The role of IL-23 and the IL-23/TH 17 immune axis in the pathogenesis and treatment of psoriasis

Hydrolyzable Tannins in the Management of Th1, Th2 and Th17 Inflammatory-Related Diseases

Plants rich in hydrolyzable tannins were traditionally used all over the world for a variety of chronic inflammatory disorders, including arthritis, colitis, and dermatitis. However, the knowledge of their immunological targets is still limited though fundamental for their rational use in phytotherapy. The recent advances regarding the pathogenesis of inflammatory-based diseases represent an opportunity to elucidate the pharmacological mechanism of plant-derived metabolites with immunomodulatory activity. This review collects recent articles regarding the role of hydrolyzable tannins and their gut metabolites in Th1, Th2, and Th17 inflammatory responses. In line with the traditional use, rheumatoid arthritis (RA), inflammatory bowel diseases (IBDs), psoriasis, atopic dermatitis (AD), and asthma were the most investigated diseases. A substantial body of in vivo studies suggests that, beside innate response, hydrolyzable tannins may reduce the levels of Th-derived cytokines, including IFN-γ, IL-17, and IL-4, following oral administration. The mode of action is multitarget and may involve the impairment of inflammatory transcription factors (NF-κB, NFAT, STAT), enzymes (MAPKs, COX-2, iNOS), and ion channels. However, their potential impact on pathways with renewed interest for inflammation, such as JAK/STAT, or the modulation of the gut microbiota demands dedicate studies.

How Does Botulinum Toxin Inhibit Itch?

Two decades after reports of the anti-pruritic effects of botulinum neurotoxins (BoNTs), there is still no approved product for the anti-itch indication of BoNTs, and most clinical case reports still focus on the off-label use of BoNTs for various itchy conditions. Few randomized clinical trials have been conducted with controversial results, and the beneficial effects of BoNTs against itch are mainly based on case studies and case series. These studies are valuable in presenting the potential application of BoNTs in chronic pruritic conditions, but due to the nature of these studies, they are categorized as providing lower levels of evidence or lower grades of recommendation. To obtain approval for the anti-pruritic indication of BoNTs, higher levels of evidence are required, which can be achieved through conducting large-scale and well-designed studies with proper control groups and established careful and reliable primary and secondary outcomes. In addition to clinical evidence, presenting the mechanism-based antipruritic action of BoNTs can potentially strengthen, accelerate, and facilitate the current efforts towards further investments in accelerating the field towards the potential approval of BoNTs for itchy conditions. This review, therefore, aimed to provide the state-of-the-art mechanisms underlying the anti-itch effect of BoNTs from basic studies that resemble various clinical conditions with itch as a hallmark. Evidence of the neuronal, glial, and immune modulatory actions of BoNTs in reducing the transmission of itch are presented, and future potential directions are outlined.

Mechanisms and inhibitors of ferroptosis in psoriasis

Psoriasis is a chronic inflammatory skin disease that features localized or widespread erythema, papules, and scaling. It is common worldwide and may be distributed throughout the whole body. The pathogenesis of psoriasis is quite complex and the result of the interplay of genetic, environmental and immune factors. Ferroptosis is an iron-dependent programmed death that is different from cell senescence, apoptosis, pyroptosis and other forms of cell death. Ferroptosis involves three core metabolites, iron, lipids, and reactive oxygen species (ROS), and it is primarily driven by lipid peroxidation. Ferrostatin-1 (Fer-1) is an effective inhibitor of lipid peroxidation that inhibited the changes related to ferroptosis in erastin-treated keratinocytes and blocked inflammatory responses. Therefore, it has a certain effect on the treatment of psoriatic lesions. Although ferroptosis is closely associated with a variety of human diseases, such as inflammatory diseases, no review has focused on ferroptosis in psoriasis. This mini review primarily focused on the pathogenesis of psoriasis, the mechanisms of ferroptosis, the connection between ferroptosis and psoriasis and ferroptosis inhibitors in psoriasis treatment. We discussed recent research advances and perspectives on the relationship between ferroptosis and psoriasis.

Interleukin-17 Family Cytokines in Metabolic Disorders and Cancer

Interleukin-17 (IL-17) family cytokines are potent drivers of inflammatory responses. Although IL-17 was originally identified as a cytokine that induces protective effects against bacterial and fungal infections, IL-17 can also promote chronic inflammation in a number of autoimmune diseases. Research in the last decade has also elucidated critical roles of IL-17 during cancer development and treatment. Intriguingly, IL-17 seems to play a role in the risk of cancers that are associated with metabolic disorders. In this review, we summarize our current knowledge on the biochemical basis of IL-17 signaling, IL-17′s involvement in cancers and metabolic disorders, and postulate how IL-17 family cytokines may serve as a bridge between these two types of diseases.

Looking beyond the Skin: Pathophysiology of Cardiovascular Comorbidity in Psoriasis and the Protective Role of Biologics

Psoriasis is a chronic systemic inflammatory disease associated with a higher incidence of cardiovascular disease, especially in patients with moderate to severe psoriasis. It has been estimated that severe psoriasis confers a 25% increase in relative risk of cardiovascular disease, regardless of traditional risk factors. Although the underlying pathogenic mechanisms relating psoriasis to increased cardiovascular risk are not clear, atherosclerosis is emerging as a possible link between skin and vascular affection. The hypothesis that the inflammatory cascade activated in psoriasis contributes to the atherosclerotic process provides the underlying basis to suggest that an anti-inflammatory therapy that improved atherosclerosis would also reduce the risk of MACEs. In this sense, the introduction of biological drugs which specifically target cytokines implicated in the inflammatory cascade have increased the expectations of control over the cardiovascular comorbidity present in psoriasis patients, however, their role in vascular damage processes remains controversial. The aim of this paper is to review the mechanistic link between psoriasis and cardiovascular disease development, as well as analyzing which of the biological treatments could also reduce the cardiovascular risk in these patients, fueling a growing debate on the modification of the general algorithm of treatment.

Phellodendri Chinensis Cortex-Based Nanoparticles Integrated in Dissolvable Microneedles for Ameliorating Psoriasis-Like Inflammation

Psoriasis is a common and highly relapsing skin disease, for which topical treatments are used by approximately 88% of people with psoriasis as their primary therapy. However, in practice, the low convenience and side effects such as skin irritation of current topical treatments limit the application of the therapy. To address these issues, we calcined Phellodendri Chinensis Cortex (PCC) to prepare Phellodendri Chinensis Cortex Nanoparticles (PCC-NPs) which were packed into dissolvable microneedles (MNs) for the treatment of psoriasis. In this study, we revealed that the trace amounts of PCCNPs delivered by MNs could exert therapeutic effects therapeutic effects in the affected skin comparable to those of standard drugs, accompanied with the suppressed psoriasis-like inflammation without significant hepatic or renal toxicity or allergic reactions. These results indicate that dissolvable PCC-NPs MNs may serve as an innovative topical therapy for the inhibition of psoriatic inflammation.

Population pharmacokinetic/pharmacodynamic analysis of AK111, an IL-17A monoclonal antibody, in subjects with moderate-to-severe plaque psoriasis

AK111 is an innovative IL-17A antibody, presenting high affinity to IL-17A and showing similar pharmacokinetic (PK) characteristics to those of typical immunoglobulin (Ig) G1 antibodies. To optimize the dosage regimen for phase 2/3 clinical trials, PK and pharmacodynamics (PD) of AK111 were first characterized in Chinese moderate-to-severe plaque psoriasis patients in a phase 1b study. AK111 PK serum sample and Psoriasis Area and Severity Index (PASI) score data were collected from 48 moderate-to-severe psoriasis patients in this study. Non-linear mixed-effects modeling was used for the population PK/PD analysis. A one-compartment model with a first-order absorption and a first-order elimination best described the PK behavior of AK111. The apparent systemic clearance was 0.182 L/day, and the central volume was 6.65 L. The exposure–response relationship was characterized using an indirect response model. The pharmacological effect of AK111 was described in the form of inhibiting the formation of psoriatic plaque, whereas placebo was quantified in the form of promoting the degradation of psoriatic skin lesions. The maximum effect of drug effect (I_max) and placebo effect (PLB_max) was 1 and 0.429, respectively. The rate constant for psoriatic plaque production (K_in) was 0.474 PASI/day and psoriatic plaque loss (K_out) was 0.024 day⁻¹. The body surface area (BSA) affected by psoriasis was identified as a significant covariate on Kout. The simulation results confirmed that all of the predicted PASI90 response rates at week 12 were higher than 60% at 150 and 300 mg dose levels with different regimens and could reach higher than 80% at week 24. We hope this first PK/PD study of AK111 in Chinese moderate-to-severe plaque psoriasis patients will be of help in the further clinical development of AK111 and provide a reference to the dosage optimization for similar antibodies with a long half-life.

