Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis

Effect of methodological choices and inclusion criteria on network meta-analysis results in psoriasis

BACKGROUND

When conducting network meta-analysis (NMA), researchers need to make several methodological and analytical decisions, which can influence the results of NMAs. Our objective was to evaluate the impact of different methodological choices on the conclusions from the analyses of a network of 20 active treatments in patients with psoriasis.

METHODS

We re-analysed the available data of a living Cochrane NMA evaluating the systemic treatments in psoriasis under various analytical scenarios defined by the combination of pre-specified methodological choices. We performed NMAs on three outcomes: Psoriasis Area Severity Index (PASI) 90, PASI 100 and serious adverse events (SAEs). Variability of the effect estimates across NMAs was summarized using ratio of relative risks (RRR) and ratio of odds ratio (ROR). We estimated the level of agreement between the treatment hierarchies using the Average Overlap (AO).

RESULTS

Overall, 560 NMAs were conducted. The median number of included interventions was 18 (IQR 17-19), for a median number of included studies of 68 (IQR 57-93). The median RRR was 1.06 (IQR 1.06-1.08) for PASI 90, 1.07 (IQR 1.06-1.10) for early PASI 90, 1.14 (IQR 1.06-1.15) for late PASI 90, 1.04 (IQR 1.01-1.05) for PASI 100, and 1.02 (IQR 1.02-1.06) for SAEs. The criteria with the greatest impact on the effect estimates were the inclusion or exclusion of studies with biological-naïve patients, inclusion or exclusion of phase II trials, and the inclusion or exclusion of studies evaluating conventional treatments. The analysis choice with the greatest impact was the use of the Mantel-Haenszel method instead of the inverse variance method. There was a high agreement of treatment hierarchies between analyses. For the top 6 ranking treatments, the median AO across all scenarios for PASI 90 was 0.84 (IQR 0.72-0.97). For early PASI 90, late PASI 90, PASI 100, and SAE, the median AO were 0.94 (IQR 0.91-0.97), 0.75 (IQR 0.65-0.97), 0.94 (IQR 0.91-0.97), and 0.59 (IQR 0.59- 0.90), respectively.

CONCLUSIONS

We found that different methodological choices could influence NMAs' results. However, even though moderate variation in effect estimates could be observed across the analyses, treatment hierarchies remained stable for the top-ranking drugs.

Targeting nail psoriasis: IL-17A inhibitors demonstrate site-specific superiority over IL-23 inhibitor in a 24-week dermoscopy-guided real-world cohort

Objective

To compare the real-world clinical efficacy and safety of interleukin (IL)-17A inhibitors (secukinumab [SEC] and ixekizumab [IXE]) versus the IL-23 inhibitor guselkumab (GUS) in patients with nail psoriasis, with a focus on site-specific biologic therapeutic responses (nail matrix vs. nail bed) in a 24-week prospective observational cohort.

Methods

This cohort enrolled 65 adult patients with plaque psoriasis and dermoscopy-confirmed nail involvement, stratified into three treatment groups: SEC (n=25), IXE (n=20), and GUS (n=20). Outcome assessments at baseline and week 24 included: Nail Psoriasis Severity Index (NAPSI) with domain-specific scoring (matrix/bed) by dermoscopic evaluation using a 10× polarized handheld device; Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA); Dermatology Life Quality Index (DLQI). Safety was monitored through treatment-emergent adverse events (TEAEs).

Results

(1) By week 24, PASI, BSA, DLQI and NAPSI scores had significantly decreased from baseline in all groups (P<0.001). (2) By week 24: SEC, IXE, and GUS groups saw nail matrix NAPSI score improvements of 65.9%, 60.5%, and 51.5%, with 68%, 55%, and 30% achieving NAPSI 60; Nail bed NAPSI score improvements were 58.8%, 68.6%, and 65.8%, with 28%, 65%, and 40% achieving NAPSI 60; Total NAPSI score improvements were 62.7%, 64.6%, and 53.7%, with 44%, 70%, and 30% achieving NAPSI 60. (3) All patients in the SEC and IXE groups achieved PASI 75, compared to 85% in the GUS group. SEC showed PASI 90 and PASI 100 response rates of 80% and 36%, while IXE of 60% and 30%. (4) TEAEs were mild, including: injection site reactions: 15% (IXE group); eczematous rashes: 8% (SEC group). No TEAEs were reported in the GUS group, and no serious adverse events occurred in any group.

Conclusion

IL-17A inhibitors and the IL-23 inhibitor demonstrated significant efficacy in improving both nail and skin lesions in psoriasis. Notably, IL-17A inhibitors exhibited superior overall efficacy compared to IL-23 inhibitor. Specifically, SEC excelled in improving dermoscopic nail matrix changes, whereas IXE was more potent for nail bed pathology. All groups significantly improved patients' life quality and exhibited good safety profiles.

Brodalumab for Plaque Psoriasis in the Canadian Real-World Setting: A Retrospective Cohort Analysis of up to 4 Years

INTRODUCTION

Psoriasis, a chronic inflammatory skin disease, affects approximately one million Canadians, with plaque psoriasis (PsO) being the most common subtype. While brodalumab has shown efficacy and safety in phase III clinical trials, Canadian real-world evidence remains limited. This retrospective cohort study aims to report on the real-world outcomes of Canadian patients with PsO who initiated treatment with brodalumab within the 4-year period following its approval by Health Canada.

