Guidelines of care for the management of psoriasis and psoriatic arthritis

Prospective Clinical Study: Full-Body Blue Irradiation in the Treatment of Atopic Dermatitis

INTRODUCTION

Ultraviolet-free (UV-free) blue light phototherapy has emerged as a promising option due to its reported efficacy and minimal adverse effects. This study aims to evaluate the effectiveness of full-body blue light irradiation in both adult and pediatric patients with atopic dermatitis (AD), assessing its impact on skin condition and mood regulation by investigating serum concentrations of serotonin and kynurenine pathway metabolites.

METHODS

20 patients (age 9-45) with moderate and severe AD were included in the study. Treatment consisted of 10 irradiations with Full Body Blue device (453 nm). Serum concentrations of serotonin, quinolinic acid, kynurenic acid, tryptophan, and kynurenine were measured before and after irradiations.

RESULTS

After 10 sessions of full blue light therapy (453 nm) statistically significant improvements were observed in Eczema Area Severity Index (EASI 13.16 vs. 8.65; p = 0.00016), SCORing Atopic Dermatitis (SCORAD 44.99 vs. 23.73; p < 0.00001), Visual Analogue Scale (VAS 6.53 vs. 3.95; p = 0.00251), 10-item pruritus severity scale (13.32 vs. 7.05; p < 0.00001). Moreover, statistically significant decrease in Dermatology Life Quality Index (DLQI) was noted (14.37 vs. 7.42; p = 0.00351). Additionally, increase in the serum concentration of serotonin was observed after completing 10 irradiation sessions (median 139.77 mg/ml vs. 274.92 mg/ml; p < 0.00001).

CONCLUSION

Blue light may be a promising and safe treatment in patients with AD. It might also positively influence mood. Further investigations are needed to confirm those findings.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT06516783.

Comparison of adalimumab with methotrexate for psoriasis: A meta-analysis of randomized controlled studies

INTRODUCTION

The efficacy of adalimumab versus methotrexate for psoriasis remained controversial. We conducted this systematic review and meta-analysis to explore the influence of adalimumab versus methotrexate on treatment efficacy for psoriasis patients.

METHODS

We have searched PubMed, EMbase, Web of Science, EBSCO, and Cochrane Library databases through August 2023 for randomized controlled trials (RCTs) assessing the efficacy of adalimumab versus methotrexate for psoriasis. This meta-analysis was performed using the random-effect or fixed-effect model based on the heterogeneity.

RESULTS

Four RCTs and 733 patients with psoriasis were included in this meta-analysis. Overall, compared with methotrexate treatment, adalimumab treatment was associated with improved Psoriasis Area and Severity Index 75 (PASI 75, odd ratio [OR] = 4.50; 95% confidence interval [CI] = 2.81-7.22; P < .00001), physician global assessment (PGA) 0/1 response (OR = 4.86; 95% CI = 3.02-7.82; P < .00001), PASI 100 (OR = 3.01; 95% CI = 1.33-6.80; P = .008) and decreased Dermatology Life Quality Index (DLQI, standard mean difference [SMD] = -0.60; 95% CI = -0.84 to -0.36; P < .00001), but exhibited no impact on PASI 90 (OR = 3.30; 95% CI = 0.77-14.20; P = .11), adverse events (OR = 1.23; 95% CI = 0.26-5.87; P = .79) or serious adverse events (OR = 2.59; 95% CI = 0.49-13.79; P = .26).

CONCLUSIONS

Adalimumab was superior to methotrexate for the treatment of psoriasis.

Adjunctive treatment of atopic dermatitis with novel at-home handheld narrow-band UVB phototherapy

While conventional in-office phototherapy has long been utilized as a successful treatment for atopic dermatitis (AD), it is associated with potential barriers including inconvenience, poor adherence, time and financial expense. In this retrospective study, we examine the efficacy, adherence, and patient-satisfaction of using adjunctive at-home, self-administered phototherapy utilizing a novel handheld narrow-band ultraviolet B (NB-UVB) device for the treatment of refractory mild to severe AD. Included AD patients were initially trained on proper use of the device. These patients treated involved areas three times per week for a period of 12 weeks. Phototherapy dosing protocol was based on skin type. The cohort included 52 patients, who were aged 20-69 and represented all skin types. They were initially categorized by disease involvement as mild, moderate, and severe. Patients were also queried to self-score their disease severity and level of satisfaction. Compared to baseline, at 12 weeks, 48% percent of patients indicated that at least one site was Clear/Almost Clear, 38% stated that more than 50% of body locations were Clear/Almost Clear, and 28% reported that 100% (all) treated sites were Clear/Almost Clear. After using at-home hand-held NB-UVB for the study duration, 67% (35/52) of patients experienced disease improvement. Mean overall satisfaction was extremely high at 4.43 on a 5-point scale. Skin type, age, gender, and disease severity at inception did not significantly affect patient satisfaction scores. Overall adherence rate among participants across all groups was 73%. In this small retrospective study, at-home handheld NB-UVB phototherapy was found to be an effective, well-tolerated, adjunctive treatment method for patients with refractory AD, which was associated with a high level of patient satisfaction and adherence.

The UPDATE trial (UVB Phototherapy in Dermatology for ATopic Eczema): study protocol for a randomized controlled trial of narrowband UVB with optimal topical therapy versus optimal topical therapy in patients with atopic eczema

BACKGROUND

Narrowband ultraviolet B (NB-UVB) phototherapy is commonly prescribed for patients with moderate-to-severe atopic eczema (AE). The efficacy of NB-UVB, however, has not yet properly been established, as current evidence is of low certainty. Our aim is to assess the short-term and long-term (cost-)effectiveness and safety of NB-UVB in adult AE patients by performing a pragmatic, multicenter, prospective, randomized, open-label, blinded-endpoint (PROBE) trial. This protocol outlines its methodology.

METHODS

A pragmatic, multicenter, PROBE trial will be performed with 1:1 randomization of 316 adult patients with moderate-to-severe AE who have inadequate disease control with topical therapy and who are eligible for optimal topical therapy (OTT) or NB-UVB in combination with OTT as a next step. Participants in the interventional arm will receive a minimum of 3 months of OTT combined with 8 to 16 weeks of NB-UVB. The control group receives 3 months of OTT. Following the interventional phase, follow-up will continue for 9 months. Physician-reported and patient-reported outcomes (according to the Harmonising Outcome Measures for Eczema (HOME) Core Outcome Set) and adverse events are assessed at 4 weeks, 3, 6, 9, and 12 months.

DISCUSSION

The UPDATE trial aims to provide high-quality evidence regarding the (cost-)effectiveness and safety of NB-UVB phototherapy in moderate-to-severe AE patients. Challenges that are addressed in the protocol include the possible bias arising from applying open-label treatment and the necessity of introducing OTT into the study design to prevent a high dropout rate.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05704205. Registered on December 8, 2022.

[Cold plasma in wound healing]

Even today, not all wounds can be healed. Treatment, which often takes many years, is a burden for patients and is very cost-intensive. Therefore, additional procedures such as cold plasma are becoming increasingly popular. Active components of cold plasma include electromagnetic radiation and free radicals. The active principle is based on, among other things, damage to bacterial cells and positive interaction with epithelial and endothelial cells. Angiogenesis and cellular oxygen metabolism are stimulated. The evidence base is still limited and heterogeneous, as some results are contradictory and comparability is difficult. However, new, well-designed studies have confirmed previous findings. In order to create a solid database, further studies are needed.

Novel pharmacotherapies and breakthroughs in psoriasis treatment: 2024 and beyond

INTRODUCTION

The use of the current available therapies for psoriasis management may sometimes be limited by reduced patients' compliance, safety issues for patients' comorbidities, primary lack of efficacy, loss of effectiveness, development of side effects. In this context, several clinical trials investigating the use of both topical and systemic therapies are ongoing, and other new drugs will be approved soon.

