EuroGuiDerm Guideline on the systemic treatment of Psoriasis vulgaris – Part 2: specific clinical and comorbid situations

Portuguese consensus on first line treatment of moderate-to-severe psoriasis with a non-TNF inhibitor therapy - a delphi methodology

INTRODUCTION

Psoriasis (PsO) is a common chronic, inflammatory, immune-mediated disease. In 2023, a 4.4% prevalence of PsO was reported in Portugal. Currently, Tumor Necrosis Factor inhibitors (TNFi) are the recommended first-line (1 L) biologic agents in Portugal given their lower cost. However, TNFi may not be suitable for several patients. In these patients, interleukin inhibitors (ILi) should be considered as they provide more effective outcomes and a better safety profile.

METHODS

Qualitative interviews with PsO experts were conducted to identify PsO biologic treatment needs, resulting in an online survey to explore clinical cases focused on subpopulations of PsO. A delphi study evaluated consensus on clinical criteria to initiate non-TNFi therapy in seven predefined subpopulations of patients.

RESULTS

This study highlights the benefit of starting non-TNFi therapy in all PsO predefined subpopulations. Patients with infection risk, mild heart failure and associated comorbidities, autoimmune diseases and family history of demyelinating disease consensually benefit from starting non-TNFi therapy in 1 L. Several risks associated with latent tuberculosis, advanced age and oncological disease were also evaluated.

CONCLUSION

Given the existence of various risks associated with TNFi usage, this clinical perspective overview of Portuguese experts in PsO treatment emphasizes the need for a tailored therapeutic framework in the management of PsO.

Safety of interleukin inhibitors in patients with plaque psoriasis and history of neoplasms: a multicenter retrospective study - IL PSO (Italian landscape psoriasis)

Background: Interleukin (IL) inhibitors are increasingly used in the management of moderate-to-severe plaque psoriasis. However, their use in patients with a history of cancer is debated.

Objective: We conducted a multicenter retrospective study across nine Italian Dermatology Units to assess the real-world effectiveness and safety of IL inhibitors (IL-23, IL-17, IL-12/23) in 136 oncological patients with moderate-to-severe plaque psoriasis. In particular, we evaluated 116 patients who developed the neoplasm before starting the biologic with a mean time from diagnosis of neoplasia to the first biologic dose of 8.31 years. We also assessed 20 patients who received a diagnosis of neoplasm during treatment with IL inhibitors after a mean time of 2.41 years from the start of the biologic with a cumulative incidence of 3.06 per 1000 individuals.

Results: Three patients experienced neoplasm recurrence during treatment with IL inhibitors, which led to the discontinuation of these drugs. In our study, biologics have demonstrated safety and effectiveness as treatment options for patients with both a history of neoplasm and those with concurrent tumors. However, further investigation is needed, particularly through larger and longer multicenter studies.

The 'totality of evidence' and 'extrapolation' of SB17, a ustekinumab biosimilar

INTRODUCTION

SB17 is a ustekinumab (UST) biosimilar targeting interleukin-12/23 for treating immune-mediated inflammatory diseases (IMIDs). The development of UST biosimilars like SB17 may help address the high cost of innovator biologics, offering affordable alternatives without compromising efficacy or safety.

AREAS COVERED

This review encompasses the totality of evidence supporting SB17's similarity to UST, its regulatory approval, and indication extrapolation. It also discusses SB17's lower immunogenicity relative to UST.

EXPERT OPINION

The approval of UST biosimilars represents a significant advancement in managing chronic IMIDs including psoriasis, plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis, providing cost-effective, efficacious alternatives. A randomized double-blind 28-week study involving over 500 patients with moderate-to-severe chronic plaque psoriasis demonstrated SB17's equivalence to UST, with more than 80% of patients achieving over 90% improvement in psoriasis severity indices. Treatment-emergent adverse events were comparable between SB17 and UST. Despite their potential to transform clinical outcomes, economic burdens, and drug utilization patterns, the adoption of UST biosimilars faces challenges, including concerns about equivalence and regulatory inconsistencies. Addressing these issues through education, consistent regulatory frameworks, real-world data, and ongoing monitoring is crucial for their successful integration into clinical practice.

Safety of interleukin-17A inhibitors in 306 patients with psoriasis with or without latent tuberculosis: a dual-centre retrospective study in China

BACKGROUND

New interleukin (IL)-17A inhibitors seem to demonstrate smaller effects on tuberculosis (TB) reactivation than expected.

OBJECTIVES

To evaluate the risk of TB reactivation, to assess serial interferon (IFN)-γ levels, and to weigh up the risks and benefits of TB chemoprophylaxis in patients with psoriasis treated with IL-17A inhibitors.

METHODS

This dual-centre study included patients with psoriasis who were treated with IL-17A inhibitors. The incidence of active TB, serial IFN-γ levels tested by IFN-γ release assays (IGRAs), adverse events (AEs) and effectiveness were evaluated through 1 year in patients with psoriasis treated with IL-17A inhibitors. According to the chemoprophylaxis treatment regimen, patients with latent TB infection (LTBI) were classified into three groups: a complete chemoprophylaxis dose regimen (CCP), an incomplete chemoprophylaxis (ICCP) or no chemoprophylaxis (NCP).

RESULTS

In 220 IGRA-negative patients, 17 of 220 (7.3%) became IGRA positive after receiving a mean of 69.1 weeks of IL-17A inhibitor treatment. Only one case of new-onset TB was observed after 52 weeks of ixekizumab therapy. Significant changes in IFN-γ levels were observed in IGRA-negative patients. Similarly, IFN-γ levels [listed as the mean (SD)] significantly increased at 1 year compared with baseline among IGRA-positive patients in the NCP [105 (68.7) vs. 236 (80.8) pg mL-1, P < 0.01] and ICCP [75.3 (48.3) vs. 608 (249) pg mL-1, P < 0.001] groups, whereas the changes were not significant [125 (26.6) vs. 131 (21.7) pg mL-1, P = 0.70] in the CCP group.

CONCLUSIONS

During IL-17A inhibitor therapy, there is a need for increased awareness of annual screening and assessment of individual risk for early detection of TB infection. LTBI treatment is generally well tolerated and is effective in preventing increased IFN-γ responses in patients with psoriasis treated with IL-17A inhibitors.

Prevalence of Psychiatric and Addictive Disorders in Patients with Psoriasis: A Cross-Sectional Study

Background/Objectives: Psoriasis is a chronic inflammatory skin disease increasingly linked to psychiatric and behavioral comorbidities, including depression, anxiety, and substance use disorders. Shared inflammatory pathways, including elevated IL-6, TNF-α, and IL-17, may link psoriasis with psychiatric disorders such as depression and anxiety. The bidirectional interaction between systemic inflammation and mental health may exacerbate the disease burden and affect treatment outcomes. The objective of this study was to determine the prevalence of psychiatric and behavioral comorbidities in patients with psoriasis and to explore potential demographic and clinical correlations. Assessing these correlations contributes to a better understanding of the mental health status of psoriasis patients, potentially influencing both therapeutic efficacy and quality of life. Methods: We conducted a cross-sectional observational study on 316 patients with clinically and histopathologically confirmed psoriasis, evaluated between January 2021 and March 2025 at the Clinical Railway Hospital in Iași, Romania. Psychiatric and behavioral comorbidities were assessed through clinical interviews, medical record reviews, and standardized tools including AUDIT-C, Fagerström Test for Nicotine Dependence, and the Binge Eating Scale. Psoriasis severity was evaluated using the Psoriasis Area and Severity Index (PASI). Results: Of 316 participants, 88 (27.8%) had psychiatric/behavioral comorbidities. The most frequent conditions were tobacco use disorder (11.1% overall; 39.8% among comorbid patients), alcohol use disorder (9.2%; 32.9%), binge eating (7.9%; 28.4%), anxiety (6.3%; 22.7%), and depression (4.1%; 14.8%). Additional diagnoses included personality disorders, dementia, PTSD, and sleep disorders. Conclusions: Psychiatric and behavioral comorbidities, particularly substance use disorders, are relatively common in patients with psoriasis. These findings support the need for regular mental health screening and integrated care approaches in psoriasis management.

