Methotrexate versus cyclosporine in moderate-to-severe chronic plaque psoriasis

BACKGROUND

Methotrexate and cyclosporine are well-known systemic therapies for moderate-to-severe chronic plaque psoriasis. We conducted a randomized, controlled trial comparing methotrexate and cyclosporine in terms of effectiveness, side effects, and the quality of life.

METHODS

A total of 88 patients with moderate-to-severe psoriasis were randomly assigned to treatment for 16 weeks with either methotrexate (44 patients; initial dose, 15 mg per week) or cyclosporine (44 patients; initial dose, 3 mg per kilogram of body weight per day) and were followed for another 36 weeks. The primary outcome was the difference between groups in the psoriasis area-and-severity index after 16 weeks of treatment, after adjustment for base-line values; scores were determined in a blinded fashion by trained observers.

RESULTS

Two patients were excluded from the analysis after randomization because they were found to be ineligible, and one patient withdrew his consent. Twelve patients in the methotrexate group had to discontinue treatment because of reversible elevations in liver-enzyme levels, and 1 patient in the cyclosporine group had to do so because of an elevation in the bilirubin level, but all 13 were included in the analysis. After 16 weeks of treatment, the mean (+/-SE) score for the psoriasis area-and-severity index decreased from 13.4+/-3.6 at base line to 5.0+/-0.7 among 43 patients treated with methotrexate, whereas the score decreased from 14.0+/-6.6 to 3.8+/-0.5 among 42 patients treated with cyclosporine. After adjustment for base-line values, the mean absolute difference in values at 16 weeks was 1.3 (95 percent confidence interval, -0.2 to 2.8; P=0.09). The physician's global assessment of the extent of psoriasis, the time to and the rates of remission, and the quality of life were similar in the two groups.

CONCLUSIONS

No significant differences in efficacy were found between methotrexate and cyclosporine for the treatment of moderate-to-severe psoriasis.

Quality of life issues in psoriasis

Psoriasis is associated with significant psychosocial morbidity and a decrease in health-related quality of life. It is important to view psoriasis as a serious disease and resist the tendency to underestimate its impact on overall patient well-being. The disability experienced by psoriasis sufferers is comparable to that of patients with other chronic illnesses such as heart disease, diabetes, cancer, and depression. Aggressive intervention is warranted in order to improve patient quality of life and decrease the potential for psychosocial sequelae. Health-related quality of life measures are becoming a necessary adjunct to traditional clinical assessments in the evaluation and treatment of psoriasis patients by the individual clinician. They also provide valuable information to government agencies and third party payers in the determination of resource allocation and reimbursement.

Nail Psoriasis Severity Index: a useful tool for evaluation of nail psoriasis

The Nail Psoriasis Severity Index (NAPSI) is a numeric, reproducible, objective, simple tool for evaluation of nail psoriasis. This scale is used to evaluate the severity of nail bed psoriasis and nail matrix psoriasis by area of involvement in the nail unit. The NAPSI will be useful during clinical trials for evaluating response to treatment of psoriatic nails. The scale is reproducible, and because there are few data points, statistical analysis is simplified.

Alefacept for chronic plaque psoriasis: a selective therapy with long-lasting disease remissions and an encouraging safety profile

Alefacept (Amevive) is a recombinant, fully human fusion protein that selectively targets memory T cells that have been implicated in the pathogenesis of psoriasis. Alefacept is approved in the United States as a treatment for chronic plaque psoriasis. Alefacept is unique among treatments for moderate to severe psoriasis because of its selective therapeutic action, favorable safety profile, and ability to induce lengthy disease remissions.

