Erythroderma (Generalized Exfoliative Dermatitis)

Background

Exfoliative dermatitis (ED) is a definitive term that refers to a scaling erythematous dermatitis involving 90% or more of the cutaneous surface. Exfoliative dermatitis is characterized by erythema and scaling involving the skin's surface and often obscures the primary lesions that are important clues to understanding the evolution of the disease. Clinicians are challenged to find the cause of exfoliative dermatitis by eliciting the history of illness prior to erythema and scaling, by probing with biopsies, and by performing blood studies. See the images below.

Exfoliative dermatitis diffuse skin involvement.

Exfoliative dermatitis close-up view showing erythema and scaling.

The term red man syndrome is reserved for idiopathic exfoliative dermatitis, in which no primary cause can be found, despite serial examinations and tests. Idiopathic exfoliative dermatitis is characterized by marked palmoplantar keratoderma, dermatopathic lymphadenopathy, and a raised level of serum immunoglobulin E (IgE) and is more likely to persist than other types.

The term l'homme rouge refers to exfoliative dermatitis often secondary to cutaneous T-cell lymphoma. Erythrodermic mycosis fungoides should be distinguished from leukemic Sézary syndrome with erythroderma. [1] The historic classification of exfoliative dermatitis into Wilson-Brocq (a chronic process associated with exacerbation and remissions), Hebra or pityriasis rubra (relentlessly progressive disease), and Savill (self-limiting) types lacks any clinical significance.

Pathophysiology

An increased skin blood perfusion occurs in exfoliative dermatitis (ED) that results in temperature dysregulation (resulting in heat loss and hypothermia) and possible high-output cardiac failure. The basal metabolic rate rises to compensate for the resultant heat loss. Fluid loss by transpiration is increased in proportion to the basal metabolic rate. The situation is similar to that observed in patients following burns (negative nitrogen balance characterized by edema, hypoalbuminemia, loss of muscle mass).

A marked loss of exfoliated scales occurs that may reach 20-30 g/d. This contributes to the hypoalbuminemia commonly observed in exfoliative dermatitis. Hypoalbuminemia results, in part, from decreased synthesis or increased metabolism of albumin. Edema is a frequent finding, probably resulting from fluid shift into the extracellular spaces. Immune responses may be altered, as evidenced by increased gamma-globulins, increased serum IgE in some cases, eosinophil infiltration, and CD4+ T-cell lymphocytopenia in the absence of HIV infection. Oxidative stress is also associated with drug-induced erythroderma. [2]

Chronic erythroderma in elderly men may represent a unique condition distinct from adult atopic dermatitis. [3]

Etiology

Determining specific etiologies in exfoliative dermatitis (ED) often is not possible; however, it is necessary to attempt since etiology may impact disease course and management options. The list of conditions that can cause exfoliative dermatitis is extensive and continues to expand. Cutaneous diseases that cause exfoliative dermatitis and the systemic diseases associated with them include the following [4, 5, 6, 7] :

• Atopic dermatitis - Acute and chronic leukemia

• Contact dermatitis - Reticulum cell sarcoma

• Dermatophytosis - Carcinoma of rectum

• Hailey-Hailey disease - Carcinoma of fallopian tubes

• Leiner disease - Graft versus host disease

• Lichen planus - HIV infection

• Lupus erythematosus - Lymphoma (including Hodgkin disease)

• Mycosis fungoides - Multiple myeloma

• Pemphigoid - Carcinoma of lung

• Pemphigus foliaceus - Mycosis fungoides

• Pityriasis rubra pilaris - Reactive arthritis

• Psoriasis

• Sarcoid

• Seborrheic dermatitis

• Stasis dermatitis

The most common causes of exfoliative dermatitis are best remembered by the mnemonic device ID-SCALP. The causes and their frequencies are as follows:

• Idiopathic - 30%

• Drug allergy - 28%

• Seborrheic dermatitis - 2%

• Contact dermatitis - 3%

• Atopic dermatitis - 10%

• Lymphoma and leukemia - 14%

• Psoriasis - 8%

More than 135 drugs have been implicated in the causation of exfoliative dermatitis (see Table). In many cases of protracted exfoliative dermatitis classified as being of undetermined cause, careful follow-up care and reevaluation implicated atopic dermatitis in older patients, intake of drugs overlooked by the patient, and prelymphomatous eruption as causative factors. It should be noted that psoriasiform erythroderma has been induced by the tumor necrosis factor (TNF)–alpha inhibitor golimumab. [8]

Sarcoidosis-associated erythroderma may demonstrate lichenoid papules as a clue to the diagnosis. [9]

Table. Drugs Implicated in the Causation of Exfoliative Dermatitis (Open Table in a new window)

99mTC-sestamibi [10]	ACE inhibitors	Allopurinol	Aminoglutethimide	Amiodarone
Amitriptyline	Amoxicillin	Ampicillin	Angiogenetic inhibitors [11]	Arsenic
Aspirin	Atropine	Auranofin	Aurothioglucose	Barbiturates
Benactyzine	Beta-blockers	Beta carotene	Bumetanide	Bupropion
Butabarbital	Butalbital	Captopril	Carbamazepine	Carbidopa
Cephalosporins [12]	Chloroquine	Chlorpromazine	Chlorpropamide	Cimetidine
Ciprofloxacin	Cisplatin	Clofarabine [13]	Clofazimine	Clofibrate
Co-trimoxazole	Cromolyn	Cytarabine	Dapsone	Demeclocycline
Desipramine	Diazepam	Diclofenac	Diflunisal	Diltiazem
Doxorubicin	Doxycycline	Efavirenz [14]	Enalapril	Escitalopram [15]
Esomeprazole [16]	Ethambutol [17]	Etodolac	Fenofibrate [18]	Fenoprofen
Fluconazole	Fluindione [19]	Fluoxetine [20]	Fluphenazine	Flurbiprofen
Furosemide	Gemfibrozil	Gliclazide [21]	Glipizide [22]	Gold
Griseofulvin	Hydroxychloroquine	Imatinib [23, 24]	Imipramine	Indomethacin
Intravenous immunoglobulin [25]	Intravesical mitomycin C [26]	Iodixanol [27]	Isoniazid	Isosorbide
Ketoconazole	Ketoprofen	Ketorolac	Leflunomide [28]	Lithium
Meclofenamate	Mefenamic Acid	Meprobamate	Methylphenidate
Midodrine [29]	Minocycline	Morphine sulfate [30]	Nalidixic Acid	Naproxen
Nevirapine [31]	Nitrazepam [22]	Nifedipine	Nitrofurantoin	Nitroglycerin
Nizatidine	Norfloxacin	Omeprazole	Pantoprazole [32]	Penicillamine
Penicillin	Pentobarbital	Perphenazine	Phenobarbital	Phenothiazines
Phenylbutazone	Phenytoin	Piroxicam	Primidone	Prochlorperazine
Propranolol	Pyrazinamide [17]	Pyrazolones	Quinapril	Quinidine
Quinine	Retinoids	Rifampin	Sorafenib [33]	Streptomycin
Strontium ranelate [34]	Sulfadoxine	Sulfamethoxazole	Sulfasalazine	Sulfisoxazole
Sulfonamides	Sulfonylureas	Sulindac	Terbinafine [35]	Tetracycline
Tobramycin	Tocilizumab [36]	Trazodone	Trifluoperazine	Trimethoprim
Vancomycin	Verapamil	Warfarin [37]

Epidemiology

Race

No racial predilection is reported for exfoliative dermatitis (ED).

Sex

Male-to-female ratio is 2-4:1.