Patient-centred Preferences for Biologic Therapies in Moderate to Severe Psoriasis in Vietnam: A Discrete Choice Experiment

Psoriasis is a chronic autoimmune disease that significantly impairs patients' quality of life. With the growing availability of biologic drugs - each varying in efficacy, safety, dosing, and cost - treatment decisions have become increasingly complex. A study conducted from March to July 2024 surveyed 302 Vietnamese patients with moderate to severe psoriasis to assess preferences for biologic therapies. Using a discrete choice experiment (DCE), participants evaluated 6 treatment attributes: short-term efficacy, long-term efficacy, sustained efficacy after drug withdrawal, frequency of administration, copayment, and risk of serious infection. Preference data were analysed using conditional logit models. Analysis revealed that treatment cost (relative importance [RI]: 31.4%) and long-term efficacy (RI: 25.3%) were the most critical factors influencing patient decisions, while sustained efficacy after withdrawal and early onset of efficacy were less impactful. Long-term efficacy and cost consistently ranked highest across all patient subgroups, with variations depending on demographic and clinical characteristics. These findings provide practical guidance for clinicians to incorporate patient preferences into the selection of biologic therapies, with particular emphasis on treatment cost and long-term efficacy. The significant influence of treatment cost also highlights the need for healthcare policymakers in Vietnam to enhance reimbursement policies and financial support programmes, improving access and equity in psoriasis care.

Riboflavin Deficiency Associated With Psoriasis: Insights From Population and Transcriptome

Psoriasis is a chronic inflammatory skin disease characterised by oxidative stress in the epidermis. Riboflavin (vitamin B2), an essential vitamin with antioxidant properties, may play a role in modulating this condition. Using data from three cycles of the National Health and Nutrition Examination Survey (NHANES), we analysed 13 825 U.S. citizens, including 409 (2.96%) cases of psoriasis. A fully adjusted weighted logistic regression model revealed that psoriasis was associated with decreased riboflavin intake: for each natural-log unit increase in riboflavin intake, the risk of psoriasis decreased by an average of 16% (OR: 0.84, 95% CI: 0.73-0.96). This association was particularly significant among middle-aged and elderly people (> 40 years). Transcriptome analysis of data series GSE41662 and GSE121212 demonstrated upregulation of riboflavin metabolising genes (SLC52A2, SLC52A3, RFK, FLAD1 and SLC25A32) in psoriatic lesional skin. In an in vitro psoriatic keratinocyte model, riboflavin reduction induced upregulation of inflammatory cytokines, ROS response and delayed keratinisation. These findings indicate that psoriasis is significantly associated with decreased riboflavin intake, and riboflavin metabolism is activated in psoriasis. The protective effect of riboflavin on psoriasis merits further attention.

Communication and Therapy Planning for Patients of Reproductive Age Under Immunomodulatory Treatments for Psoriasis or Psoriatic Arthritis-Survey of the German National Psoriasis Registry PsoBest

Background/Objective: During the systemic treatment of moderate to severe psoriasis in patients of reproductive age, contraindications and therapeutic peculiarities must be taken into account. Doctor-patient communication is crucial for therapy conduct and compliance. Methods: This survey among male and female patients from the German psoriasis registry, PsoBest, aims to provide real-world evidence on communication and patient needs for those of reproductive age (18-55). Result: In total, 404 patients were eligible for the analysis (254 m, 150 f), including 39 patients currently wishing to conceive (20 m, 19 f). Patients with and without the desire to have children received similar systemic therapy. In most cases, treatment was not adapted when patients expressed a desire to have children (85.9% m, 79.5% f). Only 38.3% of men and 49.9% of women had been informed about options for conception during or before systemic therapy, mainly by dermatologists (77.4% m, 84.6% f). The majority of patients retrieved additional information about the wish to conceive and medications from the internet and other media. This survey emphasizes the importance of open communication between patients and physicians regarding family planning and therapy options. Conclusions: Physicians need to broach the topic of family planning, conception and pregnancy with patients and support with evidence-based information to enable comprehensive medical decision making and safe therapy choices.

BMI matters: understanding the link between weight and severe psoriasis

This study aims to investigate the causal relationship between Body Mass Index (BMI) and the severity of Psoriasis (PsO) using bidirectional Mendelian Randomization (MR) and regression analyses. We conducted a multicenter study which combined bidirectional MR analyses with regression analyses. The MR analyses included 366,776 individuals from the largest up-to-date published BMI Genome-Wide Association Study (GWAS) data. Regression analyses were performed on 1,979 patients with psoriasis from 12 participating centers (from October 31, 2019, to May 31, 2022). We assessed the impact of BMI on PsO severity using odds ratios (ORs) and regression coefficients for three key measures: the Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA), and Dermatology Life Quality Index (DLQI). Two independent MR analyses revealed a significant causal association between BMI and PsO development. The first MR1 analysis showed that an increased BMI is significantly associated with a higher risk of psoriasis, with odds ratios of 2.28 (95% CI 1.33-3.92; p = 0.003). A subsequent MR2 analysis yielded consistent results, presenting an odds ratio of 2.37 (95% CI 1.16-4.85; p = 0.018) using the inverse-variance weighted method. Logistic regression showed that for every 1-unit increase in BMI (unadjusted covariates), the risk of severe psoriasis (PASI ≥ 10, BSA ≥ 10%, DLQI ≥ 10) increased by 6%, 6%, and 3%, respectively. Linear regression analysis revealed that each unit increase in BMI (not standardised) was associated with an increase of 0.25 units in the mean PASI score (p < 0.001), 0.34 units in the BSA score (p = 0.001), and 0.14 units in the DLQI score (95% CI 0.05-0.23; p = 0.001). From both the genetic and clinical severity assessment perspectives, it has been verified that abnormal weight gain is correlated with the severity of the condition in psoriasis patients. Clinicians should prioritize weight management and nutritional balance in the management of psoriatic disease. Clinicaltrials.gov: ChiCTR1900024852, date of registration: 2019-07-31.

Psoriasis and cancer: the role of inflammation, immunosuppression, and cancer treatment

INTRODUCTION

The relationship between psoriasis, immunomodulatory therapies, and the risk of malignancies is complex and still debated. The scarcity of evidence in this field makes clinicians hesitate to prescribe biological therapies for 'difficult-to-treat' patients.

AREAS COVERED

Based on a comprehensive MEDLINE/PUBMED search of articles published up to November 2024, this review synthesizes the current evidence on the association between psoriasis and cancer. This review specifically addresses four key aspects: the overall cancer risk in psoriatic patients, the potential role of cytokines involved in psoriasis pathogenesis in tumor development, the association between biological therapies and the incidence of new malignancies in this population, and the risk of cancer recurrence or progression in patients with a history of malignancy who are treated with biologics.

EXPERT OPINION

Biological therapies do not significantly elevate malignancy risk compared to non-biological treatments or the general population. Evidence is also reassuring for patients with prior malignancy, showing no tumor progression or recurrence. These findings support the timely use of biological treatments in 'difficult-to-treat' patients. Regular cancer screenings and risk-factor minimization should always be recommended for psoriatic patients undergoing immunomodulatory therapies. Multidisciplinary management involving oncologists is suggested, particularly for patients with active and advanced oncological disease.

Indirect Comparison Between Bimekizumab and Brodalumab for the Management of Moderate to Severe Psoriasis: A 36-Week Real-Life Study

INTRODUCTION

Bimekizumab and brodalumab are characterized by a different mechanism of action if compared to the other anti-interleukin (IL)-17s which target IL-17A. Indeed, brodalumab acts on IL-17RA whereas bimekizumab acts on IL-17A, IL-17F, and IL-17AF cytokines. Currently, despite real-life data on the efficacy and safety of bimekizumab and brodalumab have been reported, data comparing these two drugs are absent. However, these data are mandatory to evaluate whether a different target of the same IL can be correlated with a different profile in terms of effectiveness and safety. Moreover, it should be underlined that bimekizumab and brodalumab stood out as the psoriasis treatments with the fastest onset of action, delivering quicker therapeutic responses compared to other drugs acting on IL-17.

METHODS

A monocentric retrospective study was carried out enrolling patients affected by moderate to severe psoriasis undergoing treatment with brodalumab or bimekizumab. At baseline, clinical demographic details were collected. Clinical improvement [Psoriasis Area Severity Index (PASI), body surface area (BSA)] was collected at weeks 4, 16, and 36. Safety data were analyzed at the same timepoints.

