Psoriasis in the mature patient: Therapeutic approach in the era of biologics

Circadian Oscillations of Minimal Erythema Dose (MED) are Also Influenced by Diet in Patients with Psoriasis: A Chronomedical Study

INTRODUCTION

Minimal erythema dose (MED) remains a parameter of paramount importance to orient narrow-band (NB)-UVB phototherapy in psoriatic (PsO) patients. Recently, circadian rhythm and diet were recognized as potential MED modulators, but their mutual interaction remains understudied. Thus, we aimed to evaluate the potential diet modulation of MED circadian oscillations.

METHODS

In the first phase, a cohort study was performed comparing potential MED oscillations (morning, afternoon, and evening) among omnivorous psoriatic patients before and after a phototherapy cycle and omnivorous healthy controls. The two groups were age-, gender-, skin-type-, MED-, and diet-matched. Then, in the second phase, another cohort study was carried out comparing MED oscillations 24 h after the last phototherapeutic session only in psoriatic patients cleared with NB-UVB and undergoing different diets (vegan, vegetarian, paleo , ketogenic, intermittent circadian fasting, and omnivore). Patients with different diets were age-, gender-, and skin-type matched.

RESULTS

In the first phase, we enrolled only omnivores, specifically 54 PsO patients and 54 healthy individuals. Their MED before and after NB-UVB therapy changed significantly among the three different time-points (morning, afternoon, and evening) (p < 0.001). The time effect was statistically significant in both groups before and after phototherapy. In the second phase, we enrolled 144 PsO patients (vegan, vegetarian, paleo, ketogenic, intermittent circadian fasting, and omnivore). MED circadian oscillations preserved a significant difference also after clearance and were influenced by diet type and time of day (p < 0.001). In particular, vegans displayed the lowest MED values, whilst Ramadan fasting showed the highest values in morning, afternoon, and evening.

CONCLUSIONS

Diet, like other ongoing therapies, should be reported in the medical records of patients with psoriasis undergoing NB-UVB and patients with lower MEDs should be preferentially treated in the morning when the MED is higher.

Efficacy and safety of biologics and small molecules for psoriasis in pediatric and geriatric populations. Part II: focus on elderly patients

INTRODUCTION

The management of moderate-to-severe forms of psoriasis is becoming a frequent concern in geriatric age due to the higher risk to develop treatment adverse events, logistic issues, vulnerability to immune-related diseases and cancer, presence of comorbidities and the risk of drug interactions. In this context, traditional systemic treatments are often contraindicated, and biologic drugs and small molecules seem to be a valuable option. However, data on their effectiveness and safety in elderly patients are scant.

AREAS COVERED

The aim of this review is to analyze the current literature in order to point out data on the efficacy and safety of biologic drugs and small molecules for the management of psoriasis in elderly patients in order to put the basis for universally shared treatment algorithm following available evidence. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used for the literature research.

EXPERT OPINION/COMMENTARY

Our review suggests biologics and small molecules as an effective and safe option for the management of moderate-to-severe forms of psoriasis in elderly patients.

Treating psoriasis in the elderly: biologics and small molecules

INTRODUCTION

Psoriasis prevalence in the elderly is growing. It is estimated that 15% of elderly psoriasis patients suffer from moderate-to-severe disease, thus requiring systemic treatments. However, conventional systemic agents' use is limited due to contraindications and drug-interactions. Conversely, biologics and small molecules seem to be a valuable option, although the geriatric psoriasis population is frequently excluded from trials and shared guidelines are lacking.

AREAS COVERED

Relevant English literature (trials, real-life studies, case series, and reviews) regarding biologics and/or small molecules in the elderly were searched for up to January 17, 2022.

EXPERT OPINION

Treatment of moderate-to-severe psoriasis in the elderly may be challenging due to multiple comorbidities, polypharmacy, and increased risk of infections and cancers. However, new targeted therapies offer the possibility to perform a tailored-tail management, considering comorbidities, drug-interactions, and frailties which characterize this class of patients. Several real-world data support biologics and small molecules' efficacy and safety in the elderly with mainly no significant difference as compared to young adults. Elderly psoriasis patients' expectations are as high as those of their younger counterparts. Hence, they deserve the best therapeutic options according to their peculiarities for a long-term psoriasis remission and an improved quality of life.

Therapy of PsO in Special Subsets of Patients

Psoriasis is a chronic, inflammatory skin disease that may occur at any age, with a bimodal peak of incidence around the age of 16-20 years of age (early onset) and 57-60 years (late-onset). It is estimated that roughly 70% of patients develop the disease before the age of 40, which coincides with the reproductive years. Moreover, psoriasis is a chronic disease, meaning that, with increased life-duration expectancy, the number of patients affected with psoriasis aged over 65 years is going to increase and represent a big therapeutic challenge. Actually, no specific drug recommendation is available, based only on the age of the patients, while therapeutic prescription should take into account that elderly patients have more comorbidities than younger patients, with polypharmacy and an increased risk of drug interactions. Women with psoriasis are more likely to report a worse influence of the disease on their quality of life, and they are more susceptible to the development of depression. Furthermore, pregnancy and lactation represent a major contraindication to several systemic agents, and only a few studies exist providing the safety of certain drugs during these periods of life of a woman, such as certolizumab pegol. In this paper, we discuss systemic therapeutic strategies, including conventional and biological therapies, in a special subset of patients affected with moderate-to-severe psoriasis focusing on elderly patients and on female patients in fertile age, pregnancy, and lactation.

