Topical and Intralesional Therapies for Hidradenitis Suppurativa: A Systematic Literature Review

BACKGROUND AND OBJECTIVE

Topical and intralesional (IL) treatments may be considered the first-line therapy in patients with hidradenitis suppurativa (HS); however, the evidence supporting their use is limited. The aim of our review is to evaluate the efficacy and safety profile of topical and IL treatments in patients with HS.

MATERIALS AND METHODS

We designed a systematic review of the current medical literature available following the PICO(T) method. And including all types of studies (Study type [T]) of individuals with HS of any sex, age, and ethnicity (Population [P]) who received any topical or IL treatment for HS (Intervention [I]) compared to placebo, other treatments, or no treatment at all (Comparator [C]), and reported efficacy and/or safety outcomes (Outcomes [O]). Two outcomes were defined: quality of life and the no. of patients with, at least, one adverse event. The search was conducted in the Cochrane Library, MEDLINE, and EMBASE databases; study selection was performed based on pre-defined criteria. The risk of bias was determined in each study.

RESULTS

We obtained a total of 11,363 references, 31 of which met the inclusion criteria. These studies included 1143 patients with HS, 62% of whom were women. A total of 10, 8, 6, 2, and 5 studies, respectively, evaluated the use of photodynamic therapy (PDT), glucocorticoids, resorcinol, topical antibiotics, and other interventions. Most articles were case series (n=25), with only five randomized clinical trials (RCTs) and one cohort study. RCTs showed improvement in disease activity with topical clindamycin and botulinum toxin (BTX) vs placebo, and PDT with methylene blue (MB) niosomal vs free MB; however, intralesional triamcinolone acetonide was not superior to placebo. The risk of bias was low in three RCTs and high in two RCTs.

CONCLUSION

The quality of evidence supporting the use of topical, or IL treatments is low. However, it supports the use of topical clindamycin, PDT, and BTX. Well-designed RCTs with standardized outcomes and homogeneous populations of patients and lesions are needed to support decision-making in the routine clinical practice.

Moderate to Severe Psoriasis in Older Adults: Recommendations on Management from the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV)

Managing moderate to severe psoriasis in older adults is complex due to factors characteristic of the later years of life, such as associated comorbidity, polypharmacy, and immunosenescence. This consensus statement discusses 17 recommendations for managing treatment for moderate to severe psoriasis in patients older than 65 years. The recommendations were proposed by a committee of 6 dermatologists who reviewed the literature. Fifty-one members of the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV) then applied the Delphi process in 2 rounds to reach consensus on which principles to adopt. The recommendations can help to improve management, outcomes, and prognosis for older adults with moderate to severe psoriasis.

[Translated article] Moderate to Severe Psoriasis in Older Adults: Recommendations on Management From the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV)

Managing moderate to severe psoriasis in older adults is complex due to factors characteristic of the later years of life, such as associated comorbidity, polypharmacy, and immunosenescence. This consensus statement discusses 17 recommendations for managing treatment for moderate to severe psoriasis in patients older than 65 years. The recommendations were proposed by a committee of 6 dermatologists who reviewed the literature. Fifty-one members of the Psoriasis Working Group of the Spanish Academy of Dermatology and Venereology (AEDV) then applied the Delphi process in 2 rounds to reach consensus on which principles to adopt. The recommendations can help to improve management, outcomes, and prognosis for older adults with moderate to severe psoriasis.

Common Approach to Metabolic-Associated Fatty Liver Disease in Patients With Psoriasis: Consensus-Based Recommendations From a Multidisciplinary Group of Experts

Recent years have seen concerted efforts to understand the relation between psoriasis and metabolic-associated fatty liver disease (MAFLD). Not only is MALFD diagnosed more often in patients with psoriasis, but its clinical course is also more aggressive. A common approach is therefore needed to enable early detection of liver disease coincident with psoriasis. Especially important is an analysis of risks and benefits of potentially hepatotoxic treatments. This consensus paper presents the recommendations of a group of experts in dermatology and hepatology regarding screening for MALFD as well as criteria for monitoring patients and referring them to hepatologists when liver disease is suspected.

