Oral candidiasis in patients with psoriasis: correlation of oral examination and cytopathological evaluation with psoriasis disease severity and treatment

Oral Diseases During Systemic Psoriatic Drugs: A Review of the Literature and Case Series

INTRODUCTION

The oral health of psoriatic patients seems to be compromised compared to that of control individuals: many published studies have investigated the relationship between psoriatic disease and gingivitis, periodontitis, and missing teeth. However, data from these studies are not consistent nor exhaustive. Moreover, no study has considered the possible specific effects of conventional and biological systemic psoriatic treatments.

OBJECTIVE

We report a narrative review of the literature about the possible link between anti-psoriatic drugs and oral disease onset and present case series of patients that have experienced oral disease during systemic therapy for psoriasis.

METHODS

This is a narrative review. The literature search was performed using the MEDLINE database. From the selected articles, additional references were identified by a manual search among the cited literature.

RESULTS

Oral adverse events during psoriatic therapies can be found in sporadic cases. The specific mechanisms of interplay between oral anatomic structures and the pathway targeted by the systemic agents will be investigated in depth.

CONCLUSION

All psoriatic patients who are candidates for conventional or biological systemic therapy should have regular oral health check-ups with a dentist and a dermatologist to prevent oral complications. Dermatologists and oral medicine specialists should be ready to recognize and manage this increasing number of oral adverse drug reactions during systemic treatments for psoriatic disease so as to provide patients with sufficient information about this risk and to stress the fundamental importance of regular dental assessments and good oral hygiene.

Candida Variety in the Oral Cavity of Mexican Subjects with Type 2 Diabetes Mellitus and TLR2 Gene Expression

BACKGROUND

The aim was to diagnose Candida in the oral cavity of subjects with type 2 diabetes mellitus (T2DM) using a genotyping technique and compare the results with those from conventional diagnosis by Papanicolaou (Pap) staining.

METHODS

Palatal mucosa smears were performed on 18 dental care patients diagnosed with T2DM and grade I, II, and III prosthetic stomatitis who met the inclusion criteria; 18 healthy control subjects were also included in the study. Hemoglobin A1c (HbA1c) levels were determined from total blood. Using exfoliative cytology, the Pap staining technique was used to diagnose candidiasis. Exfoliative cytology was also used for molecular diagnosis; DNA was obtained for Candida genotyping, and RNA was used for gene expression studies.

RESULTS

Clinical patterns indicated that all subjects were positive for Candida; however, Pap analysis revealed only three positive subjects, whereas end-point polymerase chain reaction (PCR) analysis revealed 15 subjects with some type of Candida. The most common Candida species found were Candida guilliermondii (38.8%), Candida krusei (33.3%), Candida tropicalis, and Candida lusitaniae (22.2%). Interestingly, the coexpression of different species of Candida was found in various patients. In all patients, HbA1c levels were increased. Gene expression analysis showed a significant decrease (p ≤ 0.05) in TLR2 expression in positive subjects, whereas TLR4 expression did not differ significantly among patients.

CONCLUSIONS

The end-point PCR technique showed better sensitivity for the diagnosis of Candida when compared with the diagnosis by Pap staining. T2DM subjects showed an increased presence of C. guilliermondii that was correlated with decreased TLR2 expression.

Oral Candida and psoriasis: Is there association? A systematic review and trial sequential analysis

To assess (i) the prevalence of oral colonization by Candida spp. in patients with psoriasis and (ii) the prevalence of oral lesions associated with Candida spp. in patients with psoriasis and identify the risk factors for oral lesions. A systematic review was conducted in accordance with PRISMA criteria. The PROSPERO registration code is CRD42019127178. PubMed, Scopus and Web of Science were used as search engines. Meta-analyses and trial sequential analyses were performed. Among the 5805 retrieved records, nine articles were included. Among 530 psoriatic patients, 255 patients had an oral Candida spp. colonisation with an odds ratio (OR) = 3.44 (95% CI:2.38-5.00). Among 490 psoriatic patients, 43 patients developed oral Candida spp. lesions with an OR = 5.31 (95% CI:1.04-27.23). Among the patients without the main predisposing factors for infections, psoriatic patients had a higher OR (3.48, 95% CI: 2.0-6.0) for Candida spp. colonization, but not for Candida spp. infection, when compared with healthy controls (p-value > 0.05). Meta-analysis showed a higher risk of Candida spp. colonisation in patients with psoriasis. Patients who received immunosuppressive therapies were also at higher risk of developing oral lesions. Further studies are needed to understand these associations.

