Moderate Psoriasis: A Proposed Definition

Latin American consensus on psoriasis severity classification

BACKGROUND

There are different classifications of psoriasis based on its clinical presentation, impact on quality of life, requirements for specific treatments, and other patient- or physician-reported outcomes. However, the lack of unified definitions has led to the severity of the disease being underestimated. Standardizing the classification of psoriasis will promote a better approach to the disease and facilitate care by professionals.

OBJECTIVE

To present a consensus of experts in Latin America regarding the classification of psoriasis severity, based on the best available evidence and applicable to current medical practice in the region.

METHODS

An independent methodological team, together with a group of clinical dermatologists representatives from different Latin American countries, developed a consensus with a modified Delphi methodology based on a systematic review of the literature. This consensus includes the classification of psoriasis, tools to define the severity of psoriasis, and other considerations in evaluating patients with psoriasis.

RESULTS

Fifteen statements were formulated aimed at classifying the severity of cutaneous psoriasis and other forms of the disease, as well as tools to assess and define the severity of psoriasis and therapy considerations. Additionally, the consensus addresses implementation considerations.

CONCLUSION

The results of this consensus constitute a solid basis for a standard classification terminology for the varied clinical forms of psoriasis and their therapeutic implications. The importance of maintaining a personalized therapeutic approach, adjusted to each country's available resources and administrative realities, is highlighted.

Psoriatic Patient-Reported Outcomes, Adherence, and Satisfaction

BACKGROUND

Patient-reported outcomes (PROs) are outcomes evaluated by patients based on their perception of their disease and treatment.

OBJECTIVES

Determine antipsoriatic treatment-related adherence, quality of life (QoL) and satisfaction.

MATERIALS AND METHODS

We conducted an observational cross-sectional, prospective, and single-center study in which PROs surveys were conducted on adherence (Morisky-Green [MG] test), treatment satisfaction (Spanish Questionnaire of Treatment Satisfaction in Psoriasis [CESTEP]) and QoL (Skindex-29 and DLQI). Additional variables include: PASI, BSA.

STATISTICAL ANALYSIS

Jamovi®2.3.26.

RESULTS

A total of 100 surveys were conducted. Based on the MG questionnaire, we found that 75% (75/100) of patients were adherent vs 94% (94/100) from the dispensation records. Regarding CESTEP, a mean score of 7.4±7.7 (close to maximum satisfaction 0) was obtained, while DLQI yielded a score of 2.6±4.6 (indicating a small effect on QoL), and SKINDEX-29 a score of 14.6±15.4 (68% indicating mild (< 5) or very mild (6-17) impact according to Nijsten et al.). Based on CESTEP a p.Rho Spearman value of 0.338 (p=0.004) was obtained in relation to PASI when the study was conducted with a BSA of 0.255 (p=0.050), DLQI results of 0.508 (p <0.001) and Skindex-29 results of 0.397(p <0.001). At the time of the study, the correlation matrix between DLQI result and PASI was 0.365 (p=0.002) with a BSA of 0.347 (p=0.007). Skindex-29 results with PASI were 0.380 (p=0.001) and with BSA, 0.295 (p=0.022).

CONCLUSIONS

Patients on therapy exhibit a good QoL, high adherence and satisfaction with their treatment. A significant correlation was seen among satisfaction, QoL, and PASI-BSA at the time of the study.

[Translated article] Psoriatic Patient-Reported Outcomes, Adherence, and Satisfaction

BACKGROUND

Patient-reported outcomes (PROs) are outcomes evaluated by patients based on their perception of their disease and treatment.

OBJECTIVES

Determine antipsoriatic treatment-related adherence, quality of life (QoL) and satisfaction.

MATERIALS AND METHODS

We conducted an observational cross-sectional, prospective, and single-center study in which PROs surveys were conducted on adherence (Morisky-Green [MG] test), treatment satisfaction (Spanish Questionnaire of Treatment Satisfaction in Psoriasis [CESTEP]) and QoL (Skindex-29 and DLQI). Additional variables include: PASI, BSA.

STATISTICAL ANALYSIS

Jamovi®2.3.26.

RESULTS

A total of 100 surveys were conducted. Based on the MG questionnaire, we found that 75% (75/100) of patients were adherent vs 94% (94/100) from the dispensation records. Regarding CESTEP, a mean score of 7.4±7.7 (close to maximum satisfaction 0) was obtained, while DLQI yielded a score of 2.6±4.6 (indicating a small effect on QoL), and SKINDEX-29 a score of 14.6±15.4 (68% indicating mild (<5) or very mild (6-17) impact according to Nijsten et al.). Based on CESTEP a p.Rho Spearman value of 0.338 (p=0.004) was obtained in relation to PASI when the study was conducted with a BSA of 0.255 (p=0.050), DLQI results of 0.508 (p<0.001) and Skindex-29 results of 0.397(p<0.001). At the time of the study, the correlation matrix between DLQI result and PASI was 0.365 (p=0.002) with a BSA of 0.347 (p=0.007). Skindex-29 results with PASI were 0.380 (p=0.001) and with BSA, 0.295 (p=0.022).

CONCLUSIONS

Patients on therapy exhibit a good QoL, high adherence and satisfaction with their treatment. A significant correlation was seen among satisfaction, QoL, and PASI-BSA at the time of the study.

Expert consensus on systemic therapy for plaque psoriasis with limited skin involvement in JAPAN: Results from a DELPHI study

Our objective was to establish consensus on (1) which patients with plaque psoriasis and limited skin involvement (body surface area [BSA] <10%) are suitable for systemic treatment, and (2) a definition of 'topical therapy failure'. A steering committee refined 13 statements drawn from literature related to the study objectives. An independent panel of 45 clinical experts from Japan indicated their agreement to each statement using a 10-point Likert scale (Round 1; strong consensus, ≥70% of responses = 7-10 and median value ≥8). The steering committee reviewed Round 1 results and refined the statements for Round 2, as necessary. In Round 2, the panel indicated their agreement to each statement using a 3-point scale (strong consensus, ≥70% of responses and median value of 3) and were shown Round 1 responses before voting. Forty-five clinicians participated in Round 1 and 41 of those (91%) participated in Round 2. Consensus was achieved on the criteria of eligibility for systemic treatment among patients with limited skin involvement as disease involvement at special or difficult to treat areas, psoriasis-induced psychological distress, uncontrolled symptoms (e.g., scaling, bleeding, pruritus, insomnia) affecting their social life, psoriatic arthritis, or failure of topical therapy. Consensus on criteria for topical failure were persistent symptoms (e.g., itchiness, pain) and plaques, poor patient satisfaction with treatment, a need to increase medication quantity or application time after treatment with two topicals for 4 weeks; or if the Psoriasis Area Severity Index score of >3 or Physician Global Assessment Score of ≥2 after 8 weeks treatment. Our Delphi panel proposes criteria to help physicians identify patients with psoriasis and limited skin involvement who would benefit from systemic therapy and suggests a definition for topical therapy 'failure' which could indicate a move to systemic treatment is warranted.

TELEPROM Psoriasis: Enhancing patient-centered care and health-related quality of life (HRQoL) in moderate-to-severe plaque psoriasis

Background and purpose

Psoriasis is a chronic, immune-mediated inflammatory skin disease that significantly impacts patients' quality of life. The integration of telepharmacy has the potential to enhance patient care by providing flexible and personalized pharmaceutical follow-up. This study (TELEPROM Psoriasis) evaluates a telepharmacy model for evaluating electronic Patient-Reported outcomes (ePROMs) for individuals with moderate to severe plaque psoriasis in Spain with biological treatment.

Experimental approach

This multicenter prospective quasi-experimental study included 258 adult patients initiating or switching biological/immunomodulatory therapy for moderate to severe plaque psoriasis. Patients were recruited from public hospitals in Spain and monitored through the NAVETA telepharmacy platform over a six-month period. PROMs assessed were the Psoriasis Symptoms and Signs Diary and the Dermatology Life Quality Index at baseline, 1 month, 3 months, and 6 months. Data were analyzed using ANOVA, Student's t-test, multiple regression, and machine learning algorithms to evaluate ePROMs evolution and response and satisfaction with Telepharmacy follow up.

Key results

The analysis revealed significant influences of gender, employment status, educational level, and daily activity, but no effect of age, on responses to Patient-Reported Outcomes questionnaires. Machine learning models, particularly Random Forest (AUC = 0.98) and Support Vector Machine (AUC = 0.96), effectively predicted patient engagement. DLQI scores significantly decreased from 9.33 ± 7.75 at baseline to 4.34 ± 5.86 at 6 months. Similarly, the PSSD - 7 Days questionnaire showed major reductions, with scores dropping from 55.43 ± 29.94 to 30.73 ± 30.66 at 6 months, and 53% of patients reaching a score of 20 or less. Notably, women reported worse scores at all time points compared to men. Regression analysis explained only 13.2% of the variance in PROMs scores, identifying Employment Status and BMI Range as key contributors.

