The importance of disease associations and concomitant therapy for the long-term management of psoriasis patients

Qinzhu Liangxue inhibits IL-6-induced hyperproliferation and inflammation in HaCaT cells by regulating METTL14/SOCS3/STAT3 axis

ETHNOPHARMACOLOGICAL RELEVANCE

Psoriasis, an immune-mediated chronic inflammatory skin condition, is treatable with Qinzhu Liangxue (QZLX), a therapeutic medicinal plant formula used in clinical practice. However, further investigation is needed to clarify its molecular mechanisms of action.

AIM OF THE STUDY

The potential biological mechanisms of QZLX to alleviate psoriasis involving IL-6-induced hyperproliferation and inflammation by regulating METTL14/SOCS3/STAT3 axis.

MATERIALS AND METHODS

HaCaT cell model was induced by IL-6, and dealt with serum containing QZLX. In addition, shRNAs and siRNAs were used for gene silencing, viruses were collected 48 h post-transfection and infected HaCaT cells. Cell viability was detected by CCK-8 assay, cell cycle was determined by flow cytometry. Finally, psoriasis mice model was induced by IMQ cream, then back skin tissue was used for hematoxylin and eosin (H&E). The content of IL-1β, IL-6, and IL-8 in cell supernatants were analyzed using ELISA kits. Analysis of SOCS3 was used by quantitative RT-PCR, the expression level of SOCS3, METTL3, METTL14, WTAP, SOCS3, YTHDF2, p-STAT3 and STAT3 in HaCaT cells transduced with METTL14 overexpression was detected by Western blot.

RESULTS

All results indicated that QZLX could significantly alleviate IL-6-induced HaCaT cell viability, cell cycle progression, and inhibit the level of IL-1β, IL-6, and IL-8. The m6A levels and level of METTL14 in HaCaT cells treated with IL-6 were enhanced, while it was reversed by QZLX. METTL14 silencing could inhibit IL-6-induced HaCaT cell viability, cell cycle progression and inflammation response, while SOCS3 overexpression also suppressed METTL14-induced HaCaT cell viability, cell cycle progression and inflammation. QZLX could significantly enhance the expression level of SOCS3, while inhibit the level of METTL14, and p-STAT3/STAT3. In addition, QZLX inhibits METTL14-induced HaCaT cell viability, cell cycle progression, and inhibits the level of IL-1β, IL-6, and IL-8.

CONCLUSIONS

Our finding suggested that QZLX ameliorated the inflammation response of psoriasis and performed the potential anti-psoriasis effect by regulating METTL14/SOCS3/STAT3 axis in both mice and HaCaT cells psoriasis model. Therefore, our study demonstrated a significant strategy for inhibiting psoriasis inflammation via targeting METTL14/SOCS3/STAT3 axis.

Design, Synthesis, and Biological Evaluation of an Orally Bioavailable, Potent, and Selective ROCK2 Inhibitor for Psoriasis Treatment

Psoriasis, a prevalent chronic skin disorder, remains a significant therapeutic obstacle. This study centers on rho-associated coiled-coil-containing kinase2 (ROCK2) as an advantageous target for treating psoriasis and identifies five potent and selective ROCK2 inhibitors (A31-35). Notably, A32-35 outperform KD025 in ROCK2/ROCK1 selectivity by up to 216-fold. Among these candidates, A31 emerged as an exceedingly promising molecule, showcasing remarkable inhibitory potency (IC50 = 3.7 ± 0.8 nM), 19-fold ROCK2/ROCK1 selectivity, and favorable pharmacokinetics. Insights from the binding mode study further underscored the pivotal role of interactions with Phe103 on the P-loop in determining the selectivity between ROCK1 and ROCK2. In an imiquimod-induced psoriasis-like mouse model, oral administration of A31 notably ameliorated symptoms by targeting the IL-23/Th17 axis. Based on these compelling findings, A31 was selected as a highly promising compound for further investigation as a potential treatment for psoriasis.

Economic Evaluation of Selected Interleukin Inhibitors Versus Methotrexate for Moderate-to-Severe Plaque Psoriasis From the Philippine Payer Perspective

OBJECTIVES

We conducted an economic evaluation of interleukin inhibitors (ILIs) guselkumab, ixekizumab (IXE), secukinumab (SEC), and ustekinumab to a methotrexate (MTX) comparator for biologic-naive adult Filipino patients with moderate-to-severe chronic plaque psoriasis.

METHODS

A 1-year decision tree and 5-year Markov model were used to estimate incremental cost-effectiveness ratios (ICERs) in Philippine pesos (PHP) per Psoriasis Area Severity Index improvement of at least 75%. For health technology assessment purposes, we also estimated the budget impact of subsidies for SEC to a Government of the Philippines (GoP) payer. Deterministic and probabilistic sensitivity analyses were performed. Data sources included global literature and local intervention prices.

RESULTS

All ILIs were more effective but also more expensive than MTX. In the base case, only IXE and SEC were cost-effective treatments at a gross domestic product-benchmarked threshold, yielding ICERs of PHP468 098.01 and PHP483 525.32 per PASI responder, respectively. GUS and UST were less likely to be cost-effective throughout a range of simulated thresholds. ICERs were most responsive to discontinuation rates and drug prices. Full subsidy of SEC for 5 years would cost the GoP PHP1.83 billion more than a similar subsidy for MTX.

CONCLUSIONS

ILIs were clearly more effective than MTX, but only IXE and SEC were potentially cost-effective for a GoP payer. Any case in which SEC is fully subsidized is more expensive to the GoP than the base case. This study was limited by a lack of country-specific effectiveness data, underestimation of comparator costs, exclusion of noncutaneous and quality-of-life effects, and indirect costs.