Epicutaneous Application of Mannan Induces Psoriasis-like Inflammation in an Inbred Mouse Strain

Mannan from yeast induces psoriasis-like inflammation in the skin of inbred mouse strains. Limitations of available models led us to develop a new psoriasis model with a rapid disease onset, severe disease course, short duration, and a simple and easy-to-induce protocol with much more practically convenient features and cost-benefits. Mannan-induced skin inflammation (MISI) is more severe than the classical imiquimod (IMQ)-induced skin inflammation (IISI), with characteristic features resembling human plaque psoriasis but with relatively fewer toxicity issues. Epicutaneous application of mannan (5 mg) in incomplete Freund's adjuvant or Vaseline induces severe psoriasis in BALB/c female mice. Psoriasis area and severity index (PASI) and histological evaluation of the skin could help assess the disease development. MISI mimics natural environmental factors affecting the skin relatively more closely than IISI. This disease model can be used to dissect inflammatory pathways in the skin, identify genetic and environmental factors affecting psoriasis, and test potential pharmacological agents or new combinations of available drugs for treatment before designing clinical trials. Key features • S. cerevisiae mannan induces psoriasis-like skin inflammation (MISI) when applied on the skin of inbred mice. • The MISI model has a rapid onset, severe disease, short duration, and simple and easy-to-induce protocol. • MISI is more severe than imiquimod-induced skin inflammation (IISI). • Female mice had a more severe disease than males in the MISI model, thereby allowing the study of sex-dependent disease mechanisms. • The MISI model identifies skin inflammatory pathways and genetic/environmental factors affecting psoriasis. • The MISI model can be used as a drug testing platform for potential pharmaceuticals to develop new therapeutics for psoriasis patients. • The MISI model can be used to explore the relative contribution of different pattern recognition receptors in the development and severity of psoriasis.

Oral candidiasis in patients hospitalised in the intensive care unit: Diagnosis through clinical and cytopathological examinations

OBJECTIVE

To evaluate the prevalence and clinical aspects of oral candidiasis in patients hospitalised in the intensive care unit.

METHODS

This is a longitudinal and prospective study that included 48 participants hospitalised in the intensive care unit. Sociodemographic data, presence of systemic disorders, use of medications, laboratory tests, cause of hospital admission, type of breathing, and length of hospital stay were obtained from medical records. Oral clinical inspection and cytopathological examinations were performed on all participants. The diagnosis of clinical candidiasis was based on the presence of clinical alterations together with positive cytopathological examination results. The diagnosis of subclinical candidiasis was based on the absence of clinical lesions and a positive cytopathological examination. The absence of oral candidiasis was considered when the participant did not present oral lesions and had a negative cytopathological examination.

RESULTS

Clinical candidiasis was present in 18.8% of the 48 participants, and 45.8% of them had the subclinical form. Levels of urea (P = 0.005), creatinine (P = 0.009), haemoglobin (P = 0.009), haematocrit (P = 0.011), bands (P = 0.024), international normalised ratio (INR; P = 0.034), types of breathing (P = 0.017), length of hospital stay (P = 0.037), and outcome (P = 0.014) demonstrated statistically significant differences between the groups with and without oral candidiasis.

CONCLUSIONS

Clinical and subclinical forms of oral candidiasis are frequent in intensive care unit patients. Levels of urea, creatinine, haemoglobin, haematocrit, bands, INR, type of breathing, length of hospital stay, and outcome can be associated with the presence of candidiasis.

Oral changes in patients with psoriasis

Psoriasis is one of the most frequent skin diseases. The cause of psoriasis is not fully expained as there are many factors (infectious, traumatic, hormonal, and chemical) that may play a role in the manifestation of its symptoms. One of the factors that may contribute to the appearance of psoriatic lesions may be the lesions in the oral cavity. The occurrence of lesions in the oral cavity is defined as rare, what can be explained by their nonspecific clinical image, and also by the possibility of being overlooked. Most characteristic symptoms of psoriasis occurring in the oral cavity are the geographic tongue and fissured tongue. It is also believed that there is a correlation between psoriasis and oral health- the periodontal and teeth condition as well as changes in saliva secretion. The psoriasis arthritis changes can also affect temporomandibular joint and impair the function of stomatognathic system. Because of these reports, cooperation of dermatologists and dentists in psoriasis care seems to be necessary.

Candida Infection Associated with Anti-IL-17 Medication: A Systematic Analysis and Review of the Literature

Anti-interleukin (IL)-17 agents have shown excellent therapeutic efficacy in patients with psoriasis and are expected to be expanded to other chronic inflammatory diseases. However, patients receiving anti-IL-17 agents are at an increased risk of developing Candida infection, with some agents reported to increase the incidence in a dose-dependent manner. Interleukin-17 is secreted by the Th17 subset of CD4+ lymphocytes, CD8+ T cells, and innate cells, including natural killer T cells, lymphoid tissue inducer cells, innate lymphoid cells, and γδ-T cells, and plays an important role in antifungal defense. Genetic defects in the IL-17-signaling pathway in both humans and animal models render susceptibility to candidiasis caused by Candida albicans. The purpose of this narrative review is to evaluate the literature on the role of IL-17 in protection against candidiasis, the prevalence of candidiasis in anti-IL-17 agent use, and to offer clinical recommendations on the diagnosis and management of anti-IL-17 medication-associated candidiasis.

