X-linked genodermatoses from diagnosis to tailored therapy

Background

Genodermatoses are rare heterogeneous genetic skin diseases with multiorgan involvement. They severely impair an individual's well-being and can also lead to early death.

Methods

During the progress of this review, we have implemented a targeted research approach, diligently choosing the most relevant and exemplary articles within the subject matter. Our method entailed a systematic exploration of the scientific literature to ensure a compre-hensive and accurate compilation of the available sources.

Results

Among genodermatoses, X-linked ones are of particular importance and should always be considered when pediatric males are affected. Regardless of other syndromic forms without prevalence of skin symptoms, X-linked genodermatoses can be classified in three main groups: keratinization defects, pigmentation defects, and inflammatory skin diseases. Typical examples are dyskeratosis congenita, keratosis follicularis spinulosa decalvans, hypohidrotic ectodermal dysplasia, chondrodysplasia punctata, hypohidrotic ectodermal dysplasia, incontinentia pigmenti, chronic granulomatous disease, CHILD syndrome and ichthyosis. In this field, genetic diagnosis of the specific disease is important, also considering that numerous clinical trials of orphan drugs and genetic therapies are being proposed for these rare genetic diseases.

Conclusions

Thus, this chapter starts from clinical to molecular testing and ends with a review of all clinical trials on orphan drugs and gene therapy for genodermatoses.

Omics sciences and precision medicine in melanoma

Background

This article provides an overview of the application of omics sciences in melanoma research. The name omics sciences refers to the large-scale analysis of biological molecules like DNA, RNA, proteins, and metabolites.

Methods

In the course of this review, we have adopted a focu-sed research strategy, meticulously selecting the most pertinent and emblematic articles related to the topic. Our methodology included a systematic examination of the scientific literature to guarantee a thorough and precise synthesis of the existing sources.

Results

With the advent of high-throughput technologies, omics have become an essential tool for understanding the complexity of melanoma. In this article, we discuss the different omics approaches used in melanoma research, including genomics, transcriptomics, proteomics, and metabolomics. We also highlight the major findings and insights gained from these studies, including the identification of new therapeutic targets and the development of biomarkers for diagnosis and prognosis. Finally, we discuss the challenges and future directions in omics-based melanoma research, including the integration of multiple omics data and the development of personalized medicine approaches.

Conclusions

Overall, this article emphasizes the importance of omics science in advancing our understanding of melanoma and its potential for improving patient outcomes.

Connective tissue nevus misdiagnosed as juvenile localized scleroderma

BACKGROUND

Connective tissue nevi (CTN) are congenital hamartomas caused by excessive proliferation of dermis components. In children, CTN can mimic juvenile localized scleroderma (JLS), an immune mediated skin disorder that requires aggressive immunosuppression.

OBJECTIVES

Aim of our study was to describe a series of pediatric patients with CTN misdiagnosed as JLS and the discerning characteristics between the two conditions.

METHODS

Retrospective analysis of children referred to our Center during the last two decades for JLS who received a final diagnosis of CTN. Clinical, laboratory, histopathological and instrumental data (MRI and thermography) were collected and compared with those with JLS.

RESULTS

Seventeen patients with mean age at onset 4.6 years entered the study. All came to our Center with a certain diagnosis of JLS (n = 15) or suspected JLS (n = 2). The indurated skin lesions were flat and resembled either circumscribed morphea or pansclerotic morphea. In 14 patients (82.4%) they were mainly localized at the lower limbs and in three (17.6%) at the upper limbs. No patient had laboratory inflammatory changes or positive autoantibodies. Skin biopsies confirmed the diagnosis of CTN: non-familial collagenoma in eleven (64.7%), mixed CTN in four (23.5%) and familial CTN in two (11.8%). Mean age at final diagnosis was 9.5 years, with a mean diagnostic delay of 4.8 years (range 1-15 years). Sixteen patients underwent musculoskeletal MRI that was normal in all except two who showed muscle perifascial enhancement. Thermography was normal in all patients. At our first evaluation, eleven patients (64.7%) were on systemic treatment (methotrexate 11, corticosteroids 7, biologics 2), three (17.6%) on topical corticosteroids and three untreated.

CONCLUSIONS

CTN can be misdiagnosed as JLS and therefore aggressively treated with prolonged and inappropriate immunosuppression. The absence of inflammatory appearance of the skin lesions, normal instrumental and laboratory findings and the accurate evaluation of skin biopsy are crucial to address the right diagnosis.

The Combination of Dupilumab with Other Monoclonal Antibodies

INTRODUCTION

Dupilumab is an interleukin-4 (IL-4) receptor alpha antagonist indicated for the treatment of moderate-to-severe atopic dermatitis (AD), which could be associated with atopic and non-atopic comorbidities for which concomitant administration of targeted pharmacotherapy including monoclonal antibodies could be required. However, the safety of combining dupilumab with other monoclonal antibodies for different therapeutic indication may be debated.

