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Strober B, Duffin KC, Lebwohl M, Sima A, Janak J, Patel M, Photowala H, Garg V, Bagel J. Impact of psoriasis disease severity and special area involvement on patient-reported outcomes in the real world: an analysis from the CorEvitas psoriasis registry. J DERMATOL TREAT 2024; 35:2287401. [PMID: 38073528 DOI: 10.1080/09546634.2023.2287401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/20/2023] [Indexed: 12/18/2023]
Abstract
BACKGROUND The impact of psoriasis in special areas (i.e., scalp, nails, palms, soles, genitals) on patient physical functioning, health-related quality of life (HRQoL), and work abilities has not been fully characterized. We assessed associations between disease severity and special area involvement in psoriasis symptoms, HRQoL, and work/activity impairment. METHODS Patients with psoriasis from the CorEvitas Psoriasis Registry who initiated systemic treatment between 04/2015-06/2020 were included. Outcomes were change from baseline in psoriasis symptoms, Dermatology Life Quality Index (DLQI), and work/activity impairment at 6 months stratified by baseline disease severity and special area involvement. RESULTS Among 2620 patients, increasing disease severity was associated with worsening patient-reported outcomes. Patients with (46.0%; N = 1205) versus without (54.0%; N = 1415) psoriasis in special areas reported greater HRQoL and work/activity impairment. Over 6 months, patients with unchanged or worsening disease severity had reduced HRQoL and increased symptom severity; incremental increases in patient HRQoL and decreases in symptom severity were associated with improved disease severity. CONCLUSIONS Higher disease severity and special area involvement was associated with worse outcomes and impaired work abilities. These data highlight the significant impact that adequate treatment of severe psoriasis and/or special area involvement may have on patient HRQoL and function.
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Affiliation(s)
- Bruce Strober
- Yale University, New Haven, CT, and Central Connecticut Dermatology, Cromwell, CT, USA
| | | | - Mark Lebwohl
- Icahan School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | | | | | - Jerry Bagel
- Psoriasis Treatment Center of Central New Jersey, East Windsor, NJ, USA
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Pinter A, Soliman AM, Pivneva I, Ghanbariamin R, Yang M, Truong B, Puig L, Lebwohl M. Real-World Long-Term Effectiveness of Risankizumab Among Patients with Moderate-to-Severe Psoriasis: Analysis from an International Medical Chart Review (RAPID) Study. Dermatol Ther (Heidelb) 2024; 14:1259-1271. [PMID: 38727996 PMCID: PMC11116343 DOI: 10.1007/s13555-024-01164-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 05/24/2024] Open
Abstract
INTRODUCTION Real-world data on the efficacy of risankizumab (RZB) in clinical moderate-to-severe plaque psoriasis (PsO) are limited. The RAPID study assessed real-world clinical and patient-reported outcomes in RZB-treated PsO patients using data collected from dermatologists in Canada, the Czech Republic, Germany, Japan, and Poland. METHODS This ongoing, retrospective chart review collected data from medical records of RZB-treated adults with moderate-to-severe PsO (09/2022-06/2023). Eligible patients received RZB, had ≥ 12 months of medical records after RZB initiation (index date), and had Psoriasis Area and Severity Index (PASI), Investigator Global Assessment (IGA), or static Physician's Global Assessment (sPGA) scores ≥ 3 months before and up to 18 months after the index date. The proportion of patients achieving a clear/almost clear PsO (IGA/sPGA = 0/1), PASI ≤ 1, Dermatology Life Quality Index (DLQI) = 0/1, and a 90%/100% improvement from baseline in PASI as well as the mean changes in PASI, DLQI, itch, and skin pain scores at 12 and 18 months were reported for patients with non-missing assessments at baseline and 12 months. RESULTS Most patients (66.4%) were male, 74.0% were biologic naïve, and 73.0% had scalp PsO. Mean baseline IGA/sPGA was 3.7 ± 0.5, with a mean PASI of 23.3 ± 11.8. After 12 months, 86.1% of patients reported IGA/sPGA ≤ 1, and 75.7% achieved PASI90; these further increased to 91.1% and 80.5% at 18 months. DLQI, itch, and skin pain scores improved over time. CONCLUSIONS These data demonstrated the durable, real-world effectiveness of RZB in patients with moderate-to-severe PsO through continued improvement in disease and symptom severity over 18 months, with most of the patients reporting clear/almost clear skin.
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Affiliation(s)
- Andreas Pinter
- Department of Dermatology, University Hospital Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany.
| | | | | | | | - Min Yang
- Analysis Group, Inc., Boston, USA
| | | | - Luis Puig
- Department of Dermatology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | - Mark Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
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Evyana D, Novianto E, Budianti WK, Krisanti RIA, Wisnu W, Wibawanti R, Nilasari H, Legiawati L, Hapsari SAR, Mutmainnah E. Association between the severity of hard-to-treat psoriasis and the prevalence of metabolic syndrome: A hospital-based cross-sectional study in Jakarta, Indonesia. PLoS One 2024; 19:e0302391. [PMID: 38683749 PMCID: PMC11057762 DOI: 10.1371/journal.pone.0302391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 04/02/2024] [Indexed: 05/02/2024] Open
Abstract
Psoriatic lesions on the scalp, face, intertriginous, genitals, palms/soles, and nails are often delay diagnosed, hard-to-treat, and cause disability. Metabolic syndrome (MetS) is one of the most frequent and significant comorbidities in psoriasis. Many studies have discovered a link between psoriasis and MetS, but none have specifically assessed the hard-to-treat psoriasis in Indonesian population. This is a multicenter study involving four dermatology referral hospitals to investigate the association between psoriasis severity that has hard-to-treat lesions with the prevalence of MetS in Jakarta, Indonesia. Data was collected from April to October 2022. The severity of 84 hard-to-treat psoriasis patients was measured by Psoriasis Area Severity Index (PASI) scores. The participants divided into PASI score >10 (severe) and ≤ 10 (mild-moderate) groups. MetS was identified based on the modified National Cholesterol Education Program Adult Treatment Panel III. MetS was found in 64.3% of patients. Patients with a PASI score>10 had a significantly higher risk of metabolic syndrome compared to those with a score ≤ 10 (78.6% vs 50%, OR 3.667; 95% CI 1.413-9.514; p = 0.006). The prevalence of hypertension (p = 0.028), low levels of high-density lipoprotein (HDL) cholesterol (p = 0.01), mean fasting blood sugar (p = 0.018), and triglyceride levels (p = 0.044) between the two groups differed significantly. This study found most frequent components of MetS were abdominal obesity, decreased levels of HDL cholesterol, hypertension, hyperglycemia, and hypertriglyceridemia respectively. Individuals with severe hard-to-treat psoriasis had a 3.67 times more likely to have MetS rather than the mild-moderate group.
