Current and future management of psoriasis

Real-world use, perception, satisfaction, and adherence of calcipotriol and betamethasone dipropionate PAD-cream in patients with plaque psoriasis in Spain and Germany: results from a cross-sectional, online survey

BACKGROUND

Psoriasis significantly impacts patients' quality of life (QoL). Dissatisfaction and non-adherence are major barriers associated with topical treatments. A cream based on the polyaphron dispersion (PAD) Technology containing a fixed-dose of calcipotriol (CAL) and betamethasone dipropionate (BDP) was designed for a patient-friendly psoriasis management. The CAL/BDP PAD-cream demonstrated efficacy, convenience, and safety/tolerability in clinical trials.

OBJECTIVES

This research assesses the real-world use, perception, satisfaction, and adherence of CAL/BDP PAD-cream among plaque psoriasis patients.

METHODS

Between September-November 2023, psoriasis patients from Spain and Germany using or having used CAL/BDP PAD-cream for >2 weeks were recruited via Wefight network to complete a 30-questions online survey. Anonymized results were pooled for descriptive statistical analysis.

RESULTS

The survey was completed by 129 patients (mean age: 43 years; 66% females; mean psoriasis duration: 12 years). Most patients (93%) were satisfied with CAL/BDP PAD-cream. The 66% reported high adherence (visual analogue scale 80-100) and 91% preferred CAL/BDP PAD-cream to their previous topical(s). Patients highlighted its ease/convenience of application, tolerability, and lack of itching/burning.

CONCLUSIONS

Psoriasis patients treated with CAL/BDP PAD-cream in a real-world setting show high satisfaction, good adherence, and a positive perception of the product, suggesting that favorable outcomes observed in clinical trials translate to real clinical practice.

Prescribing patterns and persistence of biological therapies for psoriasis management: a retrospective cohort study from Saudi Arabia

BACKGROUND

Biological therapies are effective for psoriasis, but patient responses vary, often requiring therapy switching or discontinuation.

OBJECTIVES

To identify physicians' prescribing patterns of biological therapies at a referral tertiary center in Saudi Arabia and assess the probability of biologic persistence following treatment initiation.

METHODS

We conducted a retrospective study of biologic-naïve adult psoriasis patients who initiated therapy from October 2013 to July 2022 in Dammam. Descriptive statistics and a Kaplan-Meier analysis evaluated treatment persistence at 6, 12, 24, and 36 months.

RESULTS

A total of 151 patients received adalimumab (n = 89), etanercept (n = 17), risankizumab (n = 30), ustekinumab (n = 14), and ixekizumab (n = 1). At 6 months, all therapies demonstrated 100% persistence. At 12 months, persistence was highest for ustekinumab (100%) and lowest for etanercept (88.2%). At 24 months, ustekinumab maintained 100% persistence, followed by risankizumab (96.6%), adalimumab (94.3%), and etanercept (76.4%). At 36 months, risankizumab had the highest persistence (96.6%), followed by adalimumab (83.1%), ustekinumab (78%), and etanercept (70.6%). The most common reasons for discontinuation were lack of effectiveness and intolerability.

CONCLUSION

This study shows changing psoriasis treatment patterns with new therapies. Risankizumab demonstrated high long-term persistence, while etanercept and ustekinumab showed declining persistence, suggesting evolving treatment considerations.

Psoriatic arthritis, biologic therapy experience, body mass index, and onset age of psoriasis were independent factors of secukinumab discontinuation in patients with psoriasis

INTRODUCTION

Despite the availability of several treatments for psoriasis (PsO), factors influencing the persistence of secukinumab (SEC) therapy remain inadequately understood. This study aimed to identify predictors of SEC persistence in PsO.

METHODS

A retrospective analysis was conducted on 109 PsO patients who received SEC treatment at least 1 year. Patients were categorized based on continued or discontinued SEC therapy.

RESULTS

Among the 109 patients, 64 continued SEC treatment while 45 discontinued. Univariate analysis demonstrated that PsA presence and previous biologic therapy use increased the risk of SEC discontinuation 3.56- and 2.33-fold (p = 0.001, %95 CI: 1.66-7.65 and p = 0.032, %95 CI: 1.08-5.04, respectively). Additionally, the risk of SEC discontinuation is 57% higher in patients with a body mass index (BMI) above 26.5 compared to those with a BMI below 26.5 (p = 0.016, %95 CI: 0.22-0.85). Additionally, patients with PsO onset age below 26.5 years were found to have a 2.93-times higher risk of discontinuing SEC compared to those with PsO onset age above 26.5 years (p = 0.004, %95 CI: 1.40-6.13).

CONCLUSION

PsA presence, previous biologic therapy experience, BMI, and PsO onset age were identified as independent predictors of SEC discontinuation. These findings underscore the importance of personalized treatment strategies for PsO patients receiving SEC therapy.

A Case of Severe Organ Dysfunction and Skin Lesions Due to Methotrexate Toxicity

Methotrexate is an anti-inflammatory and immunomodulatory drug, widely used for moderate to severe psoriasis and other rheumatological conditions such as rheumatoid arthritis, besides some types of malignancies. Side effects are more prevalent in high acute doses but can also be seen in low-dose chronic use, especially in cases of drug-dosing errors. Possible symptoms of toxicity include gastrointestinal, hepatic, hematologic and renal dysfunctions, but may also include mucositis and worsening of the psoriatic lesions. Here, we describe a case involving methotrexate toxicity in an elderly patient with psoriasis, detailing the management.

Can Essential Oils/Botanical Agents Smart-Nanoformulations Be the Winning Cards against Psoriasis?

