Psoriasis in Skin of Color: Insights into the Epidemiology, Clinical Presentation, Genetics, Quality-of-Life Impact, and Treatment of Psoriasis in Non-White Racial/Ethnic Groups

Improving Diversity in a Novel Psoriasis Study: VISIBLE as a Framework for Clinical Trial Quality Improvement

Importance

Diverse racial and ethnic representation in clinical trials has been limited, not representative of the US population, and the subject of pending US Food and Drug Administration guidance. Psoriasis presentation and disease burden can vary by skin pigmentation, race and ethnicity, and socioeconomic differences. Overall, there are limited primary data on clinical response, genetics, and quality of life in populations with psoriasis and skin of color (SoC). The Varying Skin Tones in Body and Scalp Psoriasis: Guselkumab Efficacy and Safety trial (VISIBLE) is underway and uses strategies aimed at addressing this persistent gap.

Objective

To assess the innovative strategies used in the VISIBLE trial to recruit and retain diverse participants in a randomized clinical trial of psoriasis in participants with SoC.

Design, Setting, and Participants

This was an ad hoc quality improvement assessment of participant recruitment and retention approaches used by the VISIBLE trial. VISIBLE enrolled and randomized 211 participants (mean [SD] age, 43 [13] years; 75 females [36%] and 136 males [64%]) with SoC and moderate to severe plaque psoriasis from August 2022 to March 2023 to evaluate guselkumab treatment. The self-identified race and ethnicity of the participants was: 1 American Indian/Alaska Native (0.5%), 63 Asian (29.9%), 24 Black (11.4%), 94 Hispanic/Latino (44.5%), 13 Middle Eastern (6.2%), 1 Pacific Islander/Native Hawaiian (0.5%), 12 multiracial (5.7%), and 3 of other race and/or ethnicity (1.4%). Using a combination of objective (colorimetry to determine Fitzpatrick skin type) and self-reported (race and ethnicity consistent with SoC) parameters, VISIBLE sought to broaden inclusion of participants from various backgrounds.

Results

Observed improvements were that participant enrollment occurred approximately 7 times faster than anticipated (vs historical recruitment data for psoriasis studies); 211 participants (100%) self-identified themselves as a race or ethnicity other than White; and more than 50% had skin tone in the darker half of the Fitzpatrick skin type spectrum (type IV-VI). Innovations implemented by VISIBLE were (1) assessment of the natural history of postinflammatory pigment alteration and improvements over time using combined objective colorimetry and clinician- and patient-reported outcomes; (2) evaluation of genetic and comorbidity biomarkers relevant to participants with SoC; (3) a diverse demographic-driven approach to site selection (emphasizing investigator and staff diversity and experience with populations with SoC); (4) provision of cultural competency training to enhance participant enrollment and retention; (5) collection of patient-reported outcomes data in participants' primary language; and (6) periodic, blinded central review and feedback on investigator efficacy scoring to promote consistency and accuracy in evaluating psoriasis in participants with SoC.

Conclusions and Relevance

VISIBLE is a unique study focused on addressing important knowledge and data gaps in populations of patients with psoriasis and SoC, with the goal of generating data to help improve clinical care and inform future best practices in diversity within dermatology research. The rapid study enrollment demonstrates that intentional and strategic approaches to clinical trial design and conduct can speed recruitment and bolster participation and retention of diverse populations in a dermatologic setting.

Trial Registration

ClinicalTrials.gov Identifier: NCT05272150.

Evaluation of β2-microglobulin in the condition and prognosis of psoriasis patients

BACKGROUND

Numerous studies have linked the inflammatory pathway in psoriasis and metabolic disease, while no specific marker defined it. It is worth exploring the association of β2-microglobulin (β2M) in psoriasis severity and comorbidities.

OBJECTIVES

To investigate the correlation between blood β2M level and psoriasis severity, to explore the inflammatory factors influencing the occurrence of psoriasis comorbidities such as arthritis, diabetes, and hypertension.

METHODS

Ninety-seven psoriasis patients were analyzed in the cohort retrospective study during 12 weeks.

RESULTS

Significantly higher levels of blood β2M and ESR were observed in the group that patients' PASI ≥10 than in the group that PASI <10. Blood β2M level had strong significantly positive correlations with the PASI in Pearson's correlation analysis. In the model that systemic inflammatory factors to find psoriasis comorbidity risk factors, logistic regression analysis showed that blood β2M level was the significant risk factor associated with diabetes and hypertension. High-sensitivity C-reactive protein (hsCRP) was the significant risk factor associated with arthritis.

CONCLUSIONS

Patients with a severer psoriasis tended to have higher blood β2M levels and severer inflammatory state. In the systemic inflammation indexes, the level of blood β2M affected the risk of hypertension and diabetes, and hsCRP affected the risk of arthritis in patients with psoriasis.

Patient-Reported and Economic Racial and Ethnic Disparities in Patients with Psoriatic Arthritis: Results from the National Health and Wellness Survey

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic, autoimmune form of arthritis that is associated with a substantial humanistic and economic burden. Potential differences in patient-reported outcomes (PROs) and economic outcomes among groups of varying PsA severity and different races/ethnicities have not been well studied.

METHODS

This cross-sectional study assessed sociodemographic data, PROs, and economic outcomes for participants with PsA from the National Health and Wellness Survey (2018-2020). Multivariable analyses were used to assess the association of self-reported PsA severity and race/ethnicity with health-related quality of life (HRQoL), work productivity and activity impairment (WPAI), healthcare resource utilization (HCRU), and medical costs.

RESULTS

This study included 1544 participants with PsA (1073 non-Hispanic white, 114 non-Hispanic Black, 223 Hispanic, and 134 Other). Self-reported moderate/severe PsA was associated with significantly worse HRQoL and WPAI, greater HCRU, and higher costs than self-reported mild PsA. Black participants reported more absenteeism (31.11% vs. 16.69%; P = 0.007) and activity impairment (54.27% vs. 47.96%; P = 0.047) than white participants, and fewer healthcare provider (5.93 vs. 7.42; P = 0.039) and rheumatologist visits (0.29 vs. 0.53; P = 0.028) over the past 6 months. No differences in outcomes were observed between Hispanic and white participants. Race/ethnicity moderated the association of perceived PsA severity and PROs and HCRU, such that white participants with self-reported moderate/severe PsA had a higher likelihood of depression (P < 0.001), lower HRQoL (P < 0.001), and more emergency room visits (P = 0.001) than those with self-reported mild PsA. Race/ethnicity did not moderate the relationship of PROs, HCRU, and economic outcomes among Black or Hispanic participants.

CONCLUSION

Participants with self-reported moderate/severe PsA reported a greater burden than those with self-reported mild PsA. Black participants had a greater humanistic burden than white participants but reported lower HCRU. Moderation results were driven by white participants, suggesting important differences in PROs, HCRU, and perception of PsA severity across race/ethnicity groups. Small sample sizes in Hispanic and non-Hispanic racial/ethnic groups limited ability to discern differences related to disease severity in these groups. Further research is needed to better understand the differential burden of PsA among individuals with varying perceptions of PsA severity across different racial/ethnic groups.

A Descriptive, Post Hoc Analysis of Efficacy and Safety of Risankizumab in Diverse Racial and Ethnic Patient Populations With Moderate-to-Severe Psoriasis

INTRODUCTION

Historically, patients with skin of color are underdiagnosed with psoriasis and underrepresented in clinical trials. In this study, we assess the efficacy and safety of risankizumab in patients with moderate-to-severe plaque psoriasis by race and ethnicity in the open label extension LIMMitless (NCT03047395).

METHODS

Patients received continuous treatment with 150 mg risankizumab through their initial trial and the open label extension. Patients self-identified their race and ethnicity. Efficacy was assessed using Psoriasis Area Severity Index (PASI) and Dermatology Life Quality Index (DLQI). Safety is reported by events/100 patient-years.

RESULTS

A total of 897 patients (race: 662 White, 196 Asian, 25 Black or African American, 14 Other; ethnicity: 98 Hispanic or Latino, 799 non-Hispanic or Latino) were included in this analysis. Compared to baseline, patients had a mean percent reduction in PASI between 94.6% (Asian) and 99.3% (Black or African American) and reported mean percent improvements in DLQI ranging from 87.1% (Asian and Black or African American) to 93.7% (Hispanic or Latino) at week 100.

CONCLUSION

While the data presented here comprise a small retrospective descriptive analysis and cannot detect statistical differences, efficacy of risankizumab for the treatment of moderate-to-severe plaque psoriasis appears similar across the racial and ethnic groups studied and no new safety signals were detected.

Magnitude of Psoriasis and Its Associated Factors, and Quality of Life of Psoriasis Patients among Patients Who Attend Dermatology Clinic at Tibebe Ghion Comprehensive Specialized and Addis Alem Primary Hospitals, North West Ethiopia, 2022: Institution-Based Cross-Sectional Study

Background

Psoriasis is a common immune-mediated papulosquamous inflammatory skin disease characterized by well-demarcated, erythematous silvery scaly plaques. Prevalence rates of psoriasis showed a worldwide variation and have been reported to range between 0.09% and 5.1%. It has been associated with several intrinsic as well as extrinsic factors and has a detrimental effect on health-related quality of life. Studies on the burden, factors associated with it, and quality of life of psoriasis are limited in the study area.