Deucravacitinib for the Treatment of Psoriatic Disease

Psoriasis is an immune-mediated disease, with the interleukin (IL)-23/IL-17 axis currently considered its main pathogenic pathway. Tyrosine kinase 2 (TYK2) is responsible for mediating immune signalling of IL-12, IL-23 and type I interferons, without interfering with other critical systemic functions as other JAK proteins do. This article aims to review the current knowledge on deucravacitinib, a new oral drug that selectively inhibits TYK2, granting it a low risk of off-target effects. After good efficacy and safety results in a phase II, placebo-controlled trial, two phase III, 52-week trials evaluated deucravacitinib 6 mg against placebo and apremilast—an active comparator. POETYK PSO-1 and PSO-2 involved 1688 patients with moderate-to-severe psoriasis. After 16 weeks, in both studies, over 50% of patients treated with deucravacitinib reached PASI75, which was significantly superior to placebo and apremilast. In POETYK PSO-1, these results improved until week 24 and were maintained through week 52, with over 65% of patients achieving PASI75 at this point. A reduction in signs and symptoms was also reported by patients, with greater impact on itch. Deucravacitinib was well tolerated and safe. There were no reports of serious infections, thromboembolic events, or laboratory abnormalities, which are a concern among other JAK inhibitors. Persistent efficacy and consistent safety profiles were reported for up to 2 years. Despite advances in the treatment of psoriasis, namely among biologic agents, an oral, effective and safe new drug can bring several advantages to prescribers and patients. Further investigation is required to understand where to place deucravacitinib among current psoriasis treatment options.

Gut Microbiota in Psoriasis

Psoriasis is a chronic inflammatory skin disease with autoimmune pathogenic characteristics and is caused by chronic inflammation, which results in uncontrolled keratinocyte growth and defective differentiation. The link between the gut microbiota and immune system regulation opened a novel angle to understand the pathogenesis of many chronic multifactorial diseases, including psoriasis. Current evidence suggests that modulation of the gut microbiota, both through dietary approaches and through supplementation with probiotics and prebiotics, could represent a novel therapeutic approach. The present work aims to highlight the latest scientific evidence regarding the microbiome alterations of psoriatic patients, as well as state of the art insights in terms of microbiome-targeted therapies as promising preventive and therapeutic tools for psoriasis.

Meta-Analysis of the Efficacy and Safety of Interleukin-23-Targeted Drugs in the Treatment of Moderate-to-Severe Psoriasis

In this study, our purpose was to systematically evaluate the efficacy and safety of interleukin-23 (IL-23)-targeted drugs in the treatment of moderate-to-severe psoriasis and provide an evidence-based reference for clinical treatment. A computer search of PubMed, EMBASE, Web of Science, Cochrane Library, Chinese Journal Full Text Database, Chinese Science and Technology Journal Database, and Wanfang Database was conducted from the establishment of the database to 2021-09-30. The efficacy of IL-23-targeted drugs (trial group) was compared with placebo (control group) in the treatment of psoriasis; i.e., PASI score improvement of 75% or more (PASI 75, PASI 90, and PASI 100) and the safety of randomized controlled trials (RCTs) were collected. Meta-analysis was performed using Rev Man 5.4.3 statistical software after data extraction for clinical studies that met the inclusion criteria. A total of 9 studies were included, all included studies were large multicenter, randomized, double-blind, placebo-controlled studies, and all used correct randomization methods and were of good quality. Meta-analysis showed that the improvement rates of PASI 75, PASI 90, and PASI 100 in the test group were superior to those in the control group (OR = 70.21 (42.25, 166.66), P < 0.00001), (OR = 78.41 (53.09, 115.79), P < 0.00001), and (OR = 77.10 (38.61, 153.99), P < 0.00001), P < 0.05. However, more adverse effects occurred, and the differences were statistically significant. IL-23-targeted drugs have significantly higher response rates compared to placebo in the treatment of psoriasis, and the safety was acceptable.

Aloperine Ameliorates IMQ-Induced Psoriasis by Attenuating Th17 Differentiation and Facilitating Their Conversion to Treg

Aloperine is an anti-inflammatory compound isolated from the Chinese herb Sophora alopecuroides L. Previously, our group has reported that the generation of induced Treg was promoted by aloperine treatment in a mouse colitis model. However, the effect of aloperine on effector T cell subsets remains unclear. We therefore carefully examined the effect of aloperine on the differentiation of major subsets of T helper cells. Based on our results, psoriasis, a Th17 dominant skin disease, is selected to explore the potential therapeutic effect of aloperine in vivo. Herein, we demonstrated that topical application of aloperine suppressed epidermal proliferation, erythema, and infiltration of inflammatory cells in skin lesions. Mechanistic studies revealed that aloperine suppressed the differentiation of Th17 cells directly through inhibiting the phosphorylation of STAT3 or indirectly through impairing the secretion of Th17-promoting cytokines by dendritic cells. Moreover, aloperine enhanced the conversion of Th17 into Treg via altering the pSTAT3/pSTAT5 ratio. Collectively, our study supported that aloperine possesses the capacity to affect Th17 differentiation and modulates Th17/Treg balance, thereby alleviating imiquimod (IMQ)-induced psoriasis in mice.

Comparison of the Efficacy and Safety of Biologics (Secukinumab, Ustekinumab, and Guselkumab) for the Treatment of Moderate-to-Severe Psoriasis: Real-world Data from a Single Korean Center

Biologics are important treatment options for psoriasis; however, direct comparison of their efficacy, safety, and drug survival is insufficient in clinical practice. This retrospective single-center study aimed to compare the efficacy, safety, and drug survival of three commonly used psoriasis biologics (secukinumab, ustekinumab, and guselkumab) and identify the factors affecting drug survival in actual clinics in Korea. We enrolled 111 patients with moderate to severe psoriasis and for at least 56 weeks of follow-up; among these, 27, 23, and 61 were administered secukinumab, ustekinumab, and guselkumab, respectively. All groups were comparable with respect to their baseline characteristics. Secukinumab showed a rapid response, and guselkumab was superior in terms of a long-term response and complete remission compared with other biologics, while ustekinumab showed a lower efficacy compared with other biologics. All three biologics had a favorable and similar safety profile; however, allergic reactions and latent tuberculosis were more common with secukinumab and ustekinumab, respectively. Guselkumab was the most sustained biologic, and the survival rates of secukinumab and ustekinumab were similar. Drug survival was remarkably shorter in female patients and those with hypertension. Introduction of new biologics emerged as a negative factor for drug survival in clinical settings.

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.

Risankizumab treatment in psoriasis patients who failed anti-IL17: a 52-week real-life study

Recent knowledge on the key role of interleukin (IL) 23/17 axis in psoriasis pathogenesis, led to development of new biologic drugs. Risankizumab is a humanized immunoglobulin G1 monoclonal antibody specifically targeting IL23. Its efficacy and safety were showed by both clinical trials and real‐life experiences. However, real‐life data on effectiveness and safety of risankizumab in patients who previously failed anti‐IL17 are scant. To assess the efficacy and safety of risankizumab in patients who previously failed anti‐IL17. A 52‐week real‐life retrospective study was performed to assess the long‐term efficacy and safety of risankizumab in patients who previously failed anti‐IL17. A total of 39 patients (26 male, 66.7%; mean age 50.5 ± 13.7 years) were enrolled. A statistically significant reduction of psoriasis area severity index (PASI) and body surface area (BSA) was assessed at each follow‐up (PASI at baseline vs. week 52: 13.7 ± 5.8 vs. 0.9 ± 0.8, p < 0.0001; BSA 21.9 ± 14.6 vs. 1.9 ± 1.7, p < 0.0001). Nail psoriasis severity index improved as well, being statistically significative only at week 16 and thereafter [9.3 ± 4.7 at baseline, 4.1 ± 2.4 (p < 0.01) at week 16, 1.4 ± 0.8 (p < 0.0001) at week 52]. Treatment was discontinued for primary and secondary inefficacy in 1(2.6%) and 3(7.7%) patients, respectively. No cases of serious adverse events were assessed. Our real‐life study confirmed the efficacy and safety of risankizumab, suggesting it as a valuable therapeutic weapon among the armamentarium of biologics, also in psoriasis patients who previously failed anti‐IL17 treatments.

