Psoriasis and comorbid diseases: Epidemiology

Psoriasis and Psoriatic Arthritis Cardiovascular Disease Endotypes Identified by Red Blood Cell Distribution Width and Mean Platelet Volume

In a subset of psoriasis (PsO) and psoriatic arthritis (PsA) patients, the skin and/or joint lesions appear to generate biologically significant systemic inflammation. Red cell distribution width (RDW) and mean platelet volume (MPV) are readily available clinical tests that reflect responses of the bone marrow and/or plasma thrombogenicity (e.g., inflammation), and can be markers for major adverse cardiac events (MACE). We aimed to evaluate if RDW and MPV may be employed as inexpensive, routinely obtained biomarkers in predicting myocardial infarction (MI), atrial fibrillation (AF), and chronic heart failure (CHF) in psoriatic and psoriatic arthritis patients. The study was divided into two parts: (a) case control study employing big data (Explorys) to assess MPV and RDW in psoriasis, psoriatic arthritis and control cohorts; (b) a clinical observational study to validate the predictive value of RDW and to evaluate RDW response to anti-psoriatic therapies. We used Explorys, an aggregate electronic database, to identify psoriatic patients with available MPV and RDW data and compared them to gender and age matched controls. The incidence of myocardial infarction (MI), atrial fibrillation (AF), and chronic heart failure (CHF) was highest among patients with both elevated RDW and MPV, followed by patients with high RDW and normal MPV. RDW elevation among PsA patients was associated with an increased risk of MI, AF, and CHF. In a local clinical cohort, high RDWs were concentrated in a subset of patients who also had elevated circulating resistin levels. Among a small subset of participants who were treated with various systemic and biologic therapies, and observed over a year, and in whom RDW was elevated at baseline, a sustained response to therapy was associated with a decrease in RDW. RDW and MPV, tests commonly contained within routine complete blood count (CBC), may be a cost-effective manner to identify PsO and PsA patients at increased risk of MACE.

Association of CYP2J2 polymorphism with susceptibility to psoriasis in Turkish population: a case-control study

BACKGROUND

Cytochrome P450 2J2 is mostly expressed in extrahepatic tissues; it metabolizes arachidonic acid to epoxyeicosatrienoic acids, with various cardio protective and anti-inflammatory effects. CYP2J2 polymorphism has been identified as a risk factor for cardiovascular diseases, but its association with psoriasis remains unknown.

OBJECTIVE

To evaluate CYP2J2 polymorphism as a risk factor for psoriasis in the Turkish population.

METHODS

There were 94 patients with psoriasis and 100 age- and sex-matched healthy controls included in the study. Detailed demographic and clinical characteristics were recorded, and Psoriasis Area and Severity Index (PASI) scores were calculated for psoriasis patients. Venous blood samples were collected from all the participants and CYP2J2 50G>T (rs890293) polymorphism was analyzed using polymerase chain reaction (PCR).

RESULTS

Both T allele and TT+GT genotype frequencies were increased in psoriasis vulgaris patients compared to the control group (p=0.024 and p=0.029 respectively, OR=2.82, 95% CI: 1.11-7.15) No association between CYP2J2 polymorphism and clinical features of psoriasis was identified.

STUDY LIMITATIONS

A limited number of patients were included in the study.

CONCLUSION

CYP2J2 50G>T (rs890293) polymorphism was associated with an increased risk for PsV in the Turkish population.

Risk of non-melanoma skin cancer in patients with psoriasis: An updated evidence from systematic review with meta-analysis

BackgroundPsoriasis is a chronic inflammatory skin disorder which may result in an increased cancer risk due to defects of immune surveillance. The relationship between psoriasis and risk of non-melanoma skin cancer (NMSC) has not yet been fully determined. The aim of this study was to update the evidence on the association between psoriasis and risk of NMSC.

MethodsWe conducted an extensive literature search of publications in Pubmed, EMBASE, and Cochrane Library without restrictions on language from inception through August 2019 using predefined keywords. Eligible observational studies were selected if they assessed the risk ratio of NMSC in patients with psoriasis. Data from included studies were extracted, and meta-analysis was performed using random-effects models.

ResultsSixteen cohort studies involving 16,023,503 participants published between 1999 and 2019 met inclusion criteria and were included in this systematic review. Meta-analysis demonstrated that compared with patients without psoriasis, patients with psoriasis had 1.72 times higher risk of developing NMSC (RR, 1.72, 95% CI 1.46 to 2.02). Patients with moderate to severe psoriasis had higher risk of NMSC (RR, 1.82, 95% CI 1.38 to 2.41) than those had mild psoriasis (RR, 1.61, 95% CI 1.25 to 2.09) (P for interaction<0.001). Moreover, patients with psoriasis had significantly higher risk of squamous cell carcinoma (RR, 2.08, 95% CI 1.53 to 2.83) than that of basal cell carcinoma (RR, 1.28, 95% CI 0.81 to 2.00) (P for interaction<0.001).

ConclusionsCurrent evidence suggests that patients with psoriasis may have a higher risk of NMSC than psoriasis-free patients. Periodic screening for specific cancer risk is warranted in patients with psoriasis.

Nonadherence to Treatment and Patient-Reported Outcomes of Psoriasis During the COVID-19 Epidemic: A Web-Based Survey

PURPOSE

The COVID-19 epidemic has caused difficulties in continuous treatment for patients with chronic diseases and resulted in nonadherence to treatment and adverse health outcomes. This study aimed to investigate the associations of nonadherence to treatment with patient-reported outcomes of psoriasis during the COVID-2019 epidemic.

METHODS

A cross-sectional study among Chinese patients with psoriasis was conducted through a web-based questionnaire survey during 25 Feb 2020 and 6 Mar 2020. Demographic and clinical data, nonadherence to treatment, and patient-reported outcomes were collected. The outcomes included deterioration of the disease condition, perceived stress, and symptoms of anxiety and depression. Logistic regression was used to investigate the associations.

RESULTS

A total of 926 questionnaires were collected. A total of 634 (68.5%) reported nonadherence to treatment, and worse adherence was found among patients receiving systemic treatment (adjusted odds ratio [AOR]: 2.67; 95% CI: 1.40-5.10) and topical treatment (AOR: 4.51; 95% CI: 2.66-7.65) compared to biological treatment. Nonadherence to treatment (less than two weeks and more than two weeks) was significantly associated with deterioration of psoriasis (aOR: 2.83 to 5.25), perceived stress (AOR: 1.86 to 1.57), and symptoms of anxiety (AOR: 1.42 to 1.57) and depression (AORs: 1.78). Subgroup analysis by treatment showed consistent results in general.

CONCLUSION

Nonadherence to treatment was associated with the aggravation of psoriasis conditions, perceived stress, and symptoms of anxiety and depression.

A modern approach to the treatment of plaque psoriasis

Psoriasis is a common chronic inflammatory skin disease which affects 0.5-1 % of children and 2-3 % of the adult population. In Croatia, 1.6 % of the population suffer from psoriasis. Distribution of the disease is bimodal, with the first peak at the age of 20-30, and the second at the age of 50-60. The etiopathogenesis of the disease is multifactorial, the key factors being genetic predisposition combined with immunological disorders, environmental factors and skin barrier damage. There are several clinical variants of the disease. The main signalling pathways in psoriasis include TNF-α, IL-23 and IL-17. Topical agents are used for the treatment of the mild form, and the systemic conventional therapy is used for the treatment of moderate to severe forms of the disease. In cases where's no response, or intolerance or contraindications are present, new targeted medications are to be administered. Development in the field of immunogenetics of psoriasis leads to personalized medicine.

