Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities

Assessment of the Toronto Psoriatic Arthritis Screen 2 as a Screening Tool for Psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease affecting multiple organ systems and resulting in reduced quality of life for many patients. A screening tool would be useful, particularly in underserviced or research settings with limited access to dermatologists. The Toronto Psoriatic Arthritis Screen, version 2 (ToPAS 2) is a validated screening tool for psoriatic arthritis containing questions specific for psoriasis.

OBJECTIVES

To evaluate the performance of skin-specific questions from ToPAS 2 for the diagnosis of psoriasis.

METHODS

Participants aged >18 were recruited from Dermatology and Family Medicine clinics and completed the ToPAS 2 questionnaire prior to being examined by a dermatologist for psoriasis. Two scoring indexes were derived from the ToPAS 2 skin-related questions using backward selection regression models. Statistical analysis was performed using receiver operating characteristic (ROC) curves to measure their performances.

RESULTS

Two hundred and fifty eight participants were recruited. 32 (12%) were diagnosed with psoriasis by dermatologist assessment. Index 1 includes all 5 skin-related questions from ToPAS 2, while Index 2 includes three of the five questions. Both indexes demonstrate high specificity (82% to 92%), sensitivity (69% to 84%), and excellent negative predictive value (NPV) (>95%) for a diagnosis of psoriasis. The overall discriminatory power of these models is 0.823 (Index 1) and 0.875 (Index 2).

CONCLUSIONS

Skin-related questions from ToPAS 2 have discriminatory value in detecting psoriasis, specifically questions relating to a family history, a prior physician diagnosis of psoriasis or a rash consistent with images of plaque psoriasis. This study is a valuable step in developing a screening tool for psoriasis.

Demographics, Disease Characteristics, and Patient-Reported Outcomes Among Patients with Psoriasis Who Initiated Guselkumab in CorEvitas' Psoriasis Registry

Introduction

Guselkumab is approved for the treatment of both moderate-to-severe plaque psoriasis and active psoriatic arthritis (PsA) in the USA. However, little is known about patients initiating guselkumab in a real-world setting. The objective of this study was to describe baseline characteristics among patients with plaque psoriasis who initiated guselkumab at or after enrollment in CorEvitas’ Psoriasis Registry.

Methods

Adult patients who initiated guselkumab in the Psoriasis Registry between July 18, 2017 and November 6, 2018 were included. Demographics, disease characteristics, and patient-reported outcome measures (PROMs) were assessed at the time of guselkumab initiation (baseline). Patients with psoriasis were stratified according to the number of previously received biologics (0 to 4+) for comparison. A subset of patients with psoriasis and concomitant dermatologist-diagnosed PsA were stratified into biologic-naïve and biologic-experienced groups.

Results

Among 687 patients with psoriasis who initiated guselkumab, biologic-naïve patients and those with four or more prior biologics had the most severe disease and the worst PROM scores at baseline. Among 251 patients with concomitant dermatologist-diagnosed PsA, biologic-naïve patients had more severe disease and worse PROM scores than biologic-experienced patients.

Conclusions

These findings highlight important differences in baseline characteristics according to biologic experience among patients with plaque psoriasis with or without concomitant PsA initiating guselkumab in a real-world setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13555-021-00637-2.

Discovery of Arthritis in Psoriasis Patients for Early Rheumatological Referral (DAPPER): Protocol for a Longitudinal Observational Study

Background

One in three patients with psoriasis will develop psoriatic arthritis (PsA). If left untreated, this can lead to pain, impaired function, and irreversible joint damage. Timely recognition and referral to a rheumatologist are therefore key. However, current methods used to screen patients with psoriasis for those who might benefit from referral to a rheumatologist are not performing well enough.

Objective

The Discovery of Arthritis in Psoriasis Patients for Early Rheumatological Referral (DAPPER) study is designed to determine the prevalence of PsA in a psoriasis population and to find parameters that can be used to develop a new or enhance an existing instrument for a rheumatological referral.

Methods

DAPPER is a longitudinal observational study with a 1-year follow-up. Patients with psoriasis (N=300) who are treated at an outpatient dermatological clinic will be screened extensively for signs and symptoms of PsA by a trained rheumatologist. If there is clinical suspicion of PsA and the patient is not yet treated by a rheumatologist, referral to the Department of Rheumatology will follow for confirmation of the diagnosis and further care. After 1 year, data on changes in quality of life and PsA and psoriasis disease activity will be collected from the referred patients. The screening visit will be used to gather demographical and medical data, which can later be used to develop the aforementioned screening instrument.

Results

Inclusion started in June 2019 and finished in June 2021. Follow-up with newly discovered patients with PsA is ongoing.

Conclusions

The DAPPER study is specifically designed to improve the detection of existing PsA in a dermatologic outpatient setting. Although internal validity will be tested, external validity will have to be checked using a second validation cohort. To predict the development of PsA in the future, longitudinal/prospective data collection is required and will be performed in a follow-up study (DAPPER-i).

Trial Registration

Dutch Trial Register NTR7604; https://www.trialregister.nl/trial/7397

International Registered Report Identifier (IRRID)

DERR1-10.2196/31647

Non-alcoholic fatty liver disease in patients with intestinal, pulmonary or skin diseases: Inflammatory cross-talk that needs a multidisciplinary approach

Non-alcoholic fatty liver disease (NAFLD) is currently considered the most common cause of liver disease. Its prevalence is increasing in parallel with the obesity and type 2 diabetes mellitus (DM2) epidemics in developed countries. Several recent studies have suggested that NAFLD may be the hepatic manifestation of a systemic inflammatory metabolic disease that also affects other organs, such as intestine, lungs, skin and vascular endothelium. It appears that local and systemic proinflammatory/anti-inflammatory cytokine imbalance, together with insulin resistance and changes in the intestinal microbiota, are pathogenic mechanisms shared by NAFLD and other comorbidities. NAFLD is more common in patients with extrahepatic diseases such as inflammatory bowel disease (IBD), obstructive syndrome apnea (OSA) and psoriasis than in the general population. Furthermore, there is evidence that this association has a negative impact on the severity of liver lesions. Specific risk characteristics for NAFLD have been identified in populations with IBD (i.e. age, obesity, DM2, previous bowel surgery, IBD evolution time, methotrexate treatment), OSA (i.e. obesity, DM2, OSA severity, increased transaminases) and psoriasis (i.e. age, metabolic factors, severe psoriasis, arthropathy, elevated transaminases, methotrexate treatment). These specific phenotypes might be used by gastroenterologists, pneumologists and dermatologists to create screening algorithms for NAFLD. Such algorithms should include non-invasive markers of fibrosis used in NAFLD to select subjects for referral to the hepatologist. Prospective, controlled studies in NAFLD patients with extrahepatic comorbidities are required to demonstrate a causal relationship and also that appropriate multidisciplinary management improves these patients’ prognosis and survival.