Age

Exfoliative dermatitis onset usually occurs in persons older than 40 years, except when the condition results from atopic dermatitis, seborrheic dermatitis, staphylococcal scalded skin syndrome, or a hereditary ichthyosis. Age of onset primarily is related to etiology. [38, 39]

Prognosis

The prognosis of exfoliative dermatitis depends largely on underlying etiology.

The disease course is rapid if it results from drug allergy, lymphoma, leukemia, contact allergens, or staphylococcal scalded skin syndrome.

A study [40] of pediatric patients (aged < 19 y) found that fever is a poor prognostic marker and may indicate a susceptibility to rapid deterioration. In this group, those with the following characteristics have a higher tendency to develop hypotension: age 3 years or younger, ill appearance, vomiting, glucose level of 110 mg/dL or less, calcium value of 8.6 mg/dL or less, platelet count of 300,000/μL or less, elevated creatinine value, polymorphonuclear leukocyte count of 80% or greater, and the presence of a focal infection. The risk of toxic shock syndrome is increased especially in children with erythroderma and fever who have the following additional features: age of 3 years or younger, ill appearance, elevated creatinine value, and hypotension upon arrival.

The disease course is gradual if it results from generalized spread of a primary skin disease (eg, psoriasis, atopic dermatitis).

The mean duration of illness typically is 5 years, with a median of 10 months.

Mortality varies according to the disease's cause. In a study of 91 of 102 patients with exfoliative dermatitis by Sigurdsson et al, [41] a mortality rate of 43% was observed. Only 18% of the deaths were directly related to exfoliative dermatitis. In 74% of the deaths, causes unrelated to exfoliative dermatitis were implicated.

Patient Education

Educate patients on the specifics of the underlying cause of their exfoliative dermatitis (ED) and the importance of diligent follow-up management as indicated. Patients should be educated on the benefits of a healthy lifestyle and to immediately treat occurrences of erythroderma to better manage their diseases in the long term. Patients should be advised to avoid the use of and/or contact with of irritant soaps, lotions, detergents, and chlorine, and special considerations should be made for allergies, especially for patients with atopic dermatitis. [42]  Excessive sweating should also be avoided.

Clinical Presentation

History

History is the most important aid in diagnosing exfoliative dermatitis (ED). [43] Patients may have a history of the primary disease (eg, psoriasis, atopic dermatitis). Elicit a comprehensive drug history, including over-the-counter drugs.

Disease usually evolves rapidly when it results from drug allergens, lymphoma, leukemia, or staphylococcal scalded skin syndrome. Disease evolution is more gradual when it results from psoriasis, atopic dermatitis, or the spread of primary disease.

Pruritus is a prominent and frequent symptom. Malaise, fever, and chills may occur.

Physical Examination

Patients often present with generalized erythema. Scaling appears 2-6 days after the onset of erythema, usually starting from flexural areas. Pruritus commonly results in excoriations. When exfoliative dermatitis (ED) persists for weeks, hair may shed; nails may become ridged and thickened and also may shed. Periorbital skin may be inflamed and edematous, resulting in ectropion (with consequent epiphora).

In chronic cases, pigmentary disturbances can occur (especially in darker-skinned races); patchy or widespread loss of pigment (resembling vitiligo) has been reported.

Diligent search for residual signs of underlying disease occasionally yields dividends. Residual signs may include the following:

• Islands of sparing in pityriasis rubra pilaris

• Few typical psoriatic plaques in psoriasis

• Eyelid lesion may be a presenting symptom of mycosis fungoides, a cause of exfoliative dermatitis [44]

• Papules or oral lesions of lichen planus

• Superficial blisters of pemphigus foliaceus

• Erythematous papular lesions of an early drug eruption

Dermatopathic lymphadenopathy can occur in exfoliative dermatitis not caused by lymphoma or leukemia. A lymph node biopsy is advised when lymph nodes exhibit lymphomatous characteristics (eg, large size, rubbery consistency) and the cause of exfoliative dermatitis is undetermined.

