Psoriasis in special localizations

Roflumilast Foam, 0.3%, for Psoriasis of the Scalp and Body: The ARRECTOR Phase 3 Randomized Clinical Trial

Importance

Current topical treatments for scalp psoriasis are limited by formulation, efficacy, and/or safety.

Objective

To assess safety and efficacy of roflumilast foam, 0.3%, in patients with psoriasis of the scalp and body.

Design, Setting, and Participants

This was a phase 3 double-blinded, vehicle-controlled randomized clinical trial conducted between August 24, 2021, and June 3, 2022, at 49 sites in Canada and the US. Eligible participants were 12 years and older with plaque psoriasis affecting up to 25% of the scalp and body, at least 10% of the scalp, and up to 20% of nonscalp areas, with a minimum Scalp-Investigator Global Assessment (S-IGA) score of 3 (moderate), and minimum Body-IGA (B-IGA) score of 2 (mild). Data analyses were performed from September 9 to December 30, 2022.

Interventions

Once-daily roflumilast foam, 0.3%, or vehicle for 8 weeks.

Main Outcomes and Measures

Coprimary end points were S-IGA and B-IGA success (clear [0] or almost clear [1] plus ≥2-grade improvement) at week 8. Secondary end points included S-IGA success at weeks 2 and 4, change in Scalp Itch-Numeric Rating Scale (SI-NRS), and SI-NRS and Worst Itch-NRS (WI-NRS) success (≥4-point improvement in patients with baseline score of ≥4). Safety and tolerability were also assessed.

Results

A total of 432 patients (mean [SD] age, 47.3 [14.8] years; 243 women [56.3%]) were randomized to roflumilast foam (n = 281) or vehicle (n = 151). At week 8, 66.4% of the roflumilast group achieved S-IGA success vs 27.8% of the vehicle group (P < .001); and 45.5% of the roflumilast group achieved B-IGA success compared with 20.1% of the vehicle group (P < .001). Rates for S-IGA success at week 2 and SI-NRS and WI-NRS success at weeks 2, 4, and 8 were significantly higher for roflumilast vs vehicle. Improvements in SI-NRS were greater for the roflumilast vs the vehicle group as early as the first assessment (24 hours after the first application). Both study groups had low rates of adverse events and favorable tolerability profiles.

Conclusions and Relevance

This randomized clinical trial found that roflumilast foam, 0.3%, improved signs and symptoms of psoriasis on the scalp and body, including pruritus, with low rates of adverse events in patients 12 years and older. These results demonstrate the potential of roflumilast foam, 0.3%, as monotherapy for patients with psoriasis of the scalp and body.

Trial Registration

ClinicalTrials.gov Identifier: NCT05028582.

Effectiveness of guselkumab in patients with facial and/or genital psoriasis: Interim analysis results at Week 12 from the GULLIVER study

BACKGROUND

Facial (FP) and genital psoriasis (GP) significantly affect patients' quality of life. Despite the advances in treatments, limited data on efficacy and safety are available on these difficult-to-treat areas. Guselkumab is an interleukin (IL)-23 inhibitor which has been proven effective in treating patients with moderate-to-severe plaque psoriasis.

OBJECTIVES

The aim of this interim analysis was to report the efficacy and safety of guselkumab in the treatment of patients with FP and/or GP.

MATERIALS AND METHODS

GULLIVER is a 52-week Italian observational study to evaluate the effectiveness and safety of guselkumab in a real-life setting in patients with FP and/or GP. Adult patients with facial and/or genital moderate-to-severe psoriasis (sPGA score ≥ 3) were included. The primary endpoint of this analysis was the percentage of patients achieving a facial or genital sPGA score of 0 (clear) or 1 (almost clear), at Week 12. The change in the score of the facial or genital sPGA components in patients with a score ≥3 for each sPGA component was assessed. PASI score in patients with a baseline PASI above or below 10 was evaluated.

RESULTS

Overall, 351 patients were included in the study; 83.3% of FP and 76.5% of GP patients achieved the primary endpoint. Similar response rates were observed for the facial or genital sPGA components in patients with a baseline facial or genital sPGA score ≥3 in each component. Among patients with a baseline PASI score >10, mean PASI score improved from 19.0 (SD 8.3) to 2.2 (SD 4.8). Forty-four AEs were observed in 32 patients; two mild and transient AEs (fatigue and nausea) were considered treatment related. No SAEs were observed.

CONCLUSIONS

Guselkumab, showing to be effective and safe in treating FP and GP, may be a valid therapeutic option for patients with psoriasis localized in these difficult-to-treat areas.

Genital Psoriasis in Asians: Impact on Quality of Life and Sexual Health

Genital involvement and sexual dysfunction are common amongst patients with psoriasis. However, the effects of genital psoriasis on quality of life (QOL) and sexual health of psoriasis patients are not well understood. We performed an observational study on adult Asian psoriasis patients attending psoriasis subspecialty clinics in a tertiary dermatology centre in Singapore over 1 year. Participants underwent clinical examination of the whole-body surface, with particular attention to the genitalia and questionnaires to evaluate QOL and psychosexual health were administered. A total of 62 patients participated. Most participants were male (82.3%) with a mean age of 41.7 years (SD 12.5). The mean Psoriasis Area and Severity Index (PASI) score was 7.0 (SD 4.3) with a mean Dermatology Life Quality Index (DLQI) score of 9.8 (SD 6.7), indicating moderately impaired QOL. Higher PASI scores were associated with increasing QOL impairment on DLQI (p = 0.021). The commonest site involved was the suprapubic region (61.3%). Males in whom genital psoriasis prevented sexual intercourse or diminished their libido reported more sexual dysfunction. Females reported a greater severity impact of genital psoriasis in terms of symptoms and embarrassment (p = 0.038) yet were less likely to be on treatment (37.5% vs. 45.0%). Perceived efficacy of treatment was low, and younger patients fared poorly on the Patient Health Questionnaire-9 depression questionnaire (p = 0.047). Clinicians should proactively evaluate for and treat genital psoriasis, as patients may be reluctant to discuss their genital rashes if not prompted, leading to under-recognition and undertreatment.

Update vulval dermatology - diagnostics and therapy

The vulva is a periorificial skin area and as such represents a transitional zone with unique functional and physiological characteristics. Knowledge of its anatomy is limited among both the general population and healthcare professionals, and unrealistic expectations of normal proportions are common. Ignorance of anatomical variations can cause unnecessary anxiety. In Germany, specialists in gynecology and obstetrics most commonly treat neoplastic vulvar dermatoses, while chronic inflammatory dermatoses commonly affecting the female genitalia (such as psoriasis, atopic dermatitis, hidradenitis suppurativa, and vitiligo) are typically treated by dermatologists. Both specialties treat infectious vulvar dermatoses and sexually transmitted infections. Certain dermatoses, such as lichen sclerosus, lichen planus, and lichen simplex chronicus, tend to affect the vulva preferentially; however, terminology can be confusing. Therefore, this article provides basic information on vulvar anatomy and physiology and summarizes recommendations for the diagnosis and management of the most common vulvar dermatoses, with a special focus on chronic inflammatory dermatoses, to provide a useful guide for all involved specialists in daily practice. Interdisciplinary collaboration and the establishment of dedicated consultation hours may help to improve the clinical care of vulvar dermatoses.

Updates on Psoriasis in Special Areas

Special areas of involvement in psoriasis include the scalp region, the palms and soles, genital areas, as well as intertriginous sites. The involvement of these topographical regions is associated with important physical and emotional implications, resulting in reduced quality of life, social isolation, and work disability. Palms and soles can be affected as part of the generalized form of psoriasis or can be exclusively affected as palmo-plantar psoriasis. Nail involvement may be encountered in 10-55% of patients with psoriasis, while scalp involvement occurs in 45-56% of individuals with psoriasis. Genital involvement may be the only manifestation of cutaneous psoriasis in 2-5% of patients. Inverse or intertriginous psoriasis represents a special variant of psoriasis as it may mimic and be difficult to differentiate from other dermatological entities that involve the intertriginous skin, such as bacterial or fungal infections, eczema, or lichen planus. Treatment of psoriasis in special areas is challenging due to the facts that special areas are more resistant to standard therapies and are more sensitive to potent local treatments. Biological therapies, proven to be more efficient than standard therapies, are not widely available in the absence of extensive skin involvement. This manuscript aims to provide an up-to-date literature review on psoriasis in special areas, benefiting the everyday clinical practice of physicians in optimizing the evaluation and treatment of their patients.