Biomarkers of subclinical atherosclerosis in patients with psoriasis

Psoriasis is linked with increased risk of cardiovascular disease (CVD) that is underestimated by traditional risk stratification. We conducted a large-scale plasma proteomic analysis by use of a proximity extension assay in 85 patients with a history of moderate-to-severe psoriasis with or without established atherosclerotic CVD. Differentially expressed proteins associated with CVD were correlated with subclinical atherosclerotic markers including vascular inflammation determined by 18F-fluorodeoxyglucose positron emission tomography/computed tomography, carotid intima-media thickness (CIMT), carotid artery plaques, and coronary artery calcium score (CCS) in the patients without CVD and statin treatment. We also examined the association between the neutrophil-to-lymphocyte ratio (NLR) and subclinical atherosclerosis. In unadjusted analyses, growth differentiation factor-15 (GDF-15) levels and NLR were increased, while tumor necrosis factor (TNF)-related activation-inducing ligand (TRANCE) and TNF-related apoptosis-induced ligand (TRAIL) levels were decreased in patients with established CVD compared to those without CVD. Among patients with psoriasis without CVD and statin treatment, GDF-15 levels were negatively associated with vascular inflammation in the ascending aorta and entire aorta, and positively associated with CIMT and CCS. NLR was positively associated with vascular inflammation in the carotid arteries. Our data suggest that circulating GDF-15 levels and NLR might serve as biomarkers of subclinical atherosclerosis in patients with psoriasis.

Evolution of Patient Perceptions of Psoriatic Disease: Results from the Understanding Psoriatic Disease Leveraging Insights for Treatment (UPLIFT) Survey

INTRODUCTION

Since the 2012 Multinational Assessment of Psoriasis and Psoriatic Arthritis (MAPP) survey, several systemic treatments for psoriasis (PsO) and/or psoriatic arthritis (PsA) have been approved. The population-based UPLIFT survey was conducted to understand how perceptions of treatment-related outcomes have evolved, particularly for patients with mild to moderate PsO and/or PsA and their dermatologists.

METHODS

This population- and web-based survey was conducted from 2 March to 3 June 2020, in North America, Europe, and Japan. Adults with self-reported healthcare practitioner (HCP)-diagnosed PsO and/or PsA and dermatologists who spent > 50% of time treating patients and treated ≥ 20 patients with PsO, including plaque PsO, per month were included. Patient participants were recruited at random from online panels; dermatologists were recruited randomly from representative physician panels.

RESULTS

Of 264,054 patient responses, 3806 who self-reported an HCP diagnosis of PsO and/or PsA were included in the final sample; 67% had PsO alone, 28% had PsO and PsA, and 5% had PsA alone. The estimated population prevalence of psoriatic disease was 7% (PsO only: 4%; PsO and PsA: 2%; PsA only: 1%). Most patients (78%) reported PsO-involved body surface area (BSA) ≤ 3 palms, and ~ 90% or more reported itching, redness, flaking, and scales. Many PsO patients without diagnosed PsA reported musculoskeletal symptoms suggestive of PsA (63%). Across BSA categories, approximately one in four patients was not currently receiving treatment and > 50% had Dermatology Life Quality Index score > 5. Patients and dermatologists had different perceptions of PsO severity, office visit discussions, treatment goals, and treatment satisfaction. The survey was conducted during the coronavirus disease 2019 (COVID-19) pandemic, which could have affected assessments of patient-reported outcomes and ability to have in-person HCP visits.

CONCLUSIONS

Patients with PsO and PsA in UPLIFT reported high disease burden, including patients with limited skin involvement. An opportunity exists to align patient and dermatologist perceptions to optimize management of PsO and PsA.

Risk factors associated with osteoporosis and fracture in psoriatic arthritis

BACKGROUND

Although there are few studies mentioned there may be some relationship between psoriatic arthritis (PsA) and osteoporosis, clinical data in real world still need to be clarified in China. The aim of this study was to assess the areal and volumetric bone mineral density (BMD), frequency of fracture, and risk factors in patients with PsA.

METHODS

A total of one hundred PsA patients who visited Peking University First Hospital and one hundred age- and sex-matched healthy controls with DXA data were enrolled in the study. Patients with clinical fractures confirmed by X-ray during follow-up were also recorded. Clinical characteristics of the patients were recorded and compared between the abnormal BMD group and the normal BMD group, as well as between the fracture and non-fracture groups. Risk factors for fracture and low BMD were analyzed.

RESULTS

Mean BMD at the total hip and femoral neck was significantly lower in PsA patients than that in healthy controls (0.809 ± 0.193 vs. 0.901 ± 0.152 g/cm2, P  = 0.041; 0.780 ± 0.146 vs. 0.865 ± 0.166 g/cm2, P  = 0.037, respectively). Moreover, lumbar spine BMD was negatively correlated with psoriasis duration, swollen joint count and DAS28-CRP (r = -0.503, -0.580, -0.438; P < 0.05). Total hip BMD and femoral neck BMD were negatively correlated with HAQ (r = -0.521, -0.335; P < 0.05). Fractures occurred in 29 patients during the follow-up period. Logistic regression analysis showed that older age (OR 1.132 [95%CI: 1.026-1.248), P < 0.05], higher HAQ score (OR 1.493, 95%CI: 1.214-1.836, P < 0.01), higher disease activity index for psoriatic arthritis (OR 1.033, 95% CI: 1.002-1.679, P < 0.05) and hip joint involvement (OR 6.401, 95% CI: 4.012-44.180, P < 0.05) were risk factors for fracture in the multivariate model.

CONCLUSIONS

Increased risks of osteoporosis and fracture were found in PsA patients compared to healthy controls. Besides age, high disease activity and hip joint involvement were risk factors for decreased BMD and fracture.

Neutrophil Pathways of Inflammation Characterize the Blood Transcriptomic Signature of Patients with Psoriasis and Cardiovascular Disease

BACKGROUND

Patients with psoriasis have an increased risk of atherosclerotic cardiovascular disease (CVD). The molecular mechanisms behind this connection are not fully understood, but the involvement of neutrophils have drawn attention as a shared inflammatory factor.

METHODS

RNA sequencing using the Illumina platform was performed on blood from 38 patients with moderate to severe psoriasis; approximately half had prior CVD. The neutrophil to lymphocyte ratio (NLR) was obtained from blood samples. Subclinical atherosclerosis was assessed by ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography and ultrasound imaging. Transcriptomic analysis for differential expression and functional enrichment were performed, followed by correlation analyses of differentially expressed genes (DEGs), NLR and subclinical measurers of CVD.

RESULTS

291 genes were differentially expressed between patients with psoriasis with and without CVD. These included 208 upregulated and 83 downregulated DEGs. Neutrophil degranulation was identified as the most significant process related to the upregulated DEGs. Genes for the neutrophil-associated markers MPO, MMP9, LCN2, CEACAM1, CEACAM6 and CEACAM8 were identified as being of special interest and their mRNA levels correlated with NLR, high-sensitive C-reactive protein and markers of subclinical CVD.

CONCLUSIONS

Patients with psoriasis and CVD had an increased expression of genes related to neutrophil degranulation in their blood transcriptome compared with patients with psoriasis without CVD. NLR may be a potential biomarker of subclinical CVD in psoriasis.

New Frontiers in Psoriatic Disease Research, Part II: Comorbidities and Targeted Therapies

Although psoriasis and psoriatic arthritis (PsA) have been classically considered to be diseases of the skin and joints, respectively, emerging evidence suggests that a combination of innate and environmental factors creates widespread immune dysfunction, affecting multiple organ systems. A greater understanding of the pathogenesis of psoriasis and the systemic effects of psoriatic inflammation has allowed for the development of new, more effective treatments. The second portion of this two-part review series examines the comorbidities associated with psoriasis and PsA as well as the most recent advances in targeted systemic therapies for these conditions.