[[Translated article]]Common Approach to Metabolic-Associated Fatty Liver Disease in Patients With Psoriasis: Consensus-Based Recommendations From a Multidisciplinary Group of Experts

Recent years have seen concerted efforts to understand the relation between psoriasis and metabolic-associated fatty liver disease (MAFLD). Not only is MALFD diagnosed more often in patients with psoriasis, but its clinical course is also more aggressive. A common approach is therefore needed to enable early detection of liver disease coincident with psoriasis. Especially important is an analysis of risks and benefits of potentially hepatotoxic treatments. This consensus paper presents the recommendations of a group of experts in dermatology and hepatology regarding screening for MALFD as well as criteria for monitoring patients and referring them to hepatologists when liver disease is suspected.

POS1075 CROSS-SECTIONAL OBSERVATIONAL AND MULTICENTER STUDY FOR THE VALIDATION OF THE SPANISH VERSION OF THE PURE-4 QUESTIONNAIRE

Background

The Psoriatic arthritis UnclutteRed screening Evaluation (PURE-4) has been culturally adapted to Spanish language recently following the standardized methodology.1 A group of experts in psoriasis and psoriatic arthritis (PsA) has recently recommended the use of the Spanish version of PURE-4 due to the reduced number of items, its high sensitivity and specificity and the feasibility to implement in the clinical practice.

Objectives

To validate the Spanish version of the PURE-4 questionnaire.

Methods

Cross-sectional, observational and multicenter study conducted with primary data collection under conditions of routine clinical practice in Spain. The study included adult patients with diagnosis of psoriasis of any time of evolution and any type of severity, that voluntarily accepted to participate. Primary endpoint: validation of PURE-4 questionnaire in terms of sensitivity, specificity, feasibility, reliability (internal consistency) and construct validity. The study consists in two cross-sectional evaluations: assessment I (a visit performed by a dermatologist, followed by an independent visit to the rheumatologist within the following 4 weeks after to the dermatologist’s visit and scheduled according to routine clinical practice) and assessment II (patients without PsA in assessment I will be evaluated by the rheumatologist one year ±2 months later and the rheumatologist will perform the PsA diagnostic confirmation according to the rheumatologist criteria and will collect clinical characteristics). Since data from assessment II are not yet available, data from assessment I are presented.

Results

268 evaluable patients included, 57.1% male, with a mean (SD) age of 47.1 (12.6) years, a mean (SD) time from diagnosis of 18.6 (12.9) years and mostly receiving psoriasis treatment (88.8%), biological treatment being the most common (43.3%). Mean (SD) PURE-4 score for all patients was 1.4 (1.3), being 2.3 (1.1) for patients with PsA and 1.3 (1.3) for patients without PsA diagnosis (Table 1). 268 (100.0%) patients answered the full PURE-4 questionnaire. Area under the receiver-operating characteristic (ROC) curve was 0.7185 (95% CI: 0.6391, 0.7978), showing good quality of fit or quality of the questionnaire (Figure 1). Using the Youden index, which determines the optimal cut-off point for the classification of patients, it was identified that a score ≥2 indicated a diagnosis of PsA. PURE-4 questionnaire showed a sensitivity of 77.1% and a specificity of 61.1%.

Table 1.

Sociodemographic and clinical baseline characteristics (assessment I)

CharacteristicsWith PsA diagnosis (n=35)Without PsA diagnosis (n=226)Not assesable (n=7)Total (n=268)Age, mean (SD)50.5 (10.0)46.5 (12.9)49.9 (11.2)47.1 (12.6)Female, n (%)14 (40.0%)97 (42.9%)4 (57.1%)115 (42.9%)Years since diagnosis, mean (SD)19.7 (14.2)18.3 (12.8)22.4 (9.0)18.6 (12.9)Current treatment for psoriasis, n (%)32 (91.4%)199 (88.1%)7 (100.0%)238 (88.8%)Phototherapy, n (%)5 (15.6%)16 (8.0%)0 (0.0%)21 (8.8%)Topic treatment, n (%)20 (62.5%)66 (33.2%)3 (42.9%)89 (37.4%)Conventional systemic no biological treatment, n (%)7 (21.9%)40 (20.1%)2 (28.6%)49 (20.6%)Biological treatment, n (%)8 (25.0%)91 (45.7%)4 (57.1%)103 (43.3%)Phosphodiesterase-4 inhibitors, n (%)0 (0.0%)8 (4.0%)0 (0.0%)8 (3.4%)Others, n (%)0 (0.0%)3 (1.5%)0 (0.0%)3 (1.3%)PASI, mean (SD)8.7 (5.5)7.0 (5.0)4.2 (3.1)7.2 (5.1)Mild (PASI<7), n (%)11 (31.4%)95 (42.0%)5 (71.4%)111 (41.4%)Moderate/severe (PASI≥7), n (%)24 (68.6%)131 (58.0%)2 (28.6%)157 (58.6%)

APs, psoriatic arthritis; PASI, Psoriasis Area and Severity Index; SD, standard deviation.

