Addressing challenges associated with long-term topical treatment and benefits of proactive management in patients with psoriasis

Automated Machine Learning Predicts Necessary Upcoming Therapy Changes in Patients With Psoriasis Vulgaris et Arthritis And Uncovers New Influences On Disease Progression: Retrospective Study

BACKGROUND

Psoriasis vulgaris (PsV) and Psoriatic arthritis (PsA) are intertwined multifactorial diseases with significant impact on health and quality of life, which can be debilitating due to chronicity and treatment complexity. Predicting treatment response and disease progression in these conditions is challenging, but crucial for optimising therapeutic interventions. The advancing technology of automated machine learning (AutoML) holds great promise for rapidly building highly accurate predictive models based on patient features and treatment data.

OBJECTIVE

The study aimed to develop highly accurate ML models using AutoML to address key clinical questions in PsV and PsA patients, including predicting therapy changes and identifying reasons for therapy changes, factors influencing skin lesion progression or factors associated with an abnormal BASDAI score.

METHODS

After extensive dataset preparation of clinical study data from 309 PsV and PsA patients, a secondary dataset was created and ultimately analysed using AutoML to build a variety of predictive models and select the most accurate one for each variable of interest.

RESULTS

"Therapy change at 24 weeks follow-up" was modelled using the eXtreme Gradient Boosted Trees Classifier with Early Stopping model (AUC of 0.9078 and LogLoss of 0.3955 for the holdout partition) to gain insight into the factors influencing therapy change, such as the initial systemic therapeutic agent, the score achieved in the CASPAR classification criteria at baseline, and changes in quality of life. An AVG blender of 3 models (Gradient Boosted Trees Classifier, ExtraTrees Classifier, Eureqa Generalised Additive Model Classifier) with an AUC of 0.8750 and a LogLoss of 0.4603 was used to predict therapy changes on two hypothetical patients to highlight the importance of such influencing factors. Notably, treatments such as MTX or specific biologicals showed a lower propensity for change. A further AVG Blender of RandomForest Classifier, eXtreme Gradient Boosted Trees Classifier and Eureqa Classifier (AUC of 0.9241 and LogLoss of 0.4498) was then used to estimate "PASI change after 24 weeks" with the primary predictors being the initial PASI score, change in pruritus and change in therapy. A lower initial PASI score, and consistently low pruritus were associated with better outcomes. Finally, "BASDAI classification at baseline" was analysed using an AVG Blender of Eureqa Generalised Additive Model Classifier, eXtreme Gradient Boosted Trees Classifier with Early Stopping and Dropout Additive Regression Trees Classifier with an AUC of 0.8274 and LogLoss of 0.5037. Factors influencing BASDAI scores included initial pain, disease activity and HADS scores for depression and anxiety. Increased pain, disease activity and psychological distress were generally likely to lead to higher BASDAI scores.

CONCLUSIONS

The practical implications of these models for clinical decision making in PsV and PsA have the potential to guide early investigation and treatment, contributing to improved patient outcomes.

CLINICALTRIAL

Blood MALT1 expression could help predict treatment outcomes in psoriasis patients, especially in those receiving biologics

INTRODUCTION

Mucosa-associated lymphoid tissue 1 (MALT1) modulates T helper cell differentiation, pro-inflammatory cytokine production, and epidermal hyperplasia to participate in the pathology of psoriasis. This study aimed to explore the correlation of blood MALT1 with treatment outcomes in psoriasis patients.

METHODS

MALT1 was detected in peripheral blood mononuclear cells by reverse transcription-quantitative polymerase chain reaction in 210 psoriasis patients before starting or converting to a new therapy, 50 disease controls, and 50 healthy controls. The psoriasis area severity index (PASI) score was evaluated at month (M)1, M3, and M6 in psoriasis patients.

RESULTS

MALT1 was increased in psoriasis patients versus disease controls and healthy controls (both p < .001); and positively related to body mass index (p = .019) and PASI score (p < .001) in psoriasis patients. PASI75 rate at M1, M3, and M6 was 22.9%, 46.2%, and 71.0%, respectively; while PASI90 rate at M1, M3, and M6 was 3.8%, 29.0%, and 50.5%, respectively, in psoriasis patients. PASI75/90 rates at M1, M3, and M6 were increased in psoriasis patients receiving biologics versus those without (all p < .05). Pretreatment MALT1 was higher in psoriasis patients who achieved PASI75 (p = .001) and PASI90 (p < .001) at M6 compared to those who did not achieve that. Subgroup analyses discovered that pretreatment MALT1 had a stronger ability to predict PASI75 and 90 realizations in psoriasis patients receiving biologics (area under the curve [AUC]: 0.723 and 0.808) versus those without (AUC: 0.594 and 0.675).