Topical Diacerein Decreases Skin and Splenic CD11c+ Dendritic Cells in Psoriasis

Psoriasis is an inflammatory skin disease characterized by increased neo-vascularization, keratinocyte hyperproliferation, a pro-inflammatory cytokine milieu and immune cell infiltration. Diacerein is an anti-inflammatory drug, modulating immune cell functions, including expression and production of cytokines, in different inflammatory conditions. Therefore, we hypothesized that topical diacerein has beneficial effects on the course of psoriasis. The current study aimed to evaluate the effect of topical diacerein on imiquimod (IMQ)-induced psoriasis in C57BL/6 mice. Topical diacerein was observed to be safe without any adverse side effects in healthy or psoriatic animals. Our results demonstrated that diacerein significantly alleviated the psoriasiform-like skin inflammation over a 7-day period. Furthermore, diacerein significantly diminished the psoriasis-associated splenomegaly, indicating a systemic effect of the drug. Remarkably, we observed significantly reduced infiltration of CD11c⁺ dendritic cells (DCs) into the skin and spleen of psoriatic mice with diacerein treatment. As CD11c⁺ DCs play a pivotal role in psoriasis pathology, we consider diacerein to be a promising novel therapeutic candidate for psoriasis.

'Transfersome-embedded-gel' for dual-mechanistic delivery of anti-psoriatic drugs to dermal lymphocytes

AIM

Develop a platform for co-delivering clobetasol propionate (CP) and cyclosporine (CyA) to the epidermis and dermis to treat psoriasis.

METHODS

The transfersomes were prepared by thin-film hydration method. Transfersomes were characterised by dynamic light scattering and transmission electron microscope (TEM). Then, the gel stability, viscosity, pH, and spreadability were measured. Cytotoxicity of the CyA-loaded transfersome embedded in CP-dispersed gel (TEG-CyA-CP) was assessed on both human keratinocyte cell line (HaCaT) and Jurkat cells. In vitro cellular uptake and ex vivo dermal distribution was measured. The expression of inflammatory markers was assessed by reverse-transcription PCR (RT-PCR).

RESULTS

Nanoscale (<150 nm) transferosomes with high CyA encapsulation efficiency (>86%) were made. TEG-CyA-CP demonstrated higher viscosity (4808.8 ± 12.01 mPas), which may help control dual drug release. Ex vivo results showed TEG-CyA-CP ability to deliver CyA in the dermis and CP in the epidermis. RT-PCR studies showed the optimised formulation helps reduce the tumour necrosis factor (TNF-α) and interleukin-1 (IL-1) levels to relieve psoriasis symptoms.

CONCLUSION

The developed TEG-CyA-CP represents a promising fit-to-purpose delivery platform for the dual-site co-delivery of CyA and CP in treating psoriasis.

Drug-Drug Interactions in Patients with COVID-19: A Retrospective Study at a Tertiary Care Hospital in Eastern India

Introduction: Concomitant atrial fibrillation (AF) in non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients complicates the decision-making process regarding short- and long-term antithrombotic strategies. Patient profiles and usage rates of different antithrombotic combinations in this patient subgroup in Romania are poorly described. Introduction: Coronavirus disease 2019 (COVID-19) is an emerging viral infection without any approved treatment. Investigational therapies for COVID-19 may cause clinically important drug-drug interactions (DDIs). We aimed to study drug-drug interactions (DDIs) and their risk factors in hospitalised COVID-19 patients. Methods: We conducted a retrospective study in a tertiary care hospital dedicated to COVID-19 patients. The Lexi-Interact database was used to investigate clinically important DDIs. The database output, including interacting drug pairs, risk rating, reliability rating, mechanism, and management, was evaluated. Results: Medical records of 200 COVID-19 patients were analysed. All patients had at least one clinically important DDI. More than half of interactions were associated with hydroxychloroquine and azithromycin, the most commonly prescribed medications for the management of COVID-19. Concomitant drugs for comorbid conditions leading to polypharmacy were significantly associated with the occurrence of this. Conclusion: There is a higher chance of DDI, which necessitates ongoing care evaluation and therapy adjustment. Drugs used to treat COVID-19 should be carefully selected.

Psoriasis is Associated with a High Comedication Burden: A Population Based Register Study

Introduction

A large body of evidence supports the association between psoriasis and concomitant diseases. However, the study of comedication for these diseases in patients with psoriasis is limited. The current study aimed to investigate the prescription and drug dispensation for comorbidity associated with psoriasis.

Methods

We conducted a retrospective case-control study from 9 April 2008 until 1 January 2016 using an electronic medical records database covering the entire population of the County of Jönköping and the Swedish Prescribed Drug Register. ICD-10 and Anatomical Therapeutic Chemical codes were used to identify patients with psoriasis and dispensed pharmaceutical prescriptions. Individuals without psoriasis were selected as controls. Patients receiving systemic treatment for psoriasis were considered as having moderate-severe psoriasis. Odds ratios for being dispensed pharmaceutical prescriptions and differences in mean number of dispensed prescriptions were explored.

Results

A total of 4587 patients with psoriasis were identified in the medical records, and 268,949 individuals served as controls. Patients with psoriasis had a significantly higher number of different drug dispensations compared to controls. Only 1.3% of all patients with psoriasis were without any prescription (excluding medication for psoriasis) during the study period while the number in the general population was 9.3%. Sex- and age-adjusted odds ratios for dispensation of drug groups related to comorbid disease were significantly higher among patients with psoriasis including drug groups such as anxiolytics and sedatives as well as drugs targeting COPD, migraine and erectile dysfunction. The most frequently dispensed comedications were oral antibiotics and analgesics including an increased risk for dispensation of opioids. Sex predisposed dispensation frequency for a variety of drug groups. Drugs targeting obesity, osteoporosis, psychiatric disease and anti-mycotics/-fungals were more frequent among women.