Figure 1.

Area under the ROC curve (assessment I)

Conclusion

PURE-4 is a valid and compliant questionnaire with clinical practice in dermatology. It could be answered by patients in the waiting room and reviewed by dermatologists during the visit to support decision-making. PURE-4 could also help rheumatologists to early diagnose PsA patients in clinical practice.

References

[1]Actas Dermosifiliogr. 2020;111(8):655-64.

Acknowledgements

The authors thank IQVIA and Carmen Barrull, Neus Canal and Marco Pinel for providing medical editorial assistance with this presentation.

Disclosure of Interests

Rubén Queiro Silva Speakers bureau: AbbVie, MSD, Pfizer, Novartis, Lilly, Janssen, UCB y Celgene., Consultant of: AbbVie, MSD, Pfizer, Novartis, Lilly, Janssen, UCB y Celgene., Grant/research support from: Novartis, AbbVie y Janssen., Isabel Belinchón Speakers bureau: Janssen Pharmaceuticals Inc., Almirall, Lilly, AbbVie, Novartis, Celgene, Biogen Amgen, Leo-Pharma, Pfizer-Wyeth, UCB y MSD., Consultant of: Janssen Pharmaceuticals Inc., Almirall, Lilly, AbbVie, Novartis, Celgene, Biogen Amgen, Leo-Pharma, Pfizer-Wyeth, UCB y MSD., Anna Lopez-Ferrer Speakers bureau: Novartis, Janssen, MSD, Lilly, Pfizer,Celgene, Almirall, Leo Pharma, AbbVie y Amgen., Consultant of: Novartis, Janssen, MSD, Lilly, Pfizer,Celgene, Almirall, Leo Pharma, AbbVie y Amgen., Marta Ferran i Farrés Speakers bureau: Janssen, Lilly, Novartis, Pfizer, MSD, AbbVie, Celgene y Almirall., Paid instructor for: Janssen, Lilly, Novartis, Pfizer, MSD, AbbVie, Celgene y Almirall., Consultant of: Janssen, Lilly, Novartis, Pfizer, MSD, AbbVie, Celgene y Almirall., Raquel Rivera Díaz Speakers bureau: AbbVie, Almirall, Celgene Corporation, GSK, Janssen-Cilag, Lilly, LEO Pharma, MSD, Novartis, Pfizer y UCB., Paid instructor for: AbbVie, Almirall, Celgene Corporation, GSK, Janssen-Cilag, Lilly, LEO Pharma, MSD, Novartis, Pfizer y UCB., Consultant of: AbbVie, Almirall, Celgene Corporation, GSK, Janssen-Cilag, Lilly, LEO Pharma, MSD, Novartis, Pfizer y UCB., David Vidal Sarro Speakers bureau: Lilly, Janssen, AbbVie, Novartis, UCB, Celgene, Gebro y Leo., Paid instructor for: Lilly, Janssen, AbbVie, Novartis, UCB, Celgene, Gebro y Leo., Consultant of: Lilly, Janssen, AbbVie, Novartis, UCB, Celgene, Gebro y Leo., lourdes rodriguez freire Speakers bureau: AbbVie, Janssen Pharmaceuticals Inc., MSD, Pfizer-Wyeth, Novartis, Celgene, Almirall SA, Lilly y Leo-Pharma., Consultant of: AbbVie, Janssen Pharmaceuticals Inc., MSD, Pfizer-Wyeth, Novartis, Celgene, Almirall SA, Lilly y Leo-Pharma., Pablo de la Cueva Dobao Speakers bureau: AbbVie, Almirall, Amgen, Boehringer, Biogen, Celgene, Gebro, Janssen Cilag, Leo-Pharma, Lilly, MSD, Novartis, Pfizer- Wyeth, Sandoz, Sanofi y UCB., Paid instructor for: AbbVie, Almirall, Amgen, Boehringer, Biogen, Celgene, Gebro, Janssen Cilag, Leo-Pharma, Lilly, MSD, Novartis, Pfizer- Wyeth, Sandoz, Sanofi y UCB., Consultant of: AbbVie, Almirall, Amgen, Boehringer, Biogen, Celgene, Gebro, Janssen Cilag, Leo-Pharma, Lilly, MSD, Novartis, Pfizer- Wyeth, Sandoz, Sanofi y UCB., Jorge Santos Juanes Speakers bureau: Novartis, Lilly, Janssen, Abbvie, Amgen, y Sanofi., Consultant of: Novartis, Lilly, Janssen, Abbvie, Amgen, y Sanofi., Grant/research support from: Novartis, Lilly, Janssen, Abbvie, Amgen, y Sanofi., Vicenç Rocamora Duran Speakers bureau: Jansen, Lilly, Abbvie, Almirall, Amgen y Novartis., Paid instructor for: Jansen, Lilly, Abbvie, Almirall, Amgen y Novartis., Cristina Sanabra Employee of: Novartis Pharmaceuticals Spain, Guillermo Guinea Uzábal Employee of: Novartis Pharmaceuticals Spain, Víctor Martín Vázquez Employee of: Novartis Pharmaceuticals Spain

