Whole field laser Doppler imaging of the microcirculation in psoriasis and clinically unaffected skin

BACKGROUND

Angiogenesis represents a key phenomenon in psoriasis. Insights in the microcirculation within psoriatic lesions in a whole field are lacking. Recently, the Twente Optical Perfusion Camera (TOPCam) was developed, which provides the possibility of evaluating the superficial cutaneous microcirculation in a whole field.

OBJECTIVES

This pilot study aims to examine whether the TOPCam can be used to visualize the microcirculation within and around psoriatic lesions, and whether it is capable of revealing vascular changes during topical treatment.

METHODS

Five patients with chronic plaque psoriasis were included. The superficial microcirculation and clinical local scores (SUM score) were analyzed in two comparable lesions within one patient. At baseline and after 2, 4, 6, and 8 weeks the disease's natural course was evaluated in one plaque versus topical treatment in the other.

RESULTS

The TOPCam was able to visualize an increased microcirculation within psoriatic lesions and perfusion variability due to the heartbeat. Whole field images demonstrated heterogeneity in perfusion intensity (hot and cold spots) within clinically homogeneous-looking plaques. Topical therapy induced a decrease in overall perfusion and a significant decrease in SUM score.

CONCLUSION

The TOPCam is the first noninvasive technique to visualize the microcirculation of psoriatic lesions in a whole field, to correct images for the heartbeat, and to reveal heterogeneity in perfusion intensity.

Effectiveness of adalimumab dose escalation, combination therapy of adalimumab with methotrexate, or both in patients with psoriasis in daily practice

BACKGROUND

To increase effectiveness of standard adalimumab treatment 40 mg every other week (EOW) for patients with psoriasis, dose escalation to 40 mg every week or addition of methotrexate (MTX) are possible strategies.

METHODS

Daily practice data about adalimumab treatment were extracted from a prospective observational cohort. We analyzed all patients with insufficient efficacy of adalimumab EOW who received 1) adalimumab dose escalation, 2) addition of MTX to adalimumab EOW, or 3) both. Effectiveness was analyzed after 12 and 24 weeks using PASI50, PASI75, and mean differences in PASI.

RESULTS

Forty-seven treatment episodes (TE) of adalimumab dose escalations, 11 of MTX addition and six combinations were analyzed. After a first episode of adalimumab dose escalation, 25% and 35% achieved PASI50 after 12 and 24 weeks, respectively. After MTX introduction to adalimumab EOW, 9% and 18% achieved PASI50 after 12 and 24 weeks, respectively. No related serious adverse events were reported.

CONCLUSIONS

Twenty-five percent of first TE with adalimumab dose escalation induced a PASI50 response after 12 weeks and 35% after 24 weeks. Addition of MTX to adalimumab EOW resulted in PASI50 in 9% after 12 weeks and 18% after 24 weeks. Defining patient-groups that will benefit from these interventions is important.

Humanized mouse model of skin inflammation is characterized by disturbed keratinocyte differentiation and influx of IL-17A producing T cells

Humanized mouse models offer a challenging possibility to study human cell function in vivo. In the huPBL-SCID-huSkin allograft model human skin is transplanted onto immunodeficient mice and allowed to heal. Thereafter allogeneic human peripheral blood mononuclear cells are infused intra peritoneally to induce T cell mediated inflammation and microvessel destruction of the human skin. This model has great potential for in vivo study of human immune cells in (skin) inflammatory processes and for preclinical screening of systemically administered immunomodulating agents. Here we studied the inflammatory skin response of human keratinocytes and human T cells and the concomitant systemic human T cell response.