RESULTS

A total of 125 patients were enrolled in the study [bimekizumab: 53 (42.40%); brodalumab: 72 (57.6%)]. Psoriasis severity at baseline was similar between the two cohorts. Both PASI and BSA significantly reduced at each follow-up for both treatment cohorts. The bimekizumab group reached a higher percentage of PASI90/PASI100 response at each timepoint as compared to the brodalumab cohort. In particular, the percentage of PASI100 response was significantly higher in the bimekizumab group as compared to the brodalumab cohort at week 4 (41.5% vs 23.6%, p < 0.05) and at week 16 (67.9% vs 48.6%). Discontinuation for ineffectiveness was higher in the brodalumab cohort (8.3%) as compared to the bimekizumab group (3.8%), without statistical significance. As regards safety, two cases of eczematous reactions (bimekizumab: 2, brodalumab: 0), and five cases of candidiasis (bimekizumab: 4, brodalumab: 1) were collected. Overall, 3 (5.7%) and 1 (1.4%) patients discontinued bimekizumab and brodalumab because of adverse events, respectively.

CONCLUSION

Our study confirmed the efficacy and safety of both bimekizumab and brodalumab, up to 36 weeks of treatment. Although both drugs showed a significant improvement of the investigated scores from week 4, some differences in terms of PASI90 and PASI100 responses (higher for bimekizumab at each follow-up, with only PASI100 response significantly higher at week 4 and 16) were registered. No statistical significance was found for safety data and treatment failure.

Sex Disparities of Health-related Quality of Life in Moderate to Severe Psoriasis: A Real-world Analysis from the Swiss Psoriasis Registry (SDNTT)

Real-world data on gender differences in quality of life among psoriasis patients before and during treatment are scarce. This study analysed data of 748 adults with moderate-to-severe psoriasis enrolled in the Swiss Dermatology Network of Targeted Therapy registry between 2011 and 2023. Quality of life was assessed using the Dermatological Life Quality Index at baseline and at 3, 6, 12, 18, and 24 months. At baseline, women reported significantly lower quality of life than men, with higher Dermatological Life Quality Index scores in the IL-17 inhibitor group (15.0 vs 11.0, p = 0.027), IL-12/23 inhibitor group (7.5 vs 7.0, p = 0.049), and non-biologic therapy group (13.0 vs 9.0, p < 0.001). Although quality of life improved across all subgroups during the follow-up period, women treated with IL-12/23 inhibitors continued to report worse quality of life compared with men after 2 years (p < 0.05), while no significant differences were observed with other therapies. These findings emphasize that women with psoriasis experience lower quality of life at treatment initiation and throughout non-biologic and biologic therapies, underlining the importance of addressing gender-specific differences in the management of psoriasis.

Management of Systemic Anti-psoriatic Drugs in Psoriasis Patients with Concurrent Paraplegia or Tetraplegia: Insights From a 6-Year Multicenter, Retrospective Observational Study

INTRODUCTION

Patients with psoriasis (PsO) and permanent spinal cord injuries (SCI) resulting in paraplegia and tetraplegia may experience a higher rate of infections compared to patients with PsO without SCI. It can result in further challenges for therapeutic management with immunosuppressants (biological and non-biological treatments). Thus,  we aimed to evaluate the rate of infections in patients with PsO and SCI treated with systemic immunosuppressants.

METHODS

This multicenter, retrospective observational study enrolled patients with PsO and traumatic SCI undergoing systemic immunosuppressive treatments for at least 5 years. All patients were evaluated by experienced, board-certified dermatologists and neurologists. Demographic and clinical data were collected.

RESULTS

We enrolled 23 patients with SCI (16 with paraplegia and 7 with tetraplegia) treated with methotrexate (MTX) and different biologics (tumor necrosis factor (TNF) inhibitors (i) and interleukin (IL)-17i/IL-23i). Globally, patients with SCI treated with MTX displayed higher rates of infection compared to those treated with biologics. Patients with paraplegia had lower rates of infection compared to patients with tetraplegia during anti-psoriatic therapies (p < 0.05). Those treated with TNFi had greater rates of infection than those treated with IL-17i/IL-23i (p < 0.001). Patients with psoriatic arthritis (PsA) experienced a significant diagnostic delay and clinical monitoring of PsA severity was challenging.

CONCLUSION

In patients with moderate-to-severe PsO and concurrent traumatic SCI, dermatologists should consider using IL-17i/IL-23i as first-line therapy.

Certolizumab pegol in severe hidradenitis suppurativa in pregnancy: A case report

Hidradenitis suppurativa is a chronic inflammatory disease of the skin with a suppurative-cicatricial outcome affecting the infundibular component of the pilo-sebaceous unit. The lesions are typically localized in the intertriginous and apocrine gland-rich areas. Hidradenitis suppurativa mainly affects patients at a young age and is very often refractory to conventional medical treatment. During pregnancy, the management of hidradenitis suppurativa becomes demanding due to the need of safety therapies. Certolizumab pegol is a pegylated monoclonal TNF-α inhibitor that lacks the fragment crystallizable region preventing active placental transfer and could be used in pregnancy and lactation if clinically needed and is label for chronic plaque psoriasis, rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, Crohn's disease. Herein, we describe a case of a 32-year-old pregnant woman with Hurley stage III hidradenitis suppurativa successfully treated with certolizumab pegol.

The Intersection of Psoriasis and Neoplasia: Risk Factors, Therapeutic Approaches, and Management Strategies

The association between psoriasis and increased cancer risk is gaining recognition as studies reveal shared inflammatory and immune pathways. This review examines the relationship between psoriasis and neoplasia, focusing on cancer risk factors in psoriasis patients, the biological pathways underlying this connection, and the impact of various psoriasis treatments on cancer development. Psoriasis patients have a heightened incidence of certain cancers, such as lymphomas, skin cancers, and urological malignancies, potentially linked to immune dysregulation and chronic inflammation. Immunomodulatory treatments for psoriasis, including conventional systemic therapies and biologics, present varied cancer risks, with others, such as phototherapy, associated with an elevated risk of skin cancers. For oncologic patients with psoriasis, management necessitates a tailored approach, balancing effective psoriasis control with minimizing cancer progression risks. The emergence of IL-17 inhibitors, IL-23 inhibitors, and small-molecule therapies offers promising therapeutic alternatives with favorable safety profiles for these patients. This review underscores the need for interdisciplinary collaboration to optimize care for patients managing both psoriasis and malignancy.

Need for individualized counseling regarding psoriasis systemic therapy in women of childbearing age: analysis of the PsoFem study at the University Medical Center Hamburg

Background

For patients with moderate-to-severe psoriasis and current childbearing/pregnancy, the choice of therapy is limited.

Objectives

The present study compared the disease burden and treatment choices in women of childbearing age (WoCBA) with and without a current wish for pregnancy.

Methods

Female patients aged 18 to 45 years, with moderate-to-severe psoriasis vulgaris, were consecutively recruited. The patients reported on sociodemographic/reproductive characteristics and quality of life impairments. The physicians assessed disease severity, comorbidities, and current treatment(s). Both patients' and dermatologists' perceptions of shared decision-making for the current systemic treatment were surveyed.

Results

Participants were 145 WoCBA with psoriasis: 73 were pregnant or reported a desire to conceive (group CB+) and 72 reported no wish to have (more) children (group CB-). Patients without childbearing wishes were older and often had previous children; no significant differences in clinical features or quality of life impairments were found. A significantly higher proportion of patients in the CB+ group were prescribed tumor necrosis factor alpha blockers, particularly certolizumab pegol. This treatment option was associated with previous children and the desire to conceive, but not with disease variables. Family planning was more often discussed and considered in the clinical decision for the CB+ group, but patient-doctor agreement for shared decision-making was fair-to-moderate.

Limitations

The small sample size prevented comparative analyses between patients planning a pregnancy in the short- vs long-term future. In addition, specific variables related to the decision-making process for the current therapy need to be assessed and examined in more detail in further research.

Conclusion

For WoCBA with childbearing wishes, tumor necrosis factor alpha blockers were most frequently prescribed, in accordance with current guidelines/recommendations. Decision-making for continuing or changing systemic therapy during pregnancy must take into account medication specificities and the vulnerable stages in pregnancy, as well as the limited amount of pregnancy-compatible drugs.

