The Psoriasis Area and Severity Index Is the Adequate Criterion to Define Severity in Chronic Plaque-Type Psoriasis

Serum fatty acid binding protein 5 (FABP5) as a potential biomarker of inflammation in psoriasis

Fatty acid binding protein 5 (FABP5) is elevated in psoriatic keratinocytes and could be involved in systemic metabolic disturbances in psoriasis. The aim of the study was to evaluate serum FABP5 in obese and non-obese psoriatic patients, to assess the relationship between FABP5 and the duration, severity of the disease, inflammatory and metabolic markers and influence of treatment with narrowband-ultraviolet B (NB-UVB). Seventy-four patients (30 treated with NB-UVB) with psoriasis were enrolled in the study. The serum concentrations of FABP5 were measured using Human FABP5 Enzyme-Linked Immunosorbent Assay kit. Serum fatty acids were measured by gas-liquid chromatography. Serum FABP5 levels in psoriatic patients were higher versus control group (P < 0.001). FABP5 in patients with PASI > 20 was higher compared to the mild group (PASI < 10) (P < 0.001) and serum FABP5 correlated positively with PASI score (r = 0.41, P < 0.001). There was also positive correlation between FABP5 and basic inflammation indices. Decrease of PASI after NB-UVB treatment (P < 0.001) was observed and accompanied by decrease of the serum FABP5 (P = 0.007). FABP5 is a potential marker of psoriasis, its severity and clinical outcome after therapy with NB-UVB. FABP5 may reflect metabolic disturbances in psoriatic patients.

Low serum lycopene, and adequate α-tocopherol levels in patients with psoriasis: A cross-sectional study

BACKGROUND

Psoriasis is a chronic, immune-mediated skin disease. It affects skin and joints, characterized by abnormal hyperproliferation of keratinocytes. The worldwide prevalence of psoriasis ranges from 2% to 4%. Environmental factors as smoking, alcohol consumption obesity can also work as triggers. During the inflammatory process, there is an exacerbated formation of free radicals and antioxidants are required to maintain redox balance.

AIM

Assess antioxidant profiles.

METHODS

A cross-sectional study was conducted between August/2012 and March/2014. Sociodemographic, lifestyle, and biochemical measurements, dietary intake, serum lycopene and α-tocopherol, psoriasis severity according to Psoriasis Area and Severity Index were obtained. Comparisons between serum lycopene and α-tocopherol distributions according to variables were conducted using a one-way analysis of variance. Multiple linear regression was used to investigate factors associated with serum antioxidants.

RESULTS

81 participants (56% female, 62% non-white), 34% without psoriatic lesions, 51% diagnosed with mild psoriasis, and 15% with moderate psoriasis. Median (IQR) age of 54 (41, 62) years, 10 (4, 11) years of education, 17% smokers, 46% overweight and 25% obesity. In total, 72% did not reach the daily recommendation of fruit and vegetable intake. Serum lycopene and α-tocopherol were 0.2 (0.1-0.3) µmol/L and 22.5 (18.5-25.6) µmol/L, respectively. Only 14% presented adequate concentration of lycopene, but adequate α-tocopherol level was observed among 88%.

CONCLUSIONS

Patients reported a diet low in vegetables and fruits and rich in ultra-processed foods and fatty acids. Adequate circulating α-tocopherol but low serum lycopene, was observed among patients. A linear trend was observed for lycopene according to the severity of psoriasis.

Carotid intima-media thickness and epicardial fat thickness predict precoronary artery disease status in psoriasis

BACKGROUND

Carotid intima-media thickness test is a surrogate marker of subclinical atherosclerosis. Epicardial fat thickness is an early marker of coronary artery disease. Several studies have noted that psoriasis patients have an increased risk of coronary artery disease. In the present study, we attempted to see any variation in carotid intima-media thickness and epicardial fat thickness in psoriasis patients when compared to controls.

AIMS

1) To determine the carotid intima-media thickness and epicardial fat thickness in psoriatic patients and healthy controls. 2) To evaluate the association between carotid intima-media thickness and epicardial fat thickness in psoriasis patients.

METHODS

A hospital-based study with 100 subjects (50 with psoriasis and 50 healthy controls) was conducted in the Dermatology Outpatient Department of Justice KS Hegde Charitable Hospital, a unit of KS Hegde Medical Academy affiliated to NITTE (Deemed to be University) Mangaluru. A detailed history and examination including body mass index, psoriasis area and severity index were done. Carotid ultrasound was done to measure carotid intima-media thickness and transthoracic echocardiography was done to assess epicardial fat thickness in both cases and controls. Independent sample t-test, Pearson rank correlation (r) coefficient were used for statistical analysis. P-value <0.05 was considered statistically significant. IBM Statistical Package for the Social Sciences version 22 Armonk, NY: IBM Corp was used for statistical analysis.

RESULTS

Mean carotid intima-media thickness in the right carotid ([0.51 ± 0.1mm vs 0.47 ± 0.1 mm] [P = 0.038]) and left carotid ([0.53 ± 0.12 mm vs 0.48 ± 0.1 mm] [P = 0.041]) were significantly increased in psoriasis patients than in controls. Mean epicardial fat thickness was significantly increased ([1.76 ± 0.66 mm vs. 1.49 ± 0.47 mm] ([P = 0.020]) in patients with psoriasis when compared with the controls. Epicardial fat thickness was positively correlated with carotid intima-media thickness in patients with psoriasis.

LIMITATIONS

The cross-sectional design of the study, smoking among study subjects, inter and intraobserver variability of measurement of epicardial fat thickness and carotid intima-media thickness.

CONCLUSION

Carotid intima-media thickness and epicardial fat thickness were increased in psoriasis patients when compared with healthy controls. Epicardial fat thickness was positively correlated with carotid intima-media thickness in cases.

Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis

BACKGROUND

Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis.

OBJECTIVES

To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety.

SEARCH METHODS

For this living systematic review we updated our searches of the following databases monthly to September 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We searched two trials registers to the same date. We checked the reference lists of included studies and relevant systematic reviews for further references to eligible RCTs.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of systemic treatments in adults (over 18 years of age) with moderate-to-severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate-to-severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. The primary outcomes of this review were: the proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90 at induction phase (from 8 to 24 weeks after the randomisation), and the proportion of participants with serious adverse events (SAEs) at induction phase. We did not evaluate differences in specific adverse events.

DATA COLLECTION AND ANALYSIS

Several groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the PASI 90 score) and acceptability (the inverse of serious adverse events). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes and all comparisons, according to CINeMA, as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer on treatment hierarchy: 0% (treatment is the worst for effectiveness or safety) to 100% (treatment is the best for effectiveness or safety).

MAIN RESULTS

We included 158 studies (18 new studies for the update) in our review (57,831 randomised participants, 67.2% men, mainly recruited from hospitals). The overall average age was 45 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo-controlled (58%), 30% were head-to-head studies, and 11% were multi-armed studies with both an active comparator and a placebo. We have assessed a total of 20 treatments. In all, 133 trials were multicentric (two to 231 centres). All but two of the outcomes included in this review were limited to the induction phase (assessment from 8 to 24 weeks after randomisation). We assessed many studies (53/158) as being at high risk of bias; 25 were at an unclear risk, and 80 at low risk. Most studies (123/158) declared funding by a pharmaceutical company, and 22 studies did not report their source of funding. Network meta-analysis at class level showed that all of the interventions (non-biological systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in reaching PASI 90. At class level, in reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the non-biological systemic agents. At drug level, infliximab, ixekizumab, secukinumab, brodalumab, risankizumab and guselkumab were significantly more effective in reaching PASI 90 than ustekinumab and three anti-TNF alpha agents: adalimumab, certolizumab, and etanercept. Ustekinumab and adalimumab were significantly more effective in reaching PASI 90 than etanercept; ustekinumab was more effective than certolizumab, and the clinical effectiveness of ustekinumab and adalimumab was similar. There was no significant difference between tofacitinib or apremilast and three non-biological drugs: fumaric acid esters (FAEs), ciclosporin and methotrexate. Network meta-analysis also showed that infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab, and brodalumab outperformed other drugs when compared to placebo in reaching PASI 90. The clinical effectiveness of these drugs was similar, except for ixekizumab which had a better chance of reaching PASI 90 compared with secukinumab, guselkumab and brodalumab. The clinical effectiveness of these seven drugs was: infliximab (versus placebo): risk ratio (RR) 50.29, 95% confidence interval (CI) 20.96 to 120.67, SUCRA = 93.6; high-certainty evidence; ixekizumab (versus placebo): RR 32.48, 95% CI 27.13 to 38.87; SUCRA = 90.5; high-certainty evidence; risankizumab (versus placebo): RR 28.76, 95% CI 23.96 to 34.54; SUCRA = 84.6; high-certainty evidence; bimekizumab (versus placebo): RR 58.64, 95% CI 3.72 to 923.86; SUCRA = 81.4; high-certainty evidence; secukinumab (versus placebo): RR 25.79, 95% CI 21.61 to 30.78; SUCRA = 76.2; high-certainty evidence; guselkumab (versus placebo): RR 25.52, 95% CI 21.25 to 30.64; SUCRA = 75; high-certainty evidence; and brodalumab (versus placebo): RR 23.55, 95% CI 19.48 to 28.48; SUCRA = 68.4; moderate-certainty evidence. Conservative interpretation is warranted for the results for bimekizumab (as well as mirikizumab, tyrosine kinase 2 inhibitor, acitretin, ciclosporin, fumaric acid esters, and methotrexate), as these drugs, in the NMA, have been evaluated in few trials. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. Nevertheless, the SAE analyses were based on a very low number of events with low to moderate certainty for all the comparisons. Thus, the results have to be viewed with caution and we cannot be sure of the ranking. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1) the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions.

