Consensus on the management of patients with psoriatic arthritis in a dermatology setting

BACKGROUND

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis (PsO). Early diagnosis and prompt therapeutic intervention are crucial for limiting PsA progression and prevention of disability. Dermatologists are in a privileged position to detect early PsA. The management of patients with PsA in the dermatology setting is widely variable.

OBJECTIVE

To provide practical recommendations for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

METHODS

A consensus document was written by an expert panel composed by dermatologists (n = 12) and rheumatologists (n = 6). Eleven highly relevant questions were selected and elaborated with answers/statements based on a narrative literature review. The resulting document was discussed in a face-to-face meeting adopting a nominal group technique to reach consensus (i.e. 100% agreement) using the Delphi method.

RESULTS

A consensus was achieved in defining the following: the clinical characteristics differentiating inflammatory and non-inflammatory signs and symptoms of joint disease; the most important differential diagnoses of PsA in clinical practice; the most useful screening questionnaires, serum laboratory tests and imaging techniques for the detection of early PsA; the criteria for dermatologist to refer patients with PsO to rheumatologist; the criteria for the diagnosis of PsA; the selection of the indices that the dermatologist could use for measuring the activity and severity of PsA in clinical practice; when systemic steroids and/or intra-articular steroid injections are indicated in the treatment of PsA. Finally, systemic treatments including synthetic and biologic disease-modifying antirheumatic drugs to be considered for the treatment of PsA have been reported.

CONCLUSIONS

The implementations of these practical recommendations could be very helpful for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

Italian guidelines on the systemic treatments of moderate-to-severe plaque psoriasis

Psoriasis is a common disease, which has a considerable impact on the healthcare system. Therefore, appropriate use of therapeutic resources is very important. Management of psoriasis in daily clinical practice is highly variable because many issues are still debated and not definitely addressed by the evidence-based medicine. Moreover, the different availability and reimbursability of drugs in each country justifies national guidelines. Expert consensus can provide helpful guidelines for optimizing patient care. A total of 20 dermatologists from different areas of Italy and with large experience in the treatment of psoriasis agreed to participate in the guidelines expert panel who aimed to reach consensus on the factors influencing psoriasis severity, the indications for systemic treatments, the parameters to be considered in the choice of treatment, and the factors to be considered in the choice of biological treatment. The recommendations for the use, screening and monitoring of systemic therapies were based on the 2015 S3 European Dermatology Forum/European Academy of Dermatology and Venereology psoriasis guidelines. Recommendations on the treatment of psoriasis in special patient populations were also agreed. The final document was discussed in a meeting moderated by a facilitator with participation of the entire group and adopting a nominal group technique to reach consensus. A statement was regarded as consented when agreement was achieved by at least 75% of the voting experts according to the Delphi procedure.

Carnitine and septic shock: a review

Most studies have reported reduced carnitine levels in the tissues of patients with sepsis, probably due to increased urinary excretion. Because of the increased utilization of fatty acids and ketone bodies as sources of energy in sepsis, the carnitine deficiency can further impair the fuel metabolism and contribute to the unregulated lipid metabolism in these patients.

Recently, experimental and clinical studies have shown that carnitine and its congeners are able to: (a) downmodulate the spontaneous and endotoxin (LPS)-triggered overproduction of tumor necrosis factor (TNF)-alpha; (b) ameliorate the lipid metabolism; and (c) reduce the severity of illness, accelerate recovery, and, in some cases, improve survival in experimental septic shock.

Many questions concerning the ultimate molecular mechanism of action of these compounds in endotoxaemia are still unanswered. Yet, these compounds may be helpful in patients with sepsis, when associated with conventional therapy, in that they can effectively reduce TNF-alpha levels and ameliorate the host's metabolic processes.

Investigating psoriasis awareness among patients in Italy: validation of a questionnaire

OBJECTIVE

Psoriasis can have a profound impact on quality of life (QoL) and an awareness of the processes of the disease and its treatment is important in coping with symptoms. Patients do not always understand the potential consequences of their disease and the wide range of effective treatment strategies now available. We designed and validated a questionnaire to investigate patient awareness and understanding of psoriasis including pathogenesis, diagnosis, prognosis and treatment.