The risk of hepatic adverse events of systemic medications for psoriasis: a prospective cohort study using the BIOBADADERM registry

BACKGROUND

Limited information is available regarding the risk of incident liver disease in patients with psoriasis receiving systemic therapies.

OBJECTIVES

To describe the liver safety findings of conventional and modern systemic therapies for moderate-to-severe psoriasis, and to compare the relative incidence rates of hepatic adverse events (AEs) for each drug.

METHODS

All the patients on the BIOBADADERM registry were included. Crude and adjusted incidence rate ratios (cIRR and aIRR, respectively) of hepatic AEs, using anti-TNF drugs as reference, were determined. Outcomes of interest were hypertransaminasemia, nonalcoholic fatty liver disease (NADFLD) and a group of other, less represented, hepatic AEs.

RESULTS

Our study included 3,171 patients exposed to systemic drugs (6279 treatment cycles). Incident hypertransaminasemia was the most frequent hepatic AE (incidence rate of 21 per 1000 patients-years [CI 95% CI 18-23]), followed by NAFLD (8 cases per 1000 patients-years [95% CI 6-10]). Methotrexate (aIRR 3.06 [2.31-4.4]; p = 0.000) and cyclosporine (aIRR 2.37 [1.05-5.35]; p = 0.0378) were associated with an increased risk for hypertransaminasemia when compared to anti-TNF-α agents. No differences were observed between different groups of biologics. Conventional therapies were not associated with new incident NAFLD.

CONCLUSIONS

Comparative information of the incidence of hepatic AEs could facilitate drug selection in moderate-to-severe psoriasis.

Management of Psoriasis During Preconception, Pregnancy, Postpartum, and Breastfeeding: A Consensus Statement

OBJECTIVE

To develop evidence- and experience-based recommendations for the management of psoriasis during preconception, pregnancy, postpartum, and breastfeeding.

METHODS

The nominal group technique and the Delphi method were used. Fifteen experts (12 dermatologists, 2 of whom were appointed coordinators; 1 rheumatologist; and 2 gynecologists) were selected to form an expert panel. Following a systematic review of the literature on fertility, pregnancy, postpartum, and breastfeeding in women with psoriasis, the coordinators drew up a series of preliminary recommendations for discussion by the panel at a nominal group meeting. The experts defined the scope, sections, and intended users of the statement and prepared a final list of recommendations. Consensus was obtained using a Delphi process in which an additional 51 dermatologists rated their level of agreement with each recommendation on a scale of 1 (total disagreement) to 10 (total agreement). Consensus was defined by a score of 7 or higher assigned by at least 70% of participants. Level of evidence and strength of recommendation were reported using the Oxford Center for Evidence-Based Medicine categories. The final statement was approved by the expert panel.

RESULTS

The resulting consensus statement includes 23 recommendations on preconception (fertility and contraception), pregnancy (planning, pharmacological management, and follow-up), and breastfeeding (management and follow-up). Consensus was achieved for all recommendations generated except one.

CONCLUSIONS

These recommendations for the better management of psoriasis in women of childbearing age could improve outcomes and prognosis.