METHODS

We conducted an extensive search in MEDLINE via PubMed for original articles published from January 1, 2017 to October 22, 2022, reporting clinical cases in which dupilumab has been associated with other monoclonal antibodies.

RESULTS

Four small case series were identified reporting data on a total of 16 patients. To them, we have added other patients (n = 8) derived from our clinical practice, achieving a total of 24 cases followed for a period of 2-22 months. Patients were receiving dupilumab mainly because of AD (except one patient for bullous pemphigoid and one for asthma) and other monoclonal antibodies for psoriasis treated with guselkumab (n = 7) and secukinumab (n = 1), asthma with omalizumab or benralizumab (n = 3), Crohn's disease with adalimumab (n = 3), chronic spontaneous urticaria with omalizumab (n = 3), primary familial hypercholesterolemia with evolocumab (n = 2), hidradenitis suppurativa with adalimumab (n = 1), psoriatic arthritis with secukinumab (n = 1), rheumatoid arthritis with abatacept (n = 1), ankylosing spondylitis with secukinumab (n = 1) and colorectal carcinoma with cetuximab (n = 1). No adverse events related to the combination of the two monoclonal antibodies were reported except for a mild injection site reaction (n = 1) and arthralgia, which resolved spontaneously within a few weeks (n = 1).

CONCLUSIONS

Because the evidence is modest, the question remains open as to whether dupilumab can be safely combined with other monoclonal antibodies. Dupilumab does not exert immunosuppressive effects and does not impair the activity of cytochrome P450 isozymes.

Risk of non-alcoholic fatty liver disease in patients with chronic plaque psoriasis: an updated systematic review and meta-analysis of observational studies

PURPOSE

Chronic plaque psoriasis is associated with the presence of non-alcoholic fatty liver disease (NAFLD), but the magnitude of this association remains currently uncertain. We aimed to investigate the magnitude of the association between psoriasis and the risk of prevalent and incident NAFLD, and to assess whether psoriasis severity and/or psoriatic arthritis are associated with a greater risk of NAFLD.

METHODS

A systematic review and meta-analysis of observational studies evaluating the association between psoriasis and NAFLD, as diagnosed by imaging or International Classification of Diseases codes was performed. Literature search on PubMed, Scopus and Web of Science on May 3, 2021 was undertaken. Studies using liver biopsy were not available. For the meta-analysis, the random-effects modelling was adopted.

RESULTS

We identified 15 observational (case-control and cross-sectional) studies for a total of 249,933 patients with psoriasis (49% with NAFLD) and 1,491,402 controls (36% with NAFLD). Psoriasis was associated with prevalent NAFLD (n = 11 studies; pooled random-effects odds ratio [OR] 1.96, 95% CI 1.70-2.26; I² = 97%, p < 0.01). Psoriatic patients with NAFLD had a higher mean psoriasis area and severity index (PASI) than their counterparts without NAFLD (n = 8 studies, pooled weighted mean difference: 3.93, 95% CI 2.01-5.84; I² = 88%, p < 0.01). The risk of NAFLD was marginally higher in patients with psoriatic arthritis than in those with psoriasis alone (n = 5 studies, pooled random-effects OR 1.83, 95% CI 0.98-3.43; I² = 64%, p = 0.03). Sensitivity analyses did not alter these findings. Funnel plot did not show any significant publication bias. A major limitation of the study was the high degree of heterogeneity across studies.

CONCLUSION

Psoriasis is associated with prevalent NAFLD and this risk parallels the severity of psoriasis.

AB1365 PROPOSAL FOR A STANDARDIZED ULTRASOUND SCANNING PROTOCOL OF THE NAIL PLATE

Background

Ultrasonography of the nails with high frequency linear transducers can properly perform morphological images, achieving highly descriptive power but the lack of standardization may hesitate in lack of reproducibility and scarce usefulness.

Objectives

The aim of this study was to provide a detailed scan protocol of nail plate, including comparison of scan planes and probe positioning.

Methods

Transversal and longitudinal ultrasound scans were performed on each fingernail of both hands in healthy subjects. Nail plate thickness and Power Doppler of the nail bed were recorded. All the images were acquired using Canon Aplio i800 with a linear transducer of 22 MHz (i22LHB). Two different operators performed evaluation of thickness at distal, middle and proximal portion of nail in longitudinal view and at 0°, -45° and +45° for transverse view (Figure 1). ANOVA for repeated measures was used to determine differences between nail of the different digits.

Figure 1.