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Affiliation(s)
- Dina Evyana
- Faculty of Medicine Universitas Indonesia, Department of Dermatology and Venereology, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Endi Novianto
- Faculty of Medicine Universitas Indonesia, Department of Dermatology and Venereology, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Windy K. Budianti
- Faculty of Medicine Universitas Indonesia, Department of Dermatology and Venereology, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Roro I. A. Krisanti
- Faculty of Medicine Universitas Indonesia, Department of Dermatology and Venereology, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Wismandari Wisnu
- Faculty of Medicine Universitas Indonesia, Department of Internal Medicine, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Retno Wibawanti
- Faculty of Medicine Universitas Indonesia, Department of Community medicine, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Hanny Nilasari
- Faculty of Medicine Universitas Indonesia, Department of Dermatology and Venereology, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Lili Legiawati
- Faculty of Medicine Universitas Indonesia, Department of Dermatology and Venereology, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Saskia A. R. Hapsari
- Department of Dermatology and Venereology, Tarakan General Hospital, Jakarta, Indonesia
| | - Euis Mutmainnah
- Department of Dermatology and Venereology, Persahabatan Central General Hospital, Jakarta, Indonesia
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Egeberg A, Hawkes JE, Somani N, Burge R, See K, Gallo G, McKean-Matthews M, Gooderham M, Han G, Armstrong A. Sustained Improvements in Clinical and Patient-Reported Outcomes and Quality of Life Through 5 Years Among Ixekizumab-Treated Patients with Complete Clearance of Scalp Psoriasis by Week 60. Dermatol Ther (Heidelb) 2024; 14:1007-1018. [PMID: 38647975 PMCID: PMC11052960 DOI: 10.1007/s13555-024-01147-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/20/2024] [Indexed: 04/25/2024] Open
Abstract
INTRODUCTION Ixekizumab, a high-affinity monoclonal antibody that selectively targets interleukin-17A, is approved for the treatment of moderate-to-severe plaque psoriasis. Since scalp psoriasis can be burdensome and challenging to treat with non-systemic therapies, this post hoc analysis focused on scalp psoriasis in patients with moderate-to-severe plaque psoriasis and baseline scalp involvement. The analysis considered a holistic concept of clearance through 5 years of ixekizumab treatment. METHODS Ixekizumab-treated patients with baseline scalp involvement were pooled from three multicenter, randomized, double-blind, placebo-controlled, phase 3 trials (integrated UNCOVER-1/2 and UNCOVER-3). Analyses were performed on a subpopulation of patients who achieved complete resolution of scalp psoriasis at Week 60 (i.e., Week 60 Psoriasis Scalp Severity Index [PSSI-0] responders) and on the overall patient population (i.e., Week 60 PSSI-0 responders and non-responders), which was used as a reference. Clinical outcomes (PSSI), patient-reported outcomes (Itch Numeric Rating Scale [NRS] score, Skin Pain Visual Analogue Scale [VAS]), quality of life (Dermatology Life Quality Index [DLQI]), and concurrent outcomes were assessed from baseline through 5 years. Descriptive statistics of observed data were reported. RESULTS After 60 weeks of ixekizumab treatment, 88.4% (UNCOVER-1/2) and 75.9% (UNCOVER-3) of patients with baseline scalp involvement achieved complete clearance (PSSI-0) of scalp psoriasis. Substantial improvements in the clinical outcomes (PSSI), patient-reported outcomes (Itch NRS, Skin Pain VAS), and quality of life (DLQI) were achieved by Week 60 and sustained through Week 264 in the Week 60 PSSI-0 responders and in the overall patient population. Additionally, a significant proportion of Week 60 PSSI-0 responders achieved concurrent complete scalp and skin clearance and quality of life improvement through 5 years. CONCLUSIONS Continued treatment with ixekizumab provided long-term sustained scalp clearance over 5 years to patients with moderate-to-severe plaque psoriasis and baseline scalp involvement, and holistic improvements occurred across clinical outcomes, patient-reported outcomes, and quality of life. CLINICAL TRIAL NUMBERS NCT01474512 (UNCOVER-1), NCT01597245 (UNCOVER-2), and NCT01646177 (UNCOVER-3).
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Affiliation(s)
- Alexander Egeberg
- Department of Dermatology, Bispebjerg Hospital, Copenhagen, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Jason E Hawkes
- Integrative Skin Science and Research, Pacific Skin Institute University, Sacramento, CA, USA
| | | | - Russel Burge
- Eli Lilly and Company, Indianapolis, IN, USA
- Department of Pharmaceutical Sciences, University of Cincinnati, Cincinnati, OH, USA
| | | | - Gaia Gallo
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | | | - George Han
- Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA
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Tsiogkas SG, Karamitrou EK, Grammatikopoulou MG, Zafiriou E, Bogdanos DP. Efficacy of tyrosine-kinase-2 and phosphodiesterase-4 inhibitors for scalp psoriasis: a systematic review and meta-analysis. Curr Med Res Opin 2024; 40:155-163. [PMID: 37997745 DOI: 10.1080/03007995.2023.2288280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/22/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVES Psoriasis of the scalp is challenging to manage. The only approved oral tyrosine kinase 2 and phosphodiesterase 4 inhibitors for psoriasis are deucravacitinib and apremilast. The aim of this study was to explore their efficacy for scalp psoriasis utilizing data from randomized controlled trials. METHODS We searched Medline, Scopus, Web of Science, CENTRAL, and ClinicalTrials.gov up to August 4, 2023. To determine risk of bias, the revised Risk of Bias assessment tool 2.0 was used. Inverse variance random effects meta-analyses were executed. Heterogeneity was assessed utilizing Q and I2 statistics. Pre-determined outcomes included the proportion of participants with cleared scalp skin (Scalp Physician's Global Assessment [ScPGA] of 0/1), mean change in Psoriasis Scalp Severity Index (PSSI), and mean improvement in Dermatology Life Quality Index (DLQI). RESULTS Ten RCTs fulfilled inclusion criteria. Both apremilast (RR = 2.41, 95% CI = 2.08-2.79, Tau2 = 0, I2 = 0) and deucravacitinib (RR = 3.86, 95% CI = 3.02-4.94, Tau2 = 0, I2 = 0) were more effective in inducing ScPGA of 0/1 at 16 weeks compared to placebo. Furthermore, deucravacitinib was more effective than apremilast (RR = 1.70, 95% CI = 1.44-2.00, Tau2 = 0, I2 = 0). An analysis could not be executed for the rest of the outcomes. CONCLUSIONS Apremilast and deucravacitinib are effective for scalp psoriasis. Deucravacitinib may be more efficient in clearing the scalp.
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Affiliation(s)
- Sotirios G Tsiogkas
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | | | - Maria G Grammatikopoulou
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Efterpi Zafiriou
- Department of Dermatology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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Pinter A, Tsianakas A, Eichner A. Efficacy and Safety of Topical Tacrolimus Microemulsion Applied Twice Daily in Patients with Mild to Moderate Scalp Psoriasis. Dermatol Ther (Heidelb) 2024; 14:521-532. [PMID: 38345680 PMCID: PMC10891015 DOI: 10.1007/s13555-024-01102-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 01/15/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Involvement of the scalp is common in psoriasis and severely affects the quality of life of those affected. It is difficult to treat and places special demands on the galenics of a drug formulation. Tacrolimus is a calcineurin inhibitor and is approved as an ointment formulation for the treatment of atopic dermatitis. The efficacy and safety of topically applied tacrolimus have also been studied and proven for psoriasis. However, no proprietary pharmaceutical product is currently approved for this indication. METHODS A multicenter, double-blind, vehicle-controlled phase 3 study was conducted to evaluate the efficacy and safety of 0.1% tacrolimus microemulsion when applied topically twice daily in 128 patients independently of sex with scalp psoriasis. RESULTS The primary efficacy analysis showed a scalp Investigator Global Assessment (s-IGA) of 0 (absence of disease) or 1 (very mild disease) at 8 weeks in 28.6% of subjects in the tacrolimus group, indicating a significantly better response (p = 0.0476, chi-square test) versus 12.7% of subjects in the placebo group (difference of 15.9%-points). The Dermatology Life Quality Index (DLQI) improved over time and was more pronounced in the group treated with tacrolimus-containing microemulsion than in the placebo group, but showed no statistically significant difference after 8 weeks of use (p = 0.193, ANCOVA). The safety analysis revealed no evidence of cutaneous side effects other than those known. Toxicologically relevant serum levels of tacrolimus could be excluded. CONCLUSION The study data show that 0.1% tacrolimus microemulsion has good efficacy and safety in the treatment of scalp psoriasis.