Conclusion

Patients with psoriasis have significantly increased numbers of different dispensed prescriptions than those without psoriasis. This underlines previous findings on increased comorbidity and health care costs for patients with psoriasis.

Electronic supplementary material

The online version of this article (10.1007/s13555-020-00442-3) contains supplementary material, which is available to authorized users.

Chronic toxicity of low dose monosodium glutamate in albino Wistar rats

OBJECTIVE

The objective of this study was to observe the effects of chronic dosing with monosodium glutamate on mortality, fertility, major organ functions and histology in albino Wistar rats.

RESULTS

6 male and 6 female rats (age 6 weeks) were bred in a cage, feeding on standard growers' mash, with monosodium glutamate added (120 mg/kg/day). 12 corresponding breeding rats (on standard feed without MSG) were controls. Chronic dosing with monosodium glutamate in albino Wistar rats (at a dose consistent with the human ADI) led to increased mortality, fertility impairment, and significant changes in major organ function tests and histology. 23 deaths were recorded in the rats fed with MSG additive, while mortality was zero in the control animals. Fertility was lower in rats on MSG (48 births) than in controls (117 births). The weight gain of the MSG rats was higher than in controls. Biochemical parameters and organ histology remained normal in control animals. In MSG-treated rats however, liver/renal function tests, fasting serum cholesterol and triglyceride, serum uric acid showed a significant rise at trimestrial time-points. Histology showed mild portal inflammation in MSG rats, with periglomerular fibrosis and interstitial nephritis in two rats, at 6-12 months.

Metabolic syndrome and psoriatic arthritis among patients with psoriasis vulgaris: Quality of life and prevalence

Interest has increased in comorbidities associated with psoriasis and their effects on health-related quality of life (HRQoL). This study aimed to evaluate the prevalence of metabolic syndrome (MetS) and psoriatic arthritis (PsA) and to investigate HRQoL and the prevalence of hypertension, type 2 diabetes mellitus (T2DM), obesity and dyslipidemia. In a cross-sectional design, patients diagnosed with plaque psoriasis answered an interview and standardized questionnaires (Dermatology Life Quality Index questionnaire [DLQI], 36-Item Short Form Health Survey [SF-36] and EuroQol Five-Dimension Questionnaire Three-Level version [EQ-5D-3L]). Physical examination and several tests to assess desired outcomes were performed by a dermatologist and a rheumatologist during three visits. The prevalence of MetS and PsA was 50.0% and 41.8%, respectively. Dyslipidemia was the most prevalent (74.5%) secondary comorbidity, followed by hypertension (61.8%), obesity (52.5%) and T2DM (30.9%). The mean (standard deviation) DLQI score was 6.5 (6.9), and mean physical and mental SF-36 measures were 45.2 (10.4) and 45.5 (12.3), respectively, and for EQ-5D-3L, mean utility index and EQ-VAS scores were 0.68 (0.27) and 72.7 (19.7), respectively. PsA and MetS are important comorbidities; a reduced HRQoL is noted among plaque psoriasis patients with these comorbidities, emphasizing the relevance of diagnosis and treatment beyond the care of skin lesions.

Psoriasis as a cardiovascular risk factor: updates and algorithmic approach

Although psoriasis is predominantly a chronic inflammatory skin disorder, it has been known to be associated with cardiovascular disease. Patients with psoriasis, particularly with moderate to severe forms, present an increased rate of cardiovascular mortality, myocardial infarction and stroke. However the pathophysiology of the relationship between psoriasis and cardiovascular risk and comorbidities has not yet completely known. Chronic inflammation may be considered a solid link between psoriasis and related cardiovascular events. Several cytokines and inflammatory cells play a pivotal role in the development of psoriatic lesions, resulting in angiogenesis and endothelial dysfunction. Furthermore, the imbalance between oxidative stress and antioxidant mechanisms in psoriatic patients may contribute to explain the pathogenesis of increased reactive oxygen species and the formation of atherosclerotic plaque. Other mechanistic pathways which may be involved in this relationship include cardiovascular effects of medications, a common genetic background and a higher prevalence of cardiovascular risk factors, which are often under-diagnosed and under-treated in psoriatic patients. Indeed, the early detection of specific markers of cardiovascular impairment, such as N-terminal pro B-type natriuretic peptide, homocysteine and YKL-40, may enable psoriatic patients at higher cardiovascular risk to be identified as soon as possible. This review examines the increased cardiovascular risk profile and high prevalence of cardiovascular disease associated with psoriasis, focusing on pathogenic links between psoriasis and atherosclerosis, serological markers of cardiovascular involvement and the implications of antipsoriatic therapies on cardiovascular risk and proposes a flow chart, that every dermatologist should follow to screen psoriatic patients.

Psychosocial Distress of Patients with Psoriasis: Protocol for an Assessment of Care Needs and the Development of a Supportive Intervention

BACKGROUND

Psoriasis is a chronic inflammatory disease that is often associated with a number of somatic and mental comorbidity. Patients with psoriasis show an increased risk of depression and (social) anxiety.

OBJECTIVE

The aims of this study are 1) to explore the psychosocial distress of patients with psoriasis and to assess their care needs; and 2) to develop a supportive intervention based on the prior results.