The National Psoriasis Foundation Psoriasis Score (NPF-PS) system versus the Psoriasis Area Severity Index (PASI) and Physician's Global Assessment (PGA): a comparison

The Psoriasis Area and Severity Index (PASI) and Physician Global Assessment (PGA) are commonly used, but fail to measure quality of life and the patient's perception of well-being. In response to these limitations, the National Psoriasis Foundation (NPF) Medical Advisory Board has developed the NPF Psoriasis Score (NPF-PS). This article evaluates the degree of concordance between NPF-PS, PASI, and PGA scores via an investigator-initiated, single-center, double-blind, placebo-controlled study of thirty-three patients with moderate to severe plaque psoriasis. Our results indicated that NPF-PS was strongly correlated with PASI and PGA in this study, while better reflecting patient perception. This is the first report of a double-blind placebo-controlled study demonstrating this concordance.

Pathophysiology of generalized pustular psoriasis

Generalized pustular psoriasis (GPP) is a serious dermatological disease characterized by fever, chills, rigors, and generalized pustule formation on the skin. Previous analyses in Japan have led to the proposal to divide GPP into two groups, one with a history of ordinary psoriasis (pso(+) GPP) and the other without a history of psoriasis (pso(-) GPP). Clinically the onset of the pustular outbreak is earlier in pso(-) GPP, which occurs more frequently after infections, whereas pso(+) GPP occurs more frequently following corticosteroid therapy. Substantial differences are also noted in HLA analyses. Activation of neutrophils is a basic mechanism in both types of GPP. Although the epidermal structural changes in GPP are usually not so prominent as those in psoriasis vulgaris, pso(+) GPP shows a more psoriasiform architecture than pso(-) GPP. Analysis of epidermal cell proliferation in GPP indicates that it is not less than that seen in psoriasis vulgaris. The occasional psoriasiform epidermal architecture especially seen in pso(+) GPP may be considered to be a steady-state condition achieved after epidermal cell proliferation has continued for a sustained period. Various inflammatory cytokines appear to be involved in the neutrophilic infiltrate seen in GPP.

Association between psoriasis severity and transforming growth factor beta(1) and beta (2) in plasma and scales from psoriatic lesions

Psoriasis is an inflammatory skin disorder with hyperproliferation of keratinocytes, that can be the result of insufficient inhibitory effect of transforming growth factors-beta (TGF-beta). The aim of this study was to evaluate an association between TGF-beta(1) and -beta(2) in plasma or scales from psoriatic lesions and the severity of the disease. TGF-beta concentrations were measured with an enzyme immunoassay in 41 patients with psoriasis. The mean plasma concentrations of TGF-beta(1) and TGF-beta(2) in patients were: 15.7 +/- 1.4 and 0.15 +/- 0.02 ng/ml respectively. It was also detectable in scales and varied from 24 to 1159 and from 0 to 2.95 pg/mg protein respectively. Plasma TGF-beta(1) correlated significantly with psoriasis area and severity index (PASI). Significant correlation was also demonstrated between TGF-beta(1) concentration in scales and sedimentation rate or the disease duration. There were no correlation between PASI and plasma TGF-beta(2), scales TGF-beta(1) and TGF-beta(2). The highest mean concentration of TGF-beta(1) in scales of patients with mild form of the disease (203 +/- 65 pg/mg protein) and the lowest in severe form (147 +/- 54 pg/mg protein) have been shown. These findings demonstrated association between PASI and plasma levels of TGF-beta(1), that should be considered as a possible indicator of psoriasis activity.

A survey of psoriasis patients in Japan from 1982 to 2001

BACKGROUND

The Japanese Society for Psoriasis Research has conducted an annual survey of psoriasis patients in Japan from 1982 to 2001.

OBJECTIVE

To perform the epidemiological study about a survey of psoriasis patients conducted in Japan for twenty years.

METHODS

A sample of 28628 cases was collected from 148 dermatology centers throughout Japan. The reports from each center were analyzed.