Assessing the change in disease severity based on depressive symptoms in real-world psoriasis patients

Aim: To evaluate whether the presence of a history of depression hinders psoriasis response to systemic therapies and to delineate baseline characteristics of patients whose depressive symptoms improved on systemic treatment. Methods: We studied patients within the Corrona^® Psoriasis Registry, a prospective, multicenter observational disease-based registry, that were enrolled through September 2018, comparing changes from enrollment to 12-month visit. Results: There was a statistically significant improvement in all disease characteristics and most patient-reported outcomes in patients reporting a history of depression and in those that did not while there was no statistically significant difference in the degree of change comparing these two cohorts. Patients who noted improvement in depressive symptoms had more severe baseline disease characteristics and reported overall worse baseline patient-reported outcomes. Conclusions: History of depression does not portend a differential response to systemic treatment. Patients with improvement in depressive symptoms had worse baseline characteristics.

Psoriasis and Atherosclerosis-Skin, Joints, and Cardiovascular Story of Two Plaques in Relation to the Treatment with Biologics

It is known that both psoriasis (PSO) limited to the skin and psoriatic arthritis (PSA) increase the risk of cardiovascular complications and atherosclerosis progression by inducing systemic inflammatory response. In recent decades, the introduction of biological medications directed initially against TNF-α and, later, different targets in the inflammatory cascade brought a significant breakthrough in the efficacy of PSO/PSA treatment. In this review, we present and discuss the most recent findings related to the interplay between the genetics and immunology mechanisms involved in PSO and PSA, atherosclerosis and the development of cardiac dysfunction, as well as the current PSO/PSA treatment in view of cardiovascular safety and prognosis.

Psoriasis Severity and Cardiometabolic Risk Factors in a Representative US National Study

BACKGROUND

Psoriasis is associated with metabolic syndrome; however, the relationship of psoriasis severity with individual cardiometabolic risk factors is not clear. There is a reporting gap between the cardiometabolic risks among patients with psoriasis and what has been reported in the literature using US samples.

OBJECTIVES

The objective of this study was to examine the disease burden of psoriasis and assess the associations of psoriasis severity and cardiometabolic risk factors in a nationally representative sample.

METHODS

We conducted a cross-sectional study using the weighted pooled data from the National Ambulatory Medical Care Survey (NAMCS) 2007 through 2016. The NAMCS data were collected from US office-based physicians. Each physician was randomly assigned a specific week to report a sample of their cases. Patients were categorized as severe psoriasis if they were prescribed at least one systemic therapy. We used logistic regression models adjusting for potential confounders to estimate the associations of psoriasis severity with individual cardiometabolic factors.

RESULTS

There were about 3.3 million office-based psoriasis visits per year with a mean age of 50 years, a female-to-male ratio of 1:1, and severe disease in 23%. We observed greater values of blood pressure, lipid profiles, and higher body mass index among patients with psoriasis, compared with patients without psoriasis. A higher proportion of the psoriasis patient group were overweight and obese (73.6% vs 62.9% in the non-psoriasis patient group). Compared to mild case groups, severe case groups tended to have a higher proportion of overweight/obese with a body mass index ≥  25 kg/m² (77% vs 73%). Obesity was weakly associated with psoriasis severity (adjusted odds ratio = 1.37, 95% confidence interval 0.98-1.91 for mild disease and adjusted odds ratio = 1.42, 95% confidence interval 0.80-2.52 for severe cases).

CONCLUSIONS

Cardiometabolic factors are related health issues in psoriasis, and obesity is associated with greater psoriasis severity.

Psoriasis and Cardiovascular Disease: Novel Mechanisms and Evolving Therapeutics

PURPOSE OF REVIEW

Psoriasis is a chronic inflammatory skin condition that is associated with increased cardiovascular risk compared to those without psoriasis. This review will cover emerging mechanisms of cardiovascular risk, key pathways targeted with biologic therapies, and the current evidence on therapies to modulate this risk in patients with psoriasis.

RECENT FINDINGS

Recent scientific work has highlighted mechanisms that contribute to this enhanced risk, including the role of vascular endothelial dysfunction, platelet activation, dyslipidemia, and increased cardiometabolic comorbidities. Newer biologic and targeted synthetic therapies have transformed psoriasis treatment with high rates of clinical remission and durable skin disease control now possible. Epidemiological evidence suggests that many of these therapies may lower cardiovascular risk in psoriasis, although prospective interventional data is lacking (or mixed). Recently, caution has also been raised that some treatments may negatively affect cardiovascular risk. Overall, the current data suggests a positive or neutral ability to reduce cardiovascular risk for TNF, IL-17A, and IL-12/23p40 inhibitors, but current evidence remains conflicting for anti-IL-23/p19 and JAK inhibitors. More studies that include prospective cohorts, larger number of patients, treatment duration, and validated surrogate outcomes are needed to better evaluate the role of biologic therapies on cardiovascular risk in psoriasis.

Treatment of psoriasis with biologics in the early COVID-19 pandemic: A study examining patient attitudes toward the treatment and disease course

Background

Since March 2020, the coronavirus disease 2019 (COVID‐19) pandemic has been ongoing all around the world with a wide range of clinical course including asymptomatic cases to severe and fatal respiratory tract disease. Patients on immunosuppressive treatments were predicted to be more susceptible to COVID‐19.

Aims

It was aimed to assess treatment continuity, the course of psoriasis and the course and clinical features of COVID‐19 in patients treated with biological agents for psoriasis at the early initial period of COVID‐19 pandemic.

Patients/Methods

Patients treated with biological agents for psoriasis at our institute were contacted by phone between 1 and 10 July 2020 and fulfilled a questionnaire about their continuity to psoriasis treatments, clinical course of psoriasis, and any suspicion/diagnosis of COVID‐19.

Results

A total of 106 patients, 41 females and 65 males, were enrolled. Mean age of the patients was 46.1 ± 12.1 years (range: 19–77). Median duration of psoriasis was 18 years (min–max: 1 month–51 years). Twenty‐four patients (22.6%) were using tumor necrosis alpha inhibitors (ETA:1, IFX:19, ADA:4), whereas 82 patients (77.4%) were using interleukin (IL) 12/23 or IL‐17 inhibitors (UST:48, SECU:30, IXE:4). Seventy‐six patients (71.7%) continued the treatment, whereas 30 patients (28.3%) interrupted the treatment voluntarily. Twenty out of 30 patients (66.6%) who interrupted the treatment had an exacerbation of psoriasis. None of the patients were diagnosed with COVID‐19 in the study period.

Conclusion

Patients with psoriasis who received biological therapy continued their treatment at a high rate during the early period of the COVID‐19 pandemic. No COVID‐19 diagnosis was made among patients whether they continued or discontinued treatment. Recurrence and exacerbation of psoriasis in a significant proportion of patients who interrupted treatment and absence of COVID‐19 diagnosis in each group support the importance and safety of continuity of biological treatments for psoriasis in COVID‐19 era.