METHODS

A multi-stage design with four phases combining quantitative and qualitative methodology will be used and conducted in two centers. 1) A scoping review and focus groups will be used to design a questionnaire to assess the psychosocial distress and care needs of the patients. 2) The questionnaire developed in phase 1 will be used in a cross-sectional survey to assess the extent of psychosocial distress and supportive care needs in 400 patients with psoriasis. 3) A systematic review and meta-analysis will be conducted to identify psychosocial and psychoeducational interventions for patients with psoriasis and to describe their effectiveness. 4) Based on the results of the phases 2 and 3 a manualized supportive intervention will be developed and the feasibility and acceptance of the intervention will be assessed.

RESULTS

Currently, phase 1 of the project has been completed and the recruitment for phase 2 has been started. The systematic review and meta-analysis of phase 3 are conducted simultaneously to phase 2 and results are expected soon. Phase 4 has not been started yet.

CONCLUSIONS

The expected results of this study will show the extent of psychosocial distress of patients with psoriasis in Germany and supplement previous research with findings about the supportive care needs of this patient group. Moreover, the developed intervention will help to address the psychosocial support needs of patients with psoriasis. Research shows that psychosocial support is strongly needed.

Risk of periodontitis in patients with psoriasis and psoriatic arthritis

BACKGROUND

Psoriasis and periodontitis are chronic inflammatory disorders with overlapping inflammatory pathways, but data on risk of periodontitis in psoriasis are scarce and a possible pathogenic link is poorly understood.

OBJECTIVE

We investigated the association between psoriasis and periodontitis in a nationwide cohort study.

METHODS

All Danish individuals aged ≥18 years between 1 January 1997 and 31 December 2011 (n = 5,470,428), including 54 210 and 6988 patients with mild and severe psoriasis, and 6428 with psoriatic arthritis, were linked through administrative registers. Incidence rate ratios (IRRs) were estimated by Poisson regression.

RESULTS

Incidence rates of periodontitis per 10 000 person-years were 3.07 (3.03-3.12), 5.89 (1.07-6.84), 8.27 (5.50-12.45) and 11.12 (7.87-15.73) for the reference population, mild psoriasis, severe psoriasis and psoriatic arthritis respectively. Adjusted IRRs were (1.66; 1.43-1.94) for mild psoriasis, (2.24; 1.46-3.44) for severe psoriasis and (3.48; 2.46-4.92) for psoriatic arthritis. Similar results were found when a case-control design was applied.

CONCLUSIONS

We found a significant psoriasis-associated increased risk of periodontitis, which was highest in patients with severe psoriasis and psoriatic arthritis.

More Biologic Therapies Expected To Treat Advanced Plaque Psoriasis

Psoriasis, a disorder that manifests as a variety of chronic inflammatory skin diseases, affects an estimated 7.4 million Americans. We consider five promising biologic agents poised to enter the psoriasis market for advanced disease by 2019.

Psoriasis: classical and emerging comorbidities

Psoriasis is a chronic inflammatory systemic disease. Evidence shows an association of psoriasis with arthritis, depression, inflammatory bowel disease and cardiovascular diseases. Recently, several other comorbid conditions have been proposed as related to the chronic inflammatory status of psoriasis. The understanding of these conditions and their treatments will certainly lead to better management of the disease. The present article aims to synthesize the knowledge in the literature about the classical and emerging comorbidities related to psoriasis.

Epidemiology and Comorbidity in Children with Psoriasis and Atopic Eczema

BACKGROUND

First studies have shown that juvenile psoriasis is associated with an increased prevalence of comorbidity.

OBJECTIVES

We carried out a data analysis to characterise the profiles of comorbidity in children with psoriasis and atopic eczema.

METHODS

Prevalence data were derived from the database of a German statutory health insurance company according to ICD-10 codes L40 (psoriasis) and L20 (atopic eczema) of children up to 18 years insured in 2009.

RESULTS

Data sets included 1.64 million persons and 293,181 children. 1,313 children = 0.45% (0.42-0.47) had a diagnosis of psoriasis and 30,354 = 10.35% (10.24-10.47) had a diagnosis of atopic eczema. Obesity, hyperlipidaemia, arterial hypertension and diabetes were more often diagnosed in children with psoriasis in comparison to all children without psoriasis and to those with atopic eczema.

CONCLUSION

Children with psoriasis and atopic eczema show different and specific patterns of comorbidity which should be detected early and treated adequately.

Systemic treatment with fumaric acid esters in six paediatric patients with psoriasis in a psoriasis centre

BACKGROUND

Psoriasis is one of the most common inflammatory skin disorders. There are only limited data on systemic treatment in children.

OBJECTIVE

To assess the safety and clinical efficacy of the treatment of six paediatric patients with fumaric acid esters (FAE, Fumaderm) for psoriasis.

METHODS

Six patients aged 6-17 years were treated with FAE. Patients underwent regular assessment. Treatment efficacy was evaluated using the Psoriasis Area and Severity Index (PASI) and body surface area (BSA).

RESULTS

The mean duration of treatment was 17.8 months. PASI and BSA were determined after 12 weeks. All patients showed improvement in their skin condition, two achieving PASI75, one PASI90 and three PASI100 response. Proteinuria was encountered in one patient and two patients suffered from gastrointestinal discomfort. Treatment was discontinued due to remission in two patients.

CONCLUSION

Treatment with FAE in paediatric patients is a valuable alternative option when systemic treatment is needed.

Psoriasis: to treat or to manage?