A cohort study of guselkumab in the treatment of psoriasis refractory to previous biologic therapies: effectiveness, safety and adherence

Background Guselkumab is indicated for moderate-to-severe plaque psoriasis. Data from real-life clinical practice regarding its use are scarce, especially concerning patients who relapse after previous biologic therapies. Aim This study aimed to evaluate the effectiveness, safety, and adherence to guselkumab in psoriasis refractory to biologic therapies. Method This real-life, retrospective study included patients who initiated guselkumab between February 2019 and October 2020. The main objective was to assess effectiveness, expressed as the psoriasis area and severity index (PASI) ≤5, ≤2 and 0, at the first follow-up medical visit. As secondary effectiveness outcomes, we assessed the body surface area (BSA) and dermatology life quality index (DLQI). We also evaluated adverse events and adherence (using the medication possession ratio [MPR]). Results The study included 35 patients who had previously received a median of two biologic drugs. The median basal PASI score (IQR) was 11 (7.3-15.9), decreasing to 0 (0-1.4) at first follow-up medical visit. At this point, 32 patients (94.1%) reached PASI ≤5, 28 (82.4%) PASI ≤2 and 19 (55.9%) PASI 0. We also found statistically significant improvements in PASI, BSA and DLQI at first follow-up (p<0.001). Three patients developed adverse events. Most patients (N=29, 85.3%) had an MPR ≥90%. The MPR was not associated with PASI score at first follow-up. Conclusion Our study supports evidence that guselkumab is an effective and safe drug in psoriasis refractory to biologic therapies. Adherence to treatment is not related to effectiveness, suggesting that, in some cases, the interval between doses could be increased.

Epidermal Hyperproliferation With Less Prominent Dermal Inflammation Is the Unique Histopathological Feature of the Refractory Lesions in Psoriasis Treated With Ustekinumab

ABSTRACT

Although ustekinumab (UST) shows excellent efficacy in treating psoriasis, not all patients have a complete clearance rate. The purpose of this study was to investigate the histopathological characteristics of refractory psoriasis lesions in patients with excellent response to UST. Fifty-seven patients with newly diagnosed psoriasis and 66 patients with a 75% reduction in the Psoriasis Area and Severity Index score after UST treatment were included. Computer-aided image analysis was performed to measure the epidermal thickness, horny layer thickness, number of dermal vessels, and dermal inflammatory cell infiltration rate. Parakeratosis was scored using a 4-point scale. These measurements were compared between the refractory lesions of UST-treated patients and the untreated lesions of newly diagnosed patients after the adjustment for confounding factors. The dermal inflammatory cell infiltration rate was significantly lower in the refractory lesions (P = 0.022). Meanwhile, the epidermal thickness, horny layer thickness, grade of parakeratosis, and dermal vessel count did not differ between the groups (P = 0.125, 0.719, 0.542, and 0.758, respectively). Subgroup analyses were performed within the UST-treated group after dividing them into 2 groups according to the number of treatments or treatment response rates. None of these features were significantly different between the subgroups. This study suggests that the reduction of dermal inflammation by UST was not sufficient to ameliorate the epidermal changes and implies the role of the interleukin-23-independent downstream cytokine pathway in causing the refractory lesions among patients who responded well to UST. The continuation of UST treatment might not further improve epidermal alterations.

Indonesian Ciplukan Extract Inhibited TGF-β1/NF-κB Pathway in Experimental Psoriasis Mouse Models

Background:The global prevalence of psoriasis, a chronic inflammatory skin disease, has substantially increased in the last decade. The increase activity of Transforming Growth Factor ß1 (TGFß1)/nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) pathway which cause inflammation, is the major pathological mechanism in psoriasis. Current psoriasis treatment using chemical agents is hampered by the side-effects when used long-term, which underlines the need for alternative, low side-effect anti-psoriatic agents. The extract of Physalis angulata L., also known as Ciplukan in Indonesia, contains Physalins, compounds known for their anti-inflammatory effects, but whose effect on psoriasis has not been studied. Objective:  This study aimed to investigate the effect of Ciplukan extract (CE) to TGFß1/NF-κB pathway in psoriasis mouse models. Methods: This was experimental study with posttest-only control group design. The CE active ingredients were identified using Liquid chromatography-tandem mass spectrometry (LC-MS/MS). Twenty-five female imiquimod (IMQ) induced psoriasis-like dermatitis mice were allocated into five groups, with three groups receiving 7 days of 400, 800, and 1200 mg/kg bodyweight doses of CE, respectively, and two groups serving as control and IMQ groups. The NF-κB and TGFß1 expressions were evaluated using Allred score based on immunohistochemistry (IHC) staining. Histopathology and clinical psoriasis manifestations were assessed using Baker’s from Hematoxylin Eosin (HE) staining and Psoriasis Area Severity Index (PASI) scores. The Kruskal-Wallis followed by Mann Whitney tests were conducted for data analysis. The p-value < 0.05 was considered to be statistically different.   Results: Based on LC-MS/MS test, Physalin B, D, and F were active ingredients from CE in ethyl acetate solution. An improvement in psoriasis inflammation was observed in 400 and 800 mg/kg bodyweight doses of CE, but only the dosage of 800 mg/kg BW significantly decreased of Allred scores from NF-κB and TGFß1 expressions; Baker’s and PASI scores compared to IMQ group (p<0.05). The 1200 mg/kg bodyweight doses of CE associated with acute toxicity signs and mortality, meanwhile dosage of 800 mg/kg BW showed the highest efficacy with lowest toxicity effect. Conclusions: Ciplukan extract improved psoriasis manifestations via inhibition effect to TGFß1/NF-κB pathway and the extract might be developed as an alternative anti-psoriasis agent

Psoriasis and metabolic syndrome: implications for the management and treatment of psoriasis

Psoriasis is a chronic systemic inflammatory disorder associated with several comorbidities in addition to the characteristic skin lesions. Metabolic syndrome (MetS) is the most frequent comorbidity in psoriasis and a risk factor for cardiovascular disease, a major cause of death among patients with psoriasis. Although the exact causal relationship between these two disorders is not fully established, the underlying pathophysiology linking psoriasis and MetS seems to involve overlapping genetic predispositions and inflammatory pathways. Dysregulation of the IL‐23/Th‐17 immune signalling pathway is central to both pathologies and may be key to promoting susceptibility to metabolic and cardiovascular diseases in individuals with and without psoriasis. Thus, biological treatments for psoriasis that interrupt these signals could both reduce the psoriatic inflammatory burden and also lessen the risk of developing atherosclerosis and cardiometabolic diseases. In support of this hypothesis, improvement of skin lesions was associated with improvement in vascular inflammation in recent imaging studies, demonstrating that the beneficial effect of biological agents goes beyond the skin and could help to prevent cardiovascular disease. This review will summarize current knowledge on underlying inflammatory mechanisms shared between psoriasis and MetS and discuss the most recent clinical evidence for the potential for psoriasis treatment to reduce cardiovascular risk.

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.

Cytokine Induced 3-D Organotypic Psoriasis Skin Model Demonstrates Distinct Roles for NF-κB and JAK Pathways in Disease Pathophysiology

Psoriasis vulgaris is an inflammatory skin disease that affects 2-3% of the population worldwide. One of the major challenges in discovering novel therapies is the poor translatability of animal models to human disease. Therefore, it is imperative to develop human preclinical models of psoriasis that are amenable to pharmacological intervention. Here we report a 3-D reconstituted human epidermis (RHE) culture system treated with cytokines commonly associated with psoriasis (TNFα, IL-17A and IL-22) that reproduced some key features of the human disease. The effects on epidermal morphology, gene transcription and cytokine production, which are dysregulated in psoriasis were assessed. Certain morphological features of psoriatic epidermis were evident in cytokine-stimulated RHEs, including hypogranulosis and parakeratosis. In addition, RHEs responded to a cytokine mix in a dose-dependent manner by expressing genes and proteins associated with impaired keratinocyte differentiation (keratin 10/K10, loricrin), innate immune responses (S100A7, DEFB4, elafin), and inflammation (IL-1α, IL-6, IL-8, IL-10, IL-12/23p40, IL-36γ, GM-CSF, and IFNγ) typical of psoriasis. These disease-relevant changes in morphology, gene transcription, and cytokine production were robustly attenuated by pharmacologically blocking TNFα/IL-17A-induced NF-κB activation with IKK-2 inhibitor IV. Conversely, inhibition of IL-22-induced JAK1 signaling with ABT-317 strongly attenuated morphological features of the disease but had no effect on NFκB-dependent cytokine production, suggesting distinct mechanisms of action by the cytokines driving psoriasis. These data support the use of cytokine-induced RHE models for identifying and targeting keratinocyte signaling pathways important for disease progression and may provide translational insights into novel keratinocyte mechanisms for novel psoriasis therapies.

Cytokine Profiles and the Relationship of Disease Severity in Patients with Psoriasis

Background

Psoriasis is a chronic skin disease characterized by hyperproliferation of keratinocytes and increased inflammation. Previous studies have detected the levels of cytokines in the serum of patients with psoriasis, yet few multi-cytokine combination studies have been reported.

Objective

The aim of the study was to compare the levels of cytokines in the serum between patients with psoriasis and healthy controls, elucidate which factors influence the psoriasis progression.

Methods

A total of 39 psoriasis patients and 30 healthy volunteers were enrolled. The venous blood was collected and the levels of 13 inflammatory cytokines were measured by human inflammation panel 1 kit. The severity of the disease was determined according to the psoriasis area and severity index (PASI) score.