Prevalence of fungal colonization among patients with psoriasis in difficult-to-treat areas: impact of apremilast on mycotic burden and clinical outcomes

Introduction

Fungi, including Candida, may be a trigger or exacerbate psoriasis, especially in difficult to treat (DTT) areas, through the activation of IL-17/23 axis.

Methods

In this study, seventy patients with DDT psoriasis were enrolled to evaluate Candida species and/or other opportunistic fungi colonization rate at baseline (T0) and the impact of apremilast on fungal load, clinical outcome, serum cytokine levels and biochemical serum profile of patients after 16, 24 and 52 weeks of treatment.

Results

In our population, 33 (47%) patients were colonized by Candida spp. at baseline. In 24 (34%) individuals Candida was detected in the oral cavity while in the remaining 9 (13%) individuals the fungus was isolated from stool samples. Twenty subjects were colonized by only the species C. albicans, whereas in the remaining 13 a combination of two or more species (C. albicans plus non-albicans strains) was found in the oral cavity. Moreover, 27 (39%) patients were affected by onychomycosis. At 52 weeks, apremilast treatment induced a full recovery from Candida colonization in 83% of patients colonized with a single species of Candida (C. albicans); while in those co-infected by two or more Candida spp. induced a significant reduction (colony counts >10 CFU/mL) in fungal load was observed in comparison to baseline. Among patients with onychomycosis, 78% (21/27) of them presented a complete clinical resolution of nail psoriasis and concomitant nail infections. Finally, improvements in clinical scores i.e., PASI, NAPSI, DLQI, itch VAS, PAIN VAS, scPGA and sPGA-G and biochemical serum profile, as well as a significant decrease in serum IL-17A, TGF-β 1 and IL-10 levels (from 8.51 to 4.16 pg/mL; from 66.10 to 48.70 ng/mL and from 20.05 to 14 pg/mL, respectively) were observed in all patients.

Conclusions

Fungi may play a role in the psoriasis pathogenesis. Apremilast has been shown to ameliorate psoriasis signs and symptoms and counteract fungal overgrowth, probably by dampening inflammation, triggered by the fungal infections themselves. Thus, apremilast may represent an effective therapeutic approach in the treatment of DTT psoriasis and modulate the fungal colonization.

Is there still a place for neutrophil gelatinase-associated lipocalin to serve as a biomarker in psoriasis?

Introduction

Neutrophil gelatinase-associated lipocalin (NGAL) is believed to be involved in the pathogenesis of psoriasis, and its serum level was previously found to decline after administration of biologics, UV, and cyclosporine therapy.

Aim

To investigate whether NGAL may serve as a biomarker of disease activity in psoriasis vulgaris.

Material and methods

To measure the level of NGAL in serum, 36 patients with psoriasis vulgaris and 33 healthy controls were enrolled. Measurements were correlated to patients' and disease characteristics, including the Psoriasis Activity and Severity Index (PASI), Body Surface Area (BSA), itch and its intensity measured with the Peak Pruritus Numerical Rating Scale (PP-NRS), and involvement of special regions (scalp, genitals, hands, nails).

Results

A significantly higher level of NGAL in serum was found in patients with psoriasis than in healthy controls. It showed a moderate correlation with PASI but none with BSA. The genital involvement was associated with significantly greater serum level of NGAL. Itch corresponded to higher concentration of NGAL, and PP-NRS corelated moderately with the level of circulating NGAL.

Conclusions

An elevated level of circulating NGAL indicates its participation in the pathogenesis of psoriasis and the development of the itch. The serum level of NGAL does not allow for the evaluation of disease severity because it shows only moderate correlation with PASI. Determination of the circulating NGAL level may help to identify patients with greater risk for involvement of the genital region.

Bimekizumab Efficacy in High-Impact Areas: Pooled 2-Year Analysis in Scalp, Nail, and Palmoplantar Psoriasis from Phase 3/3b Randomized Controlled Trials

INTRODUCTION

Psoriasis in high-impact areas, including the scalp, nails, palms, and soles, can disproportionately impair patient quality of life. Here, we evaluate the 2-year efficacy of bimekizumab treatment in patients with moderate to severe plaque psoriasis in post hoc analyses of five phase 3/3b trials.

METHODS

High-impact area efficacy data were pooled through 2 years across five phase 3/3b trials: BE VIVID, BE READY, BE SURE, their ongoing open-label extension (OLE) BE BRIGHT, and BE RADIANT (including its double-blinded treatment period and the first year of its OLE). Complete clearance of psoriasis in high-impact areas is reported over 2 years using the scalp Investigator's Global Assessment (IGA), palmoplantar IGA, and modified Nail Psoriasis Severity Index (mNAPSI). Patients included in these analyses had baseline moderate to severe scalp or palmoplantar involvement (scalp or palmoplantar IGA score ≥ 3) or mNAPSI score > 10.

RESULTS

A total of 1107 patients were randomized to bimekizumab and entered the OLEs. Subsets of 821 patients had scalp IGA ≥ 3 at baseline, 377 had mNAPSI > 10, and 193 had palmoplantar IGA ≥ 3. Complete scalp clearance in patients with baseline scalp IGA ≥ 3 randomized to bimekizumab was achieved rapidly, with high responses sustained from first (86.4%) to second year (85.9%). Nail clearance responses in patients with baseline mNAPSI > 10 increased from 63.4% to 68.5% from first to second year. Palmoplantar clearance in patients with baseline palmoplantar IGA ≥ 3 was sustained from first (88.3%) to second year (89.8%). Similar trends were seen in the 374 patients who received bimekizumab 320 mg every 4 weeks (Q4W)/every 8 weeks (Q8W) initial/maintenance dosing.

CONCLUSION

In these analyses pooled across 2 years, bimekizumab showed sustained efficacy in psoriasis in high-impact areas.

CLINICALTRIALS

GOV TRIAL REGISTRATION NUMBERS

NCT03370133, NCT03410992, NCT03412747, NCT03598790, NCT03536884.

Disease heterogeneity and molecular classification of inflammatory palmoplantar diseases

BACKGROUND

Palmoplantar pustulosis (PPP) is an inflammatory disease characterized by relapsing eruptions of neutrophil-filled, sterile pustules on the palms and soles that can be clinically difficult to differentiate from non-pustular palmoplantar psoriasis (palmPP) and dyshidrotic palmoplantar eczema (DPE).

OBJECTIVE

We sought to identify overlapping and unique PPP, palmPP, and DPE drivers to provide molecular insight into their pathogenesis.

METHODS

We performed bulk RNA sequencing of lesional PPP (n = 33), palmPP (n = 5), and DPE (n = 28) samples, as well as 5 healthy nonacral and 10 healthy acral skin samples.

RESULTS

Acral skin showed a unique immune environment, likely contributing to a unique niche for palmoplantar inflammatory diseases. Compared to healthy acral skin, PPP, palmPP, and DPE displayed a broad overlapping transcriptomic signature characterized by shared upregulation of proinflammatory cytokines (TNF, IL-36), chemokines, and T-cell-associated genes, along with unique disease features of each disease state, including enriched neutrophil processes in PPP and to a lesser extent in palmPP, and lipid antigen processing in DPE. Strikingly, unsupervised clustering and trajectory analyses demonstrated divergent inflammatory profiles within the 3 disease states. These identified putative key upstream immunologic switches, including eicosanoids, interferon responses, and neutrophil degranulation, contributing to disease heterogeneity.

CONCLUSION

A molecular overlap exists between different inflammatory palmoplantar diseases that supersedes clinical and histologic assessment. This highlights the heterogeneity within each condition, suggesting limitations of current disease classification and the need to move toward a molecular classification of inflammatory acral diseases.

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.

Efficacy and Safety of Topical Roflumilast for the Treatment of Psoriasis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND OBJECTIVE

Plaque psoriasis is commonly treated topically with glucocorticoids and vitamin D derivatives. However, potential side effects such as skin atrophy underscore the need for safe and effective alternative topical therapies. Recently, the US Food and Drug Administration (FDA) and Health Canada approved roflumilast 0.3% cream as an option for treating this disease. A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted to assess the efficacy and safety of topical roflumilast 0.3% compared with vehicle for plaque psoriasis.

METHODS

PubMed, Embase, ClinicalTrials.gov, and Cochrane databases were searched from inception to 1 May 2024, assessing the outcomes of Investigator's Global Assessment (IGA) or body-IGA success (clear or almost clear status plus an at least 2-grade improvement from baseline), Psoriasis Area and Severity Index (PASI)-50, PASI-75, PASI-90, intertriginous-IGA success (clear or almost clear status on the intertriginous-IGA plus an at least 2-grade improvement from baseline), and adverse events (AEs). Statistical analysis was performed using Review Manager, R software, and RStudio. Heterogeneity was determined using the Cochran Q test and I2 statistics.

