Development of antidrug antibodies against adalimumab maps to variation within the HLA-DR peptide-binding groove

Targeted biologic therapies can elicit an undesirable host immune response characterized by the development of antidrug antibodies (ADA), an important cause of treatment failure. The most widely used biologic across immune-mediated diseases is adalimumab, a tumor necrosis factor inhibitor. This study aimed to identify genetic variants that contribute to the development of ADA against adalimumab, thereby influencing treatment failure. In patients with psoriasis on their first course of adalimumab, in whom serum ADA had been evaluated 6-36 months after starting treatment, we observed a genome-wide association with ADA against adalimumab within the major histocompatibility complex (MHC). The association signal mapped to the presence of tryptophan at position 9 and lysine at position 71 of the HLA-DR peptide-binding groove, with both residues conferring protection against ADA. Underscoring their clinical relevance, these residues were also protective against treatment failure. Our findings highlight antigenic peptide presentation via MHC class II as a critical mechanism in the development of ADA against biologic therapies and downstream treatment response.

Incidence and prevalence of psoriasis in multiethnic Johor Bahru, Malaysia: a population-based cohort study using electronic health data routinely captured in the Teleprimary Care (TPC®) clinical information system from 2010 to 2020: Classification: Epidemiology

BACKGROUND

There are no population-based epidemiological data on psoriasis in Southeast Asia, including Malaysia.

OBJECTIVES

To determine the incidence and prevalence of psoriasis over 11 years in multiethnic Johor Bahru, Malaysia.

METHODS

A population-based cohort study was made using the Teleprimary Care database between January 2010 and December 2020. Cases of psoriasis, identified by ICD-10 diagnostic codes, were validated by dermatologists. Annual prevalence and incidence were estimated and stratified by age, sex and ethnicity.

RESULTS

We identified 3932 people with dermatologist-confirmed psoriasis, including 1830 incident cases, among 1 164 724 Malaysians, yielding an 11-year prevalence of 0·34% [95% confidence interval (CI) 0·33-0·35] and incidence of 34·2 per 100 000 person-years (95% CI 32·6-35·8). Rates were higher in Indian patients; the prevalences were 0·54% (0·50-0·58) in Indian, 0·38% (0·36-0·40) in Chinese and 0·29% (0·28-0·30) in Malay patients, and the respective incidences per 100 000 person-years were 52·5 (47·3-57·7), 38·0 (34·1-41·8) and 30·0 (28·2-31·8). Rates were higher in males; the prevalence was 0·39% (0·37-0·41) in males and 0·29% (0·27-0·30) in females, and the respective incidences per 100 000 person-years were 40·7 (38·2-43·2) and 28·3 (26·4-30·3). Between 2010 and 2020, annual psoriasis prevalence and incidence increased steadily from 0·27% to 0·51% and from 27·8 to 60·9 per 100 000 person-years, respectively. Annual rates were consistently higher in male and Indian patients. Overall, psoriasis was significantly more common in males than females [odds ratio (OR) 1·37, 95% CI 1·29-1·46] and in Indian and Chinese patients vs. Malay (OR 1·85, 1·71-2·01 and OR 1·30, 1·20-1·41, respectively). Prevalence increased with age, with the highest rates in the groups aged 50-59 and 60-69 years at 0·67% and 0·66%, respectively. A modest bimodal trend in age of psoriasis onset was observed, with first and second peaks at 20-29 and 50-59 years. Disease onset was significantly earlier in females than males [mean (SD) 36·8 (17·3) vs. 42·0 (17·2) years, P < 0·001] and in Malay vs. Indian and Chinese patients [mean (SD): Malay 36·4 (17·5), Indian 40·8 (15·2), Chinese 47·4 (16·9) years, P < 0·001].