Although psoriasis remains one of the most devastating inflammatory disorders due to its huge negative impact on patients’ quality of life, new “green” treatment approaches still need to be fully explored. The purpose of this review article is to focus on the utilization of different essential oils and active constituents of herbal botanical origin for the treatment of psoriasis that proved efficacious via both in vitro and in vivo models. The applications of nanotechnology-based formulations which displayed great potential in augmenting the permeation and delivery of these agents is also addressed. Numerous studies have been found which assessed the potential activity of natural botanical agents to overcome psoriasis. Nano-architecture delivery is applied in order to maximize the benefits of their activity, improve properties, and increase patient compliance. This field of natural innovative formulations can be a promising tool to optimize remediation of psoriasis while minimizing adverse effects.

Multivariable Predictive Models to Identify the Optimal Biologic Therapy for Treatment of Patients With Psoriasis at the Individual Level

Importance

Identifying the optimal long-term biologic therapy for patients with psoriasis is often done through trial and error.

Objective

To identify the optimal biologic therapy for individual patients with psoriasis using predictive statistical and machine learning models.

Design, Setting, and Participants

This population-based cohort study used data from Danish nationwide registries, primarily DERMBIO, and included adult patients treated for moderate-to-severe psoriasis with biologics. Data were processed and analyzed between spring 2021 and spring 2022.

Main Outcomes and Measures

Patient clusters of clinical relevance were identified and their success rates estimated for each drug. Furthermore, predictive prognostic models to identify optimal biologic treatment at the individual level based on data from nationwide registries were evaluated.

Results

Assuming a success criterion of 3 years of sustained treatment, this study included 2034 patients with a total of 3452 treatment series. Most treatment series involved male patients (2147 [62.2%]) originating from Denmark (3190 [92.4%]), and 2414 (69.9%) had finished an education longer than primary school. The average ages were 24.9 years at psoriasis diagnosis and 45.5 years at initiation of biologic therapy. Gradient-boosted decision trees and logistic regression were able to predict a specific cytokine target (eg, interleukin-17 inhibition) associated with a successful treatment with accuracies of 63.6% and 59.2%, and top 2 accuracies of 95.9% and 93.9%. When predicting specific drugs resulting in success, gradient boost and logistic regression had accuracies of 48.5% and 44.4%, top 2 accuracies of 77.6% and 75.9%, and top 3 accuracies of 89.9% and 89.0%.

Conclusions and Relevance

Of the treatment prediction models used in this cohort study of patients with psoriasis, gradient-boosted decision trees performed significantly better than logistic regression when predicting specific biologic therapy (by drug as well as target) leading to a treatment duration of at least 3 years without discontinuation. Predicting the optimal biologic could benefit patients and clinicians by minimizing the number of failed treatment attempts.

Psoriasis: Interplay between dysbiosis and host immune system

With advancement in human microbiome research, an increasing number of scientific evidences have endorsed the key role of both gut and skin microbiota in the pathogenesis of psoriasis. Microbiome dysbiosis, characterized by altered diversity and composition, as well as rise of pathobionts, have been identified as possible triggers for recurrent episodes of psoriasis. Mechanistically, gut dysbiosis leads to "leaky gut syndrome" via disruption of epithelial bilayer, thereby, resulting in translocation of bacteria and other endotoxins to systemic circulation, which in turn, results in inflammatory response. Similarly, skin dysbiosis disrupts the cutaneous homeostasis, leading to invasion of bacteria and other pathogens to deeper layers of skin or even systemic circulation further enhanced by injury caused by pruritus-induced scratching, and elicit innate and adaptive inflammation. The present review explores the correlation of both skin and gut microbiota dysbiosis with psoriasis. Also, the studies highlighting the potential of bacteriotherapeutic approaches including probiotics, prebiotics, metabiotics, and fecal microbiota transplantation for the management of psoriasis have been discussed.

The impact of gender and sex in psoriasis: What to be aware of when treating women with psoriasis

Psoriasis is a common chronic inflammatory skin disease with an exceptionally high burden for women.

Exploration of the Potential Mechanism of the Common Differentially Expressed Genes in Psoriasis and Atopic Dermatitis

Backgrounds. Psoriasis and atopic dermatitis are two common chronic inflammatory skin diseases that enormously deteriorate the psycho-physical and socio-economic condition of the patients. Although differential immune responses have been found to operate in the pathomechanisms of atopic dermatitis and psoriasis, the epidermal keratinocytes are the major targets in both diseases, and sometimes, they show similar clinical presentations. The skin barrier, itching, and inflammation are current and future treatment targets for both of them, but the relevant shared mechanisms of the two diseases are far from understood. Methods. The differential analyses of GSE14905 (psoriasis) and GSE32924 (atopic dermatitis) deposited in GEO database were conducted and obtained their differential expressed genes. Moreover, PPI, functional modules, GO, and KEGG enrichment analyses were used for the further analysis. The mouse models of psoriasis and atopic dermatitis were established, and then, RT-qPCR and Western blotting assay were performed to check the abundant changes of hub genes. Results. There are 732 differentially expressed genes in psoriasis versus nonlesional skin samples. Besides, 611 differentially expressed genes were identified in atopic dermatitis versus nonlesional skin data sets. Based on these differentially expressed genes, we predicted their joint and individual protein-protein interaction networks and functional modules in both psoriasis and atopic dermatitis. Through the PPI network of genes, we calculated the hub nodes and do the GO and KEGG enrichment analysis of overlapped genes of psoriasis and atopic dermatitis, which suggested there were some terms like “positive regulation of interleukin-12 production,” “centromeric region,” and “TNF signaling pathway.” Conclusion. We constructed the predicted PPI networks and functional modules related to psoriasis and atopic dermatitis and distinguished the key candidate target genes CXCL8, STAT1, and MMP9 in