Evidence Lacking for Tocilizumab Use in Dermatologic Conditions

Tocilizumab use may be limited for therapeutic trial only in selected patients with refractory dermatologic conditions who have a concurrent rheumatologic indication for the drug, researchers reported in a study published in Dermatologic Therapy.

The investigators reviewed off-label uses of tocilizumab and its potential role in the management of dermatologic conditions that are refractory to first-line immunosuppressive and disease-modifying agents.¹

A case series has shown efficacy of tocilizumab in patients with morphea, and the potential benefits of tocilizumab for psoriasis are limited to case reports as well. A phase 2 trial has shown clinically meaningful improvements in patients with systemic sclerosis, it was noted.

For patients with severe atopic dermatitis refractory to topical corticosteroids, multiple immunosuppressive agents, and light therapy, a case series found efficacy of tocilizumab. Another report cited by the researchers has detailed the first case of vitiligo that responded to tocilizumab in a patient with rheumatoid arthritis. Although minimal improvement was observed for the arthritis, almost complete remission was achieved for the vitiligo lesions.

Management of cutaneous adverse reactions, especially when interleukin-6 is elevated, is another reported use for tocilizumab. However, tocilizumab may partially mask the presentation of cutaneous adverse reactions to other drugs, according to the study authors.

A phase 2 randomized trial investigated the use of tocilizumab in patients with acute graft-versus-host disease (aGvHD). The investigators elaborated that adding tocilizumab to a regimen of methotrexate and tacrolimus was associated with a statistically significant reduction in grade II to IV aGvHD and improvement in GvHD-free survival, compared with matched controls who only received methotrexate and tacrolimus.

Tocilizumab is associated with common adverse cutaneous reactions, such as maculopapular rashes and urticaria, and less frequently pustular eruptions, desquamation, and erythroderma. Tocilizumab-related drug reactions generally resolve with topical corticosteroids and antihistamines. Other adverse effects include infection, gastrointestinal events, hyperlipidemia, hematologic events, and malignancy.

Current guidelines recommend against using tocilizumab for management of patients with COVID-19 outside a clinical trial.

“Overall, the rheumatologic indications for tocilizumab remain far stronger than for those in dermatology,” the authors commented. “While there is certainly substantial case-based evidence to suggest some degree of benefit in dermatology, clinicians must be wary of the possibility of publication bias which inherently exists, in which there is a tendency for case reports with positive findings to be published rather than negative studies.”

Reference

Choong DJ, Tan E. Does tocilizumab have a role in dermatology? A review of clinical applications, its adverse side effects and practical considerations. Dermatol Ther. Published online May 18, 2021. doi:10.1111/dth.14990