Effect of Sex in Systemic Psoriasis Therapy: Differences in Prescription, Effectiveness and Safety in the BIOBADADERM Prospective Cohort

The effect of sex on systemic therapy for psoriasis has not been well studied. The aim of this study was to analyse a large multicentre Spanish cohort of 2,881 patients with psoriasis (58.3% males), followed from January 2008 to November 2018, to determine whether sex influences prescription, effectiveness of therapy, and the risk of adverse events. The results show that women are more likely than men to be prescribed biologics. There were no differences between men and women in effectiveness of therapy, measured in terms of drug survival. Women were more likely to develop adverse events, but the difference in risk was small and does not justify different management. Study limitations include residual confounding and the use of drug survival as a proxy for effectiveness.

Dermatologists' Role in the Early Diagnosis of Psoriatic Arthritis: Expert Recommendations

Psoriatic arthritis is a common type of inflammatory arthritis found in up to 40% of patients with psoriasis. Because skin involvement usually precedes joint involvement, dermatologists play a key role in early detection. Early diagnosis is important for reducing the risk of irreversible structural damage, attenuating the deterioration of physical function, and improving patients' quality of life. This consensus statement was drafted by a group of 9 dermatologists and 1 rheumatologist to provide simple recommendations to help dermatologists screen for psoriatic arthritis in patients with psoriasis. The experts offer consensus-based guidelines that draw on a review of available scientific evidence and on experience acquired in routine clinical practice.

Real-world effectiveness and safety of apremilast in psoriasis at 52 weeks: a retrospective, observational, multicentre study by the Spanish Psoriasis Group

BACKGROUND

Little has been published on the real-world effectiveness and safety of apremilast in psoriasis.

OBJECTIVES

To evaluate the effectiveness, safety and drug survival of apremilast at 52 weeks in patients with moderate to severe plaque psoriasis or palmoplantar psoriasis in routine clinical practice.

METHODS

Retrospective, multicentre study of adult patients with moderate to severe plaque psoriasis or palmoplantar psoriasis treated with apremilast from March 2016 to March 2018.

RESULTS

We studied 292 patients with plaque psoriasis and 85 patients with palmoplantar psoriasis. The mean (SD) Psoriasis Area and Severity Index (PASI) score was 10.7 (7.0) at baseline and 3.0 (4.2) at 52 weeks. After 12 months of treatment, 73.6% of patients had a PASI score of 3 or less. In terms of relative improvement by week 52, 49.7% of patients achieved PASI-75 (≥75% reduction in PASI score) and 26.5% achieved PASI-90. The mean physician global assessment score for palmoplantar psoriasis fell from 4.2 (5.2) at baseline to 1.3 (1.3) at week 52. Overall drug survival after 1 year of treatment with apremilast was 54.9 %. The main reasons for treatment discontinuation were loss of efficacy (23.9%) and adverse events (15.9%). Almost half of the patients in our series (47%) experienced at least one adverse event. The most common events were gastrointestinal problems.

CONCLUSIONS

Apremilast may be a suitable alternative for the treatment of moderate to severe psoriasis and palmoplantar psoriasis. Although the drug has a good safety profile, adverse gastrointestinal effects are common.

OP0262-HPR COST OF ILLNESS IN PATIENTS WITH PSORIASIS AND PSORIATIC ARTHRITIS. COEPSO STUDY

Background:

Psoriasis (Ps) and psoriatic arthritis (PsA) have a major impact on patients’ health-related quality of life. Cost of illness of patients with Ps, PsA and both diseases (PsA+Ps) is an important subject as they are associated with a substantial economic impact, with implications from a health management perspective.

Objectives:

To describe the economic burden of direct non-healthcare and indirect resources of patients with Ps, PsA and PsA+Ps in Spain.

Methods:

COEPSO (“Evaluation of Costs in patients with Psoriatic Disease”) was an observational, retrospective, cross-sectional study performed in 22 Spanish centers (17 Dermatology and 14 Rheumatology Services), from February 2017 to February 2018, including moderate to severe Ps and PsA patients (with or without Ps), naive to biologics. Direct non-healthcare (social services, home care, physical adaptations, private health and non-health professionals, non-reimbursed and non-pharmaceutical therapies), indirect (loss of productivity) and total costs (direct non-healthcare and indirect costs) related to the disease during the previous year to the study were obtained. Unitary costs (€, 2018) were calculated: out-of-pocket costs were specified directly by patients and loss of productivity costs by means of average salaries based on occupation specified by patients. The information was collected through a case report form filled out by the investigators and a telephone survey administered to the patients.