RESULTS

Four RCTs were included, comprising a total of 1403 patients, of whom 885 (63.1%) received topical roflumilast 0.3% and 518 (36.9%) received vehicle. At week 8, the achievement of IGA or body-IGA success was significantly higher among those treated with topical roflumilast than in the vehicle group [relative risk (RR) 5.07; 95% confidence interval (CI) 3.55-7.23; p < 0.01]. Similar findings were observed at week 8 for PASI-50 (RR 2.73; 95% CI 2.27-3.29; p < 0.01), PASI-75 (RR 4.48; 95% CI 2.26-8.89; p < 0.01), and PASI-90 (RR 5.61; 95% CI 2.57-12.25; p < 0.01). Corresponding outcomes were found at weeks 2, 4, and 6. Additionally, a higher percentage of patients treated with topical roflumilast 0.3% once daily achieved intertriginous-IGA success, compared with those receiving vehicle, at week 8 (71.9% versus 20.5%; RR 3.32; 95% CI 2.11-5.22; p < 0.01), with similar findings at weeks 2, 4, and 6. While a significant difference was observed in the overall incidence of AEs between the topical roflumilast and vehicle groups, there was no difference in treatment-related AEs, serious AEs, or AEs leading to study discontinuation.

CONCLUSION

These findings support the superiority of topical roflumilast 0.3% over vehicle and suggest its use as a valuable asset for the treatment of plaque psoriasis.

PROTOCOL REGISTRATION

International Prospective Register of Systematic Reviews (PROSPERO), CRD42023456494.

Patient Perspectives on the Prevalence and Burden of Intertriginous Psoriasis: Results from a National Survey of Adults with Psoriasis in the United States

INTRODUCTION

A survey was conducted by The Harris Poll on behalf of Arcutis Biotherapeutics in the USA to understand perspectives and burden of patients with psoriasis using prescription topical treatments for their disease. This manuscript presents results from the subset of patients with intertriginous psoriasis.

METHODS

The survey was conducted online October 21-November 24, 2021, among 507 US adults aged 18+ years with psoriasis diagnosed by a healthcare provider and currently using prescription topical treatment. Participants with intertriginous psoriasis were patients with plaque psoriasis reporting symptoms in the armpit, groin, under breast, stomach fold, or between the buttocks.

RESULTS

Of the 507 respondents, 320 (64%) reported symptoms in intertriginous areas at some point, typically between the buttocks (31%). Most patients with intertriginous psoriasis reported it made them feel embarrassed (80%), anxious (79%), or depressed (69%). In addition, 45% of these patients reported intertriginous psoriasis caused a negative impact on sexual anxiety or distress. Quality of life impact was reported as "very strong negative impact" in 16% of patients with groin involvement vs. 6% in patients with no groin involvement and 15% in women vs. 6% in men. Patients with intertriginous psoriasis reported that itch (61%), scaling (53%), redness (49%), and skin cracking (46%) related to intertriginous psoriasis had the greatest negative impact on quality of life. Most (86%) of these patients said they would be more adherent if a single treatment option could be used to treat all affected areas of their body.

CONCLUSION

Psoriasis involvement in intertriginous areas over the course of disease is common and has a negative impact on these patients' quality of life, particularly emotional well-being and sexual health.

Association between the severity of hard-to-treat psoriasis and the prevalence of metabolic syndrome: A hospital-based cross-sectional study in Jakarta, Indonesia

Psoriatic lesions on the scalp, face, intertriginous, genitals, palms/soles, and nails are often delay diagnosed, hard-to-treat, and cause disability. Metabolic syndrome (MetS) is one of the most frequent and significant comorbidities in psoriasis. Many studies have discovered a link between psoriasis and MetS, but none have specifically assessed the hard-to-treat psoriasis in Indonesian population. This is a multicenter study involving four dermatology referral hospitals to investigate the association between psoriasis severity that has hard-to-treat lesions with the prevalence of MetS in Jakarta, Indonesia. Data was collected from April to October 2022. The severity of 84 hard-to-treat psoriasis patients was measured by Psoriasis Area Severity Index (PASI) scores. The participants divided into PASI score >10 (severe) and ≤ 10 (mild-moderate) groups. MetS was identified based on the modified National Cholesterol Education Program Adult Treatment Panel III. MetS was found in 64.3% of patients. Patients with a PASI score>10 had a significantly higher risk of metabolic syndrome compared to those with a score ≤ 10 (78.6% vs 50%, OR 3.667; 95% CI 1.413-9.514; p = 0.006). The prevalence of hypertension (p = 0.028), low levels of high-density lipoprotein (HDL) cholesterol (p = 0.01), mean fasting blood sugar (p = 0.018), and triglyceride levels (p = 0.044) between the two groups differed significantly. This study found most frequent components of MetS were abdominal obesity, decreased levels of HDL cholesterol, hypertension, hyperglycemia, and hypertriglyceridemia respectively. Individuals with severe hard-to-treat psoriasis had a 3.67 times more likely to have MetS rather than the mild-moderate group.

CD1a and skin T cells: a pathway for therapeutic intervention

The CD1 and MR1 protein families present lipid antigens and small molecules to T cells, complementing well-studied major histocompatibility complex-peptide mechanisms. The CD1a subtype is highly and continuously expressed within the skin, most notably on Langerhans cells, and has been demonstrated to present self and foreign lipids to T cells, highlighting its cutaneous sentinel role. Alteration of CD1a-dependent T-cell responses has recently been discovered to contribute to the pathogenesis of several inflammatory skin diseases. In this review, we overview the structure and role of CD1a and outline the current evidence implicating CD1a in the development of psoriasis, atopic dermatitis and allergic contact dermatitis.

A Real-Life 208 Week Single-Centred, Register-Based Retrospective Study Assessing Secukinumab Survival and Long-Term Efficacy and Safety Among Greek Patients with Moderate to Severe Plaque Psoriasis, Including Difficult-to-Treat Manifestations Such as Genitals and Scalp

INTRODUCTION

Psoriasis is a chronic inflammatory disease with multiple skin manifestations, and in case of lesions affecting the genital area, sexual health impairment and psychological distress can furthermore impair the patients quality of life. Secukinumab is a fully humanized immunoglobulin G1 kappa antagonist of IL-17A and is indicated for the treatment of moderate-to-severe psoriasis, since it shows a significant efficacy in clinical outcomes, with rapid onset of remission, prolonged treatment response rate, advantageous safety profile and a valuable improvement of the patients quality of life.

OBJECTIVES

This study was conducted in order to gather retrospective real-world data regarding the efficacy of secukinumab in treating patients with moderate-to-severe plaque psoriasis in Greece. To fill the relevant literature gap, we included difficult-to-treat manifestations in our analysis, specifically regarding the efficacy in the genital area and on the skin folds where relevant data are missing both from the drug clinical program as well as from the real-world setting.

METHODS

All adult patients receiving 300 mg secukinumab and attending follow-up visits on a regular basis, according to routine medical practice were included. The timeline of the study was from 2015 to 2020. Primary endpoint of the study was the percentage of patients who achieved a psoriasis area and severity index (PASI) 75 response rate at week 16 and week 52 post baseline. Secondary endpoints were the evaluation at baseline (week 0), week 4 (±1), week 16 (±1), week52 (±1), and week 104 (±1), week 156 (±1), week 208 (±1) of clinical outcomes, incidence of adverse events and potential predictive variables influencing response rate.

RESULTS

Ninety-nine patients were included in the study population, from whom sixty six patients (66.67%) were bio-naive, whereas 33 patients had never received systemic treatment. Regarding difficult-to-treat manifestations, we recorded scalp involvement in 74.74% (74/99) of our patients, genital psoriasis in 27.27% (27/99) and skin folds involvement (psoriasis inversa) in 17% (17/99). At week 16, PASI75/PASI90/PASI100 were observed in 87.5%/69.8%/49%, respectively. At week 4 lesions affecting the genital area and patients with skin fold involvement experienced a rapid regression and 84.1% of patients achieved sPGA 0/1 (Physician Global Assessment). Treatment with secukinumab during the 208 weeks of observation did not reveal any major adverse event or systemic infection and generally it was well tolerated.