Oral candidiasis in patients with hematological diseases: Diagnosis through clinical and cytopathological examinations

OBJECTIVE

This study is the first to analyze the prevalence of oral candidiasis in onco-hematological patients by physical and oral cytopathological examinations.

METHODS

This is a cross-sectional and observational study with a retrospective sample composed of participants hospitalized in the hematology clinic, diagnosed with hematological diseases. All participants were submitted to an oral mucosal examination and scraping from oral mucosa.

RESULTS

Of the 62 participants, 56.5% were male, 82.3% were white, with mean age of 57 years. Lymphoma was the most common hematological disease (24.2%). In total, 48.4% of the sample was diagnosed with oral candidiasis. Of these participants with oral candidiasis, 13 (21.0%) had clinical diagnosis. Cytopathological analysis revealed more 17 (27.4%) cases, without oral lesion indicative of candidiasis. Erythematous candidiasis (p=0.02), pseudomembranous candidiasis (p<0,001), clinical candidiasis (p<0,001), fibrous hyperplasia (p=0,032), and coated tongue (p=0,012) showed correlation to candidiasis cytopathologic diagnosis.

CONCLUSIONS

Oral candidiasis is common among patients with hematological disease, and the cytopathological examination proved to be a useful tool, confirming clinical diagnosis of candidiasis and identifying subclinical cases. These data are of great relevance considering the possible complications that these patients may develop such as longer hospitalizations, worsening of the general condition or even death due to candidemia.

The impact of external factors on psoriasis

Psoriasis is one of the most common chronic inflammatory skin diseases, constituting a significant health and socioeconomic problem. Despite numerous therapeutic options, the results of treatment very often remain insufficient. It is extremely important to remember that many external factors impact the effectiveness of therapy. This article discusses the importance of emollients in therapy and the influence of infectious agents and injuries on the course of psoriasis. Understanding the above-mentioned factors in the treatment of psoriasis is critical to achieve satisfactory therapeutic effects.

Oral Candida Infection in Psoriatic Patients Treated with IL17A Inhibitors: Report of 3 Cases and a Comprehensive Review of the Literature

An intact and fully functional immune system plays a crucial role in the prevention of several infectious diseases. Interleukin (IL)17 is significantly involved in oral mucosa immunity against several antigens and microorganisms, including Candida albicans (CA). Herein, we present three cases of oral candidiasis (OC) related to the use of an IL17A inhibitor for psoriasis. Three psoriatic individuals presented for evaluation of widespread symptomatic oral lesions temporally correlated with the onset of IL17A inhibitors (secukinumab in two patients and brodalumab in one patient). Clinical examination revealed either partially removable white plaques in an erythematous background (case #1) or diffuse erythematous lesions (cases #2 and 3) involving several areas of the oral mucosa. Cytology smear, accompanied by histopathologic examination in case #1, confirmed the clinical impression of OC in all three cases. All patients received antifungal therapy with satisfactory clinical response. No discontinuation of the antipsoriatic regimen was recommended, but all patients were advised to remain under monitoring for possible OC relapses. During the last few years, new systemic biologic agents targeting IL17 have been used for the management of variable immune-mediated diseases. Few clinical trials and scarce case reports have shown that these medications place individuals at high risk of developing candidiasis. We propose that patients treated with these medications should be at close monitoring for the development of OC and, if it occurs, receive appropriate management.

Prevalence of Candida species in Psoriasis

BACKGROUND

Psoriasis patients are more frequently colonised with Candida species. The correlation between fungal colonisation and clinical severity is unclear, but may exacerbate psoriasis and the impact of antipsoriatic therapies on the prevalence of Candida is unknown.

OBJECTIVES

To examine the prevalence of C species in psoriasis patients compared to an age- and sex-matched control population, we investigated the influence of Candida colonisation on disease severity, immune cell activation and the interplay on psoriatic treatments.

METHODS

The prevalence of C species was examined in 265 psoriasis patients and 200 control subjects by swabs and stool samples for fungal cultures. Peripheral mononuclear blood cells (PBMCs) were collected from 20 fungal colonised and 24 uncolonised patients and stimulated. The expression of interferon (IFN)-γ, IL-17A, IL-22 and tumour necrosis factor (TNF)-α from stimulated PBMCs was measured by quantitative real-time polymerase chain reaction (qPCR).

