British Association of Dermatologists guidelines for use of biological interventions in psoriasis 2005

Targeted therapy for immune mediated skin diseases. What should a dermatologist know?

BACKGROUND

Molecularly targeted therapies, such as monoclonal antibodies (mAbs) and Janus Kinase inhibitors (JAKis), have emerged as essential tools in the treatment of dermatological diseases. These therapies modulate the immune system through specific signaling pathways, providing effective alternatives to traditional systemic immunosuppressive agents. This review aims to provide an updated summary of targeted immune therapies for inflammatory skin diseases, considering their pathophysiology, efficacy, dosage, and safety profiles.

METHODS

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search was conducted on PubMed over the past 10 years, focusing on randomized clinical trials, case reports, and case series related to targeted immune therapies in dermatology. Eligibility criteria were applied, and data were extracted from each study, including citation data, study design, and results.

RESULTS

We identified 1360 non-duplicate articles with the initial search strategy. Title and abstract review excluded 1150, while a full-text review excluded an additional 50 articles. The review included 143 studies published between 2012 and 2022, highlighting 39 drugs currently under investigation or in use for managing inflammatory skin diseases.

STUDY LIMITATIONS

The heterogeneity of summarized information limits this review. Some recommendations originated from data from clinical trials, while others relied on retrospective analyses and small case series. Recommendations will likely be updated as new results emerge.

CONCLUSION

Targeted therapies have revolutionized the treatment of chronic skin diseases, offering new options for patients unresponsive to standard treatments. Paradoxical reactions are rarely observed. Further studies are needed to fully understand the mechanisms and nature of these therapies. Overall, targeted immune therapies in dermatology represent a promising development, significantly improving the quality of life for patients with chronic inflammatory skin diseases.

Efficacy of an adjuvant Lactobacillus rhamnosus formula in improving skin lesions as assessed by PASI in patients with plaque psoriasis from a university-affiliated, tertiary-referral hospital in São Paulo (Brazil): a parallel, double-blind, randomized clinical trial

Psoriasis is an inflammatory disease of the skin, characterized by erythematous plaques. It is rather common, affecting 2-4% of the population in western countries. Psoriasis' etiology encompasses both genetic and environmental factors. Evidence suggests that the latter reflect the importance of changes in the microbiome for developing the disease. Thus, it is hypothesized that gut microbiome manipulation may arise as a way of treating psoriasis. However, few trials assessed the use of probiotics in psoriasis, although promising results were detected in small studies. Our objective was to assess the efficacy of adjuvant probiotics (Lactobacillus rhamnosus) in treating plaque psoriasis patients. This was a randomized, parallel, placebo-controlled, double-blind trial with two arms: experimental (n = 50) and control (n = 53). Inclusion of subjects and data gathering lasted from November 2020 to August 2021. Subjects were consecutive plaque psoriasis patients under regular follow-up in the Dermatology unit of a university-affiliated, tertiary-referral hospital in São Paulo (Brazil). Eligibility criteria included being over 18 years old, having plaque psoriasis and not having other skin diseases, neoplasms nor systemic inflammatory diseases. Subjects received standard-of-care plus probiotics (Lactobacillus rhamnosus formula). Controls received standard-of-care plus placebo. Primary outcome was skin lesion improvement as assessed by psoriasis area of severity index (PASI) at six months. Secondary outcome was quality-of-life as assessed by dermatology life quality index (DLQI) at six months. Regarding within-group analyses, changes in both PASI and DLQI were non-significant for the experimental group (mean PASI decreased by 1.58, p = 0.105, and mean DLQI increased by 0.05, p = 0.873) and significant for controls (mean PASI decreased by 1.90, p = 0.019, and mean DLQI decreased by 3.33, p = 0.031). Between-group analyses returned non-significant results (p = 0.620). Our findings do not support the hypothesis that gut microbiome modulation via ingestion of Lactobacillus rhamnosus produces clinical improvement in psoriasis patients. Further research is encouraged.Trial registration: Retrospectively registered at the Brazilian Clinical Trials Registry (RBR-8js7t83) on 08/02/2022.

Nevi, biologics for psoriasis and the risk for skin cancer: A real concern? (Case presentation and short review)

Psoriasis is a systemic inflammatory cutaneous disease that affects approximately 2% of the world's population. Systemic treatments and biologic treatment therapies are a powerful option for patients with moderate to severe psoriasis. Some studies from the literature indicate an overall small, but increased, risk of neoplasia in patients with psoriasis treated with phototherapy or systemic medication. The relationship between psoriasis and malignancy is not very well established; there are few studies with conflicting results. We present the case of a 31-year-old male patient, diagnosed with psoriasis, who was deemed eligible for systemic therapy. Treatment with methotrexate was initiated, but without a satisfactory outcome. Given the patient's resistant disease involving 15% of his body surface, his desire to have a clear skin, besides his being naïve to biologic therapy, he was proposed to start treatment with secukinumab 300 mg monthly. The patient experienced complete clearance of lesions and was followed-up on the basis of clinical and biological parameters. There are limited data concerning the relationship between melanocytic lesions, psoriasis and melanoma. Immunologic pathways implicated in psoriasis induce a reduction in the number of melanocytic nevi. Nevertheless, little is known concerning the association of melanocytic nevi with psoriasis. Thorough skin examination, meaning clinical and dermoscopic evaluation of melanocytic lesions, must be encouraged in patients treated with systemic therapies such as biologic agents.

A Survey of Treatment Practices in Management of Psoriasis Patients among Dermatologists of Kerala

Introduction:

The management of psoriasis is a daily challenge for dermatologists as most patients present with varied morphological presentations and exacerbations at every visit. This exerts a heightened responsibility on the dermatologists to tailor their treatments according to each patient.

Aims:

This study was conducted to assess the variation in treatment practices in the management of psoriasis patients among dermatologists of Kerala.

Materials and Methods:

A questionnaire-based survey was conducted among the practicing dermatologists of Kerala, South India.

