Pathogenesis of Psoriasis and Current Challenges

The efficacy of methotrexate plus pioglitazone vs. methotrexate alone in the management of patients with plaque-type psoriasis: a single-blinded randomized controlled trial

Recently, thiazolidinediones have shown to be efficacious with a favorable safety profile when used in the treatment of chronic plaque-type psoriasis. The aim of this study was to evaluate and compare the efficacy and safety of a combination of methotrexate plus pioglitazone and methotrexate alone in plaque-type psoriasis. A total of 44 adult patients with plaque-type psoriasis were included in the study. Patients were randomized to treatment with methotrexate alone (group A) or methotrexate plus pioglitazone (group B) for 16 weeks. The primary efficacy outcome measure was psoriasis area and severity index (PASI) score change between the study groups at week 16 relative to baseline. The secondary efficacy outcome measure was dermatology life quality index (DLQI) score change between the two groups at week 16 relative to baseline. The PASI 75 score was also measured. After 16 weeks of therapy, the percentage of reduction in the mean PASI score was 70.3% in group B and 60.2% in group A. PASI 75 was achieved in 14 patients (63.6%) in group B compared with two patients (9.1%) in group A within 16 weeks, which was significant (P < 0.001). At 16 weeks from the baseline, a 63.6% decrease in the mean DLQI score of group B was seen, while the decrease for group A was 56.9%. Pioglitazone enhances the therapeutic effect of methotrexate in plaque-type psoriasis, as demonstrated by a reduction in the mean PASI scores. In terms of DLQI, there was no extra benefit by the addition of pioglitazone to methotrexate therapy.

TNF- alpha inhibitors

Tumor necrosis-alpha (TNF-alpha) has been implicated in many forms of inflammation and is an end-stage product of the inflammatory cytokine cascade. It is an inducer of inflammation and is involved in many cutaneous and systemic inflammatory diseases. The development of agents that block the effects of TNF-alpha has aided in the treatment of many of these diseases. This article will briefly discuss the production, structure, and administration of the TNF-alpha inhibitors. There will be a focus on the mechanism of action of each of the TNF-alpha inhibitors as well as their benefit in their FDA approved and non FDA approved dermatologic conditions. The side effect profile and monitoring recommendations for these agents will also be discussed.

The use of infliximab in dermatology

Autoimmune diseases like Crohn's disease, rheumatoid arthritis (RA) and psoriasis are often difficult to treat due to complex underlying immunologic pathways. Tumor necrosis factor (TNFalpha) is an important proinflammatory cytokine that seems to play an important role in the pathogenesis of these diseases. After the approval of a variety of drugs which block the biological activity of TNFalpha, new therapeutic options were available and especially infliximab became widely used. TNFalpha, as a member of the proinflammatory cytokine family, is a major cytokine in different inflammatory dermatological diseases such as cutaneous vasculitis, lupus erythematosus, eczema or psoriasis. Therefore infliximab has been used in a variety of inflammatory dermatoses lately, sometimes with great success. Several case reports showing new indications for a successful use of TNFalpha-inhibitors in dermatology have been published and will be reviewed in the following article. Nevertheless, infliximab is not approved for these indications at the moment and has to be considered as off-label use.

Intramuscular immunoglobulin for recalcitrant suppurative diseases of the skin: a retrospective review of 63 cases

BACKGROUND

Intramuscular human immunoglobulin (HIG) may provide a therapeutic option as an independent or combined treatment for recalcitrant suppurative skin diseases such as hidradenitis suppurativa, folliculitis decalvans, or chronic recurrent furunculosis or folliculitis.

OBJECTIVES

To define the efficacy and safety of intramuscular HIG for chronic and recalcitrant suppurative skin diseases.

METHODS

Patients who had received HIG for hidradenitis suppurativa, folliculitis decalvans, furunculosis or folliculitis at Severance Hospital, Seoul, Korea, between January 2000 and May 2005 were identified from medical/pharmacy records. All records were analysed retrospectively.

RESULTS

Sixty-three patients were identified. After treatment, 37 patients (59%) showed overall improvement and were rated as having an 'excellent response' or 'good response' by the attending physician. No improvement or worsening was seen in only three patients (5%). A period without new lesions (PWNL) was achieved in 46 patients (73%). The number of times HIG was administered to achieve PWNL ranged from 1 to 12 (mean +/- SD 2.15 +/- 1.69). There was no significant difference in the rating score between the independent intramuscular HIG and the combined treatment groups. Pain at the injection site was the major side-effect, which led to the discontinuation of treatment in five patients. No other significant systemic side-effects were observed.