Conclusion

This study demonstrates the efficacy of biologic treatments in significantly improving HRQoL for psoriasis patients. Addressing demographic variables, such as gender, is key for optimizing treatment outcomes and improving ePROMs response rates. Tailored strategies and ML techniques can help identify low-engagement patients and mitigate disparities. Integrating sociodemographic factors into clinical decision-making and patient engagement strategies is fundamental for delivering equitable and comprehensive care.

Core items to be included in a definition of moderate psoriatic arthritis: literature review and expert opinion

Evidence-based treatment recommendations for psoriatic arthritis (PsA) suggest that treatment should be individualised but acknowledge the difficulty of correctly defining levels of activity (mild, moderate and severe). The aim of this study was to define the parameters or disease characteristics that should be included in a future definition of moderate PsA. Mixed. methods: (1) literature review to identify previous assessment tools used to classify patients into mild, moderate and severe forms, and (2) survey of rheumatologists, and experts in PsA, to obtain their opinion on the degree of validation and applicability of published definitions and tools, and on the parameters that should be included in a future definition of moderate PsA. We propose eight domains/items to be included in a definition of moderate PsA: number of active joints and inflamed entheses, physician global assessment (by visual analogue scale), dactylitis, body surface area (BSA) affected by psoriasis, psoriasis in special locations, and absence of hip involvement. The Disease Activity Index for Psoriatic Arthritis (DAPSA) score would be supported as part of this definition, as would the Psoriatic Arthritis Impact of Disease (PsAID) index. This study proposes a set of items/domains to be included in a definition of moderate PsA based on literature and expert opinion, which can be the starting point for further development and validation studies of the proposed items.

[Translated article] Validation of the Spanish Version of the PURE-4 Questionnaire for the Early Detection of Psoriatic Arthritis in Psoriatic Patients

BACKGROUND AND OBJECTIVE

Psoriasis often precedes the onset of psoriatic arthritis (PsA), so dermatologists often face the challenge of early identifying signs of PsA in patients with psoriasis. Our aim was to validate the Spanish version of the PURE-4 questionnaire as a screening tool for PsA, evaluate its performance in terms of sensitivity, specificity, feasibility, reliability, and build validity.

METHODS

This was a cross-sectional, observational, multicenter trial of adult patients with psoriasis. Initially, patients were assessed by a dermatologist and completed 2 self-administered versions (in print and online) of the PURE-4 questionnaire. Afterwards, the rheumatologist, blinded to the PURE-4 results, assessed the presence/absence of PsA, being the reference to determine the performance of the PURE-4 questionnaire.

RESULTS

A total of 268 patients were included (115 [42.9%] women; mean age, 47.1±12.6). The prevalence of PsA according to rheumatologist diagnosis was 12.7% (34 patients). The mean PURE-4 score for patients with psoriasis diagnosed with PsA was 2.3±1.1, and 1.3±1.3 for patients without PsA (P<.001). The cutoff value ≥2 demonstrated the best performance for detecting PsA, with a negative predictive value of 95.1% (95% confidence interval, 90.3-97.6).

CONCLUSIONS

The PURE-4 questionnaire demonstrated good performance in detecting PsA, with an optimal cutoff point ≥2. This simple tool could facilitate early referral of patients to the rheumatology unit.

[Translated article] Comparing the Use of Topical Therapy Along with Anti-IL-17 and Anti-IL-23 to Treat Moderate-to-Severe Psoriasis in the Routine Clinical Practice

BACKGROUND

Combinations of topical (TT) and biological therapies (BT) are a common thing in the routine clinical practice. However, the scientific medical literature on how TT is, actually, used after the initiation of BT is scarce, particularly in combination with anti-IL17, or anti-IL23.

OBJECTIVES

To describe the frequency of the concomitant use of TT + BT at baseline and after a 6-month course of several drugs (anti-IL17, ustekinumab, and anti-IL23). Our secondary endpoints are to describe the type of topical therapy used, compare the frequency of use of TT among the different groups of BT, describe the survival of topical therapy in these patients, and identify the factors that can impact the use or discontinuation of topical therapy in these patients (clinical response, quality of life, type of drug, etc.).

MATERIALS AND METHODS

This was a retrospective, observational, and single-center study of patients with moderate-to-severe psoriasis treated with anti-IL17 (secukinumab, ixekizumab), anti-IL17R (brodalumab), ustekinumab, and guselkumab from January 2015 through December 2020.

RESULTS

We included a total of 138 patients. When treatment started, 82.7% were on TT (55% daily), and after 6 months, 86.6% had discontinued TT. Regarding the analysis by type of drug, at 6 months, we found that 100% of the patients with BRO had discontinued topical treatment. We did not find any significant differences in the frequency of use of TT based on the BT used during the 6-month course of treatment. The estimated mean course of TT was 4.3 months (SD, 6.7). Also, the estimated mean course of TT was significantly shorter in the group of patients who achieved PASI100 (2.8 months vs. 8.1 months).

CONCLUSIONS

In our cohort, we saw a significant decrease in the frequency of use of TT at 6 months after starting BT in the routine clinical practice. This reduction occurred earlier in patients who improved their objective clinical response and quality of life.

Validation of the Spanish Version of the PURE-4 Questionnaire for the Early Detection of Psoriatic Arthritis in Psoriatic Patients

BACKGROUND AND OBJECTIVE

Psoriasis often precedes the onset of psoriatic arthritis (PsA), so dermatologists often face the challenge of early identifying signs of PsA in patients with psoriasis. Our aim was to validate the Spanish version of the PURE-4 questionnaire as a screening tool for PsA, evaluate its performance in terms of sensitivity, specificity, feasibility, reliability, and build validity.

METHODS

This was a cross-sectional, observational, multicenter trial of adult patients with psoriasis. Initially, patients were assessed by a dermatologist and completed 2 self-administered versions (in print and online) of the PURE-4 questionnaire. Afterwards, the rheumatologist, blinded to the PURE-4 results, assessed the presence/absence of PsA, being the reference to determine the performance of the PURE-4 questionnaire.

RESULTS

A total of 268 patients were included (115 [42.9%] women; mean age, 47.1±12.6). The prevalence of PsA according to rheumatologist diagnosis was 12.7% (34 patients). The mean PURE-4 score for patients with psoriasis diagnosed with PsA was 2.3±1.1, and 1.3±1.3 for patients without PsA (P<.001). The cutoff value ≥2 demonstrated the best performance for detecting PsA, with a negative predictive value of 95.1% (95% confidence interval, 90.3-97.6).

CONCLUSIONS

The PURE-4 questionnaire demonstrated good performance in detecting PsA, with an optimal cutoff point ≥2. This simple tool could facilitate early referral of patients to the rheumatology unit.

Comparing the Use of Topical Therapy Along with Anti-IL-17 and Anti-IL-23 to Treat Moderate-to-Severe Psoriasis in the Routine Clinical Practice

BACKGROUND

Combinations of topical (TT) and biological therapies (BT) are a common thing in the routine clinical practice. However, the scientific medical literature on how TT is, actually, used after the initiation of BT is scarce, particularly in combination with anti-IL17, or anti-IL23.

OBJECTIVES

To describe the frequency of the concomitant use of TT + BT at baseline and after a 6-month course of several drugs (anti-IL17, ustekinumab, and anti-IL23). Our secondary endpoints are to describe the type of topical therapy used, compare the frequency of use of TT among the different groups of BT, describe the survival of topical therapy in these patients, and identify the factors that can impact the use or discontinuation of topical therapy in these patients (clinical response, quality of life, type of drug, etc.).

MATERIALS AND METHODS

This was a retrospective, observational, and single-center study of patients with moderate-to-severe psoriasis treated with anti-IL17 (secukinumab, ixekizumab), anti-IL17R (brodalumab), ustekinumab, and guselkumab from January 2015 through December 2020.

RESULTS

We included a total of 138 patients. When treatment started, 82.7% were on TT (55% daily), and after 6 months, 86.6% had discontinued TT. Regarding the analysis by type of drug, at 6 months, we found that 100% of the patients with BRO had discontinued topical treatment. We did not find any significant differences in the frequency of use of TT based on the BT used during the 6-month course of treatment. The estimated mean course of TT was 4.3 months (SD, 6.7). Also, the estimated mean course of TT was significantly shorter in the group of patients who achieved PASI100 (2.8 months vs. 8.1 months).

CONCLUSIONS

In our cohort, we saw a significant decrease in the frequency of use of TT at 6 months after starting BT in the routine clinical practice. This reduction occurred earlier in patients who improved their objective clinical response and quality of life.