Results

Compared with healthy controls, the levels of nine cytokines (IFN-γ, TNF-α, IL-1β, IL-6, IL-10, IL-12P40, IL-18, IL-17A and IL-23) were significantly increased, while the level of MCP-1 decreased in psoriatic patients. In addition, except for MCP-1, IL-10 and IL-12P40, these cytokine levels were positively correlated with the PASI score. Furthermore, there were higher serum lever of IFN-γ, TNF-α, IL-1β, IL-6, IL-17A, IL-18 and IL-23 in active psoriasis than healthy controls and retrograde psoriasis.

Conclusions

Increased serum levels of IFN-γ, TNF-α, IL-1β, IL-6, IL-17A, IL-18 and IL-23 in psoriatic patients were associated with PASI and the stage of disease, which suggested that these cytokines play an important role in the pathogenesis of psoriasis. The detection of these cytokines can better observe the disease activity of psoriasis and optimize the treatment strategy.

New Topical Therapies for Psoriasis

Psoriasis is a chronic immune-mediated skin disease with a significant impact on patients' quality of life. Mild-to-moderate forms of the disease usually require long-term topical treatment, but prolonged use of corticosteroids and vitamin D analogues is limited by adverse effects. With further understanding of psoriasis pathogenesis, new molecules are emerging aiming to fulfil these clinical needs. Tapinarof, an aryl hydrocarbon receptor modulator, has completed a phase III study and demonstrated good efficacy results, even in long treatment courses, with a favourable safety profile. It additionally appears to have a promising remitting effect as patients presented with an average relapsing time of over 3 months. Roflumilast, a phosphodiesterase type 4 inhibitor, also underwent a phase III study with significant lesion improvement and notable pruritus management, and with no reported side effects. Roflumilast was evaluated as an option for intertriginous areas with good outcomes in a small sample, but larger trials are required. The Janus kinase-signal transducer and activator of transcription pathway has been targeted in recent clinical investigations with promising options, currently with brepocitinib pending phase IIb results. Ongoing preclinical studies involving interleukin-2 inhibition, RNA modulators and amygdalin analogues may lead to forthcoming clinical trials. New topical drugs are successfully emerging and future research comparing them to classical options will dictate their clinical role in the treatment of psoriasis.

Biologics for Psoriasis During the COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19), a new form of acute infectious respiratory syndrome first reported in 2019, has rapidly spread worldwide and has been recognized as a pandemic by the WHO. It raised widespread concern about the treatment of psoriasis in this COVID-19 pandemic era, especially on the biologics use for patients with psoriasis. This review will summarize key information that is currently known about the relationship between psoriasis, biological treatments, and COVID-19, and vaccination-related issues. We also provide references for dermatologists and patients when they need to make clinical decisions. Currently, there is no consensus on whether biological agents increase the risk of coronavirus infection; however, current research shows that biological agents have no adverse effects on the prognosis of patients with COVID-19 with psoriasis. In short, it is not recommended to stop biological treatment in patients with psoriasis to prevent the infection risk, and for those patients who tested positive for SARS-CoV-2, the decision to pause biologic therapy should be considered on a case-by-case basis, and individual risk and benefit should be taken into account. Vaccine immunization against SARS-CoV-2 is strictly recommendable in patients with psoriasis without discontinuation of their biologics but evaluating the risk-benefit ratio of maintaining biologics before vaccination is mandatory at the moment.

The biological basis of disease recurrence in psoriasis: a historical perspective and current models

A key challenge in psoriasis therapy is the tendency for lesions to recur in previously affected anatomical locations after treatment discontinuation following lesion resolution. Available evidence supports the concept of a localized immunological ‘memory’ that persists in resolved skin after complete disappearance of visible inflammation, as well as the role of a specific subpopulation of T cells characterized by the dermotropic CCR4⁺ phenotype and forming a local memory. Increasing knowledge of the interleukin (IL)‐23/T helper 17 (Th17) cell pathway in psoriasis immunopathology is pointing away from the historical classification of psoriasis as primarily a Th1‐type disease. Research undertaken from the 1990s to the mid‐2000s provided evidence for the existence of a large population of CD8⁺ and CD4⁺ tissue‐resident memory T cells in resolved skin, which can initiate and perpetuate immune responses of psoriasis in the absence of T‐cell recruitment from the blood. Dendritic cells (DCs) are antigen‐presenting cells that contribute to psoriasis pathology via the secretion of IL‐23, the upstream regulator of Th17 cells, while plasmacytoid DCs are involved via IL‐36 signalling and type I interferon activation. Overall, the evidence discussed in this review indicates that IL‐23‐driven/IL‐17‐producing T cells play a critical role in psoriasis pathology and recurrence, making these cytokines logical therapeutic targets. The review also explains the clinical efficacy of IL‐17 and IL‐23 receptor blockers in the treatment of psoriasis.

Evaluation of cytokine gene expression in psoriasis

Introduction

Psoriasis is a chronic inflammatory disease affecting the skin with an unclear etiological significance.

Aim

In this study, we determined the mRNA expression and circulating levels of T helper (Th)/T regulatory (Treg) cytokines in psoriasis and analyzed their association with disease severity and treatment response.

Material and methods

189 psoriasis patients and 189 controls were recruited. Circulating Th/Treg cytokines (IL-12, IFN-γ, IL-17, IL-23, TGF-β and IL-4) were measured at baseline and at follow-up after 12 weeks of methotrexate treatment by ELISA and their relative mRNA expression at baseline was estimated by quantitative PCR.

Results

We observed increased levels of Th1/Th17 cytokines (IFN-γ, IL-17, IL-12 and IL-23) and a decrease in levels of Th2/Treg cytokines (IL-4 and TGF-β) in psoriasis patients at baseline, as compared to controls. Further, we observed that there was a significant decrease in Th1/Th17 cytokines, whilst Th2/Treg cytokine levels were significantly increased on follow-up after treatment with systemic metho trexate, as compared to pre-treatment levels. Our results were further confirmed by the significantly higher mRNA expression of Th1/Th17 cytokine genes and significantly lower mRNA expression of Th2/Treg cytokine genes in patients with psoriasis, as compared to controls. A significant positive correlation of Th1/Th17 cytokines was observed with disease severity in cases, whilst Th2/Treg cytokines correlated negatively with disease severity.

Conclusions

Our results show that increased Th1/Th17 cytokines and decreased Th2/Treg cytokines, both at the circulatory and gene expression level, play an important role in the immunopathogenesis and severity of psoriasis.

Real world practice indirect comparison between guselkumab and risankizumab: Results from an Italian retrospective study

IL‐23‐inhibitors, such as guselkumab and risankizumab, represent the newest class of biologics approved for psoriasis. Phase III trials have shown their efficacy and safety. However, real life data are still scant. to indirectly compare the effectiveness, safety and tolerability of guselkumab and risankizumab in real world practice. An Italian single‐center retrospective cohort study enrolling moderate‐to‐severe psoriasis patients from September 1, 2018 and December 31, 2020 was performed to indirectly compare guselkumab and risankizumab efficacy and safety. Sixty eight patients were included (36 received guselkumab and 32 risankizumab). The groups were comparable for all analyzed characteristics, except for mean psoriasis duration (p < 0.01) which was higher for guselkumab. In guselkumab group, mean PASI reduced from 16.1 ± 6.4 (baseline) 2.1 ± 0.9 (week‐28) (p < 0.001) up to 0.9 ± 0.8 (week‐44) (p < 0.001). In risankizumab group mean PASI decreased from 13.5 ± 4.9 (baseline) 1.9 ± 0.8 (p < 0.001), (week‐28) (p < 0.001) up to 0.9 ± 0.4 (week‐40) (p < 0.001). No significant difference in mean PASI and BSA were observed between the treatments. No cases of serious AEs, injection site reaction, candida, malignancy, cardiovascular events were reported in both groups. Guselkumab and risankizumab showed favorable efficacy and safety profile, being comparable in terms of PASI90 and PASI100 responses as well as in AEs frequency and discontinuation rates.

Molecular and clinical effects of selective TYK2 inhibition with deucravacitinib in psoriasis

BACKGROUND

Psoriasis, a chronic inflammatory disease dependent on the interleukin (IL)-23/T helper cell 17 (Th17) pathway, is initiated through plasmacytoid dendritic cell activation and type I interferon induction in the skin. Deucravacitinib, a selective tyrosine kinase 2 (TYK2) inhibitor, blocks IL-23, IL-12, and type I interferon signaling in cellular assays.

OBJECTIVE

Investigate changes in IL-23/Th17- and type I interferon-pathway biomarkers and gene responses, and measures of selectivity for TYK2 over Janus kinases (JAKs) 1-3, in patients with moderate to severe psoriasis receiving deucravacitinib.