Objectives

To assess the magnitude, factors associated with it, and quality of life of psoriasis patients.

Methods

Institution-based cross-sectional study was conducted among patients who attend dermatology clinics at Tibebe Ghion comprehensive specialized and Addis Alem primary hospitals from June 8 to September 5, 2022. Systematic random sampling was applied to select study participants until the sample size (318) was fulfilled. A structured interviewer-administered questionnaire was used to collect data. Collected data were coded and entered into EPI data version 3.1 and then exported to SPSS version 27 for analysis. Descriptive statistics and logistic regression analysis were done.

Result

The mean age of study participants was 22.5 with a standard deviation (SD) of 18.2 years. The proportion of psoriasis was 5.3% with a 95% CI (3.1%, 8.4%). Stressful life events (AOR = 3.32, 95% CI (1.12, 9.86)) and alcohol consumption (AOR = 3.73, 95% CI (1.03, 13.51)) were significantly associated with psoriasis. Seven (41.2%) psoriasis patients had a large effect on their quality of life. The mean dermatology quality of life index (DLQI) was 9.82.

Conclusion

The proportion of psoriasis in this study was comparable to earlier international and Ethiopian studies, but greater than studies from other African countries. Stressful life events and alcohol consumption were significantly associated with psoriasis. The majority of psoriasis patients had a large negative effect on their quality of life.

Psoriasis Vulgaris Masked by Tinea Pedis in Two Unhoused Patients

Psoriasis is a chronic inflammatory disease characterized by clearly marginated silvery plaques that affect men and women equally. Symptoms can vary among individuals; typically, it presents on the scalp, elbows, and knees. We present two cases of patients initially diagnosed with tinea pedis who showed no improvement with medical treatment. The first patient is an African American male in his 50s who arrived at a free clinic for unhoused persons with lesions to both feet initially diagnosed as tinea pedis. Although the patient was compliant with applying topical formulations of tolnaftate and clotrimazole, there was no discernible improvement in his symptoms and the skin lesions. After a thorough examination of the skin throughout the entire body, the diagnosis of psoriasis was considered. The patient started treatment with steroidal cream with improvement of the symptoms and lesions. The second patient is a Caucasian male in his 20s who also presented initially with complaints of a dry, intensely pruritic, and scaly rash on the dorsum of both his feet, as well as in between the digits of his feet for which an initial diagnosis of tinea pedis was also made. The patient remained non-compliant with treatment and, after reevaluation of his lesions along with an extensive survey of his body, was deemed to have psoriasis and prescribed topical hydrocortisone. The patient continued to remain non-compliant with his therapeutic regimen and subsequently developed cellulitis which is yet to resolve with treatment.

Dermatology in black skin

The vast majority of publications in dermatology refer to lightly pigmented skin, with few addressing the peculiarities of black skin. In addition there is no consensus on what it means to be black in different regions of the world. The lack of knowledge on the subject makes it difficult to recognize and manage dermatoses in this type of skin. This article aims to review the literature on intrinsic characteristics, as well as epidemiological and clinical aspects of the cutaneous manifestations of different dermatoses in black skin. It was found that there are sometimes striking differences, in the structural, biological, and functional aspects when comparing lightly pigmented and black skin. There are also physiological changes that need to be recognized to avoid unnecessary interventions. Some dermatoses have a higher incidence in black skin, such as acne, eczema, dyschromia and dermatophytosis. On the other hand, several dermatoses are more specific to black skin, such as pseudofolliculitis barbae, keloid, dermatosis papulosa nigra, ulcers caused by sickle-cell anemia, dactylolysis spontanea, confluent and reticulated papillomatosis of Gougerot and Carteaud, and some diseases of the hair and scalp (including fragile and brittle hair, traction alopecia, folliculitis keloidalis nuchae, folliculitis dissecans and central centrifugal cicatricial alopecia). A spectrum of peculiar aspects of specific dermatoses, including sarcoidosis, lichen planus (with emphasis on the pigmentosus variant), psoriasis, lupus erythematosus, vitiligo, syphilis, pityriasis versicolor, and neoplasms are highlighted. In the latter, characteristics of basal cell carcinoma, squamous cell carcinoma, and melanoma are compared, in addition to highlighting unusual aspects of primary cutaneous T-cell lymphoma, endemic Kaposi sarcoma, and dermatofibrosarcoma protuberans.

Comparison of visual diagnostic accuracy of dermatologists practicing in Germany in patients with light skin and skin of color

Visual clinical diagnosis of dermatoses in people of color (PoC) is a considerable challenge in daily clinical practice and a potential cause of misdiagnosis in this patient cohort. The study aimed to determine the difference in visual diagnostic skills of dermatologists practicing in Germany in patients with light skin (Ls) and patients with skin of color (SoC) to identify a potential need for further education. From April to June 2023, German dermatologists were invited to complete an online survey with 24 patient photographs depicting 12 skin diseases on both Ls and SoC. The study's primary outcomes were the number of correctly rated photographs and the participants' self-assessed certainty about the suspected visual diagnosis in Ls compared to SoC. The final analysis included surveys from a total of 129 dermatologists (47.8% female, mean age: 39.5 years). Participants were significantly more likely to correctly identify skin diseases by visual diagnostics in patients with Ls than in patients with SoC (72.1% vs. 52.8%, p ≤ 0.001, OR 2.28). Additionally, they expressed higher confidence in their diagnoses for Ls than for SoC (73.9 vs. 61.7, p ≤ 0.001). Therefore, further specialized training seems necessary to improve clinical care of dermatologic patients with SoC.

Etiopathogenesis of Psoriasis: Integration of Proposed Theories

Psoriasis is a chronic inflammatory disease characterized by squamous and erythematous plaques on the skin and the involvement of the immune system. Global prevalence for psoriasis has been reported around 1-3% with a higher incidence in adults and similar proportions between men and women. The risk factors associated with psoriasis are both extrinsic and intrinsic, out of which a polygenic predisposition is a highlight out of the latter. Psoriasis etiology is not yet fully described, but several hypothesis have been proposed: 1) the autoimmunity hypothesis is based on the over-expression of antimicrobial peptides such as LL-37, the proteins ADAMTSL5, K17, and hsp27, or lipids synthesized by the PLA2G4D enzyme, all of which may serve as autoantigens to promote the differentiation of autoreactive lymphocytes T and unleash a chronic inflammatory response; 2) dysbiosis of skin microbiota hypothesis in psoriasis has gained relevance due to the observations of a loss of diversity and the participation of pathogenic bacteria such as Streptococcus spp. or Staphylococcus spp. the fungi Malassezia spp. or Candida spp. and the virus HPV, HCV, or HIV in psoriatic plaques; 3) the oxidative stress hypothesis, the most recent one, describes that the cell injury and the release of proinflammatory mediators and antimicrobial peptides that leads to activate of the Th1/Th17 axis observed in psoriasis is caused by a higher release of reactive oxygen species and the imbalance between oxidant and antioxidant mechanisms. This review aims to describe the mechanisms involved in the three hypotheses on the etiopathogeneses of psoriasis.

Mapping the psoriasis research landscape: A comprehensive bibliometric analysis from 2012-2023

An extensive investigation explores the complex terrain of psoriasis, a persistent inflammatory dermatological disorder that impacts between 1% and 3% of the worldwide populace. Acknowledging the intricate interplay between environmental, genetic, and immunological influences on the etiology of psoriasis, the study utilizes sophisticated bibliometric techniques to investigate patterns, gaps in knowledge, and emergent trends within the field. The study utilizes advanced bibliometric techniques to analyze patterns, gaps in knowledge, and emerging trends in the field while acknowledging the intricate interplay between environmental, genetic, and immune-related influences on the etiology of psoriasis. An examination of 18,765 documents from December 2012 to December 2023 was conducted using machine learning techniques and the Scopus database. The explanation for conducting analysis is rooted in its capacity to provide significant perspectives on the dynamic progression of psoriasis research. The study facilitates the identification of significant subject areas, exposes patterns in publication trends, emphasizes influential authors and journals, and outlines the worldwide contributions to the field. The study demonstrates a steady and progressive increase in publications, with significant contributions from the Journal of the American Academy of Dermatology, the British Journal of Dermatology, and the Journal of the European Academy of Dermatology and Venereology. Prominent scholars in research output, such as the United States, China, and Germany, as well as authors including Feldman, Wu, Griffiths, Puig, and Reich K., are identified. Biochemistry, genetics, and molecular biology come to the forefront as esteemed fields that make substantial contributions to the study of psoriasis alongside medicine. This research highlights the interdisciplinary aspects of psoriasis by uncovering knowledge hubs and international collaborations between authors and organizations. The findings highlight the global reach of research on psoriasis and the importance of international cooperation.