CONCLUSIONS

We found that psoriasis incidence and prevalence are increasing and varied by age, sex and ethnicity. Our findings should help inform healthcare planning and management for patients with psoriasis in Malaysia. What is already known about this topic? The incidence and prevalence of psoriasis are generally lower in Asian populations and children. There is a lack of agreement on sex-specific differences in psoriasis incidence and prevalence. There has been no population-based study on the incidence and prevalence of psoriasis in Southeast Asia, including Malaysia. There is no information on differences in psoriasis prevalence and incidence by sex, age and ethnicity in Malaysia. What does this study add? Psoriasis incidence and prevalence are increasing in the multiethnic population of Johor Bahru, Malaysia. Incidence and prevalence rates were higher in male than female patients and were consistently highest among Indian patients, followed by Chinese and Malay. A modest bimodality in the age of psoriasis onset was observed among the groups aged 20-29 and 50-59 years. Psoriasis onset was significantly later in male than female patients and in Chinese vs. Indian and Malay patients.

Incidence, Prevalence, and Mortality of People with Psoriasis and Psoriatic Arthritis in Taiwan: A Nationwide Cohort Study

There is a recognized need to better understand chang-es in the epidemiology of psoriasis and psoriatic arthritis (PsA) over time in Asia. Using the Taiwan National Health Insurance claim records this population-based study examined changes in the prevalence, incidence, and mortality rates in patients with psoriasis or psoriatic arthritis in Taiwan over 12 years. Patients with ≥1 diagnosis code for psoriasis or psoriatic arthritis, recorded either by dermatologists or rheumatologists, were identified. Annual age- and sex-standardized prevalence and incidence rates were calculated using the Taiwan general population as reference. To investigate mortality, each patient in the incident cohort was matched to 10 comparators from the general population by sex and age (at diagnosis). The risk of mortality between study cohorts and comparators was analysed by Cox proportional hazard regression. The prevalence of psoriasis (0.18–0.86%) and psoriatic arthritis (0.01–0.08%) increased steadily b-etween 2006 and 2017. The incidence rates, however, remained stable (psoriasis: 62–65 per 100,000 person-years; psoriatic arthritis: 6–5 per 100,000 person-years). The risk of all-cause mortality for patients with psoriasis (hazard ratio 1.16; 95% confidence interval: 1.13–1.19) was higher than the general population, despite a decreasing trend over time in the all-cause mortality rates for both groups. The steady increase in the prevalence of psoriasis despite stable incidence rates suggests that improvements in life expectancy may be the key determinant of this increase.

Comorbidities in Chilean Psoriasis Patients ‐ a Global Healthcare Study on Psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory skin disease associated with several important medical comorbidities. There are scant data available on the comorbidities of patients with psoriasis in South America.

AIM

To examine the comorbidity profile of adult patients with psoriasis in Chile and its association with severity of psoriasis.

METHODS

This was a multicentre, cross-sectional study involving 16 hospitals and clinics in Chile, which used a 48-item questionnaire to study clinician- and patient-reported outcomes and comorbidities. Inferential analyses were performed by psoriasis severity, using Fisher exact test, Student t-test and multivariable logistic regression.

RESULTS

In total, 598 adult patients with psoriasis were included (51.1% male; mean age 49.2 ± 15.1 years); 48.5% mild and 51.4% moderate to severe; Psoriasis Area and Severity Index 11.6 ± 11.5; body surface area 14.7 ± 18.2%. Plaque psoriasis was the most common phenotype (90.2%), followed by guttate (13.4%). Psoriatic arthritis occurred in 27.3% of patients. Comorbidities were reported in 60.2% of all patients with psoriasis. Frequent concomitant diseases were obesity (25.3%), hypertension (24.3%), Type 2 diabetes mellitus (T2DM) (18.7%), dyslipidaemia (17.4%), metabolic syndrome (16.7%) and depression (14.4%). After adjustment, significant associations were found between moderate to severe psoriasis and obesity, T2DM and nonalcoholic fatty liver disease (NAFLD) compared with mild psoriasis.

CONCLUSIONS

We report a large study of comorbidities, including depression, dyslipidaemia, T2DM and NAFLD, in people with psoriasis in Chile. The prevalence of comorbidities with psoriasis in Chile appears similar to that found in Western countries, and emphasizes the importance of assessing patients with psoriasis for risk factors for and presence of, comorbid disease in a multidisciplinary setting.

