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Marzano AV, Fargnoli MC, Gisondi P, Balato A, Bianchi L, Calzavara-Pinton P, Chiricozzi A, Costanzo A, Megna M, Micali G, Piaserico S, Prignano F. Literature review and expert opinion on diagnosis and current management of generalized pustular psoriasis. Expert Opin Biol Ther 2025:1-9. [PMID: 39925164 DOI: 10.1080/14712598.2025.2464858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Revised: 12/17/2024] [Accepted: 02/05/2025] [Indexed: 02/11/2025]
Abstract
INTRODUCTION Generalized pustular psoriasis (GPP) is a rare, chronic, systemic, autoinflammatory disease characterized by the eruption of sterile pustules, often accompanied by more general symptoms, such as fever, fatigue, and a burning sensation in the skin. GPP can be potentially life-threatening, if untreated, as it can lead to complications, such as sepsis and heart failure. AREAS COVERED In this literature review and expert opinion article, we provide an overview of the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment of GPP. Eleven dermatologists representing seven different Italian regions considered relevant evidence in the literature to discuss the current diagnosis and treatment of GPP. The expert panel of dermatologists identified several weaknesses in the current clinical management of GPP. EXPERT OPINION There is an inconsistent definition and classification of the disease across the literature, which can lead to misdiagnosis and delay in disease treatment. Furthermore, there are no international and standardized clinical guidelines on disease management, especially in Europe. There is a profound need for the development of novel therapeutic agents with sustained efficacy to decrease the impact of the comorbidities and mortality associated with GPP, prevent the onset of complications, and support the unmet needs of these patients.
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Affiliation(s)
- Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Maria Concetta Fargnoli
- Dermatology, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Paolo Gisondi
- Department of Medicine, Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - Anna Balato
- Dermatology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Luca Bianchi
- UOSD of Dermatology, Policlinico Tor Vergata, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | | | - Andrea Chiricozzi
- Dermatologia, Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
- U.O.C. Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio Costanzo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Dermatology unit, Humanitas Clinical and Research Center, IRCCS Scientific Institute for Research, Hospitalization and Healthcare, Rozzano, Italy
| | - Matteo Megna
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | | | - Stefano Piaserico
- Dermatology Unit, Department of Medicine, University of Padua, Padua, Italy
| | - Francesca Prignano
- Department of Health Science, Section of Dermatology, University of Firenze, Firenze, Italy
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Zheng J, Ding Y, Shi Y, Yi X. Case report: Successful treatment with spesolimab of acrodermatitis continua of Hallopeau in an older patient without IL36RN mutations. Front Immunol 2025; 15:1440102. [PMID: 39882245 PMCID: PMC11774742 DOI: 10.3389/fimmu.2024.1440102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 12/27/2024] [Indexed: 01/31/2025] Open
Abstract
Background Acrodermatitis continua of Hallopeau (ACH) is a rare, sterile pustular psoriasis variant refractory to many conventional treatments. The eruption typically occurs after local trauma or infection; other etiologies include neural, inflammatory, and genetic causes. Herein we reported a single case of a 64-year-old patient with ACH that was successfully treated with spesolimab for 19 weeks. Case summary A 64-year-old Chinese male with no personal or known family history of psoriasis had recurrent episodes of redness, swelling, and pustules in the nail bed on seven fingers with progressive degeneration of the nails. The patient was monitored as to the evolution of the disease over half of a year before he referred his case to our attention. A diagnosis of ACH was made, allowing for the administration of local steroids and oral acitretin. However, after 3 months of acitretin treatment, no improvement was observed. In December 2023, this patient came to our inpatient department; his modified nail psoriasis severity index score was 32. Before starting treatment, a comprehensive set of laboratory and instrumental tests were all found to be negative. Moreover, whole-exome sequencing was performed in our patient, and it revealed no rare coding variant in IL36RN, CARD14, or AP1S3. Therefore, the patient was administrated with a dose of 900 mg spesolimab. After 10 days, the patient showed a significant decrease in discomfort and pain. In order to strengthen the therapeutic effect, he was given the second dose of 900 mg spesolimab after 4 weeks. After 19 weeks of spesolimab treatment, the patient's nail lesions showed complete resolution, and no adverse effects were reported. Conclusion The case report suggests that spesolimab may offer significant therapeutic benefits for ACH.
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Affiliation(s)
| | | | - Yuling Shi
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Institue of Psoriasis, Tongji University School of Medicine, Shanghai, China
| | - Xuemei Yi
- Department of Dermatology, Shanghai Skin Disease Hospital, Tongji University School of Medicine, Institue of Psoriasis, Tongji University School of Medicine, Shanghai, China
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Choon SE, Foley PA, Asawanonda P, Fujita H, Jo S, Shi Y, Theng C, Affandi AM, Bang CH, Frez ML, Huei HY, Le Huu D, Kim T, Morita A, Oon HH, Fernández‐Peñas P, Rajatanavin N, Robinson S, Selvarajah L, Tsai T. Asia-Pacific consensus recommendations on the management of generalized pustular psoriasis. J Dermatol 2024; 51:1579-1595. [PMID: 39390737 PMCID: PMC11624156 DOI: 10.1111/1346-8138.17471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/20/2024] [Accepted: 09/07/2024] [Indexed: 10/12/2024]
Abstract
Generalized pustular psoriasis (GPP) is a rare, chronic, heterogeneous, and potentially life-threatening disease characterized by primary, sterile, and macroscopically visible pustules with or without systemic symptoms. There are ethnic differences in the genetic mutations associated with GPP that might affect the clinical manifestations and treatment responses. Currently, there is limited evidence from the patient population in the Asia-Pacific (APAC) region, resulting in a general paucity of information on the effective management of patients with GPP in this region. This modified Delphi panel study aimed to identify current evidence and gain advanced insights to facilitate the development of a regionally tailored APAC consensus on the management of GPP. A systematic literature review (SLR) was conducted to identify published literature and develop consensus statements on (i) definition and clinical course, (ii) diagnosis of GPP, (iii) treatment outcomes, goals, and monitoring measures, and (iv) optimal management strategies and clinical practices. Statements were rated by a panel of dermatologists in two rounds, with the threshold for consensus at ≥80% agreement. Twenty experts from the APAC region reached consensus on 106 statements that were developed based on the SLR and experts' collective expertise. The experts agreed that GPP is a rare, severe, and potentially life-threatening condition that is distinct from plaque psoriasis. This consensus emphasized the importance of a tailored treatment strategy taking into account the GPP flare severity and each patient's unique clinical circumstances. The experts reached consensus on the severity classification of GPP flares and recommended first-line and maintenance treatment options for adult GPP, childhood GPP, and GPP in pregnancy. These consensus outcomes have been synthesized into treatment algorithms to guide dermatologists in the APAC region in their clinical decision-making processes.
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Affiliation(s)
- Siew Eng Choon
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health SciencesMonash UniversityJohor BahruMalaysia
| | - Peter Anthony Foley
- The University of Melbourne, St Vincent's Hospital MelbourneFitrozyVictoriaAustralia
- Skin Health InstituteCarltonVictoriaAustralia
| | | | - Hideki Fujita
- Division of Cutaneous Science, Department of DermatologyNihon University School of MedicineTokyoJapan
| | - Seong‐Jin Jo
- Department of DermatologySeoul National University College of MedicineSeoulRepublic of Korea
| | - Yu‐ling Shi
- Department of DermatologyShanghai Skin Disease Hospital, School of Medicine, Tongji UniversityShanghaiChina
- Institute of Psoriasis, School of Medicine, Tongji UniversityShanghaiChina
| | - Colin Theng
- The Skin Specialists & Laser ClinicSingaporeSingapore
| | | | - Chul Hwan Bang
- Department of DermatologySeoul St. Mary's Hospital, College of Medicine, the Catholic University of KoreaSeoulRepublic of Korea
| | - Maria Lorna Frez
- Department of DermatologySt Luke's Medical CenterQuezon CityPhilippines
| | - Huang Yu Huei
- Department of DermatologyChang Gung Memorial HospitalTaipeiTaiwan
- School of Medicine, Chang Gung UniversityTaipeiTaiwan
| | - Doanh Le Huu
- National Hospital of Dermatology and VenereologyHanoiVietnam
| | - Tae‐Gyun Kim
- Department of DermatologyCutaneous Biology Research Institute, Severance Hospital, Yonsei University College of MedicineSeoulRepublic of Korea
| | - Akimichi Morita
- Department of Geriatric and Environmental DermatologyNagoya City University Graduate School of Medical SciencesNagoya467‐8601Japan
| | - Hazel H. Oon
- National Skin Centre and Skin Research Institute of Singapore (SRIS)SingaporeSingapore
- Yong Loo Lin School of Medicine, National University of SingaporeSingaporeSingapore
| | - Pablo Fernández‐Peñas
- Department of DermatologyWestmead HospitalWestmeadNew South WalesAustralia
- Sydney Medical School, Faculty of Medicine and Health, the University of SydneyWestmeadNew South WalesAustralia
| | - Natta Rajatanavin
- Phototherapy Unit, Division of Dermatology, Department of MedicineRamathibodi Hospital, Mahidol UniversityBangkokThailand
| | | | - Latha Selvarajah
- Department of DermatologySultan Ismail HospitalJohor BahruMalaysia
| | - Tsen‐Fang Tsai
- Department of DermatologyNational Taiwan University HospitalTaipeiTaiwan
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Yuan L, Yu X, Shi Y, Yang B, Wang X. Acrodermatitis continua of hallopeau: aggravating factors and treatment outcomes of 96 patients. J DERMATOL TREAT 2024; 35:2434098. [PMID: 39608017 DOI: 10.1080/09546634.2024.2434098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2024] [Accepted: 11/13/2024] [Indexed: 11/30/2024]
Abstract
BACKGROUND Acrodermatitis continua of Hallopeau (ACH) is a rare pustular psoriasis variant predominantly affects the distal phalanges of the fingers and toes. However, data on aggravating factors and treatment outcomes is limited. OBJECTIVE This study aims to analyze the aggravating factors and treatment outcomes of ACH in a three-tertiary-hospital in South China. METHODS We analyzed ACH patients from Dermatology Hospital of Southern Medical University, considering patient and disease characteristics along with treatment experiences. RESULTS We identified 96 ACH patients. Various predisposing events were identified, including lifestyle factors, vaccination, stress, trauma, menstruation and drug exposure. A total of 293 systemic treatment courses were analyzed. 54.3% of patients received at least one biologic therapy, while 45.7% were treated with nonbiologic treatments. Acitretin was the most common therapy (20.5%). However, the effectiveness of systemic treatments was low (excellent response rate: 26.3%). Among non-biologic treatments, Acitretin showed a significant response in 30.0% (18/60) of cases, followed by cyclosporin (20.0%, 2/10). Among biologics, spesolimab had the best response rate at 75.0% (n = 3), followed by ixekizumab (44.4%, 8/18). Small molecule drugs did not yeild satisfactory outcomes in ACH treatment. CONCLUSION Identifying triggers and aggravating factors is crucial for effective ACH treatment. We suggest that biologics may be a useful first-line treatment option for clinicians managing ACH.