PATIENTS AND METHODS

This was a multicentre, cross-sectional investigation involving 14 psoriasis referral centres in Italy. The focus group technique was used by a panel of experts in psoriasis, to draw-up a list of questions exploring pathogenesis, diagnosis, prognosis, factors influencing clinical course of psoriasis as well as QoL issues and sources of information on their condition. Psychometric properties of the questionnaire were tested on a sample of 240 adult patients with psoriasis (including treatment-naïve and -experienced patients).

RESULTS

The mean age of patients was 50.3±14.9 years and 34.2% were female. The median time from diagnosis was 13.7 years (IQR 7.3-23.2). The Cronbach alpha was 0.77 and all items showed higher correlations within their own dimensions than to other dimensions. Each domain of awareness was well represented by a single dimension. Mean overall awareness was 59.7±13.1 on a 100-point scale.

CONCLUSIONS

Our questionnaire was valid in assessing patient awareness in five relevant areas of psoriasis, and can be useful in both the clinical setting and research studies to evaluate patients' knowledge of psoriasis better, with the final aim of reducing the burden of this chronic condition.

Psychopathology and eating disorders in patients with psoriasis

AIM

Psoriasis is a multifactorial chronic inflammatory skin disease that often occurs in patients who are overweight or obese. In literature the connections between obesity and eating disorders are well known, but few studies have investigated the link between eating disorders and psoriasis. We hypothesized that Eating Disorders (ED) can be considered a psychogenic cofactors, which contribute to the development of obesity and metabolic syndrome in psoriatic patients, who are frequently prone to psychiatric comorbidity.

METHODS

From January to April 2011 we enrolled 100 consecutive psoriatic outpatients and a control group of 100 selected non-psoriatic outpatients, matched by age, gender, and BMI to the study group. The assessment battery was composed by the Psoriasis Area Severity Index (PASI) score, the Eating Disorder Inventory (EDI) and the Symptom Checklist-90 Revised (SCL-90-R®).

RESULTS

Our data showed that most of EDI and SCL-90R subscales was mostly altered in psoriatic population compared to patients without psoriasis. Moreover, we noticed in patients with psoriasis an association between the progressive weight increase and an impairment on most of EDI subscales.

CONCLUSION

Psoriasis is associated with psychopathological traits, which are frequently found in EDs. Since obesity makes psoriasis less susceptible to therapy and weight loss improves drug response, dermatologists should be alert to suspect the presence of this condition.

Optimization of systemic treatments for chronic plaque psoriasis. Recommendations for switching and transitioning

AIM

The aim of this study was to provide practical recommendations for optimizing the use of conventional and biological systemic treatments for moderate-severe chronic plaque psoriasis, particularly in case of transitioning and switching.

METHODS

A total number of 147 dermatologists from 33 different countries including Italy achieved consensus in providing practical recommendations for the use of conventional and biological treatments for moderate to severe psoriasis based on systematic literature review and/or expert opinion.

RESULTS

In general, the continuous treatment regimen should be preferred in order to achieve a complete and long-term control of psoriasis. However, the treatment could be stopped or the dose reduced in case of complete disease clearance. A conventional drug could be associated to biological treatment in selected cases. Transitioning and/or switching could be considered in case of inefficacy or intolerance. A period of wash up is required if transitioning or switching is due to safety issues.

CONCLUSION

This study provides practical suggestions for the optimal use of conventional and biological treatments for chronic plaque psoriasis.

Ustekinumab does not increase body mass index in patients with chronic plaque psoriasis: a prospective cohort study

BACKGROUND

Chronic plaque psoriasis is frequently associated with metabolic disorders including obesity. Antitumour necrosis factor α treatments can induce body-weight increase in patients with psoriasis. Information on the effect of ustekinumab on body weight is not available.

OBJECTIVES

To investigate whether therapy with ustekinumab is associated with changes in body mass index (BMI) in patients with chronic plaque psoriasis.