The general picture is modified according to the nature of the underlying disease and the patient's general physical condition.

Complications

Complications in exfoliative dermatitis (ED) depend on underlying disease. Secondary infection, dehydration, electrolyte imbalance, temperature dysregulation, and high-output cardiac failure are potential complications in all cases.

Differential Diagnoses

• Acanthosis Nigricans

• Acute Complications of Sarcoidosis

• Allergic Contact Dermatitis

• Bullous Pemphigoid

• Cutaneous T-Cell Lymphoma

• Dermatologic Manifestations of Graft Versus Host Disease

• Familial Benign Pemphigus (Hailey-Hailey Disease)

• Irritant Contact Dermatitis

• Lichen Planus

• Pediatric Atopic Dermatitis

• Pemphigus Foliaceus

• Pityriasis Rubra Pilaris

• Plaque Psoriasis

• Reactive Arthritis

• Seborrheic Dermatitis

• Stasis Dermatitis

Workup

Laboratory Studies

Increased erythrocyte sedimentation rate, anemia, hypoalbuminemia, and hyperglobulinemia are frequent findings.

Byer and Bachur [40]  report that the levels of glucose, calcium, and creatinine and the platelet and polymorphonuclear leukocyte counts are of prognostic significance in children who present with erythroderma and fever.

A clinical diagnosis is made for psoriasis, as there is no consensus on diagnostic criteria and tests.

Increased IgE may be observed in exfoliative dermatitis (ED) when caused by atopic dermatitis.

Peripheral blood smears and bone marrow examination may be useful in a leukemia workup.

Immunophenotyping, flow cytometry, and particularly, B- and T-cell gene rearrangement analysis may be helpful in confirming the diagnosis if lymphoma is strongly suspected. High-scatter T cells are a biomarker for cutaneous T-cell lymphoma, [45]  and high throughput T-cell receptor sequencing is helpful for diagnosis. [46]

Skin scrapings may reveal hyphae or scabies mites.

Cultures may show bacterial overgrowth or the herpes simplex virus.

Perform HIV testing in the right setting; use polymerase chain reaction for viral detection, rather than enzyme-linked immunoassay, since exfoliative dermatitis has been reported to predict seroconversion in HIV infection. CD8 T-cell infiltration of the skin has been observed in patients with HIV infection and severe erythroderma. [47]

In a report by Griffiths et al, [48] decreased CD4+ T-cell count was observed in patients with exfoliative dermatitis in the absence of HIV disease.

Imaging Studies

Pursue further tests (eg, positron emission tomography, computed tomography scanning, magnetic resonance imaging, chest radiography, mammography) if the clinical features so indicate. Fluorescence diagnosis can be helpful in assessing the response to therapy in patients with mycosis fungoides. [49]

Other Tests

If the cause of exfoliative dermatitis (ED) is in doubt, survey patients for occult tumors or cancers. Perform chest radiography and routine cancer screenings appropriate for age and sex (eg, mammogram, stool occult blood test, sigmoidoscopy, prostate examination, serum prostate specific antigen level, cervical smear).

Patch testing can be performed to unveil contact allergens but should be performed only during periods of remission. In the patch test, include systemic drugs the patient was taking prior to the onset of exfoliative dermatitis.

Direct immunofluorescence studies diagnosed at least two reported cases of pemphigoid erythroderma, according to Scrivener et al. [50] TP53 mutations have been noted in Sézary syndrome and erythrodermic mycosis fungoides. [51]

Procedures

Skin biopsies reveal nonspecific findings of spongiotic dermatitis; however, primary disease may be evident.

Histologic Findings

The appearance of exfoliative dermatitis (ED) usually masks the underlying disease's specific histologic features. The most common histopathologic appearance is of either subacute or chronic dermatitis; however, biopsy is indicated, since diagnostic findings are present in 40-60% of cases. [52]

A search for the underlying cause is necessary because of possible prognostic and therapeutic implications. Detailed histopathologic analysis with clinicopathologic correlation is mandatory in the remaining cases for which a specific cause is not apparent. Often, repeated biopsies and hematologic studies may be necessary to detect specific conditions (eg, cutaneous T-cell lymphoma). [53]

Repeated biopsies have been reported to result in a diagnosis in 50% of cases that do not reveal specific findings initially.