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Affiliation(s)
- Liyan Yuan
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaoling Yu
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Yanqiang Shi
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Bin Yang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Xiaohua Wang
- Dermatology Hospital, Southern Medical University, Guangzhou, Guangdong, China
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Nieto-Benito LM, Baniandrés-Rodríguez O. [Translated article] Elderly-Onset Generalized Pustular Psoriasis in the Elderly: A 5-Case Series. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:T1012-T1014. [PMID: 39260608 DOI: 10.1016/j.ad.2024.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 09/19/2023] [Accepted: 10/09/2023] [Indexed: 09/13/2024] Open
Affiliation(s)
- L M Nieto-Benito
- Departamento de Dermatología, Clínica Universidad de Navarra, Madrid, Spain.
| | - O Baniandrés-Rodríguez
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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Nieto-Benito LM, Baniandrés-Rodríguez O. Elderly-Onset Generalized Pustular Psoriasis in the Elderly: A 5-Case Series. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:1012-1014. [PMID: 38969169 DOI: 10.1016/j.ad.2023.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 09/19/2023] [Accepted: 10/09/2023] [Indexed: 07/07/2024] Open
Affiliation(s)
- L M Nieto-Benito
- Departamento de Dermatología, Clínica Universidad de Navarra, Madrid, España.
| | - O Baniandrés-Rodríguez
- Servicio de Dermatología, Hospital General Universitario Gregorio Marañón, Madrid, España
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Hsieh CY, Tsai TF. Lack of IL36RN sequence variation in three Chinese patients with subcorneal pustular dermatoses. J Dermatol 2024; 51:e412-e413. [PMID: 38874482 DOI: 10.1111/1346-8138.17336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/29/2024] [Accepted: 05/30/2024] [Indexed: 06/15/2024]
Affiliation(s)
- Chang-Yu Hsieh
- Department of Dermatology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Nguyen Thi Thuy T, Trung Nguyen K, Le Nguyen B, Tran Thi Minh T, Do Tran H, Gia Tran H. IL36RN Mutations and Correlated Characteristics in Generalized Pustular Psoriasis Patients in Can Tho City, Vietnam: A Cross-Sectional Study. Dermatology 2024; 240:750-757. [PMID: 39378855 DOI: 10.1159/000541886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2024] [Accepted: 10/04/2024] [Indexed: 10/10/2024] Open
Abstract
INTRODUCTION Pustular psoriasis is a rare and severe form of psoriasis characterized by sterile pustules on an erythematous background. The disease ranges from localized to generalized forms, with the latter being particularly life-threatening and recurrent. Understanding the genetic basis of pustular psoriasis, particularly IL36RN mutations, is crucial for developing better treatments. This study aimed to determine the prevalence and types of IL36RN gene mutations and their relationship with clinical and paraclinical features in patients with pustular psoriasis in Can Tho City, Vietnam. METHODS A cross-sectional study was conducted at Can Tho Dermatology Hospital involving 59 patients diagnosed with generalized pustular psoriasis (GPP) according to ERASPEN and Japanese Dermatological Association criteria. Data on demographic, clinical, and laboratory characteristics were collected. IL36RN gene mutations were identified through genomic DNA sequencing. Statistical analyses were performed to explore associations between IL36RN mutations and clinical features. RESULTS The study included 59 participants, predominantly female (69.5%), with an average age of 39.12 years. A significant proportion (83.1%) had a history of psoriasis, with frequent recurrences (94.9%). The most common IL36RN mutation identified was p.Arg10ArgfsX1, present in 44.1% of patients. Other mutations included p.Pro76Leu (20.3%) and p.Arg102Trp (1.7%). Patients with IL36RN mutations were younger and had an earlier disease onset. Significant associations were found between IL36RN mutations and clinical features such as fever (OR = 11, p < 0.0001) and geographic tongue (OR = 14.67, p < 0.0001). CONCLUSION Our study reveals a high prevalence of IL36RN mutations, particularly p.Arg10ArgfsX1, in Vietnamese pustular psoriasis patients, strongly associating these mutations with clinical features like fever and geographic tongue.
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Affiliation(s)
- Trang Nguyen Thi Thuy
- Department of Dermato-Venereology, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | | | | | | | - Hung Do Tran
- Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Hung Gia Tran
- Department of Dermato-Venereology, Faculty of Medicine, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
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Sugiura K, Fujita H, Komine M, Yamanaka K, Akiyama M. The role of interleukin-36 in health and disease states. J Eur Acad Dermatol Venereol 2024; 38:1910-1925. [PMID: 38779986 DOI: 10.1111/jdv.19935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/29/2024] [Indexed: 05/25/2024]
Abstract
The interleukin (IL)-1 superfamily upregulates immune responses and maintains homeostasis between the innate and adaptive immune systems. Within the IL-1 superfamily, IL-36 plays a pivotal role in both innate and adaptive immune responses. Of the four IL-36 isoforms, three have agonist activity (IL-36α, IL-36β, IL-36γ) and the fourth has antagonist activity (IL-36 receptor antagonist [IL-36Ra]). All IL-36 isoforms bind to the IL-36 receptor (IL-36R). Binding of IL-36α/β/γ to the IL-36R recruits the IL-1 receptor accessory protein (IL-1RAcP) and activates downstream signalling pathways mediated by nuclear transcription factor kappa B and mitogen-activated protein kinase signalling pathways. Antagonist binding of IL-36Ra to IL-36R inhibits recruitment of IL-1RAcP, blocking downstream signalling pathways. Changes in the balance within the IL-36 cytokine family can lead to uncontrolled inflammatory responses throughout the body. As such, IL-36 has been implicated in numerous inflammatory diseases, notably a type of pustular psoriasis called generalized pustular psoriasis (GPP), a chronic, rare, potentially life-threatening, multisystemic skin disease characterised by recurrent fever and extensive sterile pustules. In GPP, IL-36 is central to disease pathogenesis, and the prevention of IL-36-mediated signalling can improve clinical outcomes. In this review, we summarize the literature describing the biological functions of the IL-36 pathway. We also consider the evidence for uncontrolled activation of the IL-36 pathway in a wide range of skin (e.g., plaque psoriasis, pustular psoriasis, hidradenitis suppurativa, acne, Netherton syndrome, atopic dermatitis and pyoderma gangrenosum), lung (e.g., idiopathic pulmonary fibrosis), gut (e.g., intestinal fibrosis, inflammatory bowel disease and Hirschsprung's disease), kidney (e.g., renal tubulointerstitial lesions) and infectious diseases caused by a variety of pathogens (e.g., COVID-19; Mycobacterium tuberculosis, Pseudomonas aeruginosa, Streptococcus pneumoniae infections), as well as in cancer. We also consider how targeting the IL-36 signalling pathway could be used in treating inflammatory disease states.
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Affiliation(s)
- Kazumitsu Sugiura
- Department of Dermatology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Hideki Fujita
- Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | - Mayumi Komine
- Department of Dermatology, Faculty of Medicine, Jichi Medical University, Tochigi, Japan
| | - Keiichi Yamanaka
- Department of Dermatology, Graduate School of Medicine, Mie University, Tsu, Japan
| | - Masashi Akiyama
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Chen J, Xue X, Wang Z, Liu H, Zhang F. Genetic analysis of different subtypes of aseptic pustulosis in the Chinese population. Clin Exp Dermatol 2024; 49:1217-1226. [PMID: 38651209 DOI: 10.1093/ced/llae144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/06/2024] [Accepted: 04/16/2024] [Indexed: 04/25/2024]
Abstract
Aseptic pustulosis involves inflammatory skin conditions with nonbacterial pustules on erythema, accompanied by neutrophil and eosinophil infiltration in the epidermis. Dysregulation of the interleukin (IL)-36 pathway leads to neutrophil aggregation and pustule formation. Variants in IL36RN, CARD14, AP1S3, MPO, SERPINA3 and BTN3A3 have been identified in generalized pustular psoriasis (GPP) in the past. Some patients with acrodermatitis continua of Hallopeau (ACH), palmoplantar pustulosis and acute generalized exanthematous pustulosis (AGEP) also exhibit mutations in IL36RN, CARD14 and AP1S3, albeit with regional and population-specific variations. This study aims to explore a shared genetic foundation among those with aseptic pustulosis. We performed Sanger sequencing on six genes in 126 patients with aseptic pustulosis. Genetic analysis identified IL36RN variants strongly associated with ACH, AGEP and subcorneal pustular dermatosis (SPD). Immunohistochemistry revealed elevated inflammatory cytokines in all subtypes. This study establishes a significant association between IL36RN variants and ACH, AGEP and SPD, emphasizing the IL-1/IL-36-chemokine-neutrophil axis as a common pathogenic mechanism. Targeting this axis holds promise for therapeutic interventions for aseptic pustulosis.
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Affiliation(s)
- Jing Chen
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Xiaotong Xue
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Zhenzhen Wang
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Hong Liu
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
| | - Furen Zhang
- Shandong Provincial Hospital for Skin Diseases & Shandong Provincial Institute of Dermatology and Venereology, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, China
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Gwillim EC, Nichols AJ. Spesolimab for generalized pustular psoriasis: a review of two key clinical trials supporting initial US regulatory approval. Front Immunol 2024; 15:1359481. [PMID: 39104539 PMCID: PMC11298804 DOI: 10.3389/fimmu.2024.1359481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/13/2024] [Indexed: 08/07/2024] Open
Abstract
Generalized pustular psoriasis (GPP) is a chronic, rare, and potentially life-threatening inflammatory disease, characterized by the rapid and widespread eruption of small, sterile pustules with surrounding skin erythema. Abnormal signaling of the interleukin-36 (IL-36) pathway appears to have a central role in GPP immunopathology, and provides a rational therapeutic target. Spesolimab is a first-in-class humanized monoclonal antibody that binds specifically to the IL-36 receptor, and antagonizes IL-36 signaling. Spesolimab obtained regulatory approval in the United States (US) in September 2022 for use in the treatment of GPP flares in adults, and was subsequently approved for GPP flare treatment in many other countries across the world. Recently, regulatory approval was granted for subcutaneous dosing of spesolimab for treatment of GPP when not experiencing a flare. Here, we review data from two key clinical trials that supported the initial US regulatory approval; namely, the phase 1 proof-of-concept trial (ClinicalTrials.gov ID, NCT02978690), and Effisayil™ 1 (NCT03782792), which remains the largest and only randomized clinical trial in patients experiencing GPP flares published to date. In the phase 1 proof-of-concept trial, a Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) score of 0 or 1 (clear or almost clear skin) was attained in 5/7 (71%) patients by week 1 and in all 7 patients by week 4; and the mean percent improvement in the Generalized Pustular Psoriasis Area and Severity Index (GPPASI) score from baseline was 59.0% at week 1, 73.2% at week 2, and 79.8% at week 4. In Effisayil™ 1, a GPPGA pustulation subscore of 0 (no visible pustules) was achieved in 19/35 (54%) patients receiving spesolimab at the end of week 1, versus 1/18 (6%) receiving placebo (difference, 49 percentage points; 95% confidence interval [CI], 21 to 67; P<0.001); and a GPPGA total score of 0 or 1 was achieved by 15/35 (43%) patients in the spesolimab group, versus 2/18 (11%) patients in the placebo group (difference, 32 percentage points; 95% CI, 2 to 53; P = 0.02). Infections at week 1 were reported in 6/35 (17%) patients receiving spesolimab and in 1/18 (6%) patients receiving placebo. These data demonstrate the efficacy and safety of spesolimab in providing rapid and sustained clinical improvement for patients with GPP flares, which translates into improved quality of life, by offering a targeted therapy for GPP.
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Affiliation(s)
- Eran C. Gwillim
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
- Jackson Health System, Miami, FL, United States
| | - Anna J. Nichols
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
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Hsieh CY, Chen PH, Huang CM, Tsai TF. Characteristics of psoriatic plaques in generalized pustular psoriasis patients with or without IL36RN mutation. Arch Dermatol Res 2024; 316:321. [PMID: 38822916 DOI: 10.1007/s00403-024-03063-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 01/19/2024] [Accepted: 04/26/2024] [Indexed: 06/03/2024]
Affiliation(s)
- Chang-Yu Hsieh
- Department of Dermatology, College of Medicine, National Taiwan University Hospital, National Taiwan University, No.7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taipei, Taiwan (R.O.C.)
| | - Po-Hua Chen
- Department of Dermatology, College of Medicine, National Taiwan University Hospital, National Taiwan University, No.7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taipei, Taiwan (R.O.C.)
| | - Chang-Ming Huang
- Department of Dermatology, College of Medicine, National Taiwan University Hospital, National Taiwan University, No.7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taipei, Taiwan (R.O.C.)
| | - Tsen-Fang Tsai
- Department of Dermatology, College of Medicine, National Taiwan University Hospital, National Taiwan University, No.7, Zhongshan S. Rd., Zhongzheng Dist., Taipei City 100, Taipei, Taiwan (R.O.C.).
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Hsu FLT, Hsieh CY, Tsai TF. Acquired diffuse palmoplantar erythema with keratoderma in Chinese patients with pustular psoriasis: A predictor for IL36 receptor antagonist c.115+6T>C mutation? Exp Dermatol 2024; 33:e15056. [PMID: 38488485 DOI: 10.1111/exd.15056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 02/14/2024] [Accepted: 03/03/2024] [Indexed: 03/19/2024]
Abstract
Several studies have suggested that mutation of the interleukin 36 receptor antagonist gene (IL36RN) is related to generalized pustular psoriasis (GPP), and the presence of IL36RN mutation may affect the clinical manifestations and treatment responses. However, genetic testing is not routinely available in clinical practice for the diagnosis of GPP. Previously, GPP patients with acrodermatitis continua of Hallopeau (ACH) were found to have a high percentage of carrying IL36RN mutation. In this study, we reported six patients with pustular psoriasis presenting as diffuse palmoplantar erythema with keratoderma among 60 patients who carried IL36RN mutation. ACH was present in five patients and five patients had acute flare of GPP. This unique presentation may serve as a predictor for IL36RN mutation in patients with pustular psoriasis, similar to ACH.