CONCLUSIONS

According to our outcomes secukinumab is an effective treatment choice for treating chronic plaque psoriasis, but, additionally, it can be efficacious in the subgroups of patients with difficult-to-treat manifestations, as our patients experienced great improvement starting even 5 weeks after treatment initiation. This real-life study offers information about clinical efficacy, retention and safety profile of secukinumab in patients from everyday clinical practice over a long-term, 4-year, follow-up period in Greece.

Acrokeratosis neoplastica (Bazex syndrome): Report of two cases and literature review

The skin often reflects the presence of internal diseases. Acrokeratosis neoplastica (Bazex syndrome) is a unique skin manifestation characterized by its erythematous hyperkeratosis with yellowish, adherent scales on the palm, sole, or other acral locations. There is a potentially high association between Bazex syndrome and malignant pathology, especially squamous cell carcinomas (SCC). To date, various skin conditions have been recognized as diagnostic indicators of insidious malignancies. The recognition of paraneoplastic dermatoses has a strong potential for prompt cancer detection and early therapeutic intervention. Here we describe clinical and forensic cases of Bazex syndrome that are associated with SCC of the glottis and lung. Bazex syndrome has been reported to be associated with a variety of cancers in addition to SCC. We review the clinical manifestations of Bazex syndrome and include updated knowledge on disease pathogenesis.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in psoriasis: a systematic review and meta-analysis

Psoriasis is a chronic, inflammatory skin disorder characterized by well-demarcated erythematous lesions with surface scaling. The disease is underpinned by a dysregulated immune response with a shift in the balance of neutrophils, lymphocytes and platelets. We sought to evaluate the novel systemic inflammatory markers, neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), as psoriatic indicators. Pubmed, Web of Science and Scopus were systematically searched for relevant studies. Twenty-four studies consisting of a total of 2,275 psoriatic patients (1,301 males and 974 females) and 2,334 healthy controls (1,401 males and 933 females) were identified for inclusion in the quantitative analysis. The NLR and PLR were found to be significantly increased in psoriatic patients [standardized mean difference (SMD) = 0.68, 95% CI 0.56-0.80, p < 0.01, and SMD = 0.37, 95% CI 0.14-0.60, p < 0.01, respectively]. However, no association between the NLR and PLR with psoriasis severity was detected (p = 0.93, and p = 0.83, respectively). In conclusion, the NLR and PLR are simple and cost-effective markers of psoriatic presence, but their value as severity markers requires further study.

Tapinarof cream 1% once daily for the treatment of adults with mild to severe plaque psoriasis: A novel topical therapy targeting the aryl hydrocarbon receptor

Plaque psoriasis is a chronic, immunemediated skin disease characterized by scaly, erythematous, pruritic plaques. The effects of psoriasis are often debilitating and stigmatizing, significantly impacting patients' physical and psychological well-being and quality of life. Current guideline-recommended psoriasis therapies (topicals, oral systemics, and biologics) have substantial limitations that include overall efficacy, safety, tolerability, sites of application, disease severity, and duration and extent of body surface area treated. Due to these limitations, psoriasis treatment regimens often require combination therapy, especially for moderate to severe disease, leading to increased treatment burden. Psoriasis is also associated with increased indirect costs (eg, reduced work productivity), leading to greater total costs expenditures. Thus, more effective, safe, well-tolerated, and cost-effective therapeutic options are needed. Tapinarof cream 1% once daily is a first-in-class, nonsteroidal, topical aryl hydrocarbon receptor agonist approved by the US Food and Drug Administration in 2022 for the treatment of plaque psoriasis in adults. Tapinarof cream has been evaluated in plaque psoriasis, including 2 pivotal phase 3 trials (NCT03956355 and NCT03983980) and a long-term extension trial (NCT04053387). These trials demonstrated high rates of complete skin clearance with tapinarof cream, durable effects while on treatment (a lack of tachyphylaxis for up to 52 weeks), an approximately 4-month remittive effect off therapy after achieving complete clearance and stopping treatment (ie, duration during which psoriasis does not recur off therapy), and no rebound effects after cessation of therapy. According to the US Food and Drug Administration-approved prescribing information, tapinarof may be used to treat plaque psoriasis of any severity and in any location, has no restrictions on duration of use or extent of total body surface area treated, and has no contraindications, warnings, precautions, or drug-drug interactions. Tapinarof cream is thus an efficacious, well-tolerated, steroid-free topical option that addresses many of the limitations of current recommended therapies. Here we review current knowledge on the physical, psychological, and financial burdens of plaque psoriasis and identify how the clinical profile of tapinarof cream can address key treatment gaps important in the management of plaque psoriasis and patient quality of life. In this article, we aim to assist pharmacists and other managed care practitioners by providing an evidence-based overview of tapinarof cream to support patient-centric decision-making.

Tapinarof cream 1% once daily for the treatment of adults with mild to severe plaque psoriasis: A novel topical therapy targeting the aryl hydrocarbon receptor

Plaque psoriasis is a chronic, immunemediated skin disease characterized by scaly, erythematous, pruritic plaques. The effects of psoriasis are often debilitating and stigmatizing, significantly impacting patients' physical and psychological well-being and quality of life. Current guideline-recommended psoriasis therapies (topicals, oral systemics, and biologics) have substantial limitations that include overall efficacy, safety, tolerability, sites of application, disease severity, and duration and extent of body surface area treated. Due to these limitations, psoriasis treatment regimens often require combination therapy, especially for moderate to severe disease, leading to increased treatment burden. Psoriasis is also associated with increased indirect costs (eg, reduced work productivity), leading to greater total costs expenditures. Thus, more effective, safe, well-tolerated, and cost-effective therapeutic options are needed. Tapinarof cream 1% once daily is a first-in-class, nonsteroidal, topical aryl hydrocarbon receptor agonist approved by the US Food and Drug Administration in 2022 for the treatment of plaque psoriasis in adults. Tapinarof cream has been evaluated in plaque psoriasis, including 2 pivotal phase 3 trials (NCT03956355 and NCT03983980) and a long-term extension trial (NCT04053387). These trials demonstrated high rates of complete skin clearance with tapinarof cream, durable effects while on treatment (a lack of tachyphylaxis for up to 52 weeks), an approximately 4-month remittive effect off therapy after achieving complete clearance and stopping treatment (ie, duration during which psoriasis does not recur off therapy), and no rebound effects after cessation of therapy. According to the US Food and Drug Administration-approved prescribing information, tapinarof may be used to treat plaque psoriasis of any severity and in any location, has no restrictions on duration of use or extent of total body surface area treated, and has no contraindications, warnings, precautions, or drug-drug interactions. Tapinarof cream is thus an efficacious, well-tolerated, steroid-free topical option that addresses many of the limitations of current recommended therapies. Here we review current knowledge on the physical, psychological, and financial burdens of plaque psoriasis and identify how the clinical profile of tapinarof cream can address key treatment gaps important in the management of plaque psoriasis and patient quality of life. In this article, we aim to assist pharmacists and other managed care practitioners by providing an evidence-based overview of tapinarof cream to support patient-centric decision-making.

Once-daily roflumilast foam 0.3% for scalp and body psoriasis: a randomized, double-blind, vehicle-controlled phase IIb study

BACKGROUND

Scalp psoriasis affects most patients with psoriasis, but it can be difficult to treat.

OBJECTIVES

To evaluate the efficacy and safety of once-daily roflumilast foam 0.3% on scalp and body psoriasis.

METHODS

In a phase IIb randomized controlled trial, adults and adolescents aged ≥ 12 years with scalp and body psoriasis were randomized (2 : 1) to roflumilast foam 0.3% or vehicle for 8 weeks. The primary efficacy endpoint was scalp Investigator Global Assessment (S-IGA) success (score of 'clear' or 'almost clear' plus ≥ 2-grade improvement from baseline) at week 8. Safety and tolerability were also evaluated.

RESULTS

Significantly more roflumilast-treated patients (59.1%) than vehicle-treated patients (11.4%) achieved S-IGA success at week 8 (P < 0.001); differences favoured roflumilast as early as the first postbaseline visit at week 2 (P < 0.001). Significant improvements were also seen for secondary endpoints, including body IGA success, Scalp Itch Numeric Rating Scale and the Psoriasis Scalp Severity Index. The safety of roflumilast was generally similar to vehicle. Patients treated with roflumilast experienced low rates of treatment-emergent adverse events (AEs), with few discontinuations due to an AE. Few patients with skin of colour (11%) and few adolescents (0.7%) were included.

CONCLUSIONS

The results support the further development of roflumilast foam for treating scalp and body psoriasis.

