safety."

From the standpoint of quality of life, the new medications are making a huge difference for patients.

"When you sit down and talk to these people who have disfiguring sarcoidosis, hidradenitis or blistering diseases, it is really very heartwarming to see that these treatments stop the disease processes and return people to baseline or normal appearance," Dr. Heffernan says. "These drugs are really making significant differences in the quality of these people's lives."