New Oral RA Med

Yesterday, the FDA approved Pfizer’s XELJANZ (tofacitinib) for treatment of RA when methotrexate has failed to work adequately.  This oral medicine is in a new class of drugs:  Janus kinase (JAK) inhibitor.

Another JAK, ruxolitinib, was approved last year for the treatment of myelofibrosis.  Other JAK inhibitors are being tested as treatments for psoriasis, RA, and some cancers.  I have to admit that reading about JAKs made my eyes glaze over; all I retained was “just another kinase” having to do with cytokine receptors and “named after the two-faced Roman god Janus.”   Perhaps Andrew will write something comprehensible for us laymen (hint).  Until then, I know which reading material I’ll select next time insomnia strikes.

Tofacitinab comes with the black-box warning that RA patients are all too familiar with:  elevated liver enzymes, lower blood counts, high cholesterol, and increased risk of infection, tuberculosis, lymphoma, and cancers.  Post-marketing studies were ordered, so time will tell how effective this medication is, and whether there are other side effects to watch for.  Those who have run the gauntlet of every available medicine but found no relief now have a new treatment option.

See Medscape’s article here, and the FDA’s approval letter here.

Nummular Dermatitis & TNF-Inhibitors

Nummular dermatitis (aka discoid eczema) has an incidence of 2 in 1000 people, mostly men in the age range of 55-65.  However, treatment with a TNF-inhibitor is also a risk factor.

Like many medical terms, the name nummular dermatitis  comes from Latin roots:

  • nummular – from nummus - coin
  • dermis – a layer of skin
  • itis – inflammation

So, nummular dermatitis is coin-shaped inflamed patches of skin.  This rash can itch and burn, even to the extent that it disrupts sleep.  Some people, however, are fortunate enough to skip the unpleasant sensations that typically accompany this unsightly rash (sometimes there are advantages to peripheral neuropathy).

This rash is not contagious.

Appearance

Nummular dermatitis begins as a group of blisters or tiny red dots.  It quickly becomes a round or oval-shaped patch of red (sometimes pink or brown) skin.  Multiple patches are possible; they can be as small as two millimeters, or as large as four inches.  The rash usually appears on the extremities (arms, legs, feet, hands) or torso.  Thankfully, it is rare for patches to appear on the face.

  

Diagnosis

This rash is unique in appearance and can often be diagnosed based on a visual examination.  Usually no expensive tests are needed, but occasionally the rash will look like ringworm, in which case a doctor might need to take a sample to make an accurate diagnosis.

Causes

There are no known causes of nummular dermatitis, however a Dutch study of RA patients done in 2005 showed that 25% of RA patients on TNF-inhibitors needed referral to a dermatologist, vs. 13% of RA patients who had never taken a TNF-inhibitor.  Fortunately, only a small number had nummular dermatitis.  Of note, hepatitic C patients treated with a TNF-inhibitor have an increased risk of nummular dermatitis.  It will be interesting to see the results of follow-up studies now that TNF-inhibitor use is more common in the treatment of RA.

Treatment

Home treatments aren’t enough to deal with nummular dermatitis. Without adequate treatment, this rash can stick around indefinitely. Even with medical treatment, the rash can take months to resolve – some sources say it sometimes takes a full year for the rash to go away.

The goal of treatment is to:

  • reduce inflammation
  • repair the skin
  • rehydrate the skin
  • if infected, treat the infection

Credit:  http://s252.photobucket.com/albums/hh18/Jane-emma18/?action=view&current=Gumby.jpg&newest=1To reduce inflammation, prescription-strength steroid cream or ointment can be rubbed into the rash two-three times daily.  Unless you are Gumby, if your rash is on your back, you will need assistance with the application.  Oral steroids can be used when topical steroids are ineffective (this also eliminates the need for an assistant).

To increase absorption, the steroid cream/ointment should be applied to wet skin – particularly after a shower or twenty-minute soak.  Following application of the topical medicine, a good moisturizer should be applied to wet skin.  Some people recommend covering the medicated areas (ie with plastic wrap) for an hour to hold in the moisture.  Gently pat yourself dry; do not rub with a towel and remove the steroid cream & moisturizer.

Another treatment option – when topical steroids fail – is light therapy (UVB).

Although home treatments alone can’t cure nummular dermatitis, there are a few things you can do.  Take good care of your skin and be sure to moisturize it well.  Also, avoid potential flare-triggers.