Plexin B2 tissue expression and related gene polymorphisms in psoriasis and their relation to NB-UVB and Acitretin therapy

Psoriasis is a chronic, immune-mediated, hyperproliferative skin disease. Etiopathogenesis of psoriasis is not well understood. Plexin B2 was found to have effects on CD100-mediated T-cell morphology and expressed in the immune system. It may play a role in the pathogenesis of psoriasis. To assess the tissue level of plexin-B2 and plexin B2 related gene polymorphism which is signal regulatory protein gamma (SIRPγ-rs71212732) in psoriatic patients before and after NB-UVB, acitretin therapy alone or in combination and to detect correlation between level of tissue plexin B2 and disease severity and improvement. This single blinded randomized controlled trial was carried on 50 psoriatic patients and 50 healthy controls. Psoriasis Area and Severity Index score (PASI) was used to evaluate the disease severity. Tissue plexin-b2 level was measured using ELISA and SIRPγ-rs71212732 (T\C) was assessed using TaqMan™ assays and real-time PCR. A significant lower tissue plexin-B2 level was observed in control group (2.9 ± 0.6 pg/g) than cases (25.8 ± 2.8, pg/g) (p < 0.001). Also, a significantly higher tissue plexin-B2 level was observed in sever psoriasis (32.7 ± 3.8 pg/ml) in than moderate psoriasis (13.6 ± 2.1 pg/ml, p = 0.001). Tissue plexin B2 was positively correlated with diseases severity. Significantly higher (TC& TT) genotypes and mutant (C) allele among patients compared to the controls, p < 0.001 for all. Tissue plexin-b2 level was high in psoriasis vulgaris with positive correlation with disease severity and decreased after treatment. This may indicate a role of plexin-b2 in psoriasis vulgaris pathogenesis.

MicroRNA-21 and MicroRNA-125b expression in skin tissue and serum as predictive biomarkers for psoriasis

BACKGROUND/OBJECTIVE

Psoriasis is a chronic, inflammatory, and hyperproliferative skin disease. We have investigated the role of miR-21 and miR-125b in the development of psoriasis and atopic eczema and their relation with the severity of the diseases.

METHODS

Participants included 40 psoriasis patients, 40 healthy controls, and 40 atopic eczema patients as a positive control group. In addition, analysis of mRNA expression of miR-125b and miR-21 was carried out utilizing quantitative real-time reverse transcription polymerase chain reaction (RT-PCR) in serum samples and skin tissue.

RESULTS

Our results have demonstrated that miR-21 was significantly overexpressed in the psoriatic and atopic eczema skin tissue and serum samples compared to controls, whereas miR-125b was significantly down-expressed in psoriatic and atopic eczema skin tissues and serum samples. There was a statistically significant positive correlation between the psoriasis area and severity index (PASI) score and miR-21 among the studied groups in both serum and tissue samples. In contrast, there was a statistically significant negative association between the miR-125b and PASI score. On the other hand, there was no significant relation between the extent of body surface area (BSA), intensity, and subjective symptoms using visual analog scale (VAS) of atopic eczema disease and miRNA-21 and miRNA-125b in both tissue and serum.

CONCLUSION

In conclusion, miR-21 gene expression was significantly increased in psoriatic and atopic eczema skin samples and serum samples, whereas miR-125b was statistically lowered in psoriatic and atopic eczema patient samples. The miR-21 and miR-125b expression level has a possible predictive value as a marker for psoriasis severity but not for atopic eczema severity.

New-insight UVB Treatment for Psoriasis Vulgaris in Vietnamese Patients

Background

Narrowband UVB (NBUVB) has recently been used in Vietnam for the treatment of psoriasis. However, there are no data on Vietnamese patients to adopt a uniform national protocol.

Objectives

This study aimed to establish an optimal NBUVB therapy for the treatment of psoriasis in Vietnamese patients.

Materials and Methods

One hundred and twenty-two patients with psoriasis vulgaris were included. They were randomly allocated to two groups: the percentage dose (group 1, 62 patients) and the fixed dose (group 2, 60 patients). In group 1, the starting dose was 50% of the minimal erythema dose (MED) and the 10% increment dose adjusted in the next sessions. In group 2, the starting dose was based on Fitzpatrick skin types (fixed dose). Psoriasis area and severity index (PASI) was used to evaluate efficacy.

Results

More than 68% of the patients get PASI75 at session 36. Group 2 had significantly fewer sessions (20 ± 5 vs 25 ± 7, P- value = 0.0004) and lower cumulative dose than group 1 (14.1 ± 4.3 J/cm2 vs 18.0 ± 8.0 J/cm2, P- value = 0.0075) to achieve PASI75. Adverse effects were more common in group 2 than group 1, including burning sensation/erythema (43.33% vs 14.52%, P- value = 0.0009) and pruritus (75.00% vs 22.58%, P- value <0.0001).

Conclusion

NBUVB therapy was safe and effective for Vietnamese psoriasis patients. Fixed doses produced a quicker clinical response with fewer sessions and lower cumulative doses. Adverse effects were mild in both groups and less noted for the MED-based dose. For the recommendation, a fixed dose should be applied for patients who have less concern about side effects, while a MED-based dose can be suitable for patients having conditions related to light sensitivity.

Matching-Adjusted Indirect Comparison of the Long-Term Efficacy of Deucravacitinib Versus Adalimumab for Moderate to Severe Plaque Psoriasis

INTRODUCTION

Deucravacitinib, an oral tyrosine kinase 2 (TYK2) inhibitor, is approved in the United States to treat adults with moderate-to-severe plaque psoriasis (PsO). This study compared the long-term efficacy of deucravacitinib and adalimumab using results from long-term extension (LTE) trials.

METHODS

Open-label LTE trials were identified for an indirect treatment comparison (deucravacitinib: POETYK PSO-LTE [NCT04036435]; adalimumab: REVEAL extension [NCT00195676]). To ensure study design comparability, patients initially randomized to placebo and switched to deucravacitinib or adalimumab after week 16 were compared. The primary outcome was  an ≥ 75% reduction in Psoriasis Area and Severity Index score (PASI 75) at week 112 postrandomization. Secondary outcomes were PASI 75 at week 52 and an ≥ 90% reduction in PASI score (PASI 90) at weeks 52 and 112. Missing PASI data were imputed. A matching-adjusted indirect comparison was conducted; individual patient-level data from POETYK PSO-LTE were reweighted to balance baseline characteristics with those from the REVEAL extension.

RESULTS

Before reweighting, on average, patients in the POETYK PSO-LTE (N = 329) versus the REVEAL (N = 345) extension were older, had a lower body weight, received more prior systemic treatments, and had higher baseline PASI scores and week 16 placebo PASI 75 and PASI 90 response rates. Following reweighting, adjusted week 112 PASI 75 response rates were significantly higher for deucravacitinib versus adalimumab (67.2% vs. 54.0%; mean difference [95% CI], 13.2 [4.0-22.5] percentage points). Deucravacitinib had a numerically higher adjusted week 112 PASI 90 response rate (41.3% vs. 34.0%; mean difference [95% CI], 7.3 [-2.0 to 16.7] percentage points). The treatments had similar week 52 adjusted PASI 75 and PASI 90 response rates.

CONCLUSION

In this interim analysis, adults with moderate to severe PsO had higher long-term response rates at 2 years when treated with deucravacitinib versus adalimumab. Deucravacitinib response rates remained stable whereas adalimumab response rates declined in year 2.

Regular Exercise Improved Fatigue and Musculoskeletal Pain in Young Adult Psoriatic Patients without Psoriatic Arthritis

Fatigue and musculoskeletal pain are also frequent in patients with psoriasis (PsO) without arthritis (PsA). The current study aimed to assess the impact of an intervention program based on aerobic training to reduce fatigue and musculoskeletal pain in patients with PsO without PsA. A total of 118 male patients with PsO volunteered in the current interventional study and were randomly allocated to the experimental (n = 59) or control group (n = 59). The intervention consisted of a 16-week aerobic training program on a treadmill, three sessions per week, consisting of a warm-up, 35-50 min treadmill exercise (increasing 5 min/4 weeks) at a work intensity of 50-65% of peak heart-rate (increasing 5%/4 weeks), and cooling-down. The functional assessment of chronic illness therapy fatigue scale (FACIT-Fatigue), health assessment questionnaire disability index (HAQ-DI), and visual analog scale (VAS) were compared pre and post intervention. Nutritional intake, maximal aerobic power, lipid profile, serum markers of muscle damage, and body composition were also assessed. When compared to baseline, FACIT-Fatigue, HAQ-DI, and VAS scores were significantly improved without increasing markers of muscle damage. Fat mass percentage, lipid profile, and maximal oxygen consumption were also improved. In conclusion, a 16-week aerobic training program at moderate intensity was safe, well tolerated, and effective in psoriatic patients without PsA. Long-term follow-up studies are required to examine whether these promising results may improve clinical outcomes.