Conclusions:

At the end of this questionnaire-based study, we concluded that there is a wide variation in the treatment practices among practicing dermatologists of Kerala. Dermatology Life Quality Index (DLQI) is not assessed by majority of dermatologists while planning treatment. Most dermatologists rely on body surface area while planning treatment due to time constraints and did not perform PASI (Psoriasis Area and Severity Index) or PGA (Physician Global Assessment) scoring. Satisfaction and challenges related to current therapies also impact treatment rates. Our dermatologists adhered to their own individual guidelines while treating and expressed a dire need for a unified guideline.

Switching to secukinumab in difficult-to-treat psoriasis recalcitrant to methotrexate, cyclosporine and leflunomide, in a tuberculosis-endemic country

Several biological agents have been approved for the treatment of recalcitrant psoriasis. However, there is a lack of a consensus algorithm guiding the drug selection for patients who have failed conventional drugs. In cases not improving with cyclosporine, direct switching to a biological therapy usually leads to a disease flare owing to increased production of interleukin (IL)-17A. Thus, secukinumab, a rapidly acting anti-IL-17A drug, may be ideal in such situations.

Characterizing high-burden rosacea subjects: a multivariate risk factor analysis from a global survey

Objective: To characterize rosacea features suitable for identification of high-burden (HB) subjects in clinical practice.Design: Global online survey with subjects recruited using an online panel from the United States, Canada, Italy, United Kingdom, Germany and France. Subjects self-reported a physician's diagnosis of rosacea.Measurements: HB subjects were defined as those with ≥3/4 domains (quality of life, lifestyle adaptation, time trade-off, willingness to pay) greater than the median. Group characteristics were analyzed and multivariate-logistic modeling used to investigate factors most associated with HB.Results: 710 subjects completed the survey, including 158 HB subjects. HB was observed in all self-declared rosacea severities. HB subjects were more likely to spend more time daily on skin care and experienced approximately double the impact of health problems on work productivity in the past 7 days (p < .01). In the past 12 months, HB subjects were more likely to have at least one visit to the emergency room (41.8% vs 11.2%; p < .01). In the multivariate risk analysis, factors most associated with HB included rosacea severity, impact of health problems on regular daily activities and age at first symptoms.Conclusion: Rosacea has a distinct subset of HB subjects who can be successfully characterized.

Sustainability and switching of biologics for psoriasis and psoriatic arthritis at Fukuoka University Psoriasis Registry

Biologics are efficacious for treating psoriasis vulgaris (PsV) and psoriatic arthritis (PsA), but sometimes must be terminated or changed for various reasons including ineffectiveness or adverse events. To find the optimal choice of biologics for treating psoriasis, we analyzed the real-world data on drug survival and the reason for terminating or switching biologics. Medical records from patients with PsV or PsA, who visited the Department of Dermatology, Fukuoka University Hospital from 2010 to 2017, were analyzed. Two hundred and eleven patients received biologics, and 147 patients (69.7%) were treated with only one biologic, while 64 patients (30.3%) were switched to different products. Frequently used biologics in PsV were ustekinumab (UST), infliximab and adalimumab when calculated by patient-year. Tumor necrosis factor inhibitor (TNFi) use decreased while UST and interleukin (IL)-17 inhibitors increased in newly introduced patients. UST showed the highest survival rate as a first-line drug, but the advantage was lost in the second reagent's group. The major reasons for terminating/switching biologics were as follows: primary ineffectiveness (26.4%), secondary loss of efficacy (36.5%), patient's preference, including referral to nearby hospital, or stopped visiting (22.6%), side-effects (7.7%), comorbidities (3.4%) and economic burden (2.4%). In PsA patients, TNFi are more frequently employed than in PsV patients, although switching to UST or IL-17 inhibitors showed an increasing trend. Biologic reagents were changed mostly because of primary or secondary loss of efficacy, which affected drug survival. Further research is needed to find the optimal choice of biologics with larger samples at multiple facilities.

Japanese guidelines for the management and treatment of generalized pustular psoriasis: The new pathogenesis and treatment of GPP

Generalized pustular psoriasis (GPP) is a rare disease characterized by recurrent fever and systemic flushing accompanied by extensive sterile pustules. The committee of the guidelines was founded as a collaborative project between the Japanese Dermatological Association and the Study Group for Rare Intractable Skin Diseases under the Ministry of Health, Labour, and Welfare Research Project on Overcoming Intractable Diseases. The aim of the guidelines was to provide current information to aid in the treatment of patients with GPP in Japan. Its contents include the diagnostic and severity classification criteria for GPP, its pathogenesis, and recommendations for the treatment of GPP. Since there are few clinical trial data with high levels of evidence for this rare disease, recommendations by the committee are described in the present guidelines.

Successful Treatment of Inflammatory Linear Verrucous Epidermal Nevus with Concomitant Psoriasis Using Etanercept

Linear psoriasis is a rare form of the disease characterized by the linear distribution of lesions involving dermatome or along Blaschko's lines. Clinically, it may resemble inflammatory linear verrucous epidermal nevus; a combination of history, skin examination, and histopathology are required to ensure correct diagnosis and appropriate therapy. This paper describes a case of a 23-year-old male presenting with unilateral erythematous scaly plaques arranged in a linear path on the left leg. Etanercept was initiated after poor response to adalimumab. Improvement of his psoriasis was noted, with PASI 75 reduction after 24 weeks of treatment. Clinical studies have shown excellent efficacy of etanercept, and our patient well tolerated treatment with etanercept for 52 weeks without any adverse effects.