Risankizumab: Daily Practice Experience of High Need Patients

Psoriasis is a chronic inflammatory disease which affects 29.5 million people worldwide and it can negatively impact quality of life, especially when it affects a special localization, such as nails, face, palms and soles, or intertriginous regions. Risankizumab is a humanized monoclonal antibody which targets the p19 subunit of interleukin-23 and it is currently licensed also as systemic therapy for moderate to severe plaque psoriasis. Here, we present eight cases of patients with moderate to severe psoriasis treated with risankizumab with a significant efficacy in the remission of the disease. Our cases represent a real-world clinical setting and provide a valuable adjunct to results obtained in the selected patients usually included in controlled clinical trials. In our cases, risankizumab rapidly improved clinical manifestations and relieved symptoms in patients with moderate to severe psoriasis, regardless of the presence of comorbidities or the location of the plaques in special sites, and without any safety concerns.

Probiotics in dermatological and cosmetic products – application and efficiency

The term “probiotics” has first been used in 1907 by Elie Metchnikoff. Since then, probiotics have been part of research not only in regards of digestive health, but also inflammatory diseases. Lately, there has been an increased interest of probiotic’s effects in skincare. The management of atopic dermatitis, acne, psoriasis, photo aging, skin cancer, intimate care, oral care, wound healing is getting harder each passing day, due to increased antibiotic resistance and other side effects of conventional therapy. Therefore, new ingredients have been investigated and probiotics have been proved to be effective in treating various skin conditions. This review aims to evaluate the scientific evidence on topical and oral probiotics, and to evaluate the efficacy of cosmetic and dermatological products containing probiotics. Many studies have shown that skin and gut microbiome alterations have an important role in skin health. Although this is a new topic in dermatology and cosmetology, there have been some promising results in lots of research studies that the use of probiotics in cosmetic products may help improve the patient’s outcome. While oral probiotics have been shown to promote gut health, which influences the host immune system and helps treat different skin diseases, the mechanism of action of topical probiotics is not yet fully understood. Although the number of commercial probiotic cosmetic products released in the market is increasing and most of the studies have not shown any serious side effect of probiotics, further studies, in larger and heterogeneous groups are needed.

Deciphering the Function of New Therapeutic Targets and Prospective Biomarkers in the Management of Psoriasis

Psoriasis is an immune-mediated skin condition affecting people worldwide, presenting at any age, and leading to a substantial burden physically and mentally. The innate and adaptive immune systems interact intricately with the pathomechanisms that underlie disease. T cells can interact with keratinocytes, macrophages, and dendritic cells through the cytokines they secrete. According to recent research, psoriasis flare-ups can cause systemic inflammation and various other co-morbidities, including depression, psoriatic arthritis, and cardio-metabolic syndrome. Additionally, several auto-inflammatory and auto-immune illnesses may be linked to psoriasis. Although psoriasis has no proven treatment, care must strive by treating patients as soon as the disease surfaces, finding and preventing concurrent multimorbidity, recognising and reducing bodily and psychological distress, requiring behavioural modifications, and treating each patient individually. Biomarkers are traits that are assessed at any time along the clinical continuum, from the early stages of a disease through the beginning of treatment (the foundation of precision medicine) to the late stages of treatment (outcomes and endpoints). Systemic therapies that are frequently used to treat psoriasis provide a variety of outcomes. Targeted therapy selection, better patient outcomes, and more cost-effective healthcare would be made possible by biomarkers that reliably predict effectiveness and safety. This review is an attempt to understand the role of Antimicrobial peptides (AMP), Interleukin-38 (IL-38), autophagy 5 (ATG5) protein and squamous cell carcinoma antigen (SCCA) as biomarkers of psoriasis.

Increased risk of suicidality in patients with psoriasis: A Nationwide cohort study in Korea

BACKGROUND

Psoriasis has a devastating psychological impact on patients' quality of life. However, the relationship between suicidality and psoriasis remains unclear.

OBJECTIVE

This study analysed and compared the risk of suicidality (suicidal ideation, suicide attempt and completed suicide) between patients with psoriasis and the general population.

METHODS

This nationwide, population-based, retrospective, cohort study analysed the Korean National Health Insurance Service claim data from 2005 to 2018.

RESULTS

The study included 348,439 patients with psoriasis aged over 18 years and with age- and sex-matched controls. The risk of suicidality was higher in the psoriasis group than in the control group [adjusted hazard ratio (aHR) 1.21; 95% confidence interval (CI), 1.18-1.24]. The aHR of suicidality was higher in the psoriatic arthritis group (aHR, 1.46; 95% CI, 1.39-1.54) than in the psoriasis-alone group (aHR, 1.17; 95% CI, 1.13-1.20). However, the severity of psoriasis and suicidality showed no correlation (mild psoriasis group: aHR, 1.22; 95% CI, 1.18-1.25; moderate-to-severe psoriasis group: aHR, 1.16; 95% CI, 1.10-1.23).

CONCLUSION

Patients with psoriasis have an increased risk of suicidality. In particular, the presence of arthritis in patients had a more significant effect on the risk of suicidality.

Psoriasis Management Challenges Regarding Difficult-to-Treat Areas: Therapeutic Decision and Effectiveness

Psoriasis is not optimally controlled in spite of newly developed treatments, possibly due to the difficulty of objectively quantifying the disease's severity, considering the limitations of the clinical scores used in clinical practice. A major challenge addresses difficult-to-treat areas, especially in the absence of significant body surface involvement. It is controversial whether the severity evaluation of patients with several affected areas (having at least one difficult-to-treat area) should be done differently from current methods. Scores used for special areas (PSSI, NAPSI and ESIF) allow an accurate assessment of disease severity in difficult-to-treat areas, but the issue of whether to integrate these scores into PASI, BSA or DLQI remains. The review's purpose resides in providing an overview of the main current issues in determining psoriasis severity in patients with psoriasis in difficult-to-treat areas and suggesting possible solutions for the optimal integration of the area assessment in current scores: severity can be either established according to the highest calculated score (PASI or PSSI or NAPSI or ESIF) or by adding a correction factor in the calculation of PASI for special areas.

Palmoplantar Psoriasis: A Clinico-Pathologic Study on a Series of 21 Cases with Emphasis on Differential Diagnosis

Palmoplantar psoriasis (PP) is a relatively uncommon variant of psoriasis that affects palms and soles, and that frequently shares both clinical and histologic features with chronic eczema, hyperkeratotic hand dermatitis and allergic contact dermatitis. The present study aims to characterize the histologic features of PP on a series of 21 cases. The following morphological features and their distribution were included: parakeratosis, dilated vessels in papillary dermis, psoriasiform acanthosis with elongation of rete ridges, perivascular lymphocytic infiltrate, decrease/loss of granular layer, Munro's microabscesses, spongiform pustules of Kogoj, spongiosis and lymphocytic exocytosis. The main diagnostic clues and histologic differential diagnoses are also discussed.

Perianal Psoriasis as the First Manifestation of the Disease

Introduction Inverse psoriasis affects the skin of flexural areas, such as the groin, axillae, umbilicus, intergluteal fold, and external genitalia.

Clinical Case We herein report the case of a man who presented with anal pruritus and, upon physical examination, a perianal dermatosis was found, which was characterized by erythematous plaques, with fine scaling. The case was initially managed with zinc oxide, and when no improvement was observed, we decided to take an incisional biopsy, which indicated histological changes suggestive of psoriasiform dermatitis.

Discussion Inverse psoriasis affects 3% to 7% of patients with psoriasis, and it manifests with erythematous plaques without the classic scaling appearance. The skin in these areas is susceptible to maceration, irritation, and ulceration, which alter the classic clinical picture. It may present with typical lesions or, less frequently, in isolation in the anogenital region. In the anogenital presentation only, the diagnosis should be made by biopsy, looking for the classic histopathological features of psoriasis. As for the first-line treatment, low- or medium-potency topical steroids are used for short periods of time; the second-line treatment is with emollients and tar-based products; and the third-line treatment uses an immunomodulator.

Conclusion This presentation is infrequent, and it requires a high index of suspicion for the diagnosis, always supported by biopsies, in search of the classic histopathological features of psoriasis.

Efficacy and safety profile of phosphodiesterase 4 inhibitor in the treatment of psoriasis: A systematic review and meta-analysis of randomized controlled trials

Background

Systemic therapy is an important treatment for psoriasis. Phosphodiesterase 4 (PDE4) inhibitors are new candidates for psoriasis therapy.

Objectives

To evaluate the efficacy and safety of PDE4 inhibitors in psoriasis.