Efficacy and Safety of Risankizumab in Patients with Psoriasis Showing Suboptimal Response to Secukinumab or Ixekizumab: Results from a Phase 3b, Open-Label, Single-Arm (aIMM) Study

INTRODUCTION

Risankizumab has demonstrated superior efficacy compared to other psoriasis treatments, including secukinumab, adalimumab, and ustekinumab; switching to risankizumab from other psoriasis treatments has shown superior clinical and quality of life (QoL) outcomes. We evaluated the efficacy and safety of directly switching patients with moderate-to-severe plaque psoriasis and a suboptimal response to interleukin (IL)-17 inhibitors (secukinumab or ixekizumab) to risankizumab.

METHODS

This 52-week, phase 3b study enrolled patients (≥ 18 years) with moderate-to-severe plaque psoriasis who had previously been treated with the recommended dose of secukinumab or ixekizumab for ≥ 6 months but did not achieve an optimal response (static Physician's Global Assessment [sPGA] 2/3; body surface are [BSA] 3- < 10%). Patients received subcutaneous risankizumab (150 mg) without washout. The primary endpoint was the proportion of patients achieving sPGA of 0/1 at week 16. Secondary endpoints included sPGA 0/1 at week 52, sPGA 0, Dermatology Life Quality Index (DLQI) 0/1, and Psoriasis Symptoms Scale (PSS) 0 at weeks 16 and 52. Safety was monitored throughout the study.

RESULTS

The study included 244 patients. sPGA 0/1 was achieved by 57.4% and 62.3% at week 16 and 52. At week 16, sPGA 0, DLQI 0/1, and PSS 0 were achieved by 20.5%, 40.2%, and 20.9%, respectively. At week 52, these proportions increased to 27.1% for sPGA 0, 47.2% for DLQI 0/1, and 27.5% for PSS 0. Most frequently reported adverse events (reported in ≥ 5% of patients) in risankizumab-treated patients were COVID-19 infection (8.6%) and nasopharyngitis (5.7%). No new safety signals were observed.

CONCLUSIONS

Directly switching to risankizumab improved outcomes and QoL in patients with moderate-to-severe psoriasis who had suboptimal responses to anti-IL-17 inhibitors (secukinumab or ixekizumab). The safety results are consistent with previously reported safety of risankizumab. This study supports the efficacy of risankizumab in patients previously treated with biologics, including IL-17 inhibitors, and suggests a direct switch to risankizumab for improved clinical outcomes and QoL.

CLINICAL TRIALS

ClinicalTrials.gov identifier: NCT04102007.

Evaluation of β2-microglobulin in the condition and prognosis of psoriasis patients

BACKGROUND

Numerous studies have linked the inflammatory pathway in psoriasis and metabolic disease, while no specific marker defined it. It is worth exploring the association of β2-microglobulin (β2M) in psoriasis severity and comorbidities.

OBJECTIVES

To investigate the correlation between blood β2M level and psoriasis severity, to explore the inflammatory factors influencing the occurrence of psoriasis comorbidities such as arthritis, diabetes, and hypertension.

METHODS

Ninety-seven psoriasis patients were analyzed in the cohort retrospective study during 12 weeks.

RESULTS

Significantly higher levels of blood β2M and ESR were observed in the group that patients' PASI ≥10 than in the group that PASI <10. Blood β2M level had strong significantly positive correlations with the PASI in Pearson's correlation analysis. In the model that systemic inflammatory factors to find psoriasis comorbidity risk factors, logistic regression analysis showed that blood β2M level was the significant risk factor associated with diabetes and hypertension. High-sensitivity C-reactive protein (hsCRP) was the significant risk factor associated with arthritis.

CONCLUSIONS

Patients with a severer psoriasis tended to have higher blood β2M levels and severer inflammatory state. In the systemic inflammation indexes, the level of blood β2M affected the risk of hypertension and diabetes, and hsCRP affected the risk of arthritis in patients with psoriasis.

Long-term effectiveness and safety of risankizumab in patients with moderate-to-severe psoriasis with and without cardiometabolic comorbidities: a single-center retrospective study

Background: Psoriasis is a chronic skin disease driven by immune system dysfunction and associated with increased cardiovascular risk and metabolic disorders. Risankizumab is an anti-interleukin-23 humanized monoclonal antibody approved for the treatment of moderate-to-severe plaque psoriasis.

Objective: We conducted a 3-year retrospective study to evaluate the effectiveness and the safety of risankizumab in patients with moderate-to-severe psoriasis, comparing those with and without the presence of at least one cardiometabolic comorbidity (CMD).

Results: Our study included 333 patients treated with risankizumab for at least one year. One hundred and sixty-two patients had at least one CMD. After one year of treatment, a reduction of at least 90% and 100% in Psoriasis Area and Severity Index (PASI) score compared with baseline (PASI90 and PASI100, respectively) was observed in 80.3% and 63% of patients with CMDs compared to 83% and 63.2% of patients without CMDs. No statistically significant differences were observed between the two cohorts of patients in terms of effectiveness and rates of adverse events. No significant safety findings were observed throughout the study period. Our study supports data from clinical trials and real-world studies, even in patients with concomitant cardiometabolic comorbidities.

Tildrakizumab Treatment for Psoriasis in Real-world Practice: An Analysis from the Swiss Registry (SDNTT)

Real-world data on the effectiveness and safety of tildrakizumab, an interleukin 23p19 inhibitor, in Switzerland is limited. The objectives of this analysis were to assess the effectiveness and safety of tildrakizumab in patients with moderate-to-severe plaque psoriasis in Switzerland. Twenty-eight adults from the Swiss Dermatology Network for Targeted Therapies registry (SDNTT), who were on tildrakizumab treatment and had at least 3 months' follow-up, were enrolled in this prospective, multicentre study. No missing data imputation was performed. The median Psoriasis Area and Severity Index (PASI) decreased from 9.5 at baseline to 2.1 and 0.3 (both p < 0.001) after 3 and 18 months, respectively, of tildrakizumab treatment. After 3 months, 76.9%/30.8% patients reached an absolute PASI <  3/ < 1. These rates increased to 85.7%/57.1% after 18 months of treatment. The proportions of patients achieving PASI 90/100 responses were 47.8%/30.4% at month 6 and 42.9%/14.3% at month 18. A significant improvement in quality of life up to 18 months of follow-up was observed as measured by the Dermatology Life Quality Index. There were no treatment discontinuations due to adverse events. This real-world registry provides robust evidence supporting the long-term effectiveness and favourable safety profile of tildrakizumab in treating patients with moderate-to-severe psoriasis.

Early screening to identify and diagnose primary nasal tuberculosis in patients with tumor necrosis factor inhibitors

In this editorial, we comment on the article by Liu et al. Based on our analysis of a case report, we consider that early screening and recognition of primary nasal tuberculosis are crucial for patients undergoing treatment with tumor necrosis factor inhibitor (TNFi). While TNFi therapy increases the risk of reactivating latent tuberculosis, primary nasal tuberculosis remains rare due to the protective mechanisms of the nasal mucosa. Risk factors for primary nasal tuberculosis include minimally invasive nasal surgery, diabetes, and human immunodeficiency virus. Patients with early symptoms such as nasal congestion, rhinorrhea, altered olfaction, epistaxis, or ulceration, and unresponsive to conventional antibiotics and antihistamines should undergo early rhinoscopy, possibly followed by repeated tissue biopsies and acid-fast bacilli culture when necessary. When diagnosis is challenging, it is essential to consider local tuberculosis epidemiology and the efficacy of diagnostic anti-tuberculosis treatment. The preferred method for tuberculosis screening is the Interferon Gamma Release Assay, with a general recommendation for screening at 3 and 6 months after initial treatment and then every six months. However, the optimal frequency is not yet consensus-driven and may be increased in economically viable settings.

Medication use patterns in pregnant women with psoriasis: a nationwide study in Taiwan

BACKGROUND

Psoriasis, an autoimmune skin condition, affects 2-4% of the global population, with significant prevalence among women of childbearing age. Pregnancy presents challenges in managing psoriasis because of hormonal changes and treatment safety concerns. Understanding treatment patterns in pregnant women is crucial, given limited real-world evidence.