RESULTS

A significantly higher prevalence for Candida was detected in psoriatic patients (p ≤ .001) compared to the control subjects; most abundant in stool samples, showing Candida albicans. Older participants (≥51 years) were more frequent colonised, and no correlation with gender, disease severity or systemic treatments like IL-17 inhibitors was found.

CONCLUSIONS

Although Candida colonisation is significantly more common in patients with psoriasis, it does not influence the psoriatic disease or cytokine response. Our study showed that Candida colonisation is particularly more frequent in patients with psoriasis ≥51 years of age. Therefore, especially this group should be screened for symptoms of candidiasis during treatment with IL-17 inhibitors.

Fungal Infections among Psoriatic Patients: Etiologic Agents, Comorbidities, and Vulnerable Population

Background

Psoriasis is a chronic inflammatory disorder of the skin and joint, affecting nearly 2-3% of the general population. It is assumed that imbalance between the types of natural microflora can accelerate the onset of the disease. Some fungi can play the role of superantigens and prolong chronic inflammation in the skin of psoriatic patients. The aim of the present investigation was to identify fungal species isolated from patients with psoriasis.

Methods

From March 2016 to May 2019, 289 patients with prior diagnosis of psoriasis were included in this survey. Direct microscopy with potassium hydroxide (KOH 10%), culture, urea hydrolysis, hair perforation test, and growth on rice grains were used to identify clinical isolates, phenotypically. For molecular identification of Candida species and Malassezia species, PCR-RFLP and PCR-sequencing were used, respectively.

Results

Forty-six out of 289 psoriatic patients had fungal infections (15.9%). Dermatophytes (54.3%), Candida spp. (19.5%), Malassezia spp. (15.2%), Aspergillus spp. (6.5%), and Fusarium spp. (4.3%) were the causative agents of fungal infections. Among Malassezia and Candida species, M. restricta (10.8%) and C. glabrata (8.7%) were the most prevalent species, respectively.

Conclusion

Our findings suggested that fungal pathogens, particularly dermatophytes, may play an important role in the pathogenicity of psoriasis. Also, due to the high rate of yeast colonization in the clinical samples of psoriatic patients, concomitant use of anti-inflammatory drugs and antifungals may represent an effective therapeutic approach for better management of chronic lesions among these patients. Mycological tests should be applied to indicate the incidence of fungal diseases in psoriatic patients.

Atypical oral candidiasis in a psoriatic patient during targeted immunotherapy with an interleukin 17 inhibitor (secukinumab)

Background

Secukinumab is a human monoclonal antibody immunoglobulin that neutralises interleukin (IL)-17A, and as such, is effective in the treatment of psoriasis. However, as IL-17A is essential in protection against fungal infections, patients treated with this drug may develop candidiasis. This report presents a case of atypical oral candidiasis occurring during targeted drug immunotherapy with an interleukin 17 (IL-17) inhibitor (secukinumab), with the aim of emphasisinge the necessity of periodical oral health assessment and monitoring. It provides a rational clinical approach to therapeutic protocol in the treatment of side effects associated with novel medications for autoimmune diseases.

Case presentation

Symptomatic tongue lesions were observed in a 50-year-old female patient on a monthly systemic treatment of 300 mg of secukinumab, which appeared after 60 days of using the medication. Two inconclusive biopsies and an unsuccessful application of oral corticosteroids made the diagnostic process challenging. Papillae on the back of the tongue were atrophied, forming a well-defined erythema and white non-detachable plaques on the lateral border of the tongue. Cytopathological and histopathological exam results were compatible with a diagnosis of oral candidiasis. Topical antifungal medication led to subsequent regression of the tongue lesions. During asymptomatic period and follow up for 7 months, a reduced monthly dose 150 mg of secukinumab was administered.

Conclusions

Patients undergoing treatment with IL-17 blockers, such as secukinumab, should be carefully monitored in order to avoid oral side effects resulting from the use of this medication.

Interplay between Humoral and CLA+ T Cell Response against Candida albicans in Psoriasis

Candida albicans (CA) infections have been associated with psoriasis onset or disease flares. However, the integrated immune response against this fungus is still poorly characterized in psoriasis. We studied specific immunoglobulins in plasma and the CA response in cocultures of circulating memory CD45RA^- cutaneous lymphocyte antigen (CLA)^+/- T cell with autologous epidermal cells from plaque and guttate psoriasis patients (cohort 1, n = 52), and also healthy individuals (n = 17). A complete proteomic profile was also evaluated in plaque psoriasis patients (cohort 2, n = 114) regarding their anti-CA IgA levels. Increased anti-CA IgA and IgG levels are present in the plasma from plaque but not guttate psoriasis compared to healthy controls. CA cellular response is confined to CLA⁺ T cells and is primarily Th17. The levels of anti-CA IgA are directly associated with CLA⁺ Th17 response in plaque psoriasis. Proteomic analysis revealed distinct profiles in psoriasis patients with high anti-CA IgA. C-C motif chemokine ligand 18, chitinase-3-like protein 1 and azurocidin were significantly elevated in the plasma from plaque psoriasis patients with high anti-CA levels and severe disease. Our results indicate a mechanism by which Candida albicans exposure can trigger a clinically relevant IL-17 response in psoriasis. Assessing anti-CA IgA levels may be useful in order to evaluate chronic psoriasis patients.