Safety and Efficacy of Itolizumab in the Treatment of Psoriasis: A Case Series of 20 Patients

Psoriasis is a common, chronic, relapsing/remitting, immune-mediated skin disease that causes itchy skin with silvery scales. It is characterized by thickened red erythematous plaques covered with silvery scales. Biological therapies have been recently introduced for patients with psoriasis in India. The biological therapies contain protein biomolecules which can be employed to target specific immune or genetic mediator of a pathophysiological process. Here, we share our clinical experience of managing 20 patients with moderate to severe psoriasis by itolizumab a humanized IgG1 monoclonal antibody. Eighteen patients achieved Psoriasis Area and Severity Index (PASI) 75 response after receiving 10 infusion of itolizumab (at the completion of treatment). Out of 18 patients 4 patients had achieved PASI 95 response and 10 patients had achieved PASI 90 response. There was no adverse event reported during the treatment period. Itolizumab was found effective and safe in the treatment of moderate to severe psoriasis patients.

Pragmatic Multicriteria Decision Analysis (MCDA) Combined With Advanced Pharmacoepidemiology for Benefit-Risk Assessments of Medicines Adapted to the Real-Life Constraints of Regulators: Development and Case Study

BACKGROUND

Multicriteria decision analysis (MCDA) represents a promising method for benefit-risk assessment. Our goal was to develop features of pragmatic MCDA (EVIDEM [Evidence and Value: Impact on DEcisionMaking]) addressing real-life regulatory decision-making needs, incorporate advanced pharmacoepidemiology, and test the resulting benefit-risk framework using a case study.

METHODS

The Intervention Outcomes domain of EVIDEM was transformed into a generic benefit-risk framework including clinical efficacy, patient-reported outcomes, and adverse event (AE) criteria. The concept of relative benefit-risk balance (RBRB) was developed for comparability across products and therapeutic areas and over time. Evidence matrix was designed to include most relevant data from trials, observational studies, and models, including Bayesian and longitudinal modeling. The framework was tested with a panel of stakeholders using efalizumab for psoriasis as retrospective case study. Uncertainty was explored.

RESULTS

The MCDA benefit-risk tree was adapted with psoriasis-specific subcriteria. Panelists assigned similar weights to benefits (0.48; SD, 0.20-0.70) and risks (0.52; SD, 0.10-0.60), with large variations reflecting diverse perspectives. Panelist scores reflected higher efficacy versus placebo, lower efficacy versus active comparators, and serious and fatal AEs identified postlicensing. Efalizumab's RBRB was positive at licensing in 2004 (0.29, scale -1 to +1) and ranged from -0.41 (vs active comparators) to 0.01 (vs placebo) in 2009, when its market authorization was withdrawn. Retesting indicated good reproducibility. Panelists acknowledged good face validity and the importance of criteria beyond benefit-risk in real-life assessments.

CONCLUSIONS

The approach allows quantification and visualization of benefit-risk over time and across comparators. Combination of pragmatic MCDA designed to integrate criteria beyond benefit-risk and advanced statistics supports application of MCDA to further accountable benefit-risk assessments for real-life decision making.

Biologic Therapeutics in the Treatment of Psoriasis. Part 2: Practical Considerations

Background:

Psoriasis is a chronic inflammatory skin disease principally mediated by activated T cells, which release proinflammatory cytokines with reactive epidermal changes in the skin, producing the characteristic lesions of psoriasis. New research into possible treatment options has been inspired by increased understanding of the pathophysiology of psoriasis and advances in immunology and molecular biology permitting the development of targeted, highly active biologic agents.

Objective:

The aim of this article is to provide practical guidelines for integration of these agents in the management of psoriasis.

Practical Considerations for the Initiation and Maintenance of Etanercept in the Treatment of Psoriasis

Etanercept is a new treatment for moderate to severe psoriasis. In contrast to traditional systemic agents, which can be given orally, etanercept is given by subcutaneous injection. Patient selection, transitioning, dosing, safety, monitoring, duration of therapy, and patient support programs are reviewed.

Challenges and Solutions in Selecting Systemic Antipsoriatic Agents

More than nine treatment options are available in Canada for moderate to severe psoriasis vulgaris. The process of deciding on optimal systemic antipsoriatic therapy for individual patients is dependent on multiple factors, including medical contraindications, the risks and benefits of treatment, and patient values and preferences. This article addresses current challenges faced by both dermatologists and their patients in the process of selecting systemic antipsoriatic therapy. Informed shared decision making is a useful relational model to describe the interaction between dermatologists and psoriasis patients in the selection of best systemic antipsoriatic treatment. There are no systematic reviews inclusive of the spectrum of treatment options for moderate to severe psoriasis, including biologics. Current guidelines of care are of varying quality and provide disparate and conflicting recommendations. Shortcomings in facilitating informed choice include inadequate training, skills, and resources. There is an urgent need for a high-quality systematic review of systemic antipsoriatic agents that includes the biologics. The evidence from such a document can form the basis for rational clinical guidelines and policy and can provide the foundation for educational and counseling tools. Furthermore, to facilitate dialogue and values-based informed choice, the use of decision aids for patients may be useful in selection of the most appropriate therapy.

Relationship between psoriasis and non-alcoholic fatty liver disease

Introduction

Various components of metabolic syndrome have an important role in the pathogenesis of both non-alcoholic fatty liver disease (NAFLD) and psoriasis, suggesting an association between these diseases. However, at present very few studies have reported on the systematic evaluations of the prevalence of NAFLD in patients with psoriasis disorder.

Aim

To investigate the prevalence of NAFLD in patients with psoriasis vulgaris. The study also evaluated the parallel relationship between both of the diseases.

Material and methods

Patients over18 years old and with a diagnosis of psoriasis vulgaris at the outpatient unit of Department of Dermatology were considered for enrolment and were followed up by the Department of Hepatology, Madras Medical College. Each and every patient completed a questionnaire, underwent a thorough skin evaluation, and had a right upper quadrant ultrasound and fasting blood workup.

Results

Two hundred and fifty patients were enrolled in the study. The participants were predominantly middle aged (mean: 44.74 ±11.989 years), overweight (average body mass index (BMI): 24.772 ±3.611 kg/m²), and male (68%, n = 170). The overall prevalence of NAFLD among psoriasis was 45.2%.