AREAS COVERED

The aim of this manuscript is to review current literature and to provide an overview of the current and future trends in psoriasis treatment. A comprehensive review of the English-language medical literature was performed using Pubmed and clinicaltrials.gov databases.

EXPERT OPINION

Although several therapies are currently available for psoriasis' treatment, unmet needs still exist for patients with moderate and severe psoriasis and hence expanding the therapeutic armamentarium is desirable for a more personalized approach. The ongoing development of innovative therapies could provide effective and safe therapies in the future enhancing the therapeutic management of moderate-severe unresponsive psoriasis.

Fabrication and characterization of apremilast-loaded zinc oxide-mesoporous silica nanoparticles for psoriasis treatment

Aim: The study was aimed to formulate and evaluate apremilast-loaded zinc oxide-mesoporous silica nanoparticles for treatment of psoriasis. Materials & methods: Mesoporous silica nanoparticles were prepared by using sol-gel method and evaluated for particle size, in vitro drug release, in vitro cytotoxicity study and in vivo pharmacodynamic study. Results: The synthesized mesoporous silica nanoparticles showed particle size of 319.9 ± 3.9 nm, with 24 ± 0.217% of loading capacity. In vitro cytotoxicity study on A-431 cell line showed increased anti-psoriatic activity of apremilast-loaded zinc oxide-mesoporous silica nanoparticles. In vivo pharmacodynamic study and histological studies showed improved efficacy of drug in imiquimod-induced psoriasis mice model. Conclusion: The apremilast-loaded zinc oxide-mesoporous silica nanoparticles showed improved therapeutic efficacy, suggesting that they are promising approach for topical treatment of psoriasis.

Petroleum jelly: A comprehensive review of its history, uses, and safety

Petrolatum, also known as petroleum jelly, is a widely used topical agent, with a variety of uses in dermatology. Despite its popularity, many myths surround this ubiquitous dermatologic staple. This review details the history of petrolatum and how it is manufactured as well as how its biologic properties make it a great moisturizer. Additionally, data on its potential for flammability, allergenicity, and comedogenicity are detailed, dispelling misconceptions about petrolatum use around oxygen and as a cause of acne. The uses and benefits of petrolatum in dermatology are wide-ranging-a patch test instrument, a vehicle for medicated ointments, and a wound care essential. Given its ubiquitous presence, it is important for dermatologists to understand the history, safety profile, and myths surrounding this humble skincare staple.

Psoralen: a narrative review of current and future therapeutic uses

Psoralen is a family of naturally occurring photoactive compounds found in plants that acquire potential cytotoxicity when activated by specific frequencies of electromagnetic waves. Psoralens penetrate the phospholipid cellular membranes and insert themselves between the pyrimidines of deoxyribonucleic acid (DNA). Psoralens are initially biologically inert and acquire photoreactivity when exposed to certain classes of electromagnetic radiation, such as ultraviolet light. Once activated, psoralens form mono- and di-adducts with DNA, leading to marked cell apoptosis. This apoptotic effect is more pronounced in tumor cells due to their high rate of cell division. Moreover, photoactivated psoralen can inhibit tyrosine kinase signaling and influence the immunogenic properties of cells. Thus, the cytotoxicity of photoactivated psoralen holds promising clinical applications from its immunogenic properties to potential anti-cancer treatments. This narrative review aims to provide an overview of the current understanding and research on psoralen and to explore its potential future pharmacotherapeutic benefits in specific diseases.

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.

Management Strategies for Pediatric Moderate-to-Severe Plaque Psoriasis: Spotlight on Biologics

Although psoriasis onset has been reported at any ages, in up to one-third of cases, it begins during childhood, with an estimated prevalence of about 2% in pediatric population. The management of moderate-to-severe forms of childhood psoriasis may represent a challenge for dermatologists, especially for parents' concerns about the need of systemic treatments. However, a prompt safe and effective treatment is mandatory in these patients, due to the significative impact that psoriasis may have on their quality of life, with well-known consequences on psychological health of both patients and caregivers. Due to the relatively frequent parents' refusal of systemic treatments, probably due to the fear of eventual adverse events, difficulties of oral or injective route, the management of moderate-to-severe forms still represents a challenge. Herein, we report a narrative review, aiming to resume the systemic treatments for pediatric psoriasis, focusing on the use of biologics and small molecules in the pediatric ages. The most widely used therapeutic strategies today for the pediatric population with moderate-severe psoriasis are traditional systemic therapies, while more innovative drugs such as biologics and small molecules now represent a somewhat unexplored but certainly promising field for unresponsive patients.

Childhood guttate psoriasis: an updated review

Background

Guttate psoriasis is common and affects 0.5-2% of individuals in the paediatric age group. This review aims to familiarize physicians with the clinical manifestations, evaluation, diagnosis and proper management of guttate psoriasis.

Methods

A search was conducted in July 2023 in PubMed Clinical Queries using the key term "guttate psoriasis". The search strategy included all observational studies, clinical trials and reviews published within the past 10 years. The information retrieved from the search was used in the compilation of the present article.

Results

Guttate psoriasis typically presents with an abrupt onset of numerous, small, scattered, tear-drop-shaped, scaly, erythematous, pruritic papules and plaques. Sites of predilection include the trunk and proximal extremities. There may be a history of preceding streptococcal infection. Koebner phenomenon is characteristic. Guttate psoriasis may spontaneously remit within 3-4 months with no residual scarring, may intermittently recur and, in 40-50% of cases, may persist and progress to chronic plaque psoriasis. Given the possibility for spontaneous remission within several months, active treatment may not be necessary except for cosmetic purposes or because of pruritus. On the other hand, given the high rates of persistence of guttate psoriasis and progression to chronic plaque psoriasis, some authors suggest active treatment of this condition.

Conclusion

Various treatment options are available for guttate psoriasis. Triggering and exacerbating factors should be avoided if possible. Topical corticosteroids alone or in combination with other topical agents (e.g. tazarotene and vitamin D analogues) are the most rapid and efficient treatment for guttate psoriasis and are therefore the first-line treatment for mild cases. Other topical therapies include vitamin D analogues, calcineurin inhibitors, anthralin, coal tar and tazarotene. Ultraviolet phototherapy is the first-line therapy for moderate-to-severe guttate psoriasis, as it is more practical than topical therapy when treating widespread or numerous small lesions. Systemic immunosuppressive and immunomodulatory therapies (e.g. methotrexate, cyclosporine, retinoids, fumaric acid esters and biologics) may be considered for patients with moderate-to-severe guttate psoriasis who fail to respond to phototherapy and topical therapies.

Pathomechanism of Pruritus in Psoriasis and Atopic Dermatitis: Novel Approaches, Similarities and Differences

Pruritus is defined as an unpleasant sensation that elicits a desire to scratch. Nearly a third of the world's population may suffer from pruritus during their lifetime. This symptom is widely observed in numerous inflammatory skin diseases-e.g., approximately 70-90% of patients with psoriasis and almost every patient with atopic dermatitis suffer from pruritus. Although the pathogenesis of atopic dermatitis and psoriasis is different, the complex intricacies between several biochemical mediators, enzymes, and pathways seem to play a crucial role in both conditions. Despite the high prevalence of pruritus in the general population, the pathogenesis of this symptom in various conditions remains elusive. This review aims to summarize current knowledge about the pathogenesis of pruritus in psoriasis and atopic dermatitis. Each molecule involved in the pruritic pathway would merit a separate chapter or even an entire book, however, in the current review we have concentrated on some reports which we found crucial in the understanding of pruritus. However, the pathomechanism of pruritus is an extremely complex and intricate process. Moreover, many of these signaling pathways are currently undergoing detailed analysis or are still unexplained. As a result, it is currently difficult to take an objective view of how far we have come in elucidating the pathogenesis of pruritus in the described diseases. Nevertheless, considerable progress has been made in recent years.