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Affiliation(s)
- Francis Li-Tien Hsu
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Chang-Yu Hsieh
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
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14
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Chularojanamontri L, Silpa-Archa N, Pattamadilok B, Julanon N, Chuamanochan M, Pongcharoen P, Lertphanichkul C, Asawanonda P. A retrospective analysis of 65 patients with acrodermatitis continua of Hallopeau. Exp Dermatol 2024; 33:e15055. [PMID: 38519437 DOI: 10.1111/exd.15055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 02/29/2024] [Accepted: 03/02/2024] [Indexed: 03/24/2024]
Abstract
There are limited data on acrodermatitis continua of Hallopeau (ACH), particularly among Asian populations. The primary aim was to evaluate the clinical features of ACH and treatment approaches in a sizeable multicentre Asian cohort. We analysed data from adult patients diagnosed with ACH. Of 65 patients with ACH, seven patients had ACH with GPP. Females were more frequently affected in both conditions. Five (71.4%) developed GPP 5-33 years after ACH onset, while two (28.6%) developed GPP concurrently with ACH. The onset age for ACH with GPP (27.9 ± 13.6 years) was earlier than that of isolated ACH (39.8 ± 17.3 years). Metabolic comorbidities were common. ACH exhibited a chronic persistent course. Among systemic non-biologics, acitretin was the most frequently prescribed, followed by ciclosporin and methotrexate. Acitretin and ciclosporin demonstrated similar marked response rates, which surpassed that of methotrexate. Regarding biologics, a marked response was more commonly observed with interleukin-17 inhibitors than with tumour necrosis factor inhibitors. Females are predominant in both conditions. The onset age for ACH among Asian patients is earlier (late 30s) than that for Caucasian patients (late 40s). Interleukin-17 inhibitors may be more effective than tumour necrosis factor inhibitors in managing ACH.
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Affiliation(s)
- Leena Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Narumol Silpa-Archa
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Narachai Julanon
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Srinagarind Hospital, Khon Kean University, Khon Kean, Thailand
| | - Mati Chuamanochan
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Padcha Pongcharoen
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Thammasat University, Pathum Thani, Thailand
| | - Chotinij Lertphanichkul
- Department of Dermatology, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - Pravit Asawanonda
- Division of Dermatology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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15
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Wen P, Liu C, Wang T, Jiang X, Wang P, Wang S. Successful treatment of acrodermatitis continua of Hallopeau coexisting with generalized pustular psoriasis with spesolimab: a case report. Front Immunol 2024; 15:1338285. [PMID: 38464535 PMCID: PMC10920288 DOI: 10.3389/fimmu.2024.1338285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/07/2024] [Indexed: 03/12/2024] Open
Abstract
Generalized pustular psoriasis (GPP) is a rare chronic inflammatory pustular dermatosis that presents as painful erythema with sterile pustules on nonacral skin. No unified standard and guideline for the treatment of GPP has been established. Several biologics have been tried for GPP, with varying success. Acrodermatitis continua of Hallopeau (ACH) is a very rare disabling variant of pustular psoriasis characterized by sterile pustules on the fingers and toes, including the nail bed. Comparatively, treating ACH is highly challenging due to its commonly therapy-resistant disease course. The pathogenic role of IL-36 signaling axis has been currently identified in GPP development. Spesolimab, the first anti-interleukin-36 receptor biologic, has been approved for treating GPP flares and shown promising results. In view of a shared pathogenesis between GPP and ACH, specolimab may be an effective treatment for ACH. Currently, there is no case and clinical trial data exist on this condition. Therefore, this case was aim to describe real-world experience of spesolimab use in ACH coexisting with GPP. We report an Asian patient with a 16-year-history of GPP and ACH with marked pustulosis on the nail bed and onychodystrophy. He received conventional systemic regimen acitretin, cyclosporine and biologics adalimumab and secukinumab, but experienced relapse for skin lesions and refractory for nail lesions. He was then treated with a single dose of spesolimab in combination with secukinumab, which resulted in skin clearance and nearly complete resolution of nail lesions over a 32-week period. Our observation suggests that spesolimab should be considered for the treatment of ACH, especially in the patients with intractable nail lesions and concomitant GPP.
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Affiliation(s)
- Pengfei Wen
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu, China
| | - Chuan Liu
- The Department of Dermatology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tingting Wang
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu, China
| | - Xian Jiang
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu, China
| | - Ping Wang
- The Department of Dermatology, First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Sheng Wang
- Department of Dermatovenerology, West China Hospital, Sichuan University, Chengdu, China
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16
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Hsieh CY, Tsai TF. Clinical advances in biological therapy for generalized pustular psoriasis: a review. Expert Opin Biol Ther 2024; 24:37-50. [PMID: 38247394 DOI: 10.1080/14712598.2024.2309301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/19/2024] [Indexed: 01/23/2024]
Abstract
INTRODUCTION In 2022, U.S. Food and Drug Administration (FDA) approved the first biologics, intravenous spesolimab, for acute flare of generalized pustular psoriasis (GPP). The drug works by blocking IL-36 signaling, the key pathway of GPP. Among the known mutations causing GPP, IL36RN mutations are most common, and the presence of IL36RN mutations had been found to affect the clinical manifestations and treatment response of GPP. AREAS COVERED Literature search was conducted in PubMed, Embase and ClinicalTrials.gov for relevant studies discussing biologic treatment for GPP with special emphasis on larger studies, pediatric group, pregnant women, and the influence of IL36RN mutation on the effectiveness of biologics. EXPERT OPINION The approval of spesolimab for GPP flare treatment marks a new era. However, whether spesolimab will be placed as the treatment of choice remains unknown, considering its higher cost, lack of direct comparison with existing biologics, and uncertain effects on co-existing plaque-type psoriasis. However, the demonstration of numerically better efficacy for patients carrying pathogenic IL36RN mutations suggests the role of pharmacogenetics in the choices of GPP treatment. Future randomized studies are warranted to investigate the effectiveness and safety of biologics for GPP in pediatric and pregnant groups.
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Affiliation(s)
- Chang-Yu Hsieh
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
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17
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Tsai TF, Zheng M, Ding Y, Song Z, Liu Q, Chen Y, Hu H, Xu J. Efficacy and Safety of Spesolimab in Patients with Generalized Pustular Psoriasis: A Subgroup Analysis of Chinese Patients in the Effisayil 1 Trial. Dermatol Ther (Heidelb) 2023; 13:3097-3110. [PMID: 37840119 PMCID: PMC10689646 DOI: 10.1007/s13555-023-01037-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
INTRODUCTION Generalized pustular psoriasis (GPP) is a rare and potentially life-threatening skin disease. The global Effisayil 1 study investigated the efficacy and safety of spesolimab, a humanized monoclonal antibody targeting the IL-36 receptor, in patients experiencing GPP flare. This analysis aimed to explore the efficacy and safety of spesolimab in the Chinese subgroup of Effisayil 1. METHODS Effisayil 1 was a multicenter, randomized, double-blind, placebo-controlled phase II study. Eligible patients with a GPP flare were randomly assigned (2:1) to receive a single intravenous dose of spesolimab (900 mg) or placebo on day 1. On day 8, patients who had persistent symptoms that met a predefined criterion could receive open-label spesolimab. After day 8, patients with recurrent flares following clinical response could receive rescue treatment with open-label spesolimab. The primary end point was a Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) pustulation sub-score of 0 at week 1. The key secondary end point was a GPPGA total score of 0 or 1 at week 1. RESULTS Eleven Chinese patients were randomized, with five patients receiving spesolimab and six receiving placebo. At week 1, 60.0% (3/5) of patients in the spesolimab group and 16.7% (1/6) of patients in the placebo group achieved a GPPGA pustulation sub-score of 0 (risk difference 43.3%; 95% CI -22.6, 86.2); 60.0% and 16.7% of patients in the spesolimab and placebo group, respectively, achieved a GPPGA total score 0 or 1 (risk difference 43.3%; 95% CI -22.6, 86.2). Overall, four patients in each group of the spesolimab and the placebo groups reported at least one adverse event (AE) by week 1, with two and three reporting drug-related AEs, respectively. One patient reported a serious AE that was not considered to be drug related. No death occurred during the study period. CONCLUSION In the Chinese subgroup of the Effisayil 1 study, more patients receiving spesolimab experienced lesion clearance than those on placebo at week 1, with an acceptable safety profile that was consistent with the global study population. TRIAL REGISTRATION NCT03782792.
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Affiliation(s)
- Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Min Zheng
- Department of Dermatology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yangfeng Ding
- Department of Dermatology, Shanghai Skin Disease Hospital, Shanghai, China
| | - Zhiqi Song
- Department of Dermatology and Venerology, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Quanzhong Liu
- Department of Dermatology and Venerology, Tianjin Medical University General Hospital, Tianjin, China
| | - Ying Chen
- Boehringer Ingelheim (China) Investment Corporation Limited, Shanghai, China
| | - Hanzhao Hu
- Boehringer Ingelheim (China) Investment Corporation Limited, Shanghai, China
| | - Jinhua Xu
- Department of Dermatology, Huashan Hospital, Fudan University, Urumqi Middle Road No. 12, Shanghai, 200240, China.
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18
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Morita A, Strober B, Burden AD, Choon SE, Anadkat MJ, Marrakchi S, Tsai TF, Gordon KB, Thaçi D, Zheng M, Hu N, Haeufel T, Thoma C, Lebwohl MG. Efficacy and safety of subcutaneous spesolimab for the prevention of generalised pustular psoriasis flares (Effisayil 2): an international, multicentre, randomised, placebo-controlled trial. Lancet 2023; 402:1541-1551. [PMID: 37738999 DOI: 10.1016/s0140-6736(23)01378-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/28/2023] [Accepted: 06/29/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Spesolimab is an anti-interleukin-36 receptor monoclonal antibody approved to treat generalised pustular psoriasis (GPP) flares. We aimed to assess the efficacy and safety of spesolimab for GPP flare prevention. METHODS This multicentre, randomised, placebo-controlled, phase 2b trial was done at 60 hospitals and clinics in 20 countries. Eligible study participants were aged between 12 and 75 years with a documented history of GPP as per the European Rare and Severe Psoriasis Expert Network criteria, with a history of at least two past GPP flares, and a GPP Physician Global Assessment (GPPGA) score of 0 or 1 at screening and random assignment. Patients were randomly assigned (1:1:1:1) to receive subcutaneous placebo, subcutaneous low-dose spesolimab (300 mg loading dose followed by 150 mg every 12 weeks), subcutaneous medium-dose spesolimab (600 mg loading dose followed by 300 mg every 12 weeks), or subcutaneous high-dose spesolimab (600 mg loading dose followed by 300 mg every 4 weeks) over 48 weeks. The primary objective was to demonstrate a non-flat dose-response curve on the primary endpoint, time to first GPP flare. FINDINGS From June 8, 2020, to Nov 23, 2022, 157 patients were screened, of whom 123 were randomly assigned. 92 were assigned to receive spesolimab (30 high dose, 31 medium dose, and 31 low dose) and 31 to placebo. All patients were either Asian (79 [64%] of 123) or White (44 [36%]). Patient groups were similar in sex distribution (76 [62%] female and 47 [38%] male), age (mean 40·4 years, SD 15·8), and GPP Physician Global Assessment score. A non-flat dose-response relationship was established on the primary endpoint. By week 48, 35 patients had GPP flares; seven (23%) of 31 patients in the low-dose spesolimab group, nine (29%) of 31 patients in the medium-dose spesolimab group, three (10%) of 30 patients in the high-dose spesolimab group, and 16 (52%) of 31 patients in the placebo group. High-dose spesolimab was significantly superior versus placebo on the primary outcome of time to GPP flare (hazard ratio [HR]=0·16, 95% CI 0·05-0·54; p=0·0005) endpoint. HRs were 0·35 (95% CI 0·14-0·86, nominal p=0·0057) in the low-dose spesolimab group and 0·47 (0·21-1·06, p=0·027) in the medium-dose spesolimab group. We established a non-flat dose-response relationship for spesolimab compared with placebo, with statistically significant p values for each predefined model (linear p=0·0022, emax1 p=0·0024, emax2 p=0·0023, and exponential p=0·0034). Infection rates were similar across treatment arms; there were no deaths and no hypersensitivity reactions leading to discontinuation. INTERPRETATION High-dose spesolimab was superior to placebo in GPP flare prevention, significantly reducing the risk of a GPP flare and flare occurrence over 48 weeks. Given the chronic nature of GPP, a treatment for flare prevention is a significant shift in the clinical approach, and could ultimately lead to improvements in patient morbidity and quality of life. FUNDING Boehringer Ingelheim.