CONCLUSION

Blood MALT1 measurement may assist in predicting outcomes in psoriasis patients, especially in those receiving biologics.

Epidemiology of Psoriasis in Portugal: A Population-Based Study

INTRODUCTION

Psoriasis is a common, chronic, and inflammatory skin disorder with a high personal, social and economic burden and important implications for healthcare systems. The aim of this study was to provide an epidemiological characterization of individuals with psoriasis in Portugal.

MATERIAL AND METHODS

A large observational, cross-sectional, nationwide, population-based survey study developed by the Portuguese Psoriasis Group of the Portuguese Society of Dermatology and Venereology (GPP-SPDV). A structured questionnaire was designed and applied by experienced interviewers to a random, representative sample of Portuguese individuals with psoriasis and/or psoriatic arthritis. Patients were considered to have psoriasis if they replied positively to one of the following questions: "Does any physician have ever diagnosed you with psoriasis?" or "Do you have a skin disorder characterized by scaling, reddish skin lesions located in the elbows/knees/scalp?".

RESULTS

A total of 6381 individuals were interviewed, of which 283 met the criteria for psoriasis, corresponding to a prevalence rate of 4.4% (95% CI 3.95 - 4.98). Out of the participants that met psoriasis criteria, 24% had suggestive signs/symptoms but did not have a clinical diagnosis established and were not being monitored by a physician. Although more than 70% of participants had active disease (scaling, erythema, or pruritus) and one third had joint symptoms, only 12% were on systemic treatment. Fifty percent of participants with psoriasis (n = 139) had relevant comorbidities (most frequently depression/anxiety and cardiometabolic diseases). Sixteen percent of participants with psoriasis (n = 46) reported that psoriasis interfered with their daily activities (median impact of 5 in a 0 - 10 scale) and 12% mentioned the disease had an impact in their sexual life (median impact of 5 in a 0 - 10 scale).

CONCLUSION

The results of this study suggest that the prevalence rate of psoriasis is likely to be high in Portugal, and several gaps exist at different levels of healthcare delivery to these patients, from diagnosis to treatment. This study provides important data for the future planning of interventions targeting the improvement of psoriasis care in Portugal.

Topical proactive therapy in dermatology. A scoping review

The term 'proactive therapy' refers to a long-term management of clinically intact skin in previously disease-affected areas. This method was initially implemented in atopic dermatitis to maintain the remission and decrease the risk of exacerbations. Proactive therapy aims to limit the need for reactive treatment and improve the patients' quality of life. A proactive approach is likely to be adopted for other relapsing and inflammatory skin conditions in the future. This scoping review aims to identify dermatological conditions to be treated with the proactive approach, evaluate the available evidence for its efficacy and safety, as well as highlight the research gaps.

Topical roflumilast for the treatment of psoriasis

INTRODUCTION

New non-steroidal topical agents are needed for the treatment of psoriasis. Roflumilast cream 0.3% is a once daily phosphodiesterase-4 inhibitor that was recently approved by the FDA for the treatment of plaque psoriasis in adolescents and adults. It is indicated for use on all body surfaces including intertriginous areas.

AREAS COVERED

In this review, we summarize the current knowledge about roflumilast cream for the treatment of psoriasis, highlighting its efficacy and safety profile from published clinical trials. Roflumilast's mechanism of action and pharmacokinetic profile are also discussed.

EXPERT OPINION

Positive results were reported across trials with 48% of patients treated with roflumilast achieving an Investigator Global Assessment score of clear or almost clear at 8 weeks in phase III studies. Most adverse events were mild or moderate in severity and few application-site reactions were reported among participants. Unique advantages of the cream are its success in treating intertriginous areas and its ability to reduce symptoms of itch, results of which may significantly improve quality of life for patients. In the future, real-world data and active comparator trials with existing non-steroidal agents are needed to better understand roflumilast's place in the current treatment landscape.