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Affiliation(s)
- Andreas Pinter
- Clinic for Dermatology, Venereology and Allergy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | | | - Adina Eichner
- Department of Dermatology and Venereology, Martin Luther University Halle-Wittenberg, Ernst-Grube-Straße 40, 06097, Halle (Saale), Germany.
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Cacciapuoti S, Potestio L, Guerrasio G, Fabbrocini G, Scalvenzi M, Ruggiero A, Caiazzo G, Megna M. Effectiveness of Brodalumab in Patients with Moderate-to-Severe Plaque Psoriasis Located in Difficult-to-Treat Areas. Clin Cosmet Investig Dermatol 2023; 16:2637-2644. [PMID: 37780688 PMCID: PMC10541085 DOI: 10.2147/ccid.s423234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
Background Recent knowledge of psoriasis pathogenesis has led to the development of selective drugs. Among these, brodalumab is a monoclonal antibody targeting the interleukin (IL)-17A receptor approved for the treatment of moderate-to-severe plaque psoriasis. Biologics may be considered in patients with milder diseases in case of active psoriatic arthritis, severe impact on patient's quality of life, and involvement of sensitive and difficult-to-treat areas. These skin locations commonly require systemic drugs. Recently, psoriasis severity monitoring has also changed. Indeed, the clinical evaluation by means of specific efficacy scores was combined with serological evaluation by means of the assay of specific inflammatory biomarkers. Methods An observational study enrolled patients affected by moderate-to-severe plaque psoriasis involving difficult-to-treat areas, undergoing treatment with brodalumab to evaluate the effectiveness and safety of brodalumab in patients with psoriasis affecting difficult-to-treat areas (scalp and palmoplantar regions). Secondary outcomes were the assessment of the development of serum markers of inflammation during the treatment period as well as the evaluation of the dermoscopic features of the affected sites to quantify disease activity and response to treatment. Results Twenty-five patients were included in the study. A statistically significant reduction from baseline in PASI, PSSI, ppPASI and DLQI values as early as week 24 was observed, with further improvement up to week 52. Plasma levels of MMP-3, VEGF-A, and hs-PCR decreased during treatment from week 0 to week 52. Conclusion Our real-life experience suggests brodalumab as a valuable option for the management of psoriasis located in difficult-to-treat areas. Moreover, our study highlights that the use of brodalumab reduces the plasmatic levels of inflammatory biomarkers (MMP-3, VEGF-A and hs-PCR), showing how the drug modulates the skin inflammatory response by reducing systemic inflammation.
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Affiliation(s)
- Sara Cacciapuoti
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Luca Potestio
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gianluca Guerrasio
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Massimiliano Scalvenzi
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Angelo Ruggiero
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Giuseppina Caiazzo
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Matteo Megna
- Section of Dermatology - Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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Kircik LH, Alonso-Llamazares J, Bhatia N, Bukhalo M, Devani AR, Draelos ZD, DuBois J, Gooderham MJ, Kempers SE, Lain E, Lee M, Moore A, Murrell DF, Papp KA, Pariser DM, Sinclair R, Zirwas M, Burnett P, Higham RC, Krupa D, Berk DR. Once-daily roflumilast foam 0.3% for scalp and body psoriasis: a randomized, double-blind, vehicle-controlled phase IIb study. Br J Dermatol 2023; 189:392-399. [PMID: 37279795 DOI: 10.1093/bjd/ljad182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/10/2023] [Accepted: 05/23/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Scalp psoriasis affects most patients with psoriasis, but it can be difficult to treat. OBJECTIVES To evaluate the efficacy and safety of once-daily roflumilast foam 0.3% on scalp and body psoriasis. METHODS In a phase IIb randomized controlled trial, adults and adolescents aged ≥ 12 years with scalp and body psoriasis were randomized (2 : 1) to roflumilast foam 0.3% or vehicle for 8 weeks. The primary efficacy endpoint was scalp Investigator Global Assessment (S-IGA) success (score of 'clear' or 'almost clear' plus ≥ 2-grade improvement from baseline) at week 8. Safety and tolerability were also evaluated. RESULTS Significantly more roflumilast-treated patients (59.1%) than vehicle-treated patients (11.4%) achieved S-IGA success at week 8 (P < 0.001); differences favoured roflumilast as early as the first postbaseline visit at week 2 (P < 0.001). Significant improvements were also seen for secondary endpoints, including body IGA success, Scalp Itch Numeric Rating Scale and the Psoriasis Scalp Severity Index. The safety of roflumilast was generally similar to vehicle. Patients treated with roflumilast experienced low rates of treatment-emergent adverse events (AEs), with few discontinuations due to an AE. Few patients with skin of colour (11%) and few adolescents (0.7%) were included. CONCLUSIONS The results support the further development of roflumilast foam for treating scalp and body psoriasis.