RESULTS

Males (65.8%) were predominant over females (34.2%) in number. The vast majority of cases (86.0%) had plaque-form of psoriasis vulgaris, and 812 cases (2.8%) showed guttate psoriasis. Psoriatic erythroderma (0.8%), generalized pustular psoriasis (0.9%), and localized pustular psoriasis (0.5%) were rare. Three hundred of the patients (1.0%) manifested psoriatic arthritis. Local corticosteroids (67.8%) were the most used modalities, whereas local vitamin D(3) preparations (2.4%) were rarely used. For photo-therapeutic treatments, topical (12.1%) and systemic (7.5%) PUVA were predominant over UVB therapy (0.5%). In systemic treatments, drugs from the herbal medicine was the first (14.2%), followed by etretinate (7.6%), nonsteroidal anti-inflammatory drugs (4.4%), oral corticosteroids (4.1%), methotrexate (2.8%), cyclosporine (1.6%), and anti-cancer drugs (1.4%).

CONCLUSION

This survey was the first epidemiological study throughout Japan.

Psoriasis

Psoriasis affects patients to varying degrees, and may seriously impair their quality of life. Treatments minimise symptoms but cannot cure the condition.

Molecular classification of psoriasis disease-associated genes through pharmacogenomic expression profiling

Psoriasis is recognized as the most common T cell-mediated inflammatory disease in humans. Genetic linkage to as many as six distinct disease loci has been established but the molecular etiology and genetics remain unknown. To begin to identify psoriasis disease-related genes and construct in vivo pathways of the inflammatory process, a genome-wide expression screen of multiple psoriasis patients was undertaken. A comprehensive list of 159 genes that define psoriasis in molecular terms was generated; numerous genes in this set mapped to six different disease-associated loci. To further interpret the functional role of this gene set in the disease process, a longitudinal pharmacogenomic study was initiated to understand how expression levels of these transcripts are altered following patient treatment with therapeutic agents that antagonize calcineurin or NF-KB pathways. Transcript levels for a subset of these 159 genes changed significantly in those patients who responded to therapy and many of the changes preceded clinical improvement. The disease-related gene map provides new insights into the pathogenesis of psoriasis, wound healing and cellular-immune reactions occurring in human skin as well as other T cell-mediated autoimmune diseases. In addition, it provides a set of candidate genes that may serve as novel therapeutic intervention points as well as surrogate and predictive markers of treatment outcome.

Promoter polymorphisms of the genes encoding tumor necrosis factor-alpha and interleukin-1beta are associated with different subtypes of psoriasis characterized by early and late disease onset

The psoriatic inflammatory process is characterized by an overexpression of pro-inflammatory cytokines such as tumor necrosis factor-alpha and interleukin-1beta compared with a relative deficiency of anti-inflammatory factors such as interleukin-10 and the interleukin-1 receptor antagonist (interleukin-1Ra). Gene polymorphisms that affect cytokine production may contribute to the disease-associated cytokine imbalance and influence susceptibility to psoriasis. Here, we investigated the relationship between polymorphisms in the genes encoding for tumor necrosis factor-alpha (G-238A, G-308A), interleukin-1beta (C-511T, T+3953C), and interleukin-1Ra (intron 2), and cytokine production in peripheral blood mononuclear cells of healthy donors, and analyzed the distribution of these polymorphisms in patients with psoriasis vulgaris (n = 231) and healthy controls (n = 345). Carriage of tumor necrosis factor A-238 allele 2 (-238*A) was associated with increased production of tumor necrosis factor-alpha in response to lipopolysaccharide in vitro, and with early onset disease (< 40 y), especially in male patients with psoriasis [32% vs 7% in male controls; odds ratio = 6.78, 95% confidence interval = (3.18-15.15), p(adjusted) = 2 x 10(-7)]. Carriage of the interleukin-1B-511*1 (-511*C) homozygous genotype was associated with increased production of interleukin-1Ra in response to lipopolysaccharide and interleukin-10, and with late onset psoriasis [> or = 40 y; 61% vs 44% in controls; odds ratio = 2.04, 95% confidence interval = (1.19-3.53), p(adjusted) = 0.0419]. These findings indicate that gene polymorphisms associated with altered cytokine responses in vitro may modify age of onset of psoriasis. They also provide further evidence that patients with early and late onset psoriasis differ in their genetic background.

