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

Beta-defensin-2 protein is a serum biomarker for disease activity in psoriasis and reaches biologically relevant concentrations in lesional skin

BACKGROUND

Previous studies have extensively documented antimicrobial and chemotactic activities of beta-defensins. Human beta-defensin-2 (hBD-2) is strongly expressed in lesional psoriatic epidermis, and recently we have shown that high beta-defensin genomic copy number is associated with psoriasis susceptibility. It is not known, however, if biologically and pathophysiologically relevant concentrations of hBD-2 protein are present in vivo, which could support an antimicrobial and proinflammatory role of beta-defensins in lesional psoriatic epidermis.

METHODOLOGY/PRINCIPAL FINDINGS

We found that systemic levels of hBD-2 showed a weak but significant correlation with beta defensin copy number in healthy controls but not in psoriasis patients with active disease. In psoriasis patients but not in atopic dermatitis patients, we found high systemic hBD-2 levels that strongly correlated with disease activity as assessed by the PASI score. Our findings suggest that systemic levels in psoriasis are largely determined by secretion from involved skin and not by genomic copy number. Modelling of the in vivo epidermal hBD-2 concentration based on the secretion rate in a reconstructed skin model for psoriatic epidermis provides evidence that epidermal hBD-2 levels in vivo are probably well above the concentrations required for in vitro antimicrobial and chemokine-like effects.

CONCLUSIONS/SIGNIFICANCE

Serum hBD-2 appears to be a useful surrogate marker for disease activity in psoriasis. The discrepancy between hBD-2 levels in psoriasis and atopic dermatitis could explain the well known differences in infection rate between these two diseases.

Safety and efficacy of alefacept, efalizumab, etanercept and infliximab in treating moderate to severe plaque psoriasis: a meta-analysis of randomized controlled trials

BACKGROUND

The relatively recent introduction of biological agents to treat psoriasis presents clinicians with the need to objectively compare and contrast these agents to allow more effective treatment of their patients.

OBJECTIVES

To evaluate and compare the efficacy and safety of biological agents in the treatment of plaque psoriasis.

METHODS

(i)

DATA SOURCES

Four parallel systematic reviews conducted through July 2006, including peer-reviewed data and U.S. Food and Drug Administration (FDA) reports. (ii)

STUDY SELECTION

Randomized, controlled, double-blind, monotherapy trials of alefacept (n = 3), efalizumab (n = 5), etanercept (n = 4) and infliximab (n = 4); 16 studies comprising 7931 patients met inclusion criteria. (iii)

DATA EXTRACTION

Efficacy was measured by Psoriasis Area and Severity Index (PASI) 75 achievement after 10-14 weeks of treatment, using intention-to-treat analysis. Safety was evaluated by the incidence of one or more adverse event(s) (AEs) and serious adverse event(s) (SAEs) during 10-30 weeks of treatment.

RESULTS

Pooled relative risk (RR) and number needed to treat (NNT) of PASI 75 achievement compared with placebo was computed using Mantel-Haenszel methods and the random effects model. All biological agents for psoriasis were efficacious (P < 0.001); however, there was a graded response for achievement of PASI 75: infliximab (RR = 17.40, NNT = 2), etanercept (RR = 11.73, NNT = 3), efalizumab (RR = 7.34, NNT = 4) and alefacept (RR = 3.70, NNT = 8). The risk of one or more AEs was evaluated by RR and number needed to harm (NNH). This was increased in the alefacept (RR = 1.09, P = 0.03, NNH = 15), efalizumab (RR = 1.15, P < 0.001, NNH = 9) and infliximab (RR = 1.18, P < 0.001, NNH = 9) groups compared with placebo. SAEs were increased in a sensitivity analysis of four efalizumab trials (n = 2443, RR = 1.92, P = 0.03, NNH = 60).

CONCLUSIONS

The decreasing rank order for pooled efficacy was infliximab, etanercept, efalizumab and alefacept when compared with placebo. Pooling safety data revealed a previously unreported increased risk of AEs for alefacept, efalizumab and infliximab.

Disease severity, quality of life and health care in plaque-type psoriasis: a multicenter cross-sectional study in Germany

BACKGROUND

Plaque-type psoriasis produces significant morbidity, has negative effects on patients' health-related quality of life (HRQoL), and represents an economic burden.