AUTHORS' CONCLUSIONS

Our review shows that compared to placebo, the biologics infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab and brodalumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes were measured from 8 to 24 weeks after randomisation) and is not sufficient for evaluation of longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean age of 45 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly-reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the evidence for all the interventions was of low to moderate quality. In order to provide long-term information on the safety of the treatments included in this review, it will also be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies. In terms of future research, randomised trials directly comparing active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between non-biological systemic agents and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve participants, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Aryl Hydrocarbon Receptor and Autophagy-Related Protein Microtubule-Associated Protein Light Chain 3 Expression in Psoriasis

Background

The aryl hydrocarbon receptor (AHR) and autophagy are both important to maintain skin homeostasis. However, they are also involved in skin disorders. So far, their roles in psoriasis pathogenesis are unknown.

Objective

We studied the immunohistochemical and gene expression of AHR, CYP1A1, and microtubule-associated protein light chain 3 (LC3) in lesional skin of psoriasis patients to determine correlations among them.

Methods

We included 24 psoriasis patients and ten healthy volunteers. Skin biopsies were collected. AHR, CYP1A1, and LC3 protein expression was examined by immunohistochemistry, immunofluorescence, and western blotting. AHR, CYP1A1, LC3, ATG5, BECN1 and Nrf2 mRNA levels were measured by quantitative polymerase chain reaction.

Results

AHR and CYP1A1 protein expression were higher in psoriasis lesional skin than in normal skin. LC3 protein expression was lower in psoriasis lesions than in normal controls. AHR and CYP1A1 protein expression in psoriasis lesions showed significant positive correlations with mean epidermal thickness and inflammatory cell density. Significant negative correlations were noted between LC3 protein expression in psoriasis lesions and the mean epidermal thickness or inflammatory cell density. A significant negative correlation was found between AHR and LC3 expression in psoriatic skin. AHR, CYP1A1 and Nrf2 mRNA expression were upregulated while LC3, ATG5, and BECN1 mRNA were down-regulated, in psoriatic lesional skin compared with normal controls.

Conclusion

AHR and autophagy could play a role in psoriasis pathogenesis by modifying epidermal hyperproliferation and inflammation. AHR and autophagy regulation are potential therapeutic targets in chronic inflammatory skin diseases.

Evaluation of Ixekizumab Treatment for Patients With Pityriasis Rubra Pilaris: A Single-Arm Trial

Importance

Pityriasis rubra pilaris is a rare and disabling cutaneous disease that is frequently recalcitrant to conventional therapies and appears to involve interleukin (IL)-17 overexpression.

Objective

To investigate the clinical response and safety of ixekizumab in treating pityriasis rubra pilaris.

Design, Setting, and Participants

Single-arm, investigator-initiated trial conducted in adult patients with moderate to severe pityriasis rubra pilaris at a single-center academic university from June 2018 to January 2020. A total of 41 patients were screened, 12 were enrolled, and 11 completed the full duration of therapy. A referred, consecutive sample was used during participant selection. The treatment period and primary outcome occurred over 24 weeks with additional patient follow-up through 36 weeks.

Intervention

Subcutaneous administration of ixekizumab, a humanized IgG4 antibody that binds IL-17A, at the US Food and Drug Administration-approved dosing schedule for treatment of psoriasis for 24 weeks.

Main Outcomes and Measures

The primary outcome was the mean change in Psoriasis Area and Severity Index at 24 weeks. Secondary outcomes included change in affected body surface area, quality of life, induction of sustained remission, and association of improvement with CARD14 genetic variations and cutaneous cytokine expression.

Results

A total of 12 white patients (mean [SD] age, 49.8 [15.1] years; 8 male [67%]) were enrolled between June 2018 and April 2019, with 11 completing the full course of intervention. The mean (SEM) improvements in Psoriasis Area and Severity Index, affected body surface area, and Dermatology Life Quality Index were 15.2 (2.1) (P < .0001), 29.8% (9.3%) (P = .009), and 9.5 (2.5) (P = .004), respectively. The 4 participants with the most improvement in Psoriasis Area and Severity Index at week 24 stayed in remission at week 36 (defined as lack of increase in Psoriasis Area and Severity Index from week 24 through week 36), off therapy. Relative dermal IL-17A expression decreased by a 1.9 log-fold change. No participants had known pathogenic CARD14 variations. There were no serious adverse events.

Conclusions and Relevance

In this single-armed trial, ixekizumab was associated with reduced clinical signs and symptoms of pityriasis rubra pilaris in a subset of patients, including those in whom other systemic therapies have failed.

Trial Registration

ClinicalTrials.gov Identifier: NCT03485976.

Skin Barrier Function in Psoriasis and Atopic Dermatitis: Transepidermal Water Loss and Temperature as Useful Tools to Assess Disease Severity

Multiple diagnostic tools are used to evaluate psoriasis and atopic dermatitis (AD) severity, but most of them are based on subjective components. Transepidermal water loss (TEWL) and temperature are skin barrier function parameters that can be objectively measured and could help clinicians to evaluate disease severity accurately. Thus, the aims of this study are: (1) to compare skin barrier function between healthy skin, psoriatic skin and AD skin; and (2) to assess if skin barrier function parameters could predict disease severity. A cross-sectional study was designed, and epidermal barrier function parameters were measured. The study included 314 participants: 157 healthy individuals, 92 psoriatic patients, and 65 atopic dermatitis patients. TEWL was significantly higher, while stratum corneum hydration (SCH) (8.71 vs. 38.43 vs. 44.39 Arbitrary Units (AU)) was lower at psoriatic plaques than at uninvolved psoriatic skin and healthy controls. Patients with both TEWL > 13.85 g·m⁻²h⁻¹ and temperature > 30.85 °C presented a moderate/severe psoriasis (psoriasis area severity index (PASI) ≥ 7), with a specificity of 76.3%. TEWL (28.68 vs. 13.15 vs. 11.60 g·m⁻² h⁻¹) and temperature were significantly higher, while SCH (25.20 vs. 40.95 vs. 50.73 AU) was lower at AD eczematous lesions than uninvolved AD skin and healthy controls. Patients with a temperature > 31.75 °C presented a moderate/severe AD (SCORing Atopic Dermatitis (SCORAD) ≥ 37) with a sensitivity of 81.8%. In conclusion, temperature and TEWL values may help clinicians to determine disease severity and select patients who need intensive treatment.

Increased red blood cell distribution width in patients with plaque psoriasis

Background

Red blood cell distribution width (RDW) is frequently increased in inflammatory disorders, and the magnitude of its elevation correlates with disease severity. This study was hence aimed to explore RDW values in patients with psoriasis.

Methods

The study population consisted of 366 adult patients with mild to severe plaque psoriasis and 366 age- and sex-matched blood donor controls. For each psoriatic patient, demographic, clinical, and laboratory data were regularly collected.

Results

RDW and MCV were significantly higher in psoriatic patients compared to controls (13.95 vs. 13.40% and 90.4 vs. 89 fL; both p<0.01). In order to assess whether RDW elevations were related to psoriasis severity, we divided our psoriatic patient population into two groups based on a PASI cut-off of 10. No significant differences were observed between the two groups (i.e., PASI>10 and 10) in terms of RDW (p=0.36). Adopting different PASI cut-offs (i.e. 3, 5, 7, 12) did not result in statistically significant differences (p=0.93, 0.48, 0.22, 0.42, respectively). In linear regression analysis, no significant correlation was found between RDW and PASI or CRP, nor with age, gender, or the psoriasis comorbidities listed in Table I. Furthermore, no significant difference in RDW values was noted between psoriatic patients with and without PsA (p=0.27).

Conclusions

The results of this study confirm that RDW is elevated in psoriatic patients, though the magnitude of its increase did not appear to be associated with disease severity.