Treatment & Management

Medical Care

Patients presenting acutely with exfoliative dermatitis (ED) often require admission for inpatient management because their total body functions (including intake and output) can require monitoring. Hospital admission should be seriously considered in pediatric patients who present with erythroderma and fever because this presentation is a predictor of hypotension and even toxic shock syndrome. The principle of management is to maintain skin moisture, avoid scratching, avoid precipitating factors, apply topical steroids, and treat the underlying cause and complications. Exfoliative dermatitis commonly resists therapy until the underlying disease is treated (eg, phototherapy, systemic medications in psoriasis). Outcome is unpredictable in idiopathic exfoliative dermatitis. [54] The course is marked by multiple exacerbations, and prolonged glucocorticoid therapy often is needed.

Discontinue all unnecessary medications. Carefully monitor and control fluid intake, because patients can dehydrate or go into cardiac failure; monitor body temperature, because patients may become hypothermic.

Apply tap water–wet dressings (made from heavy mesh gauze); change every 2-3 hours. Apply intermediate-strength topical steroids (eg, triamcinolone cream 0.025-0.5%) beneath wet dressings. Suggest a tepid bath (as it may be comforting) once or more daily between dressing changes. Reduce frequency of dressings and gradually introduce emollients between dressing applications as exfoliative dermatitis improves.

Institute systemic antibiotics if signs of secondary infection are observed. Antihistamines help reduce pruritus and provide needed sedation.

Systemic steroids may be helpful in some cases but should be avoided in suspected cases of psoriasis and staphylococcal scalded skin syndrome.

Increased capillary permeability occasionally is severe enough to justify plasma infusion.

Preexisting malnutrition may become more marked and require nutritional intervention in older patients.

Traditionally, topical corticosteroids under moist occlusion and phototherapy have been used to manage psoriatic erythroderma. [55] Five biologic agents have been approved for the treatment of psoriasis in the United States: infliximab, adalimumab, etanercept, ustekinumab, [56] and secukinumab [57] ; however, their high costs are a deterrent. Ustekinumab and secukinumab may be particularly effective in patients with overlapping features of psoriasis and pityriasis rubra pilaris. [58] At least some of these patients have CARD14 mutations. Small-molecule agents are emerging as a lower cost, therapeutic alternative. [59] According to the Medical Board of the National Psoriasis Foundation, cyclosporine [60] and infliximab appear to be the most effective first-line treatments; other more slowly working, but effective therapies, are acitretin and methotrexate. [61] For secondary treatment options, they recommend etanercept and combination therapy. [62]

The treatment of mycosis fungoides is determined by the staging of the disease. For early refractory mycosis fungoides, skin-directed therapies are the first line of treatment and include topical corticosteroids, topical chemotherapy, topical retinoids, phototherapy, and radiotherapy. [63] In aggressive or advanced-stage disease, systemic therapy is applied, including interferon, oral retinoids, [64, 65] histone deacetylase inhibitors, monoclonal antibodies, [66] extracorporeal photopheresis, [67] and single- and multi-agent chemotherapy. In a select patient population with advanced mycosis fungoides, allogeneic stem cell transplantation is beneficial. [68] Although combination therapy for advanced-stage mycosis fungoides is often reported in the literature, Humme et al [69] found that no combination therapy was more effective than monotherapy in their systematic review. Chemotherapy has been found to have only modest efficacy, [70] and biologic agents and histone deacetylase inhibitors have shown better survival rates than multi-agent chemotherapy (2.5 y vs 9 mo, respectively). [59]  Histone deacetylase inhibitors were developed to inhibit the dysregulation of histone deacetylase enzymes that causes epigenetic changes and contributes to cancer development. [71, 72, 73]

Atopic dermatitis, despite being the most common dermatological condition among the causes of erythroderma, has no specific targeted treatment options. [74]  Therapy is based on avoiding allergens, and emollients and topical and systemic immunosuppressants are used with varying efficacy. There are no approved biologics for atopic dermatitis, mainly owing to their toxicity, contradictory outcomes, and high costs. [42] Oral immunotherapy is an emerging, novel therapy for a select patient population.