OBJECTIVES

The assessment of disease severity, HRQoL and health care in plaque-type psoriasis in everyday German medical practice.

METHODS

Details of patients with plaque-type psoriasis were recorded by 48 dermatologists in Germany. During the visit, demographic data, medical history, previous and current treatments, occupational impairment, the current state of the disease (measured by the Psoriasis Area and Severity Index; PASI), overall lesion severity, and HRQoL were evaluated.

RESULTS

In total, 1,511 plaque-type psoriasis patients were included. The average PASI score was 12.0. The average Dermatology Life Quality Index score was 8.6. Among the patients with the severest psoriasis (PASI >20), only 45.4% had ever been prescribed systemic treatments.

CONCLUSIONS

Psoriasis patients have a reduced HRQoL and are not sufficiently treated in practice. A more widespread use of systemic treatment and the definition of treatment goals are essential to improve the standard of care for psoriasis patients.

Chronic facial sarcoidosis including lupus pernio: clinical description and proposed scoring systems

BACKGROUND

Facial lesions including lupus pernio are often a form of chronic cutaneous sarcoidosis.

OBJECTIVE

To evaluate the intra- and inter-observer consistency of objective measures of chronic facial lesions.

METHOD

This was a retrospective study of patients with chronic cutaneous facial lesions including lupus pernio. The lesions were evaluated using two methods.

RESULTS

Of the 25 patients studied, 23 were women and 24 were African American. Lungs (24 patients), sinuses (11 patients), and eyes (7 patients) were also affected. The Sarcoidosis Activity and Severity Index (SASI) characterized individual areas of the face, with 95% of the observations being less than 2 points from the median. A facial SASI total gave a score for the entire face and 93.2% of the scores were within 3 points of the median.

CONCLUSION

Patients with sarcoidosis and chronic facial lesions often have lung, sinus, and eye involvement. The SASI is a reproducible scoring system for chronic facial lesions.

Psychological distress and coping strategies in patients with psoriasis: the PSYCHAE Study

OBJECTIVE

Our objectives were to determine the prevalence of psychological distress in a large sample of Italian patients with psoriasis; to establish whether disease severity and psychological distress are associated; to identify the strategies employed to cope with psoriasis; to evaluate the coping strategies employed by dermatologists; and to identify potential predictors of psychological distress.

DESIGN

Cross-sectional.

SETTING

Thirty-nine Italian dermatology centres.

SUBJECTS

One thousand five hundred and eighty (1580) patients with psoriasis.

METHODS

Minor psychological distress was evaluated using the General Health Questionnaire-12 (GHQ-12) and major psychopathological distress using the Brief Symptom Inventory (BSI); coping strategies were evaluated using the Brief COPE questionnaire; disease severity was evaluated using the body surface area index.

RESULTS

Patients were aged 44 +/- 13 years (mean +/- SD) and were mainly men (57%). Minor psychological distress was present in 46% of patients and major psychopathological distress in 11% of them. Both minor (54% vs. 40%, P < 0.0001) and major (17% vs. 7%, P < 0.0001) distress were more frequent in women than in men. The psychological status of women was worse than that of men independently from the extension of psoriasis. There was no association between the presence of distress and the treatment prescribed by dermatologists. Planning and active coping were the strategies most commonly employed by patients to cope with psoriasis, but there were between-gender differences. Most dermatologists employed a 'problem-orientated' attitude in caring for patients.

CONCLUSIONS

(i) Psychological distress was relatively frequent in our patients with psoriasis; (ii) female gender was the most important predictive factor for psychological distress; (iii) there was no association between psoriasis severity and psychological distress; (iv) planning and active coping were the coping strategies most frequently employed by patients; and (v) most dermatologists employed a problem-orientated attitude in caring for patients.

Psychosoziale Belastungen bei Psoriasis vulgaris

BACKGROUND

The successful treatment of patients with chronic plaque psoriasis depends not only on the method of therapy but also on psychosocial factors.

METHODS AND RESULTS

A pilot study was performed on 22 patients with chronic plaque psoriasis. The psychosocial stress, psychiatric features and their changes were assessed over a 3-week inpatient rehabilitation stay in a specialty clinic. The severity of the psoriasis, the subjective degree of suffering and the psychometric variables related to psychosomatic symptoms were assessed before and at the end of the treatment. After the hospitalization, the severity of disease and anger were both significantly decreased, along with an increased interest in social interactions.