OBJECTIVES

To explore the utilization patterns of medications among pregnant women diagnosed with psoriasis within real-world data, utilizing data sourced from a nationwide database in Taiwan.

METHODS

This nationwide study utilized Taiwan's National Health Insurance (NHI) database and birth certificate application records. It included registered pregnant women diagnosed with psoriasis from 2005 to 2014. Medication usage was tracked 3 years before conception to 3 years after delivery. Medications were categorized based on Anatomical Therapeutic Chemical codes, and statistical analyses were conducted using SAS software.

RESULTS

In total, 30 267 pregnant women with psoriasis were studied. In total, 11 651 (38.5%) mothers had received ≥ 1 prescription during follow-up (exposed group) and 61.5% (18 616) had never received medication (unexposed group). Demographics and comorbidities were similar between these two groups. Topical corticosteroids were the most prescribed treatment, followed by phototherapy, with systemic drugs and biologics less common. During the study period, 11 096 women with psoriasis had used topical corticosteroids, 3376 had used nonsteroidal topical agents, 218 had used systemic agents or biologics and 519 had received treatment with phototherapy. Medication usage declined during pregnancy, reaching its lowest in the third trimester but rebounded postpartum.

CONCLUSIONS

Psoriasis medications, systemic, biological or topical, were largely discontinued during pregnancy, sometimes up to 2 years before and extending postpartum. Research is needed to understand its impact on maternal and child health.

Evaluation of serial QuantiFERON-TB Gold in tube test results and tuberculosis infection status in patients with psoriasis receiving anti-IL-17 treatment (secukinumab and ixekizumab): Real-world data from a tuberculosis-endemic country

BACKGROUND

In comparison with TNF-α inhibitors, anti-IL-17A agents are considered to have a lower risk of active tuberculosis (TB) or latent TB infection (LTBI) reactivation.

METHODS

In this study, we aimed to evaluate the TB infection status and serial QuantiFERON-TB-Gold in tube test (QFT) results of psoriasis patients using IL-17 inhibitors (secukinumab [SEC] and ixekizumab [IXE]) in a real-world setting from a tuberculosis-endemic country. Patients who used an anti-IL-17 agent for at least 3 months in our follow-up were included in the study. Patients' clinical and demographic features, baseline QFT results and latest QFT results (if any), and TB infection status were noted from the past medical records.

RESULTS

A total of 717 patients, of whom 333 (46.4%) were female, were included in the study. The cumulative exposure time to an anti-IL-17 agent was 14,147 patient-months, 9743 patient-months for SEC and 4404 patient-months for IXE. Also, 459 (SEC = 305/IXE = 154) patients used an anti-IL-17 agent for ≥ 12 months. Of these, 125 had positive baseline QFT results. In all, 334 had negative baseline QFT results. The latest QFT result of 309 was also negative (persistent seronegative group). During follow-up, the QFT results of 10 patients changed from negative to positive (positive seroconversion group). Seven of them were using SEC and three were using IXE, respectively. No case of active TB infection was detected.

CONCLUSION

In our study, the positive seroconversion rate of 10/334 seems high, but this did not translate to active disease. However, closer monitoring may be required, especially in patients with advanced age, the presence of PsA, long disease duration and long anti-IL-17 treatment duration.

Drug Survival and Clinical Course of Patients with Cancer Treated with Biologic Therapy for Psoriasis

Background/Objectives: Patients with treated solid tumors (TST) are a highly heterogeneous and difficult-to-treat population due to the risk of disease progression/recurrence or infection. Methods: We conducted an observational, retrospective, single-center study at the Dermatology Clinic of Turin with a focus on the special population of cancer patients with psoriasis treated with biologics. Results: As of July 2023, 52 psoriatic patients with a prior/concomitant history of malignancy had taken biologic drugs. The median age was 67 years, and the median age of cancer onset was 55 years. The most common tumors were gastrointestinal cancer and melanoma. After the tumor diagnosis, 61% received an anti-IL17 drug; 37 patients continued the initiated biologic therapy, while 12 switched drugs due to secondary inefficacy. The estimated biologic DS was 55.6% at 50 months. Evidence suggests that IL-17 is a key pathogenic factor involved in tumorigenesis, resulting in a lower risk of malignancies in subjects managed with IL-17 inhibitors. Similarly, IL-23 plays a role in suppressing innate immunity and promoting tumor and metastases development. This is a consistent real-life case series that support the use of biologic drugs in patients with TST. Conclusions: IL-23 and IL-17 inhibitors, being immunomodulators rather than immunosuppressants, may be a safe option for patients in an active oncological setting and for immune-correlated adverse events.

Psoriasis and Seasonality: Exploring the Genetic and Epigenetic Interactions

Psoriasis is a multifactorial, chronic, and inflammatory disease that severely impacts patients' quality of life. The disease is caused by genetic irregularities affected by epigenetic and environmental factors. Some of these factors may include seasonal changes, such as solar radiation, air pollution, and humidity, and changes in circadian rhythm, especially in the temporal and polar zones. Thus, some psoriasis patients report seasonal variability of symptoms. Through a comprehensive review, we aim to delve deeper into the intricate interplay between seasonality, environmental factors, and the genetic and epigenetic landscape of psoriasis. By elucidating these complex relationships, we strive to provide insights that may inform targeted interventions and personalized management strategies for individuals living with psoriasis.

A large-scale retrospective study in China explores risk factors for disease severity in plaque psoriasis

Severe psoriasis has a long course and poor outcome, and it has long been a problem for patients. Understanding the independent risk factors that contribute to patients with severe psoriasis is critical for the development of effective treatment strategies. This large, multicenter study recruited 2,109 plaque psoriasis patients from 12 hospitals across China (October 31, 2019 - May 31, 2022). The logistic regression model underwent internal validation and external validation using two independent cohorts over future time periods (June 1, 2022 - January 31, 2023). The discriminative power of our model was substantiated by a C-index of 0.863 (95% CI: 0.848-0.879) in internal validation, further affirmed through 1,000 bootstrap validation (C-index: 0.860, 95% CI: 0.836-0.885) and external validation cohorts, where the C-index reached up to 0.910 (95% CI: 0.868-0.953) and 0.951 (95% CI: 0.924-0.977) in 2 external validation cohorts. To enhance accessibility for clinicians, the model has been made available as a dynamic nomogram and QR code. Our study identified 10 risk factors (the "DELPHI" consensus dichotomy, the DLQI index, the extent of skin involvement as measured by body surface area, the age of the patient at the time of clinical visit, sex, body weight in kilograms, career, the presence of scalp involvement, facial involvement, and arthropathy) for the overall severity of psoriasis (PASI ≥ 10). "Nomogram-10" provides clinicians with a practical tool to develop personalized intervention strategies based on an individual's risk profile.Trial registration: Chinese Clinical Trial Registry: ChiCTR1900024852.

Psychopathological Profile of Patients with Moderate-to-Severe Plaque Psoriasis and Its Correlation to DLQI: Results from a Prospective, Monocentric Clinical Study

Background: Psoriasis is associated with a high psychological burden and comorbidities, such as depression and anxiety. The aim of this study was to evaluate the psychopathological profile of patients with moderate-to-severe plaque psoriasis under systemic treatment and to explore the association between DLQI and alexithymia, depression, and other psychopathological disorders. Methods: In this monocentric, prospective clinical study, 104 adult patients with moderate-to-severe plaque psoriasis were evaluated according to the disease severity (measured by PASI) influence of psoriasis on their quality of life (measured by DLQI) and their psychopathological profile (measured by the BDI, TAS-20, and SCL-90 questionnaires). Results: The psoriasis patients exhibited high levels of psychopathological symptoms, particularly for depression, obsessive-compulsive behavior, somatization, interpersonal sensitivity, and anxiety. More than half of the psoriatic patients (56.7%) were diagnosed with minimal depression, 26.9% with mild depression, and 16.3% with moderate or severe depression. The symptoms of possible and confirmed alexithymia were present in 19.2% and 15.4% of the patients, respectively. The patients with alexithymia appeared to experience a more significant impact on their QoL. Specifically, the percentage of patients with alexithymia/possible alexithymia who had a DLQI of ≥2 was 77.8% vs. 51.5% in those without alexithymia. Conclusions: Our study illuminates the intricate connection between the disease severity and psychological components that impact the QoL of patients with moderate-to-severe plaque psoriasis. It is advised that clinicians adopt a comprehensive approach to managing psoriasis, which involves addressing both the physical symptoms of the condition and the psychological impact. In cases of patients with a DLQI of ≥2, despite adequate clinical responses, evaluating the possible coexistence of general psychopathology is recommended.