Conclusions

Non-alcoholic fatty liver disease is highly prevalent among our cohort of patients with psoriasis, occurring in 45.2% of patients. Comorbidity of NAFLD is highly associated with psoriasis, which emphasises that both diseases may develop simultaneously. Health care providers should be mindful of this association since early evaluation and diagnosis of NAFLD in patients with psoriasis may play a vital role in alleviating the progression of liver disease.

Evaluating equality in psoriasis healthcare: a cohort study of the impact of age on prescription of biologics

BACKGROUND

Inequality in healthcare has been identified in many contexts. To the best of our knowledge, this is the first study investigating age inequality in the form of prescription patterns of biologics in psoriasis care.

OBJECTIVES

To determine whether patients with psoriasis have equal opportunities to receive biological medications as they age. If patients did not receive equal treatment, a subsequent objective was to determine the magnitude of the disparity.

METHODS

A cohort of biologic-naive patients with psoriasis was analysed using Cox proportional hazards models to measure the impact of each additional year of life on the likelihood of initiating biological treatment, after controlling for sex, body mass index, comorbidities, disease activity and educational level. A supporting analysis used a nonparametric graphical method to study the proportion of patients initiating biological treatment as age increased, after controlling for the same covariates.

RESULTS

The Cox proportional hazards model resulted in hazard ratios of a 1-year increase in age of 0·96-0·97 depending on calendar-year stratification, which implies that an increase in age of 30 years corresponds to a reduced likelihood of initiating biological treatment by 61·3-67·6%. The estimated proportion of patients initiating biological medication always decreased as age increased, at a statistically significant level.

CONCLUSIONS

Patients with psoriasis have fewer opportunities to access biological medications as they age. This result was shown to be applicable at all stages in a patient's life course and was not only restricted to the elderly, although it implies greater disparities as the age difference between patients increases. These results show that inequality in access to biological treatments due to age is prevalent in clinical practice today. Further research is needed to investigate the extent to which this result is influenced by patient preferences.

A multileveled approach in psoriasis assessment and follow-up: A proposal for a tailored guide for the dermatological practice

BACKGROUND

Psoriasis is a complex and heterogeneous disease resulting from interactions between genetic, immunological, and environmental factors. To make the most optimal treatment decision, the dermatologist must therefore have a detailed overview of the patient's history and lifestyle.

OBJECTIVES

We sought to offer an overview of the various relevant aspects in clinical dermatological assessment of psoriasis patients, emphasizing the importance of a multidisciplinary and integrated clinical approach.

METHODS

We gathered information on psoriasis management and developed a tailored checklist covering all health-related aspects associated with psoriasis.

RESULTS

Demographics, personal and family history were elaborately described as well as drug history to discuss how they affect psoriasis management. Relevant patient information such as the vaccination status or cardiovascular profile were included in the checklist as well and treatment recommendations were adapted and updated in accordance with evidence-based literature. This checklist also emphasizes the importance of drug surveillance, proper follow-up and specialist referral, and why the dermatologist needs to address these health-related aspects when assessing psoriasis patients, going beyond optimal skin care.

CONCLUSIONS

Our comprehensive overview can be used as a consultation checklist for good clinical practice in psoriasis patient management and aid in treatment decision.

To test or not to test? An updated evidence-based assessment of the value of screening and monitoring tests when using systemic biologic agents to treat psoriasis and psoriatic arthritis

BACKGROUND

Safety profiles of systemic biologic agents for the treatment of psoriasis and psoriatic arthritis (PsA) encompass a wide spectrum of adverse events. To date, no uniform evidence-based guidelines exist regarding screening and monitoring patients who are undergoing biologic therapy.

OBJECTIVE

We sought to identify studies evaluating screening and monitoring tests in the treatment of psoriasis and PsA with systemic biologic agents, and to propose evidence-based practical guidelines.

METHODS

The MEDLINE database was searched to identify data on risks associated with adalimumab, etanercept, infliximab, and ustekinumab. Articles were reviewed and graded according to methods developed by the US Preventative Services Task Force.

RESULTS

Evidence was strongest (grade B) for tuberculosis screening. Interferon-gamma release assay was preferable to tuberculin skin testing. Among known hepatitis B virus carriers, the evidence grade was C for monitoring liver function tests and viral load.

LIMITATIONS

This study was limited by the lack of high-quality controlled trials evaluating screening and monitoring tests in patients treated with biologic agents.

CONCLUSIONS

Baseline tuberculosis testing remains the only screening test with strong evidence to support its practice. Other screening and monitoring tests commonly performed in patients who are taking biologic agents are supported only in certain clinical settings or lack evidence to support or recommend against their practice.

Lack of evidence of viral reactivation in HBsAg-negative HBcAb-positive and HCV patients undergoing immunosuppressive therapy for psoriasis

BACKGROUND

HBV and HCV reactivation have been widely reported in patients undergoing immunosuppressive therapy (IT); however, few data are available on the risk of reactivation in patients with psoriasis receiving IT. The aim of our study was to assess the prevalence of HBV and HCV infection in patients with psoriasis and to evaluate the effects of IT during the course of the infection.

METHODS

The study included psoriatic patients who attended an Italian tertiary referral hospital from 2009 to 2012. A total of 224 patients were enrolled. We evaluated: HBV and HCV markers, type of IT and the occurrence of viral reactivation. The observational period ranged from the beginning of IT to the last visit, with a mean follow-up period of 54 months.

RESULTS

Two hundred and twenty patients (135 males and 89 females; mean age 59 years; range 18-86 years) with psoriasis, with or without psoriatic arthritis, receiving conventional IT and/or biological drugs were tested for markers of infection. We identified 23/224 patients (10.2%) with isolated positivity for HBcAb positivity, 36/224 (16%) with positivity for HBsAb/HBcAb, and 15/224 (6.6%) with positivity for HCV-Ab. No patient was HBsAg positive, none of them underwent pre-emptive therapy with lamivudine or other antiviral drugs and no one showed episodes of viral reactivation.