Hyaluronic Acid-Based Dissolving Microneedle Patch Loaded with Methotrexate for Improved Treatment of Psoriasis

Methotrexate (MTX) is one of the first-line treatments for moderate to severe psoriasis, while the side effects caused by injection and oral administration of MTX greatly restrict its clinical application. Transdermal drug delivery offers a desirable alternative to the conventional approaches, but the performances of the currently available skin penetration enhancement techniques are not so satisfactory. To address these limitations, we developed a dissolving microneedle (MN) patch made of hyaluronic acid (HA) with excellent water solubility, biocompatibility, biodegradability, and mechanical properties. The amount of MTX encapsulated in the needles of the patch could be controlled during the fabrication process for precise dosage. Interestingly, the MTX-loaded MNs successfully penetrated imiquimod (IMQ)-induced thickened epidermis in mice and delivered the drug intralesionally. Meanwhile, fast dissolution of HA endowed the MNs with operability for patients. We found that the MTX-loaded MNs not only showed well-maintained inhibitory effect in vitro but also alleviated the psoriasis-like skin inflammation in mice. Moreover, the MTX-loaded MNs were significantly more efficacious than taking the same dose of drug orally. Consequently, a higher oral dose of MTX was required for a comparable amelioration, which in turn increased its systemic toxicity. Taken together, the proposed MTX-loaded dissolving MN patch strategy provides a new opportunity for efficient and safe treatment of psoriasis.

The role of gut microbiome in the pathogenesis of psoriasis and the therapeutic effects of probiotics

The adult intestine hosts a huge number of diverse bacterial species, collectively referred to as the microbiome, that reside mainly in the lower gut, where they maintain a symbiotic relationship with their host. Recent research points to a central role of the microbiome in many biological processes. These microbial communities are influenced by multiple environmental and dietary factors and can modulate immune responses. In addition to local effects on the gastrointestinal tract, the microbiota is associated with effects on other organs and tissues, such as the skin. Indeed, an altered microbiome has been associated with skin disorders in several instances. Thus, in this review, we describe the recent advances regarding the interplay between gut microbiota and the skin. We explore how this potential link affects skin homeostasis and its influence on modulating the cutaneous immune response, focusing on psoriasis disorder. Finally, we discuss how to take advantage of this interplay to manage this disorder, particularly through probiotics administration. In the gastrointestinal tract, the microbiome has been proven to be important in the maintenance of the balance between effector T cells and regulatory T cells, and the induction of immunoglobulin A. Moreover, gut bacterial dysbiosis is associated with chronic inflammatory disorders of the skin, such as psoriasis. Thus, the microbiome can be considered an effective therapeutical target for treating this disorder. Despite some limitations, interventions with probiotics seem promising for the development of a preventive therapy by restoring altered microbiome functionality or as an adjuvant in specific immunotherapy.

Mesenchymal Stem Cells Alleviate Moderate-to-Severe Psoriasis by Reducing the Production of Type I Interferon (IFN-I) by Plasmacytoid Dendritic Cells (pDCs)

The anti-inflammatory and immunomodulatory properties of mesenchymal stem cells (MSCs) have been proposed to be involved in some autoimmune diseases and have been successfully tested in patients and mice. But their contribution to psoriasis and the underlying mechanisms involved remains elusive. Here, we explored the feasibility of using human umbilical cord-derived MSC (hUC-MSC) infusion as a therapeutic approach in an imiquimod- (IMQ-) induced psoriasis mouse model. MSC infusion were found to significantly reduce the severity and development of psoriasis, inhibit the infiltration of immune cells to the skin, and downregulate the expression of several proinflammatory cytokines and chemokines. Our results provide an explanation for the therapeutic effects of MSC infusion by first suppressing neutrophil function and then downregulating the production of type I interferon (IFN-I) by plasmacytoid dendritic cells (pDCs). Therefore, we discovered a novel mechanism of stem cell therapy for psoriasis. In summary, our results showed that MSC infusion could be an effective and safe treatment for psoriasis.

Risankizumab in moderate-to-severe plaque psoriasis

Psoriasis is a chronic inflammatory disease affecting multiple organ systems affecting approximately 2% of the population worldwide. The etiology is multifactorial etiology with multiple co-morbidities complicating the disease. Therapeutic options for patients with moderate-to-severe psoriasis have made tremendous strides since the turn of the century and biologic agents are now generally considered to be safe, efficacious and common options for these patients. However, some patients remain recalcitrant to the current treatment options. Risankizumab is a newly US FDA-approved biologic therapy that inhibits IL-23p19 subunit, which is specific to IL-23. Risankizumab has proven rapid onset, safety and efficacy in moderate-to-severe psoriasis and is currently being studied in other diseases utilizing the IL-23 pathway.

The association between biologic agents and the risk of cardiovascular events in patients with psoriasis and psoriatic arthritis: A protocol for a systematic review and meta-analysis

BACKGROUND

Psoriasis (Pso) is a chronic, recurrent, and inflammatory disease involving genetic and immune factors. Psoriatic arthritis (PsA), accounting for 30% of Pso, is an inflammatory arthropathy. Pso and PsA are associated with increased cardiovascular events (CVEs). Biologic therapies for Pso and PsA are drawing arising attention for its therapeutic effects. Large evidences have shown that biologic agents could lower the risk of CVEs in patients with Pso and PsA. However, not all studies support this point. A systematic review is needed.

METHODS

Four databases (PubMed, Web of Science, The Cochrane Library, and EMBASE) will be searched from the inception to July 1st, 2019. Randomized controlled trials and observational studies (including case-control studies and cohort studies) reporting CVEs in patients with Pso and PsA treated with biologic agents will be included. The primary outcome is the incidence of CVEs. The secondary outcome is the incidence of each individually reported cardiovascular event. Study selection, data extraction, and assessment of quality will be conducted independently by 2 reviewers. RevMan5.3.5 software will be used for data synthesis.

RESULTS

The results of this study will provide evidence for the effect of biologic agents on the risk of CVEs in patients with Pso and PsA, so as to further provide guidance for clinical management.

CONCLUSION

The findings of this study will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42019142778.

Users of biologics in clinical practice: would they be eligible for phase III clinical studies? Cohort Study in the French Psoriasis Registry PSOBIOTEQ

BACKGROUND

Numerous inclusion and exclusion criteria are involved in phase III moderate to severe psoriasis trials investigating the safety and efficacy of biologics. This questions the generalization of results.

METHODS

In this cohort study, we applied inclusion/exclusion criteria for phase III trials from original protocols (adalimumab - REVEAL, ustekinumab - PHOENIX, brodalumab - AMAGINE, secukinumab FIXTURE) to all patients enrolled in the PsoBioTeq prospective registry who received a biological agent for the first time between July 2012 and November 2017. We then compared the efficacy, drug survival and occurrence of adverse events between patients who satisfied/did not satisfy the eligibility criteria for these phase III trials.

RESULTS

A total of 1267 patients were enrolled, of whom 993 (78.4%) were not eligible for at least one RCT (randomized controlled trial) and 251 (19.1%) did not meet the PASI/PGA severity requirements. Apart from disease severity, the most frequent criteria resulting in exclusion were as follows: non-plaque psoriasis (12.6%), significant cardiac disease (8.4%), significant liver disease (7.3%), elevated liver enzymes (4.9-9.6%) and personal history of diabetes (9.2%). There was no difference in drug survival between the two groups. The incidence ratio of adverse events was significantly lower in eligible versus non-eligible patients [0.78 (95% CI 0.62-0.97) (P = 0.03)].