Longitudinal and transverse view of the nail. In yellow the position and angles of the caliper used for acquiring the measures

Results

The study sample was composed of 27 healthy subjects between 25- and 40- year old with no rheumatological or dermatological nail issues. A total of 270 nails were scanned; none of them was excluded due to comorbidity, trauma or other conditions which can interfere in the evaluation. A decrease in nail thickness was observed from first to fifth digit, regardless the hand (dominant or not), that resulted significant for the ANOVA. No differences were found regarding the thickness in the different segments of nail plate and this occurred both for longitudinal and transverse scans.

Conclusion

We demonstrated the absence of a statistically significant difference between thickness at proximal, middle and distal portion of the nail in longitudinal view or at any different angle in transverse view, concluding the fastest and easiest way to measure the nail plate thickness is in the longitudinal view at the middle segment, avoiding potential issues in positioning the probe in the transverse view or in positioning the caliper at proximal or distal segment in longitudinal view. All the nails should be scanned per protocol, since the thickness is variable and the fifth may be the most interesting in order to consider its highest variance.

References

[1]Fassio A. et al.; Clin Rheumatol. 2020 May;39(5):1391-1404. doi: 10.1007/s10067-019-04748-2. Epub 2019 Aug 22.

Table 1.

ANOVA for repeated measures of the nail plate thickness. A trend in decreasing P value is clearly visible from first to fifth. P considered statistically significant when ≤ 0.05

LONGITUDINALTRANSVERSEPROXIMAL-45°Row-mean1234Row-mean123421.00020.73130.7651.00030.2641.00040.0280.8881.00040.0000.0560.18750.0000.0010.0030.15850.0000.0050.0231.000MIDDLE0°Row-mean1234Row-mean123421.00020.71931.0001.00030.0561.00040.0701.0001.00040.0000.1581.00050.0000.0010.0020.09550.0000.0250.3891.000DISTAL+45°Row-mean1234Row-mean123421.00021.00030.8541.00030.7651.00040.0060.0930.75440.0500.5831.00050.0000.0000.0000.11450.0000.0010.0160.323

Disclosure of Interests

None declared

POS1409 ASSOCIATION BETWEEN SHORT-TERM EXPOSURE TO ENVIRONMENTAL AIR POLLUTION AND PSORIASIS FLARE

Background

Psoriasis is a chronic inflammatory disease with a relapsing-remitting course. Selected environmental factors such as infections, stressful life events or drugs may trigger disease flares. Whether the air pollution could trigger psoriasis flares is still unknown.

Objectives

To investigate whether the short-term exposure to environmental air pollution is associated to psoriasis flares.

Methods

Observational study with both case-crossover and cross-sectional design was conducted. We retrospectively analyzed longitudinal data from 2013 to 2020 of patients with psoriasis attending the outpatient dermatologic clinic of the University Hospital of Verona. For the case-cross over analysis patients with at least one disease flare, defined as PASI increase ≥5 between 2 consecutive assessments in a time frame of 3-4 months, were considered. In the case-crossover analysis each patient serves as its own control; the exposure of interest is compared in two different periods in the same group of patients followed longitudinally (Figure 1). For the cross-sectional analysis, patients receiving any systemic treatment for ≥6 months, with ≥2 consecutive PASI assessment were included. We compared the mean and cumulative (area under the curve) concentrations of several air pollutants (CO, NO2, NOx, C6H6, PM10 and PM2.5) in the 60 days preceding the psoriasis flare and the control visits.

Results

A total of 957 patients with plaque psoriasis with 4,398 follow-up visits were included in the study. More than 15,000 measurements of air pollutants concentration from the official, open-source, bulletin of the Italian Institute for Environmental Protection and Research (ISPRA) were retrieved. Among the overall cohort, 369 (38.6%) patients with psoriasis flare were included in the case-crossover study. We found that concentrations of all pollutants were significantly higher in the 60 days before psoriasis flare (median PASI at the flare 12, IQR 9-18), compared to the control visit (median PASI 1, IQR 1-3, p <0.0001). In the cross-sectional analysis, exposure to mean PM10 over 20 μg/m3 and mean PM2.5 over 15 μg/m3 in the 60 days before assessment were associated with a higher risk of PASI ≥5 point worsening, aOR 1.55, 95% CI 1.21-1.99 and aOR 1.25, 95% CI 1.0-1.57, respectively (Figure 1). Sensitivity analyses that stratified for trimester of evaluation, with various lag of exposure and adjusting for type of treatment yielded similar results.

Conclusion

Air pollution may be a trigger factor for psoriasis flare.