Artificial intelligence in psoriasis: Where we are and where we are going

Artificial intelligence (AI) is a field of computer science that involves the development of programs designed to replicate human cognitive processes and the analysis of complex data. In dermatology, which is predominantly a visual-based diagnostic field, AI has become increasingly important in improving professional processes, particularly in the diagnosis of psoriasis. In this review, we summarized current AI applications in psoriasis: (i) diagnosis, including identification, classification, lesion segmentation, lesion severity and area scoring; (ii) treatment, including prediction treatment efficiency and prediction candidate drugs; (iii) management, including e-health and preventive medicine. Key challenges and future aspects of AI in psoriasis were also discussed, in hope of providing potential directions for future studies.

Clinical features, therapeutic choice and response by phototype in psoriasis: analysis of the French PsoBioTeq cohort

BACKGROUND

Little is known about phototype and the response to systemic treatment in psoriasis.

OBJECTIVES

To assess the characteristics of psoriasis, the therapeutic choice and its efficacy according to phototype.

METHODS

We included patients from the PsoBioTeq cohort initiating a first biologic. Patients were classified according to their phototype. The evaluation included disease characteristics, choice of the initial biologic and therapeutic response at 12 months based on 90% improvement from baseline in Psoriasis Area and Severity Index (PASI 90) and Dermatology Life Quality Index (DLQI) 0/1.

RESULTS

Of the 1400 patients included, 423 (30.2%), 904 (64.6%) and 73 (5.2%) were in the phototype I-II, III-IV and V-VI groups, respectively. The V-VI group had a higher initial DLQI, and more frequently initiated ustekinumab. Patients in the V-VI group maintained the initial biologic prescribed as did the other phototype groups, even though the proportion of patients reaching PASI 90 and DLQI 0/1 at 12 months was lower in this group than the other groups.

CONCLUSIONS

Patient phototype seems associated with quality of life and choice of the initial biologic in psoriasis. The phototype V-VI group less frequently switched treatments than did the other groups when the response was not efficient.

Diagnosing Disorders of Facial Erythema

Identification of specific patterns, shades, and intensity of erythema in the skin has always been critical and fundamental to diagnostic accuracy in dermatology. Erythema is often less noticeable in darker skin types. The interplay of inflammation and variance of skin tone contributes to appreciable differences in the clinical appearance of cutaneous disease in darker complexions. In this article, we discuss common disorders that present with facial erythema in skin of color and offer distinguishing features of each disorder to assist the clinician with diagnosing these conditions in the presence of deeply pigmented skin.

Diagnosing Psoriasis in Skin of Color Patients

Diagnosing psoriasis in patients of color can pose both diagnostic and treatment challenges. It is important to keep psoriasis on the differential diagnosis with conditions such as lichen planus, tinea corporis, and subcutaneous lupus for patients of color. Biopsy can help delineate the causes and guide treatment. Although there is no documented difference in efficacy of certain treatments for psoriasis based on racial group, cultural norms, hair washing practices, health literacy, and attitudes toward certain treatment options should be elicited in all patients.

The skin is no barrier to mixtures: Air pollutant mixtures and reported psoriasis or eczema in the Personalized Environment and Genes Study (PEGS)

BACKGROUND

Autoimmune (AI) diseases appear to be a product of genetic predisposition and environmental triggers. Disruption of the skin barrier causes exacerbation of psoriasis/eczema. Oxidative stress is a mechanistic pathway for pathogenesis of the disease and is also a primary mechanism for the detrimental effects of air pollution.

METHODS

We evaluated the association between autoimmune skin diseases (psoriasis or eczema) and air pollutant mixtures in 9060 subjects from the Personalized Environment and Genes Study (PEGS) cohort. Pollutant exposure data on six criteria air pollutants are publicly available from the Center for Air, Climate, and Energy Solutions and the Atmospheric Composition Analysis Group. For increased spatial resolution, we included spatially cumulative exposure to volatile organic compounds from sites in the United States Environmental Protection Agency Toxic Release Inventory and the density of major roads within a 5 km radius of a participant's address from the United States Geological Survey. We applied logistic regression with quantile g-computation, adjusting for age, sex, diagnosis with an autoimmune disease in family or self, and smoking history to evaluate the relationship between self-reported diagnosis of an AI skin condition and air pollution mixtures.

RESULTS

Only one air pollution variable, sulfate, was significant individually (OR = 1.06, p = 3.99E-2); however, the conditional odds ratio for the combined mixture components of PM2.5 (black carbon, sulfate, sea salt, and soil), CO, SO2, benzene, toluene, and ethylbenzene is 1.10 (p-value = 5.4E-3).

SIGNIFICANCE

While the etiology of autoimmune skin disorders is not clear, this study provides evidence that air pollutants are associated with an increased prevalence of these disorders. The results provide further evidence of potential health impacts of air pollution exposures on life-altering diseases.

SIGNIFICANCE AND IMPACT STATEMENT

The impact of air pollution on non-pulmonary and cardiovascular diseases is understudied and under-reported. We find that air pollution significantly increased the odds of psoriasis or eczema in our cohort and the magnitude is comparable to the risk associated with smoking exposure. Autoimmune diseases like psoriasis and eczema are likely impacted by air pollution, particularly complex mixtures and our study underscores the importance of quantifying air pollution-associated risks in autoimmune disease.

Experiences and coping behaviours of patients with psoriasis: a qualitative study

BACKGROUND

Psoriasis is a complex, chronic, lifelong inflammatory skin disease characterized by the development of erythematous, indurated, scaly, pruritic and often painful skin plaques, and it is currently incurable. It profoundly affects psychological wellbeing and social functioning and has significant associated co-morbidities. To improve clinical approaches, understanding of the experiences of patients with psoriasis is needed.

OBJECTIVE

To explore the experiences and coping behaviours of patients with psoriasis.

METHODS

A qualitative study approach was conducted. Through semi-structured interviews, 20 patients with psoriasis were recruited from general practices and specialist dermatology practices in a regional teaching hospital in Taiwan. Recorded interviews were transcribed and analysed by content analysis.

RESULTS

Three themes and nine subthemes were identified: 1. Symptoms distress: (a) trouble with scaling, (b) bothersome itching, and (c) complex pain experiences; 2. Psychological distress: (a) encountering discrimination and (b) feeling stigmatised; 3. Managing psoriasis: (a) coping with symptoms, (b) seeking alternative methods, (c) using biologic agents, and (d) changing thinking and coexisting with the disease.

CONCLUSION

The experience of patients with psoriasis has significant negative impacts on their lives. The findings of this study can provide healthcare professionals with a reference for the care of patients with psoriasis.

Comparative Effectiveness of Biologics Across Subgroups of Patients with Moderate-to-Severe Plaque Psoriasis: Results at Week 12 from the PSoHO Study in a Real-World Setting

INTRODUCTION

In routine clinical care, important treatment outcomes among patients with moderate-to-severe plaque psoriasis (PsO) have been shown to vary according to patient demographics and disease characteristics. This study aimed to provide direct comparative effectiveness data at week 12 between anti-interleukin (IL)-17A biologics relative to other approved biologics for the treatment of PsO across seven clinically relevant patient subgroups in the real-world setting.

METHODS

From the international, non-interventional Psoriasis Study of Health Outcomes (PSoHO), 1981 patients with moderate-to-severe PsO were grouped a priori according to seven clinically relevant demographic and disease variables with binary categories, which were sex (male or female), age (< 65 or ≥ 65 years), body mass index (≤ 30 or > 30 kg/m²), race (White or Asian), PsO disease duration (< 15 or ≥ 15 years), psoriatic arthritis (PsA) comorbidity (present or absent), and prior biologic use (never or ≥ 1). Across these subgroups, effectiveness was compared between the anti-IL-17A cohort (ixekizumab, secukinumab) versus all other approved biologics and ixekizumab versus five individual biologics. The proportion of patients in each subgroup who achieved 90% improvement in Psoriasis Area and Severity Index (PASI90) and/or static Physician Global Assessment (sPGA) 0/1, PASI100, or PASI90 at week 12 were assessed. Comparative analyses were conducted using frequentist model averaging (FMA). Missing data were imputed using non-responder imputation.

RESULTS

Patients in each of the seven subgroups achieved similar response rates to those of the overall treatment cohort, apart from patients with PsA treated with other biologics who had 7-10% lower response rates. Consequently, patients with comorbid PsA had significantly higher odds of achieving skin clearance at week 12 with anti-IL-17A biologics compared to other biologics. Patients in all subgroups had significantly higher odds of achieving PASI90 and/or sPGA (0,1), PASI100, and PASI90 in the anti-IL-17A cohort relative to the other biologics cohort, except for the Asian subgroup. No sex- or age-specific differences in treatment effectiveness after 12 weeks were identified, neither between the treatment cohorts nor between the individual treatment comparisons.