As new findings in the inflamed human skin of the huPBL-SCID-huSkin model we here identified: 1. Parameters of dermal pathology that enable precise quantification of the local skin inflammatory response exemplified by acanthosis, increased expression of human β-defensin-2, Elafin, K16, Ki67 and reduced expression of K10 by microscopy and immunohistochemistry. 2. Induction of human cytokines and chemokines using quantitative real-time PCR. 3. Influx of inflammation associated IL-17A-producing human CD4+ and CD8+ T cells as well as immunoregulatory CD4+Foxp3+ cells using immunohistochemistry and -fluorescence, suggesting that active immune regulation is taking place locally in the inflamed skin. 4. Systemic responses that revealed activated and proliferating human CD4+ and CD8+ T cells that acquired homing marker expression of CD62L and CLA. Finally, we demonstrated the value of the newly identified parameters by showing significant changes upon systemic treatment with the T cell inhibitory agents cyclosporine-A and rapamycin.

In summary, here we equipped the huPBL-SCID-huSkin humanized mouse model with relevant tools not only to quantify the inflammatory dermal response, but also to monitor the peripheral immune status. This combined approach will gain our understanding of the dermal immunopathology in humans and benefit the development of novel therapeutics for controlling inflammatory skin diseases.

Induction of nocebo and placebo effects on itch and pain by verbal suggestions

Physical complaints, such as pain, can be effectively reduced by placebo effects through induction of positive expectations, or increased by nocebo effects through induction of negative expectations. In the present study, verbally induced nocebo and placebo effects on itch were experimentally investigated for the first time. In part 1, the role of verbal suggestions in inducing nocebo effects on itch and pain was investigated. All subjects received the same somatosensory quantitative sensory testing stimuli, that is, mechanical and electrical stimuli and application of histamine, and verbal suggestions to manipulate expectations regarding the stimuli. The suggestions were designed to produce either high expectations for itch (itch nocebo) or pain (pain nocebo) or low expectations for itch (itch nocebo control) or pain (pain nocebo control). Results showed that high itch and pain expectations resulted in higher levels of itch and pain, respectively. When comparing nocebo effects, induced by verbal suggestions, results were more pronounced for itch than for pain. In part 2, verbal suggestions designed to produce a placebo effect on itch (itch placebo) or pain (pain placebo), or neutral suggestions (itch placebo control and pain placebo control) were given regarding a second application of histamine and compared with the first application applied in part 1. Results of placebo effects only showed a significantly larger decrease in itch in the itch placebo condition than in the pain placebo condition. In conclusion, we showed for the first time that nocebo and possibly placebo responses can be induced on itch by verbal suggestions.

Genital psoriasis: A systematic literature review on this hidden skin disease

It is well known that the genital skin may be affected by psoriasis. However, little is known about the prevalence and clinical appearance of genital psoriasis, and genital skin is often neglected in the treatment of psoriatic patients. We performed an extensive systematic literature search for evidence-based data on genital psoriasis with respect to epidemiology, aetiology, clinical and histopathological presentation, diagnosis and treatment. Three bibliographical databases (PubMed, EMBASE and the Cochrane Library) were used as data sources. Fifty-nine articles on genital psoriasis were included. The results show that psoriasis frequently affects the genital skin, but that evidence-based data with respect to the efficacy and safety of treatments for genital psoriasis are extremely limited. An advised treatment paradigm for genital psoriasis, based on the levels of evidence, is: first-line: (weak) topical corticosteroids; second-line: vitamin D preparations or tar-based treatments.

The clinical efficacy of topical methyl-aminolevulinate photodynamic therapy in moderate to severe actinic keratoses of the face and scalp

INTRODUCTION

Since actinic keratoses (AKs) often appear in areas with field cancerization, photodynamic therapy (PDT) may have significant advantages over the standard treatment options.

OBJECTIVES

Clinical efficacy of PDT with topical methyl aminolevulinate (MAL-PDT) in field cancerization was evaluated with respect to the number of AKs and photodamage.

METHODS

A total of 14 patients with 223 AKs on the face or scalp were treated with MAL-PDT. Two treatments with a 3-monthly interval were given. At baseline, before the second treatment and 3 months after the end of therapy, the number of AKs were counted and photodamage was assessed with respect to skin roughness, hyperpigmentation, hypopigmentation, scarring, atrophy, telangiectasia and wrinkling.