Disclosure of Interests

Giovanni Adami Speakers bureau: Galapagos, Theramex, Francesco Bellinato: None declared, Angelo Fassio: None declared, Camilla Benini: None declared, Giampiero Girolomoni Shareholder of: AbbVie, Abiogen, Almirall, Amgen, Biogen, Bristol-Meyers Squibb, Eli-Lilly, Galderma, Genzyme, Leo Pharma, Pfizer, Regeneron, Samsung and Sanofi, Paolo Gisondi Shareholder of: Abbvie, Almirall, Amgen, Biogen, Eli Lilly, Jansenn, Novartis, Sanofi, UCB, Maurizio Rossini Shareholder of: Abbvie, Amgen, Bms, Eli Lilly, Galapagos, Novartis, Pfizer, Sandoz, Theramex, Ucb

In vitro cell culture of amniotic fluid keratinocytes on amniotic membrane: the ideal tissue for repairing skin ulcers

OBJECTIVE

The amniotic fluid contains a large population of stem keratinocytes demonstrating minimal immunological rejection. Recent evidence suggests that stem cells from the amniotic fluid can be employed in the field of tissue engineering. In this work we identified precursors of the epithelial cells and expanded them in vitro.

MATERIALS AND METHODS

After collecting samples of amniotic fluid and separating the cells via centrifugation, we seeded a portion of these cells in selection media to analyze the proliferation of epithelial cells. The stem cells precursors of keratinocytes were identified through specific markers. The expression of these markers was evaluated by immunofluorescence and reverse transcription polymerase chain reaction (PCR).

RESULTS

The stem cells demonstrated 90% confluence, after undergoing proliferation in the selection medium for 15 days. Most of these cells tested positive for the keratinocyte-specific markers, but negative for stem cell specific markers. Of note, the identity of the keratinocytes was well established even after several subcultures.

CONCLUSIONS

These results suggested that it is feasible to isolate and expand differentiated cell populations in the amniotic fluid from precursor cells. Furthermore, amniotic membranes can be utilized as scaffolds to grow keratinocytes, which can be potentially exploited in areas of skin ulcer transplantation and tissue engineering interventions.

Acquired perforating dermatoses show increased levels of cutaneous advanced glycation end-products

BACKGROUND

Acquired perforating dermatoses (APDs) are characterized by transepidermal elimination of skin materials. Altered glycation of dermal components may be involved in pathogenesis.

AIM

To assess whether patients affected by APDs have increased levels of cutaneous advanced glycation end-products (AGEs).

METHODS

A cross-sectional controlled study involving a total of 109 patients was conducted, enrolling 29 patients consecutively diagnosed with primary APDs [reactive perforating collagenosis (RPC), elastosis perforans serpiginosa (EPS), perforating folliculitis (PF) and Kyrle disease (KD)], 40 age- and sex-matched healthy controls (HCs) and 40 patients with mild atopic dermatitis (AD). The levels of cutaneous AGEs were measured using a validated fluorescence technique.

RESULTS

The median skin autofluorescence value in patients with APDs was significantly higher [2.7 arbitrary units (AU), interquartile range (IQR) 1.9-3.9 AU] compared with HCs (1.8 AU, IQR 1.6-2.3 AU; P < 0.001) and patients with AD (2.1 AU, IQR 1.9-2.3 AU; P = 0.01). Median values were 3.5 AU (IQR 2.7-4.6 AU) for RPC, 1.83.5 AU (1.4-2.4 AU) for EPS, 3.1 AU (2.4-4.4 AU) for PF and 2.6 AU (2.3-3.1 AU) for KD.

CONCLUSIONS

Our results may suggest a possible physiopathological role of AGEs in the transepidermal elimination mechanisms involved in certain APDs.

Risk-mitigating behaviours in people with inflammatory skin and joint disease during the COVID-19 pandemic differ by treatment type: a cross-sectional patient survey

BACKGROUND

Registry data suggest that people with immune-mediated inflammatory diseases (IMIDs) receiving targeted systemic therapies have fewer adverse coronavirus disease 2019 (COVID-19) outcomes compared with patients receiving no systemic treatments.

OBJECTIVES

We used international patient survey data to explore the hypothesis that greater risk-mitigating behaviour in those receiving targeted therapies may account, at least in part, for this observation.

METHODS

Online surveys were completed by individuals with psoriasis (globally) or rheumatic and musculoskeletal diseases (RMDs) (UK only) between 4 May and 7 September 2020. We used multiple logistic regression to assess the association between treatment type and risk-mitigating behaviour, adjusting for clinical and demographic characteristics. We characterized international variation in a mixed-effects model.