CONCLUSIONS

Despite relative consistency of comparative treatment effectiveness across subgroups, the presence of comorbid PsA may affect a patient's clinical response to some treatments.

[Inflammatory dermatoses in skin of color]

Acne, rosacea, atopic dermatitis, and psoriasis vulgaris are common inflammatory dermatoses. Of note, the epidemiology and clinical presentation of these common dermatologic diseases varies considerably between people with different colors of skin. Yet, most dermatology textbooks present and describe the clinical pictures of White people. To provide excellent dermatological care for all patients, it is of central importance to know the epidemiology and recognize key clinical characteristics of these diseases in patients with skin of color (SOC). In acne, cultural habits of Blacks (use of steroid-based lighteners, comedogenic hair care products) may lead to manifestation of specific forms of acne. In addition, postinflammatory hyperpigmentation and keloids pose particular therapeutic challenges in this patient group. Atopic dermatitis in Asians shows a clinical and histological picture that is similar to psoriasis in Whites. By contrast, atopic dermatitis manifests on the extensor side in Black people. Due to the difficulty of recognizing erythema in SOC, the severity of the respective inflammatory diseases in these individuals is often underestimated. The treatment of acne, rosacea, atopic dermatitis, and psoriasis does not differ between people of different skin colors. The exception is the necessary therapy for postinflammatory hyperpigmentation in all the inflammatory dermatoses mentioned, and for keloids in acne.

Racial/ethnic differences in treatment efficacy and safety for moderate-to-severe plaque psoriasis: a systematic review

Biologic medications have revolutionized treatment of psoriasis; however, there remains uncertainty in which medications should be used to maximize efficacy based on race/ethnicity. The purpose was to determine if efficacy of biological medications differs based on race/ethnicity. A systematic review identified all clinical trials focused on biologic treatment outcomes from inception of database until March 5th, 2021. Included studies provided data on racial/ethnic differences in biologic skin clearance efficacy using the Psoriasis Area and Severity Index (PASI) and "clear/almost clear" scores. There were 1220 studies identified, and 24 included in the review. The races/ethnicities included were Asian (n = 2740), White (n = 9745), Black (n = 138), and Latino (n = 728). Ixekizumab provided the highest "clear/almost clear" score (90.7%, 89.4%) and PASI 75 (98.8%, 96.6%) for Asian and Latino patients, respectively. Guselkumab had the highest "clear/almost clear" score for White (86.8%) patients, while Black patients had highest "clear/almost clear" (75.0%) and PASI 75 (91.7%) scores to brodalumab. Limitations included lack of studies reporting outcome data based on race/ethnicity and lack of patients of color within psoriasis clinical trials. For treatment of plaque psoriasis, there is evidence of differences in efficacy of biologics improving clinical disease severity between different races or ethnicities.

Clinical Feature, Lifestyle Behavior and Non-Communicable Diseases Comorbidities Among Psoriasis Patients in Shanghai: Gender Disparity Analysis Based on a Cross-Sectional Study

Background

Gender difference is prevalent in clinical feature, disease severity for noncommunicable diseases (NCD), but studies on gender disparity in clinical feature, disease severity and NCD comorbidity among psoriasis patients are limited. This cross-sectional study explores gender differences in clinical feature, lifestyle behavior and NCD comorbidity among psoriasis patients.

Methods

Psoriasis patients were recruited through cluster survey method in two hospitals, and questionnaire interviews were applied to collect the demographic feature, lifestyle habits, clinical feature and NCD among patients.

Results

A total of 2102 psoriasis patients included 1332 males (63.4%), 70% were over 35 years old and approximately 50% of them were overweight or obesity. The median value for psoriasis initiation age and disease duration was 33 years old (34 for male and 32 for female) and 9 years (10 for male and 7 for female), respectively. The psoriasis recurrence was mainly in winter (73.4%) and autumn (34.2%) both for patients. The prevalence of tobacco smoking and alcohol drinking was 31.2% and 12.6%. Male patients had higher prevalence of tobacco smoking (odds ratio (OR) = 13.26, 95% confidence interval (CI): 9.54-18.44) and alcohol drinking (OR = 14.44, 95% CI: 7.90-26.40). The prevalence of diabetes, hypertension, hyperlipidemia, and metabolic syndrome were 13.2%, 28.5%, 23.4% and 21.5%, respectively. Male patients had higher prevalence of diabetes (OR = 1.53, 95% CI: 1.16-2.02), hypertension (OR = 1.87, 95% CI: 1.52-2.30), hyperlipidemia (OR = 2.34, 95% CI: 1.85-2.95) and metabolic syndrome (OR = 2.06, 95% CI: 1.63-2.62) than female patients. The proportions for 4 types of NCDs diagnosed after psoriasis onset were over 58%, which were also higher in males than females.

Conclusion

Female patients had shorter disease duration and with less NCD, and male patients had more body weight issue, with fewer sleep time and higher prevalence of tobacco smoking and alcohol drinking and NCDs. We recommend that dermatologist should notice the gender disparity in psoriasis patients, which is helpful for the disease diagnosis and treatment.

Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color. Part II: Differences in clinical presentation and disparities in cutaneous disorders in skin of color

Skin of color (SOC) patients are projected to comprise the majority of the population by 2044, yet knowledge gaps in the clinical presentation and treatment of both common and uncommon dermatologic conditions in skin of color persist. Improved awareness of disparities that disproportionately impact SOC patients is necessary to address health inequity in the field of dermatology. The first part of this CME discussed structural, genetic, and immunophenotypic differences in SOC in common inflammatory disorders as well as cutaneous malignancies. The second part of this CME highlights clinical differences in the phenotypic presentation of the inflammatory disorders of atopic dermatitis, psoriasis, and hidradenitis suppurativa as well as the cutaneous malignancies of melanoma, basal cell carcinoma, and cutaneous T-cell lymphoma. Health disparities associated with each of these conditions are also discussed.

Variations in genetics, biology, and phenotype of cutaneous disorders in skin of color - Part I: Genetic, biologic, and structural differences in skin of color

Skin of color (SOC) populations include those who identify as Black/African, Hispanic/Latinx, Asian/Pacific Islander, American Indian/Native Alaskan, Indigenous Australian, Middle Eastern, biracial/multiracial, or non-White; this list is far from exhaustive and may vary between and within cultures. Recent genetic and immunological studies have suggested that cutaneous inflammatory disorders (atopic dermatitis, psoriasis, and hidradenitis suppurativa) and malignancies (melanoma, basal cell carcinoma, and cutaneous T-cell lymphoma) may have variations in their immunophenotype among SOC. Additionally, there is growing recognition of the substantial role social determinants of health play in driving health inequalities in SOC communities. It is critically important to understand that social determinants of health often play a larger role than biologic or genetic factors attributed to "race" in health care outcomes. Herein, we describe the structural, genetic, and immunological variations and the potential implications of these variations in populations with SOC. This article underscores the importance of increasing the number of large, robust genetic studies of cutaneous disorders in SOC to create more targeted, effective therapies for this often underserved and understudied population. Part II of this CME will highlight the clinical differences in the phenotypic presentation of and the health disparities associated with the aforementioned cutaneous disorders in SOC.

Outcomes of Biologic Use in Asian Compared with Non-Hispanic White Adult Psoriasis Patients from the CorEvitas Psoriasis Registry

INTRODUCTION

Real-world data are limited comparing Asian and White patients with psoriasis using biologic therapy. This study compared the 6-month effectiveness of biologic therapy between Asian and White plaque patients with psoriasis in the CorEvitas Psoriasis Registry.

METHODS

Analyses included biologic initiations and 6-month follow-up visits from self-identified Asian (n = 293) and White (n = 2314) patients in the USA/Canada (4/2015-4/2020). Outcomes included: Psoriasis Area Severity Index (PASI) 75, disease activity measures [body surface area (BSA) ≤ 1, BSA ≤ 3, PASI90, PASI100, Investigator's Global Assessment (IGA) 0/1], and patient-reported outcomes [Dermatology Life Quality Index (DLQI) 0/1, itch, fatigue, skin pain, EuroQoL visual analog scale (EQ-VAS), patient global assessment, Work Productivity Activity and Impairment (WPAI) domains]. Unadjusted regression models were used to calculate odds ratios (OR) and 95% confidence intervals (CI) for achievement of binary outcomes and difference in mean change in continuous outcomes (β, 95% CI) at 6 months, followed by adjustment for age, sex, body mass index, alcohol, smoking, health insurance, education, comorbidities, scalp psoriasis morphology, psoriatic arthritis, biologic class, previous biologics, and baseline outcome value.

RESULTS

Asians had lower proportions of women (32.8% versus 49.1%) and obesity (27.3% versus 54.5%), and higher proportions on Medicaid (19.9% versus 8.8%), graduated college (50.9% versus 40.1%) and never smoked (67.1% versus 44.1%). In unadjusted analyses, Asians had 52% higher odds of achieving PASI75 versus White patients (OR 1.52; 95% CI 1.15, 2.02). After adjustment, the association was attenuated (OR 1.11; 0.81, 1.52). Secondary outcomes experienced similar patterns except for DLQI: Asians had 33% lower odds of achieving DLQI 0/1 in both the unadjusted (OR 0.67; 0.50, 0.90) and adjusted (OR 0.67; 0.49, 0.92) models.