Immunoregulatory complement receptor-1 and leukocyte-associated Ig-like receptor-1 expression on leukocytes in Psoriasis vulgaris

Psoriasis vulgaris (PsV) is an immune-mediated inflammatory disorder with devastating psychosocial consequences. Expression of immunoregulator molecules on leukocytes in PsV remains unclear. Leukocyte-associated Ig-like receptor-1 (LAIR-1) and complement receptor-1 (CR-1) are immunoregulator receptors reported to bind complement component 1q involved in phagocytosis. We aimed to explore if altered leukocyte expression of LAIR-1 and CR-1 is associated with PsV. This case-control study included 36 PsV patients and 36 healthy controls. Neutrophils, monocytes and B and T cells were examined by flow cytometry for LAIR-1 and CR-1 mean fluorescence intensity (MFI) and positive cell percentage. Comparison between both groups revealed a significant decrease in LAIR-1 MFI on neutrophils and T cells (P < 0.001 and P = 0.003, respectively). CR-1 MFI on neutrophils, monocytes and T cells also showed a significant decrease in patients (P = 0.033, P = 0.001 and P = 0.040, respectively). There was a significant positive correlation of LAIR-1 MFI on neutrophils with CR-1 MFI on neutrophils (r = 0.503; P = 0.002) and LAIR-1 MFI on monocytes with CR-1 MFI on monocytes (r = 0.371; P = 0.026). Receiver operating characteristic curves revealed that CR-1 MFI on monocytes had the highest discrimination power to differentiate patients from controls, with 86.1% specificity and 75% sensitivity (P = 0.001). In conclusion, altered leukocytes expression of LAIR-1 and CR-1 is associated with PsV. Down-regulated CR-1 MFI on monocytes is a promising diagnostic biomarker for PsV.

Correlation Between Psoriasis Severity and Nonalcoholic Fatty Liver Disease Degree Measured Using Controlled Attenuation Parameter

Background

A growing body of evidence links psoriasis to several metabolic disorders, but the causal relationship between psoriasis and nonalcoholic fatty liver disease (NAFLD) remains understudied.

Purpose

To measure the correlation between the severity of psoriasis and the degree of NAFLD.

Patients and Methods

A cross-sectional study was conducted on adult patients with psoriasis in the Dermatovenereology Outpatient Clinic of Cipto Mangunkusumo Hospital from December 2017 through February 2018. Psoriasis severity (psoriasis area and severity index [PASI] and body surface area [BSA]) was recorded and compared with NAFLD degree measured by controlled attenuation parameter (CAP).

Results

A total of 36 subjects were enrolled with an average age of 49.08 years (±15.52 years). The proportions of mild, moderate, and severe psoriasis were 50%, 27.8%, and 22.2%, respectively. Median of PASI was 6.1 (2–38.4) and BSA was 7.5 (2–93). The proportion of NAFLD was 77.8%. The mean of the CAP score was 250.03±45.64. There was no statistically significant correlation between psoriasis severity based on PASI and CAP score (r = 0.258; p = 0.128). However, if the degree of psoriasis was based on BSA, a significant correlation was found (r = 0.382; p = 0.021). The body mass index (BMI) and abdominal circumference were significantly correlated with CAP score (r = 0.448, p = 0.006 and r = 0.485, p = 0.003, respectively).

Conclusion

Psoriasis extension correlates with NAFLD severity; further studies should assess in detail the effect of therapies on this pathophysiological link.

Composite outcome measurement in clinical research: the triumph of illusion over reality?

Composite measures that combine different types of indicators are widely used in medical research; to evaluate health systems, as outcomes in clinical trials and patient-reported outcome measurement. The potential advantages of such indices are clear. They are used to summarise complex data and to overcome the problem of evaluating new interventions when the most important outcome is rare or likely to occur far in the future. However, many scientists question the value of composite measures, primarily due to inadequate development methodology, lack of transparency or the likelihood of producing misleading results. It is argued that the real problems with composite measurement are related to their failure to take account of measurement theory and the absence of coherent theoretical models that justify the addition of the individual indicators that are combined into the composite index. All outcome measures must be unidimensional if they are to provide meaningful data. They should also have dimensional homogeneity. Ideally, a specification equation should be developed that can predict accurately how organisations or individuals will score on an index, based on their scores on the individual indicators that make up the measure. The article concludes that composite measures should not be used as they fail to apply measurement theory and, consequently, produce invalid and misleading scores.

Psoriasis Is Associated With Elevated Gut IL-1α and Intestinal Microbiome Alterations

Background

Psoriasis is a chronic inflammatory condition that predominantly affects the skin and is associated with extracutaneous disorders, such as inflammatory bowel disease and arthritis. Changes in gut immunology and microbiota are important drivers of proinflammatory disorders and could play a role in the pathogenesis of psoriasis. Therefore, we explored whether psoriasis in a Central Asian cohort is associated with alterations in select immunological markers and/or microbiota of the gut.

Methods

We undertook a case-control study of stool samples collected from outpatients, aged 30-45 years, of a dermatology clinic in Kazakhstan presenting with plaque, guttate, or palmoplantar psoriasis (n = 20), and age-sex matched subjects without psoriasis (n = 20). Stool supernatant was subjected to multiplex ELISA to assess the concentration of 47 cytokines and immunoglobulins and to 16S rRNA gene sequencing to characterize microbial diversity in both psoriasis participants and controls.

Results

The psoriasis group tended to have higher concentrations of most analytes in stool (29/47 = 61.7%) and gut IL-1α was significantly elevated (4.19-fold, p = 0.007) compared to controls. Levels of gut IL-1α in the psoriasis participants remained significantly unaltered up to 3 months after the first sampling (p = 0.430). Psoriasis was associated with alterations in gut Firmicutes, including elevated Faecalibacterium and decreased Oscillibacter and Roseburia abundance, but no association was observed between gut microbial diversity or Firmicutes/Bacteroidetes ratios and disease status.

Conclusions

Psoriasis may be associated with gut inflammation and dysbiosis. Studies are warranted to explore the use of gut microbiome-focused therapies in the management of psoriasis in this under-studied population.

Treatment modalities and risk of adverse events associated with biologic therapy: A 10-year observational review of the Australasian Psoriasis Registry

BACKGROUND

Psoriasis is a chronic inflammatory disease affecting ~2-3% of the Australasian population. Therapeutic options include topical agents, phototherapy, systemic immunomodulators and biologic agents. Biologics present an acceptable short- and medium-term safety profile, derived mainly from randomised controlled trials (RCTs) and, however, may not represent real-world rates of adverse events (AEs).

METHODS

A retrospective, observational study of patients enrolled in The Australasian Psoriasis Registry from April 2008 to October 2018 was conducted. Data were collected from 104 sites in Australia and New Zealand. Patient characteristics, treatments and AE data were collected. AEs were classified by MedDRA System events.

RESULTS

2094 patients were included (3765 patient-treatments), comprising; 1110 phototherapy, 1280 systemic and 1375 biologic therapy patient-treatments. Treatment arms were not mutually exclusive. The mean ± SD from date of diagnosis of psoriasis to commencement of biologic therapy was 8.9 ± 12.3 years. Methotrexate had the longest exposure time (3740.3 patient-years), and ustekinumab had the longest median (95% CI) time on treatment, 4.3 years (2.2, 6.6). AE differences on biologic treatment were present between patients who would have been eligible or ineligible for RCTs. Approximately 29% of registry patients would have been excluded from clinical trials enrolment. Patients ineligible for RCTs had increased adjusted hazard ratios (95% CI) of: infections and infestations (2.3, 1.7-3.1; P < 0.001), cardiac (8.2, 3.5-25.6; P < 0.001), gastrointestinal (3.5, 1.52-8.0; P < 0.001), hepatobiliary (5.6 1.7-19.1; P < 0.001), psychiatric (4.7, 1.5-14.1; P = 0.006) and eye disorders (4.8 1.5-15.6; P = 0.008), compared to those eligible for RCTs. Incidence rates in the trial eligible patients were similar to those reported from RCT rates.

CONCLUSIONS

This study establishes treatment modalities in use for severe psoriasis and the clinical rates of AEs associated with biologic therapy.

Tolerance and efficacy of a new celastrol-containing balm as adjunct care in psoriasis

BACKGROUND

In patients with psoriasis, the non-lesional skin also presents abnormalities, requiring emollient application on the whole body.

OBJECTIVES

To evaluate the tolerance of a new emollient balm containing celastrol, an active ingredient with anti-Th17 immunomodulatory properties used alone or in association with topical or systemic drug treatments or phototherapy, and its efficacy when used alone.

