Taiwanese Dermatological Association consensus statement on management of psoriasis

Risk of thyroid diseases in patients with psoriasis: A systematic review and meta-analysis of cohort studies

Background:

An autoimmune etiology has been indicated for thyroid diseases. However, few studies have examined the association between psoriasis and thyroid diseases.

Objectives:

Explore the risk of thyroid disease in patients with psoriasis.

Methods:

We conducted a systematic review and meta-analysis of cohort studies to assess the risk of thyroid disease in patients with psoriasis. We searched PubMed, Cochrane Library, and EMBASE from their inception to April 4, 2024. Two authors independently selected the studies, assessed their quality, and extracted the data. Any disagreements were resolved through discussions with a third author. Risk ratio (RR) and 95% confidence intervals (CI) were used to present the results.

Results:

Three cohort studies were included. The risks of thyroiditis (RR: 1.74, 95% CI: 1.23–2.47), hyperthyroidism (RR: 1.22, 95% CI: 1.14–1.32), and hypothyroidism (RR: 1.42, 95% CI: 1.29–1.57) were higher among the patients with psoriasis than those in the control group.

Conclusion:

Individuals with psoriasis have a higher risk of developing thyroid disease. Further studies that provide data on different sex and age groups are needed to clarify whether any specific subgroup of patients with psoriasis has an elevated risk of developing thyroid disease.

Methotrexate did not add skin cancer risk in patients with psoriasis receiving narrowband ultraviolet B phototherapy: a nationwide retrospective cohort study

BACKGROUND

In the era of biologic therapy, phototherapy and methotrexate (MTX) are still commonly used for treatment in patients with moderate-to-severe psoriasis. However, the skin cancer risk following a combination of MTX and narrowband ultraviolet B (NB-UVB) has rarely been explored.

OBJECTIVES

To investigate whether MTX plus NB-UVB increases skin cancer risk in patients with psoriasis.

METHODS

We conducted a retrospective cohort study of data in the Taiwan National Health Insurance Research Database from 1997 to 2013. Cumulative incidences and multivariate analysis were investigated using a competing risk regression model, comparing skin cancer risk between cohorts of people having combination therapy and those using NB-UVB alone, matched for relative confounders. We further conducted a sensitivity analysis for those receiving a higher MTX dose. Standardized incidence ratios (SIRs) were calculated for skin cancer risk.

RESULTS

We enrolled 3203 participants in each cohort. No significant differences in skin cancers were noted between the two cohorts for the cumulative incidences (log-rank test, P = 0.28) and for the hazard ratio (HRs) [adjusted HR 0.50, 95% confidence interval (CI) 0.15-1.63, P = 0.247] in the competing risk regression model. There were also no significant differences between those receiving higher-dose MTX and UVB alone in the cumulative incidences of skin cancers (P = 0.23) and the HR (adjusted HR = 0.29, 95% CI 0.04-2.21, P = 0.23) in the multivariate analysis. There was no significant difference in the SIR between the two cohorts compared with the general population.

CONCLUSIONS

In the Taiwanese population, MTX does not increase skin cancer risk in patients with moderate-to-severe psoriasis receiving NB-UVB.

Epidemiological analysis of the patients with psoriasis in Asian countries and region using the same clinical case cards between 2020 and 2022

Although many epidemiological surveys for patients with psoriasis have been reported based on individual countries or facilities, there has been no study encompassing the major countries or the region in Asia. The Asian Society for Psoriasis (ASP) has been conducting an epidemiological study across various Asian countries and regions to elucidate the and compare the epidemiology of psoriasis. A total of 1948 cases were analyzed, with 938 cases from Japan, 530 cases from China, 325 cases from Korea, 141 cases from Chinese Taipei, and 14 cases from Thailand, all of which were enrolled between 2020 and 2022. In the Asian region total, the male-female ratio was 1.87:1 and the peak age at disease onset was 20-29 years. The proportion of psoriasis vulgaris (PsV), psoriatic arthritis (PsA), and pustular psoriasis (PP) was 80.1%, 17.7%, and 2.2%, respectively, and PsA was more commonly associated with nail symptoms than psoriasis vulgaris (PsV). Of the patients, 13% had a familial history of psoriasis and the most frequently affected family member was the father. Regarding treatment, 78.3% of the patients received topical medications, 9.0% underwent phototherapy, 34.0% received oral medications, and 36.1% were treated with biological agents. This study provided valuable information on the epidemiology and treatment of psoriasis using the registry data collected with the common reporting form in the same period in major Asian countries and regions. Male predominance is a distinctive feature of psoriasis in Asia. This epidemiological data registry in the ASP will continue afterwards.