CONCLUSION

The majority of patients treated with biologics in the PsoBioTeq real-life registry would not have been eligible for phase III moderate to severe psoriasis trials. Patients not eligible for psoriasis phase III clinical trials have a higher incidence of adverse events.

Management of psoriasis as a systemic disease: what is the evidence?

Background

Psoriasis is a chronic, systemic immune‐mediated disease characterized by development of erythematous, indurated, scaly, pruritic and often painful skin plaques. Psoriasis pathogenesis is driven by proinflammatory cytokines and psoriasis is associated with increased risk for comorbidities, including, but not limited to, psoriatic arthritis, cardiovascular disease, diabetes mellitus, obesity, inflammatory bowel disease and nonalcoholic fatty liver disease compared with the general population.

Objectives

To explore the pathophysiological relationship between psoriasis and its common comorbidities and discuss the need for new treatment paradigms that include strategies to reduce systemic inflammation in patients with moderate‐to‐severe psoriasis.

Methods

This narrative review summarizes the published evidence related to the ability of biological therapies to ameliorate the consequences of systemic inflammation in patients with psoriasis.

Results

Current evidence suggests that preventing damage associated with inflammation, and preventing development of future inflammatory damage and comorbidities, may be a potentially achievable treatment goal for many patients with moderate‐to‐severe plaque psoriasis when biological therapies are utilized early in the disease. Encouraging data from recent studies suggest that the loftier goal of reversing existing inflammatory damage and improving signs and symptoms of inflammatory comorbidities could also possibly be attainable.

Conclusions

Results from ongoing prospective studies regarding the effects of biologics on markers of systemic inflammation in patients with psoriasis will strengthen the clinical evidence base that can be used to inform treatment decisions for patients with moderate‐to‐severe psoriasis.

What's already known about this topic?

Psoriasis is a systemic inflammatory disease and treatments are needed to optimize patient outcomes.

What does this study add?

This review discusses new psoriasis treatment paradigms that may potentially reduce effects of systemic inflammation.

Evidence demonstrating that biological treatment may prevent or reverse inflammatory damage associated with psoriasis comorbidities is reviewed.

Linked Comment:https://doi.org/10.1111/bjd.18456

Anti-psoriasis effect of water-processed rosin in mice

ETHNOPHARMACOLOGICAL RELEVANCE

Rosin, an exudate of conifer trees such as Pinus masscnlana (Pinaceae), has been used to treat psoriasis for nearly two thousand years in China despite its so far undefined pharmacology. Unfortunately, the rosin intoxication is noted from time to time, but the water-boiled rosin (WBR) has been documented to be safer. This study was performed to evaluate the in vivo anti-psoriasis efficacy of WBR.

MATERIALS AND METHODS

The main phytochemicals in WBR were quantified by high performance liquid chromatography (HPLC). WBR was evaluated in the imiquimod-induced psoriasis-like inflammation mouse model for its anti-psoriasis effect at 130, 260, and 390 mg/kg, which were set according to the dose used for patients. Through a combination of q-PCR, flow cytometry, and histopathological and immunohistochemical (IHC) analysis, the in vivo efficacy was assessed in terms of the psoriasis area severity index (PASI), epidermal keratinocyte proliferation, Th1 and Th17 cell numbers in spleen, and mRNA expressions of inflammatory cytokines.

RESULT

Oral administration of WBR ameliorates the psoriasis-like dermatitis in the imiquimod-generated mouse model. In particular, WBR given at 260 or 390 mg/kg significantly restores the normal keratinization of dorsal lesion if compared with the untreated psoriatic mice. Such an effect was addressed to correlate to the Th1/Th17 cell reduction in spleen and the suppressed expression of IL-17A, IL-17F, IL-22, IL-23, TNF-α, K17, and proliferating cell nuclear antigen (PCNA) after the WBR administration.

CONCLUSION

WBR is effective in the imiquimod-induced psoriasis-like inflammation mouse model with the efficacy arising from its proliferation inhibition of Th1/Th17 cells and epidermal keratinocytes via the down-regulation of the relevant inflammatory cytokines such as IL-23, IL-17A, and IL-17F. Collectively, WBR harvested and processed in the traditional manner is an efficacious psoriasis-treating agent.

Metabolic syndrome is associated with an increased risk of psoriasis: A nationwide population-based study

BACKGROUND

Psoriasis is a chronic inflammatory skin disease characterized by an abnormal T-cell-mediated immune response, and is associated with metabolic syndrome (MetS) and components thereof. However, few prospective studies have investigated the associations between MetS and its components, on the one hand, and the risk of psoriasis, on the other. Therefore, we investigated the association between the presence of MetS and its components and the prospective risk of psoriasis development.

METHODS

In total, 9,718,591 adults (2,595,878 in the MetS group and 7,122,713 in the comparison group) were evaluated using data from the Korean National Health Insurance Service (2009 to 2017).

RESULTS

MetS was positively associated with an increased risk of psoriasis over an 8-year follow-up period after adjusting for age, sex, smoking status, alcohol consumption, physical activity, household income, and body mass index (hazard ratio 1.05, 95% confidence interval 1.04-1.06). The risk of psoriasis tended to increase as the number of MetS components increased, and this trend was significant in obese subjects (P for trend <0.001).

CONCLUSION

Psoriasis was significantly and positively associated with MetS and several components thereof; MetS severity and obesity affected these associations over 8 years of follow-up, suggesting that MetS is a risk factor for the development of psoriasis.

Linkage between patients' characteristics and prescribed systemic treatments for psoriasis: a semantic connectivity map analysis of the Swiss Dermatology Network for Targeted Therapies registry

BACKGROUND

Several treatment options are currently available for the treatment of psoriasis.

OBJECTIVE

To explore the main associations between patients' characteristics and systemic treatments prescribed for psoriasis in a large group of patients observed in real-life clinical practice.

METHODS

This was a retrospective analysis of baseline data collected within the Swiss Dermatology Network for Targeted Therapies registry in Switzerland between March 2011 and December 2017. Semantic map analysis was used in order to capture the best associations between variables taking into account other covariates in the system.

RESULTS

A total of 549 patients (mean age 46.7 ± 14.7 years) were included in the analysis. Conventional therapies such as retinoids and methotrexate were associated with no previous systemic therapies for psoriasis, a moderate quality of life (QoL) at therapy onset and older age (≥60 years). Fumaric acid derivatives were associated with mild psoriasis (psoriasis area severity index < 10) and long disease duration (≥20 years). On the other side, cyclosporine and psoralen and ultraviolet A/ultraviolet B treatments were linked to a more severe condition, including impaired QoL, hospitalization and inability to work. Regarding biological therapies, both infliximab and adalimumab were connected to the presence of psoriatic arthritis, severe disease condition and other comorbidities, including chronic liver or kidney diseases and tuberculosis. Etanercept, ustekinumab and secukinumab were all connected to a complex history of previous systemic treatments for psoriasis, moderate disease condition, overweight and university education.

CONCLUSIONS

The analysis shows multifaceted associations between patients' characteristics, comorbidities, disease severity and systemic treatments prescribed for psoriasis. In particular, our semantic map indicates that comorbidities play a central role in decision-making of systemic treatments usage for psoriasis. Future studies should further investigate specific connections emerging from our data.

