- Email: [email protected]
Persistence and failure rates of adalimumab monotherapy in biologic-naïve patients with psoriasis: A retrospective study
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VOLUME 74, NUMBER 3
CSU, the improvement in solar urticaria was rapidly lost when omalizumab was stopped. In conclusion, our data suggest that omalizumab may be a potentially interesting treatment for a certain subset of patients with severe and refractory solar urticaria.
Correspondence to: Manuelle Viguier, MD, PhD, Service de dermatologie, H^opital Saint-Louis, 1 avenue Claude Vellefaux 75475 Paris Cedex 10, France.
We are indebted to Claire Thenie and Philippe Pinton from Novartis Pharma for their help in supporting this study; and to Dr Isabelle Madelaine (Pharmacie, H^ opital Saint-Louis, Paris), Dr Marie-Blanche Valnet-Rabier (Pharmacologie, Centre Hospitalier Regional Universitaire [CHRU] Besanc¸on), Mrs Morgane Heberle, Mrs Kristina Mouyabi, and Mr Beranger Martin (Delegation a la Recherche Clinique et a l’Innovation, CHRU Besanc¸on) for their constant help and support in conducting the study.
REFERENCES 1. McCormark PL. Omalizumab: a review of its use in patients with chronic spontaneous urticaria. Drugs. 2014;74:1693-1699. 2. Guzelbey O, Ardelean E, Magerl M, Zuberbier T, Maurer M, Metz M. Successful treatment of solar urticaria with anti-immunoglobulin E therapy. Allergy. 2008;63:1563-1565. 3. Waibel KH, Reese DA, Hamilton RG, Devillez RL. Partial improvement of solar urticaria after omalizumab. J Allergy Clin Immunol. 2010;125:490-491. 4. Duchini G, B€aumler W, Bircher AJ, Scherer K. Failure of omalizumab (XolairÒ) in the treatment of a case of solar urticaria caused by ultraviolet A and visible light. Photodermatol Photoimmunol Photomed. 2011;27:336-337. 5. Aubin F, Porcher R, Jeanmougin M, et al. Severe and refractory solar urticaria treated with intravenous immunoglobulins: a phase II multicenter study. J Am Acad Dermatol. 2014;71: 948-953.
Franc¸ois Aubin, MD, PhD,a Martine AvenelAudran, MD,b Michel Jeanmougin, MD,c Henri Adamski, MD,d Jean-Louis Peyron, MD,e MarieClaude Marguery, MD,f Fabienne Leonard, MD,g Marc Puyraveau, MSc,h and Manuelle Viguier, MD, PhD,c on behalf of the Societe Franc¸aise de Photodermatologie Universite de Franche Comte, EA3181, SFR4234, and Centre Hospitalier Universitaire, Service de Dermatologie, Besanc¸ona; Service de Dermatologie, Centre Hospitalier Universitaire, Angersb; Universite Paris Diderot, Assistance Publique H^ opitaux de Paris, H^ opital Saint-Louis, Service de Dermatologie, Parisc; Service de Dermatologie, Centre Hospitalier Universitaire Pontchaillou, Rennesd; Service de Dermatologie, H^opital Saint-Eloi, Montpellier e; H^ opital Larrey, Service de Dermatologie, Centre Hospitalier Universitaire, Toulousef; Service de Dermatologie, Centre Hospitalier Universitaire, Reimsg; and Centre de Me thodologie Clinique, Centre Hospitalier Universitaire, Besanc¸on,h France Supported by a grant from Novartis Pharma. Omalizumab was provided free of charge by Novartis Pharma. The funders had no role in the study design or performance, manuscript writing, or decision to publish. Disclosure: Dr Viguier received consulting fees, travel support, and payment for lectures from Novartis Pharma. Drs Aubin, Avenel-Audran, Adamski, and Marguery received travel support from Novartis Pharma. Drs Jeanmougin, Peyron, and Leonard, and Mr Puyraveau have no conflicts of interest to declare. Presented as a poster in the European Academy of Dermatology and Venereology Meeting in Copenhagen, Denmark, October 7-11, 2015.