2022 Taiwanese Dermatological Association (TDA), Taiwanese Association for Psoriasis and Skin Immunology (TAPSI), and Taiwan Society of cardiology (TSOC) joint consensus recommendations for the management of psoriatic disease with attention to cardiovascular comorbidities

Psoriatic disease is a chronic inflammatory disorder with skin and joint manifestations. Due to the persistent inflammatory state exhibited by patients with psoriasis, multiple systemic comorbidities occur more frequently in patients with psoriasis than in the general population, and the risk of cardiovascular (CV) diseases is significantly increased. As the pathophysiology of psoriatic disease is becoming better understood, the sharing of underlying pathogenic mechanisms between psoriatic and CV diseases is becoming increasingly apparent. Consequently, careful attention to CV comorbidities that already exist or may potentially develop is needed in the management of patients with psoriasis, particularly in the screening and primary prevention of CV disease and in treatment selection due to potential drug-drug and drug-disease interactions. Furthermore, as the use of effective biologic therapy and more aggressive oral systemic treatment for psoriatic disease is increasing, consideration of the potential positive and negative effects of oral and biologic treatment on CV disease is warranted. To improve outcomes and quality of care for patients with psoriasis, the Taiwanese Dermatological Association, the Taiwanese Association for Psoriasis and Skin Immunology, and the Taiwan Society of Cardiology established a Task Force of 20 clinicians from the fields of dermatology, cardiology, and rheumatology to jointly develop consensus expert recommendations for the management of patients with psoriatic disease with attention to CV comorbidities.

Topical Tirbanibulin, a Dual Src Kinase and Tubulin Polymerization Inhibitor, for the Treatment of Plaque-Type Psoriasis: Phase I Results

Plaque-type psoriasis is a common skin disorder. Tirbanibulin (KX01) is a new Src kinase inhibitor with potent antiproliferative activity against keratinocytes and has been approved for treatment of actinic keratosis. This Phase I study investigates the safety and activity of KX01 ointment in patients with plaque-type psoriasis. We recruited 28 patients from two medical centers in Taiwan. This study was performed in four stages. Double-blind treatments were randomized in stages I (KX01 0.01% + placebo, two rounds of two-week treatment) and II (KX01 0.1% + placebo, four weeks) and open-labelled in stages III (KX01 1%, five days) and IV (KX01 1%, five days weekly for four weeks). The safety, tolerability, KX01 concentration, target area score, physician global assessment, and disease relapse were determined. Most treatment-emergent adverse events were mild-to-moderate application site reactions. Three (50.0%) subjects from the stage IV group showed ≥50% reduction in the target area score (TAS50), while two subjects (33.3%) showed a clinically meaningful improvement in the physician global assessment score. KX01 0.01%, 0.1%, and 1% were safe and well-tolerated. KX01 1% at four weeks showed a promising activity for the treatment of plaque-type psoriasis.

Real-World Effects of Biologics on Renal Function in Psoriatic Patients: A Retrospective Study

BACKGROUND

Patients with severe psoriasis are prone to deterioration of renal function. Whether biologics with potent anti-inflammatory action can prevent deterioration of renal function in psoriatic patients was unclear.

OBJECTIVE

To investigate the effects of different biologics on renal function in patients with severe psoriasis.

METHODS

By using the Chang Gung Research Database in Taiwan during 2006-2018, we analyzed the changes in renal function of psoriatic patients from 2 years before biologic treatments to baseline (start of biologic treatment) to after 2 years' treatment with different classes of biologics (anti-TNF, anti-IL-12/23, and anti-IL-17 agents). The renal function was evaluated by estimated glomerular filtration rate (eGFR) and the staging of chronic kidney disease (CKD). We further analyzed the risk factors of progression on the staging of CKD during biologics treatment.

RESULTS

We included 601 patients with severe psoriasis receiving continuous use of biologics for ≥ 2 years. We detected no significant differences between pre-biologic treatment with conventional systemic treatment and post-biologic treatment in the levels of eGFR and progression of CKD staging among psoriatic patients receiving different classes of biologics. Most patients (97.8%) remained at stable CKD stage, while progression of CKD stage over time occurred in 13 patients (2.2%), with seven treated with anti-TNF biologics and six treated with anti-IL-12/23 biologics. Of note, all 52 patients receiving anti-IL-17 biologics had stable CKD. Progression of CKD during biologics use was associated with lower baseline levels of eGFR, higher baseline CKD stage, older age, diabetes, and dyslipidemia. Further multiple logistic regression analysis showed diabetes as an independent factor for the deterioration of renal function during biologic treatment.