RESULTS

Of 3720 participants (2869 psoriasis, 851 RMDs) from 74 countries, 2262 (60·8%) reported the most stringent risk-mitigating behaviour (classified here under the umbrella term 'shielding'). A greater proportion of those receiving targeted therapies (biologics and Janus Kinase inhibitors) reported shielding compared with those receiving no systemic therapy [adjusted odds ratio (OR) 1·63, 95% confidence interval (CI) 1·35-1·97]. The association between targeted therapy and shielding was preserved when standard systemic therapy was used as the reference group (OR 1·39, 95% CI 1·23-1·56). Shielding was associated with established risk factors for severe COVID-19 [male sex (OR 1·14, 95% CI 1·05-1·24), obesity (OR 1·37, 95% CI 1·23-1·54), comorbidity burden (OR 1·43, 95% CI 1·15-1·78)], a primary indication of RMDs (OR 1·37, 95% CI 1·27-1·48) and a positive anxiety or depression screen (OR 1·57, 95% CI 1·36-1·80). Modest differences in the proportion shielding were observed across nations.

CONCLUSIONS

Greater risk-mitigating behaviour among people with IMIDs receiving targeted therapies may contribute to the reported lower risk of adverse COVID-19 outcomes. The behaviour variation across treatment groups, IMIDs and nations reinforces the need for clear evidence-based patient communication on risk-mitigation strategies and may help inform updated public health guidelines as the pandemic continues.

Position statement for a pragmatic approach to immunotherapeutics in patients with inflammatory skin diseases during the coronavirus disease 2019 pandemic and beyond

Coronavirus disease 2019 (COVID-19) is caused by SARS-CoV-2, a novel RNA virus that was declared a global pandemic on 11 March 2020. The efficiency of infection with SARS-CoV-2 is reflected by its rapid global spread. The SARS-CoV-2 pandemic has implications for patients with inflammatory skin diseases on systemic immunotherapy who may be at increased risk of infection or more severe infection. This position paper is a focused examination of current evidence considering the mechanisms of action of immunotherapeutic drugs in relation to immune response to SARS-CoV-2. We aim to provide practical guidance for dermatologists managing patients with inflammatory skin conditions on systemic therapies during the current pandemic and beyond. Considering the limited and rapidly evolving evidence, mechanisms of action of therapies, and current knowledge of SARS-CoV-2 infection, we propose that systemic immunotherapy can be continued, with special considerations for at risk patients or those presenting with symptoms.

Brodalumab for the treatment of moderate-to-severe plaque-type psoriasis: a real-life, retrospective 24-week experience

BACKGROUND

Brodalumab was efficacious and safe in moderate-to-severe plaque-type psoriasis in the AMAGINE trials; published reports under real-life conditions are limited.

OBJECTIVES

To evaluate the effectiveness and safety of brodalumab in patients with moderate-to-severe plaque-type psoriasis in a real-world setting.

METHODS

This observational, retrospective study enrolled adult patients (≥18 years) with moderate-to-severe plaque-type psoriasis who underwent 24 weeks of treatment with brodalumab at 17 Italian dermatological centres. Baseline data included demographics, comorbidities, age of onset and duration of psoriasis and previous treatments. Psoriasis Area and Severity Index (PASI), Physician Global Assessment (PGA), static PGA of Genitalia, Dermatology Life Quality Index and patient satisfaction were assessed at weeks 0, 4, 12 and 24; adverse events were recorded.

RESULTS

Seventy-eight patients (mean age 47.9 years, 71.8% male, average disease duration 16.8 years) were enrolled. A rapid and significant reduction in mean PASI score was observed after 4 weeks of treatment, decreasing further at weeks 12 and 24 (all P < 0.0001 vs. baseline). A higher number of cardiometabolic comorbidities and previous therapies were negatively associated with the achievement of PASI 90 at all assessments. Brodalumab was effective in bio-experienced patients, including those who had failed on anti-interleukin (IL)-17 therapies. Quality of life and patient satisfaction increased significantly during treatment (P < 0.0001 and P < 0.01 vs. baseline, respectively). Treatment was interrupted in 9 (11.5%) patients due to adverse events (n = 4), lack of efficacy (n = 3), lost to follow-up (n = 1) and surgical procedure (n = 1).

CONCLUSIONS

Brodalumab is effective and safe in the treatment of moderate-to-severe psoriasis in a real-world setting, including in patients with failure to anti-IL17 therapies.