Tildrakizumab improves high burden skin symptoms, impaired sleep and quality of life of moderate-to-severe plaque psoriasis patients in conditions close to clinical practice

BACKGROUND

Tildrakizumab (TIL) is an interleukin (IL)-23p19 inhibitor for the treatment of moderate-to-severe plaque psoriasis with long-term efficacy and safety demonstrated in Phase III trials. Studies conducted in conditions closer to clinical practice are needed.

OBJECTIVES

The TRIBUTE study (open-label, Phase IV) assessed the efficacy and impact on health-related quality of life (HRQoL) of TIL 100 mg in adult moderate-to-severe psoriasis patients (naïve to IL-23/Th17 pathway inhibitors) in conditions similar to clinical practice.

METHODS

Key efficacy measure was Psoriasis Area Severity Index (PASI). HRQoL was evaluated using the Dermatology Life Quality Index (DLQI) and Skindex-16. Additional patient-reported outcomes included Pain-, Pruritus- and Scaling-Numerical Rating Scale (NRS), Medical Outcome Study (MOS)-Sleep, Work Productivity and Activity Impairment (WPAI), Patient Benefit Index (PBI) and Treatment Satisfaction Questionnaire for Medication (TSQM).

RESULTS

One hundred and seventy-seven patients were enrolled (six patients did not complete the study). After 24 weeks, the proportion of patients achieving PASI scores ≤ 3, PASI 75, PASI 90 and DLQI 0/1 was 88.4%, 92.5%, 74.0% and 70.4%, respectively. Skindex-16 overall score improved (mean absolute change from baseline, MACB [95%CI]: -53.3 [-58.1, -48.5]). Significant benefits (MACB [95%CI]) were found on pruritus-, pain- and scaling-NRS scores (-5.7 [-6.1, -5.2], -3.5 [-4.1, -3.0] and -5.7 [-6.2, -5.2], respectively), MOS-Sleep (-10.4 [-13.3, -7.4] Sleep problems Index II) and WPAI (-36.4 [-42.6, -30.2] activity impairment, -28.2 [-34.7, -21.7] productivity loss, -27.0 [-32.9, -21.1] presenteeism and -6.8 [-12.1, -1.5] absenteeism). 82.7% of patients reported PBI ≥ 3 and the mean (SD) global TSQM score was high (80.5 [18.5]). Only one serious treatment-emergent adverse event was reported (not-related to TIL).

CONCLUSIONS

TIL 100 mg treatment after 24 weeks in conditions close to real clinical practice showed a quick and high improvement in psoriasis signs and HRQoL. Patient reported improvements in sleep outcomes and work productivity, relevant benefits and high treatment satisfaction. The safety profile was favourable and consistent with Phase III trials.

Assessing the Association between Psoriasis and Cardiovascular Ischemia: An Investigation of Vascular Endothelial Growth Factor, Cutaneous Angiogenesis, and Arterial Stiffness

Background

Vascular endothelial growth factor (VEGF)-mediated angiogenesis's role in developing psoriasis and cardiovascular events has been established. However, the interplay between the two diseases regarding this cytokine remains an understudied area.

Aim and Objectives

This case-control study aimed to investigate the relationship between VEGF-mediated angiogenesis and cardiovascular ischemia in patients with psoriasis.

Materials and Methods

The study included 200 clinically diagnosed treatment-naïve cases of psoriasis and 200 controls. The VEGF level, cutaneous vascularity, and cardiovascular ischemia were measured between cases and controls. Cutaneous vascularity was assessed using non-invasive imaging technique such as laser doppler imaging (LDI) and measuring skin blood flow measurement (SBFM). Cardiovascular ischemia was evaluated using noninvasive techniques by measuring carotid intima-media thickness (CIMT) and pulse-wave velocity (PWV). The arterial vasa vasorum was evaluated using ultrasound imaging.

Results

The study found a significant correlation between psoriasis severity and levels of VEGF (P < 0.001). Cases had significantly higher CIMT and PWV levels (P = 0.001 and <0.001, respectively). There was a significant positive correlation between the severity of psoriasis and the levels of cutaneous angiogenesis (r = 0.7, P < 0.001).

Conclusion

According to this study, patients with psoriasis are at a higher risk of developing cardiovascular ischemia due to excessive angiogenesis associated with the condition. VEGF plays a key role in atheroma formation in psoriasis patients.

Efficacy and Safety of Dimethyl Fumarate in Patients with Moderate-to-Severe Plaque Psoriasis: Results from a 52-Week Open-Label Phase IV Clinical Trial (DIMESKIN 1)

INTRODUCTION

Although dimethyl fumarate (DMF) has been approved since 2017 for treatment of moderate-to-severe plaque psoriasis, limited data on its safety and efficacy are available in clinical practice. The objective was to assess the efficacy and safety of DMF in patients with moderate-to-severe plaque psoriasis through 52 weeks in conditions close to real clinical practice.

METHODS

DIMESKIN 1 was a 52-week, open-label, phase IV clinical trial conducted at 36 Spanish sites. Adults with diagnosis of moderate-to-severe plaque psoriasis, treated with DMF as per its summary of product characteristics and with ≥ 1 post-baseline Psoriasis Area and Severity Index (PASI) value were included [intention-to-treat (ITT) population]. Efficacy analyses were performed for ITT population and are based on multiple imputation.

RESULTS

Overall, 282 and 274 patients were included in the safety and ITT populations, respectively. At week 24, 46.0%/24.8%/10.9% of patients achieved PASI 75/90/100 response, respectively. At week 52, these percentages were 46.0%/21.9%/10.9%, respectively. Mean body surface area affected decreased from 17.4% to 6.9%/7.3% after 24/52 weeks (p < 0.001, both). A total of 42.9%/49.4% of patients had a Physician's Global Assessment 0-1 at week 24/52, respectively. Mean pruritus visual analogue scale (VAS) significantly decreased after 24 and 52 weeks (p < 0.001, both), with 56.5% and 67.6% of patients, respectively, rating a pruritus VAS < 3. At week 24/52, 61.3%/73.4% patients had a Dermatology Life Quality Index (DLQI) ≤ 5 and 34.7%/32.1% had a DLQI 0-1. The most frequent adverse events were gastrointestinal disorders (mainly diarrhea/abdominal pain in 50.0%/35.1% of patients, respectively), flushing (28.0%), and lymphopenia (31.2%), mostly mild/moderate.

CONCLUSIONS

DMF significantly improves main severity and extension indexes and rates, as well as patient-reported outcomes such as pruritus and quality of life in patients with moderate-to-severe psoriasis after 24 weeks of treatment. These improvements are sustained through 52 weeks. The safety profile of DMF is similar to that previously described for fumarates.

EUDRACT NUMBER

2017-00136840.

Evaluation of Lactocare® Synbiotic Administration on the Serum Electrolytes and Trace Elements Levels in Psoriasis Patients: a Randomized, Double-Blind, Placebo-Controlled Clinical Trial Study

BACKGROUND

Despite the exact etiopathogenesis of psoriasis remains unknown, the increasing or decreasing of some trace elements and oxidative stress status are considered to play a role. In this study, the effect of Lactocare® synbiotic on the serum levels of trace elements including Zn, Cu, Mg, Na, Fe, P, Ca, and K in the patients with mild to moderate psoriasis was investigated.

METHODS

Sixty-four patients with mild to moderate psoriasis were included. Patients were randomly divided into treatment (n═32) and control (n═32) groups. The treatment group received Lactocare® and the control group received a placebo (two times daily for 12 weeks). Eight patients from the intervention group and 18 patients from the control group discontinued the study because of the recent COVID-19 condition. For routine trace element analysis, the blood samples were collected from all patients at the baseline as well as week 12 post-treatment. The serum was then isolated and the serum levels of trace elements including Fe, K, Ca, Mg, P, Zn, Na, and Cu were measured using an automatic electrolyte analyzer. For confirmation of the effect of Lactocare® on the alteration of serum levels of trace elements, intra-group analysis was performed at two interval times: baseline and week 12 post-treatment.

RESULTS

The serum levels of K, P, and Ca in the placebo group were significantly higher than that of the treatment group at baseline. Serum levels of Zn and Ca were significantly higher in the treatment group compared to the placebo group at week 12 post-treatment. Moreover, a significantly lower serum level of K, P, and Ca in the treatment group at the baseline compared to the placebo group was compensated on week 12 post-treatment. Intra-group analysis in the treatment group showed that the serum levels of Fe, Ca, Mg, P, Zn, and Na was significantly increased at week 12 post-treatment compared to baseline levels. Whereas, intra-group analysis in the control group showed only Ca has a significant difference between baseline and week 12 post-treatment.