How do dermatologists’ personal models inform a patient–centred approach to management: a qualitative study using the example of prescribing a new treatment (Apremilast)

Background

The quality of dermatology consultations is partly determined by how clinicians approach patient care. The term ‘Personal Models’ describes the explanatory frameworks of thoughts, feelings and experiences that drive behaviour. One study found that clinicians’ personal models, specifically their beliefs about autonomy and patient self‐management, influenced the degree to which clinicians engage patients in shared decision making during consultations. Further research is needed to further explore how clinicians’ personal models inform and affect the quality of patient care.

Objectives

To explore how clinicians’ personal models inform shared decision making and consultation style in managing people living with psoriasis in the context of a new treatment, Apremilast.

Methods

A framework analysis of qualitative semi‐structured telephone interviews with 13 dermatologists from the UK and Germany who participated in a novel medicine trial for psoriasis called APPRECIATE.

Results

Two themes were derived from the data. Theme 1, ‘personal working models of patient care’, comprised two subthemes: ‘patient‐centredness: a continuum’ and ‘stereotypes and assumptions’. Theme 2, ‘impact of personal working models on patient care’, included three subthemes: ‘shared decision making: a continuum’, ‘consultation skills’ and ‘impact of concerns about Apremilast on prescribing behaviour’.

Conclusions

Although many dermatologists endorsed a patient‐centred approach, not all reported working in this way. Clinicians’ personal models, their beliefs, stereotypes, personal perceptions and assumptions about patients are likely to affect their prescribing behaviour and shared decision making. Additional specialized training and education could increase patient‐centredness and whole‐person management.

What is already known about this topic?

‘Personal models’ is the term used to describe the thoughts, feelings and experiences that determine behaviour.

Research has shown that clinicians’ personal models can influence their approach to psoriasis management, although the evidence base is limited.

What does this study add?

Some, but not all, clinicians endorse a patient‐centred approach. Clinicians’ beliefs and attitudes about patients, psoriasis and evidence for psoriasis treatments all potentially influence the degree to which clinicians champion whole‐person management.

Clinicians’ personal models impact how clinicians communicate with and behave towards patients during consultations and more specifically, the extent to which they demonstrate techniques to engage patients in joint decisions related to their condition and treatment.

What are the clinical implications ofthiswork?

Additional specialized training and education could help clinicians to recognize how their beliefs, feelings and experiences influence their clinical practice, extend their skills in shared decision making, and facilitate whole‐person management.

Linked Comment: F. Cowdell. Br J Dermatol 2022; 187:4.

Plain language summary available online

Efficacy of Dupilumab in Different Racial Subgroups of Adults With Moderate-to-Severe Atopic Dermatitis in Three Randomized, Placebo-Controlled Phase 3 Trials

Dupilumab, a monoclonal antibody that blocks the shared receptor subunit for interleukin (IL)-4 and IL-13, is currently approved for the treatment of adults with inadequately controlled moderate-to-severe atopic dermatitis (AD). The efficacy and safety of dupilumab for AD among racial subgroups is unknown. This post hoc analysis from three phase 3 trials assessed the efficacy and safety of dupilumab vs placebo by racial subgroup (White, Asian, Black/African American). Data from LIBERTY AD SOLO 1 (NCT02277743), SOLO 2 (NCT02277769), and CHRONOS (NCT02260986) were pooled. Outcomes included mean and percent change from baseline to week 16 in the key therapeutic domains Eczema Area and Severity Index (EASI), Peak Pruritus Numerical Rating Scale (NRS), Dermatology Life Quality Index (DLQI), and Patient-Oriented Eczema Measure, as well as Investigator’s Global Assessment and pain or discomfort assessed by the European Quality of Life-5 Dimensions 3 level questionnaire. A total of 2,058 patients (White n=1,429, Asian n=501, Black/African American n=128) were included in the current analysis. Baseline demographics and disease characteristics were balanced between treatment groups and racial subgroups. In the three trials, dupilumab significantly (P<0.0001) improved all assessed outcomes compared with placebo in the White and Asian subgroups. In the smaller Black/African American subgroup, dupilumab significantly (P<0.0001) improved EASI endpoints and mean changes in Peak Pruritus NRS and DLQI vs placebo, with positive numeric trends favoring dupilumab in all other endpoints. Dupilumab was generally well tolerated, with an acceptable safety profile in all racial subgroups. Serious adverse events occurred more frequently with placebo; treatment discontinuations due to adverse events were rare in all treatment groups. Significant clinical improvement and a favorable benefit-risk profile can be achieved with dupilumab treatment in patients of White, Asian, and Black/African American racial subgroups with moderate-to-severe AD inadequately controlled with topical medications. ClinicalTrials.gov identifiers: NCT02277743, NCT02277769, NCT02260986