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Affiliation(s)
- Akimichi Morita
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Bruce Strober
- Department of Dermatology, Yale University School of Medicine, New Haven, CT, USA; Central Connecticut Dermatology, Cromwell, CT, USA
| | - A David Burden
- School of Infection and Immunity, University of Glasgow, Glasgow, UK
| | - Siew Eng Choon
- Department of Dermatology, Hospital Sultanah Aminah, and Clinical School Johor Bahru, Monash University Malaysia, Malaysia
| | - Milan J Anadkat
- Division of Dermatology, Washington University School of Medicine, St Louis, MO, USA
| | - Slaheddine Marrakchi
- Department of Dermatology, Hedi Chaker Hospital, University of Sfax, Sfax, Tunisia
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Kenneth B Gordon
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Diamant Thaçi
- Comprehensives Center for Inflammation Medicine, University of Lübeck, Lübeck, Germany
| | - Min Zheng
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Na Hu
- Boehringer Ingelheim (China) Investment Co, Shanghai, China
| | | | | | - Mark G Lebwohl
- Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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19
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Heidemeyer K, May Lee M, Cazzaniga S, Yawalkar N, Naldi L. Palmoplantar Pustulosis: A Systematic Review of Risk Factors and Therapies. PSORIASIS (AUCKLAND, N.Z.) 2023; 13:33-58. [PMID: 37772169 PMCID: PMC10522454 DOI: 10.2147/ptt.s400402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/16/2023] [Indexed: 09/30/2023]
Abstract
Palmoplantar pustulosis (PPP) is a chronic, relapsing, inflammatory disease that can occur alone or in association with arthritis. There is still controversy about whether it should be separated from psoriasis or classified as pustular psoriasis. Furthermore, drug-induced paradoxical PPP is a special variant of PPP that differs from classic PPP in several ways. Treatment of PPP is still challenging, and there are a number of treatment-resistant cases. This review summarizes the risk factors for the development of PPP and the currently available treatment modalities. Female sex, smokers or ex-smokers, obesity, thyroid dysfunction, and treatment with a tumor necrosis factor (TNF)-α inhibitor have been identified as risk factors for the disease's development, severity, and course. Topical treatments and phototherapy are effective for some patients and are used as a first-line or adjuvant treatment modality. Conventional treatments including retinoids and fumaric acid show good effects and can increase the efficacy of treatment with psoralen + ultraviolet light therapy (PUVA). Ciclosporin is fast acting, but relapse mostly occurs immediately after cessation. TNF-α inhibitors are efficient, and an even better response can be achieved with IL-17 and IL-23 blockers as well as apremilast. The effect of Janus kinase inhibitors seems to be promising according to case reports, but further investigations with larger cohorts are needed.
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Affiliation(s)
- Kristine Heidemeyer
- Department of Dermatology, Inselspital University Hospital of Bern, Bern, Switzerland
- Centro Studi GISED, Bergamo, Italy
| | - Marco May Lee
- Section of Dermatology, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy
| | - Simone Cazzaniga
- Department of Dermatology, Inselspital University Hospital of Bern, Bern, Switzerland
- Centro Studi GISED, Bergamo, Italy
| | - Nikhil Yawalkar
- Department of Dermatology, Inselspital University Hospital of Bern, Bern, Switzerland
| | - Luigi Naldi
- Centro Studi GISED, Bergamo, Italy
- Dermatology Department, S. Bortolo Hospital, Vicenza, Italy
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20
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Tsai TF. Heterogeneity of generalized pustular psoriasis in multiethnic Johor Bahru, Malaysia. Br J Dermatol 2023; 189:361-362. [PMID: 37379585 DOI: 10.1093/bjd/ljad197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 07/04/2023] [Indexed: 06/30/2023]
Affiliation(s)
- Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
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21
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Choon SE, Wright AK, Griffiths CEM, Wong KW, Tey KE, Lim YT, Chua KY, Ashcroft DM. Incidence and prevalence of generalized pustular psoriasis in multiethnic Johor Bahru, Malaysia: a population-based cohort study using routinely captured electronic health records in the Teleprimary Care (TPC®) clinical information system from 2010 to 2020. Br J Dermatol 2023; 189:410-418. [PMID: 37162007 DOI: 10.1093/bjd/ljad158] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/04/2023] [Accepted: 05/06/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND There is limited understanding of the epidemiology of generalized pustular psoriasis (GPP) internationally, with no population-based estimates of GPP in South East Asia. OBJECTIVES To determine the incidence and prevalence of GPP in the Malaysian population and characterize its flares and trigger factors. METHODS We conducted a population-based cohort study using the Teleprimary Care database between January 2010 and December 2020. We identified 230 dermatologist-confirmed GPP cases using International Classification of Diseases, 10th revision, diagnostic codes. Annual prevalence and incidence rates were stratified by age, sex and ethnicity. We compared data regarding flares and trigger factors for patients with GPP who had associated psoriasis vulgaris (PV) with those who did not have associated PV. RESULTS The prevalence of GPP was 198 per million (267 women, 127 men) and incidence was 27.2 per million person-years [95% confidence interval (CI) 22.8-31.6]; 35.3 (28.4-42.2) per million person-years for women and 18.3 (13.1-23.5) per million person-years for men. Rates were higher in Chinese individuals [prevalence 271 per million; incidence 41.6 per million person-years (28.9-54.3)] than in the Malay population [prevalence 186; incidence 24.6 (19.4-29.7)] or the Indian ethnic group [prevalence 179; incidence 25.0 (13.8-36.3)]. Annual prevalence was consistently higher in women than in men and highest among the Chinese population, followed by the Indian and Malay populations. Overall, 67% of patients with GPP had associated PV. The prevalence and incidence of GPP without PV were lower than GPP with PV at 66 vs. 132 per million and 19.3 (95% CI 15.6-23.0) vs. 8.0 (95% CI 5.6-10.3) per million person-years, respectively. The mean age at GPP onset was 42.7 years (SD 18.4). A bimodal trend in the age of GPP onset was observed, with first and second peaks at age 20-29 years and age 50-59 years, respectively. Disease onset was significantly earlier in patients with GPP without PV than in those with PV [mean age 37.5 years (SD 20.7) vs. 44.9 years (SD 17.0), P = 0.026]. Flares occurred more frequently in patients without PV than in those with PV [mean number of flares per patient per year was 1.35 (SD 0.77) vs. 1.25 (SD 0.58), P = 0.039]. Common triggers of flares in patients with GPP who did not have PV were infections, pregnancy, menstruation and stress, whereas withdrawal of therapy, particularly systemic corticosteroids, was a more frequent trigger in patients with GPP who also had PV. CONCLUSIONS Our findings contribute to the global mapping of GPP, which will help inform the management of this rare condition.
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Affiliation(s)
- Siew Eng Choon
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Alison K Wright
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health
| | - Christopher E M Griffiths
- Centre for Dermatology Research, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
- Department of Dermatology, King's College Hospital, King's College London, London, UK
| | - Kit Wan Wong
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Kwee Eng Tey
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Yee Ting Lim
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Keow Yin Chua
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health
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22
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Chularojanamontri L, Rattanakorn K, Julanon N, Chuamanochan M, Griffiths CEM. Acrodermatitis continua of Hallopeau and generalised pustular psoriasis: Should they be the same or different entities? Exp Dermatol 2023; 32:1235-1245. [PMID: 37057764 DOI: 10.1111/exd.14805] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/26/2023] [Accepted: 03/28/2023] [Indexed: 04/15/2023]
Abstract
Pustular psoriasis is characterised by eruptions of neutrophilic sterile pustules. The European Rare and Severe Psoriasis Expert Network consensus defines pustular psoriasis into three subtypes; generalised pustular psoriasis (GPP), palmoplantar pustulosis and acrodermatitis continua of Hallopeau (ACH). Mixed forms are categorised according to their predominant features. However, the Japanese Dermatological Association includes ACH under the diagnosis of GPP. This article aims to review the similarities and differences between ACH and GPP. Based on our review, interleukin (IL)-36RN mutations, the most frequent genetic findings in pustular psoriasis are found most commonly in GPP, followed by ACH. Genotypes of IL-36RN mutations among GPP patients and ACH patients are different between European and Asian ethnicities. IL-36 signalling pathway is the main mechanism. Metabolic diseases are common comorbidities and joint involvement can occur in 20.5%-36.4% of both conditions. Associated plaque psoriasis is more common in GPP than in ACH. Generally, ACH, even the generalised type, does not have systemic inflammation whereas GPP can occur with or without systemic inflammation. ACH can occur before, simultaneously, or after the development of GPP. However, response to treatment for GPP and ACH even in the same patients appear to be different. ACH seemed to be more recalcitrant to treatment than GPP but severe flare of GPP can lead to morbidity and mortality. Although GPP and ACH share genotypes and pathogenesis, we believe that ACH should be classified separately from GPP, and not under diagnosis of GPP. Future research is warranted to satisfactorily distinguish the two conditions.
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Affiliation(s)
- Leena Chularojanamontri
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Krittaya Rattanakorn
- Division of Dermatology, Department of Medicine, Chiangrai Prachanukroh Hospital, Phayao, Thailand
| | - Narachai Julanon
- Division of Dermatology, Department of Medicine, Faculty of Medicine Srinagarind Hospital Khon Kean University, Khon Kean, Thailand
| | - Mati Chuamanochan
- Division of Dermatology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Christopher E M Griffiths
- Dermatology Centre, Salford Royal Hospital, University of Manchester, NIHR Manchester Biomedical Research Centre Manchester, Salford Manchester, UK
- Department of Dermatology, King's College Hospital, King's College London, London, UK
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23
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Capon F. A viewpoint on the genetic determinants of generalised pustular psoriasis. Exp Dermatol 2023; 32:1188-1193. [PMID: 36645252 DOI: 10.1111/exd.14746] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/17/2023]
Abstract
Generalised pustular psoriasis (GPP) is a rare and severe neutrophilic skin disorder, manifesting with acute episodes of pustulation and systemic upset. The discovery of recessive IL36RN mutations associated with GPP has transformed our understanding of disease drivers, paving the way for the development of targeted anti-IL36 therapeutics. In the light of these remarkable successes, this viewpoint reviews the significance of IL36RN mutations in GPP, their functional impact and their correlation with clinical phenotypes. It then covers the discovery of further genetic determinants (recessive MPO mutations) and risk factors (AP1S3 and CARD14 low-frequency variants) for the disease. It discusses the growing evidence for genetic complexity in GPP and concludes by outlining collaborative strategies that may be adopted to overcome the challenges ahead.
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Affiliation(s)
- Francesca Capon
- Department of Medical and Molecular Genetics, School of Basic and Medical Biosciences, King's College London, London, UK
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24
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Hsieh CY, Huang YW, Huang YH, Tsai TF. Deficiency of interleukin-36 receptor antagonist (DITRA): An analysis of 58 Chinese patients in a tertiary hospital in Taiwan. Exp Dermatol 2023; 32:1272-1278. [PMID: 36843341 DOI: 10.1111/exd.14783] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/30/2023] [Accepted: 02/23/2023] [Indexed: 02/28/2023]
Abstract
DITRA, acronym for deficiency of interleukin-36 receptor antagonist (IL36RN), leads to unopposed pro-inflammatory signalling which typically manifests as pustular psoriasis. In Asian patients, c.115 + 6 T > C mutation is the most common and important single-nucleotide variant in DITRA. We present the largest case series consisting of 58 DITRA patients carrying heterozygous or homozygous c.115 + 6 T > C mutation. The mean age of onset (±SD) was 20.74 (±20.86), and the median age of onset was 13 years old. Twelve patients (20.7%) had disease onset before the age of two. Twenty-two patients (37.9%) had disease onset between the ages of 2-18. Main clinical phenotype was generalized pustular psoriasis (GPP) with systemic symptoms (33 patients, 56.9%), followed by acrodermatitis continua of Hallopeau (ACH) (16 patients, 27.6%). Nearly half of our patients (27 patients, 46.6%) ever had ACH, and only three of them are free of ACH currently, which indicates that the development of ACH is relatively persistent and irreversible. Thirty-four patients (58.6%) had recurrent GPP and 29 patients (50%) have been admitted due to GPP flare. Compared to those with heterozygous (C/T) mutation, more patients carrying homozygous mutation (C/C) have recurrent episodes of GPP (C/T vs. C/C: 25.53 vs. 76.47%, p = 0.0367). Two patients with squamous cell carcinomas arising from the pustular psoriasis skin lesions were noted. Two patients had elevated serum IgG4 levels.