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Affiliation(s)
- Leon H Kircik
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Indiana Medical Center, Indianapolis, IN, USA
- Physicians Skin Care PLLC, Louisville, KY, USA
- Skin Sciences PLLC, Louisville, KY, USA
| | | | - Neal Bhatia
- Therapeutics Clinical Research, San Diego, CA, USA
| | | | - Alim R Devani
- Dermatology Research Institute, Calgary, AB, Canada
- Skin Health and Wellness Centre, Calgary, AB, Canada
- Probity Medical Research, Calgary, AB, Canada
| | - Zoe D Draelos
- Dermatology Consulting Services, High Point, NC, USA
| | | | - Melinda J Gooderham
- SkiN Centre for Dermatology, Peterborough, ON, Canada
- Probity Medical Research, Peterborough, ON, Canada
- Queen's University, Peterborough, ON, Canada
| | | | | | - Mark Lee
- Progressive Clinical Research, San Antonio, TX, USA
| | - Angela Moore
- Arlington Research Center, Arlington, TX, USA
- Baylor University Medical Center, Dallas, TX, USA
| | | | - Kim A Papp
- Probity Medical Research, Waterloo, ON, Canada
- K. Papp Clinical Research, Waterloo, ON, Canada
| | - David M Pariser
- Eastern Virginia Medical School, Norfolk, VA, USA
- Virginia Clinical Research Inc., Norfolk, VA, USA
| | | | - Matthew Zirwas
- Dermatologists of the Central States, Probity Medical Research, Bexley, OH, USA
- Ohio University, Bexley, OH, USA
| | | | | | - David Krupa
- Arcutis Biotherapeutics Inc., Westlake Village, CA, USA
| | - David R Berk
- Arcutis Biotherapeutics Inc., Westlake Village, CA, USA
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Lebwohl MG, Kircik LH, Moore AY, Stein Gold L, Draelos ZD, Gooderham MJ, Papp KA, Bagel J, Bhatia N, Del Rosso JQ, Ferris LK, Green LJ, Hebert AA, Jones T, Kempers SE, Pariser DM, Yamauchi PS, Zirwas M, Albrecht L, Devani AR, Lomaga M, Feng A, Snyder S, Burnett P, Higham RC, Berk DR. Effect of Roflumilast Cream vs Vehicle Cream on Chronic Plaque Psoriasis: The DERMIS-1 and DERMIS-2 Randomized Clinical Trials. JAMA 2022; 328:1073-1084. [PMID: 36125472 PMCID: PMC9490499 DOI: 10.1001/jama.2022.15632] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Once-daily roflumilast cream, 0.3%, a potent phosphodiesterase 4 inhibitor, demonstrated efficacy and was well tolerated in a phase 2b trial of patients with psoriasis. OBJECTIVE To evaluate the efficacy of roflumilast cream, 0.3%, applied once daily for 8 weeks in 2 trials of patients with plaque psoriasis. DESIGN, SETTING, AND PARTICIPANTS Two phase 3, randomized, double-blind, controlled, multicenter trials (DERMIS-1 [trial 1; n = 439] and DERMIS-2 [trial 2; n = 442]) were conducted at 40 centers (trial 1) and 39 centers (trial 2) in the US and Canada between December 9, 2019, and November 16, 2020, and between December 9, 2019, and November 23, 2020, respectively. Patients aged 2 years or older with plaque psoriasis involving 2% to 20% of body surface area were enrolled. The dates of final follow-up were November 20, 2020, and November 23, 2020, for trial 1 and trial 2, respectively. INTERVENTIONS Patients were randomized 2:1 to receive roflumilast cream, 0.3% (trial 1: n = 286; trial 2: n = 290), or vehicle cream (trial 1: n = 153; trial 2: n = 152) once daily for 8 weeks. MAIN OUTCOMES AND MEASURES The primary efficacy end point was Investigator Global Assessment (IGA) success (clear or almost clear status plus ≥2-grade improvement from baseline [score range, 0-4]) at week 8, analyzed using a Cochran-Mantel-Haenszel test stratified by site, baseline IGA score, and intertriginous involvement. There were 9 secondary outcomes, including intertriginous IGA success, 75% reduction in Psoriasis Area and Severity Index (PASI) score, and Worst Itch Numeric Rating Scale score of 4 or higher at baseline achieving 4-point reduction (WI-NRS success) at week 8 (scale: 0 [no itch] to 10 [worst imaginable itch]; minimum clinically important difference, 4 points). RESULTS Among 881 participants (mean age, 47.5 years; 320 [36.3%] female), mean IGA scores in trial 1 were 2.9 [SD, 0.52] for roflumilast and 2.9 [SD, 0.45] for vehicle and in trial 2 were 2.9 [SD, 0.48] for roflumilast and 2.9 [SD, 0.47]) for vehicle. Statistically significantly greater percentages of roflumilast-treated patients than vehicle-treated patients had IGA success at week 8 (trial 1: 42.4% vs 6.1%; difference, 39.6% [95% CI, 32.3%-46.9%]; trial 2: 37.5% vs 6.9%; difference, 28.9% [95% CI, 20.8%-36.9%]; P < .001 for both). Of 9 secondary end points, statistically significant differences favoring roflumilast vs vehicle were observed for 8 in trial 1 and 9 in trial 2, including intertriginous IGA success (71.2% vs 13.8%; difference, 66.5% [95% CI, 47.1%-85.8%] and 68.1% vs 18.5%; difference, 51.6% [95% CI, 29.3%-73.8%]; P < .001 for both), 75% reduction in PASI score (41.6% vs 7.6%; difference, 36.1% [95% CI, 28.5%-43.8%] and 39.0% vs 5.3%; difference, 32.4% [95% CI, 24.9%-39.8%]; P < .001 for both), WI-NRS success (67.5% vs 26.8%; difference, 42.6% [95% CI, 31.3%-53.8%] and 69.4% vs 35.6%; difference, 30.2% [95% CI, 18.2%-42.2%]; P < .001 for both). The incidence of treatment-emergent adverse events was 25.2% with roflumilast vs 23.5% with vehicle in trial 1 and 25.9% with roflumilast vs 18.4% with vehicle in trial 2. The incidence of serious adverse events was 0.7% with roflumilast vs 0.7% with vehicle in trial 1 and 0% with roflumilast vs 0.7% with vehicle in trial 2. CONCLUSIONS AND RELEVANCE Among patients with chronic plaque psoriasis, treatment with roflumilast cream, 0.3%, compared with vehicle cream resulted in better clinical status at 8 weeks. Further research is needed to assess efficacy compared with other active treatments and to assess longer-term efficacy and safety. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT04211363, NCT04211389.
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Affiliation(s)
| | - Leon H. Kircik
- Icahn School of Medicine at Mount Sinai, New York, New York
- Indiana Medical Center, Indianapolis
- Physicians Skin Care PLLC, Louisville, Kentucky
- Skin Sciences PLLC, Louisville, Kentucky
| | - Angela Y. Moore
- Arlington Research Center, Arlington, Texas
- Baylor University Medical Center, Dallas, Texas
| | | | - Zoe D. Draelos
- Dermatology Consulting Services, High Point, North Carolina
| | - Melinda J. Gooderham
- SkiN Centre for Dermatology, Peterborough, Ontario, Canada
- Probity Medical Research, Peterborough, Ontario, Canada
- Queen’s University, Peterborough, Ontario, Canada
| | - Kim A. Papp
- Probity Medical Research, Waterloo, Ontario, Canada
- K Papp Clinical Research, Waterloo, Ontario, Canada
| | - Jerry Bagel
- Psoriasis Treatment Center of Central New Jersey, East Windsor
| | - Neal Bhatia
- Therapeutics Clinical Research, San Diego, California
| | - James Q. Del Rosso
- JDR Dermatology Research Center LLC, Las Vegas, Nevada
- Advanced Dermatology and Cosmetic Surgery, Maitland, Florida
| | - Laura K. Ferris
- University of Pittsburgh Clinical and Translational Science Institute, Pittsburgh, Pennsylvania
| | - Lawrence J. Green
- George Washington University School of Medicine, Rockville, Maryland
| | | | | | | | - David M. Pariser
- Eastern Virginia Medical School, Norfolk
- Virginia Clinical Research Inc, Norfolk
| | - Paul S. Yamauchi
- David Geffen School of Medicine at UCLA, Los Angeles, California
- Dermatology Institute and Skin Care Center Inc, Santa Monica, California
| | - Matthew Zirwas
- Dermatologists of the Central States, Bexley, Ohio
- Probity Medical Research, Bexley, Ohio
- Ohio University, Bexley, Ohio
| | - Lorne Albrecht
- Enverus Medical Research, Surrey, British Columbia, Canada
- Probity Medical Research, Surrey, British Columbia, Canada
| | - Alim R. Devani
- Dermatology Research Institute, Calgary, Alberta, Canada
- Probity Medical Research, Calgary, Alberta, Canada
| | - Mark Lomaga
- DermEdge Research, Mississauga, Ontario, Canada
- Probity Medical Research, Mississauga, Ontario, Canada
| | - Amy Feng
- Arcutis Biotherapeutics Inc, Westlake Village, California
| | - Scott Snyder
- Arcutis Biotherapeutics Inc, Westlake Village, California
| | | | | | - David R. Berk
- Arcutis Biotherapeutics Inc, Westlake Village, California
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10
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Gargiulo L, Ibba L, Pavia G, Vignoli CA, Piscazzi F, Valenti M, Sanna F, Perugini C, Avagliano J, Costanzo A, Narcisi A. Real-Life Effectiveness and Safety of Risankizumab in 131 Patients Affected by Moderate-to-Severe Plaque Psoriasis: A 52-Week Retrospective Study. Dermatol Ther (Heidelb) 2022; 12:2309-2324. [PMID: 36063283 PMCID: PMC9443623 DOI: 10.1007/s13555-022-00795-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/11/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Risankizumab is a humanized monoclonal antibody that selectively targets interleukin-23. It is approved for treatment of moderate-to-severe plaque psoriasis. We conducted a 52-week monocentric retrospective study to evaluate the effectiveness and safety of risankizumab in a real-life setting. Methods Our study included 131 adults with moderate-to-severe plaque psoriasis all treated with risankizumab for at least 52 weeks. Patient characteristics and PASI (Psoriasis Area and Severity Index) at each visit were recorded. The percentages of patients achieving 75%/90%/100% (PASI 75/90/100) improvement in PASI with respect to baseline were registered. Results At week 52, 93.9%, 78.6%, and 61.1% of patients achieved PASI 75/90/100, respectively. An absolute PASI ≤ 2 was reached by 90.8% at week 52. The higher body mass index and the presence of cardio-metabolic comorbidities did not interfere with the odds of reaching PASI 75/90/100 at each time-point. At week 52, comparable percentages of patients achieved PASI 100, regardless of the involvement of difficult-to-treat-areas. No significant safety findings were recorded and none of the patients had to interrupt the treatment because of adverse events. Conclusions Our findings confirmed that risankizumab is a safe and effective therapeutic option for the treatment of a wide “real-life” cohort of patients with psoriasis.