METHODS

Deucravacitinib was evaluated in a randomized, placebo-controlled, dose-ranging trial. Biopsies from non-lesional (Day 1) and lesional skin (Days 1, 15, and 85) were assessed for changes in IL-23/IL-12 and type I interferon pathway biomarkers by quantitative reverse-transcription polymerase chain reaction, RNA sequencing, and immunohistochemistry. Laboratory markers were measured in blood. Percent change from baseline in Psoriasis Area and Severity Index (PASI) score was assessed.

RESULTS

IL-23 pathway biomarkers in lesional skin returned toward non-lesional levels dose-dependently with deucravacitinib. Interferon and IL-12 pathway genes were normalized. Markers of keratinocyte dysregulation, keratin-16, and β-defensin genes approached non-lesional levels with effective dosages. Select laboratory parameters impacted by JAK1-3 inhibition were unaffected by deucravacitinib. Greater improvements in PASI scores, correlated with biomarker changes, were seen with the highest dosages of deucravacitinib versus lower dosages or placebo.

CONCLUSION

Robust clinical efficacy with deucravacitinib treatment was associated with decreases in IL-23/Th17 and interferon pathway biomarkers. The lack of effect seen on biomarkers specific to JAK1-3 inhibition support selectivity of deucravacitinib for TYK2; larger studies are needed to further confirm.

Interplay Between Skin Microbiota Dysbiosis and the Host Immune System in Psoriasis: Potential Pathogenesis

Psoriasis is a multifactorial immune-mediated disease. The highly effective and eligible treatment for psoriasis is limited, for its specific pathogenesis is incompletely elucidated. Skin microbiota is a research hotspot in the pathogenesis of immune-mediated inflammatory skin diseases nowadays, and it may have significant involvement in the provocation or exacerbation of psoriasis with broadly applicable prospects. It is postulated that skin microbiota alternation may interplay with innate immunity such as antimicrobial peptides and Toll-like receptors to stimulate T-cell populations, resulting in immune cascade responses and ultimately psoriasis. Achieving a thorough understanding of its underlying pathogenesis is crucial. Herein, we discuss the potential immunopathogenesis of psoriasis from the aspect of skin microbiota in an attempt to yield insights for novel therapeutic and preventive modalities for psoriasis.

Current Concepts of Psoriasis Immunopathogenesis

Psoriasis is a recurrent, chronic, immune-mediated, systemic inflammatory disease of the skin, joints, and other organic systems. After atopic dermatitis, chronic stationary psoriasis is the most common inflammatory skin disease, affecting an average of 2-4% of the world's population. The disease carries a significant burden due to its numerous comorbidities and the major impact on patients' social and emotional aspects of life. According to current knowledge, psoriasis is a multifactorial disease that occurs in genetically predisposed individuals under various environmental factors, which trigger an immune response disorder with a series of complex inflammatory cascades. The disease is initiated and maintained by mutual interaction of the innate and adaptive immune cells, primarily dendritic cells, T lymphocytes, and keratinocytes, whose leading role alternates at different stages of the disease, consisting mainly in the IL-23/Th17 pathway. Inflammatory events result in consequent epidermal and dermal changes and evolution of the characteristic psoriatic phenotype, respectively. This paper aims to present a comprehensive overview of current knowledge on psoriasis genetic and environmental etiological factors, immunopathogenesis, and the leading cellular and cytokine participants in the inflammatory pathways of this disease.

Drug Persistence of Biologic Treatments in Psoriasis: A Swedish National Population Study

Introduction

Biologic treatments for psoriasis are commonly switched. Treatment persistence represents an important parameter related to long-term therapeutic performance. The objective of the study was to analyse the real-world persistence with biologics over time in the treatment of psoriasis.

Methods

A retrospective observational study of adults with psoriasis was conducted based on Swedish national registry data from 2010 to 2018. Patients included were treated with a biologic between 2010 and 2018. Treatment episodes were identified from the drug’s date of dispensation recorded in the Prescribed Drug Register to the end of supply of the drug. Median persistence was estimated by Kaplan–Meier survival curves for patients who received adalimumab, etanercept, secukinumab, ustekinumab and ixekizumab. Descriptive analysis of change in persistence over time for 3-year running cohorts was also carried out.

Results

A total of 2292 patients were analysed. Patients who received ustekinumab had the longest median persistence [49.3 months, 95% confidence interval (CI) 38.0–59.1] and etanercept the shortest (16.3 months, 95% CI 14.5–19.0). Median persistence was longer in biologic-naive than biologic-exposed patients. Persistence for ustekinumab decreased by almost 50% over the study period, from a median of 62.3 (95% CI 45.6–∞) months in 2010–2011 to 32.7 (21.2–49.3) months in 2014–2016.

Conclusions

Persistence with biologics was, on average, relatively low, given the chronic nature of psoriasis. Changes in persistence over time seemed to be attributable to changes in the therapeutic landscape, providing patients with more options to switch biologic treatments if their current management was considered suboptimal.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00616-7.

Cellular nanovesicles with bioorthogonal targeting enhance photodynamic/photothermal therapy in psoriasis

The interaction between over-proliferating keratinocytes and excessive activated immune cells contributes to the development and progression of psoriasis. Photodynamic therapy (PDT)/photothermal therapy (PTT) is a promising method to treat skin diseases due to their synergistic effect and low side effect. Cell membrane is an ideal cell-mediated drug delivery platform with inherent biocompatibility, but lacks of specific targeting properties to increase drug accumulation in the psoriatic site. Here, we develop a new PDT/PTT strategy to treat psoriasis, based on cell membrane functionalization by metabolic glycoengineering with unnatural sugars, which label cell membranes with chemical tags for subsequent targeting. In our study, in order to enhance the PDT/PTT effect, N₃-labeled cell membrane-derived nanovesicles coated with IR-780 nanoparticals (N₃-NV-INPs) are constructed, which can specifically recognize DBCO-modified psoriatic lesions through bioorthogonal click chemistry to achieve targeted PDT/PTT effect. The results showed that N₃-NV-INPs could specifically target the psoriatic lesions, enhance the synergistic effect of PDT/PTT under the irradiation of near-infrared light, exhaust excessive proliferation of keratinocytes, regulate immunity, reduce the release of cytokines, such as IL-17, IL-22, TNF-α, improve epidermal hyperplasia, and effectively relieve the symptoms of psoriasis. Taken together, we constructed cellular nanovesicles based on an alternative artificial targeting strategy to enhance PDT/PTT effect in psoriasis, which shows great potential in clinical application. STATEMENT OF SIGNIFICANCE: The major challenge in the treatment of psoriasis is how to effectively deliver drugs to the lesions to exhaust overproliferating keratinocytes and modulate immunity. A newly-developed cell membrane-coating technology combined with biorthogonal targeted delivery promotes more drug accumulation at the lesions of the disease. Incorporation of an effective photosensitizer into the lesions of psoriasis site results in exert PDT/PTT effect under the irradiation of near-infrared light. The synergistic PDT/PTT effect can effectively exhaust keratinocytes and immune cells in the epidermis and dermis, reduce the release of inflammatory cytokines, and relieve the symptoms of psoriasis. This unique functional cell membrane nanovesicles combined with bioorthogonal targeting is applied to enhance the PDT/PTT effect in psoriasis and may provide a solution for the clinical treatment of other inflammatory skin diseases.

Cav1.4 calcium channels control cytokine production by human peripheral TH17 cells and psoriatic skin-infiltrating T cells

BACKGROUND

Type-17 inflammation characterizes psoriasis, a chronic skin disease. Because several inflammatory cytokines contribute to psoriasis pathogenesis, inhibiting the simultaneous production of these cytokines in T_H17 cells may be beneficial in psoriasis. We found that Ca_v1.4, encoded by CACNA1F, was the only Ca_v1 calcium channel expressed in T_H17 cells.

OBJECTIVE

We sought to investigate the role of Ca_v1.4 expression in early T_H17-activation events and effector functions, as well as its association with T_H17 signature genes in lesional psoriatic (LP) skins.

METHODS

Transcriptional gene signatures associated with CACNA1F expression were examined in LP skins by RT-PCR and in situ hybridization. Ca_v1 inhibitor and/or shRNA lentivectors were used to assess the contribution of Ca_v1.4 in T_H17 activation and effector functions in a 3-dimensional skin reconstruction model.

RESULTS

CACNA1F expression correlated with inflammatory cytokine expression that characterizes LP skins and was preferentially associated with RORC expression in CD4⁺ and CD4^- cells from LP biopsies. Nicardipine, a Ca_v1 channel antagonist, markedly reduced inflammatory cytokine production by T_H17 cells from blood or LP skin. This was associated with decreased TCR-induced early calcium events at cell membrane and proximal signaling events. The knockdown of Ca_v1.4 in T_H17 cells impaired cytokine production. Finally, Ca_v1 inhibition reduced the expression of the keratinocyte genes characteristic of T_H17-mediated psoriasis inflammation in human skin equivalents.