The recognition of psoriasis as a systemic disorder with characteristic skin symptoms and associated diseases has changed treatment concepts substantially. The complexity of psoriasis disease not only requires appropriate therapy but also weight-loss and smoking cessation programmes as well as trigger factor elimination. The term 'management' may better reflect the aim for a holistic approach of disease control. Comorbidity and the presence of psoriatic arthritis are important denominators for drug selection. However, there is a lack of prospective data substantiating a benefit of associated diseases by antipsoriatic therapy. Securing success using treatment goals helps to establish an efficacious therapy and to control inflammation. A regular scoring of disease severity, patients' quality of life and assessment of other clinically relevant conditions are mandatory to closely follow the disease course. There is debate whether an early treatment may modulate the future course of psoriasis. Concepts of minimal disease activity have not been implemented in psoriasis yet. There is a lack of evidence how long any treatment should be given and when and how to terminate. Finally, outcome tools should specifically be tailored for psoriasis to evaluate disease-related items as well as the benefit of management from the patient's perspective.

Drug therapies in dermatology

This article explores the current and emerging therapies for skin disease, with a particular focus on chronic plaque psoriasis and metastatic malignant melanoma. We discuss the current biological therapies used for psoriasis and those on the horizon, including small molecules and biosimilars. We also summarise the recent advances in the use of novel therapeutic agents in other dermatological diseases and outline the promise of translational research and stratified medicine approaches in dermatology. Better matching of patients with therapies is anticipated to have a major effect on both clinical practice and the development of new drugs and diagnostics.

Health-related quality of life worsens disproportionately to objective signs of psoriasis after withdrawal of adalimumab therapy

Introduction

Health-related quality of life (HRQoL) is an important part of the clinical assessment and management of psoriasis. Few studies have investigated the effects of withdrawing treatment on the relationship between HRQoL and objective clinical manifestations of psoriasis. This post hoc subanalysis of a clinical trial (REVEAL) examined the relationship of HRQoL [assessed with the Dermatology Life Quality Index (DLQI)] and objective disease activity [assessed with the Psoriasis Area and Severity Index (PASI)] among patients before and after they underwent protocol-mandated discontinuation of psoriasis therapy.

Methods

Adult patients with moderate-to-severe plaque psoriasis who received adalimumab from baseline and had 75% or greater improvement in the PASI score at weeks 16 and 33 were re-randomized to adalimumab 40 mg or placebo every other week from weeks 33 to 52. DLQI and PASI scores were compared at baseline (week 0), early in treatment (week 4), directly before randomized withdrawal (week 33), and up to 19 weeks after treatment discontinuation (week 52; last observations carried forward). Correlations between DLQI total score and PASI score at week 4 and week 52 were modeled by linear regression.

Results

In the patients (N = 240) who underwent protocol-mandated discontinuation of psoriasis treatment after achieving PASI 75 response, mean PASI scores at week 52 were lower (i.e., better) compared with week 4, yet mean DLQI scores were higher (i.e., worse). An approximately twofold disproportionately greater degree of worsening of DLQI score compared with the degree of worsening of PASI was observed while patients underwent discontinuation of therapy (week 52) compared with early in treatment (week 4). There was a significant interaction (P < 0.0001) between the PASI–DLQI correlation and study period (week 4 or 52).

Conclusion

Discontinuing therapy in patients who initially responded to treatment, as seen in this analysis with adalimumab, disproportionately worsened patient-reported HRQoL relative to the worsening of PASI.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-014-0043-4) contains supplementary material, which is available to authorized users.

S3 - Guidelines on the treatment of psoriasis vulgaris (English version). Update

Psoriasis vulgaris is a common and often chronic inflammatory skin disease. The incidence of psoriasis in Western industrialized countries ranges from 1.5% to 2%. Patients afflicted with severe psoriasis vulgaris may experience a significant reduction in quality of life. Despite the large variety of treatment options available, surveys have shown that patients still do not received optimal treatments. To optimize the treatment of psoriasis in Germany, the Deutsche Dermatologi sche Gesellschaft (DDG) and the Berufsverband Deutscher Dermatologen (BVDD) have initiated a project to develop evidence-based guidelines for the management of psoriasis. They were first published in 2006 and updated in 2011. The Guidelines focus on induction therapy in cases of mild, moderate and severe plaque-type psoriasis in adults including systemic therapy, UV therapy and topical therapies. The therapeutic recommendations were developed based on the results of a systematic literature search and were finalized during a consensus meeting using structured consensus methods (nominal group process).

Evaluating practice patterns for managing moderate to severe plaque psoriasis: role of the family physician

OBJECTIVE

To describe practice patterns for care of Canadian patients with moderate to severe plaque psoriasis.

DESIGN

Online survey of a consumer panel.

SETTING

Participants were drawn from a population-wide Canadian consumer database.

PARTICIPANTS

To be eligible to participate, respondents had to have been diagnosed with plaque psoriasis within the past 5 years, and to have had body surface area involvement of 3% or greater in the past 5 years, or to have psoriasis on a sensitive area of the body (hands, feet, scalp, face, or genitals), or to be currently receiving treatment with systemic agents or phototherapy for psoriasis.

MAIN OUTCOME MEASURES

Proportion of respondents with psoriasis managed by FPs and other specialists, psoriasis therapies, comorbidities, and patient satisfaction.

RESULTS

Invitations were sent to 3845 panelists with self-reported psoriasis, of which 514 qualified to complete the survey. Family physicians were reported to be the primary providers for diagnosis and ongoing care of psoriasis in all provinces except Quebec. Overall physician care was reported to be satisfactory by 62% of respondents. Most respondents receiving over-the-counter therapies (55%) or prescribed topical therapies (61%) reported that their psoriasis was managed by FPs. Respondents receiving prescription oral or injectable medications or phototherapy were mainly managed by dermatologists (42%, 74%, and 71% of respondents, respectively). Ongoing management of respondents with body surface area involvement of 10% or greater was mainly split between dermatologists (47%) and FPs (45%), compared with rheumatologists (4%) or other health care professionals (4%). Of those respondents receiving medications for concomitant health conditions, treatment for high blood pressure was most common (92%), followed by treatment for heart disease (75%) and elevated cholesterol and lipid levels (68%).