RESULTS

Complete clearance was reached in patients with a moderate degree of actinic damage, whereas a severe degree of field cancerization demonstrated only partial clearance. The global score for photodamage improved significantly. After the follow-up period, none of the patients reaching clearance had developed relapsing or new AKs.

CONCLUSIONS

MAL-PDT induces a high clearance rate of AKs, dependent on the degree of field cancerization, with a good improvement in photodamage and prevention of developing new AKs. Thus, more PDT sessions are needed in patients with a severe degree of field cancerization.

Dimethylfumarate for psoriasis: Pronounced effects on lesional T-cell subsets, epidermal proliferation and differentiation, but not on natural killer T cells in immunohistochemical study

BACKGROUND

T-cell infiltration, epidermal hyperproliferation, and disturbed keratinization are pathologic hallmarks of plaque psoriasis. Oral fumaric acid esters are an effective therapy for psoriasis and are believed to exert their effects mainly through their anti-inflammatory properties.

OBJECTIVE

To investigate the differential effects of dimethylfumarate (BG-12; FAG-201) for psoriasis on lesional T-cell subsets, natural killer (NK) T cells, and keratinocyte hyperproliferation and differentiation.

STUDY DESIGN

A before-and-after clinical and immunohistochemical study as part of a larger clinical trial.

SETTING

Single outpatient clinic.

PATIENTS

Six patients with moderate-to-severe psoriasis.

INTERVENTION

Dimethylfumarate 720 mg daily for 16 weeks.

METHODS

Biopsies were taken from the lesional skin of six psoriatic patients, at baseline and after 16 weeks of treatment with dimethylfumarate. Clinical severity scores were obtained (Psoriasis Area Severity Index [PASI] and psoriasis severity SUM scores). T-cell subsets (CD4+, CD8+, CD45RO+, CD45RA+, CD2+, CD25+), cells expressing NK receptors (CD94, CD161), an epidermal proliferation marker (Ki67), and a keratinization marker (K10) were immunohistochemically stained and, together with 'epidermal thickness,' quantified using image analysis.

RESULTS

At week 16, the mean PASI and SUM scores were reduced by 55% (p < 0.01) and 49% (p < 0.01), respectively. In line with these results, epidermal hyperproliferation, keratinocyte differentiation, and epidermal thickness significantly improved. In the dermis and the epidermis, the relevant T-cell subsets significantly declined. However, in both the lesional psoriatic dermis and epidermis, cells expressing NK receptors (CD94 and CD161) persisted after 16 weeks of treatment.

CONCLUSIONS

Dimethylfumarate is an effective therapy for moderate-to-severe plaque psoriasis. The drug may act by reducing lesional T-cell subsets and normalizing epidermal hyperproliferation and keratinization, but does not reduce NKT cells.

Pustulosis palmoplantaris is a disease distinct from psoriasis

Pustulosis palmoplantaris (PPP) is a chronic inflammatory skin disease with a considerable impairment of quality of life and is characterized by sterile pustules and red, scaly skin on the palms and soles. The position of PPP in relation to psoriasis is unclear. Some authors regard PPP as a distinct disease entity, whereas others categorize PPP as a manifestation of psoriasis. Related to this discussion is the question on the treatment of PPP. Should the treatment of PPP follow the guidelines for psoriasis or is it a disease that has to be treated in a different way? The purpose of this editorial is to review the differences between PPP and psoriasis and to understand these differences with respect to the pathogenesis and treatment.

Heterotopic pruritic conditioning and itch--analogous to DNIC in pain?

