Novel and Off-Label Biologic Use in the Management of Hidradenitis Suppurativa, Pyoderma Gangrenosum, Lichen Planus, and Seborrheic Dermatitis: A Narrative Review

Abstract

With advances in drug development and our understanding of the pathophysiology of skin disease, biologic medications have emerged as powerful management tools for dermatologists. While biologics have most often been used in the management of psoriasis, they are being used off-label for the management of a variety of other immune-mediated skin diseases with overlapping molecular targets. This narrative review focuses on the novel and off-label use of biologic medications for the management of hidradenitis suppurativa (HS), pyoderma gangrenosum (PG), lichen planus (LP), and seborrheic dermatitis (SD). Review of the literature revealed that IL-17, IL-23, and tumor necrosis factor (TNF) inhibitors were being used across a variety of immune-mediated skin pathologies with variable efficacy, among other targeted biologics. While biologics were generally safe in the treatment of primary immune-mediated skin disorders, paradoxical disease eruptions were noted with biologic use and were theorized to occur owing to immune dysregulation and cytokine imbalance. While numerous case reports show promise for the use of biologics in immune-mediated skin pathologies, the variable efficacy and safety reported warrants more thorough investigations of the role of these targeted medications in comprehensive disease management.

Recalcitrant Pyoderma Gangrenosum: Clinical Burden and Unmet Needs

“…[16][17][18] Of note, while such agents continue to be used off-label in the United States, Japan has recently approved adalimumab for use in PG which could be seen as an indication of the growing consensus regarding the benefit of biologics in PG. 19 Therefore, the observed benefit from biologics we observed in our review might argue for a lower threshold to begin a biologic in PG patients, such as a patient who has failed two or more previous treatments. The reinforced utility of biologics also advances a need for a decreased threshold for prior authorizations even without comorbidities given the observed clinical benefit for PG patients.…”

“… 10 The use of standardized language and diagnostic criteria would improve both research methodology but more importantly patient outcomes. Efforts to standardize PG research, such as work by the C3 UPGRADE (Understanding Pyoderma Gangrenosum: Review and Analysis of Disease Effects) initiative 19 are a crucial step though more work is needed for such initiatives to be more universally adopted.…”

A Case Report and Literature Review of the Role of Dupilumab in the Management of Lichen Planus: Cause or Treatment?

“…While the previous reports discussed a potential correlation between the initiation of dupilumab and the development of LP, other studies described the treatment of LP with dupilumab [ 14 - 16 ]. Pousti et al described the case of a 52-year-old man who progressively developed biopsy-proven LP over a six-month period.…”