Glucocorticoids and Glucocorticoid-Induced-Leucine-Zipper (GILZ) in Psoriasis

Psoriasis is a prevalent chronic inflammatory human disease initiated by impaired function of immune cells and epidermal keratinocytes, resulting in increased cytokine production and hyperproliferation, leading to skin lesions. Overproduction of Th1- and Th17-cytokines including interferon (IFN)-γ, tumor necrosis factor (TNF)-α, interleukin (IL)-23, IL-17, and IL-22, is a major driver of the disease. Glucocorticoids (GCs) represent the mainstay protocol for treating psoriasis as they modulate epidermal differentiation and are potent anti-inflammatory compounds. The development of safer GC-based therapies is a high priority due to potentially severe adverse effects associated with prolonged GC use. Specific efforts have focused on downstream anti-inflammatory effectors of GC-signaling such as GC-Induced-Leucine-Zipper (GILZ), which suppresses Th17 responses and antagonizes multiple pro-inflammatory signaling pathways involved in psoriasis, including AP-1, NF-κB, STAT3, and ROR-γt. Here we review evidence regarding defective GC signaling, GC receptor (GR) function, and GILZ in psoriasis. We discuss seemingly contradicting data on the loss- and gain-of-function of GILZ in the imiquimod-induced mouse model of psoriasis. We also present potential therapeutic strategies aimed to restore GC-related pathways.

Psoriasis treat to target: defining outcomes in psoriasis using data from a real-world, population-based cohort study (the British Association of Dermatologists Biologics and Immunomodulators Register, BADBIR)

Background

The ‘treat to target’ paradigm improves outcomes and reduces costs in chronic disease management but is not yet established in psoriasis.

Objectives

To identify treatment targets in psoriasis using two common measures of disease activity: Psoriasis Area and Severity Index (PASI) and Physician's Global Assessment (PGA).

Methods

Data from a multicentre longitudinal U.K. cohort of patients with psoriasis receiving systemic or biologic therapies (British Association of Dermatologists Biologics and Immunomodulators Register, BADBIR) were used to identify absolute PASI thresholds for 90% (PASI 90) and 75% (PASI 75) improvements in baseline disease activity, using receiver operating characteristic curves. The relationship between PGA (clear, almost clear, mild, moderate, moderate–severe, severe) and PASI (range 0–72) was described, and the concordance between absolute and relative definitions of response was determined. The same approach was used to establish treatment response and eligibility definitions based on PGA.

Results

Data from 13 422 patients were available (58% male, 91% white ethnicity, mean age 44·9 years), including over 23 000 longitudinal PASI and PGA scores. An absolute PASI ≤ 2 was concordant with PASI 90 and an absolute PASI ≤ 4 was concordant with PASI 75 in 90% and 88% of cases, respectively. These findings were robust to subgroups of timing of assessment, baseline disease severity and treatment modality. PASI and PGA were strongly correlated (Spearman's rank correlation coefficient 0·92). The median PASI increased from 0 (interquartile range 0–0, range 0–23) to 19 (interquartile range 15–25, range 0–64) for PGA clear to severe, respectively. PGA clear/almost clear was concordant with PASI ≤ 2 in 90% of cases, and PGA moderate–severe severe was concordant with the National Institute for Health and Care Excellence PASI eligibility criteria for biologics in 81% of cases.

Conclusions

An absolute PASI ≤ 2 and PGA clear/almost clear represent relevant disease end points to inform treat‐to‐target management strategies in psoriasis.

What's already known about this topic?

The most commonly used relative disease activity measure in psoriasis is ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90); however, it has several limitations including dependency on a baseline severity assessment.

Defining an absolute target disease activity end point in psoriasis has the potential to improve patient outcomes and reduce costs, as demonstrated by treat‐to‐target approaches in other chronic diseases such as hypertension and diabetes.

The Physician's Global Assessment (PGA) is a popular alternative measure of psoriasis severity in daily practice; however, its utility has not been formally assessed with respect to PASI.

What does this study add?

An absolute PASI ≤ 2 corresponds with PASI 90 response and is a relevant disease end point for treat‐to‐target approaches in psoriasis.

There is a strong correlation between PASI and PGA.

PGA moderate–severe/severe may serve as an alternative eligibility criterion for biologics to PASI‐based definitions, and PGA clear/almost clear is an appropriate alternative absolute treatment end point.

What are the clinical implications of this work?

Absolute PASI ≤ 2 and PGA clear/almost clear represent relevant disease end points to inform treat‐to‐target management strategies in psoriasis.

Linked Editorial: Takeshita. Br J Dermatol 2020; 182:1075–1076.

Dietary Recommendations for Adults With Psoriasis or Psoriatic Arthritis From the Medical Board of the National Psoriasis Foundation: A Systematic Review

Importance

Psoriasis is a chronic, inflammatory skin disease and has significant associated morbidity and effect on quality of life. It is important to determine whether dietary interventions help reduce disease severity in patients with psoriatic diseases.

Objective

To make evidence-based dietary recommendations for adults with psoriasis and/or psoriatic arthritis from the Medical Board of the National Psoriasis Foundation.

Evidence Review

We used literature from prior systematic reviews as well as additional primary literature from the MEDLINE database from January 1, 2014, to August 31, 2017, that evaluated the impact of diet on psoriasis. We included observational and interventional studies of patients with psoriasis or psoriatic arthritis. The quality of included studies was assessed using the Newcastle-Ottawa scale for observational studies and the Cochrane Risk of Bias Tool for interventional studies. We made evidence-based dietary recommendations, which were voted on by the National Psoriasis Foundation Medical Board.

Findings

We identified 55 studies meeting the inclusion criteria for this review. These studies represent 77 557 unique participants of which 4534 have psoriasis. Based on the literature, we strongly recommend dietary weight reduction with a hypocaloric diet in overweight and obese patients with psoriasis. We weakly recommend a gluten-free diet only in patients who test positive for serologic markers of gluten sensitivity. Based on low-quality data, select foods, nutrients, and dietary patterns may affect psoriasis. For patients with psoriatic arthritis, we weakly recommend vitamin D supplementation and dietary weight reduction with a hypocaloric diet in overweight and obese patients. Dietary interventions should always be used in conjunction with standard medical therapies for psoriasis and psoriatic arthritis.

Conclusions and Relevance

Adults with psoriasis and/or psoriatic arthritis can supplement their standard medical therapies with dietary interventions to reduce disease severity. These dietary recommendations from the National Psoriasis Foundation Medical Board will help guide clinicians regarding the utility of dietary interventions in adults with psoriatic diseases.

Coronary Artery Disease Assessed by Computed Tomography in Patients with Psoriasis: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with psoriasis have an increased risk of coronary artery disease (CAD) but data on coronary calcium score (CCS) and cardiac computed tomography angiography (CCTA) are inconsistent.

OBJECTIVES

The present study quantitatively summarizes the literature data on the prevalence and burden of CAD in patients with psoriasis compared with controls using CCS and CCTA.

METHODS

A systematic review and meta-analysis was conducted. The search included all studies examining CAD prevalence and burden detected by CCS with or without CCTA in patients with psoriasis without prior CAD compared with controls, between the year 2000 and May 30, 2018.