CONCLUSION

Unadjusted differences in biologic therapy effectiveness between Asians compared with White patients were likely explained by differences in demographic, lifestyle, and psoriatic disease characteristics between groups. However, Asians still experienced lesser improvements in skin-related quality of life, even after adjustment.

Mapping opportunities for the earlier diagnosis of psoriasis in primary care settings in the UK: results from two matched case-control studies

BACKGROUND

The diagnosis of psoriasis may be missed or delayed in primary care settings.

AIM

To examine trends in healthcare events before a diagnosis of psoriasis.

DESIGN AND SETTING

Two matched case-control studies using electronic healthcare records delineated from the Clinical Practice Research Datalink (CPRD GOLD and Aurum) in the UK.

METHOD

Individuals aged ≥18 years with an incident diagnosis of psoriasis (case group) between 1 January 2010 and 29 December 2017 were identified and matched by age, sex, and general practice with six individuals without psoriasis (control group). Healthcare activities were examined and annual incidence rates and incidence rate ratios (IRRs) with 95% confidence intervals (CIs) for 10 years before the index date were compared between case and control groups.

RESULTS

There were 17 320 people with psoriasis and 99 320 controls included from CPRD GOLD, and 11 442 people with psoriasis and 65 840 controls extracted from CPRD Aurum. Data from CPRD GOLD showed that people with psoriasis were up to eight times more likely to be diagnosed with pityriasis rosea at 6 months (IRR 7.82, 95% CI = 4.09 to 14.95) before the index date than the control group. The case group were twice as likely to be diagnosed with eczema (IRR 1.90, 95% CI = 1.76 to 2.05) or tinea corporis (IRR 1.99, 95% CI = 1.74 to 2.27) 1 year before the index date. The case group were more likely to report dry skin, rash, skin texture changes, and itching than the control group up to 5 years before the index date. The most frequently reported clinical feature was rash with an IRR of 2.71 (95% CI = 2.53 to 2.92) at 1 year before the index date. The case group were prescribed topical corticosteroids (IRR 1.97, 95% CI = 1.88 to 2.07) or topical antifungals (IRR 1.92, 95% CI = 1.78 to 2.07) in the year before the index date twice as often as those in the control group.

CONCLUSION

Findings suggest that the diagnosis of psoriasis may be missed or delayed in a UK primary care setting for up to 5 years for some individuals, hence leading to a potentially detrimental delay in establishing an appropriate treatment regimen.

Elevation of IgE in patients with psoriasis: Is it a paradoxical phenomenon?

Immunoglobulin E (IgE) elevation is a hallmark of allergic conditions such as atopic dermatitis (AD). The pathogenesis of AD is typically associated with high levels of IL-4 and IL-13 produced by activated T helper 2 (Th2) cells. Psoriasis, on the other hand, is an inflammatory skin disease mainly driven by Th17 cells and their related cytokines. Although the immunopathologic reactions and clinical manifestations are often easily distinguished in the two skin conditions, patients with psoriasis may sometimes exhibit AD-like manifestations, such as elevated IgE and persistent pruritic lesions. Given the fact that the effective T cells have great plasticity to re-differentiate in response to innate and environmental factors, this unusual skin condition could be a consequence of a cross-reaction between distinct arms of T-cell and humoral immunity. Here we review the literature concerning the roles of IgE in the development of AD and psoriasis, showing that elevated IgE seems to be an important indicator for this non-typical psoriasis.

The Impact of Pruritus on the Quality of Life and Sleep Disturbances in Patients Suffering from Different Clinical Variants of Psoriasis

Background: Quality of life (QoL) and sleep, which are essential for well-being in the mental, physical, and socioeconomic domains, are impaired in psoriatic patients. However, the exact role of the clinical subtype of psoriasis in this aspect remains poorly studied. Objectives: The aim of this study was to investigate differences in QoL impairment and sleeping problems in patients suffering from various clinical subtypes of psoriasis and to evaluate the effects of pruritus on QoL. Methods: This cross-sectional, multicenter study included 295 eligible subjects with diagnosed psoriasis. Each patient was examined with the use of the same questionnaire. Measures included predominant subtype of psoriasis, disease severity, pruritus scores, patients’ health-related QoL and the incidence of sleep disturbance. Results: The QoL of most patients was decreased irrespectively of clinical psoriasis subtype, however, the most impaired QoL was in patients with erythrodermic psoriasis. The majority of patients reported sleep disturbances caused by pruritus, albeit there was no relevant differences between analyzed subgroups in this aspect of patients’ well-being. Pruritus was an important factor determining QoL and sleeping problems in the studied population. Conclusions: Identifying the most disturbing area of life and recognizing the most bothersome subjective symptoms of psoriasis are pivotal to focusing on the most relevant treatment goal and achieving therapeutic success.

Unmet Need in People with Psoriasis and Skin of Color in Canada and the United States

The experience of dermatological conditions such as psoriasis is different for people with skin of color (SoC) than for white individuals. The objective of this literature review was to understand challenges and unmet needs associated with access to care, diagnosis, and treatment of psoriasis among people with SoC in Canada and the United States. The review focused on studies published in the last 5 years. After screening 919 unique records, 26 studies were included. Importantly, lack of culturally competent care was identified as a key unmet need for psoriasis among people with SoC. In addition, cost of care and cultural views of psoriasis may influence decisions to seek care among people with SoC. Baseline patient characteristics in psoriasis studies and the prevalence/incidence of psoriasis vary across racial/ethnic groups, which may reflect differences in the rate and/or timing of diagnosis. The presentation of psoriasis differs across racial/ethnic groups, which may contribute to challenges in proper and timely diagnosis. Compared with white patients with psoriasis, individuals with SoC may be less familiar with and have different rates of treatment with biologic therapies for psoriasis, are more likely to be hospitalized for psoriasis, and their access to physicians may differ. Further, people with SoC are underrepresented in clinical trials of psoriasis therapies. Overall, the results of this literature review suggest that people with psoriasis and SoC face unique challenges in their disease experience. It is essential that clinicians and other stakeholders recognize and address these disparities to ensure equitable care.

Skin conditions such as psoriasis are experienced differently by people with skin of color (SoC) compared with white individuals. Although it is known that psoriasis can vary in how it appears between these groups, other factors that affect care for patients with SoC are not well understood. For this review, we focused on challenges associated with accessing healthcare, receiving a diagnosis, and receiving treatment for psoriasis among people with SoC. A search of the academic literature identified several such challenges for people with SoC in Canada and the United States. A major challenge for people with psoriasis and SoC is having access to care that is compatible with their cultural values and practices. The cost of healthcare and cultural views of psoriasis may influence whether individuals with SoC decide to seek care. People with SoC are more likely to be hospitalized for psoriasis, and their access to physicians may differ compared with white individuals. In addition, differences in how psoriasis appears across racial/ethnic groups may hinder diagnosis. Psoriasis treatments that patients with SoC receive may differ from those that white individuals receive, and people with SoC may be less likely to be properly represented in clinical trials evaluating psoriasis therapies. Taken together, the findings of our review indicate that people with psoriasis and SoC face unique challenges in how they receive medical care for their condition. It is essential that clinicians and other stakeholders in the healthcare system recognize these challenges and work to address them.

A Pilot Study to Assess the Reliability of Digital Image-Based PASI Scores Across Patient Skin Tones and Provider Training Levels

Introduction

The ability to perform psoriasis skin assessments remotely through digital image-based psoriasis area and severity index (DIB-PASI) would be a valuable tool for psoriasis clinical trials. An ideal teledermatological assessment would be robust across patients of diverse skin tones as well as across assessors of varying experience levels. In this pilot study, we evaluated the reliability of face-to-face (FTF) versus DIB-PASI scores determined by trained clinical assessors with a spectrum of experience and with patients of different skin tones.

Methods

Fourteen subjects of varying skin tones with moderate-to-severe plaque psoriasis were treated with adalimumab. In-person PASI assessments and digital photography were performed in the clinic at weeks 0, 12, and 24. Photographs were reviewed by four independent assessors to derive a digital image-based PASI score. The concordance of face-to-face PASI (FTF-PASI) and DIB-PASI were analyzed across patient and assessor factors.

Results

Overall concordance between FTF-PASI and DIB-PASI was high (ICC 0.82, p < 0.0001), with good agreement across individual assessors. When analyzed by PASI score component or body region, digital assessors also demonstrated good agreement with the FTF assessor. Similarly, DIB-PASI showed high concordance with FTF-PASI for patients with light skin tones and patients with medium-to-dark skin tones, and across clinical training levels.