Cutaneous manifestations of SARS-CoV-2 infection: a clinical update

On 11 March 2020, the World Health Organization (WHO) has declared the novel coronavirus disease (COVID‐19) a global pandemic, caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2 virus). A consistent number of case reports and clinical series have been already published describing a complex spectrum of skin manifestations associated with the SARS‐CoV‐2 infection. We carried out a review of the English‐language literature up to 20 May 2020, reporting original cases or case series of the cutaneous manifestations of SARS‐CoV‐2 virus infection. The following databases were consulted: PubMed, Embase, Google Scholar and ResearchGate. The search of papers was conducted by using the key term ‘COVID‐19’ or ‘SARS‐CoV‐2’ or ‘coronavirus’ combined with each of the following: ‘skin’, ‘cutaneous’, ‘dermatologic’ or ‘dermatology’, ‘manifestation’, ‘lesions’, or ‘rash’. The patterns of dermatological manifestations associated with SARS‐CoV‐2 infection could be classified into four categories: exanthema (varicella‐like, papulo‐vesicular and morbilliform rash), vascular (chilblain‐like, purpuric/petechial and livedoid lesions), urticarial and acro‐papular eruption. Lastly, other skin manifestations to be considered are the cutaneous adverse reactions to the drugs prescribed for the treatment of COVID‐19. Whether SARS‐CoV‐2 infection can directly cause a worsening of chronic inflammatory diseases such as psoriasis or atopic dermatitis remains to be determined. Dermatology's outlook in the COVID‐19 pandemic is multidimensional.

Dermatologists and SARS-CoV-2: the impact of the pandemic on daily practice

Since the first case of 'pneumonia of unknown aetiology' was diagnosed at the Wuhan Jinyintan Hospital in China on 30 December 2019, what was recognized thereafter as 'severe acute respiratory syndrome coronavirus 2' (SARS-CoV-2) has spread over the four continents, causing the respiratory manifestations of coronavirus disease-19 (COVID-19) and satisfying the epidemiological criteria for a label of 'pandemic'. The ongoing SARS-CoV-2 pandemic is having a huge impact on dermatological practice including the marked reduction of face-to-face consultations in favour of teledermatology, the uncertainties concerning the outcome of COVID-19 infection in patients with common inflammatory disorders such as psoriasis or atopic dermatitis receiving immunosuppressive/immunomodulating systemic therapies; the direct involvement of dermatologists in COVID-19 care for patient assistance and new research needs to be addressed. It is not known yet if skin lesions and derangement of the skin barrier could make it easier for SARS-CoV-2 to transmit via indirect contact; it remains to be defined if specific mucosal or skin lesions are associated with SARS-CoV-2 infection, although some unpublished observations indicate the occurrence of a transient varicelliform exanthema during the early phase of the infection. SARS-CoV-2 is a new pathogen for humans that is highly contagious, can spread quickly, and is capable of causing enormous health, economic and societal impacts in any setting. The consequences may continue long after the pandemic resolves, and new management modalities for dermatology may originate from the COVID-19 disaster. Learning from experience may help to cope with future major societal changes.

SAT0412 ACCURACY OF AN INSTRUMENT FOR SCREENING PSORIATIC ARTHRITIS AMONG PSORIATIC PATIENTS: RESULTS FROM THE MULTICENTRE ITALIAN STUDY HERACLES (SCREENING STRATEGIES FOR RHEUMATOLOGICAL REFERRAL OF PSORIATIC SUBJECTS AIMED TO DISCLOSE PSORIATIC ARTHRITIS)

Background:

Identifying psoriatic arthritis (PsA) among people with psoriasis is often challenging due to low specificity of symptoms at early PsA stage and/or delayed referral to the rheumatologist. Screening instruments -assisting the dermatologist to decide when rheumatological assessment is beneficial- have potential to reduce the diagnostic delay.

Objectives:

To evaluate the accuracy of a dermatologist-filled-out questionnaire designed for screening PsA among psoriatic patients under dermatology care.

Methods:

HERACLES is a multicentre, cross-sectional study running at 9 Italian dermatology and rheumatology tertiary centres. All participants were under dermatology care for skin psoriasis. Previous diagnosis of PsA precluded eligibility. Dermatologists at each site assessed consecutive psoriatic subjects, filled in the specifically-designed HERACLES questionnaire (HQ, Figure 1) and finally referred the participants to rheumatologists for clinical evaluation. All participants filled in the ToPAS, PASE, PEST and EARP questionnaires. Rheumatologists assessed the participants regardless of the questionnaires’ scores. The gold standard applied to assess the instruments’ accuracy was the diagnosis of PsA as established by the rheumatologists. ROC curve analysis evaluated the performance of the scores associated with the clinical criteria listed in the HQ, estimating the sensitivity and specificity of different cut-off levels. Further exploratory ROC curve analysis compared HQ performance to that of the other four questionnaires tested.

Figure 1.

Results:

Out of 759 subjects enrolled, 524 (69%) attended rheumatology assessment. Rheumatologists diagnosed PsA in 73/524 patients (13.9%, Figure 2). Mean age was 53 (SD 16) years and 46% were female. Mean psoriasis duration was 20 (SD 19) years. The area under the ROC curve of HQ was 0.775. The HQ score cut-off value of 2 yielded a sensitivity of 92% and a specificity of 47%; a cut-off value of 3 yielded a sensitivity of 66% and a specificity of 75%. The comparison between the ROC curve of the HQ and those of the other four questionnaires evaluated did not show any significant difference (p=0.523 versus TOPAS; p=0.201 versus PASE; p=0.345 versus PEST and p=0.240 versus EARP).