CONCLUSIONS

Biologic treatments failed to improve but did not worsen renal function of psoriatic patients during a 2-year follow-up period. Diabetes is an important risk factor for the deterioration of renal function.

Persistence and Adherence to Biologics in Patients with Psoriasis in Taiwan: A New Biologics User Cohort Study

Background: Biologics are used to treat moderate-to-severe psoriasis, and persistence to biologics may reflect clinical effectiveness. Limited information describing how biologics are used in patients with moderate-to-severe psoriasis in Asian countries is available. We conducted a population-based, retrospective, new user cohort study using the National Health Insurance Research Database (NHIRD) in Taiwan to assess treatment persistence and adherence to biologics. Methods: Adults with a diagnosis of psoriasis between 01 January 2015 and 31 December 2017 were identified in the NHIRD (ICD-9-CM 696.1; ICD-10 L40.0). New users were patients who initiated treatment with etanercept, adalimumab, ustekinumab or secukinumab between 01 January 2015 and 31 December 2017. All eligible patients were followed until 31 December 2018, death or disenrollment. Kaplan-Meier analysis was conducted to estimate persistence of treatment for index biologics. A Cox-proportional hazard regression model was used to compare risks of biologic discontinuation between biologic groups. Adjustments for potential confounding factors (age, gender and Charlson comorbidity index score) were made in the Cox model. Results: There were 1,397 new biologic users with psoriasis during the study period. The ratio men:women was approximately 4:1. Mean age of patients ranged from 44.6 to 47.7 years across exposure groups. The 1-year/2-years persistence rates were 94.2%/84.9% for ustekinumab, 96.2%/not calculated (due to too few patients at year 2) for secukinumab, 66.0%/29.9% for etanercept, and 59.8%/40.3% for adalimumab. The risk of discontinuation was significantly lower in patients initiating ustekinumab compared with adalimumab (hazard ratio adjusted for age, sex and co-morbidities 0.289, 95%CI 0.247-0.339, p < 0.0001). Drug survival was significantly higher for ustekinumab compared with adalimumab and etanercept (log-rank test p < 0.0001). The proportions of patients with 1-year/2-years medication possession ratios of ≥80% were 95.3%/92.0% for ustekinumab, 98.1%/not calculated for secukinumab, 89.4%/83.1% for etanercept, and 70.8%/59.4% for adalimumab. Limitations: Clinical improvement and response to treatment data were not available. Conclusion: There was relatively high persistence amongst biologic users with psoriasis in Taiwan. There is a trend towards greater persistence of ustekinumab compared to other biologics, the magnitude of which depends on the treatment gap used for its calculation. This study provides real-world evidence that may facilitate optimal treatment choice.

Uncovering the unmet needs among psoriasis patients in the Asia-Pacific region

Studies on the psychosocial and emotional burden of psoriasis have been extensive; however, there is limited knowledge and awareness of patients’ attitude and behavior towards psoriasis treatment. To understand psoriasis patients’ attitude and behavior towards treatment of psoriasis, especially those treated with biologics, a multi‐stage study qualitative and quantitative methodology was conducted among psoriasis patients. An online survey was conducted with 45 moderate‐to‐severe psoriasis patients each in Australia, Japan, South Korea, and Taiwan for 20 min. This was followed by qualitative in‐depth interviews conducted among psoriasis patients in Australia (n = 3) and Japan (n = 2) for 60 min. All of the findings were workshopped with key opinion leaders and patient advisory groups to identify potential solutions addressing patients’ unmet needs. Five common insights were identified across the region, highlighting patients’ attitude and behavior towards psoriasis treatment, especially for those treated with biologics. These insights comprised the following: (i) one of the key factors driving patients’ treatment choice included their ability to enjoy clear skin for longer period (68%); (ii) bio‐maintenance patients had a higher expectation (4.9 months) of how long their skin could stay clear, compared to their pre‐biologics initiation days (2.9 months); (iii) once a good response is achieved, bio‐maintenance patients were more concerned about symptoms returning (44%) than development of side‐effects (19%); (iv) bio‐maintenance patients felt psychologically and physically affected during flare‐ups despite being on more efficacious treatment; and (v) bio‐maintenance patients still felt they were at risk of flare‐ups (4.5/7), almost similar risk perception as non‐biologics patients (4.9/7). Findings from this study showed that psoriasis patients look for treatment with the least risk of flare‐ups so that they were able to enjoy clear skin for a long time.