An investigation into most effective method of treating stained teeth: an in vitro study

OBJECTIVE

To assess the most efficacious method of treating stained teeth: bleaching alone, veneering alone or a combination of bleaching and veneering and whether the choice alters depending on the degree of staining.

METHODS

Extracted teeth were sectioned to give 117 samples. These samples were split into unstained, lightly and darkly stained groups based on CIE-Lab value L*. The lightly and darkly stained groups were stained using tea. Teeth from each group were then assigned to one of four subgroups (control (C), bleaching alone (B), veneering alone (V), or a combination of bleaching and veneering (BV), each containing 13 samples. Veneering was performed using 0.8-mm thick ceramic veneer of shade B1. CIE-Lab values were recorded using a spectrophotometer and the colour difference (Delta E) was calculated for each intervention. The final colour was compared to the value for obtained from a B1 (Vita) Shade tab. Statistical significance was assessed using analysis of variance.

RESULTS

In all three test groups, intervention resulted in a statistically significant colour change compared to the C group (p<or=0.001). In the unstained group, the only intervention that reached statistically significant parity to B1 was BV (p=0.015). In the lightly stained group, BV produced the most colour change and the value closest to B1 (p<or=0.003). In dark group, BV produced the greatest colour change and the value closest to B1 however; this was not statistically significantly better than V (p=0.146).

CONCLUSIONS

All the interventions produced a statistically significant and clinically visible colour change compared to the control. External light-activated bleaching produced a clinically visible colour change. In all groups the combination of bleaching and veneering gave the closest value to B1.

Lymphocyte trafficking in psoriasis: a new perspective emphasizing the dermal dendrocyte with active dermal recruitment mediated via endothelial cells followed by intra-epidermal T-cell activation

Prominent within the inflammatory infiltrate of psoriasis are HLA-DR positive T lymphocytes and factor XIIIa positive dermal dendrocytes. Many investigators studying psoriasis have assumed that the HLA-DR positive T cells are activated, and thereby capable of producing lymphokines such as gamma interferon. However, by immunohistochemical analysis, greater than 95% of the dermal T cells in psoriatic lesions are Ki-67 negative, which suggests that they are in a resting or non-cycling (Go) state. In contrast to the dermal T-cell population, the epidermal T-cell population contains a greater population of Ki-67 positive lymphocytes. The entry of the T cells into the epidermis is, therefore, apparently associated with an important activation event, which in all likelihood involves interaction with the keratinocyte. The presence of activated intraepidermal T cells has been substantiated by the ability to detect gamma interferon mRNA by polymerase chain reaction in epidermal sheets of psoriatic lesions. The pathophysiologic implication in psoriasis for these distinctions and compartmentalization involving dermal and epidermal T cells are placed into the context of a cascade of cellular trafficking events, which are further dissected into a specific network of molecular mediators of inflammation. This report suggests that more attention should be placed on the microenvironment of the skin, with specific emphasis on the mechanism by which T cells accumulate in the dermis and epidermis, and elucidation of the selective inductive and recruitment capabilities of endothelial cells, perivascular dermal dendrocytes, and keratinocytes.