CONCLUSION

In psoriasis patients, one can distinguish between different psychosocial factors, some of which are more likely to change. Stable attributes such as personality style can impact on compliance as well as on coping behaviors, thereby influencing treatment success. Our study shows that even within a rather short inpatient treatment period of 3 weeks not only the disease severity but also negative psychosocial stressors can be improved.

Analysis of perforin expression in peripheral blood and lesions in severe and mild psoriasis

BACKGROUND

Perforin is a membrane-disrupting protein that allows the entry of granzymes into a target cell inducing degradation of target substances in the cytoplasm and nucleus thus leading to programmed cell death or apoptosis. Recent work demonstrated a possible involvement of perforin mediated cytotoxicity in immunopathogenesis of psoriasis.

OBJECTIVES

To investigate a difference in systemic (peripheral blood) and local (lesions) expression and distribution of perforin in psoriatic patients with severe and mild disease.

METHODS

Flow cytometry was used for simultaneous detection of intracellular (perforin) and cell surface antigens in peripheral blood lymphocytes. The expression of perforin in skin lesions was evaluated by immunohistochemistry.

RESULTS

Significant increase of perforin expression in T lymphocytes, especially cytotoxic CD8+ cells was found in severe psoriasis compared to mild disease (p<0.01 and p<0.05, respectively). There was also an increase of CD56+P+ NK cells (p<0.05) in severe compared to mild psoriasis. The psoriatic plaque of both, severe and mild disease were abundant with perforin showing no significant difference on local level.

CONCLUSION

Based on our results we suggest the association between perforin expression and disease severity.

Systemische Psoriasistherapie – der nächste Schritt

Adalimumab is the first fully human monoclonal antibody against TNFalpha and has been approved for treatment of rheumatoid arthritis, ankylosing spondylitis and psoriatic arthritis. Its efficacy for both joint and skin involvement has been confirmed in clinical trials. The recommended dose is 40 mg administered every other week subcutaneously. It may be combined with methotrexate and all topical psoriasis treatment modalities. User-friendly administration devices make self-injection possible. Patients should be evaluated for active/latent tuberculosis and serious infections prior to initiation of therapy. Adalimumab rapidly reduces joint symptoms within a few days. Adalimumab is used for the management of adult psoriatic arthritis patients who have had an inadequate response to disease-modifying antirheumatic drugs. Adalimumab is yet another biological for the treatment of psoriasis. Since the TNFalpha antagonists can be switched if one is ineffective, this agent broadens the therapeutic spectrum.

Acceptance of chronic illness in psoriasis vulgaris patients

BACKGROUND

Acceptance of an illness is regarded as a considerable problem in patients with chronic diseases. Lack of acceptance can lead to lower adherence to medical treatment and delayed clinical improvement. Psoriasis, being a chronic skin disease, is known to cause considerable distress to patients.

OBJECTIVES

To examine whether selected demographic factors and personal resources have an impact on acceptance of illness in psoriasis vulgaris patients.

METHODS

Self-reported data on acceptance of illness, self-efficacy, health locus of control, optimism and coping strategies were collected from 100 psoriasis vulgaris inpatients and PASI was calculated by a dermatologist. The following measures were employed: acceptance of illness scale, generalized self-efficacy scale, multidimensional health locus of control scale, life orientation test and mental adjustment to disease scale.

RESULTS

Physical factors such as sex, age, disease duration and severity, and family history of psoriasis had no effect on acceptance of illness. However, based on multiple regression analysis, higher levels of optimism, lower conviction of others' influence on one's health and the less frequently employed coping strategy concentration on emotions, together with more severe disease expressed by PASI, were correlated with higher acceptance of disease in psoriasis patients.

CONCLUSIONS

The results obtained seem to confirm that personal resources play an important role in acceptance of chronic illness. Enhancement of optimism, and minimizing one's conviction that one's health depends on others could lead to higher acceptance of illness.

Impacto de la psoriasis en la calidad de vida relacionada con la salud

BACKGROUND AND OBJECTIVE

Different studies have reported of physical, social and psychological disadvantages in patients with psoriasis. Nevertheless, its impact on the health-related quality of life is not clarified sufficiently. Our objective is to know the repercussion of the moderate-severe psoriasis on the health-related quality of life with the Psoriasis Disability Index (PDI).