RESULTS

Fourteen eligible studies provided data on 1,427 patients with psoriasis and 9,670 controls. Pooled data provided the estimated risk ratio (RR) of CAD and weighted mean differences of CCS in psoriasis patients versus controls. Meta-analysis of the prevalence and burden of CCS showed that patients with psoriasis had an increased risk of CAD (RR 1.14, 95% CI 1.04-1.26; p = 0.004), and for more severe CAD (CCS >100) the risk was further increased (RR 1.71, 95% CI 1.28-2.30; p < 0.001) compared with controls. Weighted mean difference for CCS was significantly higher in patients with psoriasis (12.74, 95% CI 10.70-14.78; p < 0.001). The risk of high-risk coronary plaques identified by CCTA was also significantly higher in psoriasis patients compared with controls (RR 1.77, 95% CI 1.37-2.28; p < 0.001).

CONCLUSIONS

Patients with psoriasis have a higher prevalence of subclinical CAD, a higher burden of the disease, and more high-risk coronary plaques compared with controls without psoriasis.

Tildrakizumab in the treatment of psoriasis - literature review

Psoriasis is a chronic, inflammatory disease. The incidence of its occurrence in developed countries is 1–4%. The aim of this study is to present the current state of knowledge and characterize the antibody tildrakizumab, which in March 2018 was approved by the FDA agency for use in adult patients with moderate to severe plaque psoriasis. The work presents the mechanism of action of tildrakizumab and the way it affects the immunological pathways associated with the pathogenesis of psoriasis. Recent studies indicate that interleukin 23 and its p19 subunit are a key target in the effective treatment of psoriasis. The paper also presents the latest clinical trials that present the safety profile and efficacy of tildrakizumab in the treatment of psoriasis. According to clinical trials, tildrakizumab is an effective and safe drug for use in adult patients in the treatment of moderate to severe psoriasis.

Telmisartan Lowers Elevated Blood Pressure in Psoriatic Mice without Attenuating Vascular Dysfunction and Inflammation

BACKGROUND

Psoriasis is hallmarked by vascular dysfunction, arterial hypertension, and an increased risk for cardiovascular diseases. We have shown recently that skin-driven interleukin (IL)-17A expression promotes psoriasis-like disease in mice, and this is associated with vascular inflammation, vascular dysfunction, and hypertension. As an intensive risk-factor reduction is recommended for psoriasis patients, we aimed to elucidate the impact of the angiotensin II receptor type 1 (AT1) antagonist telmisartan in a mouse model of severe psoriasis-like skin disease.

METHODS AND RESULTS

Elevated blood pressure measured by tail-cuff plethysmography in mice with keratinocyte-specific IL-17A overexpression (K14-IL-17A^ind/+ mice) was significantly reduced in response to telmisartan. Importantly, vascular dysfunction, as assessed by isometric tension studies of isolated aortic rings, vascular inflammation measured by flow cytometry analysis of CD45⁺CD11b⁺ immune cells, as well as the increased peripheral oxidative stress levels assessed by L-012-enhanced chemiluminescence were not attenuated by telmisartan treatment of K14-IL-17A^ind/+ mice, nor was the persisting skin inflammation.

CONCLUSION

We provide first evidence for an effective antihypertensive treatment in experimental psoriasis by AT1 blockade, but without any impact on vascular inflammation and dysfunction in our mouse model of severe psoriasis-like skin disease. This suggests that vascular function and inflammation in psoriasis might not be attenuated as long as skin inflammation persists.

Risankizumab for the treatment of psoriasis

Introduction: The interleukin （IL）-23 and IL-17 pathway is closely related to the pathogenesis of psoriasis. This pathway is considered to be an important target for treating psoriasis. Risankizumab can selectively inhibit IL-23p19 subunit and for the treatment of psoriasis. This article aims to review risankizumab and provides reference for clinicians. Areas covered: The chemical property, mechanism of action, pharmacokinetics, clinical efficacy, safety of risankizumab was introduced in this paper. A PubMed search using the terms 'risankizumab,' 'IL-23,' 'p19 subunit,' and 'psoriasis,' was performed, and the results were screened for the most relevant English language publications. Expert opinion: Risankizumab is a humanized IgG monoclonal antibody that binds to the p19 subunit of IL-23 and inhibits its interaction with the IL-23 receptor. Clinical trials showed that risankizumab was significantly more effective than ustekinumab. Risankizumab was well tolerated, upper respiratory tract infection was the common adverse reactions. Therefore, the market of risankizumab provides an important therapeutic means for psoriasis.

Treatment of plaque psoriasis with IL-23p19 blockers: A systematic review and meta-analysis

OBJECTIVES

Interleukin(IL)-23 is a key cytokine in the pathogenesis of psoriasis, this meta-analysis was to analyze the efficacy and safety of IL-23p19 blockers in patients with plaque psoriasis.

METHODS

A systematic review of the literature was performed to collect double-blind randomized controlled trials(RCTs). The pooled relative risk(RR) with 95% confidence interval(CI) was calculated. All analyses were conducted with intention-to-treat basis.

RESULTS

A total of 13 studies contained 5155 plaque psoriasis patients were included in our meta-analysis. The results indicated that IL-23p19 blockers had better efficacy than placebo for Psoriasis Area Severity Index score reductions from baseline of 75% or more (PASI75) (RR = 11.47, P < 0.001) and static Physician's Global Assessment score of 0 or 1(sPGA0/1) (RR = 11.32, P < 0.001). IL-23p19 blockers have similar safety with placebo about the incidence of adverse events(AEs) (RR = 1.22, P = 0.096) and serious adverse events(SAEs) (RR = 2.93, P = 0.965), but IL-23p19 blockers carried an increased incidence rate of infections (RR = 1.39, P < 0.001). While compared with adalimumab and ustekinumab, IL-23p19 blockers were more effective and had the similar tolerance. Among three IL-23p19 blockers, guselkumab was the most efficacious treatments, and risankizumab was better tolerated than the others.

CONCLUSION

The IL-23p19 blockers have excellent efficacy and great safety in plaque psoriasis patients, but long-term safety remains to be determined.

Increased risk of atherosclerotic cardiovascular disease among patients with psoriasis in Korea: A 15-year nationwide population-based cohort study

The association between psoriasis and risk of atherosclerotic cardiovascular disease has not been thoroughly evaluated in a large longitudinal cohort of an Asian population. We conducted a nationwide population-based retrospective cohort study encompassing more than 1.7 million Koreans with a 15-year follow-up period. The period prevalence of psoriasis was 0.33% among the baseline participants (1997-2000). In Cox proportional hazard analyses, the individuals with psoriasis had a higher adjusted hazard ratio (HR) for incidence of overall atherosclerotic cardiovascular disease (HR, 1.18; 95% confidence interval [CI], 1.09-1.27) compared with controls. Subgroup analyses revealed that the risk for myocardial infarction was commonly increased in both sexes with moderate to severe psoriasis (male: HR, 2.09; 95% CI, 1.35-3.24; female: HR, 3.23; 95% CI, 1.34-7.76), whereas the risk for ischemic stroke was specifically increased in female individuals with moderate to severe psoriasis (HR, 2.02; 95% CI, 1.24-3.30). Our data suggest that appropriate medical screening for possible cardiovascular comorbidities is warranted in Asian psoriatic patients according to disease severity and sex.

Risk of malignancy in patients with psoriasis: a 15-year nationwide population-based prospective cohort study in Korea

BACKGROUND

The association between psoriasis and risk of malignancy has not been thoroughly evaluated in a large longitudinal cohort of Asian population.