E-mail: [email protected]
http://dx.doi.org/10.1016/j.jaad.2015.11.021
Persistence and failure rates of adalimumab monotherapy in biologic-na€ıve patients with psoriasis: A retrospective study To the Editor: Pivotal controlled trials (CHAMPION, REVEAL)1,2 have examined the efficacy of adalimumab therapy and contributed to its Food and Drug Administration approval for the treatment of severe psoriasis. It is important, however, to gather efficacy data in real-world settings to allow dermatologists to prescribe adalimumab with more confidence. The aim of this study was to determine the persistence rate, failure rate, and drug survival of monotherapy adalimumab under methods of common practice. This retrospective chart review focused on patients with cutaneous psoriasis who presented to Kaiser Permanente Los Angeles Medical Center from 2008 to 2015 and did not have a change in insurance coverage. In all, 79 patients met inclusion criteria of at least 10% body surface area coverage, biologicna€ıve status, and minimum 3-month adalimumab use. Thirteen patients had coexisting psoriatic arthritis, which increased the likelihood of adalimumab therapy. Failure was defined as the need to add a second therapy, either an oral medication (methotrexate, cyclosporine, acitretin) or phototherapy, or switch to a different oral or biologic agent (etanercept, infliximab, ustekinumab, or secukinumab). The date of failure was set as the start date of the new systemic agent or first phototherapy session.
J AM ACAD DERMATOL
576 Letters
Fig 1. Distribution of years to adalimumab persistence or failure.
MARCH 2016
3.7 years (95% confidence interval 10911528 days). Median drug survival was 1259 days (3.5 years). The data from our study can address expectations of patients using biologic therapy for the first time. L opez-Ferrer et al3 found the mean drug survival to be 38.1 months (3.2 years) for 119 patients. However, only 41% of these patients were biologic-na€ıve, and studies have shown biologic-na€ıve patients to have longer drug persistence than nonna€ıve patients.4 Another Italian study found a failure rate of 41.2%, with a mean treatment duration of 10.8 months (330 days) in this group, results that are comparable with ours.5 Although our study is limited by 13.9% (11 of 79) of patients lost to follow-up, it presents response durations in real-world practice with a substantial number of patients with severe psoriasis. Adalimumab efficacy can persist well over 4 years of follow-up (Fig 1). However, Fig 2 suggests that the efficacy of biologic agents diminishes with time,4 a phenomenon that should be addressed in future studies. Shivani P. Reddy, BS,a Elaine J. Lin, BS,b Vidhi V. Shah, BS,c and Jashin J. Wu, MDd
Fig 2. Cumulative probability of drug survival in patients using adalimumab.
Kaplan-Meier methodology was used to calculate probability of drug survival in the entire cohort ( persistence and loss to follow-up groups were censored) and provide a comprehensive survival duration. This study was approved by the Kaiser Permanente Southern California Institutional Review Board. Our results showed that 53.2% (42 of 79) of patients persisted on adalimumab therapy from 13 months to as long as 6.8 years before the end of study. The remaining 46.8% (37 of 79) of patients eventually failed therapy. These patients used monotherapy adalimumab for an average of 541 days (17.7 months) and median of 432 days (14.2 months) before failure. Of the 13 patients with coexisting psoriatic arthritis, only 3 failed adalimumab therapy, indicating a higher persistence rate in this subset of patients. Fig 1 stratifies treatment duration in the persistence group versus failure group. Fig 2 plots the cumulative probability of adalimumab survival. Mean drug survival was 1337 days, or
University of Illinois at Chicago College of Medicinea; Loma Linda University School of Medicine, Los Angeles, Californiab; University of MissouriKansas City School of Medicinec; and Department of Dermatology, Kaiser Permanente Los Angeles Medical Centerd Funding sources: None. Disclosure: Dr Wu received research funding from AbbVie, Amgen, AstraZeneca, Coherus Biosciences, Dermira, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Regeneron, Sandoz, and Sun Pharmaceutical Industries; he is a consultant for AbbVie, Amgen, Celgene, Dermira, Eli Lilly, Pfizer, and Sun Pharmaceutical Industries. Ms Reddy, Ms Lin, and Ms Shah have no conflicts of interest to declare. Correspondence to: Jashin J. Wu, MD, Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, 1515 N Vermont Ave, Fifth Floor, Los Angeles, CA 90027 E-mail: [email protected] REFERENCES 1. Saurat JH, Stingl G, Dubertret L, et al. Efficacy and safety results from the randomized controlled comparative study of adalimumab vs. methotrexate vs. placebo in patients with psoriasis (CHAMPION). Br J Dermatol. 2008;158(3):558-566.