CONCLUSION

Patient-reported practice patterns for the diagnosis and management of moderate to severe psoriasis vary among provinces and in primary and secondary care settings.

Ustekinumab biotherapy and real-time psoriasis capacitance mapping: a pilot study

In recent years, the treatment of moderate to severe psoriasis has benefited from the development of targeted biologicals. Assessing this new class of drugs calls for precise modalities of severity/improvement ratings of the disease. Bioengineering-driven dermometrology aims at improving objective and quantitative assessments of disease severity and treatment efficacy. Skin capacitance mapping/imaging is one of those emerging methods. Among its clinical applications, psoriasis capacitance mapping (PCM) was introduced in order to assess both skin scaliness and water trapping inside the stratum corneum (inflammatory serum deposits) on lesional skin. PCM was used for assessing the therapeutic effects of ustekinumab on target lesions of 5 psoriatic patients. The reduction in the inflammatory dampness of the stratum corneum was conveniently seen after a 1-month ustekinumab treatment. The present pilot study suggests that PCM could be used as a fast and convenient method for assessing the anti-inflammatory efficacy of ustekinumab and other biotherapies.

Management of psoriasis in Africa and the Middle East: a review of current opinion, practice and opportunities for improvement

Psoriasis is a common, chronic, systemic, inflammatory disease of the skin that is often associated with inflammatory musculoskeletal disease. Psoriasis impacts on affected individuals and on society at many levels, being associated with considerable economic burden and impaired quality of life. This article aims to provide dermatologists and their allied healthcare professionals, particularly those practicing in Africa and the Middle East, with a review of the current understanding of psoriasis, its treatment and impact, as a backdrop for further discussion of the management of psoriasis in these regions. Insight into the real-life, day-to-day challenges and unmet needs currently facing dermatologists in Africa and the Middle East is provided by the authors, most of whom are experienced dermatologists practicing in this region.

Evaluation of reliability, validity, and responsiveness of the CDASI and the CAT-BM

To properly evaluate therapies for cutaneous dermatomyositis (DM), it is essential to administer an outcome instrument that is reliable, valid, and responsive to clinical change, particularly when measuring disease activity. The purpose of this study was to compare two skin severity DM outcome measures, the Cutaneous Disease and Activity Severity Index (CDASI) and the Cutaneous Assessment Tool-Binary Method (CAT-BM), with the Physician Global Assessment (PGA) as the "gold standard". Ten dermatologists evaluated 14 patients with DM using the CDASI, CAT-BM, and PGA scales. Inter- and intra-rater reliability, validity, responsiveness, and completion time were compared for each outcome instrument. Responsiveness was assessed from a different study population, where one physician evaluated 35 patients with 110 visits. The CDASI was found to have a higher inter- and intra-rater reliability. Regarding construct validity, both the CDASI and the CAT-BM were significant predictors of the PGA scales. The CDASI had the best responsiveness among the three outcome instruments examined. The CDASI had a statistically longer completion time than the CAT-BM by about 1.5 minutes. The small patient population may limit the external validity of the findings observed. The CDASI is a better clinical tool to assess skin severity in DM.

Serum paraoxonase-1 activities and oxidative status in patients with plaque-type psoriasis with/without metabolic syndrome

OBJECTIVE

Psoriasis is a chronic immune-mediated inflammatory skin disease associated with metabolic syndrome, which is made up of a cluster of disorders, including obesity, diabetes mellitus, dyslipidemia, and cardiovascular disease. The aim of this study was to investigate serum paraoxonase-1 activities and oxidative status parameters in patients with plaque-type psoriasis with or without metabolic syndrome.

METHODS

In this study, patients with plaque-type psoriasis with (n=25) or without (n=27) metabolic syndrome, according to the criteria of the International Diabetes Federation (IDF), were matched for age and sex to an equally sized control group (n=25).

RESULTS

In patients without metabolic syndrome, serum paraoxonase and arylesterase activities showed mean decreases of 29 and 6%, respectively, whereas in patients with metabolic syndrome, the mean decreases in the enzymes' activities were 35 and 11%, respectively, compared with those in the control group. Serum total antioxidant capacity and total oxidant status were not statistically significant in any of the three groups. Multiple linear regression analysis revealed that HDL cholesterol and log-transformed triglyceride were independent variables for serum arylesterase activity and that fasting glucose and diastolic blood pressure were independent variables for serum paraoxonase activity.

CONCLUSIONS

These results suggest that according to the criteria of the IDF, the significant decrease observed in serum paraoxonase activity was independent of the metabolic syndrome in patients with mild-to-moderate plaque-type psoriasis, whereas the significant decrease in serum arylesterase activity was associated with the metabolic syndrome.

Peptidoglycan recognition protein Pglyrp2 protects mice from psoriasis-like skin inflammation by promoting regulatory T cells and limiting Th17 responses

Skin protects the body from the environment and is an important component of the innate and adaptive immune systems. Psoriasis is a frequent inflammatory skin disease of unknown cause determined by multigenic predisposition, environmental factors, and aberrant immune response. Peptidoglycan recognition proteins (Pglyrps) are expressed in the skin, and we report in this article that they modulate sensitivity in an experimentally induced mouse model of psoriasis. We demonstrate that Pglyrp2(-/-) mice (but not Pglyrp3(-/-) and Pglyrp4(-/-) mice) are more sensitive to the development of 12-O-tetradecanoylphorbol 13-acetate-induced psoriasis-like inflammation, whereas Pglyrp1(-/-) mice are less sensitive. The mechanism underlying this increased sensitivity of Pglyrp2(-/-) mice to 12-O-tetradecanoylphorbol 13-acetate-induced psoriasis-like inflammation is reduced recruitment of regulatory T cells to the skin and enhanced production and activation of Th17 cells in the skin in Pglyrp2(-/-) mice, which results in more severe inflammation and keratinocyte proliferation. Thus, in wild type mice, Pglyrp2 limits overactivation of Th17 cells by promoting accumulation of regulatory T cells at the site of inflammation, which protects the skin from the exaggerated inflammatory response.

