Insights Into the Pathogenesis of Psoriasis and Psoriatic Arthritis

Sharing Patient and Clinician Experiences of Moderate-to-Severe Psoriasis: A Nationwide Italian Survey and Expert Opinion to Explore Barriers Impacting upon Patient Wellbeing

A nationwide survey was conducted in adult patients with psoriasis (PsO) across Italy to obtain their real-world perspective of the impact of PsO on their wellbeing. Patients completed a 26-question survey (based on the patient benefit index; PBI, The Dermatology Life Quality Index; DLQI and the World Health Organization-five; WHO-5 wellbeing index) and workshop discussion sessions were undertaken by dermatologists to interpret results from the survey. 392 patients with PsO completed the survey. Analysis of results was restricted to patients who had moderate-to-severe plaque psoriasis (assessed by patients; n = 252; 64.3%). Dermatologists (n = 32) completed one question from the survey related to wellbeing and rated social, physical and mental domains as contributing to a similar extent, with comparable scores also observed by patients. For treatment, biologics yielded higher scores on average, whereas little difference was observed between topical and conventional systemic treatments. Only 23.8% of patients felt that their dermatologist was taking into consideration their wellbeing and 32.6% of the patients considered their therapy as inadequate in improving signs and symptoms of the disease. This survey identified key factors contributing to barriers impacting on patient wellbeing. Simple, but comprehensive questionnaires can provide important insight to patients’ needs that may significantly increase clinician awareness during visits leading to tailored treatment.

Toll-like receptors in rheumatic diseases: are we paying a high price for our defense against bugs?

In the last decade Toll-like receptor (TLR) research has led to new insights in the pathogenesis of many rheumatic diseases. In autoimmune diseases like systemic lupus erythematosus, rheumatoid arthritis and systemic sclerosis TLR signaling is likely to be involved in tolerance breakthrough and chronic inflammation via combined Fc gamma receptors and TLR recognition of immune complexes. Furthermore, inflammatory diseases like psoriatic arthritis and gout also show more and more evidence for TLR involvement. In this review we will discuss the involvement of TLR signaling in several rheumatic diseases and stress their similarities and differences based on recent findings.

Alternative treatment of psoriasis with balneotherapy using Leopoldine spa water

BACKGROUND

Leopoldine spa water is a hypotonic water rich in sulphate that has been used occasionally for balneological treatments in psoriatics. We evaluated the anti-inflammatory effects of this salso-sulphate water on the skin of subjects with psoriasis.

PATIENTS AND METHODS

We selected 10 volunteer subjects (23-58 years old), who presented symmetrical, bilateral psoriasis involving at least 40% of the body surface. All the subjects were subjected to the following treatment schedule: (i) immersion of both arms in water twice a day [the right arm was immersed in Leopoldine spa water at its natural source temperature (27.2 degrees C) for 30 min, and the left arm was immersed in double-distilled water for 30 min at a constant temperature of 27 degrees C]; (ii) both arms were exposed to the sun for 60 min after each immersion; and (iii) vaseline containing moisturizing creams were applied liberally. The treatment was continued for 4 weeks and was well tolerated by all subjects. Response to treatment was assessed by means of the modified Psoriasis Area and Severity Index (PASI). Six of the 10 subjects volunteered to undergo a cutaneous biopsy of lesional skin both before and 4 weeks after treatment to allow for assessment of modifications of the cutaneous infiltrate in the areas treated.

RESULTS

At the end of 4 weeks the average pretreatment PASI score of the left arms was 5.72 (range 4-9.6) while the right arms had a mean PASI of 5.56 (range of 3.2-9). At the end of the study the average PASI score was 0.78 for the arms treated with Leopoldine spa water and 2.83 for the arms treated with double-distilled water. The mean PASI improvement score for the Leopoldine spa water treated arms was 85.9% while the double-distilled water treated arms showed a PASI improvement score of 50.5%. An immunohistological study showed significant differences between the cutaneous samples taken 4 weeks after treatment and those taken before treatment with Leopoldine spa water. There were significant decreases in the numbers of epidermal CD4+ and CD8+ T lymphocytes and CD1a+ Langerhans cells (microscopic field at x 22 objective), as well as a decrease in the epidermal keratinocyte expression of intercellular adhesion molecule-1 and interleukin-8 and the dermal expression of CD4+ and CD8+ T lymphocytes.

CONCLUSIONS

These data show the potential anti-inflammatory effects of Leopoldine mineral waters on human skin affected by psoriasis.

T-cell studies in the spondyloarthropathies

A growing body of evidence suggests that T lymphocytes play an important role in initiating and maintaining the inflammatory process characteristic of the human leukocyte antigen (HLA)-B27-associated spondyloarthropathies. T cells seem to be involved in the primary defense reaction against arthritis-triggering gram-negative bacteria at the site of extra-articular infection, in determining the systemic cytokine pattern, in the recirculation process between gut mucosa and the joint, and in mediating secondary autoimmune joint inflammation. The factors involved in disease chronicity (namely in ankylosing spondylitis and psoriatic arthritis) are still unknown. Autoreactive T cells may contribute to this process by recognition of cross-reactive self-epitopes (ie, molecular mimicry between bacterial and self-antigens). Autoreactive T cells may as well be inappropriately upregulated by bacterial superantigens, or by local inflammatory reactions leading to the uncovering of former cryptic self-epitopes. In this paper, we review recent studies on peripheral blood and synovial T cells in patients with reactive arthritis, enteropathic spondyloarthropathy, psoriatic arthritis, and ankylosing spondylitis.

Myofibroblasts. I. Paracrine cells important in health and disease

Myofibroblasts are a unique group of smooth-muscle-like fibroblasts that have a similar appearance and function regardless of their tissue of residence. Through the secretion of inflammatory and anti-inflammatory cytokines, chemokines, growth factors, both lipid and gaseous inflammatory mediators, as well as extracellular matrix proteins and proteases, they play an important role in organogenesis and oncogenesis, inflammation, repair, and fibrosis in most organs and tissues. Platelet-derived growth factor (PDGF) and stem cell factor are two secreted proteins responsible for differentiating myofibroblasts from embryological stem cells. These and other growth factors cause proliferation of myofibroblasts, and myofibroblast secretion of extracellular matrix (ECM) molecules and various cytokines and growth factors causes mobility, proliferation, and differentiation of epithelial or parenchymal cells. Repeated cycles of injury and repair lead to organ or tissue fibrosis through secretion of ECM by the myofibroblasts. Transforming growth factor-beta and the PDGF family of growth factors are the key factors in the fibrotic response. Because of their ubiquitous presence in all tissues, myofibroblasts play important roles in various organ diseases and perhaps in multisystem diseases as well.