Immunity to commensal skin fungi promotes psoriasiform skin inflammation

Under steady-state conditions, the immune system is poised to sense and respond to the microbiota. As such, immunity to the microbiota, including T cell responses, is expected to precede any inflammatory trigger. How this pool of preformed microbiota-specific T cells contributes to tissue pathologies remains unclear. Here, using an experimental model of psoriasis, we show that recall responses to commensal skin fungi can significantly aggravate tissue inflammation. Enhanced pathology caused by fungi preexposure depends on Th17 responses and neutrophil extracellular traps and recapitulates features of the transcriptional landscape of human lesional psoriatic skin. Together, our results propose that recall responses directed to skin fungi can directly promote skin inflammation and that exploration of tissue inflammation should be assessed in the context of recall responses to the microbiota.

Predictive role of vitamin A serum concentration in psoriatic patients treated with IL-17 inhibitors to prevent skin and systemic fungal infections

The use of biological drugs in psoriasis is replacing traditional therapies due to their specific mechanism and limited side effects. However, the use of Interleukin 17 inhibitors and the modification of its cytokine pathway could favor the risk of fungal infections. All-trans retinoic acid is an active metabolite of vitamin A with anti-inflammatory and immunoregulatory properties through its capacity to stimulate both innate and adaptive immunity and to its effects on proliferation, differentiation and apoptosis in a variety of immune cells. Furthermore, it has been recently discovered that All-trans retinoic acid has a direct fungistatic effect against Candida and Aspergillus Fumigatus. On the basis of these new insights, in the current review, we suggest that the evaluation of serum level of All-trans retinoic acid or vitamin A should be considered as a predictive marker for the development of fungal infections among psoriatic patients treated with Interleukin 17 inhibitors. In clinical practice, vitamin A test could be added in the routine hospital diagnostic management for a better selection of psoriatic patients eligible to Interleukin 17 inhibitors.

Antistreptococcal interventions for guttate and chronic plaque psoriasis

BACKGROUND

Psoriasis is a chronic skin disease that affects approximately two per cent of the general population. Plaque psoriasis is the most common form: it usually appears as raised, red patches of inflamed skin, covered with silvery white scales. The patches often occur in a symmetrical pattern. Guttate psoriasis is a particular form of psoriasis with widespread, small erythematosquamous lesions. Streptococcal infection is suspected to be a triggering factor for the onset of guttate psoriasis, and flare-up of chronic plaque psoriasis. The previous Cochrane Review on this topic was published in 2000; it required an update because antistreptococcal treatment continues to be used to treat psoriasis, especially for the acute form of guttate psoriasis.

OBJECTIVES

To assess the effects of antistreptococcal interventions for guttate and chronic plaque psoriasis.

SEARCH METHODS

We searched Cochrane Skin Specialised Register, Cochrane Register of Studies Online, CENTRAL, MEDLINE, Embase, LILACS, and five trials registers (January 2019). We checked the reference lists of included and excluded studies and searched conference proceedings from the American Academy of Dermatology, Society for Investigative Dermatology, and European Academy of Dermatology and Venereology.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) assessing antistreptococcal interventions (tonsillectomy or systemic antibiotic treatment) in people with clinically diagnosed acute guttate and chronic plaque psoriasis compared with placebo, no intervention, or each other.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcome measures were: 1) time-to-resolution; achieving clear or almost clear skin (Physician Global Assessment (PGA) 0 or 1 or Psoriasis Area and Severity Index (PASI) 90 or 100); 2) proportion of participants with adverse effects and severe adverse effects. Secondary outcomes were: 1) proportion of participants achieving clear or almost clear skin; 2) proportion of participants achieving PASI 75 or PGA 1 to 2; 3) risk of having at least one relapse at long-term follow-up. Short-term assessment was defined as within eight weeks of the start of treatment; long-term was at least one year after the start of treatment.