Method

Randomized clinical trials with PDE4 inhibitors vs placebos in patients with psoriasis were identified from MEDLINE, Embase, Cochrane Controlled Register of Trials, ClinicalTrials.gov, from inception to July 14, 2022. The study was registered in PROSPERO (CRD42022345700).

Results

18 studies were identified, 9 of which included moderate-to-severe plaque psoriasis, 2 mild-to-moderate plaque psoriasis, and 7 psoriatic arthritis. A total of 6036 patients were included. Only one oral PDE4 inhibitor, apremilast, met the inclusion criteria. Overall, compared with the placebo, apremilast was associated with higher response rates in PASI-75 (RR, 3.22; 95% CI, 2.59-4.01), ScPGA of 0 or 1 (RR, 2.21; 95% CI, 1.69-2.91), PPPGA of 0 or 1 (RR 2.33; 95%CI, 1.16-4.66), and a significant decrease in NPASI (SMD, -0.46; 95% CI, -0.58 to -0.33). There were no significant differences in serious adverse events. Subgroup analyses showed that significantly more patients achieved PASI-75 after 16 weeks of therapy with apremilast of 20 mg bid (RR, 2.82; 95% CI, 2.01-3.95) and 30 mg bid (RR, 4.08; 95% CI, 3.12-5.33). Heterogeneity was not significant across studies.

Conclusion

Apremilast is a safe and effective treatment for plaque psoriasis and psoriatic arthritis, especially for difficult-to-treat sites.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier (CRD42022345700).

Effect of Roflumilast Cream vs Vehicle Cream on Chronic Plaque Psoriasis: The DERMIS-1 and DERMIS-2 Randomized Clinical Trials

IMPORTANCE

Once-daily roflumilast cream, 0.3%, a potent phosphodiesterase 4 inhibitor, demonstrated efficacy and was well tolerated in a phase 2b trial of patients with psoriasis.

OBJECTIVE

To evaluate the efficacy of roflumilast cream, 0.3%, applied once daily for 8 weeks in 2 trials of patients with plaque psoriasis.

DESIGN, SETTING, AND PARTICIPANTS

Two phase 3, randomized, double-blind, controlled, multicenter trials (DERMIS-1 [trial 1; n = 439] and DERMIS-2 [trial 2; n = 442]) were conducted at 40 centers (trial 1) and 39 centers (trial 2) in the US and Canada between December 9, 2019, and November 16, 2020, and between December 9, 2019, and November 23, 2020, respectively. Patients aged 2 years or older with plaque psoriasis involving 2% to 20% of body surface area were enrolled. The dates of final follow-up were November 20, 2020, and November 23, 2020, for trial 1 and trial 2, respectively.

INTERVENTIONS

Patients were randomized 2:1 to receive roflumilast cream, 0.3% (trial 1: n = 286; trial 2: n = 290), or vehicle cream (trial 1: n = 153; trial 2: n = 152) once daily for 8 weeks.

MAIN OUTCOMES AND MEASURES

The primary efficacy end point was Investigator Global Assessment (IGA) success (clear or almost clear status plus ≥2-grade improvement from baseline [score range, 0-4]) at week 8, analyzed using a Cochran-Mantel-Haenszel test stratified by site, baseline IGA score, and intertriginous involvement. There were 9 secondary outcomes, including intertriginous IGA success, 75% reduction in Psoriasis Area and Severity Index (PASI) score, and Worst Itch Numeric Rating Scale score of 4 or higher at baseline achieving 4-point reduction (WI-NRS success) at week 8 (scale: 0 [no itch] to 10 [worst imaginable itch]; minimum clinically important difference, 4 points).

RESULTS

Among 881 participants (mean age, 47.5 years; 320 [36.3%] female), mean IGA scores in trial 1 were 2.9 [SD, 0.52] for roflumilast and 2.9 [SD, 0.45] for vehicle and in trial 2 were 2.9 [SD, 0.48] for roflumilast and 2.9 [SD, 0.47]) for vehicle. Statistically significantly greater percentages of roflumilast-treated patients than vehicle-treated patients had IGA success at week 8 (trial 1: 42.4% vs 6.1%; difference, 39.6% [95% CI, 32.3%-46.9%]; trial 2: 37.5% vs 6.9%; difference, 28.9% [95% CI, 20.8%-36.9%]; P < .001 for both). Of 9 secondary end points, statistically significant differences favoring roflumilast vs vehicle were observed for 8 in trial 1 and 9 in trial 2, including intertriginous IGA success (71.2% vs 13.8%; difference, 66.5% [95% CI, 47.1%-85.8%] and 68.1% vs 18.5%; difference, 51.6% [95% CI, 29.3%-73.8%]; P < .001 for both), 75% reduction in PASI score (41.6% vs 7.6%; difference, 36.1% [95% CI, 28.5%-43.8%] and 39.0% vs 5.3%; difference, 32.4% [95% CI, 24.9%-39.8%]; P < .001 for both), WI-NRS success (67.5% vs 26.8%; difference, 42.6% [95% CI, 31.3%-53.8%] and 69.4% vs 35.6%; difference, 30.2% [95% CI, 18.2%-42.2%]; P < .001 for both). The incidence of treatment-emergent adverse events was 25.2% with roflumilast vs 23.5% with vehicle in trial 1 and 25.9% with roflumilast vs 18.4% with vehicle in trial 2. The incidence of serious adverse events was 0.7% with roflumilast vs 0.7% with vehicle in trial 1 and 0% with roflumilast vs 0.7% with vehicle in trial 2.

CONCLUSIONS AND RELEVANCE

Among patients with chronic plaque psoriasis, treatment with roflumilast cream, 0.3%, compared with vehicle cream resulted in better clinical status at 8 weeks. Further research is needed to assess efficacy compared with other active treatments and to assess longer-term efficacy and safety.

TRIAL REGISTRATION

ClinicalTrials.gov Identifiers: NCT04211363, NCT04211389.

Real-world health outcomes in US adult patients with mild to moderate plaque psoriasis taking topical therapy

BACKGROUND

Limited health outcomes information exists for patients with mild to moderate plaque psoriasis (hereafter, referred to as psoriasis) prescribed topical treatment(s).

AIM

We evaluated clinical characteristics of patients with systemic-naïve mild to moderate psoriasis after topical use in the United States.

METHODS

Data were drawn from 2017 to 2018 Adelphi Psoriasis Disease Specific Programme™, a point-in-time survey of physicians and adult psoriasis patients, capturing data on topical treatment at time of consultation prescribed to systemic-naïve patients with mild to moderate psoriasis (i.e. body surface area [BSA] ≤ 10%) at current treatment initiation. Patient clinical characteristics before/after topical use were evaluated descriptively.

RESULTS

Among 304 patients (median age 43.0 years; 53.6% female), mean time since diagnosis was 60.9 months. After a mean 6.9 months on their current topical, 14.5% of patients achieved ≥75% BSA reduction, 38.9% ≥50% BSA reduction, and 50.2% no BSA reduction. Residual psoriasis symptoms included scaling (76.5%), inflamed skin (65.9%), and itching (60.4%). Most patients (71.2%) had residual psoriasis in special body areas: nails (92.3%), palmoplantar (78.9%), scalp (75.9%), and face (65.8%).

CONCLUSION

We found unmet need in topical treatment effectiveness in mild to moderate psoriasis patients, in terms of BSA reduction, symptoms, and special body areas affected.

Secukinumab treatment showed improved quality of life in patients with chronic plaque psoriasis in Australia: Results from the HOPE study

BACKGROUND

Psoriasis imposes a disease burden that can have a profound negative impact on patients' quality of life (QoL). HOPE was the first non-interventional study conducted in patients with severe chronic plaque psoriasis in Australia that evaluated health-related QoL in response to treatment with secukinumab.

METHODS

HOPE was a prospective, open-label, single-arm, multicentre, non-interventional, exploratory study in patients with severe chronic plaque psoriasis in Australia. The study investigated the change in QoL, using the Dermatology Life Quality Index (DLQI), Assessment Quality of Life-8 Dimension questionnaire (AQoL-8D) and Psoriasis Area and Severity Index (PASI), and safety profile in response to treatment with secukinumab 300 mg SC weekly for 4 weeks followed by monthly maintenance for 58 weeks.

RESULTS

At Week 14, the mean percentage reduction in total DLQI score from baseline was -82.4% (n = 65), which indicates a substantial improvement in QoL. This level of improvement was sustained up to Week ≥58, with a mean percentage change of -87.4%. The mean percentage change from baseline for AQoL-8D weighted total score decreased from Week 14 (41.1%) to Week 58 (35.2%), indicating an improvement in patients' QoL. A high proportion of patients achieved PASI 75/90/100 responses at Week 14 (97.0%/71.2%/34.8%), with rates sustained up to Week ≥58 (100%/87.9%/43.1%). The safety profile of secukinumab was favourable, with no cumulative or unexpected safety concerns.