OBJECTIVE

To determine the long-term risk of malignancy in Korean adult patients with psoriasis.

METHODS

We conducted a nationwide population-based prospective cohort study with a 15-year observational period. During the baseline period (1997-2000), total 1 773 786 Korean subjects who received health insurance from the National Health Insurance System were enrolled and 5788 subjects were defined as a psoriasis group. The number of new-onset malignancy was collected during the observational period (2001-2015).

RESULTS

Patients with psoriasis had a higher adjusted hazard ratio (aHR) for development of overall malignancy [aHR 1.08, 95% confidence interval (CI) 1.00-1.18] and gastric cancer (aHR 1.31, 95% CI 1.08-1.58) compared to controls. The risks of non-Hodgkin lymphoma and non-melanoma skin cancer were significantly increased only in patients with psoriasis who received systemic treatments (aHR 2.86, 95% CI 1.07-7.61 and aHR 3.93, 95% CI 1.47-10.47, respectively).

CONCLUSION

Psoriasis is associated with long-term risk for overall malignancy in Koreans, which was primarily driven by the increased risk of gastric cancer.

Th17 Cells and the IL-23/IL-17 Axis in the Pathogenesis of Periodontitis and Immune-Mediated Inflammatory Diseases

Innate immunity represents the semi-specific first line of defense and provides the initial host response to tissue injury, trauma, and pathogens. Innate immunity activates the adaptive immunity, and both act highly regulated together to establish and maintain tissue homeostasis. Any dysregulation of this interaction can result in chronic inflammation and autoimmunity and is thought to be a major underlying cause in the initiation and progression of highly prevalent immune-mediated inflammatory diseases (IMIDs) such as psoriasis, rheumatoid arthritis, inflammatory bowel diseases among others, and periodontitis. Th1 and Th2 cells of the adaptive immune system are the major players in the pathogenesis of IMIDs. In addition, Th17 cells, their key cytokine IL-17, and IL-23 seem to play pivotal roles. This review aims to provide an overview of the current knowledge about the differentiation of Th17 cells and the role of the IL-17/IL-23 axis in the pathogenesis of IMIDs. Moreover, it aims to review the association of these IMIDs with periodontitis and briefly discusses the therapeutic potential of agents that modulate the IL-17/IL-23 axis.

Skin disease related to metabolic syndrome in women

Sex hormones are involved in pathways of metabolic syndrome (MetS), an observation supported by animal studies. The relationships of sex hormones with components of MetS, such as insulin resistance and dyslipidemia, have been studied in pre- and postmenopausal women. High testosterone, low sex hormone-binding globulin, and low estrogen levels increase the risks of MetS and type 2 diabetes in women. Cutaneous diseases that are sex hormone mediated, such as polycystic ovary syndrome, acanthosis nigricans, acne vulgaris, and pattern alopecia, have been associated with insulin resistance and increased risk for MetS. Furthermore, inflammatory skin conditions, such as hidradenitis suppurativa and psoriasis, increase the risk for MetS. Patients with such skin conditions should be followed for metabolic complications, and early lifestyle interventions toward these populations may be warranted.

Discovery of the IL-23/IL-17 Signaling Pathway and the Treatment of Psoriasis

Psoriasis vulgaris is a common, heterogeneous, chronic inflammatory skin disease characterized by thickened, red, scaly plaques and systemic inflammation. Psoriasis is also associated with multiple comorbid conditions, such as joint destruction, cardiovascular disease, stroke, hypertension, metabolic syndrome, and chronic kidney disease. The discovery of IL-17-producing T cells in a mouse model of autoimmunity transformed our understanding of inflammation driven by T lymphocytes and associations with human inflammatory diseases, such as psoriasis. Under the regulation of IL-23, T cells that produce high levels of IL-17 create a self-amplifying, feed-forward inflammatory response in keratinocytes that drives the development of thickened skin lesions infiltrated with a mixture of inflammatory cell populations. Recently, the Food and Drug Administration approved multiple highly effective psoriasis therapies that disrupt IL-17 (secukinumab, ixekizumab, and brodalumab) and IL-23 (guselkumab and tildrakizumab) signaling in the skin, thus leading to a major paradigm shift in the way that psoriatic disease is managed.

Access to Dermatological Care with an Innovative Online Model for Psoriasis Management: Results from a Randomized Controlled Trial

Background:Many patients with chronic skin diseases lack regular access to dermatologists in the United States and suffer poor clinical outcomes.Introduction:We performed a 12-month randomized controlled trial to evaluate the impact of an online, collaborative connected health (CCH) model for psoriasis management on access to specialty care.Materials and Methods:The 300 enrolled patients were randomized to online or in-person care. We compared distance traveled as well as transportation and in-office waiting time between the two groups and obtained patient and provider perspectives on CCH.Results:At baseline, no differences existed between the groups in difficulties obtaining specialty care. Over 12 months, the mean (standard deviation [SD]) distance traveled to and from appointments was 174.8 (±577.4) km/person for the in-person group and 2.2 (±14.2) km/person for the online group (p = 0.0003). The mean (SD) time spent on transportation and in-office waiting for in-person appointments was 4.0 (±4.5) h/person for the in-person group and 0.1 (±0.4) h/person for the online group (p = 0.0001). Patients found CCH to be safe, accessible, equitable, efficient, effective, and patient-centered. Providers found CCH to be useful for providing psoriasis care.Discussion:The CCH model resulted in significantly less distance traveled as well as transportation and in-office waiting time compared to in-person care. Both patients and providers were highly satisfied with CCH.Conclusions:The CCH model resulted in increased access to specialty care and enabled patient-centered, safe, and effective management of psoriasis patients.

Risankizumab in the treatment of psoriasis - literature review

Risankizumab is a humanized, monoclonal antibody directed against subunit p19 of interleukin 23 (IL-23). In February 2019, risankizumab was approved for the treatment of moderate to severe psoriasis. The aim of the work is to collect up-to-date information on risankizumab and present its mechanism of action and recent clinical trials in which it was applied. This work also compares the mechanisms of action of risankizumab and ustekinumab and their importance in the treatment of psoriasis and describes the role of IL-23 in the etiopathogenesis of psoriasis. The work also refers to the effectiveness of risankizumab treatment and its safety profile. The results of molecular and histological studies that show changes in psoriatic skin after risankizumab treatment are also described.

Efficacy and safety of risankizumab in Japanese patients with moderate to severe plaque psoriasis: Results from the SustaIMM phase 2/3 trial

Risankizumab, a humanized immunoglobulin G1 monoclonal antibody, selectively inhibits interleukin‐23, a key cytokine in the pathogenesis of psoriasis, by binding to its p19 subunit. In SustaIMM (ClinicalTrials.gov/NCT03000075), a phase 2/3, double‐blinded, placebo‐controlled study, Japanese patients with moderate to severe plaque psoriasis (n = 171) were stratified by bodyweight and concomitant psoriatic arthritis and randomized 2:2:1:1 to 75 mg risankizumab, 150 mg risankizumab, placebo with cross‐over to 75 mg risankizumab and placebo with cross‐over to 150 mg risankizumab. Dosing was at weeks 0, 4, 16, 28 and 40, with placebo cross‐over to risankizumab at week 16. The primary end‐point was 90% or more improvement from baseline in Psoriasis Area and Severity Index (PASI‐90) at week 16 for risankizumab versus placebo. Missing data were imputed as non‐response. All primary and psoriasis‐related secondary end‐points were met for both risankizumab doses (P < 0.001). At week 16, PASI‐90 responses were significantly higher in patients receiving 75 mg (76%) or 150 mg (75%) risankizumab versus placebo (2%). Corresponding response rates were 86%, 93% and 10% for static Physician Global Assessment (sPGA) score of clear/almost clear; 90%, 95% and 9% for PASI‐75; and 22%, 33% and 0% for PASI‐100, with significantly higher responses for both risankizumab doses versus placebo. Through week 52, PASI and sPGA responses increased or were maintained and treatment‐emergent adverse events were comparable across treatment groups. Both doses of risankizumab were superior to placebo in treating patients with moderate to severe plaque psoriasis. The safety profile was consistent with previous risankizumab trials, with no new or unexpected safety findings.