Psoriasis in Childbearing Age: A Real-Life, Retrospective, Single-Center Study on Anti-IL17 and IL-23 Agents

Background: Psoriasis (PSO) involves about 1-3% of the population, and around 75% of women develop PSO before the age of 40. Official guidelines on the treatment of woman with anti-IL17 and anti-IL23 during this potential childbearing time are not currently available. Objective: To investigate the effectiveness and safety of biologic treatments in women of childbearing age. Methods: At the Dermatology Clinic of the University of Turin, Italy, 172 women aged 20-55 years underwent IL-17 and IL-23 inhibitor therapy for moderate-severe PSO and were followed up to 52 weeks in a real-life, retrospective, single-center study. Results: Overall, 40% of patients achieved PASI 100 at week 16, and 72% at week 52. A similar trend was observed for PASI 90 and PASI < 3 with almost 80% and 90% of patients achieving the target at 52 weeks. As for PASI 100, a statistically significant difference (p = 0.004) was found at 16 weeks, with 23.84% of patients achieving PASI 100, with IL-17 and 15.70% with the IL-23 inhibitor. No statistically significant differences were found at 28 and 52 weeks. No statistically significant differences in PASIs at any time points were recorded across the different biologic agents. Forty-six patients discontinued treatment. The most reported side effects were headache, nausea, asthenia, injection site pain, and rhinitis. Conclusions: This study showed that biologic drugs are effective and safe in women of childbearing age, with negligible side effects.

Global Comparison of COVID-19 Vaccination Rates among Psoriasis Patients

(1) Background: The purpose of this study is to compare the rate of COVID-19 vaccination among psoriasis patients internationally and to correlate it with their treatment regimens. (2) Methods: We conducted a cross-sectional study from January 2021 to October 2022 among adults in the United States (US), Chile, China, Switzerland, and Singapore using the Global Healthcare Study on Psoriasis survey. (3) Results: A total of 310 psoriasis patients in the US (98), Chile (32), China (80), Switzerland (39), and Singapore (61) were surveyed. Of these, 248 patients (80.0%) were vaccinated at least once for COVID-19 (Chile: 100%, Singapore: 100%, US: 93.9%, Switzerland: 69.2%, China: 45.0%). Compared with other countries, patients in China were 89% less likely to report at least one COVID-19 vaccination (1 - 0.11 = 0.89; OR 0.11; 95% CI: 0.03-0.48), and patients in Switzerland were 80% less likely (1 - 0.20 = 0.80; OR 0.20; 95% CI: 0.05-0.79). Compared with patients on biologics, patients on topicals were 10.9 (95% CI: 2.1-56.6) times more likely to report at least one COVID-19 vaccination, and patients on oral systemics were 7.2 times more likely (95% CI: 1.6-31.6). (4) Conclusions: Country of residence and treatment regimen are associated with different COVID-19 vaccination rates in psoriasis patients.

Psoriasis localization patterns in the Swiss Psoriasis Registry (SDNTT) over 11 years: an analysis by sex and age

Real-world data on anatomically localized psoriasis and its response to systemic therapy across different age-groups and sexes is limited. This study aimed to evaluate the severity and distribution of psoriasis over time in female and male patients receiving systemic therapies, categorized by age within the Swiss psoriasis registry (SDNTT). Patient-data was obtained over 11 years through the SDNTT. The localized Psoriasis Area and Severity Index (locPASI) of the head, trunk, upper and lower extremities was analyzed over two years following the start of systemic non-/biologic treatment. A total of 316 female and 517 male patients were analyzed. Male patients had a higher baseline locPASI for legs, trunk and arms (p < 0.001), but not for the head (p = 0.961). The locPASI for the head in younger female patients (18-40 years) had a higher score than those aged 55 + (p = 0.022) and after two years, middle aged (41-54) showed a lower score compared to younger patients (p = 0.045). Younger male patients revealed a lower score after two years of therapy in the leg- and arm-area compared to older (p = 0.018 and p = 0.048, respectively). Female patients on non-biologics had a fast initial response, converging with male patients' scores over 24 months. Over 75% locPASI reduction was observed for female head-area (81.4%), male trunk (82.7%) and legs (76.1%). Absolute locPASI ≤ 2 was achieved 3-6 months for all locations with interleukin (IL)-17, IL-12/23 and IL-23-inhibitors, except for the legs of male patients on anti-IL-17 and female patients on anti-IL-12/23 and -IL-23. After two years, male patients did not achieve a locPASI ≤ 2 for any biologic-treatment in the legs, nor for the arms on anti-TNF-α. Significant disparities in localized PASI were observed between female and male patients. The age, sex and severity of distinct localizations should be considered to optimize treatment goals.

[Monoclonal antibodies for inflammatory, autoimmune and oncological skin diseases]

In 1997 rituximab, a genetically engineered chimeric monoclonal antibody (mAb) targeting CD20 expressed on B cells was approved for treatment of non-Hodgkin's lymphoma. Since then, pharmacological improvements combined with increased knowledge on the immunopathogenesis of diseases led to the development of specific mAb targeting different antigens (e.g., interleukins or transmembrane receptors). This approach reshaped the therapeutic methodology in many fields, including dermatology. Nowadays, the treatment of frequent and possibly impairing inflammatory disorders such as psoriasis, atopic dermatitis or hidradenitis suppurativa have different mAbs approved for both adult and pediatric patients. This class of drugs often shows a more favorable outcome and a better safety profile than routine immunosuppressants, such as steroids and steroid-sparing substances. For many years mAbs also represented a pillar of oncological treatment for severe diseases such as malignant melanoma or Merkel cell carcinoma. This review summarizes the current knowledge on already approved and promising new mAbs for the treatment of inflammatory and oncological skin diseases.

Predictors of initiating biologics in the treatment of psoriasis

BACKGROUND

Biologics are among the most effective therapies for psoriasis. However, many patients are only introduced to them at advanced stages of the disease course.

OBJECTIVES

Our aim was to identify predictors of initiating biologic therapy in patients with psoriasis and compare patients initiating biologics early versus late in their disease course.

METHODS

Kaplan-Meier curves visualized time to biologic initiation, while Cox regression models further explored variables as predictors of biologic initiation. Mann-Whitney U and chi-squared tests compared patients who started biologics early with those who began biologics later in the disease course.

RESULTS

Our primary analysis included 233 psoriasis patients. Cox regression showed that age at diagnosis (P = 0.007), general physical well-being (P = 0.02), and nail psoriasis severity (P = 0.02) were significantly associated with time to biologic initiation. Our secondary analysis, the comparisons between patients starting biologics early versus later in the disease course, included a total of 378 patients. The median (interquartile range [IQR]) age at diagnosis was 34.5 (25.0-51.2) years for patients initiating biologics within 5 years, compared to 22.0 (15.0-32.8) years for patients initiating biologics later (P < 0.0001). The median (IQR) age at initiation was 37.0 (27.0-53.2) and 45.0 (36.0-55.0) years for patients initiating biologics earlier versus later than 5 years (P = 0.04).

CONCLUSIONS

Age at diagnosis, general well-being, and severity of nail psoriasis significantly predicted future initiation of biologic treatment. Patients initiating biologics early in their disease course were generally older at diagnosis but younger at the time of biologic initiation compared to patients initiating biologics later in their disease course.

[Translated article] Recommendations from the Spanish Academy of Dermatology and Venereology Psoriasis Working Group on the Management of Patients with Cancer and Psoriasis

Several studies suggest that patients with psoriasis have a higher incidence of neoplasms, especially of the skin, which could be associated with the use of therapies to treat psoriasis. Furthermore, the evidence available on the safety profile of some treatments in this context, and the management of these patients is scarce, which is why clinical practice guidelines with recommendations on the management of psoriasis in cancer patients are ambiguous. This study provides recommendations on the management and use of the therapies currently available for these patients. They are the result of a Delphi consensus reached by 45 dermatologists of the Spanish Academy of Dermatology and Venereology Psoriasis Working Group, and their goal is to help specialists in the field in their decision-making processes.