METHODS

Data from patients with PsO initiating brodalumab treatment in the Canadian patient support program between July 1, 2018 and June 30, 2022 were analyzed. The primary objective evaluated the proportion of patients achieving a 100% reduction in the Psoriasis Area and Severity Index (PASI 100) at selected time windows. Secondary and exploratory objectives included assessing the 90% reduction in PASI score (PASI 90), changes from baseline in mean PASI, body surface area (BSA), and Dermatology Life Quality Index (DLQI) scores, as well as treatment persistence.

RESULTS

A total of 2482 patients (58.5% male; mean age 51.0 years) were included, with over half being biologic-naïve (56.9%). In a subset of patients with baseline and at least one follow-up data, 66.1% and 53.2% achieved PASI 90 and PASI 100, respectively, within the first 3 months. These rates were sustained, with 68.1% and 52.2% achieving PASI 90 and PASI 100, respectively, beyond 24 months. Significant improvements from baseline were observed for PASI, BSA, and DLQI scores, and these improvements were maintained over time. Among all patients, the 1-year persistence rate was 73.4%.

CONCLUSIONS

This study provides valuable insights into the profile of patients treated with brodalumab in Canada. While the rapid and sustained skin clearance, as well as improvements in PASI, BSA, and DLQI scores, support the therapeutic benefits of brodalumab beyond clinical trials, further research on long-term effectiveness and safety is warranted.

Systemic Therapies for Psoriatic Disease and Serious Infections in Older Adults

Importance

Systemic treatments for psoriatic disease affect the immune system and may increase infection risk. Older adults are at high risk for infection, and the relative safety of systemic treatments for them is unknown.

Objective

To evaluate the association of systemic treatments for psoriatic disease with rates of serious infection among older adults.

Design, Setting, and Participants

This cohort study used linked population-based health administrative data from 2002 to 2021 in Ontario, Canada. Participants included Ontario residents 66 years and older with psoriatic disease who were dispensed their first systemic medication between April 1, 2002, and December 31, 2020. Data were analyzed between November 2021 and August 2024.

Exposure

Time-varying use of systemic medications categorized as (1) methotrexate; (2) other older systemic medications; (3) anti-tumor necrosis factor (anti-TNF) biologics; (4) other biologics (targeting interleukin [IL]-12, IL-23, and IL-17); and (5) tofacitinib.

Main Outcomes and Measures

The main outcome was time to serious infection, defined as hospitalization for any infectious cause occurring up to March 2021. Multivariable Andersen-Gill recurrent event regression was used to estimate the association between each medication category and serious infection rates. The relative rates (RRs) of serious infection with 95% CIs for time actively using each medication category vs time not using that medication category were calculated.

Results

Of 11 641 new users of systemic therapy, 6114 (53%) were female, and the median (IQR) age was 71 (68-76) years. There were 1967 serious infections during a median (IQR) of 4.8 (2.3-8.4) years of follow-up. There were 2.7 serious infections per 100 person-years using methotrexate, 2.5 per 100 person-years using other older systemic drugs, 2.2 per 100 person-years using anti-TNF biologics, 1.4 per 100 person-years using other biologics, and 8.9 per 100 person-years using tofacitinib. In the multivariable-adjusted model, methotrexate (RR, 0.95 [95% CI, 0.85-1.07]), other older systemic medications (RR, 0.92 [95% CI, 0.79-1.07]), and anti-TNF biologics (RR, 0.87 [95% CI, 0.69-1.10]) were not associated with serious infection compared to person-time not using those respective medications. Other biologics (RR, 0.65 [95% CI, 0.48-0.88]) were associated with lower rates of serious infection, whereas tofacitinib (RR, 2.89 [95% CI, 1.14-7.34]) was associated with higher rates of serious infection.

Conclusions and Relevance

In this cohort study, biologics targeting IL-12, IL-23, or IL-17 were associated with a lower rate of serious infection among older adults with psoriatic disease. These biologics may have important safety benefits for older adults with higher infection risk.

Comparative study between botulinum toxin and topical steroid in treatment of psoriasis vulgaris

Psoriasis is an immune-mediated systemic and chronic disease that can affect males and females equally. Treatments of psoriasis may and may not be effective and is based on the patients' case and severity. There is currently no cure but treatments generally can help to control the symptoms. This work aims to compare the safety and efficacy of botulinum toxin as an intralesional injection versus topical steroid in treatment of plaque psoratic patients by evaluating the PASI score as well as the clinical improvement of the cases. Twenty patients with psoriasis vulgaris were included in the study where body was splitted into two bilaterally symmetrical psoriatic plaques and treated differently one side with single intradermal injecton of botulinum toxin and the other side with topical steroid. Both treatments showed significant decrease in PASI score in two and four weeks of treatment and follow-up. There was no significant difference between the two methods; however there were small changes in the results of the score and on skin generally. Improvement of psoriasis vulgaris lesions with botulinum toxin as single application with a high safety profile proposes a good target in psoriasis vulgaris treatment; however, more investigations showed be considered.