The Use of Apremilast in Psoriasis: An Indian Perspective on Real-World Scenarios

Apremilast, an oral phosphodiesterase-4 inhibitor, is approved for use in the management of psoriasis and psoriatic arthritis. Although its efficacy and safety have been well established in clinical studies, in real-world settings, different practice scenarios have been reported. This review paper serves to evaluate clinical real-world scenarios and aspects of treatment for which the information in the literature was considered to be lacking or controversial. Following a literature review, a panel of five dermatologists with expertise in psoriasis considered five scenarios; namely, the positioning of apremilast in psoriasis, its use in difficult-to-treat areas, special conditions and populations, safety, dose titration and dose in maintenance therapy. These were then assessed with psoriasis experts in India using a web-based questionnaire. A total of 28 questions were discussed regarding these scenarios. According to the responses, apremilast is effective in stable mild to moderate psoriasis as monotherapy and in severe psoriasis in combination. Also, a positive response was received with regard to its effectiveness in difficult locations such as the scalp, palms and soles. To reduce adverse effects, prolonged titration therapy over 4 weeks is required and lower doses can be prescribed to maintain remission. Apremilast therapy should be continued for a minimum of 8 weeks once initiated to achieve the desired results, and the total duration of therapy should be about 24 weeks for better efficacy. It is also effective in many other cases, such as obese patients, patients with hepatitis B or C and HIV, or patients on polypharmacy. It was also reported that apremilast requires less prescreening and monitoring than other conventional and biologic systemic therapies. Overall, apremilast is an attractive option for the individualized treatment of psoriasis owing to its favorable safety profile, its ease of oral administration without the need for screening or ongoing laboratory monitoring, and its positive impact on symptoms and lesions in difficult-to-treat areas.

Psoriasis Prevalence in Adults in the United States

IMPORTANCE

Determining psoriasis prevalence is fundamental to understanding the burden of the disease, the populations most affected, and health policies to address the disease.

OBJECTIVE

(1) To determine the prevalence of psoriasis among adults in the US and (2) to evaluate the change in psoriasis prevalence over time since the 2003-2004 National Health and Nutrition Examination Survey (NHANES) data.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cross-sectional study used 2011-2014 NHANES data (collected from January 1, 2011, to December 31, 2014) with sampling from a general, noninstitutionalized US civilian population. Participants were 20 years or older and were selected via a multistage probability sampling design to ensure that surveys were nationally representative. Eligible participants had an in-person interview followed by a medical examination by medical professionals. Data were analyzed from July 15, 2019, to December 23, 2020.

EXPOSURES

None.

MAIN OUTCOMES AND MEASURES

Psoriasis prevalence in the US, as measured by the percentage of people in the representative sample with psoriasis, and trend statistics comparing prevalence estimates from the 2003-2004, 2009-2010, and 2011-2014 NHANES cycles.

RESULTS

A total of 12 625 participants (mean [SD] age, 32.8 [24.1] years; 6492 women [51.4%]; and 4828 non-Hispanic White participants [38.2%]) answered the question of whether they were given the diagnosis of psoriasis by a physician or another health care professional. Psoriasis prevalence among US adults 20 years or older was 3.0% (95% CI, 2.6%-3.4%). Based on the 2020 US census data, this outcome translates to an estimated 7.55 million US adults with psoriasis. Psoriasis prevalence was similar between women and men, with 3.2% (95% CI, 2.6%-3.8%) in women and 2.8% (95% CI, 2.4%-3.3%) in men. Psoriasis prevalence was highest in White individuals at 3.6% (95% CI, 2.9%-4.2%), followed by other racial/ethnic groups (non-Hispanic, including multiracial) at 3.1% (95% CI, 1.2%-5.1%), Asian individuals at 2.5% (95% CI, 1.6%-3.3%), Hispanic individuals (including Mexican American and other Hispanic individuals) at 1.9% (95% CI, 1.3%-2.5%), and Black individuals at 1.5% (95% CI, 1.0%-2.0%). Psoriasis prevalence was not different based on patients' marital status, education, income, or medical insurance status. The prevalence of psoriasis among US adults did not differ significantly since 2003.

CONCLUSIONS AND RELEVANCE

The results of this cross-sectional study suggest that psoriasis remains a common, immune-mediated disease that affects 3.0% of the US adult population, or more than 7.5 million adults. Its prevalence has not differed since evaluation in 2003. These prevalence data are foundational to determining the burden of psoriasis and for supporting efforts in research, education, and health policy.

Work absenteeism and disability associated with psoriasis and psoriatic arthritis in the USA-a retrospective study of claims data from 2009 TO 2020

OBJECTIVES

To compare work absenteeism and short-term disability among adults with psoriasis or psoriatic arthritis (PsA), versus controls in the USA.

METHODS

Adults eligible for work absenteeism and/or short-term disability benefits between 1/1/2009 and 4/30/2020 were screened in the IBM® MarketScan® Commercial and Health and Productivity Management Databases. The following groups were defined: (1) psoriasis: ≥ 2 psoriasis diagnoses ≥ 30 days apart and no PsA diagnoses; (2) PsA: ≥ 2 PsA diagnoses ≥ 30 days apart; (3) control: absence of psoriasis and PsA diagnoses. Controls were matched to psoriasis and PsA patients based on age, gender, index year, and comorbidities. Non-recreational work absences and sick leaves were evaluated in absentee-eligible patients, and short-term disability was evaluated in short-term disability-eligible patients. Costs (in 2019 USD) associated with each type of work absence were evaluated.

RESULTS

4261 psoriasis and 616 PsA absentee-eligible and 25,213 psoriasis and 3480 PsA short-term disability-eligible patients were matched to controls. Average non-recreational work absence costs were $1681, $1657, and $1217 for the PsA, psoriasis, and control group, respectively. Compared with psoriasis patients and controls, more PsA patients had sick leaves after 1 year (56.2% versus 55.6% and 41.5%, p < 0.0001). Similarly, short-term disability was more frequent in PsA patients than psoriasis patients and controls at year one (8.8% versus 5.6% and 4.7%, p < 0.0001) and corresponding costs were higher ($605, $406, and $335 on average, p < 0.0001).

CONCLUSION

Annual work absenteeism and short-term disability were consistently greater among patients with PsA and psoriasis than controls, highlighting the substantial economic burden of psoriatic disease. Key points • Patients with PsA had greater short-term disability compared with patients with psoriasis and patients with neither psoriasis nor PsA. • Patients with PsA and patients with psoriasis incurred greater non-recreational work absences and sick leaves than patients with neither psoriasis nor PsA.

Saudi consensus statement on biologic treatment of chronic plaque psoriasis (2020)

Psoriasis is a common chronic and complex inflammatory skin disease that affects over 125 million people worldwide. Management of psoriasis in daily clinical practice in Saudi Arabia is variable. Local preferences for management differ, which may have a bearing on the treatment selection. Biologic therapy is now a well-established strategy for managing moderate-to-severe plaque psoriasis. There is a clear need for national consensus statements due to the extended role and high availability of literature on these agents. As a result of an initiative of the Ministry of Health, a multidisciplinary expert panel of dermatologists and pharmacists with practical experience in the clinical management of psoriasis were invited to be part of a work group to update the previous practical guidelines on the biologic treatment of psoriasis published in the Journal of Dermatological Treatment, 2014. The overall aim of this consensus document is to deliver evidence-based recommendations on the use, screening, and monitoring of biologic therapy in patients with moderate-to-severe plaque psoriasis. These recommendations also address the use of biologic therapy in special patient populations. They were developed after rigorous evaluation of existing international guidelines as well as the latest emerging evidence. Updates of the present consensus document will be provided as needed to incorporate new data or agents.

Gout Augments the Risk of Cardiovascular Disease in Patients With Psoriasis: A Population-Based Cohort Study

Objective

Patients with psoriasis (PsO) have a high frequency of concomitant gout and increased risk of cardiovascular diseases (CVD). We aimed to estimate the synergistic impact of gout on the risk of CVD in patients with PsO.