METHODS

A prospective, multicentre study comparing the changes in BMI in two closed cohorts of patients with psoriasis during 7-month treatment with ustekinumab (n = 79) or infliximab (n = 83).

RESULTS

Patients treated for 7 months with infliximab showed a significant (P < 0.001) increase in mean BMI (2.1 ± 4.5%) and body weight (2.5 ± 3.3 kg) compared with patients treated with ustekinumab (0.1 ± 3.3%; 0.6 ± 1.1 kg). Some 45% of patients treated with infliximab had a BMI increase > 2%, compared with only 11% of those receiving ustekinumab (P = 0.01). In the multivariate analysis, all other clinical parameters predicted the BMI increase, except for the use of infliximab. At month 7, 96% of patients treated with infliximab and 82% of patients treated with ustekinumab achieved at least a 50% improvement from their baseline psoriasis area and severity index (PASI 50), and 69% of the infliximab group compared with 58% of the ustekinumab group achieved at least PASI 75. There was no difference in the proportion of PASI 50 and PASI 75 responders between the two groups.

CONCLUSIONS

In contrast to infliximab, ustekinumab does not increase BMI in patients with chronic plaque psoriasis. This difference could be taken into account in the selection of biologics when treating patients with psoriasis.

Psoriasis and erythema nodosum: two comorbidities of inflammatory bowel diseases

Extra-intestinal manifestations are a relatively common complications of Inflammatory Bowel Diseases (IBD) and skin is one of the organs most commonly affected. Cutaneous findings in IBD patients may be related to different pathogenetic mechanisms and in some cases the etiologic link has not been fully elucidated. In particular, this is the case of psoriasis and erythema nodosum, two of the most frequent skin diseases observed in IBD patients. Aim of this paper was to review the epidemiology and the possible pathogenetic mechanisms implicated in the occurrence of these two dermatosis. In particular, an association between IBD and psoriasis has been observed in several epidemiological studies: psoriasis occurs in about 1-2% of the general population, compared with 3-11% of patients with IBD. Several studies have also evaluated the prevalence of IBD in psoriatic patients, with contrasting results. A common pathogenic pathways between these two conditions seems to be sustained by the responsiveness to therapy with biological treatments, such as anti-Tumor Necrosis Factor (TNF)-alpha agents and ustekinumab (a monoclonal antibody against p40 subunit common to IL-12 and IL-23). On the other hand, although usually idiopathic in half of the patients, erythema nodosum has been associated with a variety of disorders and conditions and IBD accounts for 1-4% of cases.

Circulating endothelial cell levels in psoriatic patients and their modification after an anti-TNF-alpha (Etanercept) treatment

BACKGROUND

Endothelial function in psoriatic patients has been mainly evaluated through a high-resolution ultrasound measurement of flow-mediated vasodilation in the brachial artery, which is an operator-dependent and technically demanding technique: this characteristic, together with different patient selection criteria, could account for the conflicting results emerging from different studies. Recently, Circulating Endothelial Cells (CECs) level has been suggested as a novel biomarker of vascular injury.

METHODS

The number of CECs was determined by a semi-automated immunomagnetic system (CellSearch system) in peripheral blood of psoriatic patients (n = 48) and healthy subjects (n = 50). In 15 patients, CEC level was also evaluated after 6 months of treatment with an anti-TNF-alpha agent, Etanercept. The plasma levels of high-sensitivity C-reactive Protein (CRP), E-selectin, VEGF and PAI-1 were measured by ELISA. The psoriasis severity was assessed by PASI score.

RESULTS

A statistically significant difference (P = 0.001) was found between CEC level in psoriatic patients (10.6 ± 9.4 cells/mL) vs. the control group (3.9 ± 0.9 cells/mL). This count inversely correlated with sE-selectin levels (r(2) = 0.16; P = 0.03). After 6 months of therapy, patients experienced a significant (P < 0.05) decrease in CEC levels (3.4 ± 1.3 cells/mL) and in PASI score (from 11.7 ± 8.1 to 2.1 ± 4.0).

CONCLUSIONS

The elevated CECs level that we found in a sample of high selected psoriatic patients could be expression of endothelial damage. Lowering of CECs count after treatment with Etanercept support the hypothesis that an effective systemic therapy of psoriasis may also improve the endothelial function.