Figure 2.

Conclusion:

The HERACLES questionnaire, a tool designed for dermatologists, showed good sensitivity and specificity in identifying PsA cases among subjects with cutaneous psoriasis.

Acknowledgments:

The HERACLES project was supported by a research grant from FIRA and Pfizer Italia SRL

Disclosure of Interests:

Gabriele De Marco: None declared, Maria Manara Consultant of: Consultant and/or speaker for Eli-Lilly, MSD, Sanofi-Genzyme, Novartis, Alfa Wasserman and Cellgene, Speakers bureau: Consultant and/or speaker for Eli-Lilly, MSD, Sanofi-Genzyme, Novartis, Alfa Wasserman and Cellgene, Paolo Gisondi: None declared, Luca Idolazzi: None declared, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly, Stefano Piaserico: None declared, Alberto Cauli: None declared, Marco Amedeo Cimmino: None declared, Veronica Tomatis: None declared, Carlo Salvarani: None declared, Rosanna Scrivo: None declared, Anna Zanetti: None declared, Greta Carrara: None declared, Carlo Alberto Scirè: None declared, Angelo Cattaneo: None declared, Antonio Marchesoni Speakers bureau: Abbvie, Pfizer, UCB, Novartis, Celgene, Eli Lilly

Evidence for a 'window of opportunity' in hidradenitis suppurativa treated with adalimumab: a retrospective, real-life multicentre cohort study

BACKGROUND

The anti-tumour necrosis factor (TNF)-α adalimumab is the only licenced biologic for moderate-to-severe hidradenitis suppurativa (HS). No predictors of response have been identified so far.

OBJECTIVES

To identify clinical parameters predicting response to adalimumab and confirm its efficacy/safety.

METHODS

The data of 389 patients with HS treated with adalimumab in 21 Italian centres were reviewed. Sex, age at onset/diagnosis/baseline, body mass index, smoking, phenotype, previous treatments, concomitant antibiotics and 'therapeutic delay', defined as the time from HS onset to adalimumab initiation, were assessed. Response to adalimumab and its impact on quality of life (QoL) were evaluated using the Hidradenitis Suppurativa Clinical Response (HiSCR) and the Dermatology Life Quality Index (DLQI) or the Visual Analogue Scale for pain (VAS pain), respectively. Logistic regression analysis was performed.

RESULTS

The therapeutic delay correlated to lack of response to adalimumab at week 16 [odds ratio (OR) 1·92 for therapeutic delay > 10 years; 95% confidence interval (CI) 1·28-2·89; P = 0·0016). HiSCR was achieved in 43·7% and 53·9% patients at week 16 and 52, respectively. Significant reductions in both DLQI and VAS pain were found between week 16 vs. baseline (P < 0·0001 for both) and week 52 vs. baseline (P < 0·0001 for both). Previous immunosuppressants inversely correlated to HiSCR at week 52 (OR = 1·74, 95% CI 1·04-2·91, P = 0·0342).

CONCLUSIONS

Inverse correlation between therapeutic delay and clinical response was found, supporting early adalimumab use and providing evidence for a 'window of opportunity' in HS treatment. Adalimumab efficacy and safety were confirmed, along with patients' QoL improvement. Immunosuppressants could negatively influence the response to adalimumab inducing a switch to non-TNF-α-driven pathways.

The role of the interleukin-23/Th17 pathway in cardiometabolic comorbidity associated with psoriasis

Alterations in the innate and adaptive immunity underpin psoriasis pathophysiology, with the Th17 cells subset now recognized as the fundamental cells in the key controlling pathway involved in its pathogenesis. Since psoriasis is a systemic disease with important comorbidity, further knowledge on the interleukin (IL)‐23/Th17 axis led to the hypothesis that there may be shared pathogenic pathways between primary skin disease and comorbidity. Psoriasis has been identified as a risk factor for cardiovascular and metabolic disease, and increasing evidence gives support to this epidemiological observation from the clinical‐pathologically field. As an example, increased levels of IL‐23 and IL‐23R have been found in human atherosclerotic plaque, and levels correlated with symptom duration and mortality. Also, upregulation of IL‐23/IL‐17 seems to play an important role in both myocardial damage and stroke, with interesting reports on deleterious effect neutralization after administration of related anti‐bodies in both associated conditions. In diabetic patients, increased levels of IL‐23/IL‐17 have also been observed and available data support a synergistic role of IL‐23/IL‐17 in β‐cells damage. In obesity, signs of an expansion of Th17 subset in adipose tissue have been reported, as well as elevated concentrations of IL‐23 in obese patients. In non‐alcoholic fatty liver disease, closely related to metabolic syndrome, but also in other mentioned cardiometabolic disorders, a predominance of IL‐23 and other related pro‐inflammatory factors has been identified as participating in their pathogenesis. Thus, the involvement of the IL‐23/Th17 axis in these shared psoriasis‐cardiometabolic pathogenic mechanisms is reviewed and discussed in the light of the existing preclinical and clinical evidence, including that from comorbid psoriasis patients.