Methods

A population-based cohort of patients registered in the National Health Insurance Research Database of Taiwan between 2000 and 2013 was stratified according to the presence of PsO and gout. Propensity score analysis was used to match age and gender at a ratio of 1:4. Cox proportional hazard models and subgroup analyses were used to estimate the hazard ratios (HRs) for CVD adjusted for traditional risk factors. The Kaplan–Meier method was used to plot the cumulative incidence curves.

Results

Patients with combined PsO and gout (n = 97), PsO alone (n = 388), gout alone (matched, n = 388) and matched controls (n = 388) were identified. Compared with the patients with PsO alone, the patients with combined PsO and gout had a significantly higher risk of CVD (relative risk 2.39, 95% CI 1.56 to 3.65). After adjustment for traditional risk factors, the risk of CVD was higher in patients with gout alone (HR 2.16, 95% CI 1.54 to 3.04) and in patients with combined PsO and gout (HR 2.72, 95% CI 1.73 to 4.28).

Conclusions

Gout augments the risk of CVD independently of traditional risk factors in patients with PsO.

Updated Evidence of the Association Between Elevated Serum Uric Acid Level and Psoriasis

Background: Our earlier meta-analysis showed that the correlation between psoriasis and hyperuricemia might be region-dependent and that hyperuricemia was more common in patients with psoriasis in Western Europe. However, no further analysis could be conducted owing to the scarcity of data. Objective: Our study aimed to further explore the association between psoriasis and hyperuricemia. Methods: Six databases (PubMed, Embase, the Cochrane Central Register of Controlled Trials, the China National Knowledge Infrastructure database, the Chinese Scientific Journals Full Text Database, and the Wanfang Data Knowledge Service Platform) were searched for studies published between January 1980 and February 2021. Results: The search strategy yielded 291 relevant studies, of which 27 observational studies were included in this analysis. Serum uric acid (SUA) levels (mean difference [MD] 0.99, 95% confidence interval [CI] 0.48-1.49, P = 0.0001) and hyperuricemia frequency (odds ratio [OR] 5.39, 95% CI 1.88-15.40, P = 0.002) were higher in the psoriasis group than in the control group, and the subgroup differences were significant. In addition, SUA levels were significantly higher in patients with moderate to severe psoriasis from European and American countries (MD 0.89, 95% CI 0.18-1.60, P = 0.01) and Southeast Asia (MD 1.79, 95% CI 0.55-3.02, P = 0.004), while no significant differences were found between the Middle East subgroup (MD 0.63, 95% CI -0.33 to 1.59, P = 0.20). Similar results were obtained from the meta-analysis of SUA levels in patients with metabolic syndrome, obesity, or a special type of psoriasis (such as arthritic or erythrodermic psoriasis). Conclusions: Our meta-analysis study provides extended data regarding the correlation between psoriasis and hyperuricemia and the differences in SUA levels between psoriasis patients and controls in Southeast Asia, the Middle East, and European and American countries. Patients with moderate to severe psoriasis in European and American countries and Southeast Asia or those with metabolic syndrome and obesity were more likely to have higher uric acid levels. Systematic Review Registration: PROSPERO, identifier: CRD42014015091.

Musculoskeletal Imaging for Dermatologists: Techniques in the Diagnosis and Management of Psoriatic Arthritis

Psoriatic arthritis is an inflammatory condition affecting up to 30% of patients with psoriasis. Patients may experience irreversible joint damage if not treated early, and diagnostic delays of even 6 months are associated with radiographic progression and impaired function. Therefore, early detection and intervention are of critical importance in patients with psoriatic arthritis. Given that psoriasis often precedes symptoms of psoriatic arthritis, dermatologists are uniquely positioned to identify patients with psoriatic arthritis early in their disease course, before permanent damage has occurred. Several screening tools have been developed to help dermatologists identify patients who may have psoriatic arthritis, but these tools may not capture patients with subclinical disease or quantify the type and severity of the underlying tissue insult, which is often the presenting sign of psoriatic arthritis. In these cases, a combination of clinical assessment and musculoskeletal imaging (e.g., ultrasound) is required. This review summarizes three common musculoskeletal imaging techniques used in the diagnosis and management of patients with psoriatic arthritis: conventional radiography, ultrasound, and magnetic resonance imaging. Further understanding of musculoskeletal imaging will assist dermatologists in making treatment decisions and allow them to have a more active role in the detection of psoriatic arthritis.

Self-practice among patients with psoriasis: University hospital experience

OBJECTIVES

This study aimed to assess the self-care practices of patients with psoriasis and factors affecting them.

METHODS

A cross-sectional study was conducted on 110 adult patients with confirmed diagnosis of psoriasis. Each patient underwent a personal structured interview with the physician using two predetermined questionnaires, one for assessing self-care practices and another for evaluating patients' knowledge of their disease and sociodemographic and clinical features.

RESULTS

Most studied patients had poor level of self-care practices and knowledge. Patients' level of self-care was positively associated with the level of the knowledge of their disease. Poor level of self-care practice was significantly associated with low level of education, disease severity, and Psoriasis Area and Severity Index score.

CONCLUSION

Patients with low level of education or disease knowledge will mostly have poor self-care behavior.

The Association Between Psoriasis and Cardiovascular Diseases

Cardiovascular diseases and psoriasis have been well established as separate entities, however, there is uncertainty with regards to a link between the two diseases. A few environmental, psychological and social factors have been implicated as potential common risk factors that may exacerbate the two diseases, and an array of complex immune and non-immune inflammatory mediators can potentially explain a plausible link. Pharmacotherapy has also played a role in establishing a potential association, especially with the advent of biological agents which directly act on inflammatory factors shared by the two diseases. This review will look at existing evidence and ascertain a potential correlation between the two.

Comparison of guidelines for the use of Ustekinumab for psoriasis in the United States, Europe, and the United Kingdom: A critical appraisal and comprehensive review

The aim of this review is to compare and contrast evidence-based clinical practice guidelines from global dermatological organizations for the use of ustekinumab in psoriasis. Clinical practice guidelines from the American Academy of Dermatology, National Psoriasis Foundation, British Association of Dermatologists, and European S3 were reviewed and compared. Practice guidelines from the three dermatological organizations are similar with regards to treatment dosage and initiation but differ in their recommendations for baseline screening and interval laboratory monitoring, treatment in patients undergoing surgery or receiving live vaccines, and treatment contraindications. Ustekinumab is an effective and well-tolerated systemic treatment for patients with psoriasis and should be considered in the line of therapy that dermatologists discuss with their patients. Consideration should be given to evidence-based practice guidelines of global dermatology organizations to effectively guide treatment decisions in patients with psoriasis.

Psoriasis in Patients with Metabolic Syndrome or Type 2 Diabetes Mellitus: Treatment Challenges

Psoriasis is a chronic inflammatory disease that affects 2-3% of the population worldwide. It is associated with plaques, psoriatic arthritis, and metabolic syndrome and its components, including obesity, diabetes, dyslipidemia, nonalcoholic fatty liver disease, and cardiovascular disease. In this review, we highlight the shared pathogenic pathways leading to the comorbid existence of both diseases and the impact of drugs used for psoriasis on metabolic syndrome and vice versa. Persistent inflammation is common to both diseases. They share increased inflammatory cytokines such as tumor necrosis factor (TNF)-α and interleukin-6. Biologics have revolutionized the treatment of plaque psoriasis and also have a positive impact on metabolic syndrome. There is some evidence that TNFα inhibitors decrease insulin resistance and improve glycemic indices. Some psoriasis treatments may result in decreased body weight. Lifestyle measures used in the management of metabolic syndrome, such as weight loss, exercise, and healthy diet, are beneficial in patients with psoriasis. Considering the association between metabolic syndrome and psoriasis, we recommend screening patients with psoriasis for metabolic syndrome with clinical examinations and laboratory tests. Patients with a co-diagnosis of these diseases deserve special attention for optimal treatment.