Physical and psychologic measures are necessary to assess overall psoriasis severity

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Childhood psoriasis: a clinical review of 1262 cases

Our aim was to describe the types of psoriasis seen in a large series of patients presenting to a tertiary referral pediatric dermatology department using a classification system combining conventional terminology and additional categories based on the site and characteristics of the rash. A total of 1262 patients seen consecutively in the dermatology department of the Royal Alexandra Hospital for Children, Sydney, Australia, between 1981 and 1995 are described and classified according to the pattern of psoriasis at the time of presentation. Additional information recorded included family history, facial involvement, and history of a psoriatic type of diaper rash in infancy. The ages of the children ranged from 1 month to 15 years. There was an equal gender distribution and a high rate of positive family history at 71%. Twenty-six percent of children had a history of a psoriatic diaper rash and facial involvement occurred in 38% of children. Plaque psoriasis was the most common type overall, affecting 430 patients (34%). Three hundred forty-five children were less than 2 years of age, and this is the largest series of children with psoriasis in this age group presented to date. An entity defined by us as psoriatic diaper rash with dissemination was the most common type of psoriasis in the less than 2-year age group, affecting 155 (45%) patients. This large series offers information on the manifestations of psoriasis in childhood, but is particularly useful in examining the previously less well-described infant age group. The classification used is proposed as a practical way to describe psoriasis in children, particularly with respect to future descriptive studies.

The impact of the frequency of short contact dithranol treatment

Dithranol short contact treatment is usually applied once a day. For some patients this does not fit their possibilities or needs. Therefore we investigated the efficacy of two other treatment strategies in two small groups of patients. In the attempt to shorten the treatment time, one group of patients was treated twice daily. In order to not withhold short contact dithranol treatment from patients who are unable to perform the treatment daily or at home, a thrice-weekly treatment regimen was studied. 8 patients were treated twice daily and all achieved at least a 90% reduction of the area of involved skin (clearance) within 12.3 (+/- 1.6) weeks. In the thrice weekly group six out of eight patients achieved a clearance of their psoriasis within 13.1 (+/- 4.2) weeks. The aim of shortening the treatment period was not achieved by twice daily treatment in a day-care centre. However, the thrice-weekly treatment regimen certainly appeared to be an effective one. Further studies are needed on larger populations of patients to find out the optimal regimen for intermittent dithranol short contact treatment.

[Clinical study on effect of zhuhuang granule no. 2 in treating psoriasis with liver-qi stagnancy]

OBJECTIVE

To observe the efficacy of Zhuhuang Granule No. 2 (ZHG2) in treating psoriasis with Liver-Qi stagnancy.

METHODS

Sixty-seven patients were randomly divided into two groups, the 33 patients in the control group were treated with composite indigo capsule and the 34 in the treated group treated with ZHG2, and the clinical effect, changes of main symptoms and local skin lesion after treatment were evaluated. Meanwhile, the plasma levels of substance P (SP) and vasoactive intestinal peptide (VIP) in 15 patients and 13 healthy subjects were measured using radioimmunoassay (RIA).

RESULTS

The total effective rate in the treated group and the control group was 97.1% and 78.8% respectively with significant difference, P < 0.05. ZHG2 showed a significant effect in reducing plasma level of SP and VIP in patients of psoriasis with Liver-Qi stagnancy.

CONCLUSION

The effect of ZHG2 in treating psoriasis patients with Liver-Qi stagnancy is satisfactory, and worth further studying.

HLA-C and guttate psoriasis

BACKGROUND

Psoriasis is a heterogeneous disease in its clinical expression. Both genetic and environmental factors are thought to contribute to the pathogenesis of the inflammatory and hyperproliferative components of the typical skin lesions. Predisposing genetic influences include associations with human leucocyte antigens (HLA) of which that with HLA-Cw6 is the strongest. Guttate psoriasis is a specific clinical manifestation of psoriasis frequently associated with group A beta-haemolytic streptococcal throat infection.

OBJECTIVES

We set out to determine whether further clinical subdivision of psoriasis is associated with tighter correlation with HLA-C alleles.