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Affiliation(s)
- Chang-Yu Hsieh
- National Taiwan University Hospital, Department of Dermatology, Taipei, Taiwan
| | - Yi-Wei Huang
- National Taiwan University Hospital, Department of Dermatology, Taipei, Taiwan
| | - Yi-Hsuan Huang
- National Taiwan University Hospital, Department of Dermatology, Taipei, Taiwan
| | - Tsen-Fang Tsai
- National Taiwan University Hospital, Department of Dermatology, Taipei, Taiwan
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25
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Choon SE, Tok PSK, Wong KW, Lim YT, Nanu NM, Barker JN, Capon F. Clinical profile of patients with acute generalized pustular psoriasis with and without IL36RN mutations in multi-ethnic Johor Bahru, Malaysia. Exp Dermatol 2023; 32:1263-1271. [PMID: 36843152 DOI: 10.1111/exd.14776] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/11/2023] [Accepted: 02/19/2023] [Indexed: 02/28/2023]
Abstract
Generalized Pustular psoriasis (GPP), a rare and potentially life-threatening auto-inflammatory disease, is associated with IL36RN mutations. Here, we analyse the prevalence of IL36RN mutations in our multi-ethnic GPP cohort and assess differences in the clinical profile of patients with (IL36RN-positive) and without (IL36RN-negative) mutations. IL36RN mutations were present in 17.7% of 137 GPP patients (29.7% of Chinese cases, 17.3% of Malay cases, but 0% of Indian patients). 92% of these individuals carried the c.115 + 6 T > C mutation. Male: female ratio was 1:2.3. Females predominate in both groups with no significant difference between IL36RN-positive and IL36RN-negative individuals. The overall mean age (±SD) at disease onset for GPP was 37.6 ± 17.2 years, but disease onset was significantly earlier in IL36RN-positive vs IL36RN-negative cases (mean age:30.6 ± 18.92 vs. 39.2 ± 16.49 years, p = 0.027). IL36RN-positive patients were less likely to have associated plaque psoriasis (52.4% vs. 83.5%, p-value = 0.002). There was no difference in the common clinical and laboratory manifestations or triggers of GPP between IL36RN-positive and -negative patients, except for geographic tongue which was significantly more common in IL36RN-positive patients (41.7% vs. 11.9%, p-value = 0.002). Annual flare rate was significantly higher in IL36RN-positive compared to IL36RN-negative (mean ± SD of 1.92 ± 1.32 vs. 1.46 ± 0.90, p = 0.041) cases. However, no significant difference in the rate of hospitalization and length of hospital stay was observed between the two groups. These observations demonstrate that IL36RN disease alleles occur with varying frequencies among Asian populations and are associated with a severe, early-onset clinical phenotype.
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Affiliation(s)
- Siew Eng Choon
- Department of Dermatology, Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Kuala Lumpur, Malaysia
| | - Peter Seah Keng Tok
- Institute for Clinical Research, National Institutes of Health, Ministry of Health Malaysia, Putrajaya, Malaysia
| | - Kit Wan Wong
- Department of Dermatology, Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
| | - Yee Ting Lim
- Department of Dermatology, Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
| | - Nalini M Nanu
- Department of Dermatology, Hospital Sultanah Aminah Johor Bahru, Johor Bahru, Malaysia
| | - Jonathan N Barker
- St John's Institute of Dermatology at Guys and St Thomas's Hospitals and Kings College London, London, UK
| | - Francesca Capon
- Department of Medical and Molecular Genetics, King's College London, London, UK
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26
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Hüffmeier U, Klima J, Hayatu MD. Genetic underpinnings of the psoriatic spectrum. MED GENET-BERLIN 2023; 35:46-54. [PMID: 38835412 PMCID: PMC10842586 DOI: 10.1515/medgen-2023-2005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
The psoriatic field includes both rare and common subtypes. Common complex forms include psoriasis vulgaris and psoriatic arthritis. In these subtypes, certain HLA alleles remain the most relevant genetic factors, although genome-wide association studies lead to the detection of more than 80 susceptibility loci. They mainly affect innate and adaptive immunity and explain over 28 % of the heritability. Pustular psoriasis comprises a group of rarer subtypes. Using exome sequencing, several disease genes were identified for mainly generalized pustular psoriasis, and an oligogenic inheritance is likely. Treatment studies based on the affected IL-36 pathway indicate a high response rate in this subtype further supporting the pathophysiological relevance of the affected gene products.
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Affiliation(s)
- Ulrike Hüffmeier
- Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg Institute of Human Genetics Schwabachanlage 10 91054 Erlangen Deutschland
| | - Janine Klima
- Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg Institute of Human Genetics Schwabachanlage 10 91054 Erlangen Germany
| | - Mohammad Deen Hayatu
- Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg Institute of Human Genetics Schwabachanlage 10 91054 Erlangen Germany
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27
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Morita A, Tsai TF, Yee EYW, Okubo Y, Imafuku S, Zheng M, Li L, Quaresma M, Thoma C, Choon SE. Efficacy and safety of spesolimab in Asian patients with a generalized pustular psoriasis flare: Results from the randomized, double-blind, placebo-controlled Effisayil™ 1 study. J Dermatol 2023; 50:183-194. [PMID: 36282833 PMCID: PMC10092680 DOI: 10.1111/1346-8138.16609] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/24/2022] [Accepted: 09/27/2022] [Indexed: 02/04/2023]
Abstract
Generalized pustular psoriasis is a potentially life-threatening neutrophilic skin disease characterized by recurrent flares of widespread erythema and eruption of sterile pustules. In the Effisayil™ 1 study (NCT03782792), 53 patients with a generalized pustular psoriasis flare were treated with placebo or spesolimab, a humanized anti-interleukin-36 receptor monoclonal antibody, the first targeted treatment to be studied in a randomized clinical trial. Spesolimab treatment resulted in rapid pustular and skin clearance, with an acceptable safety profile. Here, we evaluate the efficacy and safety of spesolimab in 29 Asian patients in the Effisayil™ 1 study. The primary endpoint, a Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) pustulation subscore of 0 (no visible pustules) at Week 1, was achieved by 10 patients (62.5%) randomized to spesolimab and one patient (7.7%) randomized to placebo (risk difference 54.8, 95% confidence interval [CI] 17.3-79.8). The key secondary endpoint, a GPPGA total score of 0 or 1 (clear or almost clear skin) at Week 1, was achieved by eight (50.0%) and two (15.4%) patients, respectively (risk difference 34.6, 95% CI -3.1-64.7). This was similar to previously published data in the overall population in whom the primary and key secondary endpoints were achieved by 54% versus 6% and 43% versus 11% of patients, respectively. The percentages of Asian patients randomized to spesolimab with a GPPGA pustulation subscore of 0 and GPPGA total score of 0 or 1 were sustained above 60% for up to 12 weeks. In these patients, patient-reported outcomes also improved and markers of systemic inflammation were normalized. Eleven (68.8%) and eight (61.5%) of spesolimab- and placebo-treated patients, respectively, experienced at least one adverse event. In conclusion, spesolimab improved outcomes in Asian patients compared with placebo, supporting its use in the treatment of generalized pustular psoriasis flares.
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Affiliation(s)
- Akimichi Morita
- Department of Geriatric and Environmental Dermatology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Evelyn Yap Wen Yee
- Department of Dermatology, Hospital Pakar Sultanah Fatimah, Muar, Malaysia
| | - Yukari Okubo
- Department of Dermatology, Tokyo Medical University, Tokyo, Japan
| | - Shinichi Imafuku
- Department of Dermatology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Min Zheng
- Department of Dermatology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ling Li
- Boehringer Ingelheim (China) Investment Corporation Limited, Shanghai, People's Republic of China
| | | | | | - Siew Eng Choon
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia, and Clinical School Johor Bahru, Monash University Malaysia, Johor Bahru, Malaysia
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28
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Prinz JC, Choon SE, Griffiths CEM, Merola JF, Morita A, Ashcroft DM, Viguier M. Prevalence, comorbidities and mortality of generalized pustular psoriasis: A literature review. J Eur Acad Dermatol Venereol 2023; 37:256-273. [PMID: 36331364 DOI: 10.1111/jdv.18720] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 10/25/2022] [Indexed: 11/06/2022]
Abstract
Generalized pustular psoriasis (GPP) is a rare auto-inflammatory skin disease characterised by acute episodes of sterile pustule formation. Diagnosis and treatment of the disease have historically been complicated by a lack of awareness, and no consistent global definition or clinical coding standards. Now acknowledged as a distinct clinical entity with a recognised genetic component, GPP can take a serious and life-threatening course due to systemic inflammatory complications and its association with various comorbidities. As with other rare diseases, there are significant challenges to understanding the epidemiology of GPP, notably a small patient population, non-standardised study methodologies and ethnic differences in its presentation. A clearer understanding of GPP is therefore required for clinicians to better manage patients with this rare condition. In this review article, we present an overview of the available data on GPP prevalence estimates in key demographics and report the frequency of genetic mutations associated with the disease. We detail the incidence of known comorbidities and summarise the data on mortality and assigned causes of death. Lastly, we discuss the various factors that impact the collection, interpretation and comparison of these data.
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Affiliation(s)
- Jörg C Prinz
- Department of Dermatology and Allergy, University Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Siew Eng Choon
- Department of Dermatology, Hospital Sultanah Aminah, Clinical School Johor Bahru, Monash University Malaysia, Johor Bahru, Malaysia
| | - Christopher E M Griffiths
- Dermatology Centre, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Joseph F Merola
- Department of Dermatology and Medicine, Division of Rheumatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Akimichi Morita
- Department of Geriatric and Environmental Dermatology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Darren M Ashcroft
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Manuelle Viguier
- Department of Dermatology-Venereology, Hôpital Robert Debré, Université Reims-Champagne Ardenne, Reims, France
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29
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Trai NN, Van Em D, Van BT, My LH, Van Tro C, Hao NT, Vu HA, Tram DB, Van Thuong N, Doanh LH. Correlation of IL36RN and CARD14 mutations with clinical manifestations and laboratory findings in patients with generalised pustular psoriasis. Indian J Dermatol Venereol Leprol 2022; 89:378-384. [DOI: 10.25259/ijdvl_1054_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 03/01/2022] [Indexed: 11/04/2022]
Abstract
Background
Generalized pustular psoriasis (GPP) is a chronic disease associated with genetic factors related to mutations of the interleukin 36 receptor antagonist gene (IL36RN) and the caspase recruitment domain 14 gene (CARD14). However, the relevance of these mutations to the clinical features and severity of GPP remains unclear.
Aims
Our objective was to correlate the presence of IL36RN and CARD14 mutations with the clinical and laboratory findings in patients with GPP.
Methods
This cross-sectional descriptive study was conducted in 64 subjects with GPP. Clinical manifestations were recorded and the severity was graded as mild, moderate, or severe. Routine laboratory tests were performed and blood samples were collected for Sanger sequencing. The clinical data of patients were compared among the different mutation groups.
Results
The two main variants of IL36RN were c.115+6T > C (p.Arg10ArgfsX1) and c.227C > T (p.Pro76Leu). The major CARD14 mutations were c.2458C > T (p.Arg820Trp), c.1641C > T (p.Arg547Ser), and c.1753G > A transitions.
Provocative factors were uncommon in the group with both IL36RN and CARD14 mutations. Drugs (unspecified), especially herbals, were the most common triggers. A history of psoriasis was frequent in patients with only CARD14 mutations, but fever was uncommon. The c.1641C > T mutation was associated with leukocytosis > 15000/mm3 and the c.1753G > A mutation was associated with hypoalbuminemia <3.8g/dL.
Both the c.115+6T > C and c.227C > T variants of IL36RN were associated with fever ≥38.5°C while the c.115+6T > C variant was also associated with geographic tongue.
No gene mutations were associated with the total severity and severity grades.
Limitations
Four patients without the two major IL36RN mutations were excluded from the study.
Conclusion
The presence of IL36RN and CARD14 mutations were associated with a history of psoriasis, various provocative factors, fever, leukocytosis, hypoalbuminemia, and geographic tongue. Further studies to explore the role of these mutations in therapeutic efficacy and disease outcomes are necessary.
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Affiliation(s)
| | - Dang Van Em
- Department of Dermatology, Institute of Clinical Research and Medicine, Hanoi, Vietnam
| | - Bui Thi Van
- Department of Dermatology, Institute of Clinical Research and Medicine, Hanoi, Vietnam
| | - Le Huyen My
- Department of Dermatology, Hanoi Central Institute of Dermatology, Dong Da, Hanoi, Vietnam
| | | | - Nguyen Trong Hao
- Department of Dermatology, Ho Chi Minh City Hospital of Dermato Venereology, Ho Chi Minh City, Vietnam
| | - Hoang Anh Vu
- Center for Molecular Biomedicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Duong Bich Tram
- Center for Molecular Biomedicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Nguyen Van Thuong
- Department of Dermatology, Hanoi Central Institute of Dermatology, Dong Da, Hanoi, Vietnam
| | - Le Huu Doanh
- Department of Dermatology, Hanoi Central Institute of Dermatology, Dong Da, Hanoi, Vietnam
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30
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Fukasawa T, Yoshizaki-Ogawa A, Enomoto A, Miyagawa K, Sato S, Yoshizaki A. Involvement of Molecular Mechanisms between T/B Cells and IL-23: From Palmoplantar Pustulosis to Autoimmune Diseases. Int J Mol Sci 2022; 23:8261. [PMID: 35897837 PMCID: PMC9332852 DOI: 10.3390/ijms23158261] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/22/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
Palmoplantar pustulosis (PPP) is a disease that causes recurrent blisters and aseptic pustules on the palms and soles. It has been suggested that both innate and acquired immunity are involved. In particular, based on the tonsils and basic experiments, it has been assumed that T and B cells are involved in its pathogenesis. In addition, the results of clinical trials have suggested that IL-23 is closely related to the pathogenesis. This review describes PPP and the genetic background, the factors involved in the onset and exacerbation of disease and its relation to the molecular mechanism. In addition, we describe the usefulness of biological therapy and its implications in relation to the importance in pathology, the pathogenesis of PPP, the importance of the role of the IL-23-Th17 axis and IL-36 in PPP. Furthermore, we describe an animal experimental model of PPP, the efficacy and mechanism of action of guselkumab, an anti-IL-23 antibody, the latest research, and finally the possibility for it to be effective for other autoimmune diseases.