A few of the things that sometimes cause flare-ups of this condition are:

  • frequent use of detergents or harsh soaps
  • hot tub usage
  • extreme temperatures (very hot or very cold)
  • extremes in humidity (or lack thereof)
  • rough wool clothing
  • skin injury (ie cut, burn, or insect bite)
  • some medications  (examples include accutane, neomycin, and TNF-inhibitors)
  • sensitivity or allergy to rubber, nickel, cobalt, formaldehyde, or mercury

This means that if your routine is to take a long, hot shower first thing in the morning before dressing in a nice warm, wool sweater and cozy wool socks, you might need to modify your routine.  Make it a shorter lukewarm shower, apply a good moisturizer to your skin, then dress is loose cotton clothing.  If your workout routine later includes spending twenty minutes in a steam room, followed by half an hour soaking/stretching in a hot tub, followed by an hour in a swimming pool, ten minutes in the dry sauna, and then another hot shower, you’re intentionally doing five of the eight things you need to avoid.

See a doctor for accurate diagnosis and treatment if you suspect nummular dermatitis.

Vocabulary for Reading Medical Literature about Nummular Dermatitis

erythematous – red
papules – bumps
vesicles – very small blisters
pruritic – itchy
xerosis – abnormal dryness

References

Arthritis Research & Therapy
Medscape
Skinsight
American Academy of Dermatology
DermNet NZ
British Association of Dermatologists

Symptoms vs. Treatment Plan

Report symptoms; don’t propose a treatment plan.  That’s one rule of obtaining good medical care that’s quickly apparent when reading medblogs.

Knowing that’s how doctors feel, and having an excellent family physician who I don’t want to annoy, I was a bit hesitant to phone my doctor’s office and give my reason for visit as “I need a cortisone shot,” so I followed that with, “But if you want, you can just say ‘shoulder pain’ and let the doctor determine that I need a cortisone injection.”  That earned me a laugh and the comment, “It sounds like you’ve figured out how things work.”

The way it’s supposed to work is that patients report symptoms, then doctors consider those subjective symptoms as they decide what type of exam to perform and determine whether it’s necessary to order any tests.  This generates objective data.  Doctors then assess the information to develop a treatment plan.  The entire process is carefully documented in a SOAP note (another SOAP explanation; real-life example).

When I called the doctor’s office, I’d hoped that there would be an appointment available early next week, but by a huge stroke of luck, I got the office manager on the phone instead of my doctor’s brand-new receptionist, and was offered a same-day appointment.

Once in the exam room, I explained to the nurse that my rheumatologist offered to do a cortisone shot at my two previous appointments, but the first time I didn’t think it was bad enough, and the last time I said yes, but then she got busy confirming that other pain was costochondritis instead of a need for a cardiology referral and she didn’t do the shot in my shoulder.  I’ve been living with it, but it’s getting worse instead of better.  It hurts all the time, and I have limited range of motion that interferes with my ability to demonstrate various strokes to the kids in my swimming classes (it also interferes with my ability to dust the top of my refrigerator, but I don’t mind that nearly as much).  Constant pain is something I’ve learned to live with, but I need to be able to swim.  I doubt that I’ll ever do the butterfly again, but a basic crawl stroke is a must.  Also, it would be nice to be able to play my guitar again.  This is interfering with my life.

My doctor always reads the nurse’s notes before entering the exam room so he knows what he facing.  This time, as soon as he walked into the room, he asked, “Do you want a cortisone injection?”  It was sooooooo nice to get right to the point!  Of course he still did an exam and documented the limited range of motion, the crunching sounds, and all the rest, before giving the shot, but it was more along the lines of, “prove the patient right” instead of being treated as if I know nothing.

I like the fact that my family physician is thorough about doing an exam.  Documenting the extent of the problem and finding the most appropriate treatment is important.  The fact is, maybe I don’t need a cortisone injection.  In the past, these symptoms have led to a shot, but that doesn’t automatically mean that’s what’s best this time.  There might be a different problem, and it’s good to not make assumptions.

I’m not very appreciative when people with no training tell me how to do my job, and it’s no surprise when others – including doctors – feel the same way.  It was nice to discover how easy it can be to stick with describing symptoms, reporting facts, and letting my doctor determine the best treatment plan.