Breakthrough Psoriasis in Patients Receiving Biologicals

Background

Biological therapies, including TNF-alpha, IL12/23, IL17 and IL23 antagonists, adequately control a very high number of patients with moderate-to-severe psoriasis with an excellent long-term safety profile. However, on occasion, patients on biological therapy with stabilized disease or complete remission report episodes of sudden breakthrough psoriasis.

Aim

To study prospectively in a monocentric tertiary setting, the clinical characteristics of patients presenting a sudden breakthrough psoriasis although completely stabilized (PASI 90-100) under biological therapy.

Materials and Methods

Psoriasis patients treated by biological therapies achieving PASI 90-100 and with stabilized disease for at least 6 months were invited to enter the follow-up study for 5 years. The clinical features of patients presenting a breakthrough psoriasis were described as well as the rescue therapies and outcomes.

Results

From the total cohort of 1121 patients with psoriasis receiving biologicals, 985 patients responded to the inclusion criteria. After 5 years, 10/882 cases (1,13%) of breakthrough psoriasis were identified. Two cases were induced by the Köbner phenomenon and 8 cases by severe psychological stress. Rescue therapies included topical very potent corticosteroids or additional injections of the biological. Two patients recovered spontaneously when the stressful event was resolved. In none of the cases, there was a consistency between the breakthrough event and the next scheduled injection, nor the duration of the exposure to the treatment. No biological class or agent could be systematically incriminated.

Conclusion

Breakthrough psoriasis is an exceptional event among patients with stabilized psoriasis using biologicals, either triggered by the Köbner phenomenon or by severe psychological stress. The pathogenesis of the breakthrough events could be linked to stress- or Köbner-related immunomodulation, permitting breakthrough psoriasis lesions to appear.

Comparative Effectiveness of Biologic Classes in Clinical Practice: Month 12 Outcomes from the International Observational Psoriasis Study of Health Outcomes (PSoHO)

INTRODUCTION

Studies directly comparing the effectiveness of different biologics over long observation periods are lacking. As many treatment guidelines are formulated based on drug class, there is a particular need to compare drug classes rather than specific biologic agents.

METHODS

This post hoc analysis compares the effectiveness and durability of biologics that target the interleukin (IL)-17 A ligands or the IL-17 receptor A (IL-17RA) relative to other approved drug classes in patients with moderate-to-severe plaque psoriasis, through 12 months in a real-world setting.

RESULTS

In the Psoriasis Study of Health Outcomes (PSoHO) (N = 1981), patients treated with anti-IL-17A/RA resulted in a higher proportion of patients who achieved the primary outcome [proportion of patients who had at least a 90% improvement in Psoriasis Area and Severity Index score (PASI90) and/or a score of 0 or 1 in static Physician Global Assessment (sPGA)] compared to anti-IL-23-, anti-IL-12/23-, and tumor necrosis factor (TNF)-α-treated patients at week 12, month 6, and month 12, except versus anti-IL-23 at month 12. Similar trends were observed for a 100% improvement in PASI score (PASI100), PASI90, and Dermatology Life Quality Index score of 0 or 1 [DLQI (0,1)]. At month 12, the unadjusted response rates across the drug classes were 53.5-69.1% for the primary outcome, 27.6-40.8% for PASI100, 41.7-55.9% for PASI90, and 31.8-33.0% for DLQI (0,1). Regarding the durability of effectiveness, anti-IL-17A/RA patients had the highest response rate, and for the adjusted analysis, using Frequentist Model Averaging (FMA), patients had 1.4-2.6 times higher odds of achieving the primary durability outcome compared to patients treated with any other drug class.

CONCLUSION

Overall, anti-IL-17A/RA had the highest effectiveness of achieving early response to treatment and maintaining that response through 12 months compared to other drug classes.

TRIAL REGISTRATION

The study was registered at the European Network of Centers for Pharmacoepidemiology and Pharmacovigilance (ENCEPP24207).

An empirical study on 209 networks of treatments revealed intransitivity to be common and multiple statistical tests suboptimal to assess transitivity

BACKGROUND

Transitivity assumption is the cornerstone of network meta-analysis (NMA). Investigating the plausibility of transitivity can unveil the credibility of NMA results. The commonness of transitivity was examined based on study dissimilarities regarding several study-level aggregate clinical and methodological characteristics reported in the systematic reviews. The present study also demonstrated the disadvantages of using multiple statistical tests to assess transitivity and compared the conclusions drawn from multiple statistical tests with those from the approach of study dissimilarities for transitivity assessment.

METHODS

An empirical study was conducted using 209 published systematic reviews with NMA to create a database of study-level aggregate clinical and methodological characteristics found in the tracenma R package. For each systematic review, the network of the primary outcome was considered to create a dataset with extracted study-level aggregate clinical and methodological characteristics reported in the systematic review that may act as effect modifiers. Transitivity was evaluated by calculating study dissimilarities based on the extracted characteristics to provide a measure of overall dissimilarity within and between the observed treatment comparisons. Empirically driven thresholds of low dissimilarity were employed to determine the proportion of datasets with evidence of likely intransitivity. One-way ANOVA and chi-squared test were employed for each characteristic to investigate comparison dissimilarity at a significance level of 5%.