Conclusion

Overall, PASI scores derived from digital images showed good agreement with those determined in person. Importantly, these remote assessments were reliable for both light and medium-to-dark skin tones, and robust to training level of the assessor. The findings from this pilot study lay the foundation for expanding teledermatology-based clinical trials for patients with psoriasis and enabling accurate, remote monitoring of disease severity and therapy response.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-022-00750-w.

Causal Effects of Circulating Cytokines on the Risk of Psoriasis Vulgaris: A Mendelian Randomization Study

Background: Psoriasis vulgaris is an inflammatory skin disease. Observational studies have shown associations between circulating cytokine levels and psoriasis vulgaris. But the causal relationship between circulating cytokine and psoriasis vulgaris remains elusive.

Methods: To assess the causal effects of cytokine levels on the risk of psoriasis vulgaris and vice versa, we performed a two-sample Mendelian randomization (MR) study by using the inverse-variance weighted (IVW), weighted median, and Mendelian randomization pleiotropy residual sum and outlier (MR-PRESSO) in genome-wide association summary statistics of 41 circulating cytokines in up to 8,293 individuals and psoriasis vulgaris in 399,883 individuals.

Results: We identified that increasing RANTES level induced an elevated risk of psoriasis vulgaris in IVW (β = 0.33, S.E. = 0.12, p = 0.006). This causal effect showed consistency across the weighted median (β = 0.35, S.E. = 0.15, p = 0.022) and MR-PRESSO method (β = 0.33, S.E. = 0.11, p = 0.028).

Conclusions: Our results suggest a potential causal effect of elevated RANTES concentration on the increased risk of psoriasis vulgaris.

Roles Played by Stress-Induced Pathways in Driving Ethnic Heterogeneity for Inflammatory Skin Diseases

Immune-mediated skin conditions (IMSCs) are a diverse group of autoimmune diseases associated with significant disease burden. Atopic dermatitis and psoriasis are among the most common IMSCs in the United States and have disproportionate impact on racial and ethnic minorities. African American patients are more likely to develop atopic dermatitis compared to their European American counterparts; and despite lower prevalence of psoriasis among this group, African American patients can suffer from more extensive disease involvement, significant post-inflammatory changes, and a decreased quality of life. While recent studies have been focused on understanding the heterogeneity underlying disease mechanisms and genetic factors at play, little emphasis has been put on the effect of psychosocial or psychological stress on immune pathways, and how these factors contribute to differences in clinical severity, prevalence, and treatment response across ethnic groups. In this review, we explore the heterogeneity of atopic dermatitis and psoriasis between African American and European American patients by summarizing epidemiological studies, addressing potential molecular and environmental factors, with a focus on the intersection between stress and inflammatory pathways.

Annoying Psoriasis and Atopic Dermatitis: A Narrative Review

Skin is an important organ that mainly functions as a barrier. Skin diseases can damage a person's self-confidence and reduce their willingness to socialize, as well as their social behavior and willingness. When the skin appearance is abnormal, in addition to affecting the quality of life, it often leads to personal, social, and psychological dysfunction and even induces depression. Psoriasis and atopic dermatitis are common chronic skin diseases. Their prevalence in the world is 3-10%, and there is an increasing trend year by year. These congenital or acquired factors cause the dysfunction of the immune system and then destroy the barrier function of the skin. Because these patients are flooded with a variety of inflammatory mediators, this causes skin cells to be in chronic inflammation. Therefore, psoriasis and atopic dermatitis are also considered systemic chronic inflammatory diseases. In the healthcare systems of developed countries, it is unavoidable to spend high costs to relieve symptoms of psoriasis and atopic dermatitis patients, because psoriasis and atopic dermatitis have a great influence on individuals and society. Giving a lot of attention and developing effective treatment methods are the topics that the medical community must work on together. Therefore, we used a narrative review manuscript to discuss pathogenesis, clinical classification, incidence, and treatment options, including topical medication, systemic therapeutics, immunosuppressive medication for psoriasis, and atopic dermatitis, as well as also comparing the differences between these two diseases. We look forward to providing readers with comprehensive information on psoriasis and atopic dermatitis through this review article.

Ginsenoside Rg1 ameliorates psoriasis-like skin lesions by suppressing proliferation and NLRP3 inflammasomes in keratinocytes

As a common chronic skin disease, psoriasis is characterized by the involvement of congenital acquired inflammatory immune diseases. In the study, our results indicated the effect of ginsenoside Rg1 on psoriasis-like skin and the potential protection mechanisms that have not yet been investigated. In vivo, psoriasis-like skin mice model was induced by imiquimod (IMQ), then was treated by ginsenoside Rg1 for consecutive 4 weeks to evaluate its effect, respectively. In vitro, M5 cocktail treatment of human immortalized keratinocyte HaCaT-induced psoriasis-like skin cell model, which was exposed to ginsenoside Rg1. The inflammatory cell infiltration, expression level of keratinocyte proliferation marker Ki67, keratinocyte proliferation, inflammatory cytokines, and ROS/NLRP3 pathway-related proteins in vivo and in vitro were examined by hematoxylin and eosin, immunohistochemistry, ELISA, CCK-8, flow cytometry, and western blot. All results demonstrated that ginsenoside Rg1 attenuated the injury of psoriasis-like skin, which inhibited the proliferation of skin keratinocytes and the activation of NLRP3 inflammasome and the level of inflammatory factors such as IL-1β and IL-18, and decreased the level of Ki67, NLRP3, and caspase-1 in mice and HaCaT. Furthermore, NLRP3 overexpression attenuates the effect of ginsenoside Rg1 on M5 cocktail-induced proliferation and NLRP3 inflammasomes in HaCaT. These results demonstrated that ginsenoside Rg1 could suppress the ROS/NLRP3 pathway to treat psoriasis-like skin. PRACTICAL APPLICATIONS: This is the very first study to explore the efficacy of ginsenoside Rg1 against psoriasis-like skin lesions to reveal the underlying mechanism. In this paper, the detection of skin histopathological analysis, CCK-8, flow cytometry, western blot, and ELISA analysis shows that ginsenoside Rg1 has preventive effect on psoriasis caused by imiquimod or M5 cocktail through inhibiting NLRP3 inflammasome, which helps in the development of novel nutraceutical/functional food against psoriasis and thus could improve the quality of life in psoriasis patients.

Racial/Ethnic Health Disparities in Dermatology in the United States Part 2: Disease-specific Epidemiology, Characteristics, Management, and Outcomes

Racial and ethnic disparities in dermatology negatively affect outcomes such as mortality and quality of life. Dermatologists and dermatologic surgeons should be familiar with disease-specific inequities that may influence their practice. The second article in this two-part continuing medical education series highlights gaps in frequency, clinical presentation, management, and outcomes by race and ethnicity. We review cutaneous malignancies including basal cell carcinoma, squamous cell carcinoma, melanoma, Merkel cell carcinoma, dermatofibrosarcoma protuberans, and cutaneous T cell lymphoma, and inflammatory disorders including atopic dermatitis, psoriasis, hidradenitis suppurativa, acne vulgaris, and rosacea.

Prevalence and consequences of psoriasis in recent axial spondyloarthritis: an analysis of the DESIR cohort over 6 years

OBJECTIVES

The consequences of psoriasis associated to axial spondyloarthritis (axSpA) are unclear. The objectives were to determine the prevalence and the consequences of psoriasis in recent axSpA over 6 years of follow-up.

METHODS

The multicentric prospective cohort DESIR (NCT01648907) of adult patients with recent inflammatory back pain suggestive of axSpA was analysed over 6 years. Psoriasis was recorded at each visit and cumulative prevalence and incidence were calculated. Patients with vs without psoriasis at any time point were compared. Outcomes included disease activity (Ankylosing Spondylitis Disease Activity Score-C reactive protein (ASDAS-CRP), joint and enthesitis count, CRP), patient-reported outcomes for function (Health Assessment Questionnaire for axSpA, HAQ-AS) and quality of life, and treatment use over 6 years. Outcomes were compared through univariable and multivariable analyses, as well as linear mixed effect models.

RESULTS

In 589 patients, mean age 40.5±8.7 years, 45.8% men and baseline mean symptom duration 1.5±0.9 years, the cumulative prevalence of psoriasis increased from 16.8% (99/589) at baseline to 26.8% (158/589) at 6 years, leading to an incidence of 2.1/100 patient-years. Over 6 years of follow-up, patients with psoriasis developed more synovitis (p=0.008), and received more methotrexate (cumulative use, 25.5% vs 11.8%, p<0.001) and biological disease-modifying drugs (55.7% vs 38.5%, p<0.001). There were no significant consequences of psoriasis on other outcomes, including disease activity (ASDAS-CRP), functional capacity (HAQ-AS) and quality of life.

CONCLUSION

Psoriasis is frequent in early axSpA. AxSpA patients with psoriasis had more swollen joints over time and received more biologics; they did not have worse outcomes related to axSpA in terms of activity and severity.

TRIAL REGISTRATION NUMBER

NCT01648907.