PATIENTS AND METHOD

An observational, cross-sectional, international study developed in dermatology practices in Spain and Portugal. During a period of 9 months, 332 participating dermatologist included a minimum of 10 consecutive patients with moderate to severe psoriasis. The date report form includes information about the health-related quality of life (PDI), as well as objective variables of severity as body surface area and PASI (Psoriasis Area and Severity Index), pruritus, costs and willingness to pay.

RESULTS

A total of 3,320 patients were assessed. The majority of cases were males (57%) and the mean age at study inclusion time was 47 years. The mean value of the PDI was 8.93 (95% confidence interval, 7.83-9.21), which represents a percentage of global disability lower than 20%. The floor effect varies between 8.3% and 61.2%, and the ceiling effect varies between 0% and 3%. The correlations between the PDI and objective variables of severity (PASI and body surface area) were weak though statistically significant (p < 0.001) They all indicate that to higher severity of the psoriasis, upper negative impact in the health-related quality of life.

CONCLUSIONS

Psoriasis causes a negative impact in the health-related quality of life, though the magnitudes are weak and suggest some problems with the questionnaire. Possibly, the PDI reflects more the disability that the form in which the patients perceive and react to their state of health, and, several items seem to have a scanty applicability in the Spanish and Portuguese population. The PDI doesn't seem the appropriate instrument for this type of patients in our environment.

Understanding the relationship between objective disease severity, psoriatic symptoms, illness-related stress, health-related quality of life and depressive symptoms in patients with psoriasis - a structural equations modeling approach

OBJECTIVES

The aim of this study was to assess associations between objective disease severity, psoriasis symptoms, illness-related stress (IRS), health-related quality of life (HRQL) and depressive symptoms in patients with psoriasis.

METHOD

Cross-sectional study conducted between January and May 2005. Recruitment of 265 adult patients with psoriasis through Internet advertisements. Analysis of the validity of different measurement models and the fit of hypothesized structural models using a structural equations modeling approach.

RESULTS

Thirty-two percent of the participants screened positive for depression. Because of poor discriminant validity (correlation: 0.919), IRS and HRQL were considered as one factor. The final measurement model had adequate validity and fit. A significant proportion of the variance of depressive symptoms was explained by HRQL (standardized direct effect: 0.916; P<.001). After adjustment for HRQL, objective severity of psoriasis was inversely related to depressive symptoms (standardized direct effect: -0.250; P=.094).

CONCLUSION

In psoriasis - a condition without direct brain involvement - specific disease-related problems in everyday life seem to cause depression in a significant proportion of patients. It is therefore critically important to regularly assess and work to maximize HRQL in psoriasis patients. Patients with high HRQL impairment despite objectively mild psoriasis should be screened for depression.

Need and greed in dermatology: disease and outcome measures in dermatological healthcare planning

Assessing dermatological needs in the population and our ability to meet them is a challenge. The choice of outcome measures is central in dermatological healthcare planning. The concept of ill health and its relationship to dermatological outcome measures is described. Outcome measures used should provide information on these issues in order to gain insight into genuine needs and illness behavior in the population and to ensure quality of healthcare. Nevertheless, the dilemma of assigning priorities in healthcare planning remains; outcome measures in dermatology should be perceived as appropriate by patients as well as by caregivers and policy makers. It is important to stimulate research to develop and refine person-focused outcome measures. Their use is essential to assess dermatological health needs and to understand illness behavior. The information they can provide can enable provision and evaluation of healthcare quality and contribute to the challenge of making appropriate priority decisions in healthcare.

Interleukin 6 and 8 levels in plasma and fibroblast cultures in psoriasis

Fibroblasts have been implicated in psoriatic inflammatory processes. The aim of the study was to evaluate soluble interleukin 2 receptor (sIL-2R), interleukin 6 (IL-6), and interleukin 8 (IL-8) plasma levels in psoriatic patients and IL-6 and IL-8 levels in fibroblast culture supernatants. Cytokines levels in plasma and supernatants were measured by ELISA. Plasma sIL-2R, IL-6, and IL-8 levels were higher before the treatment in comparison to healthy controls (P < 0.001) and decreased after treatment. Fibroblasts from healthy controls, psoriatic lesional skin, and noninvolved psoriatic skin, when stimulated with tumor necrosis factor alpha, released considerable amounts of IL-6 and IL-8. No significant difference between healthy controls and psoriatic fibroblasts was observed. Monitoring plasma sIL-2R levels could be employed as a reliable method of psoriasis activity. IL-8 and IL-6 plasma levels seem to reflect psoriasis activity, and treatment response, respectively. Fibroblasts are not a major source of increased IL-6 and IL-8 production in psoriasis.