CONCLUSIONS

The prevalence of HBsAg in patients with psoriasis is lower than that observed in the general population. The prevalence of isolated positivity for HBcAb and of combined positivity for HBcAb and HBsAb is 10.2% and 16%, respectively. The prevalence of HCV infection (HCV-RNA+) is 4%. In patients with psoriasis and HCV-Ab or HBcAb positivity, the IT seems to be safe, regardless of the type of drugs.

Dyslipidemia in Psoriasis: A Case Controlled Study

Multiple observational studies have demonstrated associations of psoriasis with metabolic syndrome including obesity, diabetes, hypertension, dyslipidemia, and osteoporosis. However there is paucity of Indian studies on dyslipidemia in psoriasis. The aim of this study was to assess the serum lipids in psoriasis and to investigate the association of lipids with disease severity and its duration. 100 cases of psoriasis (75/M, 25/F), between 15 and 72 years, were recruited with age and sex matched 73 controls. Using Psoriasis Area Severity Index (PASI) cases were graded into mild, moderate, and severe psoriasis. Serum total cholesterol and triglycerides were analyzed using enzymatic method. Using independent t-test, significant elevation of serum cholesterol, triglycerides, high density lipoprotein (HDL) and very low density lipoprotein was observed (P < 0.05) when compared to controls. The levels of low density lipoproteins were comparable in cases and controls. Lipid aberrations in hypertensive patients were significant. There was a decrease in HDL levels with increase in disease severity. A fall in the levels of HDL was seen in cases with long term psoriasis. There is a strong association of dyslipidemia with psoriasis. There exist racial and ethnic variation in the prevalence of psoriasis; however, dyslipidemia is consistently seen in diverse population. Whether genetic factors are implicated in lipid derangements in psoriasis needs further research.

Quality of life in psoriasis patients

Patient-reported outcomes are major components of decision making in clinical research, reimbursement, health policy and health care for psoriasis. The most important construct in patient-reported outcomes is health-related quality of life (HRQoL) which encompasses the individual's well-being with respect to health. HRQoL cannot directly be measured but is assessed in single dimensions, especially physical, emotional, social and functional aspects. For this, disease- and condition-specific instruments are used. Psoriasis is a chronic inflammatory disease affecting the skin as well as other tissues and organ systems. Patients suffer from a large scale of impairments, for example, physical symptoms, stigmatization and embarrassment, psychological strain and disabilities in profession. Improvement of HRQoL is a major objective of disease management. Current knowledge on determinants of HRQoL and the treatments available increase QoL in clinical care.

Psoriasis: correlation between severity index (PASI) and quality of life index (DLQI) in patients assessed before and after systemic treatment

BACKGROUND

Psoriasis is a chronic inflammatory disease of the skin that affects patients of all ages andboth genders. The impact of the disease on quality of life is greater among patients with moderate to severe psoriasis.

OBJECTIVE

to establish a correlation between the psoriasis area and severity index (PASI) and theDermatology Life Quality Index (DLQI) based on a quality of life questionnaire adapted to the Brazilian contextfor patients with plaque psoriasis before and after systemic treatment.

METHODS

This was a cross-sectional, descriptive study of psoriasis patients who did not undergo treatment or who manifested clinical activity of the disease. Patients were evaluated according to the PASI and the quality of life questionnaire adapted to theBrazilian context before and 60 days after systemic treatment.

RESULTS

Thirty-five patients participated in thestudy. Twenty-six were men, with a mean age of 46 years. There was no correlation between the PASI and thequality of life questionnaire adapted to the Brazilian context, but there was a correlation between the PASI andsome items of the quality of life questionnaire adapted to the Brazilian context, such as jobs involving public contact.

CONCLUSION

The non-correlation between the PASI and the quality of life questionnaire adapted to the Brazilian context in this work may be associated with a history of chronic disease, which implies greater acceptance of the illness, or may be related to the low income and social status of the patients studied. The correlationobserved among patients with careers involving public contact suggests that some professions are more impacted by the disease. It may be necessary to adapt the quality of life questionnaire to patients with a low income andcultural and social limitations. The small sample size (n=35 patients) and the short follow-up period of 60 dayswere some of the limitations of this work.

Risk of moderate to advanced kidney disease in patients with psoriasis: population based cohort study

OBJECTIVE

To determine the risk of chronic kidney disease in patients with psoriasis.

DESIGN

Population based cohort study and nested cross sectional study.

SETTING

Electronic medical records database based in United Kingdom.

PARTICIPANTS

Cohort study: patients with psoriasis aged 18-90 each matched to up to five patients without psoriasis based on age, practice, and time of visit. Nested study: patients with psoriasis aged 25-64 with confirmed data on psoriasis severity, each matched to up to 10 patients without psoriasis based on age and practice.

MAIN OUTCOME MEASURES

Cohort study: incident moderate to advanced (stage 3 through 5) chronic kidney disease. Nested study: baseline prevalence of chronic kidney disease.

RESULTS

136,529 patients with mild psoriasis and 7354 patients with severe psoriasis based on treatment patterns were matched to 689,702 unaffected patients. The adjusted hazard ratios (95% confidence intervals) for incident chronic kidney disease were 1.05 (1.02 to 1.07), 0.99 (0.97 to 1.02), and 1.93 (1.79 to 2.08) in the overall, mild, and severe psoriasis groups, respectively. Age was a significant effect modifier in the severe psoriasis group, with age specific adjusted hazard ratios (95% confidence intervals) of 3.82 (3.15 to 4.64) and 2.00 (1.86 to 2.17) for patients aged 30 and 60, respectively. In the nested analysis of 8731 patients with psoriasis with measurements of affected body surface area matched to 87,310 patients without psoriasis, the adjusted odds ratios (95% confidence intervals) for chronic kidney disease were 0.89 (0.72 to 1.10), 1.36 (1.06 to 1.74), and 1.58 (1.07 to 2.34) in the mild, moderate, and severe psoriasis groups, respectively.

CONCLUSIONS

Moderate to severe psoriasis is associated with an increased risk of chronic kidney disease independent of traditional risk factors.

Safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and chronic viral hepatitis B or C: a retrospective, multicentre study in a clinical setting

BACKGROUND

Both the safety and efficacy of biologic therapy may be affected in the presence of highly prevalent chronic viral hepatitis.

OBJECTIVE

To evaluate the safety and effectiveness of ustekinumab and antitumour necrosis factor therapy in patients with psoriasis and concomitant chronic viral hepatitis.

METHODS

This was a retrospective, multicentre study. Twenty-five patients with psoriasis and concurrent hepatitis C virus (HCV) (20 patients) or hepatitis B virus (HBV) (five patients) infection who had received at least one biologic agent (etanercept, 21 treatments; adalimumab, four; ustekinumab, four; infliximab, two) were included. Clinical, imaging and laboratory data were recorded.

RESULTS

In the case of HCV infection, the majority of the patients did not exhibit increases in their viral load or serum liver tests. Aspartate aminotransferase, alanine aminotransferase and gamma glutamyl transpeptidase were doubled from the baseline measurement in only one patient treated with etanercept. Two other cases exhibited viral load increases during the follow-up period. In total, 18 of the 26 treatments achieved a 75% improvement in their Psoriasis Area and Severity Index (PASI 75) score during the follow-up period. Two patients treated with etanercept were diagnosed with hepatocellular carcinoma. In the case of HBV infection, all of the patients were being treated with antiviral therapy, and none presented significant variations in viral load or serum liver enzymes. All patients achieved a PASI 75 during follow-up.

CONCLUSIONS

Biologic therapy was effective and safe for the majority of our patients with HCV and HBV infection, although there may be a risk of reactivation or aggravation. We describe the first cases to receive ustekinumab. The use of biologics should be limited to those cases in which the risk-benefit ratio is justified.

Barriers to the prescription of systemic therapies for moderate-to-severe psoriasis--a multinational cross-sectional study

Despite the availability of a plethora of approved systemic treatments, high proportions of patients with moderate-to-severe psoriasis do not receive systemic treatment. This study aims at identifying barriers that hinder dermatologists from prescribing systemic treatments for psoriasis. A cross-sectional online survey in six countries (Canada, Germany, Spain, France, Italy, UK) was performed among 300 dermatologists, assessing the relevance of 15 potential barriers towards prescribing acitretin, cyclosporine, methotrexate, adalimumab, etanercept, infliximab and ustekinumab. Multivariate regression analyses were used to explore provider characteristics related to these barriers. Treatment barriers are perceived differently in the countries investigated, with Spanish, Italian and Canadian dermatologists being particularly concerned about the safety of methotrexate and Canadian dermatologists about the safety of cyclosporine. In general, safety concerns were the most important barrier to the use of cyclosporine, (18 % of participants' moderate/9 % strong or very strong barrier). Costs were being perceived as a strong or very strong barrier to the use of the different biologics by 19-24 % of the participants. Overall, country and work place were the most important determinants of treatment barriers. Sex, age, training, position and experience were minor determinants of treatment barriers. Medical reasons such as safety concerns or an inappropriate risk-benefit profile are particularly relevant barriers to the prescription of conventional treatments; whereas for biological treatments, economic reasons such as costs are more prevalent. Country specific analysis showed national differences in the perception of safety. The treatment barriers identified in this exploratory study should be confirmed in further health services research.

Long-term safety of anti-TNF adalimumab in HBc antibody-positive psoriatic arthritis patients: a retrospective case series of 8 patients

Immunosuppressive drugs commonly used in the treatment of psoriatic arthritis make patients more susceptible to viral, bacterial, and fungal infections because of their mechanism of action. They not only increase the risk of new infections but also act altering the natural course of preexisting infections. While numerous data regarding the reactivation of tuberculosis infection are available in the literature, poor information about the risk of reactivation or exacerbation of hepatitis viruses B and C infections during treatment with biologics has been reported. Furthermore, reported series with biological therapy included short periods of followup, and therefore, they are not adequate to verify the risk of reactivation in the long-term treatment. Our study evaluated patients with a history of hepatitis B and psoriatic arthritis treated with adalimumab and monitored up to six years. During the observation period, treatment was effective and well tolerated in all patients, and liver function tests and viral load levels remained unchanged.

Which antipsoriatic drug has the fastest onset of action? Systematic review on the rapidity of the onset of action

The time necessary for a treatment to become effective is crucial for patients and physicians but has been largely neglected in the reporting and comparison of clinical trials in dermatology. The aim of this systematic review is to determine the time until the onset of action (TOA) of systemic agents approved for moderate-to-severe psoriasis. Primary outcome is the TOA defined as the weighted mean time until 25% of the patients achieved a psoriasis area and severity index (PASI) 75 response. Among the biologics, infliximab has the shortest TOA (3.5 weeks), followed by ustekinumab (high dose 4.6/low dose 5.1 weeks/not weight adapted), adalimumab (4.6 weeks), etanercept (high dose 6.6/low dose 9.5 weeks), and alefacept (high dose 15.4 weeks/low dose: no data). Among the conventional treatments, good data are available for cyclosporine A (CsA; TOA: 6.0 weeks) and limited data are found for methotrexate (MTX; TOA: high dose 3.2/low dose 9.9 weeks). No data are available for fumaric acid esters and retinoids. This systematic review provides clinically relevant information on the onset of action of antipsoriatic agents, although the data currently available allow only a limited assessment. Psoriasis trials should consider including TOA as an additional outcome measure.

Biologic therapies in dermatology

Biologic therapies, the anti-cytokines in particular, have proved to be a significant addition to the dermatologist’s armamentarium for the management of severe skin disease. This article summarizes the mechanism of action, dosage, approved indications, off-label uses and the future of biologic therapies in dermatology.