Traditional and high potency probiotic preparations for oral bacteriotherapy

Current research continues to improve the treatment options available to clinicians for oral bacteriotherapy. Recently, a greater understanding of the role of endogenous digestive microflora has generated renewed interest in the potential of oral bacteriotherapy for the management of a wide spectrum of gastrointestinal and systemic disorders. Several treatment strategies for oral bacteriotherapy have already entered clinical trials and it is hoped that some of these strategies will become widely available in the near future. This review summarises the current status of oral probiotic preparations for bacteriotherapy and discusses any obstacles to their successful clinical development. Newer probiotic preparations include high potency preparations that are greatly enriched in lactic acid bacteria, both in terms of bacterial concentrations and the number of bacterial strains. These preparations have a greater potential for clinical effectiveness than traditional preparations and are entering clinical evaluation especially in patients with inflammatory bowel disease and pouchitis, irritable bowel syndrome, or cryptosporidiosis. The pitfalls of previous clinical investigations of traditional probiotic preparations and the perils of future clinical trials with high potency preparations are discussed in the context of unmet needs and realistic expectations of success. Although considerable progress has been made in oral bacteriotherapy, focused efforts by basic scientists and clinical investigators and continued support from pharmaceutical companies is required to successfully develop probiotics for use in clinical medicine. Newer high potency probiotic preparations appear to have a great advantage over traditional preparations and should be the area of most active biomedical research in the field.

Clinical applicability of Quantiferon-TB-Gold testing in psoriasis patients during long-term anti-TNF-alpha treatment: a prospective, observational study

BACKGROUND

Psoriasis patients who are treated with tumour necrosis factor (TNF)-alpha antagonists are at increased risk of reactivation of latent tuberculosis infection (LTBI) and should be adequately screened and monitored during active treatment.

OBJECTIVES

To evaluate in a prospective study, the performance of Quantiferon-TB-Gold in tube (QFT) in vitro assay compared to the conventional tuberculin skin test (TST) in detecting LTBI among a cohort of non-BCG-vaccinated patients with moderate-to-severe psoriasis during long-term treatment (12 months) with TNF-alpha antagonists.

METHODS

A total of 50 patients underwent QFT and TST testing at baseline and after 6 and 12 months of continuous anti-TNF-alpha treatment. Diagnosis of LTBI was made on the basis of a positive QFT result and negative chest-radiographic and microbiological assays. Patients with LTBI were subjected to standard isoniazid chemoprophylaxis and after 1 month, they resumed anti-TNF-alpha treatment with subsequent QFT and TST testing after 6 months. In all the cases, a follow-up period of 12 months was observed.

RESULTS

During the 12-month-study period, 14% of patients presented a QFT conversion. During active anti-TNF-alpha treatment, a QFT conversion was observed in 10% of patients (five cases). Agreement between QFT and TST was moderate (κ=0.408) at screening, good (κ=0.734) after 6 months and fair (κ=0.328) after 12 months of treatment. A total of 18% of patients presented a positive, discordant TST during the study period.

CONCLUSIONS

A single-test QFT-based screening strategy for LTBI in psoriasis patients receiving long-term anti-TNF-alpha treatment could reduce the incidence of false-positive LTBI cases, preventing unnecessary TB chemoprophylaxis.

Regulatory T cells in the skin lesions and blood of patients with systemic sclerosis and morphoea

BACKGROUND

Systemic sclerosis (SSc) and morphoea are connective tissue diseases characterized by fibrosis of the skin. Although to date their pathogenesis has not been clearly defined, it is thought that autoimmunity may play a role in the development of the skin lesions observed in both these diseases. As regulatory T cells (Tregs) play a key role in the modulation of immune responses, it has recently been suggested that Treg impairment may lead to the development of autoimmune diseases.

OBJECTIVES

To investigate the presence of Tregs and their immunomodulatory cytokines, transforming growth factor (TGF)-beta and interleukin (IL)-10, in patients with SSc and morphoea.