Safety and Efficacy of a Novel Combination Cream (GN-037) in Healthy Volunteers and Patients with Plaque Psoriasis: A Phase 1 Trial

INTRODUCTION

Psoriasis is a common skin disorder associated with physical and psychological burdens. Visible disfiguration can trigger a negative reaction which can cause much of the readily measurable psychological burden of the disease. Although many biological treatments provide some success in the initial clearance of lesions, there is a dispute about the long-term maintenance of the disease, as no current biological treatment has been shown to be curative. Topical therapies are still the most widely used agents as first-line and maintenance treatment for psoriasis. The present study aimed to investigate the safety, tolerability, and, to some extent, efficacy of GN-037 cream in patients with psoriasis and healthy volunteers.

METHODS

A randomized, double-blind, single-center, placebo-controlled phase 1 clinical study was conducted to evaluate the safety, tolerability, and clinical efficacy of GN-037 cream topically applied twice daily for 2 weeks in healthy subjects (n = 12) and patients (n = 6) diagnosed with plaque-type psoriasis. Six healthy subjects received placebo. Patients with plaque psoriasis were evaluated by a dermatologist, and Physician Global Assessment (PGA) score was required to be ≥ 3 (moderate psoriasis) at screening.

RESULTS

A total of 31 adverse events (AEs) occurred in 13 participants during the study: 9 AEs in healthy subjects receiving GN-037 cream, 3 AEs in healthy subjects receiving placebo, and 1 AE in one psoriatic patient. The most frequently reported AEs were reactions at the application site, including erythema, exfoliation, pruritus, and burning sensation. During the baseline evaluation, one patient had a PGA score of 3 (moderate) and five patients had a PGA score of 4 (severe). On day 14, in treatment, four patients experienced second grade and two patients third grade improvements compared with baseline, indicating a shift of patients from moderate and severe disease to mild disease and to almost clear (score 2 or 1). There were slight increases in plasma tumor necrosis factor (TNF)-α, interleukin-17 (IL-17) and interleukin-23 (IL-23) levels in both healthy volunteers and patients throughout the study, as compared with baseline.

CONCLUSION

The results of this phase 1 trial conducted in 18 healthy volunteers and 6 patients with plaque psoriasis demonstrated a favorable safety and tolerability profile for GN-037; therefore, further clinical development of GN-037 in a phase 2 clinical trial has been initiated in patients with mild to moderate plaque psoriasis (NCT05706870).

TRIAL REGISTRATION NUMBER

NCT05428202.

The role of topical therapies along the psoriasis patient journey: An overview from the Symposium 'Tailoring topical psoriasis treatments to patients' needs and expectations' of the 30th EADV Congress 2021

This article summarizes a presentation titled 'The role of topical therapies along the psoriasis patient journey' held at the Satellite Symposium of the 30^th European Academy of Dermatology and Venereology Congress. During this session, the role of topical treatments in the management of psoriasis was presented, with a particular focus on the current unmet needs and data gaps. Psoriasis plays a significant role in a patient's daily life, impacting them not only physically but also psychologically and socially. The disease burden increases with duration and severity. Topical therapies are the keystone of the management of psoriasis. About 70%-80% of patients present a mild-to-moderate form of psoriasis that can be successfully treated with topical agents. According to a German recommendation, patients with mild psoriasis should initiate a topical therapy in combination with skin care products. In the real-life setting, the calcipotriol/betamethasone dipropionate (CAL/BDP) fixed combination was the most prescribed topical treatment for beyond-mild patients in Germany, Spain and the United Kingdom. Healthcare professionals also often or very often prescribed topicals as an alternative to non-biologic systemics in certain situations, such as patient preference (51%), contraindication (50%) and to limit side effects (26%). Adjunctive topical therapy to patients using systemic therapy is used to optimize treatment outcomes and improving the quality of life for patients. Topical treatments can be also effective in severe forms of psoriasis. However, there are still some gaps and unmet needs on topical therapy. Ineffectiveness, patient dissatisfaction and adherence are the largest barriers to treatment success. Main strengths of topical treatments include the availability of various topical ingredients and galenics, the adaptability to different anatomical areas and the possible combination with phototherapy and systemics. Moreover, patients in specific situations can benefit from switching to topical treatments (e.g. pregnancy or surgery).