RESULTS

Study dissimilarities covered a wide range of possible values across the datasets. A 'likely concerning' extent of study dissimilarities, both intra-comparison and inter-comparison, dominated the analysed datasets. Using a higher dissimilarity threshold, a 'likely concerning' extent of study dissimilarities persisted for objective outcomes but decreased substantially for subjective outcomes. A likely intransitivity prevailed in all datasets; however, using a higher dissimilarity threshold resulted in few networks with transitivity for semi-objective and subjective outcomes. Statistical tests were feasible in 127 (61%) datasets, yielding conflicting conclusions with the approach of study dissimilarities in many datasets.

CONCLUSIONS

Study dissimilarity, manifested from variations in the effect modifiers' distribution across the studies, should be expected and properly quantified. Measuring the overall study dissimilarity between observed comparisons and comparing it with a proper threshold can aid in determining whether concerns of likely intransitivity are warranted.

Comparative effectiveness of tildrakizumab 200 mg versus tildrakizumab 100 mg in psoriatic patients with high disease burden or above 90 kg of body weight: a 16-week multicenter retrospective study - IL PSO (Italian landscape psoriasis)

PURPOSE

Tildrakizumab is a selective inhibitor of IL-23 approved for the treatment of moderate-to-severe plaque psoriasis in two dosages. We conducted a 16-week multicenter retrospective study to compare the effectiveness and safety of tildrakizumab 200 mg versus tildrakizumab 100 mg in patients with a high disease burden or high body weight.

MATERIALS AND METHODS

Our retrospective study included 134 patients treated with tildrakizumab 200 mg and 364 patients treated with tildrakizumab 100 mg from 28 Italian Dermatology Units affected by moderate-to-severe plaque psoriasis. The patients had a body weight above 90 kg or a high disease burden (Psoriasis Area and Severity Index [PASI] ≥ 16 or the involvement of difficult-to-treat areas). We evaluated the effectiveness of tildrakizumab at the week-16 visit in terms of PASI90, PASI100 and absolute PASI ≤ 2.

RESULTS

After 16 weeks of treatment with tildrakizumab 200 mg, PASI90 was reached by 57.5% of patients and PASI100 by 39.6% of patients. At the same time point, 34.3% and 24.2% of patients treated with tildrakizumab 100 mg achieved PASI90 and PASI100, respectively.

CONCLUSIONS

Our data suggest that tildrakizumab 200 mg has better effectiveness than tildrakizumab 100 mg in patients with a body weight ≥ 90 kg and a high disease burden.

Brodalumab Is Effective for Psoriasis Patients with Difficult-To-Treat Body Regions: Results from an Observational Clinical Study

INTRODUCTION

Brodalumab, a human monoclonal antibody that selectively inhibits the interleukin (IL)-17 receptor subunit A, has been approved for the treatment of moderate-to-severe plaque psoriasis. The treatment benefit of brodalumab has been clearly demonstrated in multiple clinical studies. However, data on effectiveness for difficult-to-treat body regions, especially in everyday clinical practice, are still limited.

METHODS

In this exploratory observational clinical study, psoriasis patients suffering from nail and scalp involvement who received brodalumab during routine clinical care were enrolled at 7 centers in Germany. Patients were observed for over 60 weeks. The co-primary endpoints were 75% improvement in Psoriasis Scalp Severity Index (PSSI75) at week 12 and 75% improvement in Nail Psoriasis Severity Index (NAPSI75) at week 24. Secondary endpoints included assessment of general skin and disease outcomes, quality-of-life, and patient satisfaction with treatment.

RESULTS

Eighty-seven patients were included. Mean age was 46.8 years, 70.1% patients were male, and mean body mass index was 28.9 kg/m2. The co-primary endpoints were achieved by more than 90% of patients who met criteria for effectiveness analyses (n = 62): 93.6% of patients achieved PSSI75 at week 12 and 90.3% of patients achieved NAPSI75 at week 24. Median body surface area involvement improved from 14% at baseline to 1.5% and 1% at weeks 12 and 24, respectively. Median Dermatology Life Quality Index scores improved from 16 at baseline to 2 and 1 at weeks 12 and 24, respectively. Improvements were maintained in the majority of patients throughout the 60-week study. Brodalumab was well tolerated and patients were highly satisfied with the treatment.

CONCLUSION

Outcomes assessed in this study, including assessments of scalp and nail symptoms, improved following initiation of brodalumab therapy. This study of psoriasis patients in a real-world setting supports the long-term clinical effectiveness of brodalumab on difficult-to-treat body regions.

INTRODUCTION

Brodalumab, a human monoclonal antibody that selectively inhibits the interleukin (IL)-17 receptor subunit A, has been approved for the treatment of moderate-to-severe plaque psoriasis. The treatment benefit of brodalumab has been clearly demonstrated in multiple clinical studies. However, data on effectiveness for difficult-to-treat body regions, especially in everyday clinical practice, are still limited.

METHODS

In this exploratory observational clinical study, psoriasis patients suffering from nail and scalp involvement who received brodalumab during routine clinical care were enrolled at 7 centers in Germany. Patients were observed for over 60 weeks. The co-primary endpoints were 75% improvement in Psoriasis Scalp Severity Index (PSSI75) at week 12 and 75% improvement in Nail Psoriasis Severity Index (NAPSI75) at week 24. Secondary endpoints included assessment of general skin and disease outcomes, quality-of-life, and patient satisfaction with treatment.