PATIENTS/METHODS

Fifteen patients with SSc and 15 with morphoea were enrolled. Immunohistochemistry was applied to identify FoxP3+ (forkhead/winged helix transcription factor) Tregs, TGF-beta+ cells and IL-10+ cells in the skin, cytofluorometry to detect CD4+CD25+FoxP3+ Tregs in the blood, and enzyme-linked immunosorbent assays to analyse TGF-beta and IL-10 serum levels.

RESULTS

Fewer FoxP3+ Tregs and TGF-beta+ and IL-10+ cells were found in the skin of patients with scleroderma than in controls. Similarly, there were reduced TGF-beta and IL-10 serum levels and fewer circulating CD4+CD25brightFoxP3+ cells in patients with SSc or morphoea, than in controls.

CONCLUSIONS

The quantitative reduction of Tregs, together with that of TGF-beta and IL-10 serum levels, may be responsible for the loss of tolerance observed in both SSc and morphoea.

TNFα and its Receptors in Psoriatic Skin, before and after Treatment with Etanercept

Psoriasis is a chronic inflammatory skin condition characterized by inflammatory dermal infiltrate and hyperproliferative keratinocytes. The pathogenesis of this disease is mediated by a dysregulation of the innate immunity and cytokine production. Tumor Necrosis Factor alpha (TNFα) is considered the most important cytokine involved in the pathological mechanism of psoriasis. Recently, several therapies have been introduced for the treatment of psoriasis that try to block TNF alpha activity. Among these treatments Etanercept is a fusion protein that specifically targets TNF alpha. We performed a study on twelve psoriatic patients aimed at evaluating the effect of Etanercept treatment on the production and expression of TNFα and its receptors, in lesional and uninvolved psoriatic skin. We demonstrated that after three month of Etanercept treatment at 50 mg/wk, TNF, TNF-RI and TNF-RII immunostaining in lesional and non-lesional skin samples of patients was greatly reduced, suggesting that this treatment not only acts on stable lesional plaques, but also at a very early stage of the disease.

Dermatological signs during inflammatory bowel diseases

Crohn disease (CD) and UI-cerative Colitis (UC) are characterized by ulcerative lesions of the bowel. Some patients show similar lesions of the skin or oral and/or perianal mucosa. Sometimes these lesions, or some other skin lesions are the first sign of bowel disease. Dermatologists could suspect an inflammatory bowel disease (IBD) during skin lesions such as pyoderma gangrenosum (PG) or erythema nodosum (EN). These entities are very well known by dermatologists and its role is to diagnose internal chronic disease associated to EN or PG. Depending on the associated disease the treatment may vary from steroids to anti TNF biologics.

A Multicenter Open-Label Experience on the Response of Psoriasis to Adalimumab and Effect of Dose Escalation in Non-Responders: The Aphrodite Project

There is much evidence to show the efficacy of adalimumab, a human monoclonal antibody targeting tumour necrosis factor-alpha, in the treatment of plaque psoriasis. In this open-label experience, 147 high-need patients suffering from plaque psoriasis, with a mean Psoriasis Area and Severity Index (PASI) of 18.8, and concomitant psoriatic arthritis (PsA) received subcutaneous injections of 40 mg of adalimumab every other week (EOW). This was actually the dosage regimen recommended for PsA, as the drug had not then been approved for psoriasis at the time of the patients' enrolment. At week 12, an improvement of at least 50% of the PASI (PASI-50) was observed in 111 (77%) patients. Continuation of treatment in responders with adalimumab 40 mg EOW led to a sustained response, with the PASI-50 achieved by 97% of patients in the as-treated analysis at week 24 (PASI-75 in 82% and PASI-90 in 45% out of 109 patients who received EOW injections up to week 24). Thirty subjects who failed to attain the PASI-50 response at week 12 were treated with adalimumab 40 mg every week for a further 12 weeks. At week 24, 80% of these patients obtained a PASI-50 response after dose escalation. Tolerability was good in the majority of patients. Only two patients discontinued treatment because of an adverse event (repeated flu-like episodes and a pleuropericarditis of unknown origin, respectively).