MAIN RESULTS

We included five trials (162 randomised participants); three were conducted in a hospital dermatology department. One study declared funding by a pharmaceutical company. Participants' ages ranged from 12 to 77 years; only two participants were younger than 15 years. Mean PASI score at baseline varied from 5.7 (i.e. mild) to 23 (i.e. severe) in four studies. Twenty-three of 162 participants had streptococcus-positive throat swab culture. We did not perform a meta-analysis due to heterogeneity of participants' characteristics and interventions.None of the trials measured our efficacy primary outcome, time-to-resolution, or the secondary outcome, risk of having at least one relapse at long-term follow-up.We rated the quality of the results as very low-quality evidence, due to high risk of bias (absence of blinding of participants and caregivers, and high risk of outcome reporting bias) and imprecision (single study data with a low number of events). Hence, we are very uncertain about the results presented.Guttate psoriasisOne three-armed trial (N = 43) assessed penicillin (50,000 international units (IU)/kg/day in three doses) versus erythromycin (250 mg four times per day) versus no treatment (treatment for 14 days, with six-week follow-up from start of treatment). Adverse events and the proportion of participants achieving clear or almost clear skin were not measured.One trial (N = 20) assessed penicillin (1.6 MU (million units) intramuscularly once a day) versus no treatment (six weeks of treatment, with eight-week follow-up from start of treatment). At six-week (short-term) follow-up, no adverse events were observed in either group, and there was no statistically significant difference between the two groups in the proportion of participants with clear or almost clear skin (risk ratio (RR) 2.00, 95% confidence interval (CI) 0.68 to 5.85).One trial (N = 20) assessed rifampicin (300 mg twice daily) versus placebo (14-day treatment duration; six-week follow-up from start of treatment); none of the review outcomes were measured.These trials did not measure the proportion of participants achieving PASI 75 or PGA 1 to 2.Chronic plaque psoriasisOne trial (N = 50) assessed long-term azithromycin treatment (500 mg daily dose) versus vitamin C. Adverse events were reported in the azithromycin group (10 out of 30 had nausea and mild abdominal upset), but not in the vitamin C group. The proportion of participants who achieved clear or almost clear skin was not measured. In the azithromycin group, 18/30 versus 0/20 participants in the vitamin C group reached PASI 75 at the end of 48 weeks of treatment (RR 25.06, 95% CI 1.60 to 393.59).One trial (N = 29) assessed tonsillectomy versus no treatment, with 24-month follow-up after surgery. One participant in the tonsillectomy group had minor bleeding. At eight-week follow-up, 1/15 in the tonsillectomy group, and 0/14 in the no treatment group achieved PASI 90; and 3/15 participants in the tonsillectomy group, and 0/14 in the no treatment group achieved PASI 75 (RR 6.56, 95% CI 0.37 to 116.7).

AUTHORS' CONCLUSIONS

We found only five trials (N = 162), which assessed the effects of five comparisons (systemic antibiotic treatment (penicillin, azithromycin) or tonsillectomy). Two comparisons (erythromycin compared to no treatment, and rifampicin compared to placebo) did not measure any of the outcomes of interest. There was very low-quality evidence for the outcomes that were measured, Therefore, we are uncertain of both the efficacy and safety of antistreptococcal interventions for guttate and chronic plaque psoriasis.The included trials were at unclear or high risk of bias and involved only a small number of unrepresentative participants, with limited measurement of our outcomes of interest. The studies did not allow investigation into the influence of Streptococcal infection, and a key intervention (amoxicillin) was not assessed.Further trials assessing the efficacy and tolerance of penicillin V or amoxicillin are needed in children and young adults with guttate psoriasis.

Secukinumab in moderate-to-severe plaque psoriasis: a multi-center, retrospective, real-life study up to 52 weeks observation

OBJECTIVES

To evaluate efficacy and safety of the anti-IL-17 drug secukinumab in a real-life large cohort of patients with moderate-to-severe plaque psoriasis in Central Italy.

METHODS

Multicenter, retrospective study with an observation period of up to 52 weeks. Efficacy was assessed by Psoriasis Area and Severity Index (PASI) score; clinical and laboratory examinations were performed at baseline and at weeks 4, 12, 24, 36, and 52.

RESULTS

A 90% and a 100% PASI score reduction (PASI90 and PASI100) were reported in 67.5% and 55% of patients at week 12, respectively. A rapid improvement of skin lesions was observed particularly in young patients and in patients naïve to biologics: at week 4, the achievement of PASI90 and PASI100 was higher in younger patients (odds ratio [OR] 0.95, and 0.95; p = 0.003, and 0.005, respectively); PASI90 was achieved by 42.0% of patients naïve to biologics and by 17.0% of patients with prior exposure to biologics (PBT) (OR 0.24; p = 0.001); and PASI100 was reached by 25.5% of naïve patients and 9.8% of PBT (OR 0.28; p = 0.015).The drug was well tolerated.