Cyclosporine A in the treatment of psoriasis: a clinical and mechanistic perspective

Cyclosporine A, a unique immunomodulatory agent, has been used increasingly over the last 5 years in the management of severe psoriasis. The remarkable efficacy of this drug coupled with its known immunosuppressive properties have enabled a further appreciation of the role of the immune system in the induction and maintenance of psoriatic plaques. Although acting primarily on T lymphocytes, there is also evidence for an effect of cyclosporine A on other constitutive cell types within the skin. The future use of systemically administered cyclosporine A in the treatment of psoriasis and other cutaneous diseases is dependent on the successful balance of efficacy and side-effect profile; namely, the dose-related problems of hypertension and nephrotoxicity. As a result of the toxicity encountered with systemically administered cyclosporine A, attempts to formulate a successful topical preparation for use in cutaneous disease are being made. The advent of cyclosporine A provides the dermatologist with a new therapeutic strategem in the management of psoriasis, although the long-term safety of such interventional therapy remains to be discerned.

Nuclear hormone receptors in human skin

Nuclear hormone receptors are of critical importance for skin homeostasis where they modulate cellular metabolism, proliferation, differentiation, cell death, and inflammation. The cutaneous role of the glucocorticoid, androgen, and estrogen receptors was explored initially. In recent years, sequence homology comparisons have uncovered the complete superfamily of related receptors, many of which are also implicated in cutaneous homeostasis. A subgroup of these receptors acts in concert with the retinoid X receptor by heterodimerization and has been successfully targeted for dermatologic therapy; i.e., the retinoic acid receptor and the vitamin D receptor. Ongoing research is aimed at delineating the cutaneous effects of additional members of this subgroup including the peroxisome proliferator-activated receptors and the liver X receptors. The various receptors exert differential effects in skin and can be rationally chosen as drug targets for the treatment of cutaneous pathologies.

A systematic review of antistreptococcal interventions for guttate and chronic plaque psoriasis

BACKGROUND

Guttate psoriasis is closely associated with preceding or concurrent streptococcal infection. Some authorities have claimed that chronic plaque psoriasis may also be made worse by infection. In view of this many dermatologists have recommended using antibiotics for psoriasis, particularly guttate type. Some dermatologists have also recommended tonsillectomy for psoriasis in patients with recurrent streptococcal pharyngitis.

OBJECTIVES

This review aims to assess the evidence for the effectiveness of antistreptococcal interventions, including antibiotics and tonsillectomy in the management of acute guttate and chronic plaque psoriasis.

METHODS

Studies were identified by searching the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966-September 1999), Embase (1988-September 1999), the Salford Database of Psoriasis Trials (to November 1999) and the European Dermato-Epidemiology Network (EDEN) Psoriasis Trials Database (to November 1999) for terms (STREPTOCOCC* or ANTIBIOTIC* or TONSIL*) and PSORIASIS using the Cochrane Skin Group search strategy.

RESULTS

Only one trial met the selection criteria. This compared the use of two oral antibiotic schedules in 20 psoriasis patients, predominantly of guttate type, who had evidence of beta-haemolytic streptococcal colonization. Either rifampicin or placebo was added to the end of a standard course of phenoxymethylpenicillin or erythromycin. No patient in either arm of the study improved during the observation period. No randomized trials of tonsillectomy for psoriasis were identified.

CONCLUSIONS

Although both antibiotics and tonsillectomy have frequently been advocated both for patients with guttate psoriasis and for selected patients with chronic plaque psoriasis, there is to date no good evidence that either intervention is beneficial.

A systematic review of treatments for guttate psoriasis

BACKGROUND

Many different therapies are available for treating guttate psoriasis; however, there appears to be little objective evidence for their efficacy

OBJECTIVES

This review aims to assess the evidence for the effectiveness of treatments for guttate psoriasis. Antistreptococcal interventions for guttate psoriasis are addressed in a separate review.