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Affiliation(s)
- Luigi Gargiulo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy.
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy.
| | - Luciano Ibba
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Giulia Pavia
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Carlo Alberto Vignoli
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Francesco Piscazzi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Mario Valenti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Federica Sanna
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Chiara Perugini
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Jessica Avagliano
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
| | - Antonio Costanzo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, MI, Italy
- Dermatology Unit, IRCCS Humanitas Research Hospital, Rozzano, MI, Italy
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11
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Itch as a critical factor in impaired health-related quality of life in patients with plaque psoriasis achieving clear or almost-clear skin: Analysis of the single-arm, open-label, multicenter, prospective ProLOGUE study. JAAD Int 2022; 8:146-153. [PMID: 35942062 PMCID: PMC9356143 DOI: 10.1016/j.jdin.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 11/22/2022] Open
Abstract
Background Patients with psoriasis report impaired health-related quality of life (HRQoL; Dermatology Life Quality Index score ≥ 2) even after achieving clear or almost-clear skin with biologic treatment. Objective To assess the effectiveness of brodalumab in HRQoL improvement and the factors associated with incomplete HRQoL improvement in Japanese patients with psoriasis. Methods As a part of the single-arm, open-label, multicenter, prospective ProLOGUE study (Japan Registry of Clinical Trials identifier: jRCTs031180037), patients were treated with 210 mg of subcutaneous brodalumab in daily clinical practice until week 48. The absolute Psoriasis Area and Severity Index scores and patient-reported outcomes were assessed at baseline and weeks 12 and 48. Results Seventy-three patients (male, 82.2%; median age, 54.0 years) were enrolled. The Dermatology Life Quality Index and European Quality of Life 5-Dimension 5-Level Utility Index scores significantly improved from baseline to weeks 12 and 48. At week 48, all 13 patients with a Dermatology Life Quality Index score of ≥2 and an absolute Psoriasis Area and Severity Index score of 0 to ≤2 reported itching. Limitations Unclear generalizability of the results to other biologics. Conclusion Treatment with brodalumab improved HRQoL in patients with psoriasis. Itching may contribute to incomplete HRQoL improvement in patients who have achieved clear or almost-clear skin.
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12
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Menter A, Bhutani T, Ehst B, Elewski B, Jacobson A. Narrative Review of the Emerging Therapeutic Role of Brodalumab in Difficult-to-Treat Psoriasis. Dermatol Ther (Heidelb) 2022; 12:1289-1302. [PMID: 35672564 PMCID: PMC9209590 DOI: 10.1007/s13555-022-00746-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
Psoriatic involvement in areas of the body such as nails, palms and soles (palmoplantar), and scalp is associated with dramatically negative effects on quality of life relative to involvement elsewhere in the body. Although numerous evidence-based studies demonstrate the efficacy of biologics for overall skin clearance in moderate-to-severe plaque psoriasis (including tumor necrosis factor α [TNFα] inhibitors and interleukin [IL]-17A, IL-12/IL-23, IL-23, IL-17F, and IL-17A/F inhibitors), large, randomized, placebo-controlled clinical studies of psoriasis with nail, palmoplantar, and scalp involvement are needed to better inform decision-making in clinical practice. Moreover, biologic failure caused by drug ineffectiveness is a common occurrence in patients who do not respond, lose response, or are intolerant to treatment. Brodalumab is a fully human IL-17 receptor A antagonist that demonstrates high rates of skin clearance among the latest generation of biologic therapies for treatment of moderate-to-severe psoriasis. This review summarizes current literature on the efficacy of brodalumab and other therapies in difficult-to-treat psoriasis including psoriasis in difficult-to-treat locations (such as psoriasis with nail, palmoplantar, or scalp involvement) and psoriasis in patients whose disease did not respond to other biologics.
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Affiliation(s)
| | - Tina Bhutani
- Department of Dermatology, University of California, San Francisco, CA, USA
| | | | - Boni Elewski
- Department of Dermatology School of Medicine, University of Alabama, Birmingham, AL, USA
| | - Abby Jacobson
- Ortho Dermatologics (a Division of Bausch Health US, LLC), Bridgewater, NJ, USA
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13
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Bardazzi F, Viviani F, Filippi F, Carpanese MA, Piraccini BM, Abbenante D. The legs: An underestimated difficult-to-treat area of psoriasis. Dermatol Ther 2022; 35:e15485. [PMID: 35383406 DOI: 10.1111/dth.15485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/03/2022] [Accepted: 03/31/2022] [Indexed: 11/30/2022]
Affiliation(s)
| | - Filippo Viviani
- Dermatology, IRCCS Policlinico di Sant'Orsola, Bologna, Italy.,Dermatology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Federica Filippi
- Dermatology, IRCCS Policlinico di Sant'Orsola, Bologna, Italy.,Dermatology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Miriam Anna Carpanese
- Dermatology, IRCCS Policlinico di Sant'Orsola, Bologna, Italy.,Dermatology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Bianca Maria Piraccini
- Dermatology, IRCCS Policlinico di Sant'Orsola, Bologna, Italy.,Dermatology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Diego Abbenante
- Dermatology, IRCCS Policlinico di Sant'Orsola, Bologna, Italy.,Dermatology, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
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14
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Mosca M, Hong J, Hadeler E, Brownstone N, Bhutani T, Liao W. Scalp Psoriasis: A Literature Review of Effective Therapies and Updated Recommendations for Practical Management. Dermatol Ther (Heidelb) 2021; 11:769-797. [PMID: 33893995 PMCID: PMC8163911 DOI: 10.1007/s13555-021-00521-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Indexed: 11/23/2022] Open
Abstract
The scalp is one of the most commonly affected regions in psoriasis. However, scalp psoriasis can be difficult to treat because of challenges in the delivery of therapy. Effective therapeutic regimens for scalp psoriasis are essential to improving the quality of life of patients. Recent data on topical therapies, phototherapy, systemic agents, and complementary therapy have demonstrated that it is possible to achieve and maintain significant improvement in scalp psoriasis. In this review, efficacy data for these modalities and an algorithm for the practical management of scalp psoriasis are presented.