Heart Rate and Arrhythmia in Patients with Psoriasis Vulgaris

BACKGROUND

Psoriasis is a chronic inflammatory disease involving 1-3% of the human population worldwide. Many systemic diseases including cardiovascular disturbances have been described in psoriatic patients. However, there is a scarcity of data on heart rate, heart rate variability, arrhythmia and conduction abnormalities in this group of patients.

METHODS

The study comprised 32 patients with chronic psoriasis vulgaris and negative personal history of heart problems. Severity of the disease was evaluated by Psoriasis Area and Severity Index (PASI). Twenty-four-h continuous electrocardiographic monitoring (24-h Holter ECG) was performed in all patients.

RESULTS

Heart rate was significantly higher both during the day and at night in patients with psoriasis vulgaris than in the control group (p < 0.0001). There was a positive correlation between the increased heat rate, both during the day and at night, in psoriatic patients and severity of the disease expressed as PASI. Single supraventricular beats were significantly more frequently observed in psoriatic patients vs. the control group (p < 0.0001).

CONCLUSIONS

An active inflammatory process observed in psoriasis seems to exert its influence on increased heart rate and supraventricular beats development. However, to confirm the above findings, further studies on larger groups of psoriatic patients, presenting different types of the disease are mandatory.

Effectiveness of Inpatient Treatment on Quality of Life and Clinical Disease Severity in Atopic Dermatitis and Psoriasis Vulgaris – A Prospective Study

BACKGROUND

Financial constraints challenge evidence of the effectiveness of dermatological inpatient management.

OBJECTIVE

To evaluate the effectiveness of hospitalization in atopic dermatitis and psoriasis regarding initial and sustained benefits.

METHODS

Prospective study on adults with psoriasis vulgaris (n = 22) and atopic dermatitis (n = 14). At admission, discharge, and 3 months after discharge, validated outcomes of objective and subjective disease severity were assessed by trained investigators.

RESULTS

Hospitalization resulted in substantial benefit in quality of life and clinical disease severity. Looking at mean scores, the observed benefit appeared stable until 3-month follow-up. The analysis of individual patient data revealed significant changes in disease severity between discharge and 3-month follow-up with some patients relapsing, others further improving. Reasons for hospitalization and treatment performed were not related to sustained benefit.

CONCLUSIONS

In psoriasis vulgaris and atopic dermatitis, hospitalization effectively improved quality of life and clinical disease severity. Further research should focus on prognostic factors for sustained improvement.

Echinococcosis: A Possible Etiology in Psoriatic Disease

We aimed to investigate seroprevalence of Echinococcus granulosus in patients with psoriasis to determine a possible etiologic role, since both echinococcosis and psoriasis are defined as T cell-mediated diseases. Forty psoriatic patients and 50 age- and sex-matched control subjects were included in the study. IgG-specific ELISA was used to determine seropositivity. E. granulosus-specific IgG antibodies were found to be positive in 17/40 (42.5%) of the patients with psoriasis and in 11/50 (22%) of the control subjects (p = 0.008). Our results suggest that echinococcosis might be one of the causative pathogens in the etiopathogenesis of psoriasis in highly endemic regions.

Epidemiology of psoriasis. Review and the German perspective

According to population-based European studies, 2-3% of the population are affected by psoriasis. However, commonly accepted and validated diagnostic criteria are lacking. Psoriasis patients, compared to those with other dermatological disorders, are among those who suffer the highest impact on their quality of life, and this affection is comparable to other common diseases. Several lifestyle factors including alcohol and smoking have been associated with psoriasis. There is also evidence for associations with other diseases including cancer. Treatment of psoriasis engenders considerable costs, which should always be taken into account together with the relevant clinical outcome parameters. Prevention of psoriasis is crucial, as in the case of other common chronic diseases where causative treatments are lacking, but has barely been studied.