CONCLUSION

The serum levels of Fe, Zn, P, Mg, Ca, and Na are increased significantly 12 weeks after oral administration of Lactocare® in psoriatic patients. The serum level of Fe and Cu is affected by sex at pre- and post-treatment. This study supports the concept that Lactocare® exerts beneficial effects in the gastrointestinal tract to improve mineral absorption in psoriatic patients.

A Systematic Review with Meta-Analysis of Comparative Efficacy and Safety of Risankizumab and Ustekinumab for Psoriasis Treatment

Biological targeted therapy serves as a new alternative treatment for psoriasis due to its minimal side effects. This study is aimed at examining the drug effectiveness and safety of risankizumab and ustekinumab for psoriasis treatment, so as to provide a reference for clinical decision-making. Databases from Embase, Web of Science, PubMed, and Cochrane Library were gathered, starting from inception to March 1, 2022, for randomized controlled trials regarding risankizumab and ustekinumab for psoriasis treatment. All retrieved articles were carefully selected in strict accordance with a set of inclusion and exclusion criteria. Stata 15.0 and RevMan 5.4 were applied to perform meta-analysis and risk of bias assessment. A total of two trials with three NCTs were selected, with 384 participants in the risankizumab group and 140 participants in ustekinumab. Meta-analysis showed that in the long-term and short-term PASI100, risankizumab was more effective than ustekinumab (RR = 2.27, 95% CI (1.77, 2.90), p < 0.05; RR = 2.33, 95% CI (1.75, 3.08), p < 0.05). In PASI90, RR = 1.77, 95% CI (1.54, 2.03), and p < 0.05 and RR = 1.72, 95% CI (1.48, 2.00), and p < 0.05. In short-term PASI75, RR = 1.23, 95% CI (1.13, 1.34), and p < 0.05. In sPGA of 0, the results at week-16 and week-52 showed that risankizumab was significantly more effective than ustekinumab (RR = 2.24, 95% CI (1.67, 3.01), p < 0.05; RR = 2.30, 95% CI (1.80, 2.95), p < 0.05). Risankizumab was significantly more effective than ustekinumab in improving the quality of life and PSS scores (RR = 1.48, 95% CI (1.26, 1.75), p < 0.05; RR = 2.01, 95% CI (1.41, 2.85), p < 0.05). Nevertheless, risankizumab and ustekinumab did not show significant difference in the incidence of adverse responses (RR = 1.02, 95% CI (0.75, 1.39), p > 0.05). Risankizumab was more effective than ustekinumab for the treatment of psoriasis. The adverse reactions of both risankizumab and ustekinumab were similar and could be tolerated. Risankizumab might be a better alternative option for their treatment.

Role of Shear-Wave Elastography in Achilles Tendon in Psoriatic Arthritis and Its Correlation with Disease Severity Score, Psoriasis Area and Severity Index

Purpose  The aim of this study was to compare accuracy of shear-wave elastography (SWE) with gray scale (GS) ultrasound and power Doppler (pD) for diagnosing Achilles tendinopathy in psoriatic patients with and without arthritis and correlation with achillodynia and disease severity score, psoriasis area and severity index (PASI).

Methods  A total of 100 Achilles tendons were evaluated where 56% were cases of psoriatic arthritis with achillodynia; 44% were controls of psoriasis without arthritis in this prospective study. Evaluation was done with GS, pD, SWE at proximal, mid, and distal third of the tendon. Qualitative (color maps) and quantitative data, elastic modulus, kilopascal (kPa), were generated. Pearson's correlation was done to see association between kPa, PASI and clinical symptoms, achillodynia, scored using visual analog scale (VAS).

Results  Significant negative correlation was seen between duration of arthritis, VAS and PASI with SWE values with r  = −0.34, −0.47, and −0.41, respectively. SWE could identify abnormal tendons in 71/100 (71%) in the overall study, 53/56 (94.6%) in cases, and 18/44 (40.9%) in control. The statistical significance was set at p  ≤ 0.05. In comparison, conventional ultrasound, GS, and pD together could identify 13/56 (23.21%) in cases and no abnormal tendon was identified in the control group.

Conclusion  SWE is a reliable, noninvasive, and valuable tool to detect early tendinopathy and monitor progression of disease.

Moderate Psoriasis in Clinical Practice: French Expert Consensus Using a Modified Delphi Method

INTRODUCTION

Despite the existence of multiple assessment scores for psoriasis severity, skin disease with limited skin lesions but significant impairment of quality of life can be difficult to classify, leading to under- or overtreatment. Our objective was to obtain consensus on clinical criteria to classify psoriasis severity in French clinical practice, with a focus on moderate disease, using a modified Delphi method.

METHODS

A steering committee (SC) formulated a 22-item questionnaire to classify moderate psoriasis. An independent panel of French dermatologists indicated their level of agreement for each item using a 9-point Likert scale (round 1). Items without a strong consensus were modified and included in round 2. For each item, strong consensus was defined as at least 75% of scores ≥ 7 and median score ≥ 8; good consensus was defined as at least 75% of scores ≥ 7 or median score ≥ 8.

RESULTS

Of 80 dermatologists who agreed to participate, 47 (59%) responded in round 1. All participants from round 1 responded in round 2. Fifteen (68%) items achieved strong consensus and four (18%) achieved good consensus. For psoriasis severity, several clinical dimensions assessed both by the physician (location, symptoms, temporality, previous treatments) and the patient (perception, physical and psychological impairment) obtained consensus. The following were considered sufficient to confirm that psoriasis is at least at a moderate stage: limited involvement but with an impact on patient/family quality of life; involvement of a special area; presence of uncontrolled symptoms (scaling, bleeding, pruritus, insomnia); accumulation of mild intensity symptoms; presence of burdensome onychodystrophy; failure of well-applied topical treatments. There was strong consensus that recognition of moderate psoriasis should lead to reassessment of topical treatments.

CONCLUSION

Our modified Delphi panel suggests detailed criteria to help physicians classify patients with psoriasis which is at least at a moderate stage, which could, in turn, improve treatment in these patients.

Applicability of the Geographic Tongue Area and Severity Index among Healthcare Professionals: A Cross-Sectional Clinical Validation of a Newly Developed Geographic Tongue Scoring System

Geographic tongue (GT) is a chronic condition of unknown aetiology, with no defined parameters to establish the protocol for evidence-based management. Validation of a newly developed and proposed clinical index to assess the severity of GT could assist in its diagnosis, especially in cases associated with systemic dermatological diseases in the form of psoriasis.

OBJECTIVE

To verify the applicability of the geographic tongue area and severity index (GTASI). This involved healthcare professionals from different specialties to evaluate the usefulness of the GTASI in supporting GT classification, as well as the follow-up process.

METHODS

One hundred cases of previously diagnosed GT were initially evaluated by three independent, experienced researchers/clinicians to obtain a standardised classification baseline. Subsequently, nine cases of GT were selected, three cases for each category-mild, moderate and severe. These stages were professionally evaluated by 51 healthcare professionals from three groups: 17 dentists (33%), 22 oral medicine specialists (43%) and 12 specialist dermatologists (24%) during a cross-sectional survey.

RESULTS

The quantitative and qualitative assessment based on experts' opinions in the cross-sectional survey demonstrated an acceptable, similar level of GT clinical diagnosis (p > 0.05), with coherence between the various groups of professionals critically appraising the GTASI. An apparent divergence was observed for the moderate GT category, as well as in the group of less experienced evaluators.

CONCLUSION

Whilst the validation of GTASI applicability was successfully executed, the general dental practitioners, specialists in oral medicine and dermatologists were equally capable of correct GT diagnosis and appropriately rating its severity. These coherent results were especially replicated among the experienced clinicians. The validation of the newly proposed index confirmed its reliability as a feasible instrument in oral medicine, with the prospect of its wider implementation in clinical practice.

Screening for Comorbid Cardiovascular Risk Factors in Pediatric Psoriasis Among Iraqi Patients: A Case-Control Study

Background: Psoriasis is a polygenic multifactorial immune-mediated skin disease associated with comorbidities. As one-third of adult psoriasis starts during childhood, early detection of these comorbidities might help to mitigate their impact on future health.

Objectives: To investigate the risk for cardiovascular events and their relationship with psoriasis severity among Iraqi children and adolescents.

Patients and methods: A prospective, case-control, cross-sectional study on 150 patients with psoriasis and 150 age and sex-matched individuals. The study was carried out at the Department of Dermatology/Basra Teaching Hospital from December 2018 to December 2020. Psoriasis severity was assessed by PASI (psoriasis area severity index) score, and in both groups, blood pressure and body mass index (BMI) were measured. Laboratory tests including fasting blood sugar (FBS) and lipid profile were also done.

