Off-Label Therapeutics in Adult Patients

At the 2022 Society of Dermatology Physician Assistants Conference in Miami, Florida, Ted Rosen, MD, professor and vice-chair of dermatology at the Baylor College of Medicine in Houston, Texas, reviewed several adult dermatologic cases and the best off-label treatment options to consider. Overall, Rosen stressed the importance of thinking outside of the box when it comes to challenging cases.

Red scrotum syndrome:

• Presents persistent redness, itching, burning, and pain
• Best off-label treatment option: indomethacin

According to Rosen, indomethacin is the recommended treatment for red scrotum syndrome, but physicians need to be aware of potential adverse events such as severe headaches and gastritis if indomethacin is taken on an empty stomach.

Addictive obsession compulsions:

• Consistent with yanking hair out, skin picking, and neurotic excortication 
• Best off-label treatment option: N-acetylcysteine

N-acetylcysteine, a glutamate-modifying drug, helps ease obsessive compulsive disorders. According to Rosen, “It’s not perfect, but it does really seem to help a lot of obsessive compulsive, chronic, repetitive actions.”

Generalized granuloma annulare:

• Recognized as a raised rash or bump in a circular pattern, and can be associated with diabetes
• Best off-label treatment option: a small dosage (12.5mg or less) of methotrexate a week for a couple of months

Anywhere from 5-7mg will help achieve total clarity for 2/3 of patients. The use of methotrexate for generalized granuloma annulare was originally studied by the University of Connecticut. Rosen mentioned that biologics are occasionally successful as well, including adalimumab, ustekinumab, apremilast, and dupilumab.

Molluscum contagiosum:

• While normally associated with pediatric patients, molluscum contagiosum can also affect adults
• Best off-label treatment: heat applied for 30 minutes to the affected area.

A small Chinese prospective study (n=21) found that 111°F heat applied for 30 minutes, once a week, for 12 weeks, can achieve complete clearance in both adults and children by the end of 12 weeks. Rosen recommended a heating pad as the best way to apply direct heat. Rosen also reminded physicians to encourage their patients and parents to read the maximum temperature on a heating pad before purchasing to guarantee it reaches the necessary 111°F.

Reference

Rosen T. Off-label therapeutics in adult and pediatric patients for the experienced and daring clinician. Presented at the 2022 Society of Dermatology Physician Assistants Conference; November 17-20, 2022; Miami, Florida.