METHODS

Adults with body plaque psoriasis applied the product over the whole body once a day for 4 weeks (balm used alone in 41 patients and with ongoing treatment in 50 patients). At D1, D8 ('balm alone' study) or D15 ('balm in association' study) and D29, the dermatologist rated physical and functional signs and assessed pruritus and body global lesion score (evaluating erythema, induration/thickness, scaling and dryness) in the 'balm alone' study.

RESULTS

No reaction related to the product was reported, and the tolerance was deemed excellent. In the 'balm alone' study, mean pruritus intensity score significantly decreased at D8 (-39%, P < 0.001) and D29 (-60%, P < 0.001) compared with D1, together with the body global lesion score (-24% at D8 and -26% at D29, P < 0.001). In parallel, quality of life improved, as evidenced by a patient-reported outcome questionnaire. Cosmetic acceptability was good.

CONCLUSION

This new emollient balm was very well tolerated by patients with body plaque psoriasis either alone or in association with drug treatment or phototherapy, which is important to ensure long-term compliance. Daily application during one month improved pruritus, physical signs and quality of life.

[Role of artificial intelligence in assessing the extent and progression of dermatoses]

BACKGROUND

In recent years, many medical specialties with a visual focus have been revolutionized by image analysis algorithms using artificial intelligence (AI). As dermatology belongs to this field, it has the potential to play a pioneering role in the use of AI.

OBJECTIVE

The current use of AI for the diagnosis and follow-up of dermatoses is reviewed and the future potential of these technologies is discussed.

MATERIALS AND METHODS

This article is based on a selective review of the literature using Embase and MEDLINE and the keywords "psoriasis", "eczema", "dermatoses" and "acne" combined with "artificial intelligence", "machine learning", "deep learning", "neural network", "computer-guided", "supervised machine learning" or "unsupervised machine learning" were searched.

RESULTS

In comparison to examiner-dependent intra- and interindividually fluctuating scores for the assessment of inflammatory dermatoses (e.g. the Psoriasis Areas Severity Index [PASI] and body surface area [BSA]), AI-based algorithms can potentially offer reproducible, standardized evaluations of these scores. Whereas promising algorithms have already been developed for the diagnosis of psoriasis, there is currently only scarce work on the use of AI in the context of eczema.

CONCLUSIONS

The latest developments in this field show the enormous potential of AI-based diagnostics and follow-up of dermatological clinical pictures by means of an autonomous computer-based image analysis. These noninvasive, optical examination methods provide valuable additional information, but dermatological interaction remains indispensable in daily clinical practice.

Folate Nutritional Status among Psoriasis Patients not Exposed to Antifolate Drug

Background:

Folic acid fortification program has been established to prevent tube defects. However, concern has been raised among patients using anti-folate drug, i.e. psoriatic patients, a common, chronic, autoimmune inflammatory skin disease associated with obesity and smoking.

Objective:

To investigate dietary and circulating folate, vitamin B12 (B12) and homocysteine (hcy) in psoriatic subjects exposed to the national mandatory folic acid fortification program.

Methods:

Cross-sectional study using the Food Frequency Questionnaire, plasma folate, B12, hcy and psoriasis severity using the Psoriasis Area and Severity Index score. Median, interquartile ranges (IQRs) and linear regression models were conducted to investigate factors associated with plasma folate, B12 and hcy.

Results:

82 (73%) mild psoriasis, 18 (16%) moderate and 12 (11%) severe psoriasis. 58% female, 61% non-white, 31% former smokers, and 20% current smokers. Median (IQRs) were 51 (40, 60) years. Only 32% reached the Estimated Average Requirement of folate intake. Folate and B12 deficiencies were observed in 9% and 6% of the blood sample respectively, but hyperhomocysteinaemia in 21%. Severity of psoriasis was negatively correlated with folate and B12 concentrations. In a multiple linear regression model, folate intake contributed positively to 14% of serum folate, and negative predictors were psoriasis severity, smoking habits and saturated fatty acid explaining 29% of circulating folate.

Conclusion:

Only one third reached dietary intake of folate, but deficiencies of folate and B12 were low. Psoriasis severity was negatively correlated with circulating folate and B12. Stopping smoking and a folate rich diet may be important targets for managing psoriasis.

Physical activity engagement and responses to exercise in plaque psoriasis: a multifactorial investigation of influential factors

Background: Psoriasis may increase the risk of physical inactivity, but few studies have evaluated the etiology.Objective: To identify barriers to and predictors of physical activity in psoriasis.Methods: Twenty individuals with psoriasis (PsO) and 23 controls recorded activity with accelerometers and completed self-paced 20-min treadmill bouts. Questionnaires on self-efficacy for exercise (SEE), pruritus, and dermatology life quality index (DLQI) were completed. Psoriasis severity was measured via body surface area (BSA), psoriasis area and severity index (PASI), and investigator's global assessment (IGA).Results: No differences in moderate-vigorous activity existed between PsO and controls (ANCOVA means: 26 ± 4 versus 27 ± 4 min, p = .802). Relative to controls, PsO selected treadmill speeds that were 13-18% slower and experienced more pruritus while exercising. Among the PsO group, PASI, BSA, IGA, and DLQI showed inverse correlations with vigorous activity (partial rhos= -0.55 to -0.62, p < .05). Likewise, BSA, IGA, DLQI, and pruritus were inversely correlated with footsteps (partial rhos= -0.47 to -0.62, p < .05). SEE was consistently positively correlated with activity levels among PsO (partial rhos ≥0.60 for moderate activity, vigorous activity, and footsteps).Conclusion: Individuals with extensive psoriasis and poorer SEE engage in less vigorous activity and take fewer footsteps. Among other factors, pruritus is a novel explanation.

Calcipotriol/betamethasone dipropionate aerosol foam in the treatment of psoriasis: new perspectives for the use of an innovative topical treatment from real-life experience

The fixed-dose combination of calcipotriol/betamethasone dipropionate (Cal/BD foam) in aerosol foam formulation is approved for the treatment of plaque psoriasis, and showed prompt onset of action, persistent efficacy and safety both in clinical trials and in real-life studies. The use of Cal/BD foam and its future perspectives of use were discussed during the symposium "Go beyond with topical treatment in psoriasis", held at the 2019 World Congress of Dermatology. We herein present the key topics of the symposium, namely the importance of Cal/BD foam in overcoming poor adherence, the possibility of a proactive (long-term) management of psoriasis and its potential role beyond mild psoriasis. Furthermore, proper adherence to treatment is crucial to achieve optimal clinical outcomes. In clinical trials and real-life experiences, Cal/BD foam has proven to have a fast onset of action and a good benefit/risk ratio due to increased efficacy and similar safety profile compared with other Cal/BD formulations. Given its chronic nature, psoriasis requires a long-term management, also due to the presence of underlying 'silent' inflammation that persists beyond resolution of flares. Cal/BD foam appears a favorable treatment for long-term management, and a specific trial is ongoing to investigate this new proactive approach. Lastly, evidence both from clinical studies and real-life experiences supports the use of Cal/BD foam in patients with moderate-to-severe disease, and this approach also showed greater effectiveness over some non-biologic systemic treatments. Therefore, Cal/BD foam may be considered as the new gold standard in topical therapy for patients with plaque psoriasis.

The evaluation of efficacy and safety of methotrexate and pioglitazone in psoriasis patients: A randomized, open-labeled, active-controlled clinical trial

OBJECTIVES

Psoriasis is a chronic inflammatory disease showing co-existence with metabolic syndrome (MS), as has been confirmed by numerous epidemiologic studies in recent times. In this study, the aim was to ascertain the beneficial effects of pioglitazone in psoriasis, simultaneously targeting the improvement of MS parameters.

MATERIALS AND METHODS

We conducted a prospective randomized open-labeled parallel-group interventional study in patients of moderate-to-severe chronic plaque psoriasis. A total of 90 patients were inducted in study and divided into three groups of standard treatment (methotrexate 7.5 mg/week for 12 weeks), active treatment (pioglitazone 15 mg tablets once daily for 12 weeks), and their combination. Primary outcome was taken as percentage Psoriasis Area and Severity Index (PASI) improvement from baseline; secondary outcomes were PASI-75, safety profile, and MS parameters.

RESULTS

Intergroup evaluation of PASI score showed that standard treatment methotrexate and active treatment pioglitazone were comparable. Combination of methotrexate and pioglitazone proved superior in efficacy from both standard and active treatment in 8 and 12 weeks. Adverse drug reactions were mild and treated symptomatically. Pioglitazone and combination group also demonstrated beneficial efficacy in parameter of MS hence establishing it as a potential therapy in psoriasis with MS.

CONCLUSIONS

Pioglitazone alone or in combination with standard treatment may be a safe alternative drug for psoriasis coexisting with MS proving beneficial for both.