RESULTS

Eighty-seven patients were included. Mean age was 46.8 years, 70.1% patients were male, and mean body mass index was 28.9 kg/m2. The co-primary endpoints were achieved by more than 90% of patients who met criteria for effectiveness analyses (n = 62): 93.6% of patients achieved PSSI75 at week 12 and 90.3% of patients achieved NAPSI75 at week 24. Median body surface area involvement improved from 14% at baseline to 1.5% and 1% at weeks 12 and 24, respectively. Median Dermatology Life Quality Index scores improved from 16 at baseline to 2 and 1 at weeks 12 and 24, respectively. Improvements were maintained in the majority of patients throughout the 60-week study. Brodalumab was well tolerated and patients were highly satisfied with the treatment.

CONCLUSION

Outcomes assessed in this study, including assessments of scalp and nail symptoms, improved following initiation of brodalumab therapy. This study of psoriasis patients in a real-world setting supports the long-term clinical effectiveness of brodalumab on difficult-to-treat body regions.

Short term efficacy of biological treatment for moderate-to-severe plaque psoriasis: a systematic review and network meta-analysis

Psoriasis is a chronic inflammatory disease that is debilitating, particularly in its more severe forms. Multiple systemic therapies are used in moderate-to-severe psoriasis, but the development of biological interventions has revolutionized its management and improved its outcomes. To compare the effectiveness and safety of the different biological interventions approved for use in moderate-to-severe plaque psoriasis. Multiple databases were searched for relevant articles and a prospectively planned network meta-analysis was conducted on randomized controlled trials that assessed biological treatments in moderate-to-severe psoriasis. The search yielded 84 trials that encompassed 39,798 patients. Infliximab 5 mg/kg had the highest probability of achieving 75% reduction on PASI scale in comparison to placebo (RR = 18.76, 95% CI [12.31; 28.57], high certainty), while Ixekizumab 80 mg and Brodalumab 210 mg had the highest probability at achieving PASI90 and PASI100 (37.81, [28.57; 50.03] and 81.04, [26.16; 251.01], respectively, with moderate certainty) On the other hand, Risankizumab 150 mg and Ustekinumab 90 mg were the only regimens with significantly less withdrawal rates due to adverse events (0.41, [0.18-0.96], and 0.57, [0.35-0.91], respectively with High certainty) compared to placebo. Anti-IL17 and Infliximab were among the most effective in ameliorating the symptoms of psoriasis, however, anti-IL17 were better at achieving full or almost full improvement on the PASI scale. Real life decision-making is not so clear-cut and should remain patient centered, taking into consideration factors such as safety, comorbidities, biologic naivety, dosing preferences and insurance considerations.

Intradermal Injection of a Thermoresponsive Polymeric Dexamethasone Prodrug (ProGel-Dex) Ameliorate Dermatitis in an Imiquimod (IMQ)-Induced Psoriasis-like Mouse Model

Psoriasis is a chronic immune-mediated inflammatory skin disease, affecting ∼ 3% of the US population. Although multiple new systemic therapies have been introduced for the treatment of psoriatic skin disease, topical and intralesional glucocorticoids (GCs) continue to be used as effective psoriasis therapies. Their clinical utility, however, has been hampered by significant adverse effects, including skin atrophy and pigmentation as well as elevated blood glucose levels and hypertension. To mitigate these limitations, we have developed a N-(2-hydroxypropyl) methacrylamide (HPMA) copolymer-based thermoresponsive dexamethasone (Dex) prodrug (ProGel-Dex) and assessed its therapeutic efficacy and safety in an imiquimod (IMQ)-induced psoriasis-like (PL) mouse model. ProGel-Dex was intradermally administered once at three dosing levels: 0.5, 1.0, and 2.0 mg/kg/day Dex equivalent at the beginning of the study. PL mice were also treated with daily topical saline or Dex, which were used as control groups. Treatment of PL mice with ProGel-Dex dosed at 0.5 mg/kg/day resulted in a significant reduction in scaling and erythema. Improvement in gross pathology scores, skin histological scores, and serum cytokine levels was also observed. Interestingly, for mice treated with ProGel-Dex at 1.0 and 2.0 mg/kg/day Dex equivalent, only improvement in skin erythema was observed. GC-associated side effects, such as elevation of serum alanine aminotransferase (ALT) and amylase levels and body weight loss, were not observed in mice treated with ProGel-Dex at 0.5 and 1.0 mg/kg/day Dex equivalent. Collectively, these results demonstrate the efficacy and improved safety of ProGel-Dex in treating psoriatic skin lesions when compared to topical Dex treatment, supporting its translational potential for clinical management of lesional skin psoriasis.