J AM ACAD DERMATOL VOLUME 74, NUMBER 3
2. Menter A, Tyring SK, Gordon K, et al. Adalimumab therapy for moderate to severe psoriasis: a randomized, controlled phase III trial. J Am Acad Dermatol. 2008;58(1):106-115. 3. L opez-Ferrer A, Vilarrasa E, Gich IJ, Puig L. Adalimumab for the treatment of psoriasis in real life: a retrospective cohort of 119 patients at a single Spanish center. Br J Dermatol. 2013;169(5): 1141-1147. 4. Gniadecki R, Kragballe K, Dam TN, Skov L. Comparison of drug survival rates for adalimumab, etanercept and infliximab in patients with psoriasis vulgaris. Br J Dermatol. 2011;164(5): 1091-1096. 5. Esposito M, Gisondi P, Cassano N, et al. Survival rate of antitumor necrosis factor- treatments for psoriasis in routine dermatological practice: a multicenter observational study. British Journal of Dermatology. 2013;169(3): 666-672. http://dx.doi.org/10.1016/j.jaad.2015.11.005
Characteristics and treatment of adult-onset linear morphea: A retrospective cohort study of 61 patients at 3 tertiary care centers To the Editor: Linear morphea (LM) is characterized by linear sclerotic plaques on the limbs or face and scalp. The disorder predominantly manifests in the pediatric population and often results in functional disability or permanent disfigurement. In 2012, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) recommended methotrexate (MTX) with or without systemic corticosteroids (CS) as first-line therapy for pediatric-onset LM.1 However, little is known about adult-onset LM. Thus, we sought to describe the characteristics and treatment of adult-onset LM at 3 tertiary care centers. After IRB approval, we used a natural language search and ICD-9 code 701.0 (‘‘circumscribed scleroderma’’) to query the Partners Research Patient Data Registry (1995-2015; Brigham and Women’s and Massachusetts General Hospitals) and two medical record systems at New York University (2005-2014), together including more than 20 million patient visits. All patients with LM onset at 18 years or older were included. Data were extracted on demographics, disease presentation, and treatment regimens (as defined in Table I). Clinical response (as defined in Table II) was determined by medical record review and available clinical photographs. Sixty-one patients with adult-onset LM were identified (Table I). The mean delay in diagnosis, defined as the interval between symptom onset and diagnosis of LM by a dermatologist, was 27 months. Forty-four percent of patients with extremity LM had functional limitations; only half were referred for physical therapy. One patient had limb length discrepancy. Among en coup de sabre or hemifacial
Letters 577
atrophy patients, 41% had magnetic resonance imaging of the brain, and 23% underwent ophthalmologic evaluation. MTX with or without systemic CS was used in 23% of treatment regimens. Disease resolution was significantly more likely (29% vs 4%, P \ .001), and progression (4% vs 34%, P ¼ .004) and recurrence (13% vs 56%, P \ .001) significantly less likely, with treatment regimens including MTX as compared to those without, during a mean follow-up of 38 months (Table II). This study represents the largest adult-onset LM cohort to date, and is the first to analyze both the characteristics and management of adult-onset LM.2-4 Delayed diagnosis and permanent functional sequelae were common. Referrals for physical therapy, neurologic imaging, and evaluation of ocular involvement were underused. Treatment regimens incorporating MTX were more likely to result in resolution and less likely to result in progression or reactivation. This is notable given that flares in LM are common regardless of age at disease onset.2 While MTX is considered first-line for pediatric-onset LM, this study is the first to support its use for adult-onset LM. Nevertheless, in this study, less than a quarter of treatment regimens included MTX. Although our study period largely predates the CARRA guidelines, a 2015 national survey found that physicians treating adults with LM were more likely to prescribe topical CS or phototherapy, whereas those treating children were more likely to prescribe MTX.5 Thus, MTX appears to be underused in the treatment of adultonset LM. This study’s limitations include its retrospective nature and lack of objective outcome measures in patients treated at various disease stages. Despite the small sample size, this study represents the largest adult-onset LM cohort to date. Further investigation is needed to determine a treatment algorithm for adult-onset LM. Daniel R. Mazori, BA,a Natalie A. Wright, MD,b Mital Patel, MD,b Stephanie W. Liu, MD,b Sarika M. Ramachandran, MD,a Andrew G. Franks, Jr, MD,a Ruth Ann Vleugels, MD, MPH,b and Alisa N. Femia, MDa The Ronald O. Perelman Department of Dermatology, New York University Langone Medical Center, New York,a and Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusettsb Mr Mazori and Dr Wright share first authorship. Drs Vleugels and Femia share last authorship.