Pediatric Psoriasis Comorbidities: Screening Recommendations for the Primary Care Provider

Psoriasis, which affects up to 2% of children may be associated with significant comorbidity, including obesity, diabetes, cardiovascular disease, depression, and reduced quality of life. Screening and decision-making require a multidisciplinary approach with the management of potential comorbidities championed by primary care providers and supported by respective specialists and subspecialists. Research into the comorbidities and systemic manifestations has generated significant data culminating in several proposals for a consensus guideline for both pediatric and nonpediatric populations. Our aim is to provide a summary targeted to the pediatric primary care provider from the best available evidence when caring for children with psoriasis.

Genital and Inverse/Intertriginous Psoriasis: An Updated Review of Therapies and Recommendations for Practical Management

Genital and inverse psoriasis can develop in more than one-third of patients who have psoriasis. Psoriatic plaques in the genital and intertriginous skin are challenging to treat because the skin is thin and often occluded, making it more sensitive to certain therapies. Traditional guidelines indicate topical therapies, such as corticosteroids, topical calcineurin inhibitors (TCI), and vitamin D analogs as first-line recommendation in treating genital and inverse psoriasis. There have been developments in the treatment of genital and inverse psoriasis using systemic therapies, including IL-17 inhibitors and PDE-4 inhibitors.

Oral and Topical Vitamin D, Sunshine, and UVB Phototherapy Safely Control Psoriasis in Patients with Normal Pretreatment Serum 25-Hydroxyvitamin D Concentrations: A Literature Review and Discussion of Health Implications

Vitamin D, sunshine and UVB phototherapy were first reported in the early 1900s to control psoriasis, cure rickets and cure tuberculosis (TB). Vitamin D also controlled asthma and rheumatoid arthritis with intakes ranging from 60,000 to 600,000 International Units (IU)/day. In the 1980s, interest in treating psoriasis with vitamin D rekindled. Since 1985 four different oral forms of vitamin D (D2, D3, 1-hydroxyvitaminD3 (1(OH)D3) and 1,25-dihydroxyvitaminD3 (calcitriol)) and several topical formulations have been reported safe and effective treatments for psoriasis-as has UVB phototherapy and sunshine. In this review we show that many pre-treatment serum 25(OH)D concentrations fall within the current range of normal, while many post-treatment concentrations fall outside the upper limit of this normal (100 ng/mL). Yet, psoriasis patients showed significant clinical improvement without complications using these treatments. Current estimates of vitamin D sufficiency appear to underestimate serum 25(OH)D concentrations required for optimal health in psoriasis patients, while concentrations associated with adverse events appear to be much higher than current estimates of safe serum 25(OH)D concentrations. Based on these observations, the therapeutic index for vitamin D needs to be reexamined in the treatment of psoriasis and other diseases strongly linked to vitamin D deficiency, including COVID-19 infections, which may also improve safely with sufficient vitamin D intake or UVB exposure.

Biologics recommendations for patients with psoriasis: a critical appraisal of clinical practice guidelines for psoriasis

PURPOSE

This review article serves to assess the consistency of recommendations from guidelines on biologic agents for psoriasis, based on the quality evaluation of psoriasis Clinical Practice Guidelines (CPGs).

METHODS

We conducted a systematic literature search to identify CPGs that provide recommendations on diagnosis and treatment for psoriasis. Four reviewers performed a quality assessment of the included CPGs with the Appraisal of Guidelines Research and Evaluation II (AGREE II) Instrument.

RESULTS

A total of 51 sets of CPGs from 22 medical societies or separate working groups fulfilled the inclusion criteria. The overall quality of the eligible sets of guidelines was moderate to high, with an overall average score of 55%The highest domain scores were Score and Purpose (70%) and Clarity of Presentation (68%). A total of 95 biologic agent recommendations were extracted from the 18 recommended CPGs.Three biologic agents (Etanercept, Adalimumab, Ustekinumab) were recommended for pediatric patients. Three biologic agents (Adalimumab, Ustekinumab, Secukinumab) were recommended as first-line biologic agents for adults with psoriasis.

CONCLUSION

The overall methodological quality of CPGs for psoriasis is medium to high. More attention should be paid to applicability in guideline development. The recommendations and the basis for them among various sets guidelines were almost consistent.

Fire needle therapy for blood stasis syndrome of plaque psoriasis: A protocol for systematic review and meta-analysis

BACKGROUND

Plaque psoriasis (PSO) is a common clinical chronic inflammatory skin disease. The incidence rate is increasing year by year due to the fast pace of work and unhealthy diet. Fire needle has been widely used in the treatment of PSO. However, the efficacy of fire needle for PSO is uncertain. Thus, the purpose of this systematic review is to evaluate the effectiveness and safety of fire needle for PSO (blood stasis syndrome).

METHODS

The following electronic databases will be searched from inception to October 2020:PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure, WangFang Database, Chinese Science Journal Database, Chinese Biomedical Literature Database. In addition, other documents that meet the requirements will be manually searched, including conference papers, dissertations, etc. All randomized controlled trials using fire needle to treat PSO (blood stasis syndrome) that meet the criteria for inclusion will be included. The primary outcomes are clinical efficacy, Psoriasis area and severity index. Secondary outcomes include Itchy, TCM evaluation standard syndrome score, Dermatological quality of life index, and adverse events. To complete data synthesis and assess the risk of bias, we will use the RevMan V.5.3 software.

RESULTS

The review results will be published in a peer-reviewed journal.

CONCLUSION

This study will provide high-quality evidence based medicine to evaluate the effectiveness and safety of fire needle for PSO (blood stasis syndrome), and further seek its scientific and effective chinese medicine treatment methods.

INPLASY REGISTRATION NUMBER

INPLASY202120007.

Interleukin-17 and Interleukin-23: A Narrative Review of Mechanisms of Action in Psoriasis and Associated Comorbidities

Psoriasis is an immune-mediated inflammatory skin disease associated with numerous inflammatory comorbidities, including increased cardiovascular risk. The interleukin (IL)-23/IL-17 axis plays a central role in the immunopathogenesis of psoriasis and related comorbidities by acting to stimulate keratinocyte hyperproliferation and feed-forwarding circuits of perpetual T cell-mediated inflammation. IL-17 plays an important role in the downstream portion of the psoriatic inflammatory cascade. This review discusses the distinct mechanisms of action of IL-17 and IL-23 in the immunopathogenesis of psoriasis and related comorbidities plus the significant therapeutic benefits of selectively inhibiting these cytokines in patients with moderate to severe plaque psoriasis.

Cardiovascular Risk in Patients With Psoriasis: JACC Review Topic of the Week

Psoriasis is a chronic inflammatory skin disease that affects 2% to 3% of the U.S. population. The immune response in psoriasis includes enhanced activation of T cells and myeloid cells, platelet activation, and up-regulation of interferons, tumor necrosis factor-α, and interleukins (ILs) IL-23, IL-17, and IL-6, which are linked to vascular inflammation and atherosclerosis development. Patients with psoriasis are up to 50% more likely to develop cardiovascular disease (CV) disease, and this CV risk increases with skin severity. Major society guidelines now advocate incorporating a psoriasis diagnosis into CV risk prediction and prevention strategies. Although registry data suggest treatment targeting psoriasis skin disease reduces vascular inflammation and coronary plaque burden, and may reduce CV risk, randomized placebo-controlled trials are inconclusive to date. Further studies are required to define traditional CV risk factor goals, the optimal role of lipid-lowering and antiplatelet therapy, and targeted psoriasis therapies on CV risk.