CONCLUSION

Secukinumab was effective in this real-life analysis, with rapid clinical improvement and long-term maintenance of results.

Prevalence and Possible Role of Candida Species in Patients with Psoriasis: A Systematic Review and Meta-Analysis

Although fungal colonization is implicated in the pathogenesis of psoriasis, its prevalence remains unclear. The aim of this systematic review and meta-analysis was to provide an overview on the prevalence of Candida species in patients with psoriasis. We searched databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and http://clinicaltrials.gov) to identify studies involving subjects of any age with an established diagnosis of psoriasis and healthy controls, who were tested for carriage of Candida spp. on the skin or mucosal membranes (or saliva and stool), or presented with clinical candidiasis with microbiologically confirmed etiology. We identified nine cross-sectional studies including a total of 1038 subjects with psoriasis (psoriatics) and 669 controls. We found Candida species detection rates for psoriatics were significantly higher than those in the controls, especially in the oral mucosa milieux. These results suggest psoriasis may be one of the systemic diseases that predispose to oral Candida spp. carriage and infection.

Mannan-induced Nos2 in macrophages enhances IL-17-driven psoriatic arthritis by innate lymphocytes

Previous identification of the inducible nitric oxide synthase (NOS2) gene as a risk allele for psoriasis (Ps) and psoriatic arthritis (PsA) suggests a possible pathogenic role of nitric oxide (NO). Using a mouse model of mannan-induced Ps and PsA (MIP), where macrophages play a regulatory role by releasing reactive oxygen species (ROS), we found that NO was detectable before disease onset in mice, independent of a functional nicotinamide adenine dinucleotide phosphate oxidase 2 complex. MIP was suppressed by either deletion of Nos2 or inhibition of NO synthases with NG-nitro-l-arginine methyl ester, demonstrating that Nos2-derived NO is pathogenic. NOS2 expression was also up-regulated in lipopolysaccharide- and interferon-γ-stimulated monocyte subsets from patients with PsA compared to healthy controls. Nos2-dependent interleukin-1α (IL-1α) release from skin macrophages was essential for arthritis development by promoting IL-17 production of innate lymphoid cells. We conclude that Nos2-derived NO by tissue macrophages promotes MIP, in contrast to the protective effect by ROS.

Oral Candida colonization and plaque type psoriasis: Is there any relationship?

AIM

The potential role of superantigens derived from microbial agents could be considered in the pathogenesis of psoriasis, but the association between Candida albicans and psoriasis severity is still controversial. The present study was designed to compare the prevalence of oral candidiasis in a group of psoriatic patients and healthy patients, and its correlation with psoriasis severity.

METHODS

Seventy psoriatic patients with no history of systemic treatment and 70 closely-matched control patients underwent oral examination. Scraping of oral mucosa to detect Candida species was done using a sterile cytobrush.

RESULTS

Candida was detected in the oral cavity of 20% of patients with psoriasis and 2.8% of control cases (P = .002), but none had clinical features of oral candidiasis. Candida albicans was the only species isolated from the oral cavity of both groups. No correlation was found between sex, age, phototherapy, and presence of oral candidiasis. There was a positive correlation between psoriasis severity and colony count (P < .001).

CONCLUSIONS

The prevalence of oral candidiasis is higher in psoriatic patients and is associated with disease severity. It is not exactly clear whether oral candidiasis can aggravate psoriasis or if psoriasis can predispose patients to oral candidiasis.

A Clinician's Guide to the Diagnosis and Treatment of Candidiasis in Patients with Psoriasis

Many of the molecular pathways associated with psoriasis pathogenesis are also involved in host defense mechanisms that protect against common pathogens. Candida can stimulate the production of cytokines that trigger or exacerbate psoriasis, and many systemic psoriasis treatments may put patients at increased risk for developing oral, cutaneous, and genitourinary candidiasis. Therefore, dermatologists should regularly screen patients with psoriasis for signs of Candida infection, and take steps to effectively treat these infections to prevent worsening of psoriasis symptoms. This review provides an overview of candidiasis epidemiology in patients with psoriasis, followed by a primer on the diagnosis and treatment of superficial Candida infections, with specific guidance for patients with psoriasis. Candidiasis in patients with psoriasis typically responds to topical or oral antifungal therapy. While biologic agents used to treat moderate-to-severe psoriasis, such as tumor necrosis factor-α inhibitors and interleukin-17 inhibitors, are known to increase patients’ risk of developing localized candidiasis, the overall risk of infection is low, and candidiasis can be effectively managed in most patients while receiving systemic psoriasis therapies. Thus, the development of candidiasis does not usually necessitate changes to psoriasis treatment regimens.