An Overview of Potential Natural Photosensitizers in Cancer Photodynamic Therapy

Cancer is one of the main causes of death worldwide. There are several different types of cancer recognized thus far, which can be treated by different approaches including surgery, radiotherapy, chemotherapy or a combination thereof. However, these approaches have certain drawbacks and limitations. Photodynamic therapy (PDT) is regarded as an alternative noninvasive approach for cancer treatment based on the generation of toxic oxygen (known as reactive oxygen species (ROS)) at the treatment site. PDT requires photoactivation by a photosensitizer (PS) at a specific wavelength (λ) of light in the vicinity of molecular oxygen (singlet oxygen). The cell death mechanisms adopted in PDT upon PS photoactivation are necrosis, apoptosis and stimulation of the immune system. Over the past few decades, the use of natural compounds as a photoactive agent for the selective eradication of neoplastic lesions has attracted researchers' attention. Many reviews have focused on the PS cell death mode of action and photonanomedicine approaches for PDT, while limited attention has been paid to the photoactivation of phytocompounds. Photoactivation is ever-present in nature and also found in natural plant compounds. The availability of various laser light setups can play a vital role in the discovery of photoactive phytocompounds that can be used as a natural PS. Exploring phytocompounds for their photoactive properties could reveal novel natural compounds that can be used as a PS in future pharmaceutical research. In this review, we highlight the current research regarding several photoactive phytocompound classes (furanocoumarins, alkaloids, poly-acetylenes and thiophenes, curcumins, flavonoids, anthraquinones, and natural extracts) and their photoactive potential to encourage researchers to focus on studies of natural agents and their use as a potent PS to enhance the efficiency of PDT.

Assessment of efficacy and safety of UV-based therapy for psoriasis: a network meta-analysis of randomized controlled trials

BACKGROUND

Previous studies have proven that ultraviolet (UV)-based phototherapy, including UVB or psoralen UVA (PUVA), and their combination therapies, is effective for psoriasis treatment.

OBJECTIVE

To compare the clinical efficacy and adverse events (AEs) of different UV-based phototherapy in psoriasis.

METHODS

PubMed, Cochrane Library, Scopus and Embase were systematically searched. A random-effect model network meta-analysis with frequentist framework was performed, and results were reported as risk ratios (RRs) with 95% CI. The main variable for assessing effectiveness and safety are PASI 75 response and withdrawal due to AEs. Ranking effects were calculated by surface under the cumulative ranking analysis (SUCRA).

RESULTS

Thirty-two studies involving a total of 2120 psoriasis patients were included in this network meta-analysis. Overall, no significant difference was reported with respect to withdrawal due to AEs or incidence of erythema. The relatively safest strategy was combined adjuvant therapy with PUVA (cPUVA), especially PUVA combined with calcium/vitamin D derivatives (RR 0.98, 95% CI [0.30-3.17], SUCRA = 80.8%). Both cPUVA (RR 1.39, 95% CI [1.00- 1.94]) and combined adjuvant therapy with UVB (cUVB) (RR 1.27, 95% CI [1.03-1.57]) showed a superior effect than the monotherapy of UVA or UVB, respectively. PUVA combined with vitamin D and its derivatives (PAVD) ranked highest concerning clinical effect and safety (clusterank value = 7393.2).

CONCLUSIONS

The efficacy of all the combination therapy regimens was significantly superior to that of UV monotherapy, without significant differences in tolerability and safety. cUVB and cPUVA, and particularly the combination of UVA with calcium/vitamin D derivatives, was ranked as the overall safest and most effective phototherapy method.

An Update on Photodynamic Therapy of Psoriasis—Current Strategies and Nanotechnology as a Future Perspective

Psoriasis (PS) is an immune-mediated skin disease with substantial negative effects on patient quality of life. Despite significant progress in the development of novel treatment options over the past few decades, a high percentage of patients with psoriasis remain undertreated and require new medications with superior long-term efficacy and safety. One of the most promising treatment options against psoriatic lesions is a form of phototherapy known as photodynamic therapy (PDT), which involves either the systemic or local application of a cell-targeting photosensitizing compound, followed by selective illumination of the lesion with visible light. However, the effectiveness of clinically incorporated photosensitizers in psoriasis treatment is limited, and adverse effects such as pain or burning sensations are frequently reported. In this study, we performed a literature review and attempted to provide a pooled estimate of the efficacy and short-term safety of targeted PDT in the treatment of psoriasis. Despite some encouraging results, PDT remains clinically underutilized. This highlights the need for further studies that will aim to evaluate the efficacy of a wider spectrum of photosensitizers and the potential of nanotechnology in psoriasis treatment.

Phototherapy in dermatological maladies (Review)

Since the introduction of modern phototherapy in 1903 by Nobel Prize-winner Niels Ryberg Finsen, the usage of this therapy in the medical field has grown, techniques have been refined and developed, and it has gained widespread acceptance. Psoriasis vulgaris, parapsoriasis, lichen planus, atopic dermatitis, neonatal jaundice, urticaria, morphea, vitiligo, granuloma annulare and cutaneous T cell lymphoma are only a few dermatological indications that come along with satisfactory results. Most often, it is a 2nd or 3rd line therapy being an alternative in more severe or refractory diseases. Despite the side effects that may occur after phototherapy, which are often minor, the benefits can be significant. Unfortunately, the absolute contraindications limit the use of this type of treatment and implicitly the management of these patients. The current review aimed to combine the recommendations of phototherapy in dermatology, the types of phototherapy that can be suitable for certain dermatological diseases and to emphasize its importance in certain conditions that are associated with significant remission rates.

Phototherapy for atopic eczema

BACKGROUND

Atopic eczema (AE), also known as atopic dermatitis, is a chronic inflammatory skin condition that causes significant burden. Phototherapy is sometimes used to treat AE when topical treatments, such as corticosteroids, are insufficient or poorly tolerated.

OBJECTIVES

To assess the effects of phototherapy for treating AE.

SEARCH METHODS

We searched the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and ClinicalTrials.gov to January 2021.

SELECTION CRITERIA

We included randomised controlled trials in adults or children with any subtype or severity of clinically diagnosed AE. Eligible comparisons were any type of phototherapy versus other forms of phototherapy or any other treatment, including placebo or no treatment.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology. For key findings, we used RoB 2.0 to assess bias, and GRADE to assess certainty of the evidence. Primary outcomes were physician-assessed signs and patient-reported symptoms. Secondary outcomes were Investigator Global Assessment (IGA), health-related quality of life (HRQoL), safety (measured as withdrawals due to adverse events), and long-term control.