Letters 575
VOLUME 74, NUMBER 3
CSU, the improvement in solar urticaria was rapidly lost when omalizumab was stopped. In conclusion, our data suggest that omalizumab may be a potentially interesting treatment for a certain subset of patients with severe and refractory solar urticaria.
Correspondence to: Manuelle Viguier, MD, PhD, Service de dermatologie, H^opital Saint-Louis, 1 avenue Claude Vellefaux 75475 Paris Cedex 10, France.
We are indebted to Claire Thenie and Philippe Pinton from Novartis Pharma for their help in supporting this study; and to Dr Isabelle Madelaine (Pharmacie, H^ opital Saint-Louis, Paris), Dr Marie-Blanche Valnet-Rabier (Pharmacologie, Centre Hospitalier Regional Universitaire [CHRU] Besanc¸on), Mrs Morgane Heberle, Mrs Kristina Mouyabi, and Mr Beranger Martin (Delegation a la Recherche Clinique et a l’Innovation, CHRU Besanc¸on) for their constant help and support in conducting the study.
REFERENCES 1. McCormark PL. Omalizumab: a review of its use in patients with chronic spontaneous urticaria. Drugs. 2014;74:1693-1699. 2. Guzelbey O, Ardelean E, Magerl M, Zuberbier T, Maurer M, Metz M. Successful treatment of solar urticaria with anti-immunoglobulin E therapy. Allergy. 2008;63:1563-1565. 3. Waibel KH, Reese DA, Hamilton RG, Devillez RL. Partial improvement of solar urticaria after omalizumab. J Allergy Clin Immunol. 2010;125:490-491. 4. Duchini G, B€aumler W, Bircher AJ, Scherer K. Failure of omalizumab (XolairÒ) in the treatment of a case of solar urticaria caused by ultraviolet A and visible light. Photodermatol Photoimmunol Photomed. 2011;27:336-337. 5. Aubin F, Porcher R, Jeanmougin M, et al. Severe and refractory solar urticaria treated with intravenous immunoglobulins: a phase II multicenter study. J Am Acad Dermatol. 2014;71: 948-953.
Franc¸ois Aubin, MD, PhD,a Martine AvenelAudran, MD,b Michel Jeanmougin, MD,c Henri Adamski, MD,d Jean-Louis Peyron, MD,e MarieClaude Marguery, MD,f Fabienne Leonard, MD,g Marc Puyraveau, MSc,h and Manuelle Viguier, MD, PhD,c on behalf of the Societe Franc¸aise de Photodermatologie Universite de Franche Comte, EA3181, SFR4234, and Centre Hospitalier Universitaire, Service de Dermatologie, Besanc¸ona; Service de Dermatologie, Centre Hospitalier Universitaire, Angersb; Universite Paris Diderot, Assistance Publique H^ opitaux de Paris, H^ opital Saint-Louis, Service de Dermatologie, Parisc; Service de Dermatologie, Centre Hospitalier Universitaire Pontchaillou, Rennesd; Service de Dermatologie, H^opital Saint-Eloi, Montpellier e; H^ opital Larrey, Service de Dermatologie, Centre Hospitalier Universitaire, Toulousef; Service de Dermatologie, Centre Hospitalier Universitaire, Reimsg; and Centre de Me thodologie Clinique, Centre Hospitalier Universitaire, Besanc¸on,h France Supported by a grant from Novartis Pharma. Omalizumab was provided free of charge by Novartis Pharma. The funders had no role in the study design or performance, manuscript writing, or decision to publish. Disclosure: Dr Viguier received consulting fees, travel support, and payment for lectures from Novartis Pharma. Drs Aubin, Avenel-Audran, Adamski, and Marguery received travel support from Novartis Pharma. Drs Jeanmougin, Peyron, and Leonard, and Mr Puyraveau have no conflicts of interest to declare. Presented as a poster in the European Academy of Dermatology and Venereology Meeting in Copenhagen, Denmark, October 7-11, 2015.