METHODS

Studies were identified by searching the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966-September 1999), Embase (1988-September 1999), Salford Database of Psoriasis Trials (to November 1999) and the European Dermato-Epidemiology Network (EDEN) Psoriasis Trials Database (to November 1999) for terms GUTTATE and PSORIASIS. We also searched 100 unselected randomized controlled trials of psoriasis therapy and all 112 randomized controlled trials of phototherapy for psoriasis in the Salford Database of Psoriasis Trials for separate stratification of guttate psoriasis.

RESULTS

No published report could be found to support or to challenge current commonly used methods of management. Only one trial that met the selection criteria was identified. In this small study of 21 hospitalized patients with guttate psoriasis, intravenous infusion of an n-3 fatty acid rich lipid emulsion was compared with placebo emulsion containing n-6 fatty acids. The n-3 preparation appeared to be of some benefit for patients with guttate psoriasis.

CONCLUSION

There is currently no firm evidence on which to base treatment of acute guttate psoriasis. Studies comparing standard treatment modalities, including phototherapy and topical regimens, are required to enable informed decisions on treatment choices to be made.

Patient satisfaction with teledermatology is related to perceived quality of life

BACKGROUND

There is a lack of good data about patient satisfaction with teledermatology and about its potential interaction with quality-of-life factors.

OBJECTIVES

To assess the association between perceived skin-related quality of life and patient satisfaction with a nurse-led teledermatology service.

METHODS

In a mobile nurse-led teledermatology clinic located in four inner city general practices in Manchester, the teledermatology service used digital cameras to capture and store images of skin conditions for remote diagnosis by dermatologists. One hundred and twenty-three adult patients, non-urgent dermatology referrals from primary care, completed the Dermatology Life Quality Index (DLQI) and a 15-item patient satisfaction questionnaire.

RESULTS

In common with other studies of patient satisfaction, subjects reported highly favourable views of 'hotel' aspects of the service (93%) and found it 'convenient' (86%). However, 40% of patients would have preferred to have had a conventional face-to-face consultation with a dermatologist, and 17% felt unable to speak freely about their condition. Patient satisfaction with the service was related to quality of life. Patients reporting lower quality of life as measured by the DLQI were more likely to prefer a face-to-face encounter with a dermatologist (r = 0.216, P < 0.05), and to evince anxiety about being photographed (r = 0.223, P < 0.05).

CONCLUSIONS

Patient acceptance and satisfaction with telemedicine services is complicated by patients' subjective health status. Telehealthcare providers need to recognize that patients with poor quality of life may want and benefit from face-to-face interaction with expert clinicians.

Muco-cutaneous retinoid-effects and facial erythema related to the novel triazole antifungal agent voriconazole

Voriconazole is a new azole antifungal drug with activity against a wide range of systemic fungal pathogens, including Aspergillus spp. Five patients with chronic invasive aspergillosis were treated for 12-58 weeks with voriconazole, 200 mg twice daily and developed facial erythema and cheilitis. One who received 58 weeks of therapy also developed discoid lupus erythematosus-like lesions on both sides of her neck. Both erythema and cheilitis resolved after discontinuation of voriconazole. Serum retinoids were elevated in the three patients in whom they were measured. Voriconazole has the potential for retinoid-like side-effects and facial erythema.

Treatments for chronic palmoplantar pustular psoriasis

Chronic palmoplantar pustular psoriasis (PPP) is a disabling condition characterized by recurrent crops of sterile pustules on a background of erythema, fissuring and scaling. Genetic and environmental factors have been implicated in its etiology. Topical treatments are frequently ineffective although corticosteroids under hydrocolloid occlusion have been demonstrated to be useful. There is evidence supporting the use of systemic retinoids, PUVA and a combination of both. Oral tetracycline antibiotics may be helpful, but rarely clear PPP. Cyclosporine has been shown to be of some benefit at low doses. The choice of systemic treatments for an individual patient is influenced as much by their potential side effects as by differences in efficacy.