Skin capacitance mapping of psoriasis

BACKGROUND

The pathobiological dynamics of psoriatic lesions are complex and difficult to perceive by clinical inspection alone. Non-invasive bioengineering methods may prove to be useful in this field.

OBJECTIVE

To identify some subtle capacitance variations in the stratum corneum of chronic psoriasis lesions.

METHOD

The newly developed method of skin capacitance imaging was used to provide non-optical images of the hydration of the superficial layers of the stratum corneum.

RESULTS

Compared to the uninvolved skin, psoriatic lesions usually showed an overall lowered capacitance, admixed with foci of moderately higher capacitance. Still other sharply circumscribed blotches with higher capacitance were present. The latter aspect corresponded to inflammatory areas. Sweating appeared markedly impaired inside the lesions. The fingerprint of some patients was altered, thus potentially interfering with the current biometric security procedures using the same method.

CONCLUSION

Skin capacitance imaging is a non-invasive, non-optical method that distinguishes three contrasting levels of stratum corneum hydration in psoriatic lesions. The lowest capacitance level probably corresponded to xerotic orthokeratosis. The medium capacitance level presumably identified foci of parakeratosis and clumps of neutrophils. The highest capacitance level suggested exsudation at the site of prominent vessel dilation and dermal inflammation. Impaired sweating in the psoriatic lesions may potentially interfere with body thermoregulation.

Work Limitations and Productivity Loss Are Associated with Health-Related Quality of Life but Not with Clinical Severity in Patients with Psoriasis

BACKGROUND

According to current guidelines the cost of productivity loss should be considered in pharmacoeconomic analyses. The cost of health-related productivity loss in psoriasis patients is unknown.

OBJECTIVE

To estimate the cost of productivity loss in psoriasis and its association with health-related quality of life and clinical disease severity.

METHODS

Cross-sectional study, recruitment of adult participants through Internet advertisements. 201 (72.3%) out of 278 eligible participants completed the study. Health-related work productivity loss, quality of life and clinical severity of psoriasis were assessed by standardized instruments.

RESULTS

Indirect costs of productivity loss clearly exceed the total direct cost. In contrast to objective clinical disease severity, health-related quality of life (measured by the Dermatology Life Quality Index) is an independent predictor of work productivity.

CONCLUSIONS

There is good reason to believe that intervention can reduce health-related productivity loss by improving patients' quality of life. Savings from increased work productivity might offset comparatively high acquisition costs of biological agents.

Psoriasis is associated with lipid abnormalities at the onset of skin disease

BACKGROUND

Psoriasis appears to have increased cardiovascular morbidity. The underlying pathogenetic mechanisms remain unclear. Multiple factors, including systemic inflammation, oxidative stress, aberrant lipid profile, and concomitant established risk factors, have been discussed. However, previous studies consist of heterogeneous patient materials, including persons with highly varying disease duration and treatment.

METHODS

Two-hundred patients were investigated at the onset of psoriasis, comparing plasma concentrations of lipids, lipoproteins, and apolipoproteins with those of matched controls (N = 285).

RESULTS

Psoriasis patients manifest significant lipid abnormalities. Specifically, patients had significantly higher cholesterol concentrations in the very-low-density lipoprotein and high-density-lipoprotein fractions. Adjustment for established environmental risk factors did not affect the results.

LIMITATION

The response rate among control subjects was low. However, an additional analysis of a random subset of nonresponders demonstrated no substantial differences in the main results.

CONCLUSION

The study supports the notion that lipid abnormalities in psoriasis may be genetically determined rather than acquired.

Low Levels of Emotional Awareness Predict a Better Response to Dermatological Treatment in Patients with Psoriasis

BACKGROUND

Personality and emotional factors are thought to influence the onset of psoriasis, the occurrence of relapses, and the sensitivity of this condition to dermatological treatments.

OBJECTIVE

To explore the relationships between emotional disorders and emotional information processing in the one hand, and psoriasis severity and response to treatment on the other.