Results:

A total of 318 patients were included (196 Ps; 43 PsA and 79 PsA+Ps), mean age 48.7 years and 51.3% males. Metabolic syndrome was the most frequent comorbidity in all groups. The average annual total cost per patient was 1,042.71€ (SD 3,817.55), 1,137.84€ (SD 3,070.39) and 1,830.26€ (SD 5,835.81) for Ps, PsA and PsA+Ps, respectively. The average annual direct non-healthcare cost per patient was 749.57€ (SD 2,393.77), 750.50€ (SD 1,641.82) and 1,247.56€ (SD 4,467.19) for Ps, PsA and PsA+Ps, respectively. The average annual indirect cost per patient was 293.14€ (SD 2,855.27), 387.35€ (SD 2,409.63) and 582.71€ (SD 3,842.12) for Ps, PsA and PsA+Ps, respectively.

Patients with combined PsA+Ps had higher annual total cost (direct non-healthcare and indirect costs) than patients with only one of these manifestations separately (75.5% and 60.9% above patients with Ps and PsA, respectively). Total costs in patients with Ps and PsA were similar. Direct non-healthcare costs represent between 66.0% (patients with PsA) to 71.9% (patients with Ps) of total cost. Indirect costs represent between 28.1% (patients with Ps) to 34.0% (patients with PsA) of total cost.

Conclusion:

PsA and Ps have proved to be diseases with a high economic burden, and the total costs were mainly driven by direct non-healthcare costs. Moreover, although annual total costs in patients with PsA were similar to those of Ps patients, the combination of both manifestations yielded the highest costs suggesting the importance of the increased disease load.

Disclosure of Interests:

Santos Castañeda: None declared, Esther Vicente Speakers bureau: BMS, Roche., Mar Llamas Velasco: None declared, Javier Sanchez Perez: None declared, José Pardo: None declared, Rita Cabeza-Martínez: None declared, Mercedes Miranda-Fontes: None declared, Juan Márquez: None declared, Jaime Calvo Grant/research support from: Lilly, UCB, Consultant of: Abbvie, Jansen, Celgene, susana armesto: None declared, Isabel Belinchón: None declared, Alejandro Gómez: None declared, María Dolores Miranda: None declared, Silvia Martinez Pardo: None declared, Leticia Merino-Meléndez: None declared, Miguel Angel Casado Consultant of: UCB Pharma, María Yébenes: None declared, Araceli Casado: None declared

Linguistic and Cultural Adaptation to Spanish of the Screening Tool Psoriatic Arthritis UnclutteRed Screening Evaluation (PURE4)

BACKGROUND AND OBJECTIVE

The 4-item Psoriatic arthritis UnclutteRed screening Evaluation (PURE-4) questionnaire is a useful tool for identifying patients with suspected psoriatic arthritis before referring them to a rheumatology department for confirmation. The original English version has good discriminant validity (sensitivity, 85.7%; specificity, 83.6%). We aimed to produce an adapted Spanish version of the PURE-4 for validation and use in Spain.

MATERIAL AND METHOD

We applied the method recommended by the International Society for Pharmacoeconomic and Outcome Research for the cultural adaptation of patient-centered measurement tools. The phases in the processes involved forward translation, reconciliation, back translation review, harmonization, cognitive debriefing and review, and proofreading.

RESULTS

We obtained the permission of the author of the original questionnaire. Two native-speaking translators translated the questionnaire into Spanish. Small changes, mainly in the way the items were expressed, were then made in order to reconcile the 2 translations. The questionnaire was then back translated to English and revised to achieve a version equivalent to the original. A Spanish translation derived from the revision was tested for understandability in 7 patients, and the final Spanish version was then produced. During the translation phases, the project manager and a scientific committee made up of a dermatologist and a rheumatologist reviewed the different versions. Team members exchanged information throughout the process, providing for harmonization and the quality control that guaranteed conceptual equivalence.

CONCLUSIONS

This adaptation of the PURE-4 questionnaire for use in Spain has been the first step toward using it in routine clinical practice. The standardized method we used ensures that the Spanish and the original versions are equivalent.

Definition of minimal disease activity in psoriasis

OBJECTIVE

To generate an operational definition to adequately reflect the construct 'Minimal Disease Activity (MDA)' in psoriasis.

METHODS

A systematic review of domains included in clinical trials of psoriasis was presented to a panel of dermatologists and patients. Further domains were elicited by panel discussions. Domains (and instruments measuring these) were items of two consecutive Delphi rounds targeting dermatologists from the Psoriasis Group of the Spanish Academy of Dermatology and Venereology and patients from the Acción Psoriasis association. The instruments selected were used to generate 388 patient vignettes. The expert group then classified these vignettes as 'No MDA/MDA/Unclassifiable'. The items were further reduced by factorial analysis. Using the classification variable as gold standard, several operational constructions were tested in regression models and ROC curves and accuracy was evaluated with area under the curve (AUC).