Investigation of the Relationship between the Disease Severity and Quality of Life of Psoriasis Patients and Their Anthropometric Measurements and Diets

Psoriasis is a multifaceted, chronic, inflammatory skin disease that impacts patients’ quality of life. The aim of this study was to investigate the relationship between the disease severity and quality of life of psoriasis patients and their nutritional status. The study included 40 patients in the psoriasis group, compared with 40 healthy individuals in the control group. A questionnaire for determination of socio-demographic characteristics and nutritional intake, anthropometric measurements, psoriasis area and severity index (PASI), and dermatology life quality index (DLQI) were used for the assessments. Daily food consumption details were recorded for three consecutive days to determine daily energy and nutrient intakes. Compared to the control group, the frequencies of single participants, primary school graduates, and housewives were higher in the psoriasis group (p < 0.05). The psoriasis patients weighed more and had an increased waist/hip ratio in comparison with the healthy individuals. The energy intake was lower in the psoriasis group (p < 0.01). There was not a significant statistical difference in the intake of proteins, fiber, vitamin A, vitamin E, vitamin C, Zn, Fe, and Mg supplements between the groups. However, there was an inverse correlation between the daily vitamin E intake and PASI scores (p < 0.05). There was a positive moderate correlation between the DLQI and PASI scores (p < 0.01). Our study indicated that lower daily vitamin E intake levels were associated with the severity of psoriasis. In addition to this, abdominal obesity seems to be another risk factor in psoriasis patients, even if they have a normal body mass index (BMI). An integrated healthcare approach with dermatologists, family physicians, and dietitians is essential to the management of psoriasis.

The Effect of the Long-Term Calcipotriol/Betamethasone Dipropionate Local Therapy on Tissue Resident Memory Cells Markers in Psoriatic Eruptions

Background: The natural course of psoriasis is characterized by the long-term persistence of lesions and a predilection for relapse in the same area. It is caused by the inherence of TRM (tissue resident memory T cells) in apparently healthy skin. These cells are able to initiate an inflammatory cascade and induce relapse of the disease. These cells are characterized by high resistance to damaging factors and apoptosis, which determines their longevity. Aim: The aim of our study was to evaluate the presence of TRM in psoriatic plaques before, during and after 12 weeks of therapy in patients treated with topical calcipotriol and betamethasone dipropionate (Cal/BD) foam. Methods: TRM markers (CD4, CD8, CD103, CD69, CD49, CXCR6) and tissue expression of cytokines (IL-17A, IL-22) in the lesional psoriatic skin from 10 patients compared to 10 healthy skin samples were estimated by immunohistochemistry. Biopsy samples from the area of the same psoriatic plaque were collected three times: before the initiation of therapy, 4 and 12 weeks after its initiation. Results: The presence of TRM markers in the epidermis and dermis of psoriatic lesions was significantly higher when compared to the skin of control group patients. A reduction in the expression of the characteristic TRM markers (CD8, CD4, CD103, CD69, CXCR6, IL-17A and IL-22) was observed in the epidermis on week 12 of therapy, while a depletion in the expression of TRM in the dermis was demonstrated only in CD4 and IL-22. Conclusions: Topical treatment with Cal/BD foam significantly decreased the expression of TRM markers mainly in the epidermis, and to a lesser extent in the dermis, during the 12-week observation period. It probably results from a worse penetration of the drug into the dermis and the effect of the preparation mainly on the epidermis. The persistence of a high expression of TRM markers in the dermis may result in the rapid recurrence of lesions after discontinuation of topical treatment.

Short Term and Long-Term Efficacy of Calcipotriene/ Betamethasone Dipropionate Foam Combination

Psoriasis is a well-known chronic disease characterized by the development of erythematous, indurated, scaly, pruritic plaques on the skin with cycles of remission and symptom flare-ups. The management of patients with chronic plaque psoriasis has been more challenging since the Covid-19 pandemic as health care professionals have had to adapt to remote consultations for some patients, and patients have had to adapt to the changing health landscape. The rapid resolution of psoriasis symptoms especially those with a substantial impact on quality of life can improve patient satisfaction and adherence, making it an important factor in successful treatment. Cal/BD foam contributes to improved patient adherence and treatment outcome through its rapid action and superior efficacy versus Cal or BD monotherapy, Cal/BD ointment and gel and clobetasol cream in the short-term flare treatment of psoriasis. Moreover, the benefits of proactive long-term management of psoriasis compared to reactive management and its favourable safety profile are higher efficacy and a better health-related quality of life. Cal/BD foam should be considered an effective topical treatment for short-term flare treatment and long-term control of adult psoriatic patients.