CONCLUSIONS

Ca_v1.4 channels promote T_H17-cell functions both at the periphery and in inflammatory psoriatic skin.

First-in-class topical therapeutic omilancor ameliorates disease severity and inflammation through activation of LANCL2 pathway in psoriasis

Psoriasis (PsO) is a complex immune-mediated disease that afflicts 100 million people. Omilancor is a locally-acting, small molecule that selectively activates the Lanthionine Synthetase C-like 2 (LANCL2) pathway, resulting in immunoregulatory effects at the intersection of immunity and metabolism. Topical omilancor treatment in an imiquimod-induced mouse model of PsO ameliorates disease severity, epidermal hyperplasia and acanthosis. Further, pharmacological activation of LANCL2 results in significant downregulation of proinflammatory markers including local reduction of IL17, and infiltration of proinflammatory cell subsets. These therapeutic effects were further validated in an IL-23 PsO model. This model reported increased preservation of homeostatic skin structure, accompanied by a decreased infiltration of proinflammatory T cell subsets. In CD4+ T cells and Th17 cells, the LANCL2 pathway regulates proinflammatory cytokine production, proliferation and glucose metabolism. Metabolically, the loss of Lancl2 resulted in increased glycolytic rates, lactate production and upregulated enzymatic activity of hexokinase and lactate dehydrogenase (LDH). Inhibition of LDH activity abrogated the increased proliferation rate in Lancl2^-/- CD4+ T cells. Additionally, topical omilancor treatment decreased the metabolic upregulation in keratinocytes, keratinocyte hyperproliferation and expression of inflammatory markers. Omilancor is a promising topical, LANCL2-targeting therapeutic candidate for the treatment of PsO and other dermatology indications.

IL-23 blockade with guselkumab potentially modifies psoriasis pathogenesis: rationale and study protocol of a phase 3b, randomised, double-blind, multicentre study in participants with moderate-to-severe plaque-type psoriasis (GUIDE)

BACKGROUND

Guselkumab is an interleukin (IL)-23 pathway blocker with proven efficacy in patients with moderate-to-severe plaque psoriasis. Early intervention with guselkumab may result in changes to the clinical disease course versus later intervention.

METHODS AND ANALYSIS

Here we present the rationale and design of a phase 3b, randomised, double-blind, multicentre study (GUIDE), comparing treatment effects of guselkumab in patients with short (≤2 years) or longer (>2 years) duration of plaque-type psoriasis, measured from first appearance of psoriatic plaques. Participants achieving skin clearance (Psoriasis Area and Severity Index (PASI)=0) by week 20 and maintaining complete clearance at week 28 visit ('super-responders' (SRe)) will be randomised to continue approved maintenance dosing every 8 weeks (q8w) versus an investigational maintenance dosing interval of 16 weeks (q16w) until week 68. Primary endpoint: proportion of participants in the q8w vs q16w arms with absolute PASI <3 at week 68. Participants with PASI <3 at week 68 will be withdrawn from guselkumab treatment for up to 48 weeks. Participants not achieving SRe criteria (non-SRe) will remain in the study with q8w guselkumab dosing through week 68. Additional to serum samples obtained from all patients, skin biopsies and whole-blood samples will be taken from SRe and non-SRe participants at various time points in optional substudies. Analyses include: genetics; immunophenotyping (fluorescence-activated cell sorting); gene and protein expression profiling; immunohistology. By merging clinical endpoints with mechanistic findings, this study aims to elucidate how IL-23 blockade with guselkumab can modify the disease course by altering molecular and cellular drivers that cause relapse after treatment withdrawal, particularly among SRe.

ETHICS AND DISSEMINATION

Approval obtained from ethics committee Medical Council Hamburg, Germany (PVN5925). GUIDE is compliant with the Declaration of Helsinki.

TRIAL REGISTRATION NUMBER

Registered at ClinicalTrials.gov (NCT03818035). All primary endpoint results (prespecified analyses) will be submitted to peer-reviewed, international journals within 18 months after primary completion date.

Expectation-induced enhancement of pain, itch and quality of life in psoriasis patients: study protocol of a randomised controlled trial

INTRODUCTION

Experimental and clinical data demonstrate that skin diseases like psoriasis are affected by psychological factors and can be modulated by interventions other than conventional drug therapy. The expectation of patients towards the benefit of a forthcoming treatment as well as treatment pre-experiences have been demonstrated as crucial factors mediating placebo responses in inflammatory skin diseases. However, it is unknown whether and to what extent treatment outcomes of psoriasis patients under therapy with monoclonal antibodies like secukinumab can be experimentally modulated at subjective and physiological levels by modifying the expectation of patients via verbal instruction or prior experience.

METHODS AND ANALYSIS

Treatment expectations will be modulated in patients with moderate-to-severe psoriasis undergoing treatment with the anti-interleukin-17A monoclonal antibody secukinumab. Patients with a Psoriasis Area and Severity Index (PASI) >12 will be randomly allocated to one of three groups (N=40 each). As a standard schedule, patients in the pharmacological control group (group 1) will be treated weekly with 300 mg secukinumab, while patients in groups 2 and 3 will receive only 75 mg secukinumab (75% dose reduction) during all treatment weeks. In addition to the injections, patients in group 3 will ingest a novel tasting drink, with a cover story explaining that previous studies showed additional beneficial effects of this combination (drug and drink). Patients will be assessed and treated at nine visits over a 16-week period, during which the severity of pain and itch symptoms, skin lesions and quality of life will be analysed with standardised questionnaires and the PASI.

ETHICS AND DISSEMINATION

This study was approved by the Ethics committee of the Medical Faculty of the University Duisburg-Essen. Study outcomes will be published in peer-reviewed scientific journals.

Purinergic Signaling and Inflammasome Activation in Psoriasis Pathogenesis

Psoriasis is a chronic inflammatory disease of the skin associated with systemic and joint manifestations and accompanied by comorbidities, such as metabolic syndrome and increased risk of cardiovascular disease. Psoriasis has a strong genetic basis, but exacerbation requires additional signals that are still largely unknown. The clinical manifestations involve the interplay between dendritic and T cells in the dermis to generate a self-sustaining inflammatory loop around the TNFα/IL-23/IL-17 axis that forms the psoriatic plaque. In addition, in recent years, a critical role of keratinocytes in establishing the interplay that leads to psoriatic plaques’ formation has re-emerged. In this review, we analyze the most recent evidence of the role of keratinocytes and danger associates molecular patterns, such as extracellular ATP in the generation of psoriatic skin lesions. Particular attention will be given to purinergic signaling in inflammasome activation and in the initiation of psoriasis. In this phase, keratinocytes’ inflammasome may trigger early inflammatory pathways involving IL-1β production, to elicit the subsequent cascade of events that leads to dendritic and T cell activation. Since psoriasis is likely triggered by skin-damaging events and trauma, we can envisage that intracellular ATP, released by damaged cells, may play a role in triggering the inflammatory response underlying the pathogenesis of the disease by activating the inflammasome. Therefore, purinergic signaling in the skin could represent a new and early step of psoriasis; thus, opening the possibility to target single molecular actors of the purinome to develop new psoriasis treatments.

Serum lactate dehydrogenase level as a possible predictor of treatment preference in psoriasis

BACKGROUND

The efficacy of small molecule inhibitors for intracellular signal mediators varies among the individuals, and their mechanism of action is broad. A phosphodiesterase 4 inhibitor apremilast shows a dramatic effect on a certain proportion of psoriatic patients by modulating the cellular metabolism and regulating the production of pro-inflammatory molecules. However, it is unclear to which disease subtype this drug benefits. While psoriasis is a Th17-mediated disease, how immune cells are affected by the modulation of cellular metabolism is not fully evaluated, either.

OBJECTIVE

This study aims to identify the indices which predict the efficacy of apremilast in psoriasis, and to investigate the impact of metabolic activity in immune cells on the psoriatic pathogenesis.

METHODS

The association of treatment efficacy with clinical and laboratory data of the 58 psoriatic patients was evaluated. The reflector of the associated index was also sought among the indices of cellular metabolic pathways by use of an extracellular flux analyzer.

RESULTS

There was a correlation between clinical improvement and the serum lactate dehydrogenase (LDH) level in the patients treated with apremilast but not in those with biologics. Serum LDH level did not correlate with the cutaneous disease severity but correlated with the oxygen consumption rate of blood T cells.

CONCLUSION

Psoriatic patients with high serum LDH level can be benefitted by apremilast. The serum LDH level reflects the augmented respiratory activity of T cells in psoriasis. Our results would highlight the importance of regarding metabolic skew in immune cells as a treatment target in psoriasis.