Medicinal Treatment of Elderly Psoriasis Patients before and after Entering a Nursing Home

Psoriasis (PS) is a chronic inflammatory skin disease, and it increasingly appears also in the elderly population. There is a rising interest in drug therapy for PS, especially for people receiving care in nursing homes (NH). Which PS-related drugs are prescribed in the time before nursing home admission (NHA), and to what extent does the supply of drugs change after NHA? Which specialties prescribe PS-related drugs? Statutory health insurance data were examined for people with PS, aged ≥ 65 years, who were newly admitted to a NH in the period 2011-2014 and observed for one year before and after NHA. Changes in prescription prevalence (pre-post comparison) were examined for significant differences. Prescriptions of PS-relevant drugs were measured by defined daily dose and stratified according to the prescribing specialist group. The analysis included 718 insured persons with PS (76.2% female, mean age 83.3 years). Systemic therapeutics played a minor role (pre: 2.6% vs. post: 2.1%) in drug therapy. Topical steroids had a high share of about 40% in the pre-post comparison. Overall, the proportion of people with PS who received treatment remained at a comparable level before and after NHA. A structured assessment of the skin is crucial, specifically in people with cognitive impairment.

Circulating microRNA profile unveils mechanisms of action of acitretin for psoriasis vulgaris

Psoriasis vulgaris is a common chronic and recurrent inflammatory skin disease. In clinical practice, acitretin is the first-line treatment drug for psoriasis vulgaris. MicroRNAs (miRNAs) play a vital role in the initiation and development of psoriasis vulgaris. However few studies focused on the mechanisms of acitretin in the treatment of psoriasis vulgaris from the perspective of miRNAs. Here, the expression profiles of circulating miRNAs in the plasma of 12 patients with psoriasis vulgaris before and after acitretin treatment were sequenced. Three miRNAs (miR-146a-5p, miR-122-5p and miR-21-5p) were identified using expression pattern analysis, and the levels were significantly decreased after acitretin treatment (P< 0.001). Receiver operating characteristic (ROC) analyses indicated that the three miRNAs have the potential to be utilized as molecular markers to evaluate the therapeutic effect of acitretin, and the values of the area under the curve (AUC) were 0.825, 0.831, and 0.796, respectively. In addition, we predicted target genes of the three miRNAs and performed signaling pathway enrichment analyses. The results demonstrated that the target genes were mainly involved in the MAPK, JAK-STAT, and NF-κB signaling pathways, which were further validated through in vitro experiments. In conclusion, acitretin can suppress miRNA-mediated MAPK, JAK-STAT, and NF-κB signaling pathways by decreasing miRNAs expression, thereby inhibiting the proliferation and inflammatory response of keratinocytes.

Sociodemographic and Clinical Characteristics of Geriatric Patients with Psoriasis Receiving Narrowband Ultraviolet B Phototherapy

Background

Although the demographic and clinical characteristics of patients with psoriasis have been evaluated in many countries, studies specifically on geriatric patients remain scarce and none have focused on those receiving phototherapy. This study describes the sociodemographic and clinical characteristics of geriatric patients with psoriasis in Indonesia, specifically those who received narrowband ultraviolet B (NB-UVB) phototherapy.

Methods

This retrospective study using data obtained from phototherapy and medical records of psoriasis patients who received phototherapy in 2014–2019 was conducted at the Dermatovenereology Clinic of Dr. Cipto Mangunkusumo National General Hospital.

Results

Among 24 geriatric patients with psoriasis who received NB-UVB phototherapy, the median age of onset was 61 years (range, 36–74 years). Regarding comorbidities, 15 patients (62.5%) had dyslipidemia, 15 patients (62.5%) had hypertension, 11 patients (45.8%) had obesity, 9 patients (37.5%) had periodontitis/gingivitis, 9 patients (37.5%) had type 2 diabetes mellitus, and 6 patients (25.0%) had hyperuricemia.

Conclusion

Some comorbidities have been associated with psoriasis, including metabolic syndrome and periodontitis. The data from this study could help physicians in evaluating and making appropriate clinical decisions when managing psoriasis patients in the geriatric population.