Moxibustion therapy for treating psoriasis vulgaris: A protocol for systematic review and meta-analysis

BACKGROUND

Psoriasis vulgaris (PV) is an immune-mediated skin disease, which has seriously affected the quality of life of patients. At present, moxibustion therapy has been widely used in the treatment of PV. The purpose of this study is to provide high-quality evidence-based medicine to evaluate the effectiveness and safety of moxibustion for PV.

METHODS

We will search the following Electronic databases from their inceptions to February 2021 without any language limitation: PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, WangFang Database, Chinese Science Journal Database, Chinese Biomedical Literature Database. What's more, the grey literature and the references of all included literature will also be retrieved manually. Any clinical randomized controlled trials (RCTs) related to moxibustion therapy for PV will be taken into. In order to complete data synthesis and assess the risk of bias, we will use the RevMan V.5.3 software.

RESULTS

This systematic review will provide an assessment of the current state of moxibustion for PV, aiming to assess the efficacy and safety of moxibustion for patients with PV.

CONCLUSION

This systematic review will establish convincing evidence to prove the effectiveness and safety of moxibustion for PV.

INPLASY REGISTRATION NUMBER

INPLASY202120008.

Non-alcoholic fatty liver disease and psoriasis - is there a shared proinflammatory network?

Psoriasis is an immune-mediated systemic inflammatory disease that is not limited to the skin but may be associated with arthritis, cardiovascular diseases, metabolic syndrome including diabetes and obesity and, as identified more recently, non-alcoholic fatty liver disease (NAFLD) that occurs in approximately 50 % of all patients with psoriasis. NAFLD is characterized by accumulation of fat in hepatocytes in the absence of excessive alcohol consumption. Over the last two decades, NAFLD has developed to the most common chronic liver disease with an estimated prevalence of 25 % in the Western population. NAFLD ranges from non-inflammatory or bland hepatic steatosis to inflammation of hepatic tissue (non-alcoholic steatohepatitis, NASH) and consecutive liver fibrosis. It is controversial whether the underlying systemic inflammation of psoriasis is contributing to development of NAFLD or if comorbid diseases such as obesity enhance NAFLD development. Recent findings indicate that cytokine-mediated inflammation through TNFα, interleukin (IL)-6 and IL-17 might be the common link between psoriasis and NAFLD. Considering the shared inflammatory pathways, IL-17 pharmacological blockade, which is already well-established for psoriasis, may be a promising strategy to treat both psoriasis and NAFLD. Therefore, early detection of NAFLD and a better understanding of its pathophysiology in the context of the systemic inflammation in psoriasis is important with regard to individualized treatment approaches.

Use of IL-23 Inhibitors for the Treatment of Plaque Psoriasis and Psoriatic Arthritis: A Comprehensive Review

Psoriasis is a common inflammatory skin disease with multiple comorbidities, including psoriatic arthritis and coronary artery disease, that can severely impact an individual’s quality of life and daily functioning. In recent years, enhanced understanding of the pathogenesis of psoriasis, especially the role of T helper 17 cells, has resulted in the development of new classes of biologic drugs targeting modulators along its disease pathway. Among these, inhibitors of interleukin-23 (e.g., ustekinumab, guselkumab, tildrakizumab, and risankizumab) have emerged as safe and effective options for the treatment of moderate-to-severe plaque psoriasis; ustekinumab and guselkumab have additionally been approved to treat psoriatic arthritis. Selective interleukin-23 inhibitors require less frequent dosing than interleukin-17 inhibitors and may possess a more favorable risk profile without an increased risk of candidiasis or inflammatory bowel disease. Overall, these highly effective medications are contributing to a rising standard for psoriasis outcomes through resolution of skin lesions and joint manifestations and improvement of patient quality of life.

Efficacy and Safety of Continuous Risankizumab Therapy vs Treatment Withdrawal in Patients With Moderate to Severe Plaque Psoriasis: A Phase 3 Randomized Clinical Trial

Question

Is continuous risankizumab treatment efficacious and safe in adults with moderate to severe plaque psoriasis?

Findings

In this 2-part, phase 3 randomized clinical trial in 507 patients, a significantly greater proportion of patients treated with risankizumab vs placebo achieved a treatment response at week 16 and with long-term continuous risankizumab compared with withdrawal to placebo at 52 and 104 weeks. Rates of treatment-emergent adverse events were similar to those with placebo and remained stable over time.

Meaning

These findings support the use of 12-week risankizumab dosing as an efficacious and well-tolerated regimen for maintenance of clinical efficacy in patients with moderate to severe plaque psoriasis.

Importance

Risankizumab selectively inhibits interleukin 23, a cytokine that contributes to psoriatic inflammation.

Objective

To evaluate the efficacy and safety of risankizumab vs placebo and continuous treatment vs withdrawal in adults with moderate to severe plaque psoriasis.

Design, Setting, and Participants

Multinational, phase 3, randomized, double-blind, placebo-controlled trial conducted from March 6, 2016, to July 26, 2018. A total of 507 eligible patients had stable moderate to severe chronic plaque psoriasis for 6 months or longer, body surface area involvement greater than or equal to 10%, Psoriasis Area and Severity Index (PASI) greater than or equal to 12, and a static Physician’s Global Assessment (sPGA) score greater than or equal to 3. Intention-to-treat analysis was conducted.

Interventions

Patients were randomized (4:1, interactive response technology) to risankizumab, 150 mg, subcutaneously, or placebo at weeks 0 and 4 (part A1). All patients received risankizumab at week 16. At week 28, patients randomized to risankizumab who achieved an sPGA score of 0/1 were rerandomized 1:2 to risankizumab or placebo every 12 weeks (part B).

Main Outcomes and Measures

Co-primary end points for the part A1 phase included proportions of patients achieving greater than or equal to 90% improvement in PASI (PASI 90) and sPGA score of 0/1 at week 16. The PASI measures severity of erythema, infiltration, and desquamation weighted by area of skin involvement over the head, trunk, upper extremities, and lower extremities; scores range from 0 (no disease) to 72 (maximal disease activity). The sPGA assesses average thickness, erythema, and scaling of all psoriatic lesions; scores range from 0 (clear) to 4 (severe), with 0/1 indicating clear or almost clear. Primary and secondary end points in part B included proportion of rerandomized patients achieving an sPGA score of 0/1 at week 52 (primary) and week 104 (secondary).

Results

Of 563 patients screened, 507 were randomized to risankizumab (n = 407) or placebo (n = 100). Most patients were men (356 [70.2%]); median age was 51 years (interquartile range, 38-60 years). At week 16, 298 patients (73.2%) in the treatment group vs 2 patients (2.0%) receiving placebo achieved a PASI 90 response, and 340 patients (83.5%) receiving risankizumab vs 7 patients (7.0%) receiving placebo achieved sPGA 0/1 scores (placebo-adjusted differences: PASI 90: 70.8%; 95% CI, 65.7%-76.0%; sPGA 0/1: 76.5%; 95% CI, 70.4%-82.5%; P < .001 for both). At week 28, 336 responders were rerandomized to risankizumab (n = 111) or treatment withdrawal (n = 225). At week 52, the sPGA 0/1 score was achieved by 97 patients (87.4%) receiving risankizumab vs 138 patients (61.3%) receiving placebo. At week 104, the sPGA 0/1 score was achieved by 90 patients (81.1%) receiving risankizumab vs 16 patients (7.1%) receiving placebo (placebo-adjusted differences: week 52: 25.9%; 95% CI, 17.3%-34.6%; week 104: 73.9%; 95% CI, 66.0%-81.9%; P < .001 for both). Rates of treatment-emergent adverse events were similar between risankizumab (186 [45.7%]) and placebo (49 [49.0%]) in part A1 and remained stable over time.