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Affiliation(s)
- Takemichi Fukasawa
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo 113-8655, Japan; (T.F.); (A.Y.-O.); (S.S.)
| | - Asako Yoshizaki-Ogawa
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo 113-8655, Japan; (T.F.); (A.Y.-O.); (S.S.)
| | - Atsushi Enomoto
- Laboratory of Molecular Radiology, Center for Disease Biology and Integrative Medicine, The University of Tokyo Graduate School of Medicine, Tokyo 113-8655, Japan; (A.E.); (K.M.)
| | - Kiyoshi Miyagawa
- Laboratory of Molecular Radiology, Center for Disease Biology and Integrative Medicine, The University of Tokyo Graduate School of Medicine, Tokyo 113-8655, Japan; (A.E.); (K.M.)
| | - Shinichi Sato
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo 113-8655, Japan; (T.F.); (A.Y.-O.); (S.S.)
| | - Ayumi Yoshizaki
- Department of Dermatology, The University of Tokyo Graduate School of Medicine, Tokyo 113-8655, Japan; (T.F.); (A.Y.-O.); (S.S.)
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31
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Seishima M, Fujii K, Mizutani Y. Generalized Pustular Psoriasis in Pregnancy: Current and Future Treatments. Am J Clin Dermatol 2022; 23:661-671. [PMID: 35704168 DOI: 10.1007/s40257-022-00698-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/28/2022]
Abstract
Generalized pustular psoriasis (GPP) is a rare, severe neutrophilic skin disease characterized by sudden widespread eruption of sterile pustules with or without systemic symptoms. GPP may be life threatening in cases with severe complications such as cardiovascular failure, acute respiratory distress syndrome, and serious infections. Impetigo herpetiformis (IH) is a GPP that is induced and exacerbated by pregnancy and occurs most frequently during the last trimester. IH may result in poor or fatal neonatal outcomes, including placental insufficiency, fetal abnormalities, stillbirth, and early neonatal death. Most patients have prompt remission in the postpartum period; however, earlier appearance and more severe symptoms are observed during subsequent pregnancies. Appropriate treatment and close monitoring of the mother and fetus are vital for the management of patients with IH. Particular attention is required for the management of patients with IH to avoid an influence on the fetus. However, data regarding treatments for GPP in pregnant women are sparse. Over the last decade, many patients with IH have been treated with cyclosporine, corticosteroids, tumor necrosis factor-α inhibitors, interleukin (IL)-17 and IL-12/23 inhibitors, and granulocyte and monocyte adsorption apheresis (GMA). GMA may be an important option for patients with IH as it is presently one of the safest available therapeutic options, but there have been no reports to fully confirm its safety in pregnant patients with GPP. Alternatively, based on recent advances in the understanding of the role of the IL-36 axis in the pathogenesis of GPP, biologic agents that target the IL-36 pathway may demonstrate promising efficacy in IH.
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Affiliation(s)
- Mariko Seishima
- Department of Dermatology, Gifu University Graduate School of Medicine, 1-1, Yanagido, Gifu, 501-1194, Japan. .,Department of Dermatology, Asahi University Hospital, 3-23, Hashimoto-cho, Gifu, 500-8523, Japan.
| | - Kento Fujii
- Department of Dermatology, Gifu University Graduate School of Medicine, 1-1, Yanagido, Gifu, 501-1194, Japan
| | - Yoko Mizutani
- Department of Dermatology, Gifu University Graduate School of Medicine, 1-1, Yanagido, Gifu, 501-1194, Japan
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32
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Chao J, Tsai T. Elderly‐onset generalized pustular psoriasis: a case series. Clin Exp Dermatol 2022; 47:1567-1570. [DOI: 10.1111/ced.15227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jen‐Ping Chao
- Department of Dermatology National Taiwan University Hospital Taipei Taiwan
| | - Tsen‐Fang Tsai
- Department of Dermatology National Taiwan University Hospital Taipei Taiwan
- Department of Dermatology National Taiwan University College of Medicine Taipei Taiwan
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33
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Lee TL, Tsai TF. Non-immune functions of inflammatory cytokines targeted by anti-psoriatic biologics: a review. Inflamm Res 2022; 71:157-168. [PMID: 34981130 DOI: 10.1007/s00011-021-01528-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 11/25/2021] [Accepted: 11/25/2021] [Indexed: 12/01/2022] Open
Abstract
PURPOSE Psoriasis is an inflammatory disease characterized by skin thickening with silvery white desquamation due to dysregulated inflammatory pathways and elevated levels of inflammatory cytokines. Biologic agents targeting these inflammatory cytokines have brought about significant improvement in clearing psoriatic lesions in patients with moderate-to-severe psoriasis. Moreover, biologics exert both beneficial and detrimental effects on comorbidities in psoriasis, which include increased risk of cardiovascular events, metabolic syndrome, among other conditions. However, non-immune functions of cytokines targeted by biologics, and, hence, the potential risks and benefits of biologics for psoriasis to different organs/systems and comorbidities, have not been well elucidated. RESULTS This review summarizes current understanding of the pathogenesis of psoriasis-related comorbidities and emerging discoveries of roles of cytokines targeted in psoriasis treatment, including tumor necrosis factor α and interleukins 12, 23, and 17, aiming to complete the safety profile of each biologics and provide therapeutic implications on psoriasis-related comorbidities, and on diseases involving other organs or systems.
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Affiliation(s)
- Tung-Lin Lee
- Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, 7 Chung-Shan S. Rd., Taipei, 100, Taiwan.
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34
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Treatment Options and Goals for Patients with Generalized Pustular Psoriasis. Am J Clin Dermatol 2022; 23:51-64. [PMID: 35061230 PMCID: PMC8801408 DOI: 10.1007/s40257-021-00658-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2021] [Indexed: 12/17/2022]
Abstract
Generalized pustular psoriasis (GPP) is a rare, severe neutrophilic skin disorder characterized by sudden widespread eruption of superficial sterile pustules with or without systemic inflammation. GPP flares can be life-threatening if untreated due to potential severe complications such as cardiovascular failure and serious infections. Currently, there are no GPP-specific therapies approved in the USA or Europe. Retinoids, cyclosporine, and methotrexate are the most commonly used non-biologic therapies for GPP. The evidence that supports the currently available treatment options is mainly based on case reports and small, open-label, single-arm studies. However, recent advances in our understanding of the pathogenic mechanisms of GPP and the identification of gene mutations linked to the disease have paved the way for the development of specific targeted therapies that selectively suppress the autoinflammatory and autoimmune mechanisms induced during GPP flares. Several biologic agents that target key cytokines involved in the activation of inflammatory pathways, such as tumor necrosis factor-α blockers and interleukin (IL)-17, IL-23, and IL-12 inhibitors, have emerged as potential treatments for GPP, with several being approved in Japan. The evidence supporting the efficacy of these agents is mainly derived from small, uncontrolled trials. A notable recent advance is the discovery of IL36RN mutations and the central role of IL-36 receptor ligands in the pathogenesis of GPP, which has defined key therapeutic targets for the disease. Biologic agents that target the IL-36 pathway have demonstrated promising efficacy in patients with GPP, marking the beginning of a new era of targeted therapy for GPP.
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35
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Abstract
Generalized pustular psoriasis (GPP) is a rare, severe form of pustular psoriasis characterized by widespread, recurrent episodes of neutrophil-rich pustule formation in the epidermis, which can be accompanied by fever and systemic inflammation. Recent clinical, histologic, and genetic evidence indicates that GPP is a distinct entity from plaque psoriasis, with different cytokine pathways predominant in the manifestation of each disease. The interleukin-36 (IL-36) signaling cascade plays a key role in regulating the innate immune system, and its dysregulation appears central to the pathogenesis of GPP. The altered expression of various IL-36 pathway constituents has been shown to cause a positive feedback loop of uncontrolled signaling and excess production of inflammatory cytokines, which in turn leads to chemokine induction and neutrophil recruitment in the epidermis. Given the potentially life-threatening nature of GPP episodes, drug interventions that rapidly achieve disease resolution are required. Early phase data indicate that treatments targeting various components of the IL-36 inflammatory cascade represent promising areas of research. However, there are currently no therapeutic agents specifically approved for GPP in the USA or Europe. Understanding the inflammatory pathways, associated risk factors, and role of neutrophils in the manifestation and perpetuation of GPP flares remains a key goal in developing effective therapeutics. In this article, we summarize the current understanding of GPP, describe novel therapeutic opportunities, and detail how the unique pathophysiology of the disease may inform future treatment strategies.
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Affiliation(s)
| | - Lluis Puig
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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36
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Pustular psoriasis: Molecular pathways and effects of spesolimab in generalized pustular psoriasis. J Allergy Clin Immunol 2021; 149:1402-1412. [PMID: 34678325 DOI: 10.1016/j.jaci.2021.09.035] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/17/2021] [Accepted: 09/07/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND The IL-36 pathway plays a key role in the pathogenesis of generalized pustular psoriasis (GPP). In a proof-of-concept clinical trial, treatment with spesolimab, an anti-IL-36 receptor antibody, resulted in rapid skin and pustular clearance in patients presenting with GPP flares. OBJECTIVE We sought to compare the molecular profiles of lesional and nonlesional skin from patients with GPP or palmoplantar pustulosis (PPP) with skin from healthy volunteers, and to investigate the molecular changes after spesolimab treatment in the skin and blood of patients with GPP flares. METHODS Pre- and post-treatment skin and blood samples were collected from patients with GPP who participated in a single-arm, phase I study (n = 7). Skin biopsies from patients with PPP (n = 8) and healthy volunteers (n = 16) were obtained for comparison at baseline. Biomarkers were assessed by RNA-sequencing, histopathology, and immunohistochemistry. RESULTS In GPP and PPP lesions, 1287 transcripts were commonly upregulated or downregulated. Selected transcripts from the IL-36 signaling pathway were upregulated in untreated GPP and PPP lesions. In patients with GPP, IL-36 pathway-related signatures, TH1/TH17 and innate inflammation signaling, neutrophilic mediators, and keratinocyte-driven inflammation pathways were downregulated by spesolimab as early as week 1. Spesolimab also decreased related serum biomarkers and cell populations in the skin lesions from patients with GPP, including CD3+ T, CD11c+, and IL-36γ+ cells and lipocalin-2-expressing cells. CONCLUSIONS In patients with GPP, spesolimab showed rapid modulation of commonly dysregulated molecular pathways in GPP and PPP, which may be associated with improved clinical outcomes.
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Generalized Pustular Psoriasis: Divergence of Innate and Adaptive Immunity. Int J Mol Sci 2021; 22:ijms22169048. [PMID: 34445754 PMCID: PMC8396665 DOI: 10.3390/ijms22169048] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/08/2021] [Accepted: 08/11/2021] [Indexed: 12/28/2022] Open
Abstract
Generalized pustular psoriasis (GPP) is a severe, relapsing, immune-mediated disease characterized by the presence of multiple sterile pustules all over the body. The exact pathomechanisms behind GPP remain elusive, although increased interest in the genetic basis and immunological disturbances have provided some revealing insights into the underlying signaling pathways and their mutual interaction. The genetic background of GPP has been thoroughly investigated over the past few years. The conducted studies have identified genetic variants that predispose to pustular forms of psoriasis. The loss-of-function mutation of the interleukin 36 receptor antagonist gene, along with rare gain-of-function mutations in the gene that encodes the keratinocyte signaling molecule (CARD14), are examples of the uncovered abnormalities. Interleukin 36 (IL-36), along with neutrophils, is now considered a central cytokine in GPP pathogenesis, with IL-36 signaling providing a link between innate and adaptive immune responses. More recently, a new concept of inflammation, caused by a predominantly genetically determined abnormal activation of innate immune response and leading to inflammatory keratinization, has arisen. GPP is currently considered a representative of this novel group of skin conditions, called autoinflammatory keratinization diseases. As no therapeutic agents have been approved for GPP to date in the United States and Europe, the novel anti-IL-36R antibodies are particularly promising and may revolutionize management of the disease.