PATIENTS/METHODS

We determined the HLA-C locus genotype of 29 caucasian patients with guttate psoriasis presenting consecutively with guttate psoriasis associated with a history of a sore throat and/or an antistreptolysin O titre > 200 IU mL-1. Polymerase chain reaction typing using sequence-specific primers was used to detect all known HLA-C alleles. These data were compared with a control population of 604 random caucasian cadaver donors.

RESULTS

All patients (100%) with guttate psoriasis carried the Cw*0602 allele compared with 20% of the control population (odds ratio = infinity; 95% confidence limits 25.00-infinity; Pcorrected < 0.0000002).

CONCLUSIONS

This result is consistent with HLA-Cw*0602 playing a part directly in the pathogenesis of guttate psoriasis.

Psoriasis

Patients with psoriasis can find the psychological impact of the disease as debilitating as the physical symptoms. Helen Cloote describes the different types of psoriasis and the treatment methods available and emphasises the important role of the nurse in helping patients to come to terms with this condition.

Psoriasis

Psoriasis is a common affliction that family practitioners and other primary care physicians are certain to encounter in their daily practice. This disease presents in many manifestations and in a diffuse patient population. The therapeutic tools available to combat this disease are numerous, as are their untoward effects. This article, directed at the primary care physician, is a review of the spectrum of psoriasis and its manifestations, diagnosis, and management.

[Psoriasis. Rheumatologic manifestations]

THE CONTEXT: Psoriasic arthritis lies somewhere between rhumatoid polyarthritis and spondyloathropathy. Its prevalence is about 0.1% with a 1/1 sex ratio. Mean age at onset of symptoms is 40 years. In 10 to 15% of the cases, rhumatological manifestations are observed before skin lesions. Ungueal involvement is particularly frequent. FIVE CLINICAL FORMS: Classically, five clinical forms are described: arthritis limited to the distal interphalangeal joints, mutilating arthritis, symmetrical polyarthritis, asymmetrical mono- or oligoarthritis, and spondylitis. Asymmetrical oligoarticular forms and polyarithrtis predominate. DISEASE SEVERITY: In general psoriasic arthritis is a benign condition. Severe forms have however been described with erosion and osteolysis involving the distal interphalangeal joints. Typical radiological may be observed.

THERAPEUTIC OPTIONS

Non-steroidal antiinflammatory drugs help control disease progression in about one-third of the cases. In other patients, gold salts, D-penicillamine, methotrexate, or sulfasalazine may be required.

The SAPASI is valid and responsive to psoriasis disease severity changes in a multi-center clinical trial

We developed a structured Psoriasis Area Severity Index (PASI)-like instrument, the Self-administered PASI (SAPASI), that allows subjects to assess accurately the severity of their psoriasis. The major limitation of our previous SAPASI validity studies is that all were performed in a single academic center, raising questions about the generalizability of the instrument. We administered the SAPASI to 182 subjects in a 12-week, multicenter, double-blind clinical trial of topical tazarotene for psoriasis. On the same day, investigators blind to the SAPASI rating determined the degree of erythema, induration, scale, body surface area (BSA) affected, and overall lesion severity of the subjects' psoriasis. Using these data, we calculated an investigator PASI-Equivalent. Correlation analysis shows that for both initial and final assessments of psoriasis severity, the SAPASI score reflects the PASI-Equivalent score in a significant way (p = .0001), although the correlation is a modest one (r = 0.3 to 0.5). Significant (p = .0001), modest correlations were found between the subjects' reported BSAs and the investigators' reported BSAs. To assess responsiveness, the proportional changes of the SAPASI and PASI-Equivalent were found to be modestly significantly correlated (r = 0.2, p = .04). The results of this study support the general validity of the SAPASI and demonstrate that the SAPASI can detect changes in disease severity in a clinical trial. Significant correlations were also observed between SAPASI components and their investigator-reported counterparts in this multicenter trial. To the best of our knowledge, the current study represents the first multicenter validity study performed on a psoriasis severity instrument, and clearly demonstrates the value of this instrument in assessing the psoriasis severity in a population.