CD200/CD200 receptor axis in psoriasis vulgaris

BACKGROUND

Psoriasis is a chronic inflammatory multisystem disease with imbalance between the Th17 and T regulatory sub-populations. CD200/CD200R is an anti-inflammatory/immune-suppressive axis that might contribute to its pathogenesis given its relation to the Tregs induction. The current study aimed to investigate the status of the CD200/CD200R axis in the blood of psoriasis vulgaris patients versus healthy controls.

METHODS

In this comparative cross sectional study, the blood levels of sCD200 and CD200R levels were measured in 25 psoriasis vulgaris patients and an age and sex matched 25 healthy controls using ELISA and flow-cytometry respectively. Their levels were tested for correlation to disease severity.

RESULTS

sCD200 was significantly higher while CD200R was significantly lower in psoriasis vulgaris patients than in controls. They did not correlate to each other or to psoriasis severity although they differed significantly among cases of different severities.

CONCLUSION

Aberrant expression of CD200/CD200R might play a role in psoriasis vulgaris pathophysiology and disease severity. It might constitute a future target of therapy, but cannot be used as a marker of disease severity.

Comparative study of the efficacy and safety of secukinumab vs ixekizumab in moderate-to-severe psoriasis after 1 year of treatment: Real-world practice

There are no studies which directly compare efficacy in Psoriasis Area and Severity Index (PASI) response of secukinumab and ixekizumab. The main aim of this study was to compare the efficacy and safety of both drugs used to treat moderate-to-severe psoriasis patients over 52 weeks. Secondary objectives were to identify which factors related to prior biologic treatment influenced their efficacy and analyze data obtained at 12 weeks. A retrospective observational study was carried out, in which a group of the first 59 patients treated with secukinumab after its commercialization, was compared with another group of the first 29 patients treated with ixekizumab. The PASI 75, 90, and 100 response obtained at 52 weeks was 64.4%, 49.2%, and 41.4% for secukinumab and 75.9%, 62.1%, and 41.4% for ixekizumab, respectively, with no statistically significant differences. Regarding previous biological treatment, both treatments showed a decrease in efficacy as the number of prior biologics increases. No differences were found between secukinumab and ixekizumab in bio-naïve or bio-experienced patients, with the exception of a higher PASI 75 response at week 52 for ixekizumab in those patients with two or more previous biologics (P = .039) Secukinumab and ixekizumab have demonstrated high efficacy and safety, with no statistically significant differences.

Depression and sleep quality in psoriatic patients: impact of psoriasis severity

Background: Psoriatic patients often display depression and sleep disturbances. In previous research, we found high rates of depression and poor sleep quality among psoriatic patients, unrelated to psoriasis severity. However, these results referred to a sample mainly composed of patients under remission.Aim: To compared the prevalence of depression and sleep disturbances in patients suffering from mild versus moderate-tosevere plaque psoriasis, also investigating the association between psoriasis severity and psychopathological variables.KeypointsPsoriasis affects the patients' psychophysical health.Depressive symptoms and/or sleep disturbances are frequent among psoriatic patients.This study investigates these issues comparing the sub-populations of mild and moderate-to-severe psoriatic patients, with special attention to the association between sleep and pruritus.In clinical practice, the link between psychopathological disturbances and psoriasis should not be underestimated.

Comparative analysis of the body surface area calculation method used in vitiligo extent score vs the hand unit method used in vitiligo area severity index

BACKGROUND

Vitiligo Area and Severity Index (VASI) is standing on the top of the cited and implemented scoring tools for vitiligo. However, an easily applicable and time-saving tool has been a need.

AIM

This cross-sectional study aimed at comparing the body surface area (BSA) calculation method used in Vitiligo Extent Score (VES) in comparison with the hand unit method used in VASI and to consider the implementation of VES as a user-friendly tool by doctors as applied to observed clinical patterns of NSV in our population.

METHODS

For each patient with NSV, vitiligo was assessed using both VES and VASI as well as vitiligo disease extent by hand units.

RESULTS

Vitiligo extent score and VASI scores showed a strong significant correlation. Both scores were found reliable in spite of the presence of unrepresented areas in the VES with tendency of the values for the BSA by the VES to be lower than that by hand units.

CONCLUSION

In comparison with VASI, VES has proven to be a clear, user-friendly score for vitiligo assessment. However, special concern is to be given for required modification for pediatric population. A slight modification may be required regarding the pediatric population.

Calcipotriol/betamethasone dipropionate aerosol foam for the treatment of psoriasis vulgaris: a review of real-world evidence (RWE)

Background: Randomized controlled trials (RCTs) demonstrated the advantages of an aerosol foam formulation of calcipotriol/betamethasone dipropionate (Cal/BD) in patients with psoriasis. In this review, we investigated whether such benefits could also be obtained in real-world clinical practice.Methods: PubMed was searched for studies reporting real-world data in patients with psoriasis treated with Cal/BD aerosol foam.Results: Three large real-world studies with Cal/BD aerosol foam were identified: a prospective non-interventional study from Germany, a medical chart review from the US, and a retrospective non-interventional study from Spain. Some key findings included the following: high levels of adherence to treatment (82-93%); after 4 weeks, about 50% of patients achieved complete/almost complete responses; at final assessment, 85-95% of patients were extremely satisfied/very satisfied/satisfied with Cal/BD aerosol foam; all healthcare providers were satisfied or somewhat satisfied with the efficacy of Cal/BD foam and they reported similar findings for symptom improvements (itch, pain, erythema/redness, flaking, and plaque thickness). Global ratings by investigators/healthcare providers for symptom control, overall efficacy and the emotional status of patients were also very high (75-100%).Conclusion: The results from real-world studies undertaken in diverse healthcare systems reinforce the positive findings reported in RCTs with Cal/BD aerosol foam in patients with psoriasis.

Geographic tongue severity index: A new and clinical scoring system

OBJECTIVE

This study was designed to develop a severity index for geographic tongue (GT) based on the Psoriasis Area and Severity Index.

STUDY DESIGN

This cross-sectional observational study, with a retrospective sample of 100 participants, included 5 photographs of each case (dorsum, right border, left border, apex, and lingual belly), totaling 500 images of GT, which were evaluated by 3 experienced researchers in the area of GT and psoriasis. At the end of the analysis, GT was classified as mild, moderate, or severe.

RESULTS

Of the 100 patients, white women were most prevalent, accounting for 53% of cases. Of these participants, 34% had psoriasis and 24% reported a burning sensation. The values of the proposed new index obtained at time 1 (0.855) and time 2 (0.819) presented low variability, and intra- and interrater correlations produced satisfactory values ranging from 0.950 to 0.898 and 0.898 to 0.850, respectively.

CONCLUSION

The new index, Geographic Tongue Area and Severity Index, provides a better characterization of GT by assessing the severity of lesions in an easy and reliable manner, and it is indicated as a first step for interpreting the condition in clinical routines and clinical trials.

Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis

BACKGROUND

Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. This is the baseline update of a Cochrane Review first published in 2017, in preparation for this Cochrane Review becoming a living systematic review.

OBJECTIVES

To compare the efficacy and safety of conventional systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis, and to provide a ranking of these treatments according to their efficacy and safety.

SEARCH METHODS

We updated our research using the following databases to January 2019: the Cochrane Skin Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the conference proceedings of a number of dermatology meetings. We also searched five trials registers and the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) reports (until June 2019). We checked the reference lists of included and excluded studies for further references to relevant RCTs.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of systemic treatments in adults (over 18 years of age) with moderate-to-severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate-to-severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. The primary outcomes of this review were: the proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90 at induction phase (from 8 to 24 weeks after the randomisation), and the proportion of participants with serious adverse effects (SAEs) at induction phase. We did not evaluate differences in specific adverse effects.

DATA COLLECTION AND ANALYSIS

Several groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the PASI 90 score) and acceptability (the inverse of serious adverse effects). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes, according to GRADE, as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing.