MAIN RESULTS

We included 32 trials with 1219 randomised participants, aged 5 to 83 years (mean: 28 years), with an equal number of males and females. Participants were recruited mainly from secondary care dermatology clinics, and study duration was, on average, 13 weeks (range: 10 days to one year). We assessed risk of bias for all key outcomes as having some concerns or high risk, due to missing data, inappropriate analysis, or insufficient information to assess selective reporting. Assessed interventions included: narrowband ultraviolet B (NB-UVB; 13 trials), ultraviolet A1 (UVA1; 6 trials), broadband ultraviolet B (BB-UVB; 5 trials), ultraviolet AB (UVAB; 2 trials), psoralen plus ultraviolet A (PUVA; 2 trials), ultraviolet A (UVA; 1 trial), unspecified ultraviolet B (UVB; 1 trial), full spectrum light (1 trial), Saalmann selective ultraviolet phototherapy (SUP) cabin (1 trial), saltwater bath plus UVB (balneophototherapy; 1 trial), and excimer laser (1 trial). Comparators included placebo, no treatment, another phototherapy, topical treatment, or alternative doses of the same treatment. Results for key comparisons are summarised (for scales, lower scores are better): NB-UVB versus placebo/no treatment There may be a larger reduction in physician-assessed signs with NB-UVB compared to placebo after 12 weeks of treatment (mean difference (MD) -9.4, 95% confidence interval (CI) -3.62 to -15.18; 1 trial, 41 participants; scale: 0 to 90). Two trials reported little difference between NB-UVB and no treatment (37 participants, four to six weeks of treatment); another reported improved signs with NB-UVB versus no treatment (11 participants, nine weeks of treatment). NB-UVB may increase the number of people reporting reduced itch after 12 weeks of treatment compared to placebo (risk ratio (RR) 1.72, 95% CI 1.10 to 2.69; 1 trial, 40 participants). Another trial reported very little difference in itch severity with NB-UVB (25 participants, four weeks of treatment). The number of participants with moderate to greater global improvement may be higher with NB-UVB than placebo after 12 weeks of treatment (RR 2.81, 95% CI 1.10 to 7.17; 1 trial, 41 participants). NB-UVB may not affect rates of withdrawal due to adverse events. No withdrawals were reported in one trial of NB-UVB versus placebo (18 participants, nine weeks of treatment). In two trials of NB-UVB versus no treatment, each reported one withdrawal per group (71 participants, 8 to 12 weeks of treatment). We judged that all reported outcomes were supported with low-certainty evidence, due to risk of bias and imprecision. No trials reported HRQoL. NB-UVB versus UVA1 We judged the evidence for NB-UVB compared to UVA1 to be very low certainty for all outcomes, due to risk of bias and imprecision. There was no evidence of a difference in physician-assessed signs after six weeks (MD -2.00, 95% CI -8.41 to 4.41; 1 trial, 46 participants; scale: 0 to 108), or patient-reported itch after six weeks (MD 0.3, 95% CI -1.07 to 1.67; 1 trial, 46 participants; scale: 0 to 10). Two split-body trials (20 participants, 40 sides) also measured these outcomes, using different scales at seven to eight weeks; they reported lower scores with NB-UVB. One trial reported HRQoL at six weeks (MD 2.9, 95% CI -9.57 to 15.37; 1 trial, 46 participants; scale: 30 to 150). One split-body trial reported no withdrawals due to adverse events over 12 weeks (13 participants). No trials reported IGA. NB-UVB versus PUVA We judged the evidence for NB-UVB compared to PUVA (8-methoxypsoralen in bath plus UVA) to be very low certainty for all reported outcomes, due to risk of bias and imprecision. There was no evidence of a difference in physician-assessed signs after six weeks (64.1% reduction with NB-UVB versus 65.7% reduction with PUVA; 1 trial, 10 participants, 20 sides). There was no evidence of a difference in marked improvement or complete remission after six weeks (odds ratio (OR) 1.00, 95% CI 0.13 to 7.89; 1 trial, 9/10 participants with both treatments). One split-body trial reported no withdrawals due to adverse events in 10 participants over six weeks. The trials did not report patient-reported symptoms or HRQoL. UVA1 versus PUVA There was very low-certainty evidence, due to serious risk of bias and imprecision, that PUVA (oral 5-methoxypsoralen plus UVA) reduced physician-assessed signs more than UVA1 after three weeks (MD 11.3, 95% CI -0.21 to 22.81; 1 trial, 40 participants; scale: 0 to 103). The trial did not report patient-reported symptoms, IGA, HRQoL, or withdrawals due to adverse events. There were no eligible trials for the key comparisons of UVA1 or PUVA compared with no treatment. Adverse events Reported adverse events included low rates of phototoxic reaction, severe irritation, UV burn, bacterial superinfection, disease exacerbation, and eczema herpeticum.

AUTHORS' CONCLUSIONS

Compared to placebo or no treatment, NB-UVB may improve physician-rated signs, patient-reported symptoms, and IGA after 12 weeks, without a difference in withdrawal due to adverse events. Evidence for UVA1 compared to NB-UVB or PUVA, and NB-UVB compared to PUVA was very low certainty. More information is needed on the safety and effectiveness of all aspects of phototherapy for treating AE.

Differences in phototherapy among skin diseases and genders in real-life conditions-A retrospective analysis of the cumulative doses, numbers of sessions, side effects and costs in 561 patients

BACKGROUND

Phototherapy has been a mainstay therapy for dermatological diseases since more than a century. Although phototherapy is still extensively used and some recommendations exist, only scarce data are available addressing disease-specific differences in cumulative doses, treatment durations and costs. Knowledge of such differences could help to avoid over-/undertreatment, predict treatment duration and costs. Therefore, we sought to determine differences in cumulative doses, numbers of sessions, side effects and costs among different skin diseases and genders in real-life conditions.

METHODS

In this single-centre, retrospective study, patients treated with phototherapy between March 2014 and April 2019 were classified into seven diagnostic groups and analysed according to the study goals.

RESULTS

Out of 561 patients (age 53.9 ± 20.3 yrs; 52.9% females), 83.7% percent were treated with cabin NB-UVB (mean cumulative dose 17.79 ± 17.11 J/cm² ). Patients with vitiligo and psoriasis were treated with significantly higher cumulative NB-UVB doses (cabin, local) in comparison with the five other diagnostic groups as were males in comparison with females. Consequently, significantly higher UV-related costs resulted in patients with vitiligo, psoriasis and males. Patients with atopic dermatitis and pruritus were treated with significantly higher cumulative UVA1 doses compared to patients with non-atopic eczema. The complication rate (pooled from all UV modalities) in our population was 3.8% (erythema 3.4%, aggravated itch 0.4% and worsening of symptoms 0.2%).

CONCLUSIONS

Our results demonstrate that cumulative doses and phototherapy-related costs vary strongly among skin diseases-a fact not adequately considered in recommendations. A more disease-specific stratification of phototherapy could not only help to optimize outcomes, but also to facilitate comparability of clinical trials using phototherapy.

An updated guide in the management of psoriasis for every practitioner

BACKGROUND

Psoriasis is one of the most common chronic cutaneous skin disorders, having genetic and immunological components. It is currently unknown what exactly triggers it, or how far reaching are the etiological factors, although great strides have been made in uncovering the pathophysiological cascade. Presently, there is a wide diversity of treatment methods for psoriasis, yet not all are applicable for each patient. Selection of both drug and dosage depends on both the knowledge and experience of the treating dermatologist and also on the specific characteristics of each patient. Therefore, the treating physicians should be made aware of the management possibilities, their advantages and their side effects.

METHODS

We have performed a non-systematic literature review on the current treatment methods for psoriasis. We have included the studies, articles, and prescription information that provided the most relevant information regarding each therapeutic agent. Afterward, we divided the treatment methods according to delivery and illustrated the management protocols for adult, paediatric, and pregnant patients.

DISCUSSION AND CONCLUSIONS

Current therapies are divided into topical drugs, phototherapy, systemic and biological agents. Topical therapies and phototherapy are generally the first and second line of management respectively, being typically effective in treating mild to moderate forms of psoriasis. On the other hand, the chronic moderate to severe forms usually benefit from systemic drugs, whereas biologic agents are reserved for severe or unremitting cases, especially those suffering from psoriatic arthritis. Also of importance is the understanding of the pathophysiological mechanisms in psoriasis and how the selected drugs interfere in the pathological cascade. Furthermore, physicians should be able to recommend the appropriate therapy not only for adults but also for paediatric and pregnant patients as well. In the following manuscript, we present an updated version of these management options, alongside their indications, posology and most common side effects, a guide that may be useful for every practitioner in this field.