Cinnamaldehyde inhibits psoriasis‑like inflammation by suppressing proliferation and inflammatory response of keratinocytes via inhibition of NF‑κB and JNK signaling pathways

Psoriasis is a systemic immune-mediated inflammatory disease characterized by uncontrolled keratinocyte proliferation and poor differentiation. Cinnamaldehyde (CIN) has been shown to inhibit the proliferation and inflammatory response of primary and immortalized immune cells. However, to the best of our knowledge, the role of CIN in the progression of psoriasis remains unclear. Therefore, the present study aimed to investigate the biological role of CIN in psoriasis. To mimic abnormal proliferation and differentiation in keratinocytes in vitro, normal human epidermal keratinocytes (NHEKs) were stimulated with M5 (IL-1α, IL-17A, IL-22, oncostatin M and TNF-α). The viability and proliferation of NHEKs were analyzed using Cell Counting Kit-8 and 5-Ethynyl-2′-deoxyuridine assays, respectively. Western blotting was used to analyze the expression levels of keratin 1, filaggrin and loricrin in NHEKs. The results of the present study revealed that CIN significantly inhibited the proliferation and cell cycle progression, and promoted the differentiation of M5-stimulated NHEKs. CIN also markedly attenuated the extent of oxidative stress-induced damage in M5-stimulated NHEKs. Moreover, CIN ameliorated M5-induced inflammatory injury in NHEKs, as evidenced by the decreased levels of multiple inflammatory factors. Furthermore, CIN notably downregulated the expression levels of phosphorylated (p)-inhibitor of NF-κB, p-p65 and p-JNK in M5-stimulated NHEKs. In conclusion, the present data suggested that CIN may protect NHEKs against M5-induced hyperproliferation and inflammatory injury via inhibition of NF-κB and JNK signaling pathways. These results provide a novel insight on the role of CIN in psoriasis.

Risk of inflammatory bowel disease in patients with psoriasis, psoriatic arthritis and ankylosing spondylitis initiating interleukin 17 inhibitors: a nationwide population-based study using the French national health data system

OBJECTIVES

To investigate whether IL17-inhibitors (IL17i) initiation in real life is associated with a higher risk of inflammatory bowel disease (IBD) in patients with psoriasis (PsO), psoriatic arthritis and ankylosing spondylitis (PsA/AS).

METHODS

This nationwide cohort study involved the French national health data system database. All adults with PsO and PsA/AS who were new-users of IL17i during 2016-2019 were included. Two non-exposed PsO and PsA/AS population were included: new-users of (1) apremilast and (2) etanercept. End of follow-up was September 30, 2019. The primary end-point was an occurrence of IBD in a time-to-event analysis with propensity score-weighted Cox and Fine-Gray models.

RESULTS

A total of 16,793 IL17i new-users (mean age 48.4±13 years; 46% men); 20,556 apremilast new-users (mean age 52.5±14.6 years; 53% men); and 10,245 etanercept new-users (mean age 46.3±15 years; 44% men) were included. Previous systemic treatements were closer between IL17i and etanercept compared with apremilast. IBD occurred in 132 cases: 72 (0.43%) in IL17i new-users, 11 (0.05%) in apremilast new-users and 49 (0.48%) in etanercept new-users. Most IBD cases occurred after 6 months of exposure (82%, 55% and 76% respectively). After propensity score weighting, the risk of IBD was significantly greater with IL17i than apremilast (HR_w 3.8, 95%CI 2.1-6.8). No difference was observed between IL17i and etanercept new-users (HR_w 0.8, 95%CI 0.5-1.2).

CONCLUSION

Compared with patients initiating etanercept that displayed the same severity of the underlying disease, IL17i new-users did not present a higher risk of IBD. These results need to be confirmed in other large databases.

Lesional activation of Tc 17 cells in Behçet's disease and psoriasis supports HLA-class I-mediated autoimmune responses

BACKGROUND

Behçet's disease (BD) presents with lymphocytic and neutrophilic vasculitis of unknown aetiology. HLA-B*51 ERAP1 and IL12R/IL23R are genetic risk factors. IL-23 regulates IL-17A, which controls recruitment and activation of neutrophils.

OBJECTIVES

To determine pathological changes in BD skin lesions related to the complex genetic predisposition METHODS: We characterised the expression of IL-17A and IL-23A in various cell types by immunohistological double staining of sections from papulopustular skin lesions (PPL) of acute attacks of BD and lesions of psoriasis vulgaris (PV), another HLA-class I-associated T-cell mediated autoimmune disease in which excessive T-cell derived IL-17A production promotes neutrophil activation.

RESULTS

We found that in BD lesions, as in psoriasis, actively expanding CD8⁺ T cells were the predominant source of IL-17A. IL-17A⁺ CD8⁺ T (Tc17) cells outnumbered infiltrating IL-17A⁺ CD4⁺ T cells. Unlike the epidermal localisation of CD8⁺ T cells in psoriasis, Tc17 cells in BD lesions infiltrated mainly the perivascular tissue and also the blood vessel walls of dermis and subcutaneous tissue. They colocalised with a marked IL-23A expression by CD11c⁺ dendritic cells (DCs) and CD68⁺ macrophages. IL-17A expression was associated with extensive recruitment of neutrophils around blood vessels that formed neutrophil extracellular traps (NETs).

CONCLUSIONS

In BD, the genetic predisposition may mediate antigen-specific activation and differentiation of a T_c 17 response, possibly targeting endothelial antigens. Neutrophils recruited by IL-17A in this process may enhance tissue damage by extensive NET formation (NETosis). Thus, the IL-23/IL-17 axis presumably controls neutrophilic inflammation in BD vasculitis in the context of a predominant antigen-specific CD8⁺ T-cell response.

IFN-γ Drives Human Monocyte Differentiation into Highly Proinflammatory Macrophages That Resemble a Phenotype Relevant to Psoriasis

As key cells of the immune system, macrophages coordinate the activation and regulation of the immune response. Macrophages present a complex phenotype that can vary from homeostatic, proinflammatory, and profibrotic to anti-inflammatory phenotypes. The factors that drive the differentiation from monocyte to macrophage largely define the resultant phenotype, as has been shown by the differences found in M-CSF- and GM-CSF-derived macrophages. We explored alternative inflammatory mediators that could be used for in vitro differentiation of human monocytes into macrophages. IFN-γ is a potent inflammatory mediator produced by lymphocytes in disease and infections. We used IFN-γ to differentiate human monocytes into macrophages and characterized the cells at a functional and proteomic level. IFN-γ alone was sufficient to generate macrophages (IFN-γ Mϕ) that were phagocytic and responsive to polarization. We demonstrate that IFN-γ Mϕ are potent activators of T lymphocytes that produce IL-17 and IFN-γ. We identified potential markers (GBP-1, IP-10, IL-12p70, and IL-23) of IFN-γ Mϕ and demonstrate that these markers are enriched in the skin of patients with inflamed psoriasis. Collectively, we show that IFN-γ can drive human monocyte to macrophage differentiation, leading to bona fide macrophages with inflammatory characteristics.

Evaluation of short-term (16-week) effectiveness and safety of guselkumab in patients with psoriasis: A prospective real-life study on the Chinese population

Real-life data on guselkumab in psoriasis are limited and not available in China hitherto. This study aimed to evaluate the short-term effectiveness and safety of guselkumab in patients with psoriasis under Chinese real-life conditions and to explore the effect of guselkumab on CD4⁺ CD25⁺ Foxp3⁺ regulatory T cells (Tregs). A Chinese prospective and real-life study involving patients with psoriasis in Dermatology Hospital of Southern Medical University, Guangzhou, China from April to September 2020 was conducted. A total of 45 patients with psoriasis were finally enrolled in the study. Psoriasis Area Severity Index (PASI) 90 and 100 responses at week 16 were achieved by 88.6% and 45.5% of patients, respectively. The analysis of PASI response in different subgroups showed no statistically significant difference. Univariate logistic regression analysis revealed that at week 16, none of the variables were associated with decreasing PASI 90 response, whereas age at onset of disease was a predictor of PASI 100 response. Dynamic detection of CD4⁺ CD25⁺ Foxp3⁺ Tregs frequency from peripheral blood suggested a stable maintained trend in terms of guselkumab treatment duration. No severe adverse events occurred during the follow-up period. This study confirmed the short-term effectiveness and safety of guselkumab, as well as its good tolerance against psoriasis, in the Chinese population. Guselkumab treatment maintains levels of Tregs in patients with psoriasis.

Enhanced serum interferon-lambda 1 interleukin-29 levels in patients with psoriasis vulgaris

BACKGROUND

Interferon (IFN)-λ1, also named Interleukin (IL)-29, is a new member of the Type III IFN or IFN-λ family. IL-29 plays an important role in the pathogenesis of many types of autoimmune and inflammatory diseases.

OBJECTIVE

To study the role of IL-29 in the pathogenesis of psoriasis vulgaris.