Three-Dimensional Skin CT Based on Intelligent Algorithm in the Analysis of Skin Lesion Sites Features in Children with Psoriasis

This research was to explore the application value of three-dimensional computed tomography (CT) based on artificial intelligent algorithm in analyzing the characteristics of skin lesions in children with psoriasis. In this study, 15 children with psoriasis were selected as the observation group, and 15 children with other skin diseases were selected as the control group. The CT images were optimized, and the feature selection was carried out based on artificial intelligent algorithm. Firstly, the results were compared with the results of simple skin three-dimensional CT to determine the effectiveness. Then, the two groups of three-dimensional skin CT image features of skin psoriasis-like hyperplasia, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium based on intelligent algorithms were compared. After comparison, the detection rate of psoriasis-like hyperplasia, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium in the observation group was higher than that in the control group, with significant difference and statistical significance (P < 0.05). In addition, the sensitivity of psoriasis-like hyperplasia, Munro microabscess, dermal papilla vascular dilatation, and squamous epithelium in children with psoriasis was 80.0%, 86.7%, 80.0%, and 93.3%, respectively. The specificity of psoriasis-like hyperplasia, Munro microabscess, dermal papilla vascular dilatation, and squamous epithelium in children with psoriasis was 86.7%, 93.3%, 60.0%, and 73.3%, respectively. The results showed that Munro microabscess and psoriasis-like hyperplasia had high sensitivity and specificity in all diagnostic items, which could be used as important features of skin lesion sites in the diagnosis of psoriasis in children. The research provides a basis for the clinical diagnosis of psoriasis in children, which is worthy of clinical promotion.

Assessment of the Tissue Resident Memory Cells in Lesional Skin of Patients with Psoriasis and in Healthy Skin of Healthy Volunteers

BACKGROUND

In the course of plaque psoriasis, tissue resident memory cells (TRM) are responsible for the phenomenon of "immune memory" of lesions, i.e., the appearance of recurrences of lesions in the same location, as well as Koebner phenomenon. We present results determining the location and amount of TRM in psoriatic lesions in patients suffering from plaque psoriasis, as well as an analysis of the relationship between TRM markers expression and the duration and severity of the disease.

METHODS

TRM markers (CD4, CD8, CD103, CD69, CD49, CXCR6) and tissue expression of cytokines (IL-17, IL-22) in the lesional psoriatic skin of 32 patients compared with 10 healthy skin samples were evaluated by immunohistochemistry.

RESULTS

The presence of TRM markers in both the epidermis and skin with psoriatic eruptions was demonstrated in much higher amounts compared with the skin of healthy volunteers. A significant positive relationship was demonstrated between the expression of TRM markers in patients with plaque psoriasis and the duration of skin lesions. There was no relationship between the amount of TRM and the severity of plaque psoriasis.

CONCLUSIONS

A thorough understanding of the mechanisms responsible for the development and relapse of plaque psoriasis may contribute to the implementation of more effective therapies.

Systematic literature review of long-term efficacy data for topical psoriasis treatments

OBJECTIVE

To identify long-term efficacy evidence that supports use of topical therapies as regular maintenance therapy in the prevention of psoriasis relapse.

METHODS

A systematic literature review identified clinical trials and observational studies that reported efficacy outcomes for topical psoriasis therapies with treatment durations of at least 12 weeks. For therapies with long-term data, the approved treatment schedules in product labels were reviewed.

RESULTS

Forty-six studies with at least 12-week efficacy outcomes were identified. Eight randomized controlled trials and six observational studies or single-arm open-label studies reported efficacy data for >12-week treatment periods. Most studies used treatment regimens that reflect current standard of care of repeated treatment of relapses. The PSO-LONG study is the only identified randomized controlled trial to have compared regular proactive maintenance use of a topical treatment (calcipotriol/betamethasone foam) with reactive management in response to psoriasis relapses.

CONCLUSIONS

Limited high-quality long-term efficacy data are available for topical psoriasis therapies. While some product labels mention clinical experience of up to 12 months, they do not provide specific recommendations on the optimal long-term regimen. Calcipotriol/betamethasone foam is the only treatment for which the approved label allows either reactive treatment of relapse or regular (twice weekly) maintenance use.

Editorial: fixed-dose combination calcipotriol/betamethasone dipropionate foam in the treatment of patients with psoriasis

Video abstract