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Abstract
Palmoplantar pustulosis (PPP) is a chronic inflammatory condition where crops of sterile pustules with erythematous keratotic lesions causing bleeding and pain appear on the palms and soles. Recently, the European Rare and Severe Expert Network considered PPP as a variant of pustular psoriasis with or without psoriasis vulgaris. The prevalence of PPP varies from 0.050 to 0.12%. PPP occurs more frequently in women and the highest prevalence occurred between the ages of 50 and 69 years. Nail psoriasis seems to be frequent in PPP, ranging from 30 to 76%, and psoriatic arthritis in 8.6 to 26% of PPP patients. Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome and pustulotic arthro-osteitis are considered PPP-associated disorders. PPP has been reported with other co-morbidities such as psychiatric disorders, thyroid-associated disease, altered calcium homeostasis, gluten sensitivity diabetes, obesity, and dyslipidemia, but larger studies are required to prove such associations. Environmental exacerbating factors might contribute to the onset or worsening of PPP such as cigarette smoking, stress, focal infections, metal allergies, and drug intake. Genetic predisposition plays an important role in PPP. In PPP, both the innate and the adaptive immune systems are activated. The acrosyringeal expression of IL-17 has been demonstrated, indicating that the eccrine sweat gland is an active component of the skin barrier and an immune-competent structure. Increased levels of several inflammatory molecules, including IL-8, IL-1α, IL-1β, IL-17A, IL-17C, IL-17D, IL-17F, IL-22, IL-23A, and IL-23 receptor, have been detected in PPP biopsies. Increased serum levels of TNF-α, IL-17, IL-22, and IFN-γ have been detected in patients with PPP in comparison to healthy subjects, suggesting a similar inflammatory pattern to psoriasis vulgaris. Oral and tonsillar infections serve as trigger factors for PPP. Long-term therapy is required for many patients, but high-quality data are limited, contributing to uncertainty about the ideal approach to treatment.
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Zhou J, Luo Q, Cheng Y, Wen X, Liu J. An update on genetic basis of generalized pustular psoriasis (Review). Int J Mol Med 2021; 47:118. [PMID: 33955502 PMCID: PMC8083806 DOI: 10.3892/ijmm.2021.4951] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/11/2021] [Indexed: 01/28/2023] Open
Abstract
Generalized pustular psoriasis (GPP) is a rare and severe auto-inflammatory skin disease that is characterized by recurrent, acute onset, and generalized pustular eruptions on erythematous, inflamed skin. GPP is traditionally classified as a variant of psoriasis vulgaris, even though recent clinical, histological and genetic evidence suggests that it is a heterogeneous disease and requires a separate diagnosis. In recent years, variants of IL36RN, CARD14, AP1S3 and MPO genes have been identified as causative or contributing to genetic defects in a proportion of patients affected by GPP. These disease-related genes are involved in common inflammatory pathways, in particular in the IL-1/IL-36-chemokines-neutrophil pathogenic axis. At present, no standard therapeutic guidelines have been established for GPP management, and there is a profound need for novel efficacious treatments of GPP. Among them, biological agents antagonizing the IL-36 pathway are promising therapeutics. The aim of the present review is to provide the most recent updates on the genetics, genotype-phenotype correlation and pathological basis of GPP, as well as on biologic treatments available for GPP and relative clinical courses.
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Affiliation(s)
- Jiahong Zhou
- Department of Laboratory Medicine, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Qing Luo
- Department of Laboratory Medicine, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Yang Cheng
- Department of Laboratory Medicine, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Xia Wen
- Department of Laboratory Medicine, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
| | - Jinbo Liu
- Department of Laboratory Medicine, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P.R. China
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Iznardo H, Puig L. Exploring the Role of IL-36 Cytokines as a New Target in Psoriatic Disease. Int J Mol Sci 2021; 22:ijms22094344. [PMID: 33919434 PMCID: PMC8122427 DOI: 10.3390/ijms22094344] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 02/06/2023] Open
Abstract
Unmet needs in the treatment of psoriasis call for novel therapeutic strategies. Pustular psoriasis and psoriatic arthritis often represent a therapeutic challenge. Focus on IL-36 cytokines offers an interesting approach, as the IL-36 axis has been appointed a critical driver of the autoinflammatory responses involved in pustular psoriasis. Two IL-36R blocking antibodies, imsidolimab and spesolimab, are currently undergoing phase II and III clinical trials, with promising results.
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Affiliation(s)
- Helena Iznardo
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain;
| | - Lluís Puig
- Dermatology Department, Hospital de la Santa Creu i Sant Pau, 08041 Barcelona, Spain;
- Department of Medicine, School of Medicine, Universitat Autònoma de Barcelona, 08041 Barcelona, Spain
- Correspondence:
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Choon SE, Lebwohl MG, Marrakchi S, Burden AD, Tsai TF, Morita A, Navarini AA, Zheng M, Xu J, Turki H, Rajeswari S, Deng H, Tetzlaff K, Thoma C, Bachelez H. Study protocol of the global Effisayil 1 Phase II, multicentre, randomised, double-blind, placebo-controlled trial of spesolimab in patients with generalized pustular psoriasis presenting with an acute flare. BMJ Open 2021; 11:e043666. [PMID: 33785490 PMCID: PMC8011793 DOI: 10.1136/bmjopen-2020-043666] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Generalized pustular psoriasis (GPP) is a rare, potentially life-threatening disease characterised by recurrent flares of widespread neutrophilic aseptic skin pustular eruption. Despite the availability of approved biologics for GPP in Japan, Taiwan and Thailand, associated evidence is largely based on uncontrolled studies in which acute flares were not directly assessed. Therefore, there is a high unmet need to investigate new rapid-acting effective treatments that resolve symptoms associated with acute GPP flares. A prior Phase I proof-of-concept study showed rapid improvements in skin and pustule clearance with a single intravenous dose of spesolimab, a novel anti-interleukin-36 receptor antibody, in patients presenting with an acute GPP flare. Here, we present the design and rationale of Effisayil 1, a global, Phase II, placebo-controlled study to evaluate the efficacy, safety and tolerability of spesolimab in patients presenting with an acute GPP flare. METHODS AND ANALYSIS At least 51 patients with an acute GPP flare will be randomised 2:1 to receive a single 900 mg intravenous dose of spesolimab or placebo and followed for up to 28 weeks. The primary endpoint is a Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) pustulation subscore of 0 (pustule clearance) at Week 1. The key secondary endpoint is a GPPGA score of 0 or 1 (clear or almost clear) at Week 1. Safety will be assessed over the study duration by the occurrence of treatment-emergent adverse events. Blood and skin biopsies will be collected to assess biomarkers. Superiority of spesolimab over placebo in the proportion of patients achieving the primary and key secondary endpoints will be evaluated. ETHICS AND DISSEMINATION The study complies with the ethical principles of the Declaration of Helsinki, the International Council for Harmonisation's Good Clinical Practice and local regulations. Ethics committee approvals have been obtained for each centre from all participating countries and are listed in online supplementary file 1. Primary results will be published in a peer-reviewed journal. TRIAL REGISTRATION DETAILS ClinicalTrials.gov identifier: NCT03782792; Pre-results.
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Affiliation(s)
- Siew Eng Choon
- Jeffrey Cheah School of Medicine and Health Sciences, Clinical School Johor Bahru, Monash University Malaysia, Johor Bahru, Johor, Malaysia
| | - Mark G Lebwohl
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - A David Burden
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Akimichi Morita
- Department of Geriatric and Environmental Dermatology, Nagoya City University, Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Min Zheng
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Jinhua Xu
- Department of Dermatology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hamida Turki
- Dermatology Department, Hedi Chaker University Hospital, Sfax, Tunisia
| | | | - Hongjie Deng
- Boehringer Ingelheim (China), Investment Co Ltd, Shanghai, China
| | - Kay Tetzlaff
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | | | - Hervé Bachelez
- Service de Dermatologie, Assistance Publique-Hôpitaux de Paris Hôpital Saint-Louis, Paris, France
- INSERM U1163, Imagine Institute for Genetics of Human Diseases, Université de Paris, Paris, France
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42
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Martin P, Goldstein JD, Mermoud L, Diaz-Barreiro A, Palmer G. IL-1 Family Antagonists in Mouse and Human Skin Inflammation. Front Immunol 2021; 12:652846. [PMID: 33796114 PMCID: PMC8009184 DOI: 10.3389/fimmu.2021.652846] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/22/2021] [Indexed: 12/23/2022] Open
Abstract
Interleukin (IL)-1 family cytokines initiate inflammatory responses, and shape innate and adaptive immunity. They play important roles in host defense, but excessive immune activation can also lead to the development of chronic inflammatory diseases. Dysregulated IL-1 family signaling is observed in a variety of skin disorders. In particular, IL-1 family cytokines have been linked to the pathogenesis of psoriasis and atopic dermatitis. The biological activity of pro-inflammatory IL-1 family agonists is controlled by the natural receptor antagonists IL-1Ra and IL-36Ra, as well as by the regulatory cytokines IL-37 and IL-38. These four anti-inflammatory IL-1 family members are constitutively and highly expressed at steady state in the epidermis, where keratinocytes are a major producing cell type. In this review, we provide an overview of the current knowledge concerning their regulatory roles in skin biology and inflammation and their therapeutic potential in human inflammatory skin diseases. We further highlight some common misunderstandings and less well-known observations, which persist in the field despite recent extensive interest for these cytokines.
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Affiliation(s)
- Praxedis Martin
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jérémie D. Goldstein
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Loïc Mermoud
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Alejandro Diaz-Barreiro
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Gaby Palmer
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Mrowietz U, Burden AD, Pinter A, Reich K, Schäkel K, Baum P, Datsenko Y, Deng H, Padula SJ, Thoma C, Bissonnette R. Spesolimab, an Anti-Interleukin-36 Receptor Antibody, in Patients with Palmoplantar Pustulosis: Results of a Phase IIa, Multicenter, Double-Blind, Randomized, Placebo-Controlled Pilot Study. Dermatol Ther (Heidelb) 2021; 11:571-585. [PMID: 33661508 PMCID: PMC8019016 DOI: 10.1007/s13555-021-00504-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/11/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction Palmoplantar pustulosis (PPP) is a chronic, inflammatory skin disease, with high disease burden, that is often refractory to treatment. There is a high unmet clinical need for the treatment of patients with PPP. The objectives of this study were to evaluate the safety and efficacy of spesolimab, a novel anti-interleukin-36 receptor antibody, in patients with PPP. Methods This was a phase IIa, multicenter, double-blind, randomized, placebo-controlled pilot study comparing 900 mg spesolimab (n = 19), 300 mg spesolimab (n = 19), and placebo (n = 21) administered intravenously every 4 weeks until week 12 in patients with PPP. The primary efficacy endpoint was the achievement of Palmoplantar Pustulosis Area and Severity Index 50 (PPP ASI50) at week 16, defined as achieving an ≥ 50% decrease from baseline PPP ASI. Results At week 16, 31.6% of patients in both spesolimab dose groups achieved PPP ASI50 versus 23.8% receiving placebo (risk difference 0.078; 95% confidence interval –0.190, 0.338). Thus, the primary endpoint was not met. Spesolimab was well tolerated with no clinically relevant treatment-emergent safety signals observed. Conclusions PPP severity declined over time in all treatment groups after the start of treatment, with a faster decline in the spesolimab arms than in the placebo arm, indicating a potential treatment effect for spesolimab. Limitations to the study included a small sample size and lower overall disease severity than expected at baseline. It is possible that the primary efficacy endpoint may have coincided with natural disease resolution in some patients. Further effects of the efficacy of spesolimab in PPP are being explored in a phase IIb trial. Supplementary Information The online version contains supplementary material available at 10.1007/s13555-021-00504-0.
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Affiliation(s)
- Ulrich Mrowietz
- Psoriasis-Center at the Department of Dermatology, University Medical Center, Schleswig-Holstein, Campus Kiel, Kiel, Germany.
| | - A David Burden
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Andreas Pinter
- Department of Dermatology, Venereology and Allergology, University Clinic Frankfurt Am Main, Frankfurt am Main, Germany
| | - Kristian Reich
- Center of Translational Research in Inflammatory Skin Diseases, Institute for Health Services Research in Dermatology and Nursing, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Knut Schäkel
- Department of Dermatology, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Patrick Baum
- Boehringer Ingelheim International GmbH, Biberach, Germany
| | - Yakov Datsenko
- Boehringer Ingelheim International GmbH, Biberach, Germany
| | - Hongjie Deng
- Boehringer Ingelheim (China) Investment Co. Ltd, Shanghai, China
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Yamamoto T. Similarity and difference between palmoplantar pustulosis and pustular psoriasis. J Dermatol 2021; 48:750-760. [PMID: 33650702 DOI: 10.1111/1346-8138.15826] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/07/2021] [Indexed: 12/11/2022]
Abstract
Palmoplantar pustulosis is a chronic inflammatory disorder characterized by sterile pustules predominantly involving the palms and soles. Palmoplantar pustulosis has many similar aspects to psoriasis, either plaque and pustular type, namely familial occurrence between palmoplantar pustulosis and psoriasis, the appearance of the Köbner phenomenon, joint involvement, and nail involvement. Pustular psoriasis is classified into generalized and localized types, and there are a number of papers regarding palmoplantar pustulosis as an acral variant of localized pustular psoriasis. Many Japanese dermatologists consider palmoplantar pustulosis to be a distinct entity from pustular psoriasis, and the coexistence of palmoplantar pustulosis and psoriasis is rare. However, outside Japan, palmoplantar pustulosis is often considered to be palmoplantar psoriasis or palmoplantar pustular psoriasis, and extra-palmoplantar lesions are also considered to be psoriasis. The purpose of the current review is to compare the similarities and differences between palmoplantar pustulosis and generalized/localized pustular psoriasis. Japanese patients with palmoplantar pustulosis have a close relationship with focal infection, and the associated bone-joint manifestation exclusively involves the anterior chest wall. Furthermore, pediatric occurrence of palmoplantar pustulosis is extremely rare, and difference of genetic background between palmoplantar pustulosis and psoriasis has also been reported. Treatment of focal infection often results in dramatic effects on both cutaneous lesions and joint pain of palmoplantar pustulosis. Those findings suggest that palmoplantar pustulosis should be separately considered from either palmoplantar psoriasis or palmoplantar pustular psoriasis. The clinicopathological features and therapeutic approach of both diseases are discussed.