RESULTS

The following domains were included: itching, scaling, erythema and visibility by 0-10 scales, extension by BSA, impact on quality of life by DLQI, special location and presence of arthritis as yes/no. The definition with the highest AUC and best balance between sensitivity and specificity was the one including no presence of arthritis plus at least three others below the upper limit of the 95% confidence interval (AUC, 0.897; sensitivity, 95.2%, specificity, 84.1%).

CONCLUSION

This study provides, for the very first time, the construct of 'Minimal Disease Activity' in psoriasis as agreed by dermatologists and patients. MDA is defined as absence of active arthritis plus 3 out of 6: itching ≤ 1/10; scaling ≤ 2/10; redness ≤ 2/10; visibility ≤ 2/10; BSA ≤ 2; DLQI ≤ 2; and no lesions in special locations. By design, domains are representative of disease impact. This MDA definition may be used as a measure of adequate management and replace other subjective or restrictive tools.

The Use of Apremilast in Psoriasis: A Delphi Study

BACKGROUND

Experience in the use of apremilast in clinical practice complements the information available from pivotal clinical trials.

MATERIAL AND METHOD

Following a review of the literature, a panel of dermatologists with expertise in the management of psoriasis considered 5 scenarios in which the evidence supporting the use of apremilast to treat moderate psoriasis is insufficient or controversial. These scenarios were then assessed using a Delphi questionnaire.

RESULTS

Consensus was reached on 96 (67%) of the 143 items (positive in 85 and negative in 11). The therapeutic goal for apremilast should be based on 4 outcomes: clinical response, symptoms, quality of life, and patient satisfaction. The scenario in which the use of apremilast was considered to have the greatest possibility of success was in patients with stable moderate psoriasis. Most of the clinicians considered apremilast to be an appropriate treatment when conventional therapies fail or are contraindicated, preferably before the prescription of biologic therapy. Consensus was reached that apremilast is an appropriate treatment for psoriasis in difficult locations, such as the scalp or the palms and soles. It was also agreed that apremilast requires less prescreening and monitoring than other conventional and biologic systemic therapies.

CONCLUSIONS

Apremilast could be a treatment option for patients with a different profile to that of clinical trial participants. The limitations of this proposal are the absence of consensus on the definition of moderate psoriasis, the lack of real-world evidence on the use of apremilast, and certain aspects related to tolerability.

Survival of classic and biological systemic drugs in psoriasis: results of the BIOBADADERM registry and critical analysis

BACKGROUND

Few reported studies compare drug survival in moderate-to-severe psoriasis vulgaris.

OBJECTIVES

To describe and compare drug survival of systemic drugs, including biologic agents (infliximab, etanercept, adalimumab and ustekinumab) and classical drugs (acitretin, ciclosporin and methotrexate) in moderate-to-severe psoriasis.

METHODS

This was a multicenter, prospective, cohort study of patients receiving systemic therapies between 2008 and 2013 in 12 hospitals in Spain. Baseline data and drug discontinuation were collected. Drug survival is presented using Kaplan-Meier survival curves. We compared adjusted risk ratios of serious adverse events (AEs) with results of survival analysis for AEs.

RESULTS

A total of 1956 patients were included for analysis (1240 exposed to biologics during follow-up and 1076 to classic therapies). Median follow-up time was 3.3 years (0.0-5.1 years). There were 2209 discontinuations out of 3640 therapy cycles started. The main reason for discontinuation was lack of efficacy (36.4%) and remission (27.2%). Biologics showed a higher drug survival than classics and the pattern of survival results for all outcomes (positive or negative) were very similar. Adjusted risk ratios of serious AEs did not agree with results of survival analysis.

LIMITATIONS

A limitation is that this is an observational study with potential selection bias.

CONCLUSION

Survival as a proxy measure of drug safety in psoriasis is inadequate.

Adherence, satisfaction and preferences for treatment in patients with psoriasis in the European Union: a systematic review of the literature

BACKGROUND AND OBJECTIVE

Adherence to treatment in patients with psoriasis is often poor. An investigation of patient preferences and satisfaction with treatment may be important, based on the expected correlation with therapy compliance. This paper aims to examine and describe the current literature on patient preferences, satisfaction and adherence to treatment for psoriasis in the European Union (EU).