Results: More patients were overweight and obese in the psoriatic group compared to the control group (26.7% and 40% versus 11% and 8%), 5.3% of psoriatic patients who had stage 2 hypertension (defined as any blood pressure [BP] measurement higher than 99^th plus 5 mm of mercury applied to BP levels for boys and girls by age and height percentile charts), none of the control group was hypertensive, and the difference was statistically significant (p-value<0.05). A significantly higher proportion of the psoriatic patients had abnormal lipid profiles compared with the control group, 62% versus 30% (p<0.05), 15.3% versus 6.7% had elevated cholesterol (p<0.05), 24.7% versus 8% had raised low-density lipoprotein (LDL, p<0.05), 18% versus 8.6% had low high-density lipoprotein (HDL, p<0.05), and 12.6% versus 6% had elevated very-low-density lipoprotein (VLDL) and triglyceride (TG, p<0.05), 8% patients had elevated FBS (more than 100 mg per deciliter) versus 2.6% (p<0.05), and metabolic syndrome in 65 versus 2% (p<0.05). These changes were related to the severity of psoriasis.

Conclusions: Pediatric psoriatic patients in our population may have an atherogenic lipid profile with an increased prevalence of risk factors for cardiovascular diseases, especially those with moderate to severe psoriasis.

Four years stability of type D personality in patients with moderate to severe psoriasis and its implications for psychological impairment

Background

Psoriasis is a systemic auto-inflammatory disease that is related to an increased risk of organic and psychological comorbidities. Type D is a stable personality trait in healthy subjects but there is no data regarding its stability in patients with moderate-severe psoriasis.

Objectives

To assess the stability of type D personality in patients with moderate to severe psoriasis as well as assessing the influence of type D personality on anxiety and depression.

Methods

Prospective cohort study. Forty psoriasis patients with type D personality and sixty-six patients with psoriasis without type D personality were included in the study. Participants completed the DS14 test and HADS at baseline and four years later.

Results

At baseline, the prevalence of type D personality was 37.7% and at week 208 it was 27.3%. The stability of type D personality was higher in patients with an incomplete education level and in those who were separated/divorced or windowed. During follow-up, 15% of patients developed type D personality. Male sex, having topical treatment, the presence of previous depression, anxiety, and high levels of negative affectivity at baseline increase the risk of developing type D personality.

Study limitations

Sample size, psoriasis severity restricted to moderate and severe and all patients being under treatment for psoriasis.

Conclusions

The presence of type D personality varies over time in psoriasis patients. Therefore, type D personality is possibly more a state than a trait phenomenon, modified by environmental factors. Type D personality is associated with a higher risk of anxiety.

A New Classification of the Severity of Psoriasis: What's Moderate Psoriasis?

The purpose of this study is to propose a ranking system for the severity of psoriasis. The consensus method of selecting the indices to include and the classification of real patient profiles by an expert panel to create a gold standard of severity were used. The performance of potential cut-offs was evaluated to create a ranking algorithm. The combined use of PASI, BSA, and sPGA may allow the classification of the severity of psoriatic patients. The final algorithm identifies severe patients in a single step (2 out 3 are met: PASI ≥ 11 or BSA ≥ 10 or sPGA ≥ 3), while two steps are required for mild ((2 out 3 are met: PASI ≤ 3 or BSA ≤ 5 or sPGA ≤ 2) and DLQI < 5) and moderate forms (the patient does not meet 2 out 3 (PASI ≥ 11 or BSA ≥ 10 or sPGA ≥ 3) but has a DLQI ≥ 5. A ranking algorithm is presented, consisting of different measures of disease which classifies psoriatic patients into three categories: mild, moderate, and severe.

Nucleotide binding and oligomerization domain 2 in psoriasis: a clinical and immunohistochemical study

Psoriasis is a chronic immune-mediated inflammatory disease, affecting about 2 to 3% of the population worldwide. Nucleotide-binding and oligomerization domain 2-like receptor has been implicated in the pathogenesis of different inflammatory diseases. The current work aims to investigate the expression of nucleotide-binding and oligomerization domain 2-like receptor in psoriatic skin through an immunohistochemical study. This cross-sectional case-control study included 20 patients with chronic plaque psoriasis and 20 age- and sex-matched normal subjects as controls. Psoriasis severity was assessed through the use of Psoriasis Area Severity Index (PASI) score. Skin biopsies were taken under local anesthesia from cases and from matched sites of controls. Expression of nucleotide-binding and oligomerization domain 2 in epidermis of studied cases and controls showed positive epidermal expression of nucleotide-binding and oligomerization domain 2 in all cases (100%) versus 6 (30%) controls with a significant increase (χ2 = 21.54, P˂0.001). Moreover, dermal expression of nucleotide-binding and oligomerization domain 2 was higher in psoriatic skin lesion (95%) compared to controls (15%) with a significant difference (χ2 = 25.86, P˂0.001). We concluded that nucleotide-binding and oligomerization domain 2 may be implicated in psoriasis pathogenesis being higher in cases in comparison to controls.

Anti-Interleukin-17 Therapy of Severe Psoriatic Patients Results in an Improvement of Serum Lipid and Inflammatory Parameters' Levels, but Has No Effect on Body Composition Parameters

BACKGROUND

Psoriasis is frequently accompanied by metabolic syndrome. Effect of anti-tumor necrosis factor therapies on increases in body weight is well-known. Data on the effects of interleukin-17 inhibitors are limited. Authors determined the effect of anti-interleukin-17 therapies on the body composition and serum lipid and inflammatory parameters among severe psoriatic patients.

METHODS

Thirty-five severe psoriatic patients were enrolled. Twenty-two received secukinumab and 13 received ixekizumab as their 2nd-or 3rd-line biological treatment. Before treatment initiation and 6 months later, laboratory examinations measuring metabolic and inflammatory panels and body composition analyses were performed.

RESULTS

After 6 months, a significant reduction was observed in psoriasis area severity index (p < 0.001) from 18 to 0, in c-reactive protein (p < 0.001) from 6.6 to 4.00 mg/L, in low-density lipoprotein-cholesterol (p = 0.004) from 3.69 to 3.19 mmol/L, and an improvement in high-density lipoprotein-cholesterol (p = 0.022) from 1.31 to 1.40 mmol/L. Median baseline body mass index was 32.80 kg/m2. The body composition parameters did not show any significant changes.

CONCLUSIONS

Anti-interleukin-17 therapy of severe psoriatic patients does not cause significant changes in body composition parameters. Improvements in the lipid and inflammatory parameters might have a beneficial effect on patients' cardiometabolic status. This effect might be detectable in high-risk obese psoriatic patients.

Efficacy of dimethyl fumarate treatment for moderate-to-severe plaque psoriasis: presentation extracts from the 29th EADV virtual congress, 29-31 October 2020

Background: The 29th EADV Virtual Congress took place between the 29th-31st of October 2020. On October 29th, there was a Session on systemic treatment in which Professors Ulrich Mrowietz and Mar Llamas-Velasco presented the latest research on the efficacy of dimethyl fumarate (DMF) treatment for moderate-to-severe plaque psoriasis (BRIDGE and DIMESKIN 1 studies, respectively). The accepted DMF abstract from Professor Matthias Augustin, on the SKILL study, is also presented here. Results: Data from either prospective interventional (BRIDGE) or non-interventional (DIMESKIN 1, SKILL) studies among patients with moderate-to-severe psoriasis showed that DMF provides a positive efficacy profile in all four body regions included in the Psoriasis Area and Severity Index assessment (head and neck, trunk, upper and lower extremities) and a particularly interesting profile (strong efficacy) in the head and neck region. These findings may be of special interest to patients with scalp psoriasis who have been using topical therapies for a long time. Patient-reported outcomes (quality of life, pruritus) also improved during the 24 weeks of DMF treatment. The safety profile of DMF was similar to the previously described with fumaric acid esters. Conclusions: In summary, these results confirm the favorable efficacy and safety profile of DMF in long-term treatment.

Evaluation of patients diagnosed with psoriasis and multiple myeloma after autologous stem cell transplantation

INTRODUCTION

The secretion of monoclonal immunoglobulins increase in chronic inflammatory disorders such as chronic infections and autoimmune diseases. This risk is further increased by the biological agents used in the treatment of autoimmune diseases such as psoriasis. Hematological malignancies occurring in patients with psoriasis provides an opportunity to evaluate the effect of autologous or allogeneic stem cell transplantation in this immune-mediated disease.