CONCLUSION

Secukinumab treatment demonstrated a striking improvement in patients' QoL in the HOPE study, the first real-world study in patients with severe chronic plaque psoriasis in the Australian clinical setting.

Narrative Review of the Emerging Therapeutic Role of Brodalumab in Difficult-to-Treat Psoriasis

Psoriatic involvement in areas of the body such as nails, palms and soles (palmoplantar), and scalp is associated with dramatically negative effects on quality of life relative to involvement elsewhere in the body. Although numerous evidence-based studies demonstrate the efficacy of biologics for overall skin clearance in moderate-to-severe plaque psoriasis (including tumor necrosis factor α [TNFα] inhibitors and interleukin [IL]-17A, IL-12/IL-23, IL-23, IL-17F, and IL-17A/F inhibitors), large, randomized, placebo-controlled clinical studies of psoriasis with nail, palmoplantar, and scalp involvement are needed to better inform decision-making in clinical practice. Moreover, biologic failure caused by drug ineffectiveness is a common occurrence in patients who do not respond, lose response, or are intolerant to treatment. Brodalumab is a fully human IL-17 receptor A antagonist that demonstrates high rates of skin clearance among the latest generation of biologic therapies for treatment of moderate-to-severe psoriasis. This review summarizes current literature on the efficacy of brodalumab and other therapies in difficult-to-treat psoriasis including psoriasis in difficult-to-treat locations (such as psoriasis with nail, palmoplantar, or scalp involvement) and psoriasis in patients whose disease did not respond to other biologics.

Long-Term Treatment with Dimethyl Fumarate for Plaque Psoriasis in Routine Practice: Good Overall Effectiveness and Positive Effect on Impactful Areas

INTRODUCTION

Dimethyl fumarate (DMF) is an oral compound to treat plaque psoriasis. Data on the treatment of patients with psoriasis affecting impactful areas are scarce. In this interim analysis of the prospective, noninterventional SKILL study, we summarized results of DMF treatment regarding effectiveness (overall and in impactful areas) and safety.

METHODS

Data from 676 patients suffering from moderate-to-severe plaque psoriasis were analyzed after 52 weeks of DMF treatment. Of these, 257 had data available after 52 weeks. The considered impactful areas were nails, palms, soles, and scalp. Data analysis included observed cases (OC) and last observation carried forward (LOCF).

RESULTS

All effectiveness parameters improved after 52 weeks. The Psoriasis Area and Severity Index score was reduced by 79.5% (OC) and 65.7% (LOCF). Compared with baseline, improvements were shown for 70.2% of the patients in their nail psoriasis [nail-Physician Global Assessment (PGA)] and for 57.3% in palmoplantar disease (palmoplantar-PGA). The proportion of patients with scalp-PGA 0/1 (clear/almost clear) increased significantly to 79.8% (OC) and 69.3% (LOCF, both p < 0.001) (versus 37.5% and 36.6% at baseline, respectively). Significant reduction of pruritus (p < 0.001) was also observed. No unexpected adverse drug reactions were observed.

CONCLUSION

Long-term treatment with DMF in routine practice showed good overall effectiveness and safety, and a positive effect on plaque-psoriasis-affected impactful areas.

Risk of infections in psoriasis: assessment and challenges in daily management

INTRODUCTION

In daily practice management of psoriasis, evaluation of risk factors for infections is having a growing influence. Indeed, in psoriatic patients, risk of infections may be due to psoriasis itself, immunomodulatory therapy, and comorbidities that may increase this risk and patient hospitalization.

AREAS COVERED

Given the greater understanding of psoriasis pathogenesis and the increasing number of treatment options, it is particularly important to customize therapy according to each, single patient; psoriasis features and comorbidities are also essential to tailor treatment goals.

EXPERT OPINION

In this perspective, the current knowledge on the infectious risk in psoriatic patient, related to comorbidities, such as diabetes mellitus, cardiovascular disease, and chronic obstructive pulmonary, to 'special populations,' to chronic infections, such as latent tuberculosis, chronic hepatitis B and C, and HIV, and to the most recent Covid-19 pandemic scenario, is reviewed and discussed in order to suggest the most appropriate approach and achieve the best available therapeutic option.

Analytical approaches to assess metabolic changes in psoriasis

Psoriasis is one of the most common human skin diseases, although its development is not limited to one tissue, but is associated with autoimmune reactions throughout the body. Overproduction of pro-inflammatory cytokines and growth factors systemically stimulates the proliferation of skin cells, which manifests as excessive exfoliation of the epidermis, and/or arthritis, as well as other comorbidities such as insulin resistance, metabolic syndrome, hypertension, and depression. Thus, there is a great need for a thorough analysis of the pathophysiology of psoriatic patients, including classical methods, such as spectrophotometry, chromatography, or Western blot, and also novel omics approaches such as lipidomics and proteomics. Moreover, the extensive pathophysiology forces increased research examining biological changes in both skin cells, and systemically. A wide range of techniques involved in lipidomic research based on a combination of mass spectrometry and different types of chromatography (RP-LC-QTOF-MS/MS, HILIC-QTOF-MS/MS or RP-LC-QTRAP-MS/MS), have allowed comprehensive assessment of lipid modification in psoriatic skin and provided new insight into the role of lipids and their mechanism of action in psoriasis. Moreover, proteomic analysis using gel-nanoLC-OrbiTrap-MS/MS, as well as MALDI-TOF/TOF techniques facilitates the description of panels of enzymes involved in lipidome modifications, and the response of the endocannabinoid system to metabolic changes. Psoriasis is known to alter the expression of proteins that are involved in the inflammatory and antioxidant response, as well as protein biosynthesis, degradation, as well as cell proliferation and apoptosis. Knowledge of changes in the lipidomic and proteomic profile will not only allow the understanding of psoriasis pathophysiology, but also facilitate proper and early diagnosis and effective pharmacotherapy.

Histopathologic features of inverse psoriasis

BACKGROUND

Inverse psoriasis represents a less commonly described form of psoriasis in intertriginous areas. The pathologic findings of inverse psoriasis are typically grouped in with those of plaque psoriasis, as the histopathologic features specific to inverse psoriasis have not received significant investigation.

METHODS

A single institution, retrospective cohort study was performed to review biopsy slides for psoriasis occurring in typical intertriginous areas. Patient's charts were reviewed and only those where the clinical diagnosis of inverse psoriasis was also favored were included.

RESULTS

Twelve patients met inclusion criteria: 58% male and 42% female, 18 to 86 years of age. Classic features of psoriasis such as hypogranulosis, confluent parakeratosis, and thinning of the suprapapillary plate were seen in 100%. Regular psoriasiform acanthosis and dilated tortuous dermal vessels were seen in 92%. Neutrophils were present in the scale in 83% and in the dermis in 100%. Features considered atypical for psoriasis included spongiosis in 83%, eosinophils in 67%, and focal serum in the scale in 42%.

CONCLUSIONS

While inverse psoriasis commonly exhibits features considered to be classic for psoriasis, it is not unusual for inverse psoriasis to show features considered atypical for plaque psoriasis such as dermal eosinophils, epidermal spongiosis, and focal serum in the scale.

A comprehensive review on possibilities of treating psoriasis using dermal cyclosporine

Psoriasis is an autoimmune, chronic proliferative, inflammatory skin disease with high comorbidity. Psoriasis is not a curable disease; it can only be managed. Cyclosporine A (CyA) is one of the FDA-approved immunosuppressant drug used in severe Psoriasis. Till date only oral route is used for its administration. Administration of CyA by this route causes serious side effects such as hypertension and renal toxicity. Due to these side effects, a number of researches have been done and taking place in the current times for the dermal delivery of CyA for the management of psoriasis. Dermal delivery of CyA is not an easy task because of its physiochemical properties like high molecular weight, lipophilicity and resistance offered by stratum corneum (SC). Because of the above problems in the dermal delivery a number of new approaches such as nanolipid carriers, microemulsion, liposomes, niosomes etc. are explored. To those deep findings for psoriasis management with dermal delivery of CyA have not been discussed. This comprehensive review includes all the studies, advancements and their critical findings which took place in the recent times for the dermal delivery of CyA and along with the suitable modification needed for the efficient dermal delivery of CyA are also suggested.