Are Patients with Psoriasis and Psoriatic Arthritis Undertreated? A Population-Based Study from Southern Italy

This study aimed to explore the pattern of use of different treatment lines in psoriasis (PsO) and psoriatic arthritis (PsA) patients from Southern Italy. A retrospective cohort study was performed during the years 2010–2018 using data from the Caserta Local Health Unit (LHU) claims database. All of the PsO or PsA patients were identified. The proportion of PsO/PsA patients untreated or treated with ≥1 drug classes (i.e., non-disease-modifying antirheumatic drugs (non-DMARDs), conventional synthetic DMARDs (csDMARDs), biological drugs (bDMARDs) or targeted synthetic small molecules (tsDMARDs)) was calculated in the years 2016–2018. Among the bDMARD users, the median times from the first registered PsO/PsA diagnosis/from the first csDMARD to the first bDMARD were calculated. Overall, 10,296 (1.1%) and 1724 (0.2%) PsO and PsA patients were identified. More than half of the PsO patients (N = 5301; 51.6%) and 15% of the PsA patients (N = 251) were not treated with any drug. A very low proportion of PsO patients (N = 121; 1.2%) received csDMARDs/bDMARDs dispensing. Instead, 538 (32.2%) PsA patients were treated with bDMARDs. The median times from the first diagnosis to the first bDMARD dispensing were 54.0 (Q1–Q3: 30.5–72.2) and 13.3 (Q1–Q3: 3.1–43.9) months in the PsO and PsA patients, respectively. The median time from the first csDMARD to the first bDMARD dispensing was shorter in the PsO [9.2 months (Q1–Q3: 5.5–30.0)] than in the PsA [14.5 months (Q1–Q3: 8.6–33.5)] patients. A potential undertreatment of PsO (much less for PsA) in an LHU from Southern Italy, with a particularly low use of more recently marketed drugs, such as biological ones, was shown.

Oral simvastatin combined with narrowband UVB for the treatment of psoriasis: A randomized controlled trial

Psoriasis is a common chronic skin condition, which is an immune-related hyperproliferative disorder. Among the different treatments for psoriasis, statins have been found to reduce the severity of the disease. Accordingly, fluvastatin and simvastatin are known to have anti-inflammatory effects by inhibiting inflammatory cytokines and lymphocyte function. Narrowband ultraviolet B (NB-UVB) is known as an effective and safe modality for psoriasis treatment. In this double blind, randomized controlled trial, we investigated the efficacy and safety of adding simvastatin to NB-UVB phototherapy in patients with psoriasis. Forty-eight patients with psoriasis undergoing NB-UVB phototherapy were randomly divided into placebo groups; one received oral simvastatin, and the other received a placebo for 12 weeks. Psoriasis severity was assessed with the Psoriasis Area and Severity Index (PASI) and Dermatology Life and Quality Index (DLQI). Both groups showed a significant decline in PASI score after 6 and 12 weeks compared to the baseline. The differences in reducing PASI score and DLQI between the two groups were not significant neither at week sixth nor 12th. In addition, DLQI decreased significantly in the placebo group at week 12th. In contrast with previous studies, we did not find any additional effects for oral simvastatin5 in treating psoriasis with NB-UVB. Also, an insignificant difference in the improvement of quality of life between both groups was ascertained.

Photobiomodulation Regulation as One Promising Therapeutic Approach for Myocardial Infarction

Myocardial infarction refers to myocardial necrosis caused by acute or persistent coronary ischemia and hypoxia. It is considered to be one of the significant crises threatening human health in the world. Following myocardial infarction, collagen gradually replaces the original tissue due to the loss of many cardiomyocytes, myocardial contractile function decreases, and myocardial fibrosis eventually leads to heart failure. Phototherapy is a new treatment which has shown superior efficacy on the nerve, skeletal muscle, skin, and other tissues. Likewise, there is growing evidence that phototherapy also has many positive effects on the heart. Therefore, this article introduces the progress of research on phototherapy as a new therapeutic strategy in the treatment of myocardial infarction. The wavelength of photobiomodulation in the treatment of myocardial infarction is specific, and the influence of light source power and light duration on the tissue presents a bell-shaped distribution. Under these conditions, phototherapy can promote ATP synthesis and angiogenesis, inhibit the inflammatory response, improve heart function, reduce infarct size, and protect myocardium. In addition, we summarized the molecular mechanisms of phototherapy. According to the location of photoreceptors, they can be divided into mitochondrial and nonmitochondrial parts.

Blue Light in Dermatology

Phototherapy is an important method of dermatological treatments. Ultraviolet (280-400 nm) therapy is of great importance; however, there are concerns of its long-term use, as it can lead to skin aging and carcinogenesis. This review aims to evaluate the role and the mechanism of action of blue light (400-500 nm), a UV-free method. The main mediators of cellular responses to blue light are nitric oxide (NO) and reactive oxygen species (ROS). However, the detailed mechanism is still not fully understood. It was demonstrated that blue light induces an anti-inflammatory and antiproliferative effect; thus, it may be beneficial for hyperproliferative and chronic inflammatory skin diseases such as atopic dermatitis, eczema, and psoriasis. It was also found that blue light might cause the reduction of itching. It may be beneficial on hair growth and may be used in the treatment of acne vulgaris by reducing follicular colonization of Propionibacterium acnes. Further studies are needed to develop accurate protocols, as the clinical effects depend on the light parameters as well as the treatment length. There are no major adverse effects observed yet, but long-term safety should be monitored as there are no studies considering the long-term effects of blue light on the skin.

Automated psoriasis lesion segmentation from unconstrained environment using residual U-Net with transfer learning

BACKGROUND AND OBJECTIVE

The automatic segmentation of psoriasis lesions from digital images is a challenging task due to the unconstrained imaging environment and non-uniform background. Existing conventional or machine learning-based image processing methods for automatic psoriasis lesion segmentation have several limitations, such as dependency on manual features, human intervention, less and unreliable performance with an increase in data, manual pre-processing steps for removal of background or other artifacts, etc. METHODS: In this paper, we propose a fully automatic approach based on a deep learning model using the transfer learning paradigm for the segmentation of psoriasis lesions from the digital images of different body regions of the psoriasis patients. The proposed model is based on U-Net architecture whose encoder path utilizes a pre-trained residual network model as a backbone. The proposed model is retrained with a self-prepared psoriasis dataset and corresponding segmentation annotation of the lesion.

RESULTS

The performance of the proposed method is evaluated using a five-fold cross-validation technique. The proposed method achieves an average Dice Similarity Index of 0.948 and Jaccard Index of 0.901 for the intended task. The transfer learning provides an improvement in the segmentation performance of about 4.4% and 7.6% in Dice Similarity Index and Jaccard Index metric respectively, as compared to the training of the proposed model from scratch.

CONCLUSIONS

An extensive comparative analysis with the state-of-the-art segmentation models and existing literature validates the promising performance of the proposed framework. Hence, our proposed method will provide a basis for an objective area assessment of psoriasis lesions.