[Monoclonal antibodies for inflammatory, autoimmune and oncological skin diseases]

In 1997 rituximab, a genetically engineered chimeric monoclonal antibody (mAb) targeting CD20 expressed on B cells was approved for treatment of non-Hodgkin's lymphoma. Since then, pharmacological improvements combined with increased knowledge on the immunopathogenesis of diseases led to the development of specific mAb targeting different antigens (e.g., interleukins or transmembrane receptors). This approach reshaped the therapeutic methodology in many fields, including dermatology. Nowadays, the treatment of frequent and possibly impairing inflammatory disorders such as psoriasis, atopic dermatitis or hidradenitis suppurativa have different mAbs approved for both adult and pediatric patients. This class of drugs often shows a more favorable outcome and a better safety profile than routine immunosuppressants, such as steroids and steroid-sparing substances. For many years mAbs also represented a pillar of oncological treatment for severe diseases such as malignant melanoma or Merkel cell carcinoma. This review summarizes the current knowledge on already approved and promising new mAbs for the treatment of inflammatory and oncological skin diseases.

[Head-to-head studies on psoriasis and psoriatic arthritis]

Given the ever-increasing number of approved therapies for the treatment of psoriasis (PsO) and psoriatic arthritis (PsA), head-to-head (H2H) comparative studies are essential. These are aimed primarily at a comparative analysis of treatment effectiveness. In both PsO and PsA, biological disease-modifying antirheumatic drugs (bDMARD) have been shown to be superior to conventional therapies in H2H studies. In PsO interleukin 17 (IL-17) and IL-23 inhibitors proved superiority compared to tumor necrosis factor (TNF) inhibitors (etanercept and adalimumab) in several studies. Ustekinumab was more effective than etanercept, but less effective than IL-17 and IL-23 inhibitors. Only a few H2H studies have been published on the treatment of PsA. In the Spirit H2H study ixekizumab was superior to adalimumab using a combined endpoint of arthritis and psoriasis response (ACR-50 and PASI-100). When looking at arthritic symptoms only (ACR-20), secukinumab was not significantly superior to adalimumab in the EXCEED study but was superior in terms of the effect on skin involvement (PASI90). Other H2H studies focused on the treatment of enthesitis (ECLIPSA study), the efficacy of Janus kinase (JAK) inhibition (SELECT-PSA-1) or the additional administration of methotrexate to bDMARD treatment (MUST study). The H2H data have been incorporated into the treatment guidelines and have led to IL-17 and IL-23 inhibition being preferred over TNF inhibition in cases of relevant skin involvement in PsA.

Secukinumab Causing Medication-Related Osteonecrosis of the Jaw, in a Patient Diagnosed with Psoriasis and Rheumatoid Arthritis

The use of antiangiogenic and antiresorptive medications, particularly in patients with cancer or osteoporosis, can lead to osteonecrosis of the jaw following tooth extraction, trauma or arising spontaneously- A condition known as medication-related osteonecrosis of the jaw (MRONJ). In this article, we present a unique case of MRONJ in a patient with no history of antiresorptive or antiangiogenic drug use, who was instead taking the anti-interleukin 17-A (Secukinumab) medication for severe psoriasis. This association has not been previously reported in the literature.

Therapeutic Advances in Psoriasis: From Biologics to Emerging Oral Small Molecules

Psoriasis is a persistent, inflammatory condition affecting millions globally, marked by excessive keratinocyte proliferation, immune cell infiltration, and widespread inflammation. Over the years, therapeutic approaches have developed significantly, shifting from conventional topical treatments and phototherapy to more sophisticated systemic interventions such as biologics and, recently, oral small-molecule drugs. This review seeks to present a comprehensive investigation of the existing psoriasis treatment options, focusing on biologic agents, oral small molecules, and emerging treatments. Several categories of biologic treatments have received regulatory approval for psoriasis, including TNF-α, IL-17, IL-12/23, and IL-23 inhibitors. Biologics have revolutionized the treatment of psoriasis. These targeted therapies offer significant improvement in disease control and quality of life, with acceptable safety profiles. However, limitations such as cost, potential immunogenicity, and administration challenges have driven the exploration of alternative treatment modalities. Oral small molecules, particularly inhibitors of Janus kinase (JAK), have emerged as options due to their convenience and efficacy. These agents represent a paradigm shift in the management of the condition, offering oral administration and targeted action on specific signaling pathways. In addition to existing therapies, the review explores emerging treatments that hold promise for the future of psoriasis care. These include innovative small-molecule inhibitors. Early-stage clinical trials suggest these agents may enhance outcomes for psoriasis patients. In conclusion, the therapeutic landscape of psoriasis is rapidly evolving, emphasizing targeted, patient-centered treatments. Ongoing research and development are expected to lead to more personalized and effective management strategies for this complex condition.

Pre-treatment plasma retinol binding protein 4 level and its change after treatments predict systemic treatment response in psoriasis patients

BACKGROUND

Retinol binding protein 4 (RBP4) is a mediator of inflammation and related to skin lesion formation, which suggests its engagement in psoriasis pathology and progression. This study intended to explore the change in RBP4 after systemic treatments, and its ability to predict treatment response in psoriasis patients.

METHODS

This prospective study enrolled 85 psoriasis patients and 20 healthy subjects. Plasma RBP4 was detected by enzyme-linked immunosorbent assay at baseline and 12th week (W12) after systemic treatments in psoriasis patients, as well as after enrollment in healthy subjects. Psoriasis Area and Severity Index (PASI) 75 and PASI 90 were evaluated at W12 in psoriasis patients.