MAIN RESULTS

We included 140 studies (31 new studies for the update) in our review (51,749 randomised participants, 68% men, mainly recruited from hospitals). The overall average age was 45 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo-controlled (59%), 30% were head-to-head studies, and 11% were multi-armed studies with both an active comparator and a placebo. We have assessed a total of 19 treatments. In all, 117 trials were multicentric (two to 231 centres). All but two of the outcomes included in this review were limited to the induction phase (assessment from 8 to 24 weeks after randomisation). We assessed many studies (57/140) as being at high risk of bias; 42 were at an unclear risk, and 41 at low risk. Most studies (107/140) declared funding by a pharmaceutical company, and 22 studies did not report the source of funding. Network meta-analysis at class level showed that all of the interventions (conventional systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in terms of reaching PASI 90. At class level, in terms of reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents. At drug level, in terms of reaching PASI 90, infliximab, all of the anti-IL17 drugs (ixekizumab, secukinumab, bimekizumab and brodalumab) and the anti-IL23 drugs (risankizumab and guselkumab, but not tildrakizumab) were significantly more effective in reaching PASI 90 than ustekinumab and 3 anti-TNF alpha agents: adalimumab, certolizumab and etanercept. Adalimumab and ustekinumab were significantly more effective in reaching PASI 90 than certolizumab and etanercept. There was no significant difference between tofacitinib or apremilast and between two conventional drugs: ciclosporin and methotrexate. Network meta-analysis also showed that infliximab, ixekizumab, risankizumab, bimekizumab, guselkumab, secukinumab and brodalumab outperformed other drugs when compared to placebo in reaching PASI 90. The clinical effectiveness for these seven drugs was similar: infliximab (versus placebo): risk ratio (RR) 29.52, 95% confidence interval (CI) 19.94 to 43.70, Surface Under the Cumulative Ranking (SUCRA) = 88.5; moderate-certainty evidence; ixekizumab (versus placebo): RR 28.12, 95% CI 23.17 to 34.12, SUCRA = 88.3, moderate-certainty evidence; risankizumab (versus placebo): RR 27.67, 95% CI 22.86 to 33.49, SUCRA = 87.5, high-certainty evidence; bimekizumab (versus placebo): RR 58.64, 95% CI 3.72 to 923.86, SUCRA = 83.5, low-certainty evidence; guselkumab (versus placebo): RR 25.84, 95% CI 20.90 to 31.95; SUCRA = 81; moderate-certainty evidence; secukinumab (versus placebo): RR 23.97, 95% CI 20.03 to 28.70, SUCRA = 75.4; high-certainty evidence; and brodalumab (versus placebo): RR 21.96, 95% CI 18.17 to 26.53, SUCRA = 68.7; moderate-certainty evidence. Conservative interpretation is warranted for the results for bimekizumab (as well as tyrosine kinase 2 inhibitor, acitretin, ciclosporin, fumaric acid esters, and methotrexate), as these drugs, in the NMA, have been evaluated in few trials. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. Nevertheless, the SAE analyses were based on a very low number of events with low to very low certainty for just under half of the treatment estimates in total, and moderate for the others. Thus, the results have to be viewed with caution and we cannot be sure of the ranking. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1) the results were very similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions.

AUTHORS' CONCLUSIONS

Our review shows that compared to placebo, the biologics infliximab, ixekizumab, risankizumab, bimekizumab, guselkumab, secukinumab and brodalumab were the best choices for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence (low-certainty evidence for bimekizumab). This NMA evidence is limited to induction therapy (outcomes were measured from 8 to 24 weeks after randomisation) and is not sufficient for evaluation of longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean age of 45 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly-reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. Indeed, we found no significant difference in the assessed interventions and placebo in terms of SAEs, but the evidence for all the interventions was of very low to moderate quality. In order to provide long-term information on the safety of the treatments included in this review, it will also be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies. In terms of future research, randomised trials comparing directly active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between conventional systemic and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve participants, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

The role of high-dose vitamin D supplementation on disease severity and lipid profile in psoriatic patients: A pilot study

Background/Aim: Psoriasis is a chronic inflammatory skin disease that is associated with a higher prevalence of cardiovascular (CV) risk factors. The effect of vitamin D on bone health has been long known, but its extraskeletal role especially in cardiovascular disease and skin disease, is the subject of recent research. This study aimed to assess the influence of high-dose vitamin D supplementation on the Psoriasis Area and Severity Index (PASI) score and lipid profile in patients with psoriasis. Methods: The study included 20 adult patients with chronic plaque psoriasis. They received vitamin D capsules in a daily dose of 5,000 IU over 12 weeks. Measured serum concentrations of lipid metabolism parameters were triglycerides (TG), total cholesterol (TC), low-density lipoproteins (LDL) and high-density lipoproteins (HDL). PASI was used to determine the severity of the disease. Results: High-doses vitamin D supplementation had a significant influence on reduction in PASI score in all patients (17.99 ± 12.42 vs 10.27 ± 8.53; p < 0.001). The supplementation of high dose vitamin D induced statistically significant lowering of the TC, LDL-C and TG in the psoriatic patients (p < 0.05). Furthermore, significant increase in serum HDL-C level was observed. The change of PASI score showed week positive correlation with the changes in serum TC and LDL-C (r = 0.303, p = 0.03 and r = 0.357 p = 0.013). Conclusion: High-dose vitamin D supplementation had a positive impact on clinical status of the chronic plaque psoriasis patients, measured by PASI score. It also improved the serum lipid profile of these patients. Double-blinded prospective studies are needed in order to get more comprehensive data related to vitamin D, lipid metabolism and severity of psoriasis.

Effects of non-surgical periodontal therapy on inflammatory markers of psoriasis: A randomized controlled trial

AIM

The purpose of this randomized controlled clinical study was to evaluate the effect of non-surgical mechanical periodontal therapy on the inflammatory status and severity of psoriasis in subjects with psoriasis.

MATERIAL AND METHODS

The study population consisted of 92 periodontitis patients with psoriasis vulgaris suffering from an untreated periodontal disease. Two randomized groups were formed from these patients: immediate periodontal therapy (test group, n = 46) and delayed periodontal therapy (control group, n = 46). Periodontal clinical measures, on salivary interleukin 2, interleukin 6 and secretory immunoglobulin A levels and the Psoriasis Area and Severity Index (PASI) scores were evaluated at baseline and on the 8th week in control and test groups.

RESULTS

Eight weeks after completion of non-surgical periodontal therapy (test group) or initial examination (control group), a significant decrease was observed in interleukin 2, interleukin 6 level and in PASI score, whereas a significant increase was observed in secretory immunoglobulin A levels in the test group (p < .05).

CONCLUSION

Within the limits of this study, the results suggest that effective periodontal therapy improves the psoriasis condition in patients afflicted by both diseases.

Psoriasis treatment patterns: a retrospective claims study

Objective: The objective was to characterize psoriasis treatment patterns, including estimating persistence and describing subsequent events (i.e. switching and restarting) for all systemic therapies. Methods: This retrospective cohort study utilized Truven MarketScan databases from 1 January 2014 to 31 December 2016 to investigate persistence, switching and restarting in new users of systemic psoriasis medications. Descriptive statistics, time-to-event analyses and a Cox proportional hazards regression were conducted. Results: A total of 5205 patients met inclusion criteria. Regardless of treatment type, >50% lost persistence by 12 months. Patients newly initiating acitretin or non-TNF biologic experienced the highest loss of persistence (85.2%, 73.8%, respectively). Patients initiating a TNF-α inhibitor or apremilast experienced the lowest loss (51.8%, 56.4% respectively). Treatment type had a statistically significant effect on persistence loss (adjusted hazard ratio: 0.86, 95% CI: 0.81, 0.91). Restarting was the most commonly observed event for patients on an oral or biologic (60.2%, 79.9%, respectively). The most common switch from an oral was to a TNF-α inhibitor, while apremilast often followed biologics. Conclusion: Most patients lost persistence on initial treatment by 12 months, and the majority restarted treatment. This may indicate poor compliance or the cyclical nature of psoriasis. More patients switched from an oral to biologic than vice versa, likely due to formulary design and preference for orals. Studies are needed to investigate underlying reasons and patient characteristics that differentiate treatment utilization.

Abnormal serum fatty acid profile in psoriatic arthritis

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with higher risk of cardiovascular events and metabolic syndrome than psoriasis without arthritis. Fatty acids (FA) play an important role as signaling molecules in inflammatory and metabolic pathways. The aim of the study was to evaluate serum FA concentration in patients with PsA and to investigate the correlations of FA with the clinical and biochemical markers.

MATERIAL AND METHODS

We measured 14 FA serum concentrations by gas-liquid chromatography and flame-ionization detector after direct transesterification in 54 psoriatic patients (including 14 PsA patients) and 32 healthy controls. FA were divided according to their biologic properties into: saturated FA (SFA) and unsaturated FA (UFA), subdivided into monounsaturated FA (MUFA) and polyunsaturated FA (PUFA).

RESULTS

The results were correlated with Psoriasis Area and Severity Index (PASI), inflammatory and biochemical markers and lipid profile. We observed an abnormal FA profile in both psoriasis and PsA. We demonstrated lower concentrations of 10 FA in psoriasis and 7 in PsA. Patients with joint disease had a significantly higher percentage of SFA (p = 0.016) and MUFA (p = 0.001) and lower percentage of PUFA (p < 0.001) than the control group. The SFA/UFA ratio was significantly higher (p = 0.02) in PsA than in psoriasis and the controls. In the group of PsA the concentrations of docosahexaenoic acid (DHA) (p = 0.027) and n-3 PUFA (p = 0.031) correlated inversely with PASI.

CONCLUSIONS

Our findings indicate a changed FA profile both in psoriasis and PsA and reflect metabolic status that may predispose to the development of metabolic syndrome.