Recommendations for psoriatic arthritis management: A joint position paper of the Taiwan Rheumatology Association and the Taiwanese Association for Psoriasis and Skin Immunology

In Taiwan, the incidence and prevalence of psoriatic arthritis (PsA) have risen significantly in recent years. Moreover, data from the Taiwan National Health Insurance Research Database (NHIRD) show that more than 85% of PsA patients are treated with just non-steroidal anti-inflammatory drugs (NSAIDs) and/or conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). Taiwanese clinicians have also expressed concerns regarding uncertainties in the diagnosis of PsA and the delayed, interrupted, and/or tapered use of biologics, as well as differences in therapeutic preferences between and within dermatologists and rheumatologists. To address these issues, the Taiwan Rheumatology Association and the Taiwanese Association for Psoriasis and Skin Immunology jointly convened a committee of 28 clinicians from the fields of rheumatology, dermatology, orthopedics, and rehabilitation, to develop evidence-based consensus recommendations for the practical management of PsA in Taiwan. A total of six overarching principles and 13 recommendations were developed and approved, as well as a treatment algorithm with four separate tracks for axial PsA, peripheral PsA, enthesitis, and dactylitis. Psoriasis (PsO) management was not discussed here, as the Taiwanese Dermatological Association has recently published a comprehensive consensus statement on the management of PsO. Together, these recommendations provide an up-to-date, evidence-based framework for PsA care in Taiwan.

Real-world efficacy of biological agents in moderate-to-severe plaque psoriasis: An analysis of 75 patients in Taiwan

Background

Real-world clinical data on psoriasis patients receiving different biological agents is needed, especially in Asian populations.

Objectives

Our aim is to compare and analyze the efficacy and safety profile of four biological agents (etanercept, adalimumab, ustekinumab and secukinumab) in a real-world setting in Taiwan.

Methods

We retrospectively analyzed the clinical data of all patients with moderate-to-severe plaque psoriasis (Psoriasis Area and Severity Index (PASI) ≥ 10) who received etanercept, adalimumab, ustekinumab or secukinumab between January 2011 and December 2018 in a tertiary hospital in Taiwan.

Results

A total of 119 treatment episodes in 75 patients were included in this study. Ustekinumab was used in 49 treatment episodes, followed by secukinumab in 46 treatment episodes, adalimumab in 14 treatment episodes and etanercept in 10 treatment episodes. The proportion of the biologic-naïve was highest in etanercept (100%) and lowest in secukinumab (23.9%). The PASI-75, -90 and -100 were the highest in secukinumab (91.3%, 82.6%, 41.3%, respectively), followed by ustekinumab (79.6%, 44.9%, 16.3%), adalimumab (64.3%, 28.6%, 7.1%) and etanercept (50.0%, 30.0%, 0%). The rate of adverse events that required treatment was highest for secukinumab (15.2%), followed by adalimumab (14.3%), ustekinumab (8.2%), and etanercept (0%), including 4 cases of infections, 2 cases of cardiovascular diseases and 4 cases of cancers.

Conclusions

This real world data showed differential efficacy and safety of the four biological agents.

Risk for Suicidal Behavior Among Psoriasis Patients: A Nationwide Cohort Study

BACKGROUND

The link between psoriasis and suicidality remains elusive and understudied.

OBJECTIVE

The aim was to assess the risk of suicidal behavior in psoriasis patients.

METHODS

We used Taiwan's National Health Insurance Research Database to conduct a nationwide retrospective cohort study to examine the risk for suicidal behavior among psoriasis patients. We performed subgroup analyses based on the severity of psoriasis and psoriatic arthritis.

RESULTS

We included 169,909 psoriasis patients (including 13,959 with concomitant psoriatic arthritis and 155,950 with psoriasis alone) and 169,909 matched nonpsoriasis controls. Suicidal behavior occurred in 104 and 89 subjects in the psoriasis group and nonpsoriasis controls, respectively; we found no significantly increased risk for suicidal behavior among psoriasis patients when compared to nonpsoriasis controls [adjusted hazard ratio (HR) 1.17, 95% confidence interval (CI) 0.88‒1.55]. The subgroup analysis showed no significantly increased risk for suicidal behavior in both the severe psoriasis group (adjusted HR 0.92, 95% CI 0.51-1.64) and the mild psoriasis group (adjusted HR 1.26, 95% CI 0.91‒1.75) when compared to nonpsoriasis controls. Also, we found no significant increased risk for suicidal behavior in the group of psoriasis patients who also had psoriatic arthritis (adjusted HR 2.00, 95% CI 0.68‒5.85) and in the group of patients with psoriasis alone (adjusted HR 1.12, 95% CI 0.83‒1.50) when compared to nonpsoriasis controls.