Conclusions and Relevance

Risankizumab showed superior efficacy compared with placebo through 16 weeks and treatment withdrawal through 2 years. Risankizumab was well tolerated, with no unexpected safety findings during the 2-year trial.

Trial Registration

ClinicalTrials.gov Identifier: NCT02672852

The Assessment of Risk and Predictors of Sleep Disorders in Patients with Psoriasis-A Questionnaire-Based Cross-Sectional Analysis

Psoriasis is a chronic, inflammatory skin disease affecting 2-4% of the general population. Accompanying subjective symptoms (pruritus or pain) may cause decreased life quality including sleep disorders (SD). Sixty psoriatic patients fulfilled the following questionnaires: Pittsburgh Sleep Quality Index (PSQI), STOP BANG for the obstructive sleep apnea syndrome (OSAS) assessment, and Restless Legs Syndrome (RLS) Severity Scale. Patients' laboratory and clinical data were also investigated. All data obtained were compared to 40 participants without dermatoses. Mean PSQI, risk of OSAS, and RLS severity of psoriatics were significantly higher than in controls (p < 0.0001, p < 0.05, p < 0.05 respectively). There was a positive correlation between the time of suffering from psoriasis and the risk of OSAS (R = 0.286, p < 0.05). We did not observe any significant relationship between PSQI, risk of OSAS, or RLS and psoriasis severity assessed with PASI (Psoriasis Area and Severity Index). We identified four possible predictors of RLS: glucose, CRP and total cholesterol concentrations, and PSQI. SD are significantly more frequent in psoriatics than in people without chronic dermatological diseases but surprisingly they are not correlated with psoriasis severity. SD decrease patients' life quality and may result in serious consequences. Therefore, establishing recommendations concerning screening for SD and their predictors should be considered.

miR-146b correlates with increased disease activity and psoriatic tissue inflammation and promotes keratinocyte proliferation in psoriasis

The present study aimed to investigate the expression of microRNA (miR)-146b in psoriatic tissue and its correlation with psoriasis activity and inflammation. The effect of miR-146b overexpression on keratinocyte proliferation and apoptosis was also explored. The expression of miR-146b in the psoriasis-affected tissue and non-affected tissue of 110 patients was determined via reverse transcription-quantitative (RT-q)PCR. The psoriasis-affected body surface area and psoriasis area severity index (PASI) score were recorded for evaluating disease activity. The expression of various inflammatory cytokines in psoriasis-affected tissue was also detected via RT-qPCR. miR-146b overexpression and control plasmids were constructed and transfected into HaCaT cells in vitro. Subsequently, cell proliferation, apoptosis and tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL)-induced cell apoptosis were determined. The results revealed that the expression of miR-146b was increased in psoriasis-affected tissue compared with that in unaffected tissue. The results obtained from a receiver operating characteristic curve analysis demonstrated that miR-146b levels were able to discriminate between psoriasis-affected tissue and unaffected tissue, with an area under the curve value of 0.781 (95% CI: 0.720-0.843). In addition, miR-146b expression in psoriatic tissue was correlated with an increased PASI score in patients with psoriasis. miR-146b expression in psoriatic tissue was positively correlated with TNF-α, interleukin (IL)-6 and IL-17 mRNA levels. In vitro, miR-146b overexpression enhanced HaCaT cell proliferation and suppressed apoptosis as well as TRAIL-induced apoptosis when compared with that in control-transfected HaCaT cells. In conclusion, miR-146b was positively correlated with disease activity and psoriatic tissue inflammation. Keratinocyte proliferation was also promoted in psoriasis.

Enthesitis in psoriatic arthritis (Part 3): clinical assessment and management

Enthesitis is a common clinical feature of PsA, which is characterized by inflammation at the site of insertion of tendons, ligaments and joint capsule fibres into bone. Enthesitis is relatively unique to the spondyloarthritides, setting this group of diseases apart from other rheumatological conditions. The pathophysiological underpinnings of this clinical domain, and the imaging assessment of it, are described in accompanying articles in this supplement. The focus of this article is on the assessment of enthesitis by physical examination, the impact of enthesitis on function and quality of life, the impact of concomitant FM on clinical assessment, and the evidence for therapy of enthesitis garnered in trials of biologic and targeted synthetic DMARDs. Several physical examination measures of enthesitis have been developed and have proved reliable in assessment of enthesitis. Enthesitis has a significant deleterious impact on function and quality of life. The presence of concomitant FM in ≤20% of patients may result in artefactual worsening of assessment of disease severity and hinder achievement of the goal of low disease activity or remission. Several targeted therapies, which, for example, target the TNF, IL-17, IL-23, phosphodiesterase 4 or Janus kinase pathways, have shown significant efficacy in the treatment of enthesitis, resulting in improvement of function and quality of life for patients with PsA.

Treatment guidelines in psoriatic arthritis

Psoriatic arthritis (PsA) is a complex inflammatory musculoskeletal and skin disease. The treatment of PsA has changed substantially over the past 10 years. Clinical practice guidelines are developed to help busy clinicians rapidly integrate evolving knowledge of therapeutic management into practice. In this review, we compare PsA treatment recommendations or guidelines developed by one national organization [ACR and National Psoriasis Foundation (NPF) in 2018], one regional organization (EULAR in 2015), and one international organization (the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis in 2015). We examine the development of guidelines in PsA more broadly and examine similarities and differences in the three sets of recommendations.

Major depressive disorder increased risk of psoriasis: A propensity score matched cohort study

BACKGROUND

Reports showed that elevated proinflammatory cytokines, as detected in patients with psoriasis, was noted in individuals with major depressive disorder (MDD). Therefore, this study aimed to clarify the association of MDD and prospective incidence of psoriasis in human using a nationwide study.

METHOD

This population-based cohort study used the data from the Taiwan National Health Insurance system. 64,486 patients were defined as MDD cohort and 64,486 propensity score matched subjects without MDD were identified as comparison cohort. Each patient was independently tracked for a 5-year study period to assure them for a psoriasis diagnosis after the index date. Stratified Cox proportional hazard models were used to calculate the hazard ratio (HRs) for 5-year psoriasis risk.

RESULTS

After adjustments, the HR of psoriasis for MDD patients was 1.32 compared with subjects without MDD. The stratified analyses present that MDD patients had approximately 1.30-fold significantly higher risk of psoriasis than comparison subjects in most subgroups. Furthermore, compared with the matched subjects without MDD, the adjusted HRs of psoriasis in the 2-, 3-, 4- and 5-year study periods were 1.33, 1.32, 1.33 and 1.32, respectively.

LIMITATIONS

Several patients with MDD or psoriasis might not include in this study, because of using a medical claims database.

CONCLUSIONS

This study provides population-based evidence that MDD is an independent risk factor of developing psoriasis, with an increased risk in the male sex. Additional investigations verifying our findings and exploring possible pathological mechanisms would be of great interest and value to the psychiatric field.