A case of psoriasis successfully treated by extracorporeal photopheresis during COVID-19 pandemic

Psoriasis is a chronic inflammatory skin disease that is characterized by well-demarcated erythematous plaques with a silver scale. Although many new and emerging therapeutic agents are often sufficient to control the disease, there is still a need for alternative treatment options in challenging cases. Extracorporeal photopheresis (ECP) has been applied to many T-cell-mediated diseases to restore immune homeostasis and treat psoriasis effectively. In this paper, we present a psoriasis patient who did not respond to methotrexate, narrowband ultraviolet B, or acitretin. Because of a diagnosis of non-Hodgkin lymphoma, the patient had contraindications for cyclosporine, fumaric acid esters, and biologics but achieved remission with a total of 12 sessions of ECP in two and a half months. Although exacerbation was recorded after polymerase chain reaction (PCR) confirmed coronavirus 2019 (COVID-19) disease infection at the end of the first month, scores from the psoriasis area severity index (PASI) and dermatological life quality index (DLQI) were regressed significantly within two and a half months. ECP seems to provide an effective and rapid response for psoriasis and should be considered for psoriasis patients who fail to respond or have contraindications to existing treatments.

TaaI/Cdx-2 AA Variant of VDR Defines the Response to Phototherapy amongst Patients with Psoriasis

1,25-dihydroxyvitamin-D₃ plays a central role in the immune system via binding to the vitamin D receptor. VDR polymorphisms have been associated with multiple autoimmune disorders, including psoriasis. Until now, five VDR polymorphisms, FokI, ApaI, BsmI, TaqI and TaaI/Cdx2, have been studied in psoriasis, with contradicting results. Therefore, this study aimed to evaluate the association of VDR polymorphisms with susceptibility to psoriasis, effectiveness of NB-UVB phototherapy and concentration of proinflammatory cytokines and vitamin D amongst the Polish population. VDR polymorphisms were analyzed by PCR-RFLP or real-time PCR. We found that the frequency of the TaaI/Cdx-2 GG genotype was significantly higher in psoriasis patients and was associated with regulation of IL-17 and IL-23 concentration. Moreover, TaaI/Cdx-2 AA might have a significant effect on the response to phototherapy amongst patients with psoriasis. Our results suggest that VDR is a susceptibility factor for psoriasis development. Moreover, TaaI/Cdx-2 variants have a significant effect on the response to phototherapy amongst patients with psoriasis and regulation of inflammatory response via decrease of IL-17 and IL-23 level after UVB phototherapy in the Polish population. Results of our study provide some evidence in support of the hypothesis that the vitamin D signaling pathway may be of relevance for pathogenesis and treatment of psoriasis.

308-nm Excimer Lamp vs. Combination of 308-nm Excimer Lamp and 10% Liquor Carbonis Detergens in Patients With Scalp Psoriasis: A Randomized, Single-Blinded, Controlled Trial

Background: Scalp psoriasis is usually refractory to treatment. Excimer devices have been proved to be a promising therapeutic option in psoriasis. Greater efficacy of phototherapy can be achieved by concurrent use of coal tar derivatives.

Objective: We aimed to compare efficacy and safety between 308-nm excimer lamp monotherapy and a combination of 308-nm excimer lamp and 10% liquor carbonis detergens in the treatment of scalp psoriasis.

Methods: In this randomized, evaluator-blinded, prospective, comparative study, 30 patients with scalp psoriasis received either 308-nm excimer lamp monotherapy or a combination of 308-nm excimer lamp and 10% liquor carbonis detergens twice per week until complete remission of the scalp or for a total of 30 sessions. Efficacy was evaluated by the improvement of Psoriasis Scalp Severity Index (PSSI) score, itch score, and Scalpdex score.

Results: Both treatments induced significant improvement in PSSI score with greater reduction observed in the combination group. At 30th visit, a 75% reduction in PSSI (PSSI75) was attained by 4 (28.6%) and 9 (69.2%) patients treated with monotherapy and combination therapy, respectively (P < 0.05).

Conclusions: Excimer lamp is well-tolerated in patients with scalp psoriasis and liquor carbonis detergens can be used as a combination therapy to improve the efficacy of excimer lamp.

Frequency of phototherapy for treating psoriasis: a systematic review

INTRODUCTION

Narrow band ultraviolet B (NB-UVB) and psoralen-ultraviolet A (PUVA) remain inexpensive and effective anti-psoriatic therapies adopted worldwide with different frequency protocols. We aimed to systematically assess the evidence on the effects of different frequency protocols of phototherapy in treating psoriasis.

EVIDENCE ACQUISITION

We used the following terms, namely "photochemotherapy", "phototherapy", "psoriasis", "UVB", "UVA" and "ultraviolet therapy", to search the Cochrane Controlled Register of Trials, MEDLINE and Embase databases on August 1, 2019. We organized results using a PRISM diagram and analyzed bias risks with RoB-2 tool.

EVIDENCE SYNTHESIS

We included five randomized controlled trials (RCTs) on oral PUVA and three RCTs on NB-UVB. The five studies on PUVA included a total of 1452 patients with plaque psoriasis and did not find any significant difference in efficacy comparing two- vs. three- vs. four times weekly protocols. The three studies on NB-UVB included a total of 248 patients with plaque psoriasis. No differences in efficacy were reported in comparing different frequencies in delivering NB-UVB, namely twice vs. thrice weekly, twice vs. four times weekly, and thrice- vs. five times weekly protocols. Although protocols with higher treatments frequency per week achieved clearance faster than lower frequency ones, but they did not differ in terms of efficacy.

CONCLUSIONS

PUVA and NB-UVB remain an effective anti-psoriatic treatment; however further studies are needed to elucidate which protocol may be more effective in different skin phototypes.

Polymeric Gels and Their Application in the Treatment of Psoriasis Vulgaris: A Review

Psoriasis is a chronic skin disease, and it is especially characterized by the occurrence of red, itchy, and scaly eruptions on the skin. The quality of life of patients with psoriasis is decreased because this disease remains incurable, despite the rapid progress of therapeutic methods and the introduction of many innovative antipsoriatic drugs. Moreover, many patients with psoriasis are dissatisfied with their current treatment methods and the form with which the drug is applied. The patients complain about skin irritation, clothing stains, unpleasant smell, or excessive viscosity of the preparation. The causes of these issues should be linked with little effectiveness of the therapy caused by low permeation of the drug into the skin, as well as patients’ disobeying doctors’ recommendations, e.g., concerning regular application of the preparation. Both of these factors are closely related to the physicochemical form of the preparation and its rheological and mechanical properties. To improve the quality of patients’ lives, it is important to gain knowledge about the specific form of the drug and its effect on the safety and efficacy of a therapy as well as the patients’ comfort during application. Therefore, we present a literature review and a detailed analysis of the composition, rheological properties, and mechanical properties of polymeric gels as an alternative to viscous and greasy ointments. We discuss the following polymeric gels: hydrogels, oleogels, emulgels, and bigels. In our opinion, they have many characteristics (i.e., safety, effectiveness, desired durability, acceptance by patients), which can contribute to the development of an effective and, at the same time comfortable, method of local treatment of psoriasis for patients.

Oral and Topical Vitamin D, Sunshine, and UVB Phototherapy Safely Control Psoriasis in Patients with Normal Pretreatment Serum 25-Hydroxyvitamin D Concentrations: A Literature Review and Discussion of Health Implications

Vitamin D, sunshine and UVB phototherapy were first reported in the early 1900s to control psoriasis, cure rickets and cure tuberculosis (TB). Vitamin D also controlled asthma and rheumatoid arthritis with intakes ranging from 60,000 to 600,000 International Units (IU)/day. In the 1980s, interest in treating psoriasis with vitamin D rekindled. Since 1985 four different oral forms of vitamin D (D2, D3, 1-hydroxyvitaminD3 (1(OH)D3) and 1,25-dihydroxyvitaminD3 (calcitriol)) and several topical formulations have been reported safe and effective treatments for psoriasis-as has UVB phototherapy and sunshine. In this review we show that many pre-treatment serum 25(OH)D concentrations fall within the current range of normal, while many post-treatment concentrations fall outside the upper limit of this normal (100 ng/mL). Yet, psoriasis patients showed significant clinical improvement without complications using these treatments. Current estimates of vitamin D sufficiency appear to underestimate serum 25(OH)D concentrations required for optimal health in psoriasis patients, while concentrations associated with adverse events appear to be much higher than current estimates of safe serum 25(OH)D concentrations. Based on these observations, the therapeutic index for vitamin D needs to be reexamined in the treatment of psoriasis and other diseases strongly linked to vitamin D deficiency, including COVID-19 infections, which may also improve safely with sufficient vitamin D intake or UVB exposure.