Comorbidities significantly impact patients' preferences for psoriasis treatments

BACKGROUND

Non-adherence rates are high among patients with psoriasis, partly because of discordance between recommended treatments and individual preferences.

OBJECTIVES

Our aim was to assess the impact of comorbidities on patients' preferences for psoriasis treatments.

METHODS

A computer-based conjoint analysis experiment was conducted to analyze preferences of patients with psoriasis (N = 163) for treatment outcome attributes (probability, magnitude and duration of benefit; probability, severity and reversibility of side effects) and process attributes (treatment location, frequency, duration, delivery method, individual cost). The impact of comorbidities (psoriatic arthritis, cardiovascular disease, diabetes, and depression) on relative importance scores of each attribute was assessed by analyses of variance, post hoc test, and multivariate regression analysis.

RESULTS

Among the participants included (58.9% males, mean age 49.3 yrs), 27% suffered from psoriatic arthritis, 13.5% from cardiovascular disease, 8% from diabetes, and 12.9% from depression. Preferences for treatment attributes varied significantly depending on comorbidities. Participants with psoriatic arthritis cared most about the probability of benefit (β 0.166; P = .037), whereas those participants with cardiovascular disease were highly concerned about the probability of side effects (β 0.179; P = .046). For participants with depression, treatment duration (β 0.163; P = .047), and individual cost (P = .023) were highly important.

LIMITATIONS

Only patients with moderate and severe psoriasis treated at a university medical center were included.

CONCLUSIONS

Integrating patients' preferences into shared decision-making may facilitate treatment adherence and optimize outcomes. Addressing patients' comorbidities, particularly depression, may be a currently neglected opportunity to improve care.

Psoriasis--a systemic inflammatory disorder: clinic, pathogenesis and therapeutic perspectives

Psoriasis has seen a dramatic change in its perception by dermatologists as well as other medical specialties. Its well-recognized association with several other diseases makes a complete switch in its management necessary. This review summarizes current epidemiological data on the comorbidities of psoriasis. Subsequently, the evidence for insulin resistance as a cause for endothelial cell dysfunction with its relevant pathogenetic link to the development of cardiovascular comorbidity is discussed. Based on these novel insights, we propose a possible state-of-the-art approach towards comprehensive psoriasis management.

Development of the IL-12/23 antagonist ustekinumab in psoriasis: past, present, and future perspectives

The development of ustekinumab as a first-in-class anti-interleukin (IL) 12/23p40 therapeutic agent for psoriasis represents an important example of modern and rational drug design and development. Psoriasis is a chronic, systemic, immune-mediated skin disorder with considerable clinical, psychosocial, and economic burden. Ustekinumab is a human monoclonal antibody (mAb) that binds the p40 subunit common to IL-12 and IL-23, key cytokines in psoriasis pathogenesis. The therapeutic mAb was developed using human gamma-1 immunoglobulin (IgG)-expressing transgenic mice, which created a molecule with endogenous IgG(1) biologic properties and low immunogenicity. Ustekinumab was well tolerated in clinical studies and yielded rapid, significant, and sustained efficacy plus improved quality of life/work performance and reduced depression/anxiety. Its pharmacologic properties afford the most convenient dosing regimen among approved biologics, representing a significant advancement in the treatment of moderate to severe psoriasis. Ustekinumab also holds promise for other immune-mediated disorders with significant unmet need.

Health-related quality of life in patients with psoriasis

BACKGROUND

Psoriasis is a chronic skin disease that has a significant impact on patients' lives.

OBJECTIVE

The purpose of the study was to assess factors that might influence the health-related quality of life (HRQoL) of patients with psoriasis.

METHODS

We conducted a cross-sectional study of 110 outpatients with psoriasis. To assess the HRQoL, The Short Form 36 Health Survey (SF-36) and Skindex-29 were administered. Stressful life events during the last 12 months were assessed with Paykel's Interview for Recent Life Events.

RESULTS

HRQoL was significantly more impaired in older patients, those with age at onset of 40 years or more, who had a positive family history and who experienced stressful life events in the 12 months preceding the interview. Sex and clinical severity were not significantly related to patients' HRQoL.

CONCLUSION

Psoriasis patients have poorer HRQoL than the general population. This study supports the decision to use both generic and skin-specific instruments to assess the impact of psoriasis on HRQoL.

Antigens from Leishmania amastigotes inducing clinical remission of psoriatic arthritis