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Affiliation(s)
- Megan Mosca
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, 515 Spruce Street, San Francisco, CA, 94118, USA.
| | - Julie Hong
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, 515 Spruce Street, San Francisco, CA, 94118, USA
| | - Edward Hadeler
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, 515 Spruce Street, San Francisco, CA, 94118, USA
| | - Nicholas Brownstone
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, 515 Spruce Street, San Francisco, CA, 94118, USA
| | - Tina Bhutani
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, 515 Spruce Street, San Francisco, CA, 94118, USA
| | - Wilson Liao
- Department of Dermatology, Psoriasis and Skin Treatment Center, University of California San Francisco, 515 Spruce Street, San Francisco, CA, 94118, USA
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15
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Meier K, Schloegl A, Poddubnyy D, Ghoreschi K. Skin manifestations in spondyloarthritis. Ther Adv Musculoskelet Dis 2020; 12:1759720X20975915. [PMID: 33343725 PMCID: PMC7727049 DOI: 10.1177/1759720x20975915] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 11/03/2020] [Indexed: 12/30/2022] Open
Abstract
Spondyloarthritides (SpA) like psoriatic arthritis, axial spondyloarthritis/ankylosing spondylitis, reactive arthritis and inflammatory bowel disease (IBD)-associated SpA can present with characteristic skin manifestations. These SpA-associated skin disorders may precede joint involvement, reflect a loss of efficacy of a current systemic treatment or can even be treatment associated. Cutaneous manifestations in SpA not only add additional morbidity with physical impact but also impose a psychosocial burden on affected patients. Psoriasis (PsO) - the main skin disease in SpA - has a variety of clinical presentations, including plaque-type PsO, inverse PsO, guttate PsO, erythrodermic PsO, nail PsO and pustular types. SpA associated with IBD presents with neutrophilic and granulomatous skin disorders, including pyoderma gangrenosum, hidradenitis suppurativa and cutaneous Crohn's disease. Reactive arthritides has a favourable prognosis and may feature keratoderma blenorrhagicum or balanitis circinatum as typical skin manifestations. Immunologically, SpA-associated skin diseases share interleukin (IL)-17 and IL-23 dysregulation but show distinctive genetic and immunological profiles. Therefore, they vary in their treatment responses to targeted therapies with biologicals or small molecules. In this review, we highlight the clinical presentation of skin manifestations in SpA and discuss therapeutic approaches in this interdisciplinary field.
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Affiliation(s)
- Katharina Meier
- Department of Dermatology, Venereology and Allergology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, 10117, Germany
| | | | - Denis Poddubnyy
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Kamran Ghoreschi
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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16
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Muslimani MA, Bolcato V, Silvestri A, Brazzelli V. Psoriatic patients undergoing long‐term therapy with biologics: Impact of residual localization of psoriasis on quality of life in an Italian clinical setting. Dermatol Ther 2020; 33:e14337. [DOI: 10.1111/dth.14337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/09/2020] [Accepted: 09/19/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Muhammad Ali Muslimani
- Institute of Dermatology Fondazione IRCCS Policlinico San Matteo and University of Pavia Pavia Italy
| | - Vittorio Bolcato
- Department of Public Health, Experimental, and Forensic Medicine, Forensic Science Section “Antonio Fornari” University of Pavia Pavia Italy
| | - Annalisa Silvestri
- Scientific Direction, Clinical Epidemiology and Biometric Unit Fondazione IRCCS Policlinico San Matteo Pavia Italy
| | - Valeria Brazzelli
- Institute of Dermatology Fondazione IRCCS Policlinico San Matteo and University of Pavia Pavia Italy
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17
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Sindrilaru A, Filip A, Scharffetter‐Kochanek K, Crisan D. How can nanoparticle‐based technologies revolutionize the topical therapy in psoriasis? Exp Dermatol 2020; 29:1097-1103. [DOI: 10.1111/exd.14149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/30/2020] [Accepted: 07/06/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Anca Sindrilaru
- Department of Dermatology and Allergic Diseases University of Ulm Ulm Germany
| | - Adriana Filip
- Department of Physiology University of Medicine and Pharmacy “Iuliu Hatieganu” Cluj‐Napoca Romania
| | | | - Diana Crisan
- Department of Dermatology and Allergic Diseases University of Ulm Ulm Germany
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18
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Lanna C, Cesaroni GM, Mazzilli S, Vollono L, Gaziano R, Marino D, Bianchi L, Campione E. Apremilast as a target therapy for nail psoriasis: a real-life observational study proving its efficacy in restoring the nail unit. J DERMATOL TREAT 2020; 33:1097-1101. [PMID: 32715817 DOI: 10.1080/09546634.2020.1801976] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE Psoriasis, Psoriatic Arthritis and Nail psoriasis are chronic diseases that share a common underlying etiology of immunity dysregulation, enhanced activation of inflammatory pathways and remitting-relapsing course. Although nails represent a small percentage of the body surface involvement of this site can lead to impaired quality of life, severe discomfort and even result in permanent disability. Current therapeutic options for nail psoriasis include a variety of topical and systemic treatments although they are often reported as unsatisfactory from patients either due to their poor effectiveness or disturbing side effects. Recently small molecule drugs such as the PDE4 inhibitors were introduced in clinical practice and specifically apremilast has shown to be an effective new treatment option for psoriasis and psoriatic arthritis. Considering either the specific mechanism of action of apremilast, we performed a real-life observational study of 24 weeks assessing apremilast role in nail psoriasis. MATHERIALS AND METHODS Patients received apremilast 30mg bid, orally. Safety and efficacy were assessed at weeks 0, 4, 8, 12 and 24 using Dermatologic Life Quality Index (DLQI) and Nail Area Psoriasis Severity Index (NAPSI). At T0 we took a nail sample to investigate the presence of onychomycosis. Culture tests were performed in all the patients to search for fungi. RESULTS We recruited a total of 15 patients with nail psoriasis. The analysis of variance (one-way ANOVA) showed the following results: DLQI (F.15.7; p-value < .00001) and NAPSI (F.9.4; p-value < .00001). Three patients (20%) presented also onychomycoses at the beginning of the treatment. CONCLUSIONS Apremilast showed fast and sustained improvement of nail psoriasis over time and a complete resolution of life quality impairment due to the disease.