Improving psoriasis patients' adherence to topical drugs: a systematic review

Background: Poor adherence to topical antipsoriatic drugs limits treatment effectiveness.Objective: The aim of this study was to investigate how health care providers may improve psoriasis patients' adherence to topical treatment.Materials and methods: A systematic literature search was performed for English-language articles in Embase, Medline, PsycINFO, Cinahl, Scopus, and the Cochrane Library.Results: Ten studies of varying quality were identified. Two randomized controlled trials (RCTs) testing the adherence-improving potential of interventions by health care providers to support patients showed improvement in adherence to topical treatment. In a prospective study with a pre/postdesign, an individualized, face-to-face consultation reported an improvement in patient-reported adherence to topical treatment over a 9-week period. Based on seven qualitative studies obtaining insights from either patients or health care providers, health care providers may need to address socio-economic factors, health care system factors, and treatment-, patient-, and disease-related factors in interventions that aim to improve the adherence of psoriasis patients to topical antipsoriatic drugs.Conclusion: There is a need to develop better adherence-improving interventions. A good patient-health care provider relationship is considered crucial to adherence and may be an important intervention target. Before interventions to improve adherence to topicals can be recommended for the clinic, the intervention should be tested in high-quality RCTs.

Comparative efficacy and safety of targeted DMARDs for active psoriatic arthritis during induction therapy: A systematic review and network meta-analysis

OBJECTIVE

To summarize and investigate the comparative efficacy and safety of targeted disease-modifying antirheumatic drugs (DMARDs) for active psoriatic arthritis (PsA).

METHODS

Randomized clinical trials (RCTs) evaluating efficacy and safety of targeted synthetic DMARDs (tofacitinib, apremilast) as well as biological DMARDs (guselkumab, ustekinumab, secukinumab, ixekizumab, brodalumab, clazakizumab, abatacept, adalimumab, etanercept, infliximab, certolizumab, and golimumab) were identified by systemic literature review. Traditional meta-analysis and network meta-analysis using a random effects model were performed to estimate pooled odds ratios (OR) and 95% CI to compare and rank these treatments according to ACR20 response, 75% improvement in psoriasis area and severity index (PASI75), numbers of adverse events (AE) and serious adverse events (SAE). Similar analyses were conducted among biologic-naïve population and biologic-experienced/failed population.

RESULTS

We deemed 29 RCTs eligible, including 10,204 participants and 17 treatments. During induction therapy (first 12-16 weeks), all treatments except clazakizumab were more efficacious than placebo in achieving ACR20 and PASI75. Although tofacitinib, apremilast, and ixekinumab 80 mg every 2 weeks had a higher rate of AE, no significant difference was revealed for SAE among all treatments. Network meta-analysis demonstrated that infliximab, golimumab, etanercept, adalimumab, guselkumab, and secukinumab 300 mg outperformed other drugs in achieving both ACR20 and PASI75. Infliximab, guselkumab, adalimumab, golimumab, secukinumab (300 mg and 150 mg), and ustekinumab (45 mg and 90 mg) are characterized by both high efficacy and safety. Similar rankings were observed in the analysis among biologic-naïve patients. Moreover, ustekinumab, secukinumab (300 mg and 150 mg), ixekizumab, abatacept, certolizumab pegol, tofacitinib, and apremilast were still associated with higher ACR20 compared to placebo while ustekinumab, secukinumab (300 mg), ixekizumab and tofacitinib with higher PASI75 among biologic-experienced/failed patients.

CONCLUSION

Regarding the overall risk-benefit profile, infliximab, guselkumab, adalimumab, golimumab, secukinumab, and ustekinumab may be safer and more efficacious treatments than the other targeted DMARDs for active PsA during induction therapy.

Apoptotic or Antiproliferative Activity of Natural Products against Keratinocytes for the Treatment of Psoriasis

Natural products or herbs can be used as an effective therapy for treating psoriasis, an autoimmune skin disease that involves keratinocyte overproliferation. It has been demonstrated that phytomedicine, which is used for psoriasis patients, provides some advantages, including natural sources, a lower risk of adverse effects, and the avoidance of dissatisfaction with conventional therapy. The herbal products’ structural diversity and multiple mechanisms of action have enabled the synergistic activity to mitigate psoriasis. In recent years, the concept of using natural products as antiproliferative agents in psoriasis treatment has attracted increasing attention in basic and clinical investigations. This review highlights the development of an apoptotic or antiproliferatic strategy for natural-product management in the treatment of psoriasis. We systematically introduce the concepts and molecular mechanisms of keratinocyte-proliferation inhibition by crude extracts or natural compounds that were isolated from natural resources, especially plants. Most of these studies focus on evaluation through an in vitro keratinocyte model and an in vivo psoriasis-like animal model. Topical delivery is the major route for the in vivo or clinical administration of these natural products. The potential use of antiproliferative phytomedicine on hyperproliferative keratinocytes suggests a way forward for generating advances in the field of psoriasis therapy.

Plasma miR-126 expression correlates with risk and severity of psoriasis and its high level at baseline predicts worse response to Tripterygium wilfordii Hook F in combination with acitretin

BACKGROUND

Treatment of psoriasis is always difficult, which requires intensive scientific research.

OBJECTIVE

Tripterygium wilfordii Hook F (TwHF) with acitretin(TwHF + acitretin) is normally used in treating psoriasis. This study aimed to investigate the correlation of plasma miR-126 expression with risk and severity of psoriasis, and its predictive value of response to TwHF + acitretin treatment in psoriasis.

METHODS

MiRNA-126(MiR-126) expression in plasma was analyzed in psoriasis patients at month 0 (M0), M1, M3 and M6 and in health controls (HCs) at enrollment by qPCR. Psoriasis-affected body surface area (BSA) and Psoriasis Area and Severity Index (PASI) score were used to assess severity and treatment response.

RESULTS

Plasma miR-126 levels were decreased in psoriasis patients compared with HCs (P < 0.001), with area under the curve (AUC) of 0.771. MiR-126 expression was negatively correlated with PASI score (P = 0.001), and negatively associated with psoriasis-affected BSA (P = 0.825). At M6, 65.3% and 36.1% patients achieved PASI 50 and 75, respectively. MiR-126 increased at M1, M3 and M6 after TwHF + acitretin treatment when comparing with M0 (all P < 0.001). Meanwhile, miR-126 expression baseline in PASI 50 group declined when comparing with non-PASI 50 group (P < 0.001). Additionally, data revealed that the cause of high miR-126 baseline level was due to unsuccessfully achieving PASI 50 at M6 after TwHF + acitretin treatment (P < 0.001). However, miR-126 baseline expression was not a predictive factor for PASI 75 achievement (P > 0.05).