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Affiliation(s)
- Toshiyuki Yamamoto
- Department of Dermatology, Fukushima Medical University, Fukushima, Japan
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Lo Y, Chiu HY, Tsai TF. Clinical Features and Genetic Polymorphism in Chinese Patients with Erythrodermic Psoriasis in a Single Dermatologic Clinic. Mol Diagn Ther 2021; 24:85-93. [PMID: 31820331 DOI: 10.1007/s40291-019-00441-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Erythrodermic psoriasis (EP) is a rare variant of psoriasis that involves more complications and poorer biologic drug survival than plaque-type psoriasis vulgaris (PV). No prior study has explored human leukocyte antigen (HLA) or other genetic polymorphisms in patients with EP. OBJECTIVES Our objective was to describe the clinical features, comorbidities, and HLA polymorphisms among Chinese patients with EP. METHODS We enrolled consecutive patients with EP from our clinic, with EP defined as generalized confluent erythematous thin plaques covering at least 80% body surface area. Patients were categorized as having primary or secondary EP. Aggravating factors, comorbidities including psoriatic arthritis, family history of psoriasis, age of onset, and treatment history were also identified. Genetic studies were performed for HLA-C and HLA-DRB1, and the results were compared with those from a healthy population and patients with PV. RESULTS Of the 63 included patients, the male to female ratio was 2.71:1. Five (7.9%) patients had primary EP, and 58 (92.1%) had secondary EP. Genotyping of HLA-C and HLA-DRB1 was available in 61 and 58 subjects, respectively. HLA-C*0102 was the most frequent HLA-C allele (34.4%), followed by HLA-C*0702 (18.0%). The frequency of HLA-C*0602 allele (4.1%) was lower than in patients with plaque-type psoriasis (4.1 vs. 16.3%, corrected p value [Pc] = 0.02) and similar to that in the healthy population in Taiwan. The most frequent HLA-DRB1 allele was HLA-DRB1*0901 (20.7%), followed by HLA-DRB1*0803 (13.8%). An increased prevalence of psoriatic arthritis (61.9%) and higher male predominance were also noted in comparison with PV. CONCLUSIONS There are HLA differences in Chinese patients with EP compared with patients with PV. The incidence of psoriatic arthritis is also higher. The implications of the above findings await further investigation.
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Affiliation(s)
- Yang Lo
- Department of Dermatology, Cathay General Hospital, Taipei, Taiwan
| | - Hsien-Yi Chiu
- Department of Dermatology, Hsin-Chu Branch, National Taiwan University Hospital, Hsin-Chu, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
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Liu ZJ, Tian YT, Shi BY, Zhou Y, Jia XS. Association between mutation of interleukin 36 receptor antagonist and generalized pustular psoriasis: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e23068. [PMID: 33157966 PMCID: PMC7647532 DOI: 10.1097/md.0000000000023068] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Generalized pustular psoriasis (GPP) is a systemic inflammatory disease with poor outcomes, and several studies have suggested that the mutation of the interleukin 36 receptor antagonist gene (IL36RN) is related to GPP, where the polymorphism c.115+6T>C is reported to be the most common mutation of IL36RN. This study was performed to clarify and comprehensively evaluate the relationship between IL36RN gene polymorphism and the susceptibility of GPP subtypes. METHODS To conduct a thorough literature review, studies were obtained using databases such as Pubmed, EMBASE, Cochrane, China National Knowledge Infrastructure, and the Wanfang database. Only studies published up to December 2019 were included. The quality of the research studies was estimated using the Newcastle-Ottawa scale. The total odds ratios (ORs) and corresponding 95% confidence intervals (95% CIs) were pooled and analysed using STATA 14. The publication bias was evaluated through the Egger test, performed using the aforementioned software. Five common gene models were built and analysed to assess the association between the polymorphism c.115+6T>C and subtypes of GPP. RESULTS A total of 10 studies were selected, including 683 cases of GPP patients. Meta-analyses showed that there was a significant statistical correlation of IL36RN mutation between GPP with or without psoriasis vulgaris (OR = 3.82, 95%CI 2.63-5.56) and between adult GPP and paediatric GPP (OR = 0.42, 95%CI 0.23-0.77). No obvious discrepancy between European patients (OR = 4.03, 95%CI 2.23-7.26) and Asian patients was found. The gene models showed clear associations between the polymorphism c.115+6T>C and GPP through the dominant model (CC+ TC vs TT, OR 2.74, 95%CI 2.06-3.64), recessive model (CC vs CT + TT, OR 4.33, 95%CI 2.84-6.60), homozygote model (CC vs TT, OR 4.37, 95%CI 2.88-6.62), heterozygote model (CT vs TT, OR 2.26, 95%CI 1.32-3.85) and allelic model (C vs T, OR 3.35, 95%CI 2.63-4.27). CONCLUSION The IL36RN mutation is strongly related to GPP without psoriasis vulgaris and the early onset of GPP. Furthermore, the single-nucleotide polymorphism c.115+6T>C of the IL36RN gene plays a significant role in GPP vulnerability, especially in homozygous mutation. GPP could be a different inflammatory disease, independent of psoriasis.
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Affiliation(s)
| | - Yu-Tong Tian
- Neurology Department, the First Affiliated Hospital of Shihezi University School of medicine, Shihezi city, Xinjiang, China
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Huang CM, Tsai TF. Reply to Drs Brunasso and Massone about palmoplantar pustulosis and psoriasis. J Dermatol 2020; 48:e48. [PMID: 33063369 DOI: 10.1111/1346-8138.15648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Chang-Ming Huang
- Department of Dermatology, National Taiwan University Hospital, Taipei, Taiwan
| | - Tsen-Fang Tsai
- Department of Dermatology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Kromer C, Loewe E, Schaarschmidt ML, Pinter A, Gerdes S, Celis D, Poortinga S, Wilsmann-Theis D, Mössner R. Treatment of acrodermatitis continua of Hallopeau: A case series of 39 patients. J Dermatol 2020; 47:989-997. [PMID: 32632983 DOI: 10.1111/1346-8138.15466] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 05/18/2020] [Indexed: 01/10/2023]
Abstract
Acrodermatitis continua of Hallopeau (ACH) is a rare chronic inflammatory skin disease. Treatment is extremely challenging and mostly based on empirics as there is only scarce evidence from case reports and few small case series. In this retrospective study, patients with ACH treated at five university medical centers were analyzed according to patient and disease characteristics and treatment experience. We identified 39 patients with ACH with a mean age of 54.4 years at onset, of whom 22 (56.4%) were female. A total of 115 systemic treatment courses were analyzed with methotrexate as the most common therapy (27.0%). Overall, effectiveness of systemic treatments was low (excellent response rate: 14.8%). Among non-biologics, excellent response was noted in 21.1% (4/19) of treatment courses with methotrexate, followed by acitretin (13.3%; 2/15). Among biologics, guselkumab (excellent response: 100%; 2/2), secukinumab (excellent response: 42.9%; 3/7) and adalimumab (excellent response: 20.0%; 2/10) were most efficacious. The median drug survival was 7.0 months and did not differ significantly between the subgroup of non-biologic and biologic therapies. To our knowledge, this is the largest case series in ACH investigating patient characteristics and treatment outcomes. Based on our treatment experience, we suggest a treatment algorithm starting with acitretin or methotrexate as first-line therapy, followed by biologics. Cyclosporin may be used for short-term control. However, none of the applied systemic therapies yielded satisfying efficacy in our cohort. In patients with primary non-response, switch of treatment should be evaluated timely on an individual basis, considering possible irreversible disease complications such as nail loss. More research with prospective design is needed to further evaluate traditional and also particularly newer antipsoriatic drugs in ACH.
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Affiliation(s)
- Christian Kromer
- Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen, Germany
| | - Emilia Loewe
- Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen, Germany
| | | | - Andreas Pinter
- Department of Dermatology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sascha Gerdes
- Psoriasis Center, Department of Dermatology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Daniel Celis
- Faculty of Economic Sciences, Göttingen University, Göttingen, Germany
| | - Sietske Poortinga
- Department of Dermatology and Allergy, University Bonn, Bonn, Germany
| | | | - Rotraut Mössner
- Department of Dermatology, Venereology and Allergology, University Medical Center, Göttingen, Germany
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Freitas E, Rodrigues MA, Torres T. Diagnosis, Screening and Treatment of Patients with Palmoplantar Pustulosis (PPP): A Review of Current Practices and Recommendations. Clin Cosmet Investig Dermatol 2020; 13:561-578. [PMID: 32884319 PMCID: PMC7439281 DOI: 10.2147/ccid.s240607] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/23/2020] [Indexed: 12/15/2022]
Abstract
Palmoplantar pustulosis (PPP) is a rare, chronic, recurrent inflammatory disease that affects the palms and/or the soles with sterile, erupting pustules, which are debilitating and usually resistant to treatment. It has genetic, histopathologic and clinical features that are not present in psoriasis; thus, it can be classified as a variant of psoriasis or as a separate entity. Smoking and upper respiratory infections have been suggested as main triggers of PPP. PPP is a challenging disease to manage, and the treatment approach involves both topical and systemic therapies, as well as phototherapy and targeted molecules. No gold standard therapy has yet been identified, and none of the treatments are curative. In patients with mild disease, control may be achieved with on-demand occlusion of topical agents. In patients with moderate-to-severe PPP, phototherapy or a classical systemic agent (acitretin being the best treatment option, especially in combination with PUVA) may be effective. Refractory patients or those with contraindications to use these therapies may be good candidates for apremilast or biologic therapy, particularly anti-IL-17A and anti-IL-23 agents. Recent PPP trials are focusing on blockage of IL-36 or IL-1 pathways, which play an important role in innate immunity. Indeed, IL-36 isoforms have been strongly implicated in the pathogenesis of psoriasis. Therefore, blockage of the IL-36 pathway has become a new treatment target in PPP, and three studies are currently evaluating the use of monoclonal antibodies that block the IL-36 receptor in PPP: ANB019 and spesolimab (BI 655130). In this review, we explore the diagnosis, screening and treatment of patients with PPP.
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Affiliation(s)
- Egídio Freitas
- Department of Dermatology, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | | | - Tiago Torres
- Department of Dermatology, Centro Hospitalar e Universitário do Porto, Porto, Portugal.,Instituto de Ciências Biomédicas Abel Salazar, Universidade do Porto, Porto, Portugal
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Abstract
INTRODUCTION Pustular psoriasis is a group of skin diseases characterized by neutrophil infiltration in the epidermis and formation of sterile pustules. Conventional treatments, such as retinoids and immunosuppressive drugs, have improved the clinical manifestations; however, many patients suffer from drug-related toxicity or are resistant to therapy. AREAS COVERED In this review, the authors focus on the efficacy and safety of these biologics, including anti-IL-1β (gevokizumab and canakinumab), anti-IL-1 R (anakinra), anti-IL-36 R (BI 655130), anti-tumor necrosis factor-α (etanercept, infliximab, and adalimumab), anti-IL-12/23 (ustekinumab), anti-IL-17A (secukinumab and ixekizumab), anti-IL-17RA (brodalumab), anti-IL-2 R (basiliximab), anti-IL-6 R (tocilizumab), and anti-IL-23 (risankizumab and guselkumab), for treating pustular psoriasis. EXPERT OPINION Patients with pustular psoriasis treated with biologics demonstrated positive responses. Anti-TNF-α is the most available biologics for the treatment of pustular psoriasis, and anti-IL-12/23 and anti-IL-17A might be considered as the first- or second-line therapy for moderate-to-severe and refractory pustular psoriasis. Anti-IL-17A can be used in the pustular psoriasis patients who failed to respond to anti-TNF agents and anti-IL-12/23. Therapeutic efficacy of biologics in pustular psoriasis might have no association with IL-36 RN mutation status.
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Affiliation(s)
- Wen-Ming Wang
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, China
| | - Hong-Zhong Jin
- Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing, China
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