CONCLUSIONS

Our results demonstrate that intramuscular HIG may be used for the treatment of recalcitrant suppurative skin diseases as an independent or combined treatment.

Use of infliximab in pyoderma gangrenosum

A 57-year-old man, with a 2-year history of Crohn's disease, presented with a rapidly progressive abdominal ulcer. It was clinically and histologically consistent with pyoderma gangrenosum but it did not respond to either high-dose oral prednisolone or intravenous hydrocortisone. Infliximab resulted in an early, dramatic and sustained improvement. His bowel symptoms, which flared a few weeks prior to the onset of pyoderma gangrenosum, only partially improved. Despite six infliximab infusions, the inflammatory bowel disease is poorly controlled, whereas the pyoderma gangrenosum remains healed.

Panniculitis in childhood and adolescence

BACKGROUND

The purpose of the present paper was to describe the clinical manifestations and treatment of patients with panniculitis.

METHODS

From January 1983 to December 2002, 4294 patients were treated for pediatric rheumatological diseases at Pediatric Rheumatology Unit, University of São Paulo, Brazil. Of these, 35 children and adolescents (0.8%) presented with panniculitis: erythema nodosum (EN) or Weber-Christian disease (WCD). Clinical characteristics, laboratory exams, biopsy of the lesion, treatment and clinical course were studied.

RESULTS

Of the 35 patients, 29 presented with EN and six with WCD, one of these with cytophagic histiocytic panniculitis. Mean age at symptom onset was 85 months (6-204 months) and the mean duration of follow up was 55 months (1-144 months). All the patients presented with inflammatory subcutaneous nodules. The patients with WCD presented with systemic manifestations and cutaneous atrophy. The principal etiologies of EN were streptococcal infection (42%), undetermined (13.5%), pulmonary tuberculosis (10%), and acute rheumatic fever (10%). Biopsy of the nodules indicated septal panniculitis in 14 patients with EN and lobular panniculitis without vasculitis in the patients with WCD, one of which had cytophagic histiocytic panniculitis. There was recurrence in 11 patients (38%) with EN and in all those with WCD. Non-steroidal anti-inflammatory drugs were used in 15 patients with EN and corticosteroids and/or immunosuppressive drugs in the six patients with WCD. Three patients died.

CONCLUSIONS

EN is the most frequent panniculitis, with a benign course and is mainly associated with infections. WCD is a severe disease, with systemic involvement, that proceeds with cutaneous atrophy and requires the use of corticosteroids and or immunosuppressive drugs.

Pyoderma gangrenosum. Pyoderma gangraenosum

Pyoderma gangrenosum (PG) is a non-infectious reactive neutrophilic dermatosis which typically starts with pustules which rapidly evolve to painful ulcers of variable size and depth with undermined violaceous borders. Since its first description in 1930, the pathogenesis of PG has remained elusive even as an ever-widening range of systemic diseases has been described in association with it. The diagnosis of PG is based on clinical and pathologic features and requires exclusion of other conditions that produce ulcerations, since misdiagnosis exposes patients to risks associated with treatment. Critical to proper management are correct diagnosis, identification and treatment of any underlying disorder, and the appropriate choice of topical and systemic therapy. PG has four distinctive clinical and histologic variants, and the specific clinical features of the lesion may provide a clue to the associated disease. The most common associated diseases are inflammatory bowel disease, rheumatological or hematological disease or malignancy. Although there is no single successful treatment for PG, certain type of PG lesions are recognized to respond more readily to accepted therapies than others. Local treatment may be sufficient for mild disease, while systemic immunosuppressive therapy is necessary for severe cases. The treatments with the best clinical evidence are oral or pulse intravenous corticosteroids, and cyclosporine. Surgical therapy is useful in selected cases in conjunction with immunosuppression. Wound stabilization is obtained only through control of the systemic and local inflammatory process. Emerging therapies include use of platelet-derived growth factor and cell culture grafts when re-epithelialization is slow, and the TNF-alpha blocking agent infliximab for refractory disease. Despite advances in therapy, the long-term outcome for patients with PG remains unpredictable, because relapses are common.