E-mail: [email protected]
http://dx.doi.org/10.1016/j.jaad.2015.11.021
Persistence and failure rates of adalimumab monotherapy in biologic-na€ıve patients with psoriasis: A retrospective study To the Editor: Pivotal controlled trials (CHAMPION, REVEAL)1,2 have examined the efficacy of adalimumab therapy and contributed to its Food and Drug Administration approval for the treatment of severe psoriasis. It is important, however, to gather efficacy data in real-world settings to allow dermatologists to prescribe adalimumab with more confidence. The aim of this study was to determine the persistence rate, failure rate, and drug survival of monotherapy adalimumab under methods of common practice. This retrospective chart review focused on patients with cutaneous psoriasis who presented to Kaiser Permanente Los Angeles Medical Center from 2008 to 2015 and did not have a change in insurance coverage. In all, 79 patients met inclusion criteria of at least 10% body surface area coverage, biologicna€ıve status, and minimum 3-month adalimumab use. Thirteen patients had coexisting psoriatic arthritis, which increased the likelihood of adalimumab therapy. Failure was defined as the need to add a second therapy, either an oral medication (methotrexate, cyclosporine, acitretin) or phototherapy, or switch to a different oral or biologic agent (etanercept, infliximab, ustekinumab, or secukinumab). The date of failure was set as the start date of the new systemic agent or first phototherapy session.
J AM ACAD DERMATOL
576 Letters
Fig 1. Distribution of years to adalimumab persistence or failure.
MARCH 2016
3.7 years (95% confidence interval 10911528 days). Median drug survival was 1259 days (3.5 years). The data from our study can address expectations of patients using biologic therapy for the first time. L opez-Ferrer et al3 found the mean drug survival to be 38.1 months (3.2 years) for 119 patients. However, only 41% of these patients were biologic-na€ıve, and studies have shown biologic-na€ıve patients to have longer drug persistence than nonna€ıve patients.4 Another Italian study found a failure rate of 41.2%, with a mean treatment duration of 10.8 months (330 days) in this group, results that are comparable with ours.5 Although our study is limited by 13.9% (11 of 79) of patients lost to follow-up, it presents response durations in real-world practice with a substantial number of patients with severe psoriasis. Adalimumab efficacy can persist well over 4 years of follow-up (Fig 1). However, Fig 2 suggests that the efficacy of biologic agents diminishes with time,4 a phenomenon that should be addressed in future studies. Shivani P. Reddy, BS,a Elaine J. Lin, BS,b Vidhi V. Shah, BS,c and Jashin J. Wu, MDd
Fig 2. Cumulative probability of drug survival in patients using adalimumab.
Kaplan-Meier methodology was used to calculate probability of drug survival in the entire cohort ( persistence and loss to follow-up groups were censored) and provide a comprehensive survival duration. This study was approved by the Kaiser Permanente Southern California Institutional Review Board. Our results showed that 53.2% (42 of 79) of patients persisted on adalimumab therapy from 13 months to as long as 6.8 years before the end of study. The remaining 46.8% (37 of 79) of patients eventually failed therapy. These patients used monotherapy adalimumab for an average of 541 days (17.7 months) and median of 432 days (14.2 months) before failure. Of the 13 patients with coexisting psoriatic arthritis, only 3 failed adalimumab therapy, indicating a higher persistence rate in this subset of patients. Fig 1 stratifies treatment duration in the persistence group versus failure group. Fig 2 plots the cumulative probability of adalimumab survival. Mean drug survival was 1337 days, or
University of Illinois at Chicago College of Medicinea; Loma Linda University School of Medicine, Los Angeles, Californiab; University of MissouriKansas City School of Medicinec; and Department of Dermatology, Kaiser Permanente Los Angeles Medical Centerd Funding sources: None. Disclosure: Dr Wu received research funding from AbbVie, Amgen, AstraZeneca, Coherus Biosciences, Dermira, Eli Lilly, Janssen, Merck, Novartis, Pfizer, Regeneron, Sandoz, and Sun Pharmaceutical Industries; he is a consultant for AbbVie, Amgen, Celgene, Dermira, Eli Lilly, Pfizer, and Sun Pharmaceutical Industries. Ms Reddy, Ms Lin, and Ms Shah have no conflicts of interest to declare. Correspondence to: Jashin J. Wu, MD, Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, 1515 N Vermont Ave, Fifth Floor, Los Angeles, CA 90027 E-mail: [email protected] REFERENCES 1. Saurat JH, Stingl G, Dubertret L, et al. Efficacy and safety results from the randomized controlled comparative study of adalimumab vs. methotrexate vs. placebo in patients with psoriasis (CHAMPION). Br J Dermatol. 2008;158(3):558-566.