A first generation vaccine (AS100-1) was manufactured with protein from four cultured Leishmania species, which proved to be effective in the treatment of psoriasis. A single blind trial on 3,132 psoriasis patients revealed 508 (16.2%) subjects with psoriatic arthritis (PsA) that received AS100-1 antigens. The study group was distributed according to percent psoriasis area and severity index (PASI) reduction from PASI 10 to PASI 100. All groups decreased in arthritis score (AS), tender joints counts and nail changes after treatment; the highest decreased in the PASI 100 group. Relapses of psoriasis and PsA had PASI and AS lower than initial values before treatment. Clinical remissions were at lower doses and less time, after the second course of treatment. Peripheral blood mononuclear cells (PBMC) lymphocyte subsets (LS) varied with PASI range (1-10, 11-20 and 21-72). Pre-treatment, absolute values of gated LS: CD4+, CD8+HLA-, CD8+HLA+, CD8+CD3-, CD8+CD3+ decreased in PBMC as PASI increased, suggesting migration from the blood to the skin. In contrary to the previous finding, the following LS: CD8+CD4-, CD3+CD8-, HLA+CD8-, CD19, CD8+CD4+ and membrane surface immunoglobulin IgA+, IgD+, IgM+, IgE+, and IgG+ increased in PBMC as PASI increased suggesting activation and proliferation by unknown antigens creating a homeostatic cycle between skin/joints and peripheral blood. After nine doses of AS100-1, the following LS: CD8+CD3+, CD8+HLA+, CD3+CD8-, CD4+CD8-, CD8+HLA-, HLA+CD8-, CD8+CD3-, CD19+, CD8+CD4-, CD8+CD4+, IgA+, IgD+, IgM+, IgE+, and IgG+ decreased significantly as compared with values before treatment. The LS decreased stops the vicious cycle between skin/joints and blood explaining clinical remission of lesions.

Long-Term Prognosis and Comorbidities Associated with Psoriasis in the Newfoundland and Labrador Founder Population

Background:

Psoriasis is a common chronic immune-mediated inflammatory disorder of the skin with several associated comorbidities.

Objective:

To assess the prevalence of comorbidities in a cohort of psoriasis patients within the Canadian province of Newfoundland and Labrador (NL).

Methods:

This cross-sectional observational study investigated hospital-coded comorbidities associated with psoriasis in comparison to the general NL hospitalized population.

Results:

Patients died significantly younger than the general population, with patients having an earlier disease onset (≤ 25 years) dying at a younger age than those with a later onset (> 25 years; 59.3 vs 71.2; p = .001). Patients were hospitalized more frequently for several system disorders than the general population, and a potential association was observed between prognostic factors such as age at onset, disease severity, and HLA-Cw6 genotype and certain comorbid conditions.

Conclusion:

This study supports an association between psoriasis and other conditions, such as circulatory and endocrine diseases.

A prospective case-controlled cohort study of endothelial function in patients with moderate to severe psoriasis

BACKGROUND

There is well-documented evidence that patients with moderate and severe psoriasis have a significantly increased risk of cardiovascular disease (CVD). While this risk can, at least in part, be attributed to the high prevalence of traditional risk factors in the population with psoriasis, some epidemiological evidence suggests it may be independent of these.

OBJECTIVES

This prospective, case-controlled study investigates whether psoriasis is a risk factor for CVD using two, validated, sensitive markers of CVD, endothelial dysfunction and high-sensitivity C-reactive protein (hsCRP).

METHODS

Patients were recruited from a tertiary referral psoriasis clinic and exclusion criteria included established CVD and/or conventional risks for CVD. Preclinical CVD was assessed using flow-mediated brachial artery dilatation, which measures endothelial dysfunction, and hsCRP, a serological marker of atherosclerosis.

RESULTS

Sixty-four patients (22%) out of a total of 285 consecutive patients attending the severe psoriasis clinic were entered into the study. One hundred and sixty-one (56%) were excluded following identification of cardiovascular risk; 39 of the 161 (24%) had at least two cardiovascular risk factors. A further 16 (6%) patients were excluded because of established CVD. No statistically significant difference in endothelial dysfunction was observed between patients with psoriasis (n = 60) and healthy controls (n = 117) (P = 0·508). The hsCRP level was, however, significantly elevated in the psoriasis group (2·828 mg L(-1), SEM 0·219; controls 0·728 mg L(-1), SEM 0·142; P < 0·05).

CONCLUSION

This large, investigative study is the first to assess endothelial function in patients with psoriasis after exclusion of traditional risk factors for CVD. These data suggest that psoriasis per se is not a risk factor for CVD and that elevated hsCRP is possibly independent of atheroma risk. There was a high prevalence of traditional risk factors in our population with severe psoriasis.

Evidence-based recommendations to assess psoriasis severity: systematic literature review and expert opinion of a panel of dermatologists

BACKGROUND

Severity of psoriasis appears to be multidimensional and its assessment in everyday clinical practice requires a complex holistic approach.

OBJECTIVES

To develop evidence-based recommendations to assess severity of plaque-type psoriasis in adult patients in everyday clinical practice.

METHODS

A scientific committee (10 members identified on the basis of their expertise in psoriasis) using Delphi methodology selected eight questions in three domains: severity, health-related quality of life (HR-QoL) and comorbidities. Three systematic literature reviews (one per domain) of all studies published between January 1980 and June 2009 were performed based on Pub-Med, Cochrane and Embase database. Selected articles were systematically reviewed and evidence appraised according to the Oxford Levels of Evidence. On June 2009, a group of 44 French dermatologists both hospital and office based participated in a meeting including three separate rounds of discussions, plenary sessions, and modified Delphi technique votes. Recommendations for clinical practice based on systematic review and clinical experience were formulated by the group. Subsequently, agreements among the participants regarding these recommendations as well as potential impact on clinical practice were evaluated.

RESULTS

A total of 10 642 references were identified, of which 154 articles were analysed. Ten key recommendations on the assessment of psoriasis severity were formulated: three recommendations relating to severity assessment, three recommendations relating to HR-QoL (including the use of the Dermatology Life Quality Index [DLQI] in clinical practice) and four recommendations relating to comorbidities (including systematic screening for peripheral or axial inflammatory joint damage, regardless of psoriasis severity).

CONCLUSIONS

Ten recommendations to assess the severity of plaque-type psoriasis in adult patients in daily practice were developed. The recommendations are based on systematic appraisal of available evidence. They were developed and supported by a panel of dermatologists, which enhances their validity and practical relevance.