Deucravacitinib in Moderate to Severe Psoriasis: Clinical and Quality-of-Life Outcomes in a Phase 2 Trial

Introduction

Deucravacitinib is an oral, selective tyrosine kinase 2 inhibitor that demonstrated therapeutic benefit in a Phase 2 clinical trial of adults with moderate to severe plaque psoriasis. This analysis was designed to evaluate the effect of deucravacitinib on additional clinical and quality-of-life (QoL) outcomes and assess the relationship between these outcomes in adults with psoriasis.

Methods

Post-hoc analysis of a 12-week Phase 2 trial was conducted for the three most efficacious dosage groups (3 mg twice daily, 6 mg twice daily, 12 mg once daily) and placebo. Investigator assessments for efficacy included Psoriasis Area and Severity Index (PASI), body surface area (BSA) involvement, and static Physician's Global Assessment; QoL was assessed using the Dermatology Life Quality Index (DLQI). Treatment responses and their associations were evaluated over time.

Results

Deucravacitinib elicited improvement versus placebo as early as Week 4 for most efficacy measures (including changes in absolute PASI and BSA), with efficacy trends observed from Week 2 to Week 12. Improvements in QoL, assessed by achievement of a DLQI overall score of 0/1 (no effect at all on patient’s life), followed a pattern similar to deucravacitinib-related clinical outcomes over 12 weeks. Overall, patients with greater improvements in psoriasis-related clinical signs and symptoms also reported greater improvement in QoL. However, complete skin clearance was not required for achieving DLQI 0/1.

Conclusion

Deucravacitinib treatment produced early response and similar trends in improvements across multiple efficacy assessments and QoL in moderate to severe plaque psoriasis. Deucravacitinib has the potential to become a promising new oral therapy for this condition.

Trial Registration

ClinicalTrials.gov identifier; NCT02931838.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00649-y.

Psoriasis is a skin disease that affects up to 2% of the population. In psoriasis, red, scaly lesions develop on the skin driven by an aberrant immune response. Psoriasis impacts not only physical and mental health but also quality of life (QoL). Deucravacitinib is being investigated as a treatment for psoriasis. We performed a Phase 2 dose-ranging, placebo-controlled, 12-week study of deucravacitinib in adults with moderate to severe psoriasis. Patients in the USA, Australia, Canada, Germany, Japan, Latvia, Mexico, and Poland participated. The study showed that oral treatment with deucravacitinib was effective using a disease severity score (percentage of patients with ≥ 75% reduction from baseline in Psoriasis Area and Severity Index score) at Week 12—placebo 7% and deucravacitinib 67%–75% for the three highest dosages—and was generally well tolerated. We further analyzed the association between efficacy and a QoL measure, the Dermatology Life Quality Index (DLQI), in patients who received placebo or the most effective dosages of deucravacitinib (≥ 3 mg twice daily). Deucravacitinib was effective at the three dosage levels tested. Skin improvement occurred early during treatment and was mirrored by improvements in DLQI score during the 12 weeks of treatment. Although some patients did not have complete clearance of their psoriasis, a large percentage of those patients still achieved considerable improvement in QoL as measured by achieving a DLQI score of 0/1 (i.e., no effect at all on the patient’s QoL).

The Global, Regional, and National Burden of Psoriasis: Results and Insights From the Global Burden of Disease 2019 Study

Background: Psoriasis is a common, chronic, inflammatory, debilitating, systemic disease with a great impact on healthcare systems worldwide. As targeted therapies have transformed the therapeutic landscape, updated estimates of the Global Burden of Disease (GBD) imposed by psoriasis are necessary in order to evaluate the effects of past health care policies and to orient and inform new national and international healthcare strategies. Methods: Data were extracted from the GBD 2019 study, which collates a systematic review of relevant scientific literature, national surveys, claims data, and primary care sources on the prevalence of psoriasis. Prevalence data were combined with disability weight (DW) to yield years lived with disability (YLDs). Measures of burden at global, regional, and national levels were generated for incidence, prevalence, and YLDs, due to psoriatic disease. All measures were reported as absolute numbers, percentages, and crude and age-adjusted rates per 100,000 persons. In addition, psoriasis burden was assessed by socio-demographic index (SDI). Findings: According to the GBD 2019 methodology, there were 4,622,594 (95% uncertainty interval or UI 4,458,904-4,780,771) incident cases of psoriasis worldwide in 2019. The age-standardized incidence rate in 2019 was 57.8 (95% UI 55.8-59.7) per 100,000 people. With respect to 1990, this corresponded to a decrease of 20.0% (95% UI -20.2 to -19.8). By sex, the age-standardized incidence rate was similar between men [57.8 (95% UI 55.8-59.8) per 100,000 people] and women [(57.8 (95% UI 55.8-59.7) per 100,000 people]. With respect to 1990, this corresponded to a decrease by 19.5% (95% UI -19.8 to -19.2) and by 20.4% (95% UI -20.7 to -20.2) for men and women, respectively. The age-standardized incidence rate per 100,000 persons was found to vary widely across geographic locations. Regionally, high-income countries and territories had the highest age-standardized incidence rate of psoriasis [112.6 (95% UI 108.9-116.1)], followed by high-middle SDI countries [69.4 (95% UI 67.1-71.9)], while low SDI countries reported the lowest rate [38.1 (95% UI 36.8-39.5)]. Similar trends were detected for prevalence and YLDs. Conclusion: In general, psoriasis burden is greatest in the age group of 60-69 years, with a relatively similar burden among men and women. The burden is disproportionately greater in high-income and high SDI index countries of North America and Europe. With advances in psoriasis therapeutics, objective evaluation of psoriasis disease burden is critical to track the progress at the population level.

Astragalus mongholicus Bunge Water Extract Exhibits Anti-inflammatory Effects in Human Neutrophils and Alleviates Imiquimod-Induced Psoriasis-Like Skin Inflammation in Mice

Neutrophils are the primary immune cells in innate immunity, which are related to various inflammatory diseases. Astragalus mongholicus Bunge is a Chinese medicinal herb used to treat various oxidative stress-related inflammatory diseases. However, there are limited studies that elucidate the effects of Astragalus mongholicus Bunge in human neutrophils. In this study, we used isolated human neutrophils activated by various stimulants to investigate the anti-inflammatory effects of Astragalus mongholicus Bunge water extract (AWE). Cell-free assays were used to examine free radicals scavenging capabilities on superoxide anion, reactive oxygen species (ROS), and nitrogen-centered radicals. Imiquimod (IMQ) induced psoriasis-like skin inflammation mouse model was used for investigating anti-psoriatic effects. We found that AWE inhibited superoxide anion production, ROS generation, and elastase release in human neutrophils, which exhibiting a direct anti-neutrophil effect. Moreover, AWE exerted a ROS scavenging ability in the 2,2’-Azobis (2-amidinopropane) dihydrochloride assay, but not superoxide anion in the xanthine/xanthine oxidase assay, suggesting that AWE exhibited anti-oxidation and anti-inflammatory capabilities by both scavenging ROS and by directly inhibiting neutrophil activation. AWE also reduced CD11b expression and adhesion to endothelial cells in activated human neutrophils. Meanwhile, in mice with psoriasis-like skin inflammation, administration of topical AWE reduced both the affected area and the severity index score. It inhibited neutrophil infiltration, myeloperoxidase release, ROS-induced damage, and skin proliferation. In summary, AWE exhibited direct anti-inflammatory effects by inhibiting neutrophil activation and anti-psoriatic effects in mice with IMQ-induced psoriasis-like skin inflammation. Therefore, AWE could potentially be a pharmaceutical Chinese herbal medicine to inhibit neutrophilic inflammation for anti-psoriasis.

Maternal and neonatal outcomes of births to women with psoriasis: a population-based cohort of 13 million births

PURPOSE

Psoriasis is a common auto-immune disease affecting the skin and joints for which the current literature remains limited and contradictory in the context of pregnancy. The purpose of our study was to evaluate the association between psoriasis in pregnancy and maternal and newborn outcomes.

METHODS

A population based retrospective cohort study was conducted using the 1999-2015 United States' Healthcare Cost and Utilization Project Nationwide Inpatient Sample. ICD-9 codes were used to identify delivery admissions to women with or without psoriasis, as well as maternal and fetal outcomes. Adjusting for baseline characteristics, multivariate logistic regression models were performed to estimate the effects of psoriasis on maternal and newborn outcomes.

RESULTS

The cohort consisted of 3737 women with psoriasis, among a total of 13,792,544 pregnancy admissions in US hospitals between the years 1999 and 2015, for a period prevalence of 27.1 cases per 100,000 pregnant women. Psoriasis was associated with preeclampsia, OR 1.4 (95% CI 1.2-1.6), gestational diabetes, 1.27 (1.13-1.42), myocardial infarction, 13.4 (3.3-54.6), chorioamnionitis, 1.3 (1.0-1.6), delivery by cesarean section, 1.2 (1.1-1.3), anemia, 1.74 (1.18-2.57), and requiring blood transfusions, 1.4 (1.0-1.8). Their newborns were at higher risk of being born preterm, 1.2 (1.1-1.4), congenital anomalies, 1.7 (1.2-2.4), and intra-uterine growth restriction, 1.5 (1.2-1.7).