CONCLUSION

Plasma miR-126 expression is negatively correlated with psoriasis risk and severity, and its high baseline level can be used as a biomarker to predict worse clinical response to TwHF + acitretin treatment in psoriasis.

Proinflammatory and anti-inflammatory cytokine profiles in psoriasis: use as laboratory biomarkers and disease predictors

OBJECTIVE

The objectives of this study were to delineate the pro and anti-inflammatory cytokine profiles of psoriasis and cytokine profile models that externally validate the diagnosis.

SUBJECTS AND METHODS

This study recruited 70 patients with psoriasis and 76 healthy controls. Cytokine profiles were evaluated, including pro-inflammatory M1 (IL-1 + IL-6 + TNF-α), Th1 (IL-2 + IL-12 + IFN-γ), Th17 (IL-6 + IL-17), and immune-inflammatory response system (IRS = M1 + Th1 + Th17) profiles. Moreover, the anti-inflammatory potential included Th2 (IL-4), Th2 + T regulatory (Th2 + Treg, namely IL-4 + IL-10 + TGF-β), anti-inflammatory (Th2 + Treg + adiponectin), and the pro-inflammatory/anti-inflammatory index.

RESULTS

There was a highly significant association between psoriasis and cytokine levels with an effect size of 0.829 and a particularly strong impact on IL-2 (0.463), IL-12 (0.451), IL-10 (0.532) and adiponectin (0.401). TGF-β and adiponectin were significantly lower while all other cytokines (except IFN-γ) were significantly higher in psoriasis than in controls. In addition, M1, Th1, Th17, Th2 + Treg, and IRS/Anti-inflammatory index were significantly higher in psoriasis patients than in controls. The IRS index, Th2 + Treg, and adiponectin predicted psoriasis with 97.1% sensitivity and 94% specificity.

CONCLUSION

In conclusion, psoriasis is characterized by increased M1, Th1, Th2 and Th17 profiles together with lowered TGF-β and adiponectin. In addition, we propose a model based on a higher IRS and Th2 + Treg index coupled with lower adiponectin values, which may be used to externally validate the diagnosis of psoriasis. The most important single biomarker of psoriasis is adiponectin. Because the latter may play a role in the modulation of the chronic inflammatory response in psoriasis, adiponectin could be a new drug target to treat psoriasis.

Does weight loss reduce the severity and incidence of psoriasis or psoriatic arthritis? A Critically Appraised Topic

CLINICAL QUESTION

Does weight loss reduce the severity and incidence of psoriasis or psoriatic arthritis (PsA) in obese individuals?

BACKGROUND

Obesity presents a rising public health challenge and is more prevalent among individuals with psoriasis or PsA than in the general population. Longitudinal population-based studies suggest a causal role for obesity in psoriasis and PsA onset and that obesity drives greater disease severity.

METHODS

We systematically reviewed evidence within the MEDLINE, Embase and CENTRAL databases and clinical trials registries examining lifestyle, pharmacological and surgical weight loss interventions in the treatment and prevention of psoriasis and PsA in obese individuals. Meta-analysis was conducted using random-effects models, followed by sensitivity analyses.

RESULTS

Of 176 full-text articles reviewed, 14 met the inclusion criteria. Meta-analysis of six randomized control trials (RCTs) confirmed that weight loss following lifestyle interventions (diet or physical activity) improves psoriasis compared with control [mean change in Psoriasis Area and Severity Index -2·59, 95% confidence interval (CI) -4·09 to -1·09; P < 0·001]. One RCT demonstrated a greater likelihood of achieving minimal PsA activity following diet-induced weight loss (odds ratio 4·20, 95% CI 1·82-9·66; P < 0·001). Three studies of pharmacological treatments reported conflicting results, and no RCTs of bariatric surgery were identified. Two cohort studies suggested that bariatric surgery, particularly gastric bypass, reduces the risk of developing psoriasis (hazard ratio 0·52, 95% CI 0·33-0·81; P < 0·01).

CONCLUSIONS

These limited data indicate that weight loss can improve pre-existing psoriasis and PsA, and prevent the onset of psoriasis in obese individuals. Together with the National Institute for Health and Care Excellence obesity guidance, this informed a local obesity screening and management pathway, providing multidisciplinary weight loss interventions alongside conventional skin-focused care for patients with psoriasis.

T cell pathology in skin inflammation

Forming the outer body barrier, our skin is permanently exposed to pathogens and environmental hazards. Therefore, skin diseases are among the most common disorders. In many of them, the immune system plays a crucial pathogenetic role. For didactic and therapeutic reasons, classification of such immune-mediated skin diseases according to the underlying dominant immune mechanism rather than to their clinical manifestation appears to be reasonable. Immune-mediated skin diseases may be mediated mainly by T cells, by the humoral immune system, or by uncontrolled unspecific inflammation. According to the involved T cell subpopulation, T cell-mediated diseases may be further subdivided into T1 cell-dominated (e.g., vitiligo), T2 cell-dominated (e.g., acute atopic dermatitis), T17/T22 cell-dominated (e.g., psoriasis), and Treg cell-dominated (e.g., melanoma) responses. Moreover, T cell-dependent and -independent responses may occur simultaneously in selected diseases (e.g., hidradenitis suppurativa). The effector mechanisms of the respective T cell subpopulations determine the molecular changes in the local tissue cells, leading to specific microscopic and macroscopic skin alterations. In this article, we show how the increasing knowledge of the T cell biology has been comprehensively translated into the pathogenetic understanding of respective model skin diseases and, based thereon, has revolutionized their daily clinical management.

The impact of diabetes and metabolic syndromes to the effectiveness of cyclosporine a pharmacotherapy in psoriatic patients

Metabolic diseases concurrent with psoriasis may considerably affect the intensity of its symptoms and therapy efficacy. Cyclosporine A (CsA) is one of the medicines used in conventional therapy of psoriasis. The aim of the study was to determine whether Diabetes 2 and metabolic syndromes influence the efficacy of the CsA therapy in psoriatic patients. The sample group was composed of 32 patients with diagnosed moderate to severe forms of psoriasis vulgaris. The group was divided into subgroups, with regard to concurrently occurring Diabetes 2 and metabolic syndromes. The subgroups were composed of as follows: with diabetes-7 patients, without diabetes-25, with metabolic syndrome-15, without concurrent metabolic syndrome-17, with a metabolic syndrome without diabetes-8 and with both a metabolic syndrome and diabetes-7 patients. The efficacy of therapy was evaluated in each subgroup on the basis of the following scales: PASI, BSA, DLQI on the day of therapy commencing, after 42 and 84 days of the CsA therapy. The statistical analysis was performed with the use of STATISICA 12 (Cracow, Poland; p < .05). The following tests were used: The ANOVA Friedeman test, the posthoc test for ANOVA Friedeman test, the Mann-Whitney U test. We observed clinical improvement measured with PASI BSA scales in each subgroup. The patients themselves also reported improved comfort in their lives, which is confirmed by the lower score in the DLQI scale after 42 and 84 days of the pharmacotherapy. Differences in the values of each scale in a given subgroup turned to be statistically significant. The biggest differences occur after the first 42 days of therapy and they last in the later period of observations. We did not determine any statistically significant differences as a response to treatment in the subgroups subject to comparison. Diabetes and a metabolic syndrome concurrent with psoriasis vulgaris do not affect the efficacy of CsA therapy, which indicates no necessity to modify the standard dosage of the medicine and therapy regime.