Pain can be endogenously modulated by heterotopic noxious conditioning stimulation (HNCS) through a mechanism which is known as diffuse noxious inhibitory control (DNIC). Since DNIC can be impaired in patients suffering from chronic pain, a comparable impaired itch inhibition may exist in patients suffering from chronic itch. The aim of the present study was to investigate whether heterotopic pruritic conditioning stimulation (HPCS) would display an impaired modulation of itch in patients suffering from chronic itch compared with healthy subjects. To this end, electrical stimuli were applied before and after histamine application (HPCS) to female patients with psoriasis and healthy female control subjects. Subjects reported the intensity of electrically evoked itch before and after HPCS. In order to replicate earlier findings for DNIC, electrically evoked pain was additionally investigated before and after cold stimulation (HNCS). As expected, the intensity of itch evoked by the electrical stimulus was significantly less after than before HPCS in healthy subjects, and the same was found for the intensity of electrically evoked pain after compared to before HNCS. Contrarily, in the patients levels of electrically evoked itch were significantly higher after than before HPCS, and no significant difference in pain intensity before and after HNCS was observed. In line with pain modulation, results suggest that there is a DNIC analogous mechanism for itch, i.e., diffuse pruritic inhibitory control (DPIC), which is impaired in patients with chronic itch, possibly due to a dysregulation of descending itch modulatory systems.

Analysis of 4-year Dutch reimbursement application data of biological therapies for psoriatic arthritis

OBJECTIVES

To get the approval for reimbursement of biological therapies for PsA, patients need to fulfil specific criteria in many countries. The aim of this study was to evaluate the 4-year Dutch reimbursement application data, including the diagnostic, disease activity and response criteria that were applied for treatment of PsA with biologics.

METHODS

All initial and follow-up applications for approval of treatment with biologics were included for investigation. Data were analysed descriptively with regard to application characteristics, patient characteristics and response to therapy.

RESULTS

In the period studied, 3723 application forms of 1991 patients were received. This concerned 2118 initial treatment applications and 1605 follow-up applications. Of all initial treatment applications, 2003 (94.6%) were approved. The major part of all applications concerned requests for etanercept (59.1%), followed by adalimumab (38.2%). Patients were suffering from polyarthritis in most cases (63.1%). MTX was used by nearly all patients, but only 55.8% had used the required dosage of 25 mg/week. Approximately 79.4% of all patients met the response criteria after 3 months of treatment. The mean number of affected joints declined from 7.7 at first application to 1.4 at follow-up. The initial visual analogue scale (VAS) score indicated by patients decreased from 71.2 to 24.1 at follow-up. The VAS score indicated by physicians decreased from 66.0 to 18.4.

CONCLUSIONS

Biologics are expensive, but highly effective in the treatment of PsA. Careful compilation of treatment and reimbursement criteria is important for patients as well as for physicians and health insurance companies.

No increased risk of cancer after coal tar treatment in patients with psoriasis or eczema

Coal tar is an effective treatment for psoriasis and eczema, but it contains several carcinogenic compounds. Occupational and animal studies have shown an increased risk of cancer after exposure to coal tar. Many dermatologists have abandoned this treatment for safety reasons, although the risk of cancer after coal tar in dermatological practice is unclear. This large cohort study included 13,200 patients with psoriasis and eczema. Information on skin disease and treatment, risk factors, and cancer occurrence was retrieved from medical files, questionnaires, and medical registries. Proportional hazards regression was used to evaluate differences in cancer risk by treatment modality. Patients treated with coal tar were compared with a reference category of patients treated with dermatocorticosteroids (assumed to carry no increased cancer risk). The median exposure to coal tar ointments was 6 months (range 1-300 months). Coal tar did not increase the risk of non-skin malignancies (hazard ratio (HR) 0.92; 95% confidence interval (CI) 0.78-1.09), or the risk of skin cancer (HR 1.09; 95% CI 0.69-1.72). This study has sufficient power to show that coal tar treatment is not associated with an increased risk of cancer. These results indicate that coal tar can be maintained as a safe treatment in dermatological practice.

The universal detection of antigens from one skin biopsy specimen

BACKGROUND

Immunohistochemistry is an important tool in dermatology but is limited. Certain antigens can only be preserved in formalin-fixed paraffin-embedded sections, while others can only be detected on frozen sections, resulting in situations where two biopsies are needed. We aimed to develop a technique for universal detection of different antigens out of just one biopsy specimen.