CONCLUSION

Women with psoriasis and their newborns appear more prone to adverse outcomes of pregnancy. It would be prudent for these women to be followed closely during pregnancy by their obstetrical caregiver and dermatologist. Further investigation is warranted regarding the management of psoriasis during pregnancy.

Impact of moderate-to-severe psoriasis on quality of life in China: a qualitative study

Purpose

Psoriasis is a serious health problem. Since limited research has investigated the impact of psoriasis on the quality of life of patients with moderate-to-severe psoriasis, this study aimed to explore this issue.

Methods

A qualitative study was conducted with 22 psoriasis patients from two cities in Shandong province of eastern China participating in one-to-one semi-structured in-depth interviews.

Results

Thematic analysis generated five major themes: (1) Symptoms, symptoms management and pain; (2) Functioning and activities of daily living (ADLs); (3) Psychological impact; (4) Social impact; (5) Employment and finances.

Conclusion

Our study detailed the effects of psoriasis on patients’ symptoms, symptoms management and pain, functioning and activities of daily living (ADLs), psychological impact, social impact, employment and finances. These data can provide a reference for studying the quality of life in patients with psoriasis.

Topical corticosteroids for noninvasive treatment of pyogenic granulomas

Pyogenic granulomas are benign vascular proliferations of the skin and mucous membranes that tend to bleed easily. They typically require procedural treatments that can be difficult for patients with intellectual disabilities or behavioral concerns to tolerate. In our practice, we have found the use of topical clobetasol to be effective to induce regression of cutaneous pyogenic granulomas. We present here a case of an adolescent patient with autism and two bleeding pyogenic granulomas who poorly tolerated a biopsy of the first lesion and could not tolerate subsequent procedures. Topical therapy with clobetasol effectively managed the second pyogenic granuloma, an approach representative of a noninvasive practice utilized in our clinic.

Psychometric Validation of the Psoriasis Symptoms and Impacts Measure (P-SIM): A Novel Patient-Reported Outcome Instrument for Patients with Plaque Psoriasis, Using Reported Data from the BE RADIANT Phase 3b Trial

Introduction

This analysis assessed the psychometric properties of the Psoriasis Symptoms and Impacts Measure (P-SIM), a novel patient-reported outcome (PRO) tool designed to capture patient experiences of the signs, symptoms and impacts of psoriasis.

Methods

Blinded data from the BE RADIANT phase 3b trial of bimekizumab were analysed. In BE RADIANT, patients were randomised 1:1 to bimekizumab 320 mg every 4 weeks (Q4W) or secukinumab 300 mg (weekly until Week 4, then Q4W). Three items (itching, skin pain and scaling) of the P-SIM were electronically assessed throughout the trial and were scored from 0 to 10 (none to very severe signs/symptoms/impacts). Test–retest reliability was determined using intraclass correlations. Convergent validity was assessed between P-SIM and other relevant PRO and clinician-reported outcome (ClinRO) scores. Known-groups validity was assessed by comparing mean P-SIM item scores between patient subgroups based on the Psoriasis Area and Severity Index (PASI)/Investigator’s Global Assessment (IGA) scores. Responsiveness was assessed via correlations between changes from baseline in P-SIM item scores and other relevant PRO and ClinRO scores. Anchor-based responder analyses and empirical cumulative distribution function (eCDF) curves determined responder thresholds.

Results

The three P-SIM items yielded high intraclass coefficients (> 0.70). By Week 48, the three P-SIM items had moderate (> 0.30 and ≤ 0.50) to strong (> 0.50) correlations with other PROs and weaker correlations with ClinROs, demonstrating good convergent validity. For almost all known-group comparisons, statistically significant between-subgroup score differences were seen across all three P-SIM items. Changes from baseline in the P-SIM and other relevant outcomes were above the acceptable threshold of ≤ 0.30, demonstrating sensitivity to change. Anchor-based analyses determined a ≥ four-point reduction from baseline to indicate marked clinically meaningful improvement for the P-SIM.

Conclusion

These results support the validity, reliability and sensitivity to change of the P-SIM in assessing key symptoms (itching, skin pain and scaling) in patients with moderate to severe plaque psoriasis.

Trial registration

NCT03536884.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01836-1.

Psychometric Validation of the Psoriasis Symptoms and Impacts Measure (P-SIM), a Novel Patient-Reported Outcome Instrument for Patients with Plaque Psoriasis, Using Data from the BE VIVID and BE READY Phase 3 Trials

INTRODUCTION

Plaque psoriasis can significantly impact patients' quality of life. We assessed psychometric properties of the Psoriasis Symptoms and Impacts Measure (P-SIM), developed to capture patients' experiences of signs, symptoms and impacts of psoriasis.

METHODS

Pooled, blinded, 16-week data from 1002 patients in the BE VIVID and BE READY bimekizumab phase 3 trials were analysed. The suitability of the P-SIM missing score rule (weekly scores considered missing if ≥ 4 daily scores were missing) was assessed. Test-retest reliability was evaluated using intraclass correlation coefficients (ICCs). Convergent validity was assessed between P-SIM and relevant patient-reported outcome (PRO) (Dermatology Life Quality Index [DLQI], DLQI item 1 [skin symptoms], Patient Global Assessment of Psoriasis) and clinician-reported outcome (ClinRO) scores (Psoriasis Area and Severity Index [PASI], Investigator's Global Assessment [IGA]) at baseline and week 16. Known-groups validity was assessed, comparing P-SIM scores between patient subgroups predefined using PASI/IGA scores. Sensitivity to change over 16 weeks was evaluated; responder definition (RD) thresholds were explored.

RESULTS

The missing score rule used did not impact P-SIM scores. Test-retest reliability analyses demonstrated excellent score reproducibility (ICC 0.91-0.98). Inter-item correlations at baseline and week 16 were strong (> 0.5), apart from "choice of clothing" with "skin pain" and "burning" at baseline (both 0.49). All P-SIM scores were moderately to strongly correlated with other outcomes, demonstrating convergent validity, apart from ClinROs (PASI, IGA) at baseline that had low variability. P-SIM scores discriminated known groups at week 16, confirming known-groups validity. Changes from baseline to week 16 in P-SIM and other clinically relevant outcomes were strongly correlated (> 0.5; weaker with ClinROs), establishing sensitivity to change. Anchor-based RD analyses determined a four-point P-SIM item score decrease as indicative of marked clinically meaningful improvement.

CONCLUSION

P-SIM scores demonstrated good reliability, validity and sensitivity to change. A four-point RD threshold could be used to assess 16-week treatment effects.

TRIAL REGISTRATION

BE VIVID: NCT03370133; BE READY: NCT03410992.

Association between hepatitis C virus infection and subsequent chronic inflammatory skin disease

Hepatitis C virus (HCV) infection is associated with several cutaneous manifestations, including lichen planus and psoriasis. However, its association with other chronic inflammatory skin diseases (CISD) remains largely unknown. The aim of this study was to investigate the association between HCV infection and CISD. Participants were recruited from the National Health Insurance Research Database in Taiwan. Altogether 23 509 patients with HCV infection and 94 036 matched controls were included to assess the risk of CISD. A Cox regression model was used for the analyses. Compared with controls, patients with HCV infection had an adjusted hazard ratio (aHR) of 6.34 (95% confidence interval [CI], 5.30-7.58) for CISD after adjustment for potential confounders. Regarding individual CISD, patients with HCV infection had a significantly increased risk of developing lichen planus, psoriasis, vitiligo, alopecia areata, and cutaneous lupus erythematosus. Interferon-based antiviral therapy (IFN-based AVT) was significantly associated with a decreased risk of CISD (aHR = 0.42; 95% CI, 0.28-0.64). Patients with HCV infection had a significantly increased risk of CISD, while IFN-based AVT was associated with a decreased risk. These findings suggest monitoring of CISD in patients with HCV infection.

Psoriatic arthritis

Psoriatic arthritis (PsA) is a complex inflammatory disease with heterogeneous clinical features, which complicates psoriasis in 30% of patients. There are no diagnostic criteria or tests available. Diagnosis is most commonly made by identifying inflammatory musculoskeletal features in joints, entheses or the spine in the presence of skin and/or nail psoriasis and in the usual absence of rheumatoid factor and anti-cyclic citrullinated peptide. The evolution of psoriasis to PsA may occur in stages, although the mechanisms are unclear. In many patients, there may be little or no relationship between severity of musculoskeletal inflammation and severity of skin or nail psoriasis. The reason for this disease heterogeneity may be explained by differences in genotype, especially in the HLA region. New targeted therapies for PsA have been approved with additional therapies in development. These developments have substantially improved both short-term and long-term outcomes including a reduction in musculoskeletal and skin manifestations and in radiographic damage. With efforts underway aimed at improving our understanding of the molecular basis for the heterogeneity of PsA, a personalized approach to treating PsA may become possible.