AURIEL-PsO: a randomized, double-blind phase III equivalence trial to demonstrate the clinical similarity of the proposed biosimilar MSB11022 to reference adalimumab in patients with moderate-to-severe chronic plaque-type psoriasis

BACKGROUND

MSB11022 is a proposed adalimumab biosimilar.

OBJECTIVES

To compare the efficacy, safety and immunogenicity of MSB11022 with reference adalimumab.

METHODS

AURIEL-PsO was a double-blind randomized controlled equivalence trial, in which patients with moderate-to-severe chronic plaque-type psoriasis were randomized 1 : 1 to MSB11022 or reference adalimumab. The primary end point was ≥ 75% improvement in Psoriasis Area and Severity Index (PASI 75) at week 16, with a prespecified equivalence interval of ± 18%. Patients with a ≥50% improvement in PASI at week 16 were eligible to enter a double-blind extension period: patients receiving MSB11022 continued treatment, and patients receiving reference adalimumab were rerandomized 1 : 1 either to continue reference adalimumab or to switch to MSB11022. Other efficacy end points and safety, immunogenicity and pharmacokinetic parameters were evaluated at scheduled visits up to weeks 52 (efficacy and immunogenicity), 54 and 66 (safety).

RESULTS

In total, 443 patients were randomized. The difference in PASI 75 response rates at week 16 between the treatment arms was -1·9%, and the 95% confidence interval (-7·8% to 4·1%) was within the prespecified equivalence interval. No notable difference in the incidence of treatment-emergent adverse events was observed between treatment arms up to the end of the trial, and no new safety signals were observed. Following treatment switch at week 16, no clinically meaningful differences in safety or immunogenicity were seen between treatment arms through to the end of the observation period.

CONCLUSIONS

Therapeutic equivalence between MSB11022 and reference adalimumab was demonstrated. AURIEL-PsO provides evidence to support the similarity of both products with regard to efficacy, safety and immunogenicity. What's already known about this topic? Adalimumab is a fully human antitumour necrosis factor-α monoclonal antibody, indicated for the treatment of multiple inflammatory disorders, including psoriasis, psoriatic arthritis, rheumatoid arthritis, inflammatory bowel diseases and ankylosing spondylitis. MSB11022 is a proposed adalimumab biosimilar that has shown structural and functional similarity to the reference product in an extensive analytical comparability exercise. MSB11022 has demonstrated bioequivalence and comparable safety and immunogenicity profiles in a phase I study in healthy volunteers. What does this study add? This phase III study confirmed equivalent efficacy for MSB11022 and reference adalimumab in patients without any immunomodulation comedication in moderate-to-severe chronic plaque-type psoriasis at week 16. The efficacy, safety and immunogenicity of MSB11022 and reference adalimumab were similar over the respective observation periods (week 52 for efficacy and immunogenicity, week 66 for safety). A switch from reference adalimumab to MSB11022 at week 16 did not impact efficacy, safety or immunogenicity.

Recategorization of psoriasis severity: Delphi consensus from the International Psoriasis Council

BACKGROUND

Psoriasis severity categories have been important tools for clinicians to use in treatment decisions as well as to determine eligibility criteria for clinical studies. However, owing to the heterogeneity of severity classifications and their lack of consideration for the impact of psoriasis involvement of special areas or past treatment history, patients may be miscategorized, which can lead to undertreatment of psoriasis.

OBJECTIVE

To develop a consensus statement on the classification of psoriasis severity.

METHODS

A modified Delphi approach was developed by the International Psoriasis Council to define psoriasis severity.

RESULTS

After completion of the exercise, 7 severity definitions were preferentially ranked. This most preferred statement rejects the mild, moderate, and severe categories in favor of a dichotomous definition: Psoriasis patients should be classified as either candidates for topical therapy or candidates for systemic therapy; the latter are patients who meet at least one of the following criteria: (1) body surface area >10%, (2) disease involving special areas, and (3) failure of topical therapy.

LIMITATIONS

This effort might have suffered from a lack of representation by all relevant stakeholders, including patients.

CONCLUSION

The consensus statement describes 2 categories of psoriasis severity, while accounting for special circumstances where patients may require systemic therapy.

Cardiovascular Risk in Psoriasis Patients: Clinical, Functional and Morphological Parameters

BACKGROUND

Psoriasis correlates with metabolic disorders, early atheromatosis and increased cardiovascular risk.

OBJECTIVES

To assess markers of cardiovascular disease in psoriatic patients.

METHODS

Cross-sectional, observational study involving 11 psoriatic participants and 33 controls. Anthropometric, biochemical, hemodynamic and imaging parameters were evaluated. Arterial stiffness was assessed by oscillometric measurement of the brachial artery. Intima-media thickness (IMT) and left ventricular diastolic function were assessed by Doppler echography and echocardiography. Between-group comparisons of numerical variables were performed by the Student's t-test or Wilcoxon Mann-Whitney test for independent samples. Significance level was set at 5%.

RESULTS

Psoriatic patients showed increased pulse wave velocity (PWV) (9.1 ± 1.8 vs 8.0 ± 2 m/s, p = 0.033), IMT of the left common carotid artery (p = 0.018) and a higher percentage of patients above the 75th percentile according to the ELSA table when compared with controls (54.5 vs 18.2%, p = 0.045). Psoriatic patients also showed an increase in peripheral/central systolic blood pressure (137.1 ± 13.2 vs 122.3 ± 11.6 mmHg, p = 0.004)/(127 ± 13 vs 112.5 ± 10.4 mmHg, p = 0.005), peripheral/central diastolic blood pressure (89.9 ± 8.9 vs 82.2 ± 8, p = 0.022)/(91 ± 9.3 vs 82.2 ± 8.3, p = 0.014), total cholesterol (252 ± 43.5 vs 198 ± 39.8 mg/dL, p < 0.001), LDL cholesterol (167 ± 24 vs 118 ± 40.8 mg/dL, p < 0.001) and C-reactive protein (7.6 ± 35.4 vs 1 ± 1.2 mg/L p < 0.001) compared with controls.

CONCLUSION

Psoriasis patients show increased PWV, IMT, peripheral and central blood pressures, and serum cholesterol and C-reactive protein levels, denoting a higher cardiovascular risk.

Urinary orosomucoid: a new marker of cardiovascular risk in psoriatic patients?

Purpose

Psoriasis is one of the most common lifelong lasting dermatologic diseases. According to the latest studies, psoriatic patients have a higher risk of developing cardiovascular diseases. Psoriasis is considered as a systemic inflammatory disease. Several oxidative stress markers have been shown to be elevated in psoriasis. However, a panel of biomarkers has not been used yet. This study was aimed at exploring the connection between a panel of biomarkers (C-reactive protein, asymmetric dimethylarginine, uric acid, total antioxidant capacity, malondialdehyde, and orosomucoid [ORM]) and cardiovascular risk in psoriatic patients.

Patients and methods

The inclusion criterion was the onset of psoriasis with skin lesions. Exclusion criteria were impaired renal function (eGFR<60 mL/min/1.73 m²), acute inflammations (urinary, respiratory, skin inflammation, etc), autoimmune disorders (rheumatoid arthritis, systemic lupus erythematosus, or inflammatory bowel disease), and any kind of biological antipsoriatic treatment. Patients with a medical history of myocardial infarction, coronary heart disease, stroke, transient ischemic attack, and carotid artery stenosis were also excluded. Biomarkers were measured by routine procedures, ELISA and HPLC. QRISK®2-2017 was used to assess 10-year risk of cardiovascular disease development. Psoriasis severity was measured by the Psoriasis Area and Severity Index.

Results

One hundred and fourteen psoriatic patients were enrolled. Only urinary orosomucoid and urinary orosomucoid/urinary creatinine (u-ORM/u-CREAT) ratio showed significant correlation with QRISK score (u-ORM, r=0.245; u-ORM/u-CREAT, r=0.309). When comparing mild psoriatic patients to moderate psoriatic patients, significant differences could only be found in u-ORM and u-ORM/u-CREAT ratio.

Conclusion

There seems to be a connection between urinary ORM and cardiovascular risk. U-ORM and u-ORM/u-CREAT ratio could be used as an indicator of low-grade inflammation in mild and moderate psoriasis. However, it is the 10-year follow-up of cardiovascular events that will determine the usefulness of this biomarker panel.

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.