The role of retinoids in the prevention and repair of aged and photoaged skin

Retinoids, either naturally occurring or synthetic, are defined by their ability to bind nuclear retinoid receptors of the steroid/thyroid superfamily. Their protean but key function in physiology is control of cellular proliferation and differentiation. Topical retinoids, namely tretinoin, have been proven to prevent and repair clinical features of photoageing; these processes are facilitated by an ability to prevent loss of collagen from, and stimulate new collagen formation in, the papillary dermis of sun-exposed skin. Emerging evidence indicates that intrinsic, chronological ageing of the skin shares several mechanistic features with photoageing. Indeed aged skin is characterized by retinoid sensitivity and is probably reparable by application of topical retinoids.

Oral liarozole in the treatment of palmoplantar pustular psoriasis: a randomized, double-blind, placebo-controlled study

BACKGROUND

Palmoplantar pustular psoriasis (PPP) is a chronic, relapsing condition often recalcitrant to therapy. Synthetic retinoids have been found to be efficacious in the treatment of PPP, but their use is limited by side-effects. Liarozole is an imidazole-like compound that inhibits the retinoic acid (RA) 4-hydroxylase-mediated breakdown of all-trans RA, causing elevation of plasma and cutaneous levels of RA. Thus liarozole acts as a retinoid-mimetic drug. Liarozole has already been found to be effective in the treatment of retinoid-responsive conditions such as chronic plaque psoriasis and ichthyoses.

OBJECTIVES

To assess the efficacy and side-effect profile of liarozole in the treatment of PPP.

METHODS

We performed a double-blind, randomized, placebo-controlled trial of oral liarozole 75 mg twice daily for 12 weeks in the treatment of PPP. The trial was conducted at two centres and involved 15 patients.

RESULTS

Using the PPP Area and Severity Index we found a statistically significant (P = 0.02) improvement in PPP in subjects on liarozole (median 3, range 1.8-14.1) as compared with placebo (median 12.1, range 5-18) by the end of the treatment phase. There was also a statistically significant difference (P = 0.006) in the number of fresh pustules after treatment for the two study groups (liarozole median 2, range 0-18; placebo median 38, range 2-75). The severity of disease (on a scale of 0-8) between the two groups was significantly different at the end of treatment (liarozole median 1, range 1-5; placebo median 3, range 2-6; P = 0.04). No patients withdrew from the trial because of adverse events. The most commonly reported side-effects were pruritus, cheilitis and xerosis but these were rarely severe and resolved rapidly on discontinuation of treatment. Laboratory results, including haematology, liver function tests and serum cholesterol and triglycerides were not significantly different between the liarozole and placebo groups.

CONCLUSIONS

The results of this pilot study suggest that liarozole 75 mg twice daily is an effective and well-tolerated therapy for PPP. In addition, the pharmacokinetics of liarozole may help to circumvent side-effects associated with synthetic retinoids and allow its use in premenopausal women.

Efficacy of sirolimus (rapamycin) administered concomitantly with a subtherapeutic dose of cyclosporin in the treatment of severe psoriasis: a randomized controlled trial

BACKGROUND

The identification of a highly potent immunosuppressive/antiproliferative agent with an acceptable toxicity profile has long been a goal for the management of severe plaque psoriasis.

OBJECTIVES

To investigate the efficacy and safety of sirolimus (Rapamune) for severe psoriasis when given alone or in association with cyclosporin.

METHODS

In a randomized, double-blind, eight parallel group, pilot study in 24 out-patient centres in seven European countries, 150 patients, 18 years and older, with severe chronic plaque psoriasis were given sirolimus 0.5, 1.5 and 3.0 mg m(-2) daily for 8 weeks, either alone or in association with a subtherapeutic dose of cyclosporin (1.25 mg kg(-1) daily). Cyclosporin 5 mg kg(-1) daily was the positive control and cyclosporin 1.25 mg kg(-1) daily the negative control. The primary efficacy variable was the mean percentage reduction in Psoriasis Area and Severity Index (PASI). Safety assessments included monitoring of adverse events, clinical laboratory parameters and sirolimus/cyclosporin blood concentrations.