METHODS

The authors detected the serum levels of IL-29 in forty-one patients with psoriasis vulgaris, twenty-three patients with atopic dermatitis and thirty-eight age and gender-matched controls by sandwich Enzyme-Linked Immunosorbent Assay (ELISA). The effects of IL-29 on the expression of cytokines, such as IL-6, IL-17, IL-8, IL-4, IL10, Interferon (IFN-γ) and Tumor Necrosis Factor-α (TNF-α), in PBMCs and HaCat cells were determined by real-time quantitative PCR.

RESULTS

Our data indicated that serum IL-29 levels were significantly elevated in patients with psoriasis vulgaris when compared with atopic dermatitis patients and the control group. Moreover, Serum levels of IL-29 were closely associated with the severity of psoriasis vulgaris. Furthermore, IL-29 up-regulated the mRNA expression levels of IL-6, IL-17 and TNF-α in PBMCs from psoriasis vulgaris patients. In addition, IL-29 enhanced the IL-6 and IL-8 expression from the HaCat cells.

CONCLUSION

This study provides the first observations on the association of IL-29 and psoriasis vulgaris and showed elevated IL-29 serum levels. The authors suggest that IL-29 may play a role in the pathogenesis of psoriasis vulgaris.

Anoctamin1 Induces Hyperproliferation of HaCaT Keratinocytes and Triggers Imiquimod-Induced Psoriasis-Like Skin Injury in Mice

Psoriasis, a long-lasting and multifactorial skin disease, is related to comorbidities such as metabolic disease, depression, and psoriatic arthritis. Psoriasis occurs due to a variety of factors including keratinocyte hyperproliferation, inflammation, and abnormal differentiation. Proinflammatory cytokines upregulated by increased activation of keratinocytes and immune cells in the skin trigger progression of psoriasis. This study aimed to investigate the effects of anoctamin1 (ANO1) on psoriasis development in vitro and in vivo. We analyzed the proliferation of HaCaT keratinocytes and ANO1-related ERK and AKT signaling pathways after ANO1 inhibitor (T16Ainh-A01 and Ani9) treatment and knock-down of ANO1. Furthermore, after applying imiquimod (IMQ) cream or coapplying IMQ cream and T16Ainh-A01 on mouse ears, we not only observed psoriatic symptoms, including ear thickening, but also quantified the effects of treatment on ERK and AKT signaling-involved proteins and proinflammatory cytokines. Inhibition of ANO1 attenuated the proliferation of HaCaT cells and induced reduction of pERK1/2. Coapplication of IMQ and T16Ainh-A01 on ears of mice reduced not only symptoms of IMQ-induced psoriasis such as thickening and erythema, but also expression of ANO1 and pERK1/2 compared to that of application of IMQ alone. In addition, the expression levels of IL-17A, IL-17F, IL-22, IL-23, IL-6, IL-1β, and TNF-α increased after applying IMQ and were significantly reduced by coapplying IMQ and T16Ainh-A01. These results aid in understanding the underlying mechanisms of ANO1 in epidermal layer keratinocyte hyperproliferation and suggest the potential of ANO1 as a target to treat psoriasis.

Model-Based Meta-Analysis in Psoriasis: A Quantitative Comparison of Biologics and Small Targeted Molecules

Background: The response time-course information of biologics and small targeted molecules for the treatment of moderate to severe plaque psoriasis which helps clinicians to understand the onset of action and maintenance of effect are unclear. Quantitative information about the efficacy comparation of different systemic agents are needed.

Methods: Model-based meta-analysis was conducted and longitudinal models were developed by applying two clinical end points commonly reported in the clinical trials of psoriasis: the proportion of patients achieving ≥75% reduction from baseline Psoriasis Area and Severity Index score (PASI75) and the proportion of patients achieving ≥90% reduction from baseline Psoriasis Area and Severity Index score (PASI90).

Results: A total of 80 trials of thirteen biological agents and four small targeted molecules covering 235 treatment arms and 40323 patients with moderate to severe plaque psoriasis were included in this analysis. The drugs were divided into five classes of biologics and three classes of small molecules. Two longitudinal models of PASI75 and PASI90 were used to describe the time-varying drug effect and dose-effect relationship. The typical response-time courses for PASI75 and PASI90 increased over time and finally reached to the platform. For PASI75 end point at week 12, of all the therapeutic drugs, risankizumab administered as 150 mg at week 0, week 4, and q12w showed the most efficacious with PASI75 was 85.95% (95%CI, 75.71–92.60%), followed by ixekizumab administered as 160 mg at week 0, and q4w with PASI75 was 85.9% (95%CI, 76.12–92.79%). As for PASI90 end point at week 12, ixekizumab 160 mg at week 0, and q4w showed the greatest percentage of person achieved PASI90 (67.2%; 95%CI, 49.91–77.2%), followed by risankizumab 150 mg at week 0, week 4, and q12w (65.5%; 95%CI, 47.8–75.7%). What’s more, the risankizumab provided the highest response of PASI90 at week 16 and week 24.

Conclusions: This study provided a quantitative efficacy comparation of 17 systemic agents for psoriasis in term of efficacy only and that safety was not considered. Risankizumab and ixekizumab showed superiority for both the two end points.

Comparative effectiveness of guselkumab in psoriatic arthritis: results from systematic literature review and network meta-analysis

Objective

The efficacy of the novel interleukin (IL)-23p19 inhibitor guselkumab for psoriatic arthritis (PsA) has recently been demonstrated in two phase 3 trials (DISCOVER-1 & -2) but has not been evaluated vs other targeted therapies for PsA. The objective was to compare guselkumab to targeted therapies for PsA for safety and joint and skin efficacy through network meta-analysis (NMA).

Methods

A systematic literature review was conducted in January 2020 to identify randomized controlled trials. Bayesian NMAs were performed to compare treatments on American College of Rheumatology (ACR) 20/50/70 response, mean change from baseline in van der Heijde-Sharp (vdH-S) score, Psoriasis Area Severity Index (PASI) 75/90/100 response, adverse events (AEs) and serious adverse events (SAEs).

Results

Twenty-six phase 3 studies evaluating 13 targeted therapies for PsA were included. For ACR 20 response, guselkumab 100 mg every 8 weeks (Q8W) was comparable to IL-17A inhibitors and subcutaneous tumor necrosis factor (TNF) inhibitors. Similar findings were observed for ACR 50 and 70. For vdH-S score, guselkumab Q8W was comparable to other agents except intravenous TNF therapies. Results for PASI 75 and PASI 90 response suggested guselkumab Q8W was better than most other agents. For PASI 100, guselkumab Q8W was comparable to other active agents. For AEs and SAEs, guselkumab Q8W ranked highly but comparative conclusions were uncertain. Similar results were observed for all outcomes for guselkumab 100 mg every four weeks.

Conclusions

In this NMA, guselkumab demonstrated favorable arthritis efficacy comparable to IL-17A and subcutaneous TNF inhibitors while offering better PASI response relative to many other treatments.

Impact of guselkumab, an interleukin-23 p19 subunit inhibitor, on enthesitis and dactylitis in patients with moderate to severe psoriatic arthritis: results from a randomised, placebo-controlled, phase II study

Objective

To evaluate the effect of guselkumab on enthesitis and dactylitis in a phase II trial of patients with active psoriatic arthritis (PsA).

Methods

This was a phase II, randomised, placebo-controlled, double-blind trial of adults with active PsA (≥3 swollen and ≥3 tender joints and C reactive protein ≥0.3 mg/dL) despite conventional synthetic disease-modifying anti-rheumatic drug, non-steroidal anti-inflammatory drug, and/or oral corticosteroid therapy. Patients were randomised to subcutaneous injections of guselkumab 100 mg or placebo at weeks 0, 4 and every 8 weeks, with placebo crossover to guselkumab at week 24. Dactylitis was scored on a scale of 0–3 on each digit; enthesitis was assessed using the Leeds Enthesitis Index (0–6). Other assessments included American College of Rheumatology (ACR) and Psoriasis Area and Severity Index responses.

Results

Of 149 randomised patients, 107 patients had enthesitis (mean score=2.7) and 81 patients had dactylitis (mean dactylitis score=5.7) at baseline. Mean improvements in enthesitis and dactylitis at week 24 were greater in the guselkumab group versus placebo and sustained through week 56. Similar results were observed for the proportions of patients with resolution of enthesitis and dactylitis. At week 56, mean improvements in enthesitis and dactylitis among patients who switched from placebo to guselkumab treatment were similar to those in the guselkumab group. In the guselkumab group, ACR20 responders had greater improvements in enthesitis and dactylitis versus non-responders (week 24).

Conclusions

At week 24, the guselkumab group had greater mean improvements in enthesitis and dactylitis and greater proportions of patients with resolution of enthesitis and dactylitis versus placebo. ACR20 response was associated with improvements in enthesitis and dactylitis.

Trial registration number

ClinicalTrials.gov: NCT02319759.

URL: https://clinicaltrials.gov/ct2/show/NCT02319759; Registered 18 December 2014.