Recommendations from the Spanish Academy of Dermatology and Venereology Psoriasis Working Group on the Management of Patients with Cancer and Psoriasis

Several studies suggest that patients with psoriasis have a higher incidence of neoplasms, especially of the skin, which could be associated with the use of therapies to treat psoriasis. Furthermore, the evidence available on the safety profile of some treatments in this context, and the management of these patients is scarce, which is why clinical practice guidelines with recommendations on the management of psoriasis in cancer patients are ambiguous. This study provides recommendations on the management and use of the therapies currently available for these patients. They are the result of a Delphi consensus reached by 45 dermatologists of the Spanish Academy of Dermatology and Venereology Psoriasis Working Group, whose goal is to help specialists in the field in their decision-making processes.

Managing the Patient with Psoriasis and Metabolic Comorbidities

Epidemiological data demonstrate strong associations between psoriasis and metabolic comorbidities, including obesity, hypertension, diabetes mellitus, dyslipidemia, and non-alcoholic fatty liver disease. The presence of metabolic comorbidities significantly influences the selection and effectiveness of pharmacological treatments. Some drugs should be prescribed with caution in patients with metabolic comorbidities because of an increased risk of adverse events, while others could have a reduced effectiveness. The aim of this narrative review is to highlight the challenges that healthcare professionals may face regarding the management of psoriasis in patients with metabolic comorbidities. In the first part of the article, the epidemiological association between psoriasis and metabolic comorbidities and their pathogenetic mechanisms is summarized. The second part describes the efficacy and safety profile of conventional and biologic drugs in patients with selected metabolic comorbidities including obesity, non-alcoholic fatty liver disease/hepatic steatosis, and diabetes. Finally, the role of pharmacological and non-pharmacological interventions, such as diet, alcohol abstinence, physical activity, and smoking avoidance is discussed. In conclusion, the choice of the best approach to manage patients with psoriasis with metabolic comorbidities should encompass both tailored pharmacological and individualized non-pharmacological interventions.

The Emerging Field of Cardioimmunology: Past, Present and Foreseeable Future

Over the past 30 years, the field of cardioimmunology has moved from being dismissed as a field that was chasing an epiphenomenon of little biological consequence to a scientific discipline that is providing important new insights into the immunologic basis for hypertension, atherosclerosis, myocarditis, pericarditis, autoimmune heart disease, and heart failure. In this article, we will review the conceptual insights and technical breakthroughs that have allowed the field to move forward, as well as the clinical trials in the cardioimmunology space, to provide a historical context for the articles that will appear in the compendium that is focused on the interface between cardioimmunology, myocardial function, and disease.

Reducing cardiovascular risk in immune-mediated inflammatory diseases: Tumour necrosis factor inhibitors compared to conventional therapies-A systematic review and meta-analysis

Immune-mediated inflammatory disease (IMID) patients including psoriasis, inflammatory arthritides and bowel diseases have a higher risk of developing cardiovascular (CV) diseases compared to the general population. The increased CV risk may be promoted by tumour necrosis factor (TNF)-α-mediated immunological processes, which are present both in the pathomechanism of IMIDs and atherosclerosis. Our objective was to comprehensively investigate the effect of TNF inhibitors (TNFi) on CV risk compared with conventional therapies in IMIDs. The systematic literature search was conducted in three databases (MEDLINE, EMBASE, Cochrane Library) on 14 November 2022. Randomized controlled trials, cohort and case-control studies were eligible for inclusion. Outcomes consisted of the incidence of CV events, with major adverse cardiovascular events (MACE) as a main endpoint. A random-effects meta-analysis was performed by pooling fully adjusted multivariate hazard ratios (HR) and incidence rate ratios (IRR) with a 95% confidence interval (CI) comparing TNFis with conventional systemic non-biologicals (CSNBs). Of a total of 8724 search results, 56 studies were included overall, of which 29 articles were eligible for the meta-analysis, and 27 were involved in the systematic review. Including all IMIDs, the TNFi group showed a significantly reduced risk of MACE compared with the CSNB group (HR = 0.74, 95% confidence interval (CI) 0.58-0.95, p = 0.025; IRR = 0.77, 95% CI 0.67-0.88, p < 0.001). Subgroup analysis of Pso, PsA patients by pooling IRRs also confirmed the significantly decreased risk of MACE in TNFi-treated patients compared with CSNB groups (IRR = 0.79, 95% CI 0.64-0.98). The observational nature of most included studies leading to high heterogeneity represents a limitation. Based on the results, TNFis may reduce the risk of CV events compared to CSNBs. Therefore, earlier use of TNFis compared to conventional systemic agents in the therapeutic sequence may benefit CV risk in IMID patients.

Efficacy and safety of deucravacitinib for the management of psoriasis: a drug safety evaluation

INTRODUCTION

Nowadays, despite the wide availability of biological drugs and apremilast for psoriasis management, there is always a need for new therapies to customize the therapeutic approach on the basis of the patient's clinical features and comorbidities, especially in order to achieve a prolonged therapeutic response. Thus, new treatment strategies are required to offer patients a personalized approach. In this scenario, major knowledge on psoriasis pathogenesis led to the development of deucravacitinib, an orally administered selective TYK2 inhibitor.

AREAS COVERED

The aim of this manuscript is to review the current literature on the effectiveness and safety of deucravacitinib in psoriasis to offer readers a wide perspective. The current English literature was analyzed using the PubMed, Google Scholar, Embase, Cochrane Skin, and clinicaltrials.gov databases, selecting the most relevant manuscripts.

EXPERT OPINION

Deucravacitinib appears to be an innovative weapon for the management of moderate to severe psoriasis. Despite its efficacy and safety profiles have been revealed by RCTs, real-life data are still scant. Certainly, deucravacitinib broadens the range of therapeutic alternatives for psoriasis patients, thus enhancing the holistic and personalized approaches required for the treatment of this disease.

A Successful Switch From Ustekinumab to an Extended Dosing Interval of Guselkumab Without Induction in a Patient With Psoriasis Vulgaris

Psoriasis vulgaris, also known as plaque-type psoriasis, is the most common form of psoriasis. It is characterized by erythematous plaques covered with scales. Among the available treatments, the fully human monoclonal antibodies ustekinumab (UST) and guselkumab (GUS) have low immunogenicity. Additionally, GUS has not been found to have a significant risk of inducing the development of clinically relevant neutralizing antibodies. Therefore, we sometimes consider switching to GUS when UST is insufficiently effective. However, switching to another biological agent usually requires an induction phase, potentially incurring additional costs. We herein present the first case of a successful transition from UST 90 mg to an extended dosing interval of GUS without an induction phase. This approach may be a viable and cost-saving option, especially for patients with relatively low disease activity.

Management of Psoriasis Patients with Serious Infectious Diseases

The management of patients affected by moderate-to-severe psoriasis may be challenging, in particular in patients with serious infectious diseases [tuberculosis (TB), hepatitis B and C, HIV, COVID-19]. Indeed, these infections should be ruled out before starting and during systemic treatment for psoriasis. Currently, four conventional systemic drugs (methotrexate, dimethyl fumarate, acitretin, cyclosporine), four classes of biologics (anti-tumour necrosis factor alpha, anti-interleukin (IL)12/23, anti-IL-17s, and anti-IL-23], and two oral small molecules (apremilast, deucravacitinib) have been licensed for the treatment of moderate-to-severe psoriasis. Each of these drugs is characterized by a unique safety profile which should be considered before starting therapy. Indeed, some comorbidities or risk factors may limit their use. In this context, the aim of this manuscript was to evaluate the management of patients affected by moderate-to-severe psoriasis with serious infectious diseases.