Appropriate in/outpatient medications are influenced by the underlying etiology of exfoliative dermatitis. For example, prednisone may be contraindicated in exfoliative dermatitis secondary to psoriasis, while retinoids are an excellent choice for this disease. In patients with mycosis fungoides, who receive a differential diagnosis of psoriasis, special attention must be made prior to prescribing tumor necrosis factor-alpha inhibitors, given that they might cause mycosis fungoides to progress. [75]

Consultations

Consult a dermatologist for all cases of exfoliative dermatitis (ED).

Diet

Ensure adequate nutrition with emphasis on protein intake, since exfoliative dermatitis (ED) patients lose a lot of protein through excessive desquamation and show a tendency toward hypoalbuminemia. Alter diet as necessary if ingestion of a certain food group is suspected as the etiology of exfoliative dermatitis.

Activity

Patient activity is as tolerated.

Prevention

Prevention of exfoliative dermatitis (ED) depends on adequate control of underlying etiology. For example, gentle skin care is key to preventing exfoliative dermatitis flare-ups in atopic dermatitis, while specific treatments for psoriasis should be adhered to when it is the underlying cause.

Long-Term Monitoring

Follow patients discharged from the hospital on an outpatient basis for continued management of underlying disease.

Closely follow patients with no discernible underlying disease (idiopathic exfoliative dermatitis [ED]) using multiple serial biopsies to exclude cutaneous T-cell lymphoma. Since low-dose methotrexate has been shown to be efficacious in the management of erythrodermic cutaneous T-cell lymphoma (as reported by Zackheim et al [76] ), some have advocated the use of methotrexate between rebiopsy periods in patients with idiopathic exfoliative dermatitis that is unremitting despite the use of topical steroids. However, this novel approach should be taken with the understanding that cutaneous T-cell lymphoma develops only in a minority of patients with idiopathic exfoliative dermatitis (7%), especially in the subgroup with persistent chronic disease on long-term follow-up care (as reported by Sigurdsson et al [77] ), and that methotrexate is associated with many adverse effects, including toxicities of the liver, lungs, and bone marrow.

In addition to their high cost, the widespread use of biologics has been deterred by fear of an increased risk of new or recurrent malignancies in patients with psoriasis, although no recent evidence supports this claim. [78]  However tumor necrosis factor-alpha inhibitors and monoclonal antibodies can cause the formation of antidrug antibodies (ADAs) that affect the clinical response, with ADAs reported in 0-44.8% of patients. [79]

Medication

Medication Summary

Topical steroids are the primary category of medications used to treat exfoliative dermatitis (ED). A sedative antihistamine may be a useful adjunct for pruritic patients, since it helps patients to sleep at night, thus limiting nocturnal scratching and excoriations. Antimicrobial agents often are used if an infection is suspected to be precipitating or complicating exfoliative dermatitis. Biologics are the most rapidly growing treatment option, with their use most common in psoriasis. Other drugs specifically indicated for management of underlying etiology of exfoliative dermatitis may be necessary.

Topical steroids

Class Summary

Topical steroids exert anti-inflammatory effects by inhibiting early processes (eg, edema, fibrin deposition, capillary dilatation, movement of phagocytes into the area, phagocytic activities). In exfoliative dermatitis, they may inhibit the increased epidermal cell turnover that occurs. Indications include symptomatic relief of inflammation and/or pruritus associated with acute and chronic corticosteroid-responsive disorders.