Validation of a physician global assessment tool for vitiligo extent: Results of an international vitiligo expert meeting

Currently, vitiligo lacks a validated Physician Global Assessment (PGA) for disease extent. This PGA can be used to stratify and interpret the numeric scores obtained by the Vitiligo Extent Score (VES). We investigated the interrater reliability of a 5-point PGA scale during an international vitiligo workshop. Vitiligo experts from five different continents rated photographs of non-segmental vitiligo patients with varying degrees of extent with the PGA score. Good interrater agreements (intraclass correlation coefficient >0.6) were observed between the raters overall and within each continent. All hypotheses to evaluate construct validity were confirmed. Median VES values per category were for limited 1.10 [IQR: 0.21-1.67], moderate 3.17 [IQR: 1.75-6.21], extensive 9.58 [IQR: 6.21-13.03] and very extensive 42.67 [IQR: 21.20-42.67]. Defined categories for vitiligo extent can be valuable for inclusion criteria and may impact future reimbursement criteria.

Preparation, characterization, and in vivo evaluation of cyclosporine cationic liposomes for the treatment of psoriasis

Cyclosporine (CYC), a calcineurin inhibitor acts specifically on T-cells and is one of the most effective treatment options for psoriasis. Systemic administration of the drug has been associated with dose-dependent toxic effects, while its topical delivery is a challenging task due to unfavourable physicochemical properties of drug. The aim of the present study is to develop and evaluate the efficacy of topical liposomal gel containing CYC loaded cationic liposomal nanocarriers in imiquimod induced psoriatic plaque model. Liposomes composed of DOTAP and cholesterol was formulated by different liposomal preparation techniques. Optimized liposomal carriers prepared by ethanol injection method were characterized with respect to size, zeta potential, entrapment efficiency, stability, in vitro drug release and in vivo studies. Cationic liposomes with particle size of 111 ± 1.62 nm, PDI of 0.27 ± 0.08, entrapment efficiency of 93 ± 2.12%, and zeta potential of 41.12 ± 3.56 mV were obtained. Drug loaded liposomal gels showed shear thinning behaviour, which is suitable for topical application. Topical application of CYC liposomal gels on imiquimod induced psoriatic plaque model reduced the symptoms of psoriasis and levels of key psoriatic cytokines such as tumour necrosis factor-α, IL-17, and IL-22. In conclusion, the developed liposomal carrier of CYC was found to be effective and can find application in treatment of psoriasis.

A novel role for the psoriatic arthritis impact of disease (PsAID) questionnaire

BACKGROUND

The Minimal Disease Activity (MDA) uses the Health Assessment Questionnaire (HAQ) as one criterion. HAQ does not correlate well with disease activity with increased PsA disease duration, and its use in the MDA has been questioned. The Psoriatic Arthritis Impact of Disease (PsAID) was specifically developed for PsA Patients. We aimed to validate the PsAID within our patient cohort and determine if the PsAID can replace the HAQ in the MDA.

METHODS

Patients were recruited from the PsA clinic and assessed according to a standard protocol including demographics, clinical features and laboratory tests. Descriptive statistics were calculated. PsAID cut-offs for use in the MDA were generated based on the Clinical Disease Activity for Psoriatic Arthritis (cDAPSA).

RESULTS

115 patients completed the PsAID. There were 70 males, 45 females, with a mean PsA duration of 18.7 (±11.6) years. Mean scores of PsAID-9 and PsAID-12 were 3.4 (±2.4) and 3.2 (±2.3), respectively. The PsAID correlated moderately well with 9 of the PROMs administered in the clinic (ρ = 0.51-0.78). Four PsAID cutoffs based on cDAPSA were generated for use in the MDA: remission (REM) PsAID-9, REM PsAID-12, low disease activity (LDA) PsAID-9, and LDA PsAID-12. All four versions of the PsAID MDAs had sensitivity greater than 85% with the HAQ-MDA, and three versions of the PsAID-MDA had specificity greater than 85% with the HAQ-MDA.

CONCLUSIONS

The high sensitivity and specificity of the PsAID-MDA with the HAQ-MDA suggest that the PsAID is an effective replacement for the HAQ in the MDA.

Role of Serotonin and Dopamine in Psoriasis: A Case-Control Study

BACKGROUND:

Psoriasis is a chronic inflammatory disease mediated by the immune system with increased proliferation of keratinocytes. The exact cause is unknown but as a multifactor, such as infection, trauma and psychological stress have been thought to play a role in its pathophysiology. Dopamine and serotonin are believed to have a strong role in stress conditions and also directly play a role in psoriasis.

AIM:

This study aimed to evaluate the role of dopamine, serotonin, and psychological stress in psoriasis.

METHODS:

This study used a case-control design involving 30 patients with psoriasis (as a case group) and 30 healthy controls in the Dermatology and Venereology Polyclinic of Sanglah General Hospital Denpasar during the period December 2016 to February 2017. All samples were taken for venous blood examination serum dopamine and serotonin and analysed using the ELISA method. Statistical analysis using an independent t-test, partial correlation, receiver operator characteristic (ROC) curve, and logistic regression model.

RESULT:

There were significant differences in serotonin, dopamine, and stress index levels between groups with psoriasis and non-psoriasis (102.68 ± 25.44 Vs. 154.17 ± 20.90; p < 0.001), (437.13 ± 164.83 Vs. 138.11 ± 89.51; p < 0.001), and (138.5 ± 27.80 Vs. 92.55 ± 42.97; p < 0.001). Significant negative correlation was found between serotonin level and stress index (r = -0.366; p = 0.016) and between serotonin and dopamine (r = -0.634; p < 0.001) but a positive correlation was found between dopamine and stress index (r = 0.459; p = 0.042). Serotonin and dopamine showed that it could be used as a biochemical predictive model for psoriasis (AUC > 0.7). Multivariable risk analysis model high serum dopamine was the most important risk factor for the occurrence of psoriasis (adjusted OR: 7.8; 95% CI: 3.45-15.57; p = 0.024)

CONCLUSION:

Serotonin and dopamine have a significant role in the pathophysiology of the occurrence of psoriasis, and psychological stress can affect psoriasis through its influence on serotonin and dopamine.

In-depth serum proteomics reveals biomarkers of psoriasis severity and response to traditional Chinese medicine

Serum and plasma contain abundant biological information that reflect the body's physiological and pathological conditions and are therefore a valuable sample type for disease biomarkers. However, comprehensive profiling of the serological proteome is challenging due to the wide range of protein concentrations in serum. Methods: To address this challenge, we developed a novel in-depth serum proteomics platform capable of analyzing the serum proteome across ~10 orders or magnitude by combining data obtained from Data Independent Acquisition Mass Spectrometry (DIA-MS) and customizable antibody microarrays. Results: Using psoriasis as a proof-of-concept disease model, we screened 50 serum proteomes from healthy controls and psoriasis patients before and after treatment with traditional Chinese medicine (YinXieLing) on our in-depth serum proteomics platform. We identified 106 differentially-expressed proteins in psoriasis patients involved in psoriasis-relevant biological processes, such as blood coagulation, inflammation, apoptosis and angiogenesis signaling pathways. In addition, unbiased clustering and principle component analysis revealed 58 proteins discriminating healthy volunteers from psoriasis patients and 12 proteins distinguishing responders from non-responders to YinXieLing. To further demonstrate the clinical utility of our platform, we performed correlation analyses between serum proteomes and psoriasis activity and found a positive association between the psoriasis area and severity index (PASI) score with three serum proteins (PI3, CCL22, IL-12B). Conclusion: Taken together, these results demonstrate the clinical utility of our in-depth serum proteomics platform to identify specific diagnostic and predictive biomarkers of psoriasis and other immune-mediated diseases.

Silencing KRT16 inhibits keratinocyte proliferation and VEGF secretion in psoriasis via inhibition of ERK signaling pathway

Psoriasis is a multisystem disease affecting about 2% of the population, while keratin16 (KRT16) has been reported to participate in psoriasis. However, the specific mechanism of KRT16 in psoriasis was inadequately investigated. The objective of the study was to elucidate the mechanism by which siRNA-mediated silencing of KRT16 affects keratinocyte proliferation and vascular endothelial growth factor (VEGF) secretion in psoriasis through the extracellular signal-related kinase (ERK) signaling pathway. Psoriasis-related core gene KRT16 was screened out. Then, the expression of KRT16, VEGF, and ERK signaling pathway-related genes was detected in psoriatic patients. To further investigate the mechanism of KRT16, keratinocytes in psoriatic patients were treated with KRT16 siRNA or/and ERK inhibitor (PD98059) to detect the changes in related gene expression and cell survival. KRT16 was involved in psoriasis development. The expression levels of KRT16, p-ERK1/2, and VEGF in lesion tissues are significantly elevated. Keratinocytes treated with KRT16-siRNA and KRT16-siRNA + PD98059 exhibited reduced KRT16, p-ERK1/2, and VEGF expression. The cell survival rate in cells treated with KRT16-siRNA, PD98059, and KRT16-siRNA + PD98059 reduced significantly. These findings indicate that silencing KRT16 inhibits keratinocyte proliferation and VEGF secretion in psoriasis via inhibition of ERK signaling pathway, which provides a basic theory in the treatment of psoriasis.