Accurate surface ultraviolet radiation forecasting for clinical applications with deep neural network

Exposure to appropriate doses of UV radiation provides enormously health and medical treatment benefits including psoriasis. Typical hospital-based phototherapy cabinets contain a bunch of artificial lamps, either broad-band (main emission spectrum 280-360 nm, maximum 320 nm), or narrow-band UV B irradiation (main emission spectrum 310-315 nm, maximum 311 nm). For patients who cannot access phototherapy centers, sunbathing, or heliotherapy, can be a safe and effective treatment alternative. However, as sunlight contains the full range of UV radiation (290-400 nm), careful sunbathing supervised by photodermatologist based on accurate UV radiation forecast is vital to minimize potential adverse effects. Here, using 10-year UV radiation data collected at Nakhon Pathom, Thailand, we developed a deep learning model for UV radiation prediction which achieves around 10% error for 24-h forecast and 13-16% error for 7-day up to 4-week forecast. Our approach can be extended to UV data from different geographical regions as well as various biological action spectra. This will become one of the key tools for developing national heliotherapy protocol in Thailand. Our model has been made available at https://github.com/cmb-chula/SurfUVNet .

Pruritus in psoriasis and atopic dermatitis: current treatments and new perspectives

Psoriasis and atopic dermatitis (AD) are two common chronic inflammatory skin diseases. Although showing different etiology and clinical manifestations, patients with either disease suffer from low health-related quality of life due to pruritus (dermal itch). Recent studies have revealed that more than 85% of psoriasis patients suffer from pruritus, and it is also the dominating symptom of AD. However, as this is a non-life treating symptom, it was partly neglected for years. In this review, we focus on current findings as well as the impact and potential treatments of pruritus in these two skin diseases. We first distinguish the type of itch based on involved mediators and modulators. This clear delineation between the types of pruritus based on involved receptors and pathways allows for precise treatment. In addition, insights into recent clinical trials aimed to alleviate pruritus by targeting these receptors are presented. We also report about novel advances in combinatorial treatments, dedicated to the type of pruritus linked to a causal disease. Altogether, we suggest that only a focused treatment tailored to the primary disease and the underlying molecular signals will provide fast and sustained relief of pruritus associated with psoriasis or AD.

Tracing the Photoaddition of Pharmaceutical Psoralens to DNA

The psoralens 8-methoxypsoralen (8-MOP), 4,5',8-trimethylpsoralen (TMP) and 5-methoxypsoralen (5-MOP) find clinical application in PUVA (psoralen + UVA) therapy. PUVA treats skin diseases like psoriasis and atopic eczema. Psoralens target the DNA of cells. Upon photo-excitation psoralens bind to the DNA base thymine. This photo-binding was studied using steady-state UV/Vis and IR spectroscopy as well as nanosecond transient UV/Vis absorption. The experiments show that the photo-addition of 8-MOP and TMP involve the psoralen triplet state and a biradical intermediate. 5-MOP forms a structurally different photo-product. Its formation could not be traced by the present spectroscopic technique.

The Unmet Need for Clinical Guidelines on the Management of Patients with Plaque Psoriasis in Africa and the Middle East

Purpose

Dermatologists practicing in African and Middle Eastern countries face numerous challenges when managing patients with plaque psoriasis, especially those with disease in a difficult-to-treat anatomic area or those who are a pediatric, geriatric, or pregnant patient. The publication of comprehensive, up-to-date, region-specific clinical guidelines may help to address some of these challenges and improve outcomes. We conducted a literature review to identify recent guidelines and other publications describing patients with plaque psoriasis in Africa and the Middle East.

Patients and Methods

An online literature search of the PubMed database was conducted to identify publications reporting clinical guidelines and research studies on plaque psoriasis. The search included all articles published from January 2008 to March 2020 inclusive. The titles and abstracts of all search results were screened by a reader to identify those that described patients in Africa or the Middle East.

Results

A total of 145 publications were identified by the literature search and screened by a reader. There were 10 publications that described patients in Africa or the Middle East: 4 research articles, 3 reviews, 2 guidelines, and 1 case study. The 2010 guidelines from South Africa made recommendations for treating plaque psoriasis of varying severity, although without specific recommendations for difficult-to-treat anatomic areas or pediatric, geriatric, or pregnant patients. The 2014 guideline on biologics from Saudi Arabia included recommendations for the use of these agents in patients with plaque psoriasis, including difficult-to-treat anatomic areas and pediatric patients (TNF inhibitors only), but provided no recommendations for pregnant or geriatric patients.

Conclusion

There is an urgent unmet need for comprehensive clinical guidelines on the management of patients with plaque psoriasis in Africa and the Middle East. Region-specific studies on the epidemiology, burden of disease, and the safety and effectiveness of newer pharmacotherapies are needed to support the development of such guidelines.

Tolerance and efficacy of a new celastrol-containing balm as adjunct care in psoriasis

BACKGROUND

In patients with psoriasis, the non-lesional skin also presents abnormalities, requiring emollient application on the whole body.

OBJECTIVES

To evaluate the tolerance of a new emollient balm containing celastrol, an active ingredient with anti-Th17 immunomodulatory properties used alone or in association with topical or systemic drug treatments or phototherapy, and its efficacy when used alone.

METHODS

Adults with body plaque psoriasis applied the product over the whole body once a day for 4 weeks (balm used alone in 41 patients and with ongoing treatment in 50 patients). At D1, D8 ('balm alone' study) or D15 ('balm in association' study) and D29, the dermatologist rated physical and functional signs and assessed pruritus and body global lesion score (evaluating erythema, induration/thickness, scaling and dryness) in the 'balm alone' study.

RESULTS

No reaction related to the product was reported, and the tolerance was deemed excellent. In the 'balm alone' study, mean pruritus intensity score significantly decreased at D8 (-39%, P < 0.001) and D29 (-60%, P < 0.001) compared with D1, together with the body global lesion score (-24% at D8 and -26% at D29, P < 0.001). In parallel, quality of life improved, as evidenced by a patient-reported outcome questionnaire. Cosmetic acceptability was good.

CONCLUSION

This new emollient balm was very well tolerated by patients with body plaque psoriasis either alone or in association with drug treatment or phototherapy, which is important to ensure long-term compliance. Daily application during one month improved pruritus, physical signs and quality of life.

Phototherapy for Cutaneous T-Cell Lymphoma

Phototherapy with psoralen and ultraviolet A (PUVA) or narrowband-UVB (NBUVB) is frequently used for the patch and plaque stages of mycosis fungoides (MF), the most common type of cutaneous T-cell lymphoma. This article provides practical guidelines for the design and implementation of a phototherapy protocol for early stage MF, including an overview of treatment phases, response criteria, and considerations in the selection of a light source. Several evolving topics in phototherapy research are also discussed, including the relative efficacy of PUVA versus NBUVB, the role of maintenance therapy, risk of photocarcinogenicity, and combination therapies.