METHODS

Single biopsies were obtained from lesional skin of patients with psoriasis. Standard sample procedures for frozen and paraffin-embedded sections were used. To convert frozen tissue into paraffin-embedded sections, the biopsy specimen was disposed of the embedding medium and subsequently fixed in 10% neutral buffered formalin. We applied various antigen retrieval techniques with alkaline solutions. The differential expression of keratin 10, keratin 15, CD3, CD26 and human beta defensin-2 (HBD-2) was examined using immunohistochemical staining.

RESULTS

We showed that keratin 10 and 15 can be stained on both frozen and paraffin-embedded sections. Staining of paraffin-embedded sections required unmasking with trypsin and Tris-buffered saline Tween solution, respectively. CD3 and CD26 can only be detected on frozen sections, while HBD-2 can only be detected on paraffin-embedded sections.

CONCLUSION

We have described a straightforward technique that gives us the opportunity to use just one biopsy specimen to obtain frozen sections as well as paraffin-embedded sections.

Current and future treatment options for acne

Acne is a frequent skin disease with abnormalities in the process of keratinization, sebaceous gland functioning and inflammation. In this review, our understanding of the pathogenesis of acne has been updated. An overview of efficacy and side effects of available anti-acne treatments is presented. Based on the present overview a recommendation for the treatment of various manifestations of acne is provided, also reconciling beneficial combinations of treatments. It is attractive to speculate that the increased insight into the pathogenesis of acne will create new treatment options. Challenging new options comprise blue light, photodynamic therapy, retinoic acid metabolism blocking agents and inhibitors of Th-1 cytokines.

Coal tar in dermatology

Coal tar is one of the oldest treatments for psoriasis and eczema. It has anti-inflammatory, antibacterial, antipruritic and antimitotic effects. The short-term side effects are folliculitis, irritation and contact allergy. Coal tar contains carcinogens. The carcinogenicity of coal tar has been shown in animal studies and studies in occupational settings. There is no clear evidence of an increased risk of skin tumors or internal tumors. Until now, most studies have been fairly small and they did not investigate the risk of coal tar alone, but the risk of coal tar combined with other therapies. New, well-designed, epidemiological studies are necessary to assess the risk of skin tumors and other malignancies after dermatological use of coal tar.

Efficacy and safety of pulsed dye laser treatment for cutaneous discoid lupus erythematosus

BACKGROUND

Treatment of chronic discoid lupus erythematosus (CDLE) with a pulsed dye laser (PDL) has shown promising results, although outcomes in previous studies were not validated and laser parameters were inconsistent.

OBJECTIVE

We conducted an open prospective study to assess the efficacy and safety of PDL for the treatment of recalcitrant CDLE, using a validated scoring method and a fixed treatment schedule.

METHODS

Twelve patients with active CDLE lesions were treated with PDL (585 nm, fluence 5.5 J/cm(2), spot size 7 mm) 3 times with an interval of 6 weeks followed by a 6-week follow-up period. Treatment outcomes were evaluated by 3 observers using the validated Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI). Cosmetic results and adverse events were recorded.

RESULTS

A significant decline in "active" CLASI was observed after 6 weeks, after 12 weeks, and at follow-up. Baseline active CLASI was 4.4 +/- 0.2 (mean +/- SEM), reaching 1.3 +/- 0.3 after follow-up (P < .0001). Individual scores for erythema and scaling/hypertrophy significantly declined 6 weeks after treatment. The "damage" CLASI (dyspigmentation, scarring, and atrophy) did not show any significant change during or after therapy. The observed clinical improvement was confirmed by two independent observers by clinical assessment of photographs (r = 0.87 and r = 0.89; both P < .05). The treatment was well tolerated, only minimal pain was reported, and the cosmetic result was fair.

LIMITATIONS

Small sample size and short follow-up duration were limitations.

CONCLUSION

PDL treatment is an effective and safe therapy for patients with refractory CDLE.