RESULTS

The greatest mean percentage decreases in PASI were seen with cyclosporin 5.0 mg kg(-1) daily (70.5%) and with sirolimus 3.0 mg m(-2) daily + cyclosporin 1.25 mg kg(-1) daily (63.7%). Both groups demonstrated significantly better results than cyclosporin 1.25 mg kg(-1) daily (mean decrease 33.4%). Serum creatinine levels were significantly lower for groups with sirolimus alone and sirolimus plus reduced-dose cyclosporin when compared with cyclosporin 5.0 mg kg(-1) daily. Adverse events associated with sirolimus included thrombocytopenia (5%), hyperlipidaemia (9%), aphthous stomatitis (9%) and acne (13%), whereas adverse events associated with cyclosporin included hot flushes (12%), hyperlipidaemia (9%) and increased serum creatinine (9%).

CONCLUSIONS

The concomitant administration of sirolimus with a subtherapeutic dose of cyclosporin in severe psoriasis may permit a reduction in their respective toxicities, notably cyclosporin-induced nephrotoxicity.

Physical and psychologic measures are necessary to assess overall psoriasis severity

BACKGROUND

The assessment of psoriasis severity is complex and involves both the physical and psychologic assessment of the individual patient.

OBJECTIVE

We compared the Salford Psoriasis Index and several other tools for assessing psoriasis severity for their abilities to assess both the physical and psychologic effects of psoriasis.

METHODS

A total of 101 patients (44 women, 57 men) were assessed by means of the Salford Psoriasis Index (SPI), Psoriasis Area and Severity Index (PASI), Self-Administered PASI (SAPASI), Psoriasis Disability Index (PDI), Hospital Anxiety and Depression Scale (HADS), and Illness Perception Questionnaire (IPQ).

RESULTS

The "signs" score of SPI (which measures the clinical extent of psoriasis), PASI, and SAPASI correlated well with each other (r = 0.69-0.99; P <.01). They also correlated significantly, but not as strongly, with scores of psoriasis-induced disability, the PDI and SPI "psychosocial disability" score (r = 0.46-0.51; P <.01), but not with general measures of psychologic distress. There was no significant correlation between the historical treatment, "intervention," score in SPI and either the physical or the psychologic score in the SPI. The PDI and "psychosocial disability" score of SPI correlated well with each other (r = 0.69; P <.01) as well as with the depression and anxiety subscale scores of HADS (r = 0.33 and r = 0.37; P <.01, respectively), the total number of symptoms suffered by the patient (r = 0.38; P <.01), and the belief that stress or worry were associated with psoriasis (r = 0.33; P <.01).

CONCLUSION

Physical scores of psoriasis severity such as PASI, SAPASI, and the "signs" component of SPI give a partial indication of psychosocial disability caused by psoriasis. In many patients, however, the physical score does not reflect psychosocial disability. Patients should be assessed by a more holistic approach, which takes into account both physical and psychologic measurements, such as used in SPI, when assessing the severity of psoriasis.

Discordance between facial wrinkling and the presence of basal cell carcinoma

BACKGROUND

During routine surgical treatment of basal cell carcinomas (BCCs), we observed an apparent inverse relationship between the presence of a BCC and significant wrinkling of the face. To ascertain the veracity of this observation, we performed a clinical and questionnaire-based case-referent study.

OBSERVATION

One hundred eighteen successive white patients (mean +/- SD age, 71.9 +/- 9.5 years) attending the hospital for surgical treatment of a BCC and 121 control (no skin cancer) patients (mean +/- SD age, 69.1 +/- 10.8 years) were assessed for grade of facial wrinkling using a previously validated photonumeric scale of photoaging and completed a questionnaire about sun exposure. Despite being older (P =.03), patients with a BCC were found to have a lower mean grade of wrinkling than controls (P =.001). Using logistic regression, increasing grade of wrinkling was associated with a progressive reduction in risk of developing a BCC.

CONCLUSION

Mechanisms responsible for the production of facial wrinkles may either be separate to or mitigate against the development of a BCC of the face.