CONCLUSION

In a Taiwanese setting, no link between psoriasis or psoriatic arthritis and suicidal behavior was detected.

Temporal Correlations of Skin and Blood Metabolites with Clinical Outcomes of Biologic Therapy in Psoriasis

BACKGROUND

Psoriasis is an inflammatory skin disease causing multisystem effects. Introduction of biologic drugs has led to promising results in treatment of this disease. Here, we carry out time-dependent profiling of psoriasis-related putative metabolic biomarkers.

METHODS

Skin excretion specimens were collected from 17 patients with psoriasis treated with biologics for 7 months. Blood specimens were obtained from the same patients at intervals of 1-3 months. A hydrogel micropatch sampling technique was implemented to collect lesional (L) and nonlesional (NL) skin specimens. The collected skin and blood specimens were analyzed by mass spectrometric methods.

RESULTS

The metabolites present on L skin-in particular, choline, and citrulline-showed greater dynamics, corresponding to the resolution of psoriasis than the metabolites present in NL skin or blood. Choline levels in L skin and blood correlated positively, while citrulline correlated negatively with the severity of individual psoriasis plaques and general disease severity, respectively. Nevertheless, the correlations between the metabolite levels in blood and general disease severity were weaker than those between the metabolite levels on L skin and severity of individual plaques. The changes of these skin metabolites were more prominent in the responders to the treatment than in the nonresponders.

CONCLUSIONS

The results support the feasibility of characterizing dynamic changes in psoriatic skin metabolic profiles with the hydrogel micropatch probes and mass spectrometric tests. The study represents one of few attempts to explore relationships between skin and blood metabolite concentrations. However, practical use of the methodology in close clinical monitoring is yet to be demonstrated.

Remission Duration and Long-Term Outcomes in Patients with Moderate-to-Severe Psoriasis Treated by Biologics or Tofacitinib in Controlled Clinical Trials: A 15-Year Single-Center Experience

INTRODUCTION

Relapse is common after treatment discontinuation for patients with moderate-to-severe psoriasis. The objective of this study was to understand the remission duration and long-term outcomes in psoriasis patients after biologic withdrawal.

METHODS

We retrospectively included the follow-up data of 184 patients with moderate-to-severe psoriasis after the end of 11 biologic or tofacitinib trials conducted between 2004 and 2016.

RESULTS

Among the 232 treatment courses, 95 achieved (psoriasis area and severity index) PASI 75 at the end of the studies. At 6 months after treatment discontinuation, the systemic treatment-free rates of our patients who entered the PRESTA, PRISTINE, PEARL, ERASURE, CLEAR, the global tofacitinib study, and the IXORA-P study were 66.7%, 66.7%, 75.0%, 16.7%, 22.2%, 33.3%, and 29.2%, respectively. Pooled data showed a serious adverse event incidence rate of 1.5/100 person-years. The proportions of systemic treatment-free episodes were 16.8%, 7.4%, 4.3%, 3.2%, and 3.2% at 1, 2, 3, 4, and 5 years, respectively. Biologics were reinitiated in 41.9%, 66.7%, 77.1%, 83.5%, and 86.1% at 1, 2, 3, 4, and 5 years, respectively. Multivariate generalized estimating equation (GEE) regression analysis demonstrated that predictors for a longer relapse-free duration were baseline PASI, PASI improvement, biologic naivety, and early biologic intervention. Patients who received early biologic intervention, who achieved PASI 90, and who were biologic naive showed significantly higher relapse-free rate by Kaplan-Meier analysis with log rank test.

CONCLUSIONS

Systemic treatment was required in 86.1% of patients within 12 months after biologic withdrawal and biologics were reinitiated in 77.1% of patients after 3 years. However, early biologic administration within 2 years after diagnosis demonstrated a lower risk of relapse in patients with moderate-to-severe psoriasis.

Lifestyle changes for treating psoriasis

BACKGROUND

Psoriasis is an inflammatory skin disease that presents with itching, red, scaling plaques; its worsening has been associated with obesity, drinking, smoking, lack of sleep, and a sedentary lifestyle. Lifestyle changes may improve psoriasis.

OBJECTIVES

To assess the effects of lifestyle changes for psoriasis, including weight reduction, alcohol abstinence, smoking cessation, dietary modification, exercise, and other lifestyle change interventions.