J AM ACAD DERMATOL VOLUME 74, NUMBER 3
2. Menter A, Tyring SK, Gordon K, et al. Adalimumab therapy for moderate to severe psoriasis: a randomized, controlled phase III trial. J Am Acad Dermatol. 2008;58(1):106-115. 3. L opez-Ferrer A, Vilarrasa E, Gich IJ, Puig L. Adalimumab for the treatment of psoriasis in real life: a retrospective cohort of 119 patients at a single Spanish center. Br J Dermatol. 2013;169(5): 1141-1147. 4. Gniadecki R, Kragballe K, Dam TN, Skov L. Comparison of drug survival rates for adalimumab, etanercept and infliximab in patients with psoriasis vulgaris. Br J Dermatol. 2011;164(5): 1091-1096. 5. Esposito M, Gisondi P, Cassano N, et al. Survival rate of antitumor necrosis factor- treatments for psoriasis in routine dermatological practice: a multicenter observational study. British Journal of Dermatology. 2013;169(3): 666-672. http://dx.doi.org/10.1016/j.jaad.2015.11.005
Characteristics and treatment of adult-onset linear morphea: A retrospective cohort study of 61 patients at 3 tertiary care centers To the Editor: Linear morphea (LM) is characterized by linear sclerotic plaques on the limbs or face and scalp. The disorder predominantly manifests in the pediatric population and often results in functional disability or permanent disfigurement. In 2012, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) recommended methotrexate (MTX) with or without systemic corticosteroids (CS) as first-line therapy for pediatric-onset LM.1 However, little is known about adult-onset LM. Thus, we sought to describe the characteristics and treatment of adult-onset LM at 3 tertiary care centers. After IRB approval, we used a natural language search and ICD-9 code 701.0 (‘‘circumscribed scleroderma’’) to query the Partners Research Patient Data Registry (1995-2015; Brigham and Women’s and Massachusetts General Hospitals) and two medical record systems at New York University (2005-2014), together including more than 20 million patient visits. All patients with LM onset at 18 years or older were included. Data were extracted on demographics, disease presentation, and treatment regimens (as defined in Table I). Clinical response (as defined in Table II) was determined by medical record review and available clinical photographs. Sixty-one patients with adult-onset LM were identified (Table I). The mean delay in diagnosis, defined as the interval between symptom onset and diagnosis of LM by a dermatologist, was 27 months. Forty-four percent of patients with extremity LM had functional limitations; only half were referred for physical therapy. One patient had limb length discrepancy. Among en coup de sabre or hemifacial
Letters 577
atrophy patients, 41% had magnetic resonance imaging of the brain, and 23% underwent ophthalmologic evaluation. MTX with or without systemic CS was used in 23% of treatment regimens. Disease resolution was significantly more likely (29% vs 4%, P \ .001), and progression (4% vs 34%, P ¼ .004) and recurrence (13% vs 56%, P \ .001) significantly less likely, with treatment regimens including MTX as compared to those without, during a mean follow-up of 38 months (Table II). This study represents the largest adult-onset LM cohort to date, and is the first to analyze both the characteristics and management of adult-onset LM.2-4 Delayed diagnosis and permanent functional sequelae were common. Referrals for physical therapy, neurologic imaging, and evaluation of ocular involvement were underused. Treatment regimens incorporating MTX were more likely to result in resolution and less likely to result in progression or reactivation. This is notable given that flares in LM are common regardless of age at disease onset.2 While MTX is considered first-line for pediatric-onset LM, this study is the first to support its use for adult-onset LM. Nevertheless, in this study, less than a quarter of treatment regimens included MTX. Although our study period largely predates the CARRA guidelines, a 2015 national survey found that physicians treating adults with LM were more likely to prescribe topical CS or phototherapy, whereas those treating children were more likely to prescribe MTX.5 Thus, MTX appears to be underused in the treatment of adultonset LM. This study’s limitations include its retrospective nature and lack of objective outcome measures in patients treated at various disease stages. Despite the small sample size, this study represents the largest adult-onset LM cohort to date. Further investigation is needed to determine a treatment algorithm for adult-onset LM. Daniel R. Mazori, BA,a Natalie A. Wright, MD,b Mital Patel, MD,b Stephanie W. Liu, MD,b Sarika M. Ramachandran, MD,a Andrew G. Franks, Jr, MD,a Ruth Ann Vleugels, MD, MPH,b and Alisa N. Femia, MDa The Ronald O. Perelman Department of Dermatology, New York University Langone Medical Center, New York,a and Department of Dermatology, Brigham and Women’s Hospital, Boston, Massachusettsb Mr Mazori and Dr Wright share first authorship. Drs Vleugels and Femia share last authorship.