The protein kinase C inhibitor AEB071 (sotrastaurin) modulates migration and superoxide anion production by human neutrophils in vitro

We examined the effect of the protein kinase C-selective inhibitor AEB071 (sotrastaurin) on neutrophil functions in vitro. Pre-incubation with AEB071 at concentrations similar to those reached during in vivo therapy significantly reduced cell capacity to migrate toward three different chemo-attractants and to produce superoxide anions (O₂⁻) in response to phorbol myristate acetate (PMA) or to N-formyl-methionyl-leucyl-phenylalanine (fMLP). AEB071 also significantly inhibited the O₂⁻ overproduction induced by fMLP in neutrophils primed with tumor necrosis factor alpha (TNF-α) or granulocyte/macrophage-colony stimulating factor (GM-CSF). This inhibition was not linked to fMLP-receptor down-regulation since the drug had no effect on either fMLP-receptors or fMLP-induced CD11b membrane expression. When the activity of AEB071 was compared to that of the conventional protein kinase C (PKC) inhibitor Gö6850 (which, like sotrastaurin, inhibits classical and novel PKC isoforms), Gö6976 (an inhibitor of α and α PKC isoforms) and rottlerin (a prevailing δ PKC isoform inhibitor), AEB071 at an equimolar concentration of 3 μM (close to the maximum drug concentration reached in patients treated with AEB071) caused significantly more inhibition on both chemotactic response and superoxide production. These in vitro findings suggest that neutrophils may offer a cellular target for AEB071 activity in vivo.

The efficacy of a health-related quality-of-life intervention during 48 weeks of biologic treatment of patients with moderate to severe psoriasis: study protocol for a multicenter randomized controlled trial

BACKGROUND

Interest in health-related quality of life (HRQoL) outcome research in dermatology is increasing, especially in the systemic treatment of psoriasis with biologic agents. In other specialties, such as oncology, the application of a HRQoL intervention is considered to be an aid for monitoring disease and treatment over time, for the communication with the patient, and for improving treatment outcome. However, in dermatology practice, the application of this intervention is relatively new. Moreover, evidence on the effectiveness of a HRQoL intervention in dermatology is missing. It is hypothesized that the application of a HRQoL intervention in dermatology practice will have a positive impact on patients' HRQoL as well as on doctor-patient communication.

METHODS/DESIGN

In a prospective multicenter cluster randomized controlled trial, patients diagnosed with moderate to severe psoriasis who receive biologic treatment, will be followed for 48 weeks. The study sites, and not the patients, will be randomly allocated via a computer-based randomization system to either the intervention (treatment with etanercept and standardized HRQoL assessment and communication) or the control group (treatment with etanercept alone). The HRQoL intervention will include 1) the electronic assessment of the Skindex-29, a well-studied dermatology-specific HRQoL questionnaire, and 2) the communication of the resulting Skindex-29 data with the patient. Prior to study start, dermatologists in the intervention group will be educated and trained in standardized HRQoL assessment and communication using the Skindex-29. At six consecutive visits, patients at study sites in the intervention group will be asked to complete the Skindex-29 on a desk-top pc at the clinic, just before their consultation with the dermatologist. A print-out of the completed questionnaire will be made and, guided by this print-out, feedback on the HRQoL scores will be given during the consultation. Primary outcome parameters are the impact of the HRQoL intervention on patients' HRQoL, and the effect of the HRQoL intervention on doctor-patient communication. Secondary outcomes include health status and disease severity.

TRIAL REGISTRATION

The Netherlands National Trial Register (NTR): NTR1364.

Ustekinumab associated thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is a rare disorder. Plasma exchange therapy has been shown to significantly reduce mortality in patients with TTP. Here, we report a case of TTP associated with ustekinumab therapy after a period of 2-3 years. Ustekinumab, a monoclonal antibody that inhibits interleukin 12 and interleukin 23, is one of the newer treatments for psoriasis. Although our patient experienced a prolonged course of TTP requiring 1 month of daily plasma exchange therapy, he recovered and remains in remission after 6 months.

The roles of cells and cytokines in the pathogenesis of psoriasis

Psoriasis is considered an immune chronic disease in which T cells are accepted as important. Nowadays, it is believed that psoriasis is most likely a T helper (Th)1/Th17 induced inflammatory disease. However, some other cells, such as endothelial cells, dendritic cells, monocytic cells, neutrophils, keratinocytes, and several cytokines, appear to have, at different stages of the disease, an important role in its pathogenesis. For instance, the response to psoriasis therapy is dependent not only on the inactivation of Th1 and Th17 immune responses but also on the inactivation of dendritic cell products. Moreover, interleukin (IL)-23 deregulation appears to be an independent factor in the pathogenesis of psoriasis. Indeed, currently, the IL-23/Th17 axis is believed to be crucial in psoriasis pathogenesis, and its inhibition appears to be important for therapeutic achievement. This review presents the roles and interactions of cells and cytokines that are related to psoriasis pathogenesis.

Efficacy and safety of infliximab vs. methotrexate in patients with moderate-to-severe plaque psoriasis: results of an open-label, active-controlled, randomized trial (RESTORE1)

BACKGROUND

Infliximab is indicated for treatment of moderate-to-severe plaque psoriasis in adults whose disease cannot be controlled with other systemic therapies, including methotrexate (MTX). To date, no studies have directly compared the efficacy and safety of infliximab and MTX.

OBJECTIVES

To compare the efficacy and safety of infliximab vs. MTX in adults with moderate-to-severe plaque psoriasis.

METHODS

MTX-naïve patients (n = 868) were randomized 3:1 to receive infliximab 5 mg kg⁻¹ at weeks 0, 2, 6, 14 and 22 or MTX 15 mg weekly with a dose increase to 20 mg weekly at week 6 if the Psoriasis Area and Severity Index (PASI) response was < 25%. At week 16, patients with < PASI 50 response could switch treatment groups. The primary efficacy endpoint was PASI 75 response at week 16. Major secondary efficacy endpoints were PASI 75 response at week 26, and the proportion of patients achieving a Physician's Global Assessment (PGA) score of cleared (0) or minimal (1) at weeks 16 and 26. Others included Dermatology Life Quality Index, 36-Item Short Form Health Survey, and PGA, PASI 50, PASI 75 and PASI 90 responses over time.