SEARCH METHODS

We searched the following databases up to July 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched the China National Knowledge Infrastructure, the Airiti Library, and five trials registers up to July 2018. We checked the references of included trials for further relevant trials, and we asked the authors of the included trials if they were aware of any relevant unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of lifestyle changes (either alone or in combination) for treating psoriasis in people diagnosed by a healthcare professional. Treatment had to be given for at least 12 weeks. Eligible comparisons were no lifestyle changes or another active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcome measures were 'Severity of psoriasis' and 'Adherence to the intervention'. Secondary outcomes were 'Quality of life', 'Time to relapse', and 'Reduction in comorbidities'. We used GRADE to assess the quality of the evidence for each outcome.

MAIN RESULTS

We included 10 RCTs with 1163 participants (mean age: 43 to 61 years; 656 men and 478 women were reported). Six trials examined the effects of dietary intervention (low-calorie diet) in 499 obese participants (mean age: 44.3 to 61 years; where reported, 395 had moderate-to-severe psoriasis). One trial assessed a combined dietary intervention and exercise programme in 303 obese participants with moderate-to-severe psoriasis who had started a systemic therapy for psoriasis and had not achieved clearance after four weeks of continuous treatment (median age: 53 years). Another trial assessed a walking exercise and continuous health education in 200 participants (mean age: 43.1 years, severity not reported). Finally, two trials included education programmes promoting a healthy lifestyle in 161 participants (aged 18 to 78 years), with one trial on mild psoriasis and the other trial not reporting severity.Comparisons included information only; no intervention; medical therapy alone; and usual care (such as continuing healthy eating).All trials were conducted in hospitals and treated participants for between 12 weeks and three years. One trial did not report the treatment period. Seven trials measured the outcomes at the end of treatment and there was no additional follow-up. In two trials, there was follow-up after the treatment ended. Five trials had a high risk of performance bias, and four trials had a high risk of attrition bias.We found no trials assessing interventions for alcohol abstinence or smoking cessation. No trials assessed time to relapse. Only two trials assessed adverse events; in one trial these were caused by the add-on therapy ciclosporin (given in both groups). The trial comparing two dietary interventions to a no-treatment group observed no adverse events.The results presented in this abstract are based on trials of obese participants.Outcomes for dietary interventions versus usual care were measured 24 weeks to six months from baseline. Compared to usual care, dietary intervention (strict caloric restriction) may lead to 75% or greater improvement from baseline in the Psoriasis Area and Severity Index (PASI 75) (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.07 to 2.58; 2 trials, 323 participants; low-quality evidence). Adherence to the intervention may be greater with the dietary intervention than usual care, but the 95% CI indicates that the dietary intervention might also make little or no difference (RR 1.26, 95% CI 0.76 to 2.09; 2 trials, 105 participants; low-quality evidence). Dietary intervention probably achieves a greater improvement in dermatology quality-of-life index (DLQI) score compared to usual care (MD -12.20, 95% CI -13.92 to -10.48; 1 trial, 36 participants; moderate-quality evidence), and probably reduces the BMI compared to usual care (MD -4.65, 95% CI -5.93 to -3.36; 2 trials, 78 participants; moderate-quality evidence).Outcomes for dietary interventions plus exercise programme were measured 16 weeks from baseline and are based on one trial (303 participants). Compared to information only (on reducing weight to improve psoriasis), combined dietary intervention and exercise programme (dietetic plan and physical activities) probably improves psoriasis severity, but the 95% CI indicates that the intervention might make little or no difference (PASI 75: RR 1.28, 95% CI 0.83 to 1.98). This combined intervention probably results in a greater reduction in BMI (median change -1.10 kg/m², P = 0.002), but there is probably no difference in adherence (RR 0.95, 95% CI 0.89 to 1.01; 137/151 and 145/152 participants adhered in the treatment and control group, respectively). There were no data on quality of life. These outcomes are based on moderate-quality evidence.

AUTHORS' CONCLUSIONS

Dietary intervention may reduce the severity of psoriasis (low-quality evidence) and probably improves quality of life and reduces BMI (moderate-quality evidence) in obese people when compared with usual care, while combined dietary intervention and exercise programme probably improves psoriasis severity and BMI when compared with information only (moderate-quality evidence). None of the trials measured quality of life.We did not detect a clear difference in treatment adherence between those in the combined dietary intervention and exercise programme group and those given information only (moderate-quality evidence). Adherence may be improved through dietary intervention compared with usual care (low-quality evidence). Participants generally adhered well to the lifestyle interventions assessed in the review.No trials assessed the time to relapse. Trial limitations included unblinded participants and high dropout rate.Future trials should reduce dropouts and include comprehensive outcome measures; they should examine whether dietary intervention with or without an exercise programme is effective in non-obese people with psoriasis, whether an additional exercise programme is more effective than dietary intervention alone, whether the time to relapse prolongs in people who receive dietary intervention with or without exercise programme, and whether smoking cessation and alcohol abstinence are effective in treating psoriasis.