The role of hormones in the pathogenesis of psoriasis vulgaris

Psoriasis vulgaris is a chronic, common skin disease, which affects the patient’s quality of life to the highest degree. Several exogenous factors and endogenous hormonal changes may act as triggers for psoriasis.

The skin possesses a true endocrine system, which is very important in multiple systemic diseases. A number of conditions are associated with psoriasis, and its severity can also be influenced by hormones. Even though the sex hormones and prolactin have a major role in psoriasis pathogenicity, there are a lot of other hormones which can influence the psoriasis clinical manifestations: glucocorticoids, epinephrine, thyroid hormones, and insulin.

Epidemiology and treatment of psoriasis: a Brazilian perspective

Psoriasis is a chronic immune-mediated systemic disease that is influenced by genetic and environmental factors, is associated with comorbidities, and has a negative impact on the quality of life of affected individuals. The prevalence of psoriasis varies among different ethnic groups, but this topic has not been studied in Brazil to date. In this review, we evaluate the epidemiology and treatment of psoriasis from a Brazilian perspective. We focused on studies that involved Brazilian subjects. The prevalence of psoriasis in Brazil is estimated to be 2.5%, but no population study has been performed previously. Environmental factors, such as tropical climate, in association with genetic factors, such as miscegenation, may exert a beneficial impact on the course and frequency of psoriasis in Brazil. A number of studies have advanced our understanding of the cardiovascular, ophthalmic, and oral comorbidities that are associated with psoriasis. Concerns about biological therapy, such as endemic leprosy, human T-cell lymphotropic virus (HTLV), and tuberculosis infections, are discussed. The nonavailability of treatment options for psoriasis in the public health system contradicts the Brazilian Society of Dermatology guidelines, stimulating the judicialization of access to medicines in psoriasis care.

[What's new in clinical dermatology?]

L’année 2013 a été l’année des études génétiques de type GWAS (Genome wide association studies) au service de maladies fréquentes (psoriasis et dermatite atopique) visant à identifier des gènes candidats et celles des grandes cohortes de population tirées de registres publics ou privés. Ainsi des corrélations épidémiologiques sont déclinées : psoriasis et surrisque vasculaire, psoriasis et pathologies ORL, rosacée et migraines, acné et habitudes alimentaires, eczéma et carcinome basocellulaire, vitiligo et moindre risque de cancers cutanés, lupus cutané Ro/SS-A et cancer, eczéma chronique et inhibiteurs calciques, pemphigoïde et diurétiques de l’anse. Les liens entre isotrétinoïne et MICI ne sont pas confirmés. Ceux liant azathioprine et cancers cutanés le sont. Des toxidermies nouvelles voient le jour (pigmentations à l’interféron, hypodermites et sarcoïdose aux inhibiteurs de BRAF muté, toxidermies au vandétanib, etc.) et des toxidermies anciennes sont « revisitées » (patch-tests dans les toxidermies sévères, pigmentation à l’hydroxychloroquine, dermatoses neutrophiliques à l’azathioprine). Diane35^® a fait une fausse sortie en janvier 2013 mais le tétrazépam, lui, a fait une vraie sortie en juillet 2013. Des aspects originaux de différentes infections cutanées sont abordés et des données nouvelles sur les MST (méningococcémies et homosexuels masculins, PVH, herpès, syphilis congénitale). Enfin, quelques articles concernant la dermatoscopie, la microscopie confocale et la dermatologie esthétique seront discutés.

Mannan induces ROS-regulated, IL-17A-dependent psoriasis arthritis-like disease in mice

Psoriasis (Ps) and psoriasis arthritis (PsA) are poorly understood common diseases, induced by unknown environmental factors, affecting skin and articular joints. A single i.p. exposure to mannan from Saccharomyces cerevisiae induced an acute inflammation in inbred mouse strains resembling human Ps and PsA-like disease, whereas multiple injections induced a relapsing disease. Exacerbation of disease severity was observed in mice deficient for generation of reactive oxygen species (ROS). Interestingly, restoration of ROS production, specifically in macrophages, ameliorated both skin and joint disease. Neutralization of IL-17A, mainly produced by γδ T cells, completely blocked disease symptoms. Furthermore, mice depleted of granulocytes were resistant to disease development. In contrast, certain acute inflammatory mediators (C5, Fcγ receptor III, mast cells, and histamine) and adaptive immune players (αβ T and B cells) were redundant in disease induction. Hence, we propose that mannan-induced activation of macrophages leads to TNF-α secretion and stimulation of local γδ T cells secreting IL-17A. The combined action of activated macrophages and IL-17A produced in situ drives neutrophil infiltration in the epidermis and dermis of the skin, leading to disease manifestations. Thus, our finding suggests a new mechanism triggered by exposure to exogenous microbial components, such as mannan, that can induce and exacerbate Ps and PsA.