Mimics of Dermatitis

Dermatitis is a common condition frequently encountered by dermatologists. The diagnosis of dermatitis can be challenging because this condition is often multifactorial, and many skin diseases that can mimic dermatitis should be considered in the differential diagnosis. It is important to recognize and be familiar with these conditions because some of them can represent signs of systemic disease or malignancies and misdiagnosis can lead to mismanagement and adverse outcomes for the patient.

Probiotics in the Therapeutic Arsenal of Dermatologists

During the last years, numerous studies have described the presence of significant gut and skin dysbiosis in some dermatological diseases such as atopic dermatitis, psoriasis and acne, among others. How the skin and the gut microbiome play a role in those skin conditions is something to explore, which will shed light on understanding the origin and implication of the microbiota in their pathophysiology. Several studies provide evidence for the influence of probiotic treatments that target the modulation of the skin and intestinal microbiota in those disorders and a positive influence of orally administered probiotics on the course of these dermatosis. The pathologies in which the therapeutic role of the probiotic has been explored are mainly atopic dermatitis, psoriasis and acne. This article aims to review these three dermatological diseases, their relationship with the human microbiota and specially the effect of probiotics usage. In addition, the pathophysiology in each of them and the hypotheses about possible mechanisms of the action of probiotics will be described.

Optical control of adenosine A3 receptor function in psoriasis

Psoriasis is a chronic and relapsing inflammatory skin disease lacking a cure that affects approximately 2% of the population. Defective keratinocyte proliferation and differentiation, and aberrant immune responses are major factors in its pathogenesis. Available treatments for moderate to severe psoriasis are directed to immune system causing systemic immunosuppression over time, and thus concomitant serious side effects (i.e. infections and cancer) may appear. In recent years, the G_i protein-coupled A₃ receptor (A₃R) for adenosine has been suggested as a novel and very promising therapeutic target for psoriasis. Accordingly, selective, and high affinity A₃R agonists are known to induce robust anti-inflammatory effects in animal models of autoimmune inflammatory diseases. Here, we demonstrated the efficacy of a selective A₃R agonist, namely MRS5698, in preventing the psoriatic-like phenotype in the IL-23 mouse model of psoriasis. Subsequently, we photocaged this molecule with a coumarin moiety to yield the first photosensitive A₃R agonist, MRS7344, which in photopharmacological experiments prevented the psoriatic-like phenotype in the IL-23 animal model. Thus, we have demonstrated the feasibility of using a non-invasive, site-specific, light-directed approach to psoriasis treatment.

Genital and Inverse/Intertriginous Psoriasis: An Updated Review of Therapies and Recommendations for Practical Management

Genital and inverse psoriasis can develop in more than one-third of patients who have psoriasis. Psoriatic plaques in the genital and intertriginous skin are challenging to treat because the skin is thin and often occluded, making it more sensitive to certain therapies. Traditional guidelines indicate topical therapies, such as corticosteroids, topical calcineurin inhibitors (TCI), and vitamin D analogs as first-line recommendation in treating genital and inverse psoriasis. There have been developments in the treatment of genital and inverse psoriasis using systemic therapies, including IL-17 inhibitors and PDE-4 inhibitors.

Pain Management in Painful Psoriasis and Psoriatic Arthropathy: Challenging and Intricately Intertwined Issues Involving Several Systems

PURPOSE OF REVIEW

Psoriasis and psoriatic arthropathy are inflammatory autoimmune conditions that can lead to profound emotional distress, social stigmatization, isolation, disfigurement, pain, disability, unemployment, and decreased quality of life. Thus, this disease has immense psychological, social, and economic implications as the pain experienced is closely associated with the primary disease burden. This review focuses on discussing the primary disease burden of psoriasis and psoriatic arthropathy, as well as management of different types of pain in these patients.

RECENT FINDINGS

Pain affects over 40% of patients with psoriasis, ranging from neuropathic to nociceptive. Treatment of pain largely focuses on treating the underlying disease with mild topical steroids and non-steroidal medications including vitamin D analogs followed by systemic immunomodulatory agents for more severe disease. Interventional options such as corticosteroid injections are available for select cases (conditional recommendation). Psoriasis and psoriatic arthropathy have been associated with underreporting and resultant undertreatment of pain. Pain control in these conditions is complex and requires a multidisciplinary approach. More research and guidelines are needed in the areas of reporting of psoriatic disease, associated pain, psoriatic nociception, and optimal clinical management.

Gene expression profiles of transient receptor potential (TRP) channels in the peripheral blood mononuclear cells of psoriasis patients

Psoriasis is a chronic autoimmune disease in which peripheral blood mononuclear cells (PBMCs) are involved in the pathological process. Transient receptor potential (TRP) channels expressed in immune cells have been shown to be associated with inflammatory diseases. We aimed to evaluate mRNA expression levels of TRP channels in PBMCs of patients with psoriasis. 30 patients with plaque psoriasis and 30 healthy age- and gender-matched control subjects were included in this study. mRNA expression levels of TRP channels in psoriasis patients were determined by Real-time polymerase chain reaction. A decreased TRPM4, TRPM7, TRPV3, TRPV4, and TRPC6 genes expression levels were found in the patient group compared to controls, respectively (p = 0.045, p = 0.000, p = 0.000, p = 0.045, p = 0.009), whereas, an increased expression level was found in TRPM2 and TRPV1 genes in the patient group compared to controls (p = 0.001 and p = 0.028). This is the first study showing the TRP channel mRNA expressions in PBMCs of psoriasis patients. Different expression patterns of TRP channels may have a role in pathogenesis of psoriasis.

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

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

Treat-to-Target Approach for the Management of Patients with Moderate-to-Severe Plaque Psoriasis: Consensus Recommendations

Introduction

Treat-to-target strategies are used in several chronic diseases to improve outcomes. Treatment goals have also been suggested for psoriasis, but there is currently no consensus on targets, and guidance is needed to implement this strategy in clinical practice. The project ‘Treat to Target Italia’ was launched by a scientific board (SB) of 10 psoriasis experts to generate expert consensus recommendations.

Methods

On the basis of the published literature, their clinical experience, and the results of a survey among Italian dermatologists, the SB identified four relevant topics: (1) clinical remission; (2) quality of life; (3) abrogation of systemic inflammation; (4) safety. They drafted 20 statements addressing these four topics and submitted them to a panel of 28 dermatologists, in a Delphi process, to achieve consensus (greater than 80% agreement).

Results

Consensus was reached on all statements. Treatment goals defining clinical remission should include a 90% improvement from baseline in the Psoriasis Area and Severity Index (PASI90 response) or an absolute PASI score of less than or equal to 3. Patient’s quality of life and satisfaction are important targets. If PASI targets are achieved, there should be no or very low impact of psoriasis on quality of life [Dermatology Life Quality Index (DLQI) score less than or equal to 3]. If PASI or DLQI goals are not achieved within 3–4 months, treatment should be changed. Abrogation of systemic inflammation may be crucial for preventing or delaying inflammatory comorbidities. Safety is an equally important target as efficacy.

Conclusion

These 20 consensus statements define the parameters of a treat-to-target strategy for psoriasis in Italy. It is hoped that use of these in the management of patients with psoriasis will improve treatment outcomes and patient health-related quality of life.

Topographic Differential Diagnosis of Chronic Plaque Psoriasis: Challenges and Tricks

BACKGROUND

Psoriasis is an inflammatory skin disease presenting with erythematous and desquamative plaques with sharply demarcated margins, usually localized on extensor surface areas.

OBJECTIVE

To describe the common differential diagnosis of plaque psoriasis classified according to its topography in the scalp, trunk, extremities, folds (i.e., inverse), genital, palmoplantar, nail, and erythrodermic psoriasis.

METHODS

A narrative review based on an electronic database was performed including reviews and original articles published until 1 September 2020, assessing the clinical presentations and differential diagnosis for psoriasis.

RESULTS

Several differential diagnoses could be considered with other inflammatory, infectious, and/or neoplastic disorders. Topographical differential diagnosis may include seborrheic dermatitis, tinea capitis, lichen planopilaris in the scalp; lupus erythematosus, dermatomyositis, cutaneous T-cell lymphomas, atopic dermatitis, syphilis, tinea corporis, pityriasis rubra pilaris in the trunk and arms; infectious intertrigo in the inguinal and intergluteal folds and eczema and palmoplantar keratoderma in the palms and soles.

CONCLUSIONS

Diagnosis of psoriasis is usually straightforward but may at times be difficult and challenging. Skin cultures for dermatophytes and/or skin biopsy for histological examination could be required for diagnostic confirmation of plaque psoriasis.