RESULTS

RBP4 at baseline was higher in psoriasis patients than in healthy subjects [median (interquartile range): 13.39 (9.71-22.92) versus 9.59 (6.57-13.72) µg/mL] (P = 0.003). In psoriasis patients, 50 (58.8%) patients achieved PASI 75 at W12, and 25 (29.4%) patients achieved PASI 90 at W12. RBP4 was decreased at W12 compared to its level at baseline (P < 0.001). Lower RBP4 at baseline predicted achieving PASI 75 at W12 (P = 0.038). Greater RBP4 change (baseline-W12) precited achieving PASI 75 (P = 0.036) and PASI 90 (P = 0.045) at W12. Receiver operating characteristic curves suggested that after adjustment for all clinical features, RBP4 at baseline and RBP4 change (baseline-W12) had an acceptable ability to predict PASI 75 and PASI 90 at W12 with all area under curve values > 0.7.

CONCLUSION

Plasma RBP4 is decreased after systemic treatments, and its low baseline level and greater decline after treatments predict good treatment response in psoriasis patients.

Effectiveness and safety of secukinumab updosing in patients with moderate to severe plaque psoriasis: data from the PURE registry

Secukinumab is a fully human IgG1 antibody that selectively binds to and neutralizes the proinflammatory cytokine interleukin-17A. Secukinumab is an effective and well-tolerated treatment for plaque psoriasis. There is a limited real-word evidence for dose optimisation of secukinumab based on clinical response. PURE is a multi-national, prospective, observational study in patients with moderate to severe chronic plaque psoriasis in Canada and Latin America, assessing the real-world safety and effectiveness of secukinumab and other indicated therapies. The aim of the current snapshot analysis was to evaluate the effectiveness and safety of on-label dose and updosed secukinumab in patients with plaque psoriasis enrolled in the PURE study. At the time of analysis, 676 patients received secukinumab, of which 84.6% (n = 572) remained on the on-label dose, while 15.4% (n = 104) were updosed. With on-label secukinumab, the absolute Psoriasis Area and Severity Index (PASI) score was reduced from 13.6 at baseline to 1.2 over 36 months, with treatment persistence of 73% at 40 months. At Month 36, 73.2% of the patients receiving on-label secukinumab achieved Investigator's Global Assessment (IGA) 0/1. With updosed secukinumab (300 mg every 2 weeks, 300 mg every 3 weeks, 450 mg every 4 weeks, or 450 mg every 3 weeks), 57.9% of the patients showed improvement in the absolute PASI score at the first visit after updosing, with treatment persistence of 50% at 12 months after updosing. At Month 15, 40% of patients receiving updosed secukinumab achieved IGA 0/1. Patients with previous biologic exposure (odds ratio [OR]: 3.25; 95% confidence interval [CI]: 2.03, 5.18, p < 0.0001) were more likely to be updosed while those with a body weight < 90 kg (OR: 0.49; 95% CI [0.31, 0.77], p = 0.0019) were less likely to be updosed. Previous biologic exposure (HR [hazard ratio]: 1.47; 95% CI [1.24, 1.75], p < 0.0001) and current biologic exposure (secukinumab vs. other indicated therapies: HR 0.57; 95% CI [0.43, 0.75], p = 0.0001) were significantly associated with time to secukinumab updosing. No new or unexpected safety signals were observed with updosed secukinumab. Secukinumab updosing was efficacious and well-tolerated in patients with psoriasis who failed to respond to the approved on-label regimen, suggesting that updosing may be a useful therapeutic option for approved dose non-responders.

Clinical pharmacokinetics and pharmacodynamics of oral systemic nonbiologic therapies for psoriasis patients

INTRODUCTION

Psoriasis is a chronic inflammatory immune condition. Treatments for psoriasis vary with disease severity, ranging from topicals to systemic biologic agents. The pharmacokinetic (PK) and pharmacodynamic (PD) properties of these therapies establish drug efficacy, toxicity, and optimal dosing to ensure therapeutic drug levels are sustained and adverse effects are minimized.

AREAS COVERED

A literature search was performed on PubMed, Google Scholar, and Ovid MEDLINE for PK and PD, efficacy, and safety data regarding oral systemic nonbiologic therapies utilized for moderate-to-severe plaque psoriasis. The findings were organized into sections for each drug: oral acitretin, methotrexate, cyclosporine, apremilast, tofacitinib, and deucravacitinib.

EXPERT OPINION

Some psoriasis patients may not respond to initial therapy. Ongoing research is evaluating genetic polymorphisms that may predict an improved response to specific medications. However, financial and insurance barriers, as well as limited genetic polymorphisms correlated with treatment response, may restrict the implementation of genetic testing necessary to personalize treatments. How well psoriasis patients adhere to treatment may contribute greatly to variation in response. Therapeutic drug monitoring may help patients adhere to treatment, improve clinical response, and sustain disease control.

Effects of tumor necrosis factor-alpha inhibitors on lipid profiles in patients with psoriasis: a systematic review and meta-analysis

Background

There is no consensus on the effect of tumor necrosis factor-alpha (TNF-alpha) inhibitors on lipid profiles in patients with psoriasis. This study aimed to investigate the effects of TNF-alpha inhibitors on lipid profiles (triglycerides, total cholesterol, low-density lipoprotein, or high-density lipoprotein) in patients with psoriasis.