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Affiliation(s)
- C Lanna
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - G M Cesaroni
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - S Mazzilli
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - L Vollono
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - R Gaziano
- Microbiology Section, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - D Marino
- Microbiology Section, Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - L Bianchi
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - E Campione
- Dermatologic Unit, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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19
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Dattola A, Balato A, Megna M, Gisondi P, Girolomoni G, De Simone C, Caldarola G, Cama E, Piaserico S, Fargnoli M, Fidanza R, Parodi A, Burlando M, Offidani A, Diotallevi F, Potenza C, Conti A, Chiricozzi A, Campione E, Bianchi L. Certolizumab for the treatment of psoriasis and psoriatic arthritis: a real‐world multicentre Italian study. J Eur Acad Dermatol Venereol 2020; 34:2839-2845. [DOI: 10.1111/jdv.16606] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/21/2020] [Indexed: 01/11/2023]
Affiliation(s)
- A. Dattola
- Department of Dermatology University of Rome“Tor Vergata” Rome Italy
| | - A. Balato
- Department of Advanced Biomedical Sciences University of Naples Federico II Naples Italy
| | - M. Megna
- Department of Clinical Medicine and Surgery University of Naples Federico II Naples Italy
| | - P. Gisondi
- Section of Dermatology and Venereology Department of Medicine University of Verona Verona Italy
| | - G. Girolomoni
- Section of Dermatology and Venereology Department of Medicine University of Verona Verona Italy
| | - C. De Simone
- Institute of Dermatology Catholic University Rome Italy
- Dermatology Unit Fondazione Policlinico Universitario A. Gemelli IRCCS Rome Italy
| | - G. Caldarola
- Institute of Dermatology Catholic University Rome Italy
| | - E. Cama
- Dermatology Unit Department of Medicine University of Padua Padua Italy
| | - S. Piaserico
- Dermatology Unit Department of Medicine University of Padua Padua Italy
| | - M.C. Fargnoli
- Department Dermatology Department of Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy
| | - R. Fidanza
- Department Dermatology San Salvatore HospitalUniversity of L'Aquila L'Aquila Italy
| | - A. Parodi
- Section of Dermatology DISSAL San Martino‐IST Polyclinic HospitalUniversity of Genoa Genoa Italy
| | - M. Burlando
- Section of Dermatology DISSAL San Martino‐IST Polyclinic HospitalUniversity of Genoa Genoa Italy
| | - A. Offidani
- Dermatology Unit Department of Clinical and Molecular Sciences Polytechnic Marche University Ancona Italy
| | - F. Diotallevi
- Dermatology Unit Department of Clinical and Molecular Sciences Polytechnic Marche University Ancona Italy
| | - C. Potenza
- Department of Medical‐Surgical Sciences and Bio‐Technologies Sapienza University of Rome, Polo Pontino Terracina Italy
| | - A. Conti
- Dermatology Unit Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine University of Modena and Reggio Emilia Modena Italy
| | - A. Chiricozzi
- Institute of Dermatology Catholic University Rome Italy
- Dermatology Unit Fondazione Policlinico Universitario A. Gemelli IRCCS Rome Italy
- Dermatology Unit Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
| | - E. Campione
- Department of Dermatology University of Rome“Tor Vergata” Rome Italy
| | - L. Bianchi
- Department of Dermatology University of Rome“Tor Vergata” Rome Italy
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20
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Lanna C, Zangrilli A, Bavetta M, Campione E, Bianchi L. Efficacy and safety of adalimumab in difficult‐to‐treat psoriasis. Dermatol Ther 2020; 33:e13374. [DOI: 10.1111/dth.13374] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Caterina Lanna
- Dermatologic Unit, Department of Systems Medicine University of Rome Tor Vergata Rome Italy
| | - Arianna Zangrilli
- Dermatologic Unit, Department of Systems Medicine University of Rome Tor Vergata Rome Italy
| | - Mauro Bavetta
- Dermatologic Unit, Department of Systems Medicine University of Rome Tor Vergata Rome Italy
| | - Elena Campione
- Dermatologic Unit, Department of Systems Medicine University of Rome Tor Vergata Rome Italy
| | - Luca Bianchi
- Dermatologic Unit, Department of Systems Medicine University of Rome Tor Vergata Rome Italy
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21
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Gulliver W, Penney M, Power R, Gulliver S, Montmayeur S, Burge R. Moderate-to-severe plaque psoriasis patients treated with ixekizumab: early real-world outcomes and adverse events. J DERMATOL TREAT 2020; 33:354-360. [PMID: 32319327 DOI: 10.1080/09546634.2020.1755009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Data on real-world experiences for patients treated with ixekizumab is currently limited.Objectives: Describe characteristics of ixekizumab-treated psoriasis patients and provide evidence of clinical outcomes using disease severity scores Body Surface Area (BSA) and Psoriasis Area and Severity Index (PASI) in the real world.Methods: Chart review was performed for adult patients treated with ixekizumab at a single Canadian dermatology clinic (February 2017-August 2018). The cohort was stratified into responders (patients who remained on ixekizumab) and non-responders (patients who discontinued ixekizumab). Subgroup analyses were performed for responders to assess clinical improvement stratified by previous biologic exposure.Results: Thirty-eight patients were included (mean observational time 32 weeks). At baseline, mean PASI and BSA were 10.8 and 11.6%, respectively. Mean changes in PASI and BSA were -7.8 and -6.7%, respectively, at week 4. PASI 100 was achieved in 70% of patients. Significant differences in mean change of BSA were seen between bio-naïve and bio-experienced patients.Conclusion: This analysis represents the first investigation of early clinical outcomes in a small cohort of Canadian patients treated with ixekizumab. Overall, complete and rapid skin clearance was observed. Future studies including more patients and longer follow-up time are crucial to confirm these findings.
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Affiliation(s)
- Wayne Gulliver
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada.,Newlab Clinical Research Inc, St. John's, Canada
| | | | - Rebecca Power
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Canada.,Newlab Clinical Research Inc, St. John's, Canada
| | | | | | - Russel Burge
- Eli Lilly and Company, Indianapolis, IN, USA.,Division of Pharmaceutical Sciences, Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH, USA
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22
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Boutet MA, Nerviani A, Lliso-Ribera G, Lucchesi D, Prediletto E, Ghirardi GM, Goldmann K, Lewis M, Pitzalis C. Interleukin-36 family dysregulation drives joint inflammation and therapy response in psoriatic arthritis. Rheumatology (Oxford) 2020; 59:828-838. [PMID: 31504934 PMCID: PMC7188345 DOI: 10.1093/rheumatology/kez358] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/17/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES IL-36 agonists are pro-inflammatory cytokines involved in the pathogenesis of psoriasis. However, their role in the pathogenesis of arthritis and treatment response to DMARDs in PsA remains uncertain. Therefore, we investigated the IL-36 axis in the synovium of early, treatment-naïve PsA, and for comparison RA patients, pre- and post-DMARDs therapy. METHODS Synovial tissues were collected by US-guided biopsy from patients with early, treatment-naïve PsA and RA at baseline and 6 months after DMARDs therapy. IL-36 family members were investigated in synovium by RNA sequencing and immunohistochemistry, and expression levels correlated with DMARDs treatment response ex vivo. Additionally, DMARDs effects on IL-36 were investigated in vitro in fibroblast-like synoviocytes. RESULTS PsA synovium displayed a reduced expression of IL-36 antagonists, while IL-36 agonists were comparable between PsA and RA. Additionally, neutrophil-related molecules, which drive a higher activation of the IL-36 pathway, were upregulated in PsA compared with RA. At baseline, the synovial expression of IL-36α was significantly higher in PsA non-responders to DMARDs treatment, with the differential expression being sustained at 6 months post-treatment. In vitro, primary PsA-derived fibroblasts were more responsive to IL-36 stimulation compared with RA and, importantly, DMARDs treatment increased IL-36 expression in PsA fibroblasts. CONCLUSION The impaired balance between IL-36 agonists-antagonists described herein for the first time in PsA synovium and the decreased sensitivity to DMARDs in vitro may explain the apparent lower efficacy of DMARDs in PsA compared with RA. Exogenous replacement of IL-36 antagonists may be a novel promising therapeutic target for PsA patients.
