Systemic Approaches to Granulomatous Disorders S001...Systemic Approaches to Granulomatous Disorders

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  • Misha Rosenbach, MD Assistant Professor, Dermatology & Internal Medicine

    Director, Inpatient Consult Service Director, Cutaneous Sarcoidosis Clinic

    Systemic Approaches to Granulomatous Disorders

  • Conflicts of Interest Celgene - Advisory Board

    Off label uses of medications will be discussed (everything

    is off label)

  • Antimalarials

    Methotrexate

    TNF inhibitors

    Topicals, Intralesional Phototherapy

    Dapsone Retinoids

    Case reported random

    assortment of treatments

    Tetracycline antibiotics

    GIVE EVERY

    THERAPY AT LEAST

    THREE MONTHS TO WORK

  • Sarcoidosis

    Wanat KA, Rosenbach M. A practical approach to cutaneous sarcoidosis. Am J Clin Dermatol 2014 Wanat KA, Rosenbach M. Cutaneous Sarciodosis. Clin Chest Med (In Press)

  • Cutaneous Sarcoidosis Treatment Algorithm

    Topicals

    Intralesional

    SEVERITY

    Antimalarials

    Minocycline

    Methotrexate

    Thalidomide

    Adalimumab

    Infliximab

    Wanat KA, Rosenbach M. Am J Clin Dermatol 2014

  • Granuloma Annulare

    Piette E, Rosenbach M. Granuloma Annulare: CME. JAAD (In Press) Keimig EL. Granuloma Annulare. Dermatol Clin 2015 Thornsberry LA, English JC 3rd. Am J Clin Dermatol 2013

  • Antimalarials Hydroxychloroquine 400mg Chloroquine 250mg

    First Line:

    If persistent lesions after 3 months, switch

    Phototherapy PUVA 3x/week NBUVB 3x/wk

    Consider alternative systemic agents

    Piette E, Rosenbach M. Granuloma Annulare: CME. JAAD (In Press)

    Second Line:

    GA: evidence-based treatment algorithm

  • Keimig EL. Dermatol Clin 2015

  • 1980-2013 review of GA treatment 100 studies Average # of patients: 3, median is 1 Only studies with double digits:

    Phototherapy

    Largest studies in history: Phototherapy Antimalarials

  • Min MS, Lebwohl M. JAAD 2016

  • Necrobiosis Lipoidica

    Sibbald C, Reid S, Alavi A. Necrobiosis Lipoidica. Dermatol Clin 2015 Wanat KA, Rosenbach M. Necrobiosis Lipoidica. UpToDate

  • Steroids under occlusion

    PUVA, Immunosuppressives / TNFs, Immunomodulatory drugs

  • Rheumatoid Nodules

    Tilstra JS, Lienesch DW. Rheumatoid Nodules. Dermatol Clin 2015.

  • Inject, excise

    Colchicine Antimalarials

    Dapsone Allopurinol

    Consider accelerated nodulosis

    stop offending

    agent (MTX, other)

  • Necrobiotic Xanthogranuloma

    Kerstetter J, Wang J. Adult Orbital Xanthogranulomatous Disease. Dermatol Clin 2015

  • Necrobiotic Xanthogranuloma Rare non-Langerhans cell histiocytosis Generally around the eyes Characteristic violaceous and xanthomatous

    plaques, may ulcerate Extracutaneous disease: heart, eyes, various organ

    systems Strongly associated with paraproteinemia,

    especially IgGk

  • Treatment options Limited data NXG with myeloma: treat myeloma NXG without myeloma:

    Chemo (chlroambucil, melphalan, +/- steroids) IFN-alpha AZA, MTX, Thalidomide, Dapsone, Clofazamine,

    TCNs Local: XRT, excision, intralesional steroids Newer:

    IVIg (6 cases since 2010)1

    Topical nitrogen mustard2 1. Hallermann C, Arch Dermatol 2010 2. Rodriguez O, JAMA Dermatol 2016

  • Antimalarials Hydroxychloroquine safer Chloroquine works better

    Methotrexate 15-20mg weekly

    TNF inhibitors Higher dose/Frequency than

    psoriasis

    Phototherapy: PUVA is Best

    Dapsone Retinoids

    TCN Abx: Minocycline is

    Best

    THREE MONTHS TO

    ASSESS EFFICACY

  • The Dermatology Foundation

    has supported & advanced my career.

  • Key References All Clinical Atlas of Granulomatous Disorders. English JC 3rd. Dermatol Clin 2015 GA Piette E, Rosenbach M. Granuloma Annulare: CME. JAAD (In Press) Keimig EL. Granuloma Annulare. Dermatol Clin 2015 NL Sibbald C, Reid S, Alavi A. Necrobiosis Lipoidica. Dermatol Clin 2015 Wanat KA, Rosenbach M. Necrobiosis Lipoidica. UpToDate NXG Kerstetter J, Wang J. Adult Orbital Xanthogranulomatous Disease. Dermatol Clin 2015 Sarcoidosis Wanat KA, Rosenbach M. A practical approach to cutaneous sarcoidosis. Am J Clin

    Dermatol 2014 Wanat KA, Rosenbach M. Cutaneous Sarciodosis. Clin Chest Med (In Press)

    Slide Number 1Conflicts of InterestSlide Number 3SarcoidosisCutaneous Sarcoidosis Treatment AlgorithmGranuloma AnnulareGA: evidence-based treatment algorithmSlide Number 8Slide Number 9Slide Number 10Necrobiosis LipoidicaSlide Number 12Rheumatoid NodulesSlide Number 14Necrobiotic XanthogranulomaNecrobiotic XanthogranulomaTreatment optionsSlide Number 18The Dermatology Foundationhas supported & advanced my career.Key References