Home UV Phototherapy

Phototherapy is an effective treatment for multiple dermatoses. However, patient inconvenience and poor access to office-based phototherapy may jeopardize adherence and treatment outcome. Home phototherapy offers a convenient, accessible, and effective therapy. We describe the history of home phototherapy, the devices available, and associated costs. A literature review used PubMed. Keywords included: "home phototherapy," "tanning beds," "narrowband ultraviolet B." In a randomized control trial, home phototherapy had similar efficacy to office-based phototherapy. Home phototherapy is associated with significant cost savings treatment and increased adherence. Home phototherapy should be considered for its economic value, good tolerability, adherence, and efficacy.

Effect of narrow-band ultraviolet B phototherapy, methotrexate, and combined narrow-band ultraviolet B phototherapy with methotrexate on serum cathelicidin and vitamin D in patients with psoriasis vulgaris

Objective: This study aimed to evaluate the efficacy of narrow-band ultraviolet B (NB-UVB) phototherapy, methotrexate, and combined NB-UVB phototherapy with methotrexate in the treatment of psoriasis vulgaris and to assess their effects on serum cathelicidin and vitamin D.Methods: This study was conducted on 60 patients with psoriasis vulgaris. They were divided into three groups (20 patients each); Group (A) was treated with NB-UVB phototherapy. Group (B) was treated with methotrexate. Group (C) was treated with combined NB-UVB phototherapy with methotrexate. Patients were assessed with Psoriasis Area and Severity Index (PASI score), serum cathelicidin and vitamin D at the first visit and after three months of treatments.Results: The highest mean PASI score percent improvement was reported in the combined NB-UVB phototherapy with methotrexate (92%). There was a significant increase in serum vitamin D after treatments with NB-UVB phototherapy and combined NB-UVB phototherapy with methotrexate (p < .001). There was a significant decrease in cathelicidin after three months of treatment with combined NB-UVB phototherapy with methotrexate (p < .01).Conclusion: This study could contribute to the hypothesis considering the role of cathelicidin and vitamin D in the pathogenesis of psoriasis. The combined NB-UVB phototherapy with methotrexate had the highest clinical improvement of psoriasis vulgaris.

Hydrogel-Based Active Substance Release Systems for Cosmetology and Dermatology Application: A Review

Hydrogels are playing an increasingly important role in medicine and pharmacy. Due to their favorable physicochemical properties, biocompatibility, and designed interaction with living surroundings, they seem to be one of the most promising groups of biomaterials. Hydrogel formulations from natural, semi, or synthetic polymeric materials have gained great attention in recent years for treating various dermatology maladies and for cosmetology procedures. The purpose of this review is to present a brief review on the basic concept of hydrogels, synthesis methods, relevant mechanisms, and applications in dermatology or cosmetology. This review discusses transdermal therapies and the recent advances that have occurred in the field.

Role of phototherapy in the era of biologics

Phototherapy is a safe and effective treatment for many dermatologic conditions. With the advent of novel biologics and small molecule inhibitors, it is important to critically evaluate the role of phototherapy in dermatology. Surveys have shown that many dermatology residency programs do not dedicate time to teaching residents how to prescribe or administer phototherapy. Limitations of phototherapy include access to a center, time required for treatments, and insurance approval. Home phototherapy, a viable option, is also underused. However, it should be emphasized that modern phototherapy has been in use for over 40 years, has an excellent safety profile, and does not require laboratory monitoring. It can be safely combined with many other treatment modalities, including biologics and small molecule inhibitors. In addition, phototherapy costs significantly less than these novel agents. Dermatologists are the only group of physicians who have the expertise and proper training to deliver this treatment modality to our patients. Therefore, to continue to deliver high-quality, cost-effective care, it is imperative that phototherapy be maintained as an integral part of the dermatology treatment armamentarium.

Management of psoriasis in pregnancy - a review of the evidence to date

The onset of psoriasis collides with women’s reproductive timeframe, and pregnancy brings challenges to its treatment. Indeed, the health of both mother and foetus must be considered. When choosing to treat pregnant women affected by psoriasis with pharmacological therapy, it is important to be aware of all possible options and their repercussions. Although there are several pharmacological therapies available, pregnancy brings ethical concerns and any pharmacological approach must be well thought out. The data available in humans are limited, and further investigation on this matter is needed. Within biological therapies, certolizumab pegol has recently been identified as a promising approach during pregnancy because it has been shown to have no late active placental transfer and no clear signs of foetal harm. This article aims to review the impact of psoriasis during pregnancy, how the disease can be managed pharmacologically during this period according to the available armamentarium, and the possible effects of the therapeutic options for the mother and the foetus.

Topical treatment of psoriasis: questionnaire results on topical therapy as long-term continuous treatment and use on specific body sites

Background: Currently, no formalized international consensus guidelines exist to direct optimal topical treatment including long-term treatment.Objective: In this survey, we aim to examine if and which topicals are used in clinical practice in long-term continuous treatment of psoriasis and how topicals are used in treating specific sites of the body.Methods: A questionnaire was distributed electronically to dermatologists from the International Psoriasis Council (IPC) representing 26 countries.Results: The top three topicals used across all severities of disease were topical corticosteroids, vitamin D analogs, and potent topical corticosteroids in combination with vitamin D analogs. On locations where the skin is thin, flexural and genital psoriasis, lower potency topical corticosteroids were used, whereas on other sites, in particular in palmoplantar psoriasis, superpotent topical corticosteroids and combination vitamin D analogs/corticosteroids were used.Conclusions: It is relevant to optimize localized therapy for all severities of psoriasis reconciling disease activity (stable vs. unstable disease), localization of the lesions and the individual patient and his/her perspectives on disease control. Topical therapies are valuable treatments for classical mild disease and may have a position in some patients with more severe manifestations.

Practical compendium for psoriasis management

Psoriasis management is complex and challenging. It should be tailored for each patient. Treatment strategy differs according to patient's age, sex, disease type, disease severity, burden on patient's quality of life, comorbidities, involvement of specific sites, and pregnancy. The choice of the appropriate therapeutic must take into consideration the availability, the price, and the patient's preferences. It is very important that the chosen treatment is not more unpleasant, intolerable, or dangerous than the disease itself. According to the disease type, severity, and effect on patient's quality of life, dermatologist chooses whether to start with topical therapy, phototherapy or systemic therapy, or a combination of two or more of them. Under each category, there are different types of therapies that can be the first line therapeutics, second line, or even contraindicated. In this compendium, we provide dermatologists with different treatment plans considering all the mentioned variables so that a dermatologist can choose the optimum plan for the patient.

Calcipotriol/betamethasone dipropionate aerosol foam for the treatment of psoriasis vulgaris: a review of real-world evidence (RWE)

Background: Randomized controlled trials (RCTs) demonstrated the advantages of an aerosol foam formulation of calcipotriol/betamethasone dipropionate (Cal/BD) in patients with psoriasis. In this review, we investigated whether such benefits could also be obtained in real-world clinical practice.Methods: PubMed was searched for studies reporting real-world data in patients with psoriasis treated with Cal/BD aerosol foam.Results: Three large real-world studies with Cal/BD aerosol foam were identified: a prospective non-interventional study from Germany, a medical chart review from the US, and a retrospective non-interventional study from Spain. Some key findings included the following: high levels of adherence to treatment (82-93%); after 4 weeks, about 50% of patients achieved complete/almost complete responses; at final assessment, 85-95% of patients were extremely satisfied/very satisfied/satisfied with Cal/BD aerosol foam; all healthcare providers were satisfied or somewhat satisfied with the efficacy of Cal/BD foam and they reported similar findings for symptom improvements (itch, pain, erythema/redness, flaking, and plaque thickness). Global ratings by investigators/healthcare providers for symptom control, overall efficacy and the emotional status of patients were also very high (75-100%).Conclusion: The results from real-world studies undertaken in diverse healthcare systems reinforce the positive findings reported in RCTs with Cal/BD aerosol foam in patients with psoriasis.