CASES

Four patients diagnosed with psoriasis are presented, having undergone autologous bone marrow transplantation (ABMT), and eventually having remission of their psoriasis, after developing multiple myeloma during follow up. Psoriasis history of the patients was 20, 23, 2 and 2 years, respectively. All of them received peroral methotrexate or topical corticosteroid therapy. Time until myeloma diagnosis were 220, 144, 25, 18 months and follow-up after ABMT were 26, 19, 15, 22 months, respectively CONCLUSION: Psoriasis can be effectively treated with stem cell transplantation that is used in the treatment of malignancies. For this reason, stem cell transplantation can be considered as a treatment option in these patients, considering the benefit-to-harm ratio. However, uncertainty continues regarding the autologous or allogeneic application of stem cell transplantation.

Skin Barrier Function in Psoriasis and Atopic Dermatitis: Transepidermal Water Loss and Temperature as Useful Tools to Assess Disease Severity

Multiple diagnostic tools are used to evaluate psoriasis and atopic dermatitis (AD) severity, but most of them are based on subjective components. Transepidermal water loss (TEWL) and temperature are skin barrier function parameters that can be objectively measured and could help clinicians to evaluate disease severity accurately. Thus, the aims of this study are: (1) to compare skin barrier function between healthy skin, psoriatic skin and AD skin; and (2) to assess if skin barrier function parameters could predict disease severity. A cross-sectional study was designed, and epidermal barrier function parameters were measured. The study included 314 participants: 157 healthy individuals, 92 psoriatic patients, and 65 atopic dermatitis patients. TEWL was significantly higher, while stratum corneum hydration (SCH) (8.71 vs. 38.43 vs. 44.39 Arbitrary Units (AU)) was lower at psoriatic plaques than at uninvolved psoriatic skin and healthy controls. Patients with both TEWL > 13.85 g·m⁻²h⁻¹ and temperature > 30.85 °C presented a moderate/severe psoriasis (psoriasis area severity index (PASI) ≥ 7), with a specificity of 76.3%. TEWL (28.68 vs. 13.15 vs. 11.60 g·m⁻² h⁻¹) and temperature were significantly higher, while SCH (25.20 vs. 40.95 vs. 50.73 AU) was lower at AD eczematous lesions than uninvolved AD skin and healthy controls. Patients with a temperature > 31.75 °C presented a moderate/severe AD (SCORing Atopic Dermatitis (SCORAD) ≥ 37) with a sensitivity of 81.8%. In conclusion, temperature and TEWL values may help clinicians to determine disease severity and select patients who need intensive treatment.

Epidermal barrier changes in patients with psoriasis: The role of phototherapy

BACKGROUND

Some skin diseases may modify epidermal barrier function. Psoriasis is a chronic multi-systemic inflammatory disease that affects the epidermal barrier. Phototherapy is an option for treating psoriasis, but little is known about how epidermal barrier function is modified by phototherapy in psoriatic patients.

OBJECTIVES

(a) To compare skin homeostasis between involved and uninvolved skin in psoriatic patients with healthy controls (b) To evaluate changes in the epidermal barrier function in psoriatic patients treated with phototherapy.

METHODS

Sixty patients with plaque-type psoriasis and sixty gender and age-matched healthy controls were enrolled. Temperature, transepidermal water loss (TEWL), stratum corneum hydration (SCH), pH, elasticity, erythema and melanin index were measured using non-invasive tools in the healthy control and involved and uninvolved psoriatic skin before and after phototherapy.

RESULTS

Healthy controls had lower TEWL and erythema index and higher SCH than psoriatic patients, both at uninvolved psoriatic skin and psoriasis plaques. TEWL was higher at psoriasis plaques than at uninvolved skin (19.20 vs 11.57 g/h/m² ; P < .001). Following phototherapy, a decreasing trend was observed for TEWL, of 1.03 (SD 0.75) and 0.97 (SD 0.81) g/h/m² for uninvolved and involved skin respectively. SCH was significantly lower at psoriatic plaques than at uninvolved skin (7.32 vs 36.62Arbitrary Units [AU]; P < .001). SCH increased by 1.15AU (SD 0.26) on psoriatic plaques after the phototherapy session (P < .001).

CONCLUSION

Psoriatic plaques showed epidermal barrier dysfunction compared to uninvolved skin and healthy controls. Phototherapy may improve epidermal barrier function in psoriatic patients. SCH increased after a phototherapy session on the psoriatic plaques.

Paradoxical Psoriasis Induced by Anti-TNFα Treatment: Evaluation of Disease-Specific Clinical and Genetic Markers

Paradoxical psoriasis (PP) may occur during treatment with anti-tumor necrosis factor-alpha (TNF-α) drugs in various chronic immune-mediated diseases, mainly inflammatory bowel diseases (IBD) and psoriasis. In this study, clinical and genetic characteristics of PP arising in IBD and psoriatic patients were investigated to identify disease-specific markers of the paradoxical effect. A total of 161 IBD and psoriatic patients treated with anti-TNF-α drugs were included in the study. Of these patients, 39 developed PP. All patients were characterized for the main clinical–pathologic characteristics and genotyped for six candidate single nucleotide polymorphisms (SNPs) selected for their possible role in PP susceptibility. In IBD patients, the onset of PP was associated with female sex, presence of comorbidities, and use of adalimumab. IBD patients with PP had a higher frequency of the TNF-α rs1799964 rare allele (p = 0.006) compared with cases without the paradoxical effect, and a lower frequency of the human leucocyte antigen (HLA)-Cw06 rs10484554 rare allele (p = 0.03) compared with psoriatic patients with PP. Overall, these findings point to specific clinical and genetic characteristics of IBD patients with PP and provide data showing that genetic variability may be related to the paradoxical effect of anti-TNF-α drugs with possible implications into clinical practice.

SuPAR, a potential inflammatory mediator in psoriasis pathogenesis

Psoriasis is an inflammatory skin disorder that is strongly associated with the metabolic syndrome. The sole reliance on clinical examination to guide prognostication and treatment is insufficient at best; accurate diagnostic and prognostic psoriatic molecular biomarkers are needed. Soluble urokinase plasminogen activator receptor (suPAR) has been implicated in inflammation. The aim of this study is to determine whether suPAR plays a role in the pathogenesis of psoriasis and whether an association exists between suPAR levels, disease severity, and other variables like insulin, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). This study also compares the pattern of uPAR staining in healthy vs psoriatic skin: 39 psoriatic and 30 control subjects were included. Two biopsies (affected and unaffected skin) and one biopsy were taken from psoriasis patients and healthy controls, respectively, with uPAR staining of all skin biopsies. Blood samples from all subjects were obtained to determine suPAR, ESR, CRP, and fasting insulin levels. uPAR staining was prominent in unaffected skin from psoriasis patients and healthy individuals vs weak/absent uPAR staining in psoriatic skin. CRP, ESR and suPAR levels were not significantly elevated in the mild psoriasis group compared to healthy controls. The loss of epidermal uPAR is suggestive of its tentative role in the pathogenesis of psoriasis. Patients with mild-moderate psoriasis possibly lack the powerful association attributed to metabolic syndrome in psoriatic patients. Further studies on larger cohorts are needed to ascertain the validity of the mentioned conclusions.

The Use of Apremilast in Psoriasis: A Delphi Study

BACKGROUND

Experience in the use of apremilast in clinical practice complements the information available from pivotal clinical trials.

MATERIAL AND METHOD

Following a review of the literature, a panel of dermatologists with expertise in the management of psoriasis considered 5 scenarios in which the evidence supporting the use of apremilast to treat moderate psoriasis is insufficient or controversial. These scenarios were then assessed using a Delphi questionnaire.

RESULTS

Consensus was reached on 96 (67%) of the 143 items (positive in 85 and negative in 11). The therapeutic goal for apremilast should be based on 4 outcomes: clinical response, symptoms, quality of life, and patient satisfaction. The scenario in which the use of apremilast was considered to have the greatest possibility of success was in patients with stable moderate psoriasis. Most of the clinicians considered apremilast to be an appropriate treatment when conventional therapies fail or are contraindicated, preferably before the prescription of biologic therapy. Consensus was reached that apremilast is an appropriate treatment for psoriasis in difficult locations, such as the scalp or the palms and soles. It was also agreed that apremilast requires less prescreening and monitoring than other conventional and biologic systemic therapies.

CONCLUSIONS

Apremilast could be a treatment option for patients with a different profile to that of clinical trial participants. The limitations of this proposal are the absence of consensus on the definition of moderate psoriasis, the lack of real-world evidence on the use of apremilast, and certain aspects related to tolerability.

Validation of an Optical Pencil Method to Estimate the Affected Body Surface Area in Psoriasis

INTRODUCTION

Body surface area (BSA) affected by psoriasis is one of the most often used measures for assessing severity, but this method has shortcomings.

OBJECTIVE

To validate a new way to estimate BSA.