The incidence of anxiety may not be correlated with severity of psoriasis: A prospective pilot study

Psoriasis is associated with certain psychiatric disorders such as anxiety and depression. Although a growing body of literature has indicated high prevalence of anxiety in patients with psoriasis, it is unclear if the incidence of anxiety is correlated with severity of psoriasis. In this article, we hypothesize that anxiety is not correlated with severity of psoriasis, and therefore the issue of anxiety should not be neglected in patients with mild psoriasis. To testify this hypothesis, we performed a pilot study to investigate the correlation between anxiety questionnaires and severity of psoriasis. Thirty-two patients with psoriasis were recruited. The patients were further classified into mild or moderate to severe psoriasis according to their body surface area or Psoriasis Area Severity Index (PASI). Zung's self-rating anxiety scale (SAS) and SF-36 were adopted to evaluate anxiety and quality of life, respectively. Spearman's rank correlation coefficients were calculated between SAS and each scale of SF-36 among these 32 patients. SAS is negatively correlated with role limitation due to emotional problems, vitality, emotional well-being of SF-36. Although SAS is not significantly different between mild and moderate to severe psoriasis, the detected levels of anxiety were higher than normative standards. Physicians should not neglect potential anxiety in patients who have mild psoriasis. Inter-discipline collaboration between psychiatry and dermatology is required to provide comprehensive patient care.

Effectiveness and safety of secukinumab for psoriasis in real-world practice: analysis of subgroups stratified by prior biologic failure or reimbursement

Background:

Little is known about the treatment outcomes of secukinumab in clinical practice, which differ from those in clinical trials. The effectiveness of biologics may differ in psoriasis patients with previous biologics exposure. The objective of this study was to investigate the real-world effectiveness and safety of secukinumab therapy and analyze subgroups stratified by reimbursement or prior biologic failure.

Methods:

This retrospective multicenter study collected data from a cohort of 118 consecutive patients who received secukinumab treatment between December 2015 and March 2018. Effectiveness was evaluated by degree of improvement in the Psoriasis Area and Severity Index (PASI) scores. Adverse events and reasons for discontinuation were also recorded.

Results:

The mean PASI improvement rate at weeks 4, 12, 24, and 36 was 63.5%, 77.7%, 78.7%, and 76.0%, respectively. Compared with reimbursed patients, nonreimbursed patients had a significantly lower baseline PASI and a shorter mean disease duration of psoriasis; they were more frequently biologic-naïve, had used less prior traditional antipsoriatic drugs and were more likely to be treated with secukinumab 150 mg. The effectiveness of secukinumab in nonreimbursed patients was superior despite higher discontinuation rates. Compared with patients without prior biologic failure, patients with prior biologic failure had a significantly lower mean PASI improvement at weeks 12, 24, 36, and 48. The decline in response rates to secukinumab tended to be more pronounced for patients who failed ustekinumab than tumor necrosis factor-α inhibitors. Moreover, the number of prior biologic failures was associated with a decreased response rate and increased likelihood of secondary loss of effectiveness of secukinumab therapy.

Conclusion:

In a real-life clinical setting, the characteristics of nonreimbursed patients receiving secukinumab treatment differed from those of reimbursed patients. The PASI improvement for secukinumab was substantial but lower than that in clinical trials. The number and classes of prior biologic failures impact the treatment response to secukinumab.

Association of Multiple Sclerosis with Psoriasis: A Systematic Review and Meta-Analysis of Observational Studies

BACKGROUND

Previous studies have reported the occurrence of psoriasis together with multiple sclerosis (MS). Although similar predisposing genes and pathomechanisms have been hypothesized, the relationship between the two remains obscure.

OBJECTIVE

The aim of this systematic review and meta-analysis was to investigate the association between psoriasis and MS.

METHODS

We searched MEDLINE, Embase, and CENTRAL in July 2018 for case-control, cross-sectional, or cohort studies that examined either the odds or risk of psoriasis in subjects with multiple sclerosis. The risk of bias of included studies was assessed using the Newcastle-Ottawa Scale. A random-effects model meta-analysis was used to calculate the odds ratio (OR) for case-control/cross-sectional studies and hazard ratio (HR) for cohort studies.