RESULTS

The primary endpoint was achieved by a significantly greater proportion of infliximab-treated patients (508/653, 78%) than MTX-treated patients (90/215, 42%; P < 0·001). Key secondary endpoints also were achieved by a greater proportion of infliximab-treated patients. Similar responses were observed at week 26 in patients who switched from MTX to infliximab at week 16. Overall adverse event (AE) incidence was comparable between groups, but incidence of serious and severe AEs was slightly higher in the infliximab group.

CONCLUSIONS

Infliximab was well tolerated and more efficacious than MTX in patients with moderate-to-severe plaque psoriasis. Infliximab also was efficacious in patients who failed MTX and switched to infliximab.

Dermatologists' awareness of and screening practices for hepatitis B virus infection before initiating tumor necrosis factor-α inhibitor therapy

OBJECTIVE

The aim of the study was to assess dermatologists' awareness of available guidelines and drug package insert information on the screening for and management of hepatitis B (HBV) infection in patients receiving tumor necrosis factor-α inhibitor (TNF-αI) drug therapies for dermatological disorders.

MATERIALS AND METHODS

An electronic descriptive cross-sectional questionnaire was administered to a random, nationwide sample of physician members of the American Academy of Dermatology. Each participating physician answered 8 questions regarding his or her awareness of the risk of HBV reactivation.

RESULTS

More than half of the dermatologists surveyed (52%) were aware of guidelines regarding TNF-αI use in dermatological disorders. Dermatologists who were aware of the guidelines performed universal screening 81% of the time versus 3% of those who were unaware. Approximately 30% of the dermatologists were aware of drug manufacturers' package insert warnings for risk of HBV reactivation with TNF-αIs. Screening in their high-risk patients was highly variable because >90% performed screening in patients with a history of hepatitis or with elevated liver-associated enzymes. Most (73%) screened appropriately with HB surface antigen. One case of HBV reactivation was observed with infliximab use for psoriasis treatment.

CONCLUSIONS

Based on this survey, improving education among dermatologists regarding the risks of HBV reactivation and its prevention for patients receiving TNF-αI seems warranted. More specific consensus guidelines are recommended to achieve universal screening as the standard of care in these patients.

Modelling the cost-effectiveness of biologic treatments for psoriatic arthritis

OBJECTIVES

A probabilistic model was developed to determine the cost-effectiveness of three biologics, etanercept, infliximab and adalimumab, compared with palliative care for the treatment of active and progressive PsA in patients who have an inadequate response to standard treatment (including DMARDs).

METHODS

A previous model was revised to evaluate the impact of biologics on both skin and joint disease and to include new evidence from the clinical review and evidence synthesis. Initial response to biologics was determined using the PsA response criteria. The impact of biologics on the arthritis component of the disease is then modelled via a change in the HAQ and the impact of the psoriasis component measured using the Psoriasis Area and Severity Index.

RESULTS

For PsA patients with mild to moderate skin disease, the incremental cost-effectiveness ratio (ICER) for etanercept vs palliative care is around £18 000, and the ICER for infliximab vs etanercept is around £44 000 per quality-adjusted life year (QALY). Adalimumab is extendedly dominated. The probability that etanercept is cost effective is 0.436 at a threshold of £20 000 per QALY. Etanercept is also likely to be cost effective for patients with moderate to severe psoriasis or negligible skin involvement.

CONCLUSIONS

Further investigation is required to reduce uncertainties around a number of model parameters, in particular the length of time over which biologics are assumed to be effective and the progression of HAQ on and off treatment.

Clastogenic plasma factors in psoriasis--comparison of phototherapy and anti-TNF-α treatments

As previously described, Psoralen plus UVA (PUVA) therapy induces chromosome damage in psoriatic patients. This study evaluates whether these effects are transitory or persistent. In addition, we studied these effects after narrowband UVB (nUVB) and anti-tumor necrosis factor (TNF)-α treatments. Among 40 responder patients, 10 received PUVA, 10 nUVB, 10 Infliximab and 10 Etanercept. Disease activity was determined with Psoriasis Area and Severity Index. Chromosomal breakage was evaluated by the clastogenic factor (CF) test. Potential clastogenic agents, malondialdehyde (MDA) and TNF-α were measured. Before treatment, the plasma-adjusted clastogenic scores (ACS) of patients were increased. During treatment, a further increase in ACS was observed in both phototherapy groups. Chromosome damage persisted for PUVA patients at week 32, while it diminished after nUVB to ACS values lower than before treatment. MDA and TNF-α values were also increased at baseline. MDA decreased during treatment in all groups, but without reaching normal levels. Plasma TNF-α remained unchanged in PUVA and nUVB but decreased in both anti-TNF-α treatment groups. Psoriasis is accompanied by CF-induced chromosomal breakage that increases during PUVA and nUVB treatments. Plasma clastogenic activity persisted in the follow-up after PUVA, while after nUVB ACS returned to values even lower than baseline. Clastogenic activity during the induction phase with anti-TNF-α remained unchanged.

Can we rely on the Dermatology Life Quality Index as a measure of the impact of psoriasis or atopic dermatitis?

The Dermatology Life Quality Index (DLQI) is a widely used health-related quality of life measure. However, little research has been conducted on its dimensionality. The objectives of the current study were to apply Rasch analysis to DLQI data to determine whether the scale is unidimensional, to assess its measurement properties, test the response format, and determine whether the measure exhibits differential item functioning (DIF) by disease (atopic dermatitis versus psoriasis), gender, or age group. The results show that there were several problems with the scale, including misfitting items, DIF by disease, age, and gender, disordered response thresholds, and inadequate measurement of patients with mild illness. As the DLQI did not benefit from the application of Rasch analysis in its development, it is argued that a new measure of disability related to dermatological disease is required. Such a measure should use a coherent measurement model and ensure that items are relevant to all potential respondents. The current use of the DLQI as a guide to treatment selection is of concern, given its inadequate measurement properties.