Triamcinolone topical (Aristocort)

Triamcinolone topical is a medium-potency topical steroid. Use creams and lotions for moist weepy lesions and with intense inflammation (eg, exfoliative dermatitis). The frequency of use in exfoliative dermatitis depends on the acute nature of the disease and the frequency with which wet dressings are changed.

Antihistamines

Class Summary

Antihistamines exert both antipruritic and sedating effects. They are used in treating histamine-mediated allergic reactions by competitively inhibiting H1 receptors on effector cells. To varying degrees, they exert sedative effects by crossing the blood-brain barrier and blocking central histaminogenic receptors.

Hydroxyzine (Atarax, Vistaril)

Hydroxyzine antagonizes H1 receptors in the periphery. It may suppress histamine activity in the subcortical region of the central nervous system, providing antipruritic effects.

Calcineurin Inhibitors

Class Summary

Calcineurine inhibitors regulate key factors responsible for inflammatory response.

Cyclosporine (Gengraf, Neoral, Sandimmune)

Cyclosporine is an immunosuppressant drug approved for the treatment of psoriasis. It is among the most effective systemic therapeutics available for psoriasis, although it is not applicable for long-term use due to its toxicities.

Retinoids

Class Summary

Treatment with systemic retinoids may be considered.

Bexarotene (Targretin)

Bexarotene is an oral synthetic retinoid for the treatment of mycosis fungoides and refractory cutaneous T-cell lymphoma that can be used as monotherapy or in combination with other options, such as phototherapy. It has been found to be less effective in very advanced stages of cutaneous T-cell lymphoma.

Histone Deacetylase Inhibitors

Class Summary

Histone deacetylase inhibitors were developed to inhibit the dysregulation of histone deacetylase enzymes that causes epigenetic changes and contributes to cancer development. Histone deacetylase inhibitors are effective in stopping the growth, cell differentiation, and apoptosis in malignant cutaneous T-cell lymphoma.

Vorinostat (Zolinza)

Vorinostat is an oral, chemotherapeutic histone deacetylase inhibitor approved for the treatment of cutaneous T-cell lymphoma.

Romidepsin (Istodax)

Romidepsin (depsipeptide or FK228) is an intravenous histone deacetylase inhibitor approved for patients with relapsed or refractory cutaneous T-cell lymphoma.

Belinostat (Beleodaq)

Belinostat is an intravenous pan-histone deacetylase inhibitor for patients with relapsed or refractory cutaneous T-cell lymphoma.

Biologics

Class Summary

Various biologic products may be considered that are currently approved for psoriasis (eg, tumor necrosis factor [TN]F inhibitors, interleukin [IL] inhibitors, phosphodiesterase type 4 [PDE-4] inhibitors).

Infliximab (Remicade)

Infliximab is a monoclonal antibody and cytokine modulator that inhibits TNF-alpha. It is approved for intravenous injection in patients with psoriasis.

Adalimumab (Humira)

Adalimumab is a monoclonal antibody and cytokine modulator that inhibits TNF-alpha. It is approved for subcutaneous injection in patients with psoriasis.

Etanercept (Enbrel)

Etanercept is a fusion protein that binds to both TNF-alpha and TNF-beta and inhibits TNF-alpha. It is approved for subcutaneous injection in patients with psoriasis.

Ustekinumab (Stelara)

Ustekinumab is an anticytokine protein that targets IL-12/Th1 and IL-23/Th17, inhibiting both of their pathways. It is approved for subcutaneous injection in patients with psoriasis.

Secukinumab (Cosentyx)

Secukinumab is a monoclonal antibody that inhibits IL-17A. It is approved for subcutaneous administration in patients with psoriasis.

Apremilast (Otezla)

Apremilast an oral small molecule approved for the treatment of psoriasis that degrades PDE-4 and interferes with cyclic antimicrobial peptides.

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