Efficacy of secukinumab without the initial weekly loading dose in patients with chronic plaque psoriasis

BACKGROUND

Secukinumab is administered at the labelled dose of 300 mg at weeks 0, 1, 2, 3, 4 (loading dose) and every 4 weeks thereafter.

OBJECTIVES

To investigate the efficacy of secukinumab administered without the initial loading dose in patients with psoriasis.

METHODS

This was a retrospective observational study including adult patients with psoriasis (n = 156) treated with secukinumab 300 mg administered either according to the labelled dose (n = 75) or without the initial loading dose (n = 81). Efficacy was evaluated by comparing the Psoriasis Area and Severity Index (PASI) 75 and PASI 90 response rates at week 8, 12, 16, 32 and 48.

RESULTS

For patients who received the labelled dose vs. those who did not, PASI 75 response rates were achieved at week 8, 12, 16, 32 and 48 by 60% vs. 40% (P < 0·01), 72% vs. 61% (P < 0·01), 77% vs. 75%, 85% vs. 77% and 79% vs. 78%, respectively. PASI 90 responses were achieved at the same time points by 45% vs. 31% (P < 0·01), 49% vs. 40% (P < 0·01), 54% vs. 47%, 55% vs. 47% and 57% vs. 54% for those who received the labelled dose vs. those who did not, respectively. A greater proportion of patients receiving secukinumab without the loading dose discontinued treatment because of inefficacy (25% vs. 13%, P < 0·05), particularly those with body weight greater than 80 kg.

CONCLUSIONS

Secukinumab administered without the loading dose is associated with a higher proportion of primary inefficacy, and achieved inferior results compared with the labelled dose at week 8 and week 12, but showed similar efficacy thereafter. What's already known about this topic? Secukinumab is an interleukin (IL)-17A inhibitor for chronic plaque psoriasis administered by subcutaneous injections at the labelled dose of 300 mg at weeks 0, 1, 2, 3, 4 (loading dose) and every 4 weeks thereafter (maintenance dose). Dose adjustment is common in clinical practice, and can consist of dose reduction when a prolonged remission is obtained or a dose increase in order to improve efficacy. What does this study add? The efficacy of secukinumab administered without the initial weekly loading dose was significantly inferior compared with the labelled dose in the short term, but was similar after week 16 and up to week 48. A greater proportion of patients receiving secukinumab without the loading dose showed primary inefficacy, particularly those with body weight greater than 80 kg.

Serum IFI16 and anti-IFI16 antibodies in psoriatic arthritis

Nuclear interferon-inducible protein 16 (IFI16) and anti-IFI16 antibodies have been detected in subjects with several rheumatic diseases, often correlating with disease severity, and in this study we investigated their prevalence and clinical associations in psoriatic arthritis (PsA) compared to psoriasis (Pso). We tested sera and synovial fluids of patients with PsA for IFI16 protein levels by capture enzyme-linked immunosorbent assay (ELISA) and for anti-IFI16 immunoglobulin (Ig)G and IgA by ELISA, protein radio-immunoprecipitation and immunoprecipitation-Western blot of IgG. Sera from patients with Pso and healthy subjects were used as controls, and in a subgroup of patients with PsA we also studied sera after treatment with etanercept. IFI16 was detectable in the sera of 66% of patients with Pso, 46% with PsA and 19% of controls. Among PsA cases, 51% of IFI16-positive cases had elevated levels of C-reactive protein (CRP) compared to 31% of patients with undetectable IFI16. Anti-IFI16 of both IgG and IgA isoforms were detected with significantly higher frequency in PsA and Pso compared to healthy controls, with higher IgG titres in patients with elevated C-reactive protein (CRP) (P = 0·015). Immunoprecipitation confirmed the presence of anti-IFI16 IgG antibodies and these preferentially recognized epitopes outside the N-terminus of the protein. Lastly, IFI16 was detected in one of seven and anti-IFI16 in three of seven synovial fluids from patients with PsA. Therefore, IFI16 and anti-IFI16 are detectable in serum and synovial fluid of PsA patients, especially in cases of elevated CRP.