Methods

We searched PubMed, Embase, and Cochrane Library databases for articles published before October 17, 2023. Four TNF-alpha inhibitors (infliximab, etanercept, adalimumab, and certolizumab) were included in our study. (PROSPERO ID: CRD42023469703).

Results

A total of twenty trials were included. Overall results revealed that TNF-alpha inhibitors elevated high-density lipoprotein levels in patients with psoriasis (WMD = 2.31; 95% CI: 0.96, 3.67; P = 0.001), which was supported by the results of sensitivity analyses excluding the effect of lipid-lowering drugs. Subgroup analyses indicated that high-density lipoprotein levels were significantly increased in the less than or equal to 3 months group (WMD = 2.88; 95% CI: 1.37, 4.4; P < 0.001), the etanercept group (WMD = 3.4; 95% CI = 1.71, 5.09, P < 0.001), and the psoriasis group (WMD = 2.52; 95% CI = 0.57, 4.48, P = 0.011). Triglyceride levels were significantly increased in the 3 to 6-month group (WMD = 4.98; 95% CI = 1.97, 7.99, P = 0.001) and significantly decreased in the 6-month and older group (WMD = -19.84; 95% CI = -23.97, -15.7, P < 0.001). Additionally, Triglyceride levels were significantly increased in the psoriasis group (WMD = 5.22; 95% CI = 2.23, 8.21, P = 0.001).

Conclusion

Our results revealed that TNF-alpha inhibitors might temporarily increase high-density lipoprotein levels in patients with psoriasis. However, changes in triglycerides were not consistent among the different durations of treatment, with significant increases after 3 to 6 months of treatment. Future prospective trials with long-term follow-up contribute to confirming and extending our findings.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023469703.

Response Types and Factors Associated with Response Types to Biologic Therapies in Patients with Moderate-to-Severe Plaque Psoriasis from Two Randomized Clinical Trials

INTRODUCTION

This study aimed to understand treatment response dynamics, including factors associated with favorable response, among patients with moderate-to-severe psoriasis who received guselkumab, adalimumab, or secukinumab.

METHODS

These post hoc analyses used data from the phase III clinical trials ECLIPSE and VOYAGE 1, which were conducted between September 2021 and November 2022. On the basis of absolute Psoriasis Area and Severity Index (aPASI) scores, patients were divided into short-term response types (SRT1-6, based on week 20-48 response) and long-term response types (LRT1-4, based on week 52-252 response). Response types (RTs) were based on aPASI cutoffs deemed clinically relevant by the investigators; SRT1/LRT1 were the most favorable response types. Baseline characteristics were compared across RTs, and logistic regression analyses established factors associated with SRT1/LRT1.

RESULTS

Overall, 1045, 662, and 272 patients were included in the ECLIPSE short-term, VOYAGE 1 short-term, and VOYAGE 1 long-term analyses, respectively. Mean age, body mass index (BMI), baseline aPASI score, and body surface area were lower in SRT1 than SRT6. In VOYAGE 1, adalimumab treatment, high BMI, and current/former smoking status resulted in less favorable responses. In the VOYAGE 1 long-term analysis, patients in LRT4 had the highest baseline aPASI score, were older, and were more often obese compared with other LRT groups. Regression analyses showed that SRT1 (both treatments) in VOYAGE 1 and ECLIPSE, and LRT1 (guselkumab group) in the VOYAGE 1 long-term analysis, were associated with week 16 aPASI response. In VOYAGE 1, SRT1 was associated with psoriasis duration and smoking status.

CONCLUSIONS

Early treatment response and baseline characteristics, including smoking, psoriasis duration, and obesity, may be associated with longer-term response to biologics.

TRIAL REGISTRATION NUMBERS

ECLIPSE: NCT03090100, VOYAGE 1: NCT02207231.

Efficacy of biologic agents for palmoplantar psoriasis: a systematic review and network meta-analysis

BACKGROUND

Palmoplantar psoriasis (PP) represents a localized type of disease. While controversy over its' classification exists, a hyperkeratotic type, a pustular type and palmoplantar pustulosis (PPP) have been recognized. PP management is regularly supported by biologic agents. Our study aimed to review and synthesize available data regarding the efficacy of approved biologics for PP and PPP.

RESEARCH DESIGN AND METHODS

A literature search was conducted in PubMed, CENTRAL, Scopus, and ClinicalTrilas.gov. Utilizing random-effects inverse-variance frequentist network meta-analyses (NMAs), we ranked interventions. The proportion of participants with cleared skin was the primary outcome. Fifty and 75% improvement in palmoplantar psoriasis area severity index (PPASI) were also explored (PPASI50, PPASI75).

RESULTS

In total, 15 randomized controlled trials (RCTs) exploring the efficacy of on-label adalimumab, bimekizumab, etanercept, guselkumab, infliximab, ixekizumab, secukinumab, and ustekinumab were included. Data for PP were synthesized. Every biologic agent examined, except from infliximab, outperformed placebo. On-label secukinumab exhibited the highest probability of inducing complete resolution. Ixekizumab and infliximab ranked best on inducing PPASI50 and PPASI75. Our review supports that guselkumab is effective for PPP.

CONCLUSIONS

Secukinumab, ixekizumab and infliximab are effective for PP. Research is warranted to produce evidence about the efficacy of biologics in PP and PPP.