METHODS

Electronic searches were conducted using PubMed, ISI Web of Knowledge, Scopus, Spanish databases and Google Scholar. European studies published in English or Spanish between January 1, 2009 and December 31, 2014 regarding patient-reported outcomes in psoriatic patients were included. Studies conducted in non-EU countries, letters to the editor, editorials, experts' opinions, case studies, congress proceedings, publications that did not differentiate between patients with psoriasis and psoriatic arthritis or studies related to specific treatment were excluded.

RESULTS

A total of 1,769 titles were identified, of which 1,636 were excluded as they were duplicates or did not provide any relevant information. After a full-text reading and application of the inclusion/exclusion criteria, 46 publications were included. This paper will describe publications on adherence (n=4), preferences (n=5) and satisfaction with treatment (n=7). Results related to health-related quality of life articles (n=30) have been published elsewhere. Adherence rates are generally low in psoriasis patients regardless of the type of treatment, severity of disease or methods used to measure adherence. Biologic therapy is associated with greater clinical improvement. There is a direct association between physician recommendations, patient preferences and several domains of treatment satisfaction.

CONCLUSION

The results of this review support the conclusion that adherence rates in patients with psoriasis are suboptimal and highlight the need to improve patient compliance and satisfaction with treatment. Patients' preferences should be taken into account in the treatment decision-making process in order to improve patients' clinical outcomes by ensuring satisfaction and adherence.

Expert recommendations on treating psoriasis in special circumstances

INTRODUCTION AND OBJECTIVES

A great amount of information on systemic and biologic therapies for moderate to severe psoriasis is now available. However, applying the evidence in numerous clinical scenarios has engendered debate; under these circumstances, the consensus of experts is useful.

MATERIAL AND METHODS

A scientific committee systematically reviewed the literature relevant to 5 clinical scenarios. An online Delphi survey of dermatologists with experience treating moderate to severe psoriasis was then carried out in order to shed light on questions that remained unresolved by the available evidence.

RESULTS

Twenty-three dermatologists responded to the survey and consensus was reached on 37 (56%) of the 66 statements proposed. These results led to consensus on various clinical situations even though firm evidence was lacking. Thus, intermittent therapeutic regimens and strategies for reducing the intensity of treatment are considered appropriate for optimizing biologic treatment and reducing costs. The measurement of drug and antidrug antibody levels should be included routinely when following patients on biologics to treat psoriasis. Concomitant psoriatic arthritis or a history of cardiovascular conditions will influence the choice of biologic; in these situations, an agent with anti-tumor necrosis factor properties will be preferred. Tailored management is important when the patient is pregnant or intends to conceive; drug half-life and disease severity are important factors to take into consideration in these scenarios.

CONCLUSIONS

A combination of systematic review of the literature and structured discussion of expert opinion facilitates decision-making in specific clinical scenarios.

Risk of adverse events in psoriasis patients receiving classic systemic drugs and biologics in a 5-year observational study of clinical practice: 2008-2013 results of the Biobadaderm registry

BACKGROUND

Biobadaderm is the Spanish registry of psoriasis patients receiving systemic treatment in clinical practice.

OBJECTIVE

To compare the safety of biologics and classic systemic treatment.

METHODS

Prospective cohort of patients receiving biologics and classic systemic therapies between 2008 and 2013 in 12 hospitals are included. We registered demographic data, diagnoses, comorbidities, treatments and adverse events (AE). We obtained raw relative risks (RR) for specific AE. Multivariate analysis consisted of Cox models adjusting for age, gender, chronic hepatic disease and previous cancer.

RESULTS

A total of 1030 patients received biologics (2061 AE in 3681 person-years), 926 patients classic systemic drugs (1015 AE in 1517 person-years). Ninety-three per cent of AE in both groups were non-serious, 6% serious and 0.003% fatal. The age- and gender-adjusted hazard ratio of AE was lower in the biologics group [hazard ratio 0.6 (95% CI: 0.5-0.7)].We found no differences in rates of serious and mortal AE. Some system organ class AE rates differed between both groups. As limitations: Prescription bias might affect the incidence of AE in both groups. Association of drug and AE was based on timing: associations might not be causal.

CONCLUSION

Patients receiving biologics had lower risk of AE. We did not find differences in the risk of serious or fatal AE.