MATERIAL AND METHOD

Prospective, multicenter study in 56 patients with psoriasis. Each patient was evaluated by 2 dermatologists in 2 visits to the same hospital. Each dermatologist used 2 methods for estimating BSA: the traditional visual estimation in which the area of the palm equals 1% of the total body surface and an optical pencil (OP) method in which the affected area is drawn on a touch screen. Software in the application then calculates the BSA.

RESULTS

Overall concordance between the 2 methods was acceptable according to an intraclass correlation coefficient (ICC) of 0.87. However, the limits of agreement were unacceptably large and there was systematic bias: traditional estimates were consistently greater than OP calculations. Concordance between the methods was better (ICC>0.8) on the trunk and lower extremities. Intraobserver reliability was excellent with both methods (ICCs, 0.97 and 0.98 for the traditional and OP estimates, respectively). Interobserver reliability was also high (ICCs, 0.91 and 0.94 for the traditional and OP methods), although the mean BSA differed significantly between observers. The ICCs were much lower for BSA estimates on the head.

CONCLUSIONS

This study to validate the OP method for estimating the affected BSA in patients with psoriasis shows good agreement between the OP and traditional approaches. The OP calculations also showed less variance and better interobserver reliability.

Lesional upregulation of SLURP1 immunostaining parallels disease severity in psoriasis vulgaris patients

BACKGROUND AND OBJECTIVES

The exact pathogenesis of psoriasis is still unclear. SLURP1 is vital for the normal differentiation of keratinocytes, and could therefore be involved in psoriasis. In this study we investigated the immunohistochemical staining reaction of SLURP1 in psoriasis vulgaris patients and its possible relation to disease pathogenesis.

PATIENTS AND METHODS

20 patients with psoriasis vulgaris, 20 patients with psoriasiform dermatitis and 20 normal skin samples were studied. Psoriasis severity was measured with a combination of PASI and DLQI scores. Lesional and non-lesional sites were biopsied for each psoriasis patient. A single biopsy sample was taken for cases with psoriasiform dermatitis and for controls. All sections were immunostained for SLURP1 according to the manufacturer's protocol.

RESULTS

Significant differences were noted in SLURP1 immunostaining between lesional and non-lesional biopsies of psoriasis patients and between lesional biopsies of psoriasis patients and lesional sites of psoriasiform dermatitis. However, the differences between non-lesional biopsies of psoriasis patients and normal controls were not significant. Furthermore, the grading of SLURP1 immunostaining paralleled the degree of psoriasis severity.

CONCLUSIONS

SLURP1 immunostaining is significantly increased in lesional skin of psoriasis vulgaris and not in psoriasiform dermatitis, which demonstrates the role of SLURP1 in the pathogenesis of psoriasis. SLURP1 could be used as a biological marker for psoriasis severity, and this hypothesis warrants further investigation.

Hochregulation der SLURP1-Immunfärbung in Läsionen von Psoriasis-vulgaris-Patienten entspricht dem Schweregrad der Erkrankung

HINTERGRUND UND ZIELE

Die genaue Pathogenese der Psoriasis ist immer noch ungeklärt. Da SLURP1 wichtig ist für die normale Differenzierung von Keratinozyten, könnte es bei Psoriasis eine Rolle spielen. In dieser Studie untersuchten wir die immunhistochemische Färbung von SLURP1 bei Patienten mit Psoriasis vulgaris und deren möglichen Zusammenhang mit der Pathogenese der Erkrankung.

PATIENTEN UND METHODEN

Es wurden Hautproben von 20 Patienten mit Psoriasis vulgaris, von 20 Patienten mit psoriasiformer Dermatitis sowie 20 normale Hautproben untersucht. Der Schweregrad der Psoriasis wurde anhand einer Kombination von PASI- und DLQI-Scores gemessen. Bei allen Psoriasis-Patienten wurden Biopsate aus läsionalen und aus nichtläsionalen Hautpartien entnommen. Bei psoriasiformer Dermatitis und Kontrollen wurde jeweils nur ein Hautbiopsat entnommen. Alle Schnitte wurden, entsprechend des Hersteller-Protokolls, einer SLURP1-Immunfärbung unterzogen.

ERGEBNISSE

Hinsichtlich der SLURP1-Immunfärbung wurden zwischen läsionalen und nichtläsionalen Biopsaten von Psoriasis-Patienten sowie zwischen läsionalen Biopsaten von Psoriasis-Patienten und Patienten mit psoriasiformer Dermatitis signifikante Unterschiede festgestellt. Die Unterschiede zwischen nichtläsionalen Biopsaten von Psoriasis-Patienten und normalen Hautproben waren jedoch nicht signifikant. Darüber hinaus war der Grad der SLURP1-Immunanfärbung proportional zum Schweregrad der Psoriasis.

SCHLUSSFOLGERUNGEN

Bei Psoriasis vulgaris ist die SLURP1-Immunfärbung in läsionaler Haut signifikant erhöht, nicht jedoch bei psoriasiformer Dermatitis. Dies spricht für eine Rolle von SLURP1 bei der Pathogenese der Psoriasis. SLURP1 lässt sich möglicherweise als biologischer Marker für den Schweregrad der Psoriasis einsetzen, wobei diese Hypothese noch weiterer Untersuchungen bedarf.

Higher Psoriasis Skin Clearance Is Associated with Lower Annual Indirect Costs in the United States: A Post Hoc Analysis from the CLEAR Study

BACKGROUND

Psoriasis is associated with a high economic burden to society. New psoriasis systemic treatments offer the potential for improved skin clearance. Whether a higher degree of clearing translates into economic benefit through decreased work impairment has not been fully determined.

OBJECTIVE

To assess whether more complete clearing of psoriasis is associated with a reduction in disease-related indirect costs.

METHODS

Pooled data from employed patients included in the CLEAR study, a phase 3b study comparing the efficacy and safety of secukinumab (337 subjects) versus ustekinumab (339 subjects), were classified into 4 levels of skin clearance improvement at weeks 16 and 52: Psoriasis Area and Severity Index (PASI) improvement from baseline of < 50% (PASI < 50), 50%-74% (PASI 50-74), 75%-89% (PASI 75-89), and ≥ 90% (PASI ≥ 90). Patients completed the Work Productivity and Activity Impairment questionnaire for psoriasis (WPAI-PSO), which assessed absenteeism, presenteeism, and a composite overall work impairment over the previous 7 days at weeks 16 and 52. U.S. Department of Labor data were used to calculate annual indirect costs due to work productivity loss.

RESULTS

In the CLEAR study, 452 (67%) were employed at baseline and included in this analysis. At week 16, mean overall work impairment significantly decreased with higher PASI improvements: 22.8% for PASI < 50, compared with 13.3% for PASI 50-74 (P = 0.001); 6.4% for PASI 75-89 (P < 0.001); and 4.9% for PASI ≥ 90 (P < 0.001), with the majority of work impairment related to presenteeism. Calculated mean work hours lost by overall work impairment decreased with higher PASI improvements: 8.2 hours lost/week (429 hours/year) for patients with PASI 50; 4.6 hours lost/week (251 hours/year) for PASI 50-74; 2.3 hours lost/week (121 hours/year) for PASI 75-89; and 1.8 hours lost/week (93 hours/year) for PASI ≥ 90. Associated mean annual indirect costs due to work productivity loss per worker decreased with higher PASI improvements: $10,318 for PASI < 50, $6,042 for PASI 50-74, $2,901 for PASI 75-89, and $2,233 for PASI ≥ 90. Similar results were observed at week 52. Mean overall work impairment decreased with higher PASI improvements, ranging from 26.3% for PASI < 50 to 6.9% for PASI ≥ 90. A decrease in overall work hours lost (ranging from 9.5 hours lost/week [495 hours/year] for PASI < 50 to 2.5 hours/week [130 hours/year] for PASI ≥ 90), as well as associated annual indirect costs due to work productivity loss (ranging from $11,906 for PASI < 50 to $3,125 for PASI ≥ 90), were also shown with higher PASI improvements at week 52.

CONCLUSIONS

Among working patients with moderate to severe psoriasis, higher PASI improvements were associated with lower work productivity loss and reduced annual indirect costs. By improving and sustaining skin clearance, psoriasis treatments may contribute to increased work productivity and decreased societal economic burden.

DISCLOSURES

Funding for this study was provided by Novartis Pharmaceuticals. Zhao and Herrera are employed by Novartis. Gilloteau is employed by Novartis Pharma AG. McBride, Graham, and Miles are employed by RTI Health Solutions, which provides consulting and other research services to pharmaceutical, device, governmental, and nongovernmental organizations and received funding from Novartis for manuscript development, analysis development, and general consultation. Feldman reports grants and personal fees from Novartis, Abbvie, Janssen, Lilly, and Celgene, along with personal fees from Amgen and Valeant.