METHODS

We recruited 93 patients through an article in the local press. These patients attended three consultations. We evaluated psoriasis severity by Psoriasis Area and Severity Index (PASI) score and response to treatment by change in PASI score from baseline to the 3-month visit. We screened for comorbid mental disorders, using the Mini International Neuropsychiatric Interview. We used the Hospital Anxiety and Depression Scale to assess anxiety and depressive symptoms. Alexithymia (difficulty in identifying and expressing emotions) was evaluated with the 26-item version of the Toronto Alexithymia Scale (TAS-26) and the ability to integrate and differentiate emotions (emotional awareness) was assessed with the Lane and Schwartz Levels of Emotional Awareness Scale (LEAS).

RESULTS

Forty patients presented at least one psychiatric diagnosis and 33 were considered alexithymic (TAS > or =73). No psychological score was associated with baseline PASI score, which was higher in men and positively correlated with disease duration. Patients who considered their disease to be stress-reactive tended to have lower LEAS scores (p = 0.052). At the 3-month visit, PASI scores had significantly improved in the subset of patients (n = 67) presenting severe psoriasis at inclusion (PASI >2); emotional awareness and anxiety scores had also improved in these patients (p < 0.001), but dermatological and psychological changes were not statistically related. Dermatological improvement at 3 months with respect to baseline PASI was predicted by longer disease duration (>20 years) and lower baseline LEAS score (p = 0.044 and p = 0.021, respectively).

CONCLUSION

This study demonstrates the value of assessing the ability of patients with psoriasis to process emotional information, as defined by emotional awareness. Patients with low LEAS scores appear to be more reactive to stress, but also to be more responsive to treatment, suggesting the activation of a particular stress physiology by negative affective states that are not experienced.

Peptidoglycan recognition proteins Pglyrp3 and Pglyrp4 are encoded from the epidermal differentiation complex and are candidate genes for the Psors4 locus on chromosome 1q21

Psoriasis is a common inflammatory skin disease caused by genetic and environmental factors, including bacterial and viral infections. Since the skin is in constant contact with commensal and pathogenic microorganisms, we examined well-supported psoriasis genetic linkage intervals to identify genes encoding innate immune pattern recognition proteins that may play a role in pathogenesis. Two peptidoglycan recognition proteins, Pglyrp3 and Pglyrp4, are localized to the Psors4 locus on chromosome 1q21 in a gene cluster known as the epidermal differentiation complex (EDC). We show that these genes are expressed in the skin as well as in germinal centers in the tonsil. We tested 13 SNPs in or near these genes for association with psoriasis in two independent patient collections: a family-based patient set comprised of 375 individuals from 101 families, and a case-control patient collection of 282 patients with moderate to severe psoriasis and 192 healthy controls. In the family-based analysis, several SNPs in the Pglyrp3-Pglyrp4 locus show association with psoriasis (0.01 < P < 0.05). Multiple-SNP haplotypes incorporating Pglyrp3 and Pglyrp4 SNPs also show significant association in the transmission disequilibrium test (TDT; P < 0.01). In the case-control test, none of the SNPs that we tested show association with psoriasis when analyzed in single-SNP or haplotype-based tests. The discordance between the TDT and case-control results suggests that the two populations are significantly different in disease etiology, that the polymorphism responsible for the Psors4 linkage is elsewhere in the Pglyrp locus, or that the causative Psors4 polymorphism is in a location near but not in the Pglyrp locus. These data are consistent with previous reports of association of psoriasis with genes on 1q21, and suggest a role for Pglyrps in skin biology.

Etanercept

Etanercept, an inhibitor of TNF alpha, has been found effective in the treatment of psoriatic arthritis and psoriasis vulgaris. Etanercept is a fusion protein made up of domains of the soluble, fully human p75-TNF alpha receptor and the F(c) portion of human IgG(1). The drug is a protein which must be administered subcutaneously. Several controlled studies have highlighted its efficacy for both skin symptoms and joint involvement. The usual dose is 25 mg s.c. twice weekly. Higher dosages of 50 mg twice weekly may be used in severe cases. Before starting the therapy with etanercept, infections including tuberculosis have to be excluded. Methotrexate and other pharmacological immunosuppressive agents can be combined with etanercept, as can all standard topical agents. Etanercept in off-label use has been found to also be useful in several other inflammatory dermatologic conditions. If patients are carefully monitored, etanercept is generally well-tolerated and has a good safety profile. The development of novel biologic agents such as etanercept is one of the most important therapeutic innovations of recent years.