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Affiliation(s)
- Marie-Astrid Boutet
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Alessandra Nerviani
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Gloria Lliso-Ribera
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Davide Lucchesi
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Edoardo Prediletto
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Giulia Maria Ghirardi
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Katriona Goldmann
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Myles Lewis
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Costantino Pitzalis
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute and Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Segaert S, Calzavara-Pinton P, de la Cueva P, Jalili A, Lons Danic D, Pink AE, Thaçi D, Gooderham M. Long-term topical management of psoriasis: the road ahead. J DERMATOL TREAT 2020; 33:111-120. [DOI: 10.1080/09546634.2020.1729335] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
| | | | - Pablo de la Cueva
- Department of Dermatology, University Hospital Infanta Leonor de Madrid, Madrid, Spain
| | - Ahmad Jalili
- Department of Dermatology, Bürgenstock Medical Center, Obbürgen, Switzerland
| | | | - Andrew E. Pink
- St John’s Institute of Dermatology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Diamant Thaçi
- Institute and Comprehensive Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - Melinda Gooderham
- SKiN Centre for Dermatology, Probity Medical Research and Queen’s University, Peterborough, Canada
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24
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Affiliation(s)
- I. Belinchón
- Department of Dermatology Hospital General Universitario de Alicante‐ISABIAL Universidad Miguel Hernández Alicante Spain
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25
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Carubbi F, Fidanza R, Palmieri M, Ventura A, Tambone S, Cipriani P, Giacomelli R, Fargnoli MC. Safety and efficacy of certolizumab pegol in a real-life cohort of patients with psoriasis and psoriatic arthritis. J DERMATOL TREAT 2019; 31:692-697. [DOI: 10.1080/09546634.2019.1605143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Francesco Carubbi
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
- Department of Medicine, ASL1 Avezzano-Sulmona-L’Aquila, L’Aquila, Italy
| | - Rosaria Fidanza
- Department of Medicine, ASL1 Avezzano-Sulmona-L’Aquila, L’Aquila, Italy
- San Salvatore Hospital, UOSD Dermatologia, L’Aquila, Italy
| | - Maria Palmieri
- Dermatology Department, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Alessandra Ventura
- Dermatology Department, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Sara Tambone
- Dermatology Department, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Paola Cipriani
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Roberto Giacomelli
- Rheumatology Unit, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
| | - Maria Concetta Fargnoli
- Dermatology Department, Department of Biotechnological and Applied Clinical Science, School of Medicine, University of L'Aquila, L'Aquila, Italy
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IL-36, IL-37, and IL-38 Cytokines in Skin and Joint Inflammation: A Comprehensive Review of Their Therapeutic Potential. Int J Mol Sci 2019; 20:ijms20061257. [PMID: 30871134 PMCID: PMC6470667 DOI: 10.3390/ijms20061257] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 02/06/2023] Open
Abstract
The interleukin (IL)-1 family of cytokines is composed of 11 members, including the most recently discovered IL-36α, β, γ, IL-37, and IL-38. Similar to IL-1, IL-36 cytokines are initiators and amplifiers of inflammation, whereas both IL-37 and IL-38 display anti-inflammatory activities. A few studies have outlined the role played by these cytokines in several inflammatory diseases. For instance, IL-36 agonists seem to be relevant for the pathogenesis of skin psoriasis whereas, despite being expressed within the synovial tissue, their silencing or overexpression do not critically influence the course of arthritis in mice. In this review, we will focus on the state of the art of the molecular features and biological roles of IL-36, IL-37, and IL-38 in representative skin- and joint-related inflammatory diseases, namely psoriasis, rheumatoid arthritis, and psoriatic arthritis. We will then offer an overview of the therapeutic potential of targeting the IL-36 axis in these diseases, either by blocking the proinflammatory agonists or enhancing the physiologic inhibitory feedback on the inflammation mediated by the antagonists IL-37 and IL-38.
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27
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Mokni S, Ameur K, Ghariani N, Sriha B, Belajouza C, Denguezli M, Nouira R. A Case of Nail Psoriasis Successfully Treated with Intralesional Methotrexate. Dermatol Ther (Heidelb) 2018; 8:647-651. [PMID: 30255281 PMCID: PMC6261120 DOI: 10.1007/s13555-018-0261-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Indexed: 12/01/2022] Open
Abstract
Psoriasis is a chronic inflammatory disease affecting the skin, nails, and joints. About 61% of psoriatic patients have nail involvement that can cause a significant social problem. Treating nail psoriasis is challenging but can improve the health outcomes and quality of life of patients. Treatment options available for nail psoriasis including topical therapy, intralesional injections, and systemic and biologic agents have various side effects and some benefits. Management is currently inconclusive. Intralesional injection of methotrexate in nail psoriasis was previously documented in few cases. We present a case of nail psoriasis successfully treated with low-dose intralesional methotrexate with no significant side effects in a 48-year-old psoriatic patient. Given the various side effects of conventional topical and systemic therapies limiting their use, we conclude that intralesional methotrexate injection seems to be a safe and effective treatment option for nail psoriasis. However, large controlled studies are needed.
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Affiliation(s)
- Sana Mokni
- Department of Dermatology, Farhat Hached University Hospital, Sousse, Tunisia
| | - Khaoula Ameur
- Department of Dermatology, Farhat Hached University Hospital, Sousse, Tunisia.
| | - Najet Ghariani
- Department of Dermatology, Farhat Hached University Hospital, Sousse, Tunisia
| | - Badreddine Sriha
- Department of Anatomopathology, Farhat Hached University Hospital, Sousse, Tunisia
| | - Colandane Belajouza
- Department of Dermatology, Farhat Hached University Hospital, Sousse, Tunisia
| | - Mohamed Denguezli
- Department of Dermatology, Farhat Hached University Hospital, Sousse, Tunisia
| | - Rafiaa Nouira
- Department of Dermatology, Farhat Hached University Hospital, Sousse, Tunisia
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Abstract
Genital psoriasis affects approximately 63% of psoriasis patients at least once in their lifetime. More than any other area on the body, genital lesions significantly impair patients' psychologic well-being and quality of life. We aimed to systematically review the published evidence on the safety, efficacy, and tolerability of treatments of genital psoriasis and synthesize the available clinical data. A total of 1 randomized controlled trial, 11 open-label studies, and 26 case reports were included in our analysis, representing a total of 458 patients, of which 332 were adults and 126 were children. Topical corticosteroids were commonly used first-line for genital psoriasis and were well tolerated. Nonsteroidal agents, such as topical calcineurin inhibitors or vitamin D analogs, were also efficacious, but were often irritating. One systemic agent, ixekizumab, demonstrated efficacy in reducing genital psoriasis symptoms in a large, randomized, placebo-controlled trial. Various systemic and topical medications may improve genital psoriasis lesions, but there is a lack of high-quality evidence to guide clinical decision-making. Specific reporting of efficacy for genital psoriasis in larger controlled studies of psoriasis treatments are necessary to improve the available evidence regarding the optimal treatment regimen for genital psoriasis.
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