Epidemiology of psoriasis among the elderly population and volume of specialized medical care provided to patients with psoriasis in the Russian Federation in 2010–2019

Background. Population ageing is ongoing in the Russian Federation. Demographic changes may influence the age structure and dynamics of epidemiological rates of chronic skin disorders, as well as the need of elderly patients in specialized medical care. Aims. To study the dynamics of number of cases, incidence and prevalence of psoriasis, and the dynamics of the number of hospital admissions for psoriasis among elderly population (males 60 years and older, females 55 years and older) in 20102019 in the Russian Federation. Materials and methods. Analysis of federal statistic surveillance data, psoriasis prevalence and incidence rates among different age groups of population. Results. In the Russian Federation there is an increase in absolute number of cases, prevalence and incidence rates of psoriasis among elderly population. There is an increase in the number of hospital admissions due to psoriasis among patients with psoriasis of this age. Conclusions. An increase of the number and proportion of cases of psoriasis among elderly population is due to both, an increase of prevalence and incidence rates in this age group and population ageing. There is a high need in specialized medical care among elderly population with psoriasis.

Epidemiology of psoriasis among the elderly population and volume of specialized medical care provided to patients with psoriasis in the Russian Federation in 2010–2019

Background. Population ageing is ongoing in the Russian Federation. Demographic changes may influence the age structure and dynamics of epidemiological rates of chronic skin disorders, as well as the need of elderly patients in specialized medical care. Aims. To study the dynamics of number of cases, incidence and prevalence of psoriasis, and the dynamics of the number of hospital admissions for psoriasis among elderly population (males 60 years and older, females 55 years and older) in 20102019 in the Russian Federation. Materials and methods. Analysis of federal statistic surveillance data, psoriasis prevalence and incidence rates among different age groups of population. Results. In the Russian Federation there is an increase in absolute number of cases, prevalence and incidence rates of psoriasis among elderly population. There is an increase in the number of hospital admissions due to psoriasis among patients with psoriasis of this age. Conclusions. An increase of the number and proportion of cases of psoriasis among elderly population is due to both, an increase of prevalence and incidence rates in this age group and population ageing. There is a high need in specialized medical care among elderly population with psoriasis.

Safety concerns with current treatments for psoriasis in the elderly

Introduction: The approach to manage psoriasis in the elderly (ages ≥65 years) patients can be challenging. They often suffer from multiple comorbidities and polypharmacy with possible adverse effects and undergo a progressive functional impairment of the immune system that increases susceptibility to infections as well as to auto-reactivity. Despite the increasing aging of the general population and although several therapies are currently available for psoriasis treatment, data regarding their use and tolerability in the elderly are quite limited.Areas covered: This review focuses on topical and systemic therapies that have been investigated in elderly patients in order to provide their safety profile in this population.Expert opinion: Conventional systemic therapies in elderly patients should be carefully dispensed and the correct dosage individually determined, taking into account the metabolism changes, organ impairment, comorbidities, concomitant medications, and contraindications. Apremilast, due to its satisfactory safety profile and low risk of drug interactions, results as an appropriate treatment option for elderly patients. Biologics (TNF-α, IL-12/23, IL-17, and IL-23 inhibitors) come out as safe and long-term options for the management of these patients resulting not associated with a higher risk of adverse events.

Acitretin inhibits IL-17A-induced IL-36 expression in keratinocytes by down-regulating IκBζ

BACKGROUND

IL-36 plays a critical role in aggravating psoriatic inflammation, which is significantly elevated in generalized pustular psoriasis (GPP) compared to psoriasis vulgaris. It is well known that acitretin brings about a rapid and significant effect on the treatment of GPP but not psoriasis vulgaris, whereas the quick therapeutic mechanism of acitretin in GPP has not been fully clarified.

OBJECTIVES

We conducted this study to investigate whether acitretin interferes IL-36 expression in keratinocytes.

METHOD

We used 100 ng/mL IL-17A and/or various doses of acitretin (0, 0.1, 1, 10 μmol/L) to treat cultured HaCaT cells. We performed Real-time quantitative PCR and ELISA to detect gene and protein expression of IL-36 cytokines, real-time quantitative PCR and Western blot to examine IκBζ. Imiquimod (IMQ)-induced psoriasis-like mouse model was established to evaluate effect of gastrointestinal administrated acitretin. Immunohistochemistry was conducted for effect assessment.

RESULTS

Acitretin significantly down-regulated expression of IL-36β and IL-36γ induced by IL-17A stimulation at both gene and protein levels in HaCaT cells. Acitretin alone had no obvious effect on IL-36 expression in keratinocytes. In IMQ + acitretin group, the skin lesion severity was slightly relieved, however, immunohistochemistry showed IL-36β and IL-36γ expression in keratinocytes significantly declined in comparison with IMQ group. IL-17A stimulation induced significantly IκBζ expression in HaCaT cells, which could be inhibited by acitretin.

CONCLUSION

Acitretin inhibits IL-36 expression induced by IL-17A stimulation in keratinocytes by down-regulating IκBζ, and acitretin significantly inhibits keratinocytes-expressed IL-36β and IL-36γ in psoriasis-like mouse model, which reveals a new possible mechanism of the notable and quick therapeutic action of acitretin on GPP.