RESULTS

We included 10 publications that reported a total of 11 studies (5 case-control, 4 cross-sectional and 2 cohort studies). The case-control and cross-sectional studies included 18,456 MS patients and 870,149 controls, while the two cohort studies involved 25,187 MS patients and 227,225 controls in total. Three studies were rated with a high risk of bias in comparability, non-response rate, and selection of controls. MS was associated with increased odds (OR 1.29; 95% confidence interval [CI] 1.14-1.45) and risk for psoriasis (HR 1.92; 95% CI 1.32-2.80).

CONCLUSION

Patients with MS display both increased prevalence and incidence of psoriasis.

Risk of skin cancer in psoriasis patients receiving long-term narrowband ultraviolet phototherapy: Results from a Taiwanese population-based cohort study

BACKGROUND

Narrowband ultraviolet B (NB-UVB) phototherapy is a widely used treatment for various dermatoses. The risk of skin cancer following long-term NB-UVB phototherapy has rarely been explored in skin phototypes III-V.

METHODS

We conducted a nationwide-matched cohort study and identified a total of 22 891 psoriasis patients starting NB-UVB phototherapy from the Taiwan National Health Insurance Database during the period 2000-2013. Cumulative incidences of skin cancers were compared between subjects receiving less than 90 UVB treatments (S-cohort, N = 13 260) and age- as well as propensity score-matched subjects receiving more than or equal to 90 UVB treatments (L-cohort, N = 3315).

RESULTS

There were no significant differences in the overall cumulative incidences of skin cancers between the two cohorts (log-rank t test, P = 0.691) during the follow-up periods. The S-cohort had a significantly lower prevalence of actinic keratosis when compared with the L-cohort (0.54% vs 1.00%, P = 0.005).

CONCLUSION

Long-term NB-UVB phototherapy does not increase skin cancer risk compared with short-term NB-UVB phototherapy in psoriasis patients with skin phototypes III-V.

Drug survival of biologics in treating psoriasis: a meta-analysis of real-world evidence

Drug survival of biologics represents their real-world effectiveness and safety. We conducted a meta-analysis of real-world evidence on the drug survival of biologics in treating psoriasis. We searched the PubMed, CENTRAL, and EMBASE databases from inception to 7th October 2017 for studies reporting the annual drug survival for at least 1 year. Two authors independently screened and selected relevant studies, and assessed their risk of bias. A third author was available for arbitrating discrepancies. We conducted a random-effects model meta-analysis to obtain the respective pooled drug survival from year 1 to 4. We conducted subgroup analysis on biologic-naïve subjects, discontinuation for loss of efficacy and adverse effects. We included 37 studies with 32,631 subjects. The drug survival for all biologics decreased with time, dropping from 66% at year 1 to 41% at year 4 for etanercept, from 69% to 47% for adalimumab, from 61% to 42% for infliximab, and from 82% to 56% for ustekinumab. Ustekinumab was associated with the highest drug survival in all and biologic-naïve subjects. Etanercept was associated with the lowest drug survival and was most commonly discontinued for loss of efficacy. Infliximab was most frequently associated with discontinuation for adverse effects. Clinicians may use this study as a reference in treating psoriasis.

Risk of Suicidality in People with Psoriasis: A Systematic Review and Meta-Analysis of Cohort Studies

BACKGROUND

Psoriasis has been associated with psychiatric disorders such as depression and anxiety, but its relationship with suicidality (including suicide, suicide attempt, and suicidal ideation) is unclear.

OBJECTIVE

Our objective was to assess the risk of suicide, suicide attempt, suicidal ideation, and suicidality in people with psoriasis.

METHODS

We conducted a systematic review and meta-analysis of cohort studies examining the risk of suicide, suicide attempt, suicidal ideation, and suicidality in people with psoriasis. We searched the Cochrane Library, PubMed, and EMBASE from inception to 24 March 2017. Two authors independently selected studies, assessed the quality of included studies, and extracted data. Any disagreement was resolved by discussion with a third author.

RESULTS

Five population-based cohort studies were included and considered to be of high quality. We found no increase in the risk of suicide (risk ratio [RR] 1.13; 95% confidence interval [CI] 0.87-1.46), suicide attempt (RR 1.25; 95% CI 0.89-1.75), or suicidality (RR 1.26; 95% CI 0.97-1.64) among people with psoriasis. In the stratified analysis, we also found no increase in suicide, suicide attempt, and suicidality among people with either severe or mild psoriasis.

CONCLUSIONS

The available limited, very low-quality evidence does not support an association between psoriasis and suicidal thought and behavior. Further studies that provide data for different age and sex groups are needed to clarify whether a subgroup of patients with psoriasis has an elevated risk of suicidality.