Real-Life Effectiveness and Safety of Guselkumab in Patients with Psoriasis Who Have an Inadequate Response to Ustekinumab: A 3-Year Multicenter Study

Background: Guselkumab is the first approved human IgG1λ monoclonal antibody selectively targeting the p19 subunit of IL23. Its effectiveness and safety were widely reported by clinical trials. However, these results must be confirmed in real life since its safety deals with more complicated subjects with respect to trials. Currently, real-life data on the use of guselkumab following treatment failure with ustekinumab are limited, and existing studies usually show a small cohort and/or a reduced follow-up period. In this context, the aim of our study was to evaluate the use of guselkumab in patients who previously did not respond to ustekinumab after up to 3 years of treatment. Methods: A multicenter retrospective study was performed. The study enrolled patients affected by moderate-to-severe plaque psoriasis undergoing treatment with guselkumab who were attending the Psoriasis Center of nine different centers in the Campania region of Italy. Demographic and clinical features were collected for each patient at baseline. Moreover, data on psoriasis severity and adverse events (AEs) were collected at each follow-up visit (week (W)16-W36-W52-W104-W156). Results: A total of 112 patients (70 male, 62.5%; mean age 54.8 ± 11.7 years old) were enrolled. Of these, 48 (42.9%), 34 (30.4%), and 16 (14.3%) reached 1, 2, and 3 years, respectively, of follow-up under guselkumab. A statistically significant clinical improvement was observed since W16, and sustained effectiveness was reported at each timepoint up to W156. No serious AEs were collected. Moreover, a sub analysis on the body mass index, involvement of difficult-to-treat areas, and presence of psoriatic arthritis (PsA) showed that the presence of PsA or palmoplantar psoriasis was associated with a reduced clinical improvement at W16 and W36, without differences from W52. In contrast, the efficacy of guselkumab does not seem to be affected by the BMI, involvement of fingernails, or location in the genital or scalp area. Conclusions: To sum up, our long-term real-life multicenter retrospective study confirmed the efficacy and safety of guselkumab following ustekinumab discontinuation up to 156 weeks of treatment.

The Role of Interleukin 23/17 Axis in Psoriasis Management: A Comprehensive Review of Clinical Trials

Psoriasis pathogenesis is influenced by genetic factors and characterized by a complex interplay between genetic predisposition and various environmental triggers. These triggers set off metabolic processes involving inflammation, cell signaling, immune response dysregulation, and antigen presentation. Several types of innate and adaptive immune cells are involved in psoriasis. Among the cytokine cascade which leads to psoriasis development, the interleukin (IL)-23/Th17 axis, especially IL-17 production, emerges as crucial. Recognizing the pivotal role of this axis has facilitated the development of selective and effective biological drugs, such as anti-IL17 and anti-IL23 monoclonal antibodies. These drugs aim to achieve the complete or near-complete disappearance of psoriatic lesions, as indicated by PASI100 and PASI90 responses, respectively. In this context, the aim of our review was to delve into the functioning of the IL-23/Th17 axis, its dysregulation in psoriasis pathogenesis, and the therapeutic potential of its inhibition. Currently, 4 anti-IL17 (secukinumab, ixekizumab, bimekizumab and brodalumab) and 3 anti-IL23 (guselkumab, risankizumab and tildrakizumab) have been approved. All these drugs showed high levels of effectiveness in both clinical trials and real-life experiences, with an excellent profile in terms of safety. Certainly, furthers studies will allow for better characterization of biologics' profile, in order to administer the right drug for the right patients at the right moment.

Choosing the right biologic treatment for moderate-to-severe plaque psoriasis: the impact of comorbidities

INTRODUCTION

Psoriasis is a chronic inflammatory skin disease often associated with several comorbidities, such as psoriatic arthritis, inflammatory bowel disease, obesity, diabetes mellitus or cardiovascular diseases, infections, or cancer, among others. With the progressive aging of the population, a growing number of patients with psoriasis can be expected to present multiple comorbidities. Currently, there is a wide range of biological treatments available for moderate to severe psoriasis, including tumor necrosis alpha (TNF) inhibitors, IL12/23 inhibitor, IL17 inhibitors, and IL23 inhibitors.

AREAS COVERED

This review aims to describe the specific characteristics of these drugs in relation to psoriasis comorbidities, in order to facilitate decision-making in clinical practice.

EXPERT OPINION

Some of the biological treatments can influence comorbidities, in some cases even improving them. Therefore, comorbidities are a key factor when deciding on one biological treatment over another. The development of new drugs is expanding the therapeutic arsenal for psoriasis. A high level of expertise in the field with a detailed knowledge of the characteristics of every drug is imperative to provide personalized medicine.

Psoriasis and Molecular Target Therapies: Evidence of Efficacy in Preventing Cardiovascular Comorbidities

Psoriasis is now considered a systemic disease, and several comorbidities have been described such as cardiovascular diseases, neurologic and psychiatric disorders, chronic inflammatory bowel disease, psoriatic arthritis, etc. Regarding cardiovascular comorbidities, major adverse cardiovascular events have been reported in psoriasis patients by multiple epidemiologic studies. Moreover, smoking, obesity, metabolic syndrome, hypertension, dyslipidemia, diabetes and reduced physical activity are associated with psoriasis, increasing cardiovascular risk. Consequently, several aspects should be considered when making the treatment decision. The aim of this review manuscript was to investigate the effectiveness and safety of biologic drugs acting on molecular mechanisms involved in the pathogenesis of psoriasis in preventing cardiovascular complications.

Sex differences in adverse events from systemic treatments for psoriasis: A decade of insights from the Swiss Psoriasis Registry (SDNTT)

BACKGROUND

Psoriasis is a disease that often requires prolonged systemic treatment. It is important to determine the safety of available therapies. There is currently little insight into sex-specific differences in the safety of systemic psoriasis therapies.

OBJECTIVES

To examine the real-world, long-term safety of systemic psoriasis therapies with sex stratification in drug-related adverse events (ADRs).

METHODS

Ten-year data from adults with moderate-to-severe psoriasis requiring systemic treatment (conventional systemic therapies [CST], biologics) were obtained from the Swiss psoriasis registry (SDNTT). ADRs were categorized according to the international terminology Medical Dictionary for Regulatory Activities (MedDRA). Safety was assessed by calculating event rates per 100 patient-years (PY). We used descriptive statistics for patient and disease characteristics, and binomial and t-tests to compare treatment groups and sex.

RESULTS

In total, 791 patients (290 females) were included with a mean age of 46 years. 358 (45%) received CSTs and 433 (55%) biologics; both groups had similar baseline characteristics except for more joint involvement in patients using biologics (26.86% vs. 14.8%, p < 0.0001). CSTs were associated with a 2.2-fold higher ADR rate (40.43/100 PY vs. 18.22/100 PY, p < 0.0001) and an 8.0-fold higher drug-related discontinuation rate than biologics (0.16/PY vs. 0.02/PY, p < 0.0001). Trends showed non-significant higher serious adverse event rates per 100 PY for biologics (8.19, CI 6.87-9.68) compared to CSTs (7.08, CI 5.39-9.13) (p = 0.3922). Sex stratification revealed a significantly higher overall ADR rate for all treatments in females (1.8-fold for CSTs [57.30/100 PY vs. 31.69/100 PY] and 2.0-fold for biologics [27.36/100 PY vs. 13.9/100 PY], p < 0.0001), and drug-related discontinuation rates for most CSTs in females.

CONCLUSION

Females were associated with a significantly higher rate of ADRs and drug-related discontinuation rates. Sex stratification should be taken into consideration when designing studies in the patient-tailored management of psoriasis.

T cell-mediated skin-brain axis: Bridging the gap between psoriasis and psychiatric comorbidities

Psoriasis, a chronic inflammatory skin condition, is often accompanied by psychiatric comorbidities such as anxiety, depression, suicidal ideation, and other mental disorders. Psychological disorders may also play a role in the development and progression of psoriasis. The intricate interplay between the skin diseases and the psychiatric comorbidities is mediated by the 'skin-brain axis'. Understanding the mechanisms underlying psoriasis and psychiatric comorbidities can help improve the efficacy of treatment by breaking the vicious cycle of diseases. T cells and related cytokines play a key role in the pathogenesis of psoriasis and psychiatric diseases, and are crucial components of the 'skin-brain axis'. Apart from damaging the blood-brain barrier (BBB) directly, T cells and secreted cytokines could interact with the hypothalamic-pituitary-adrenal axis (HPA axis) and the sympathetic nervous system (SNS) to exacerbate skin diseases or mental disorders. However, few reviews have systematically summarized the roles and mechanisms of T cells in the interaction between psoriasis and psychiatric comorbidities. In this review, we discussed several key T cells and their roles in the 'skin-brain axis', with a focus on the mechanisms underlying the interplay between psoriasis and mental commodities, to provide data that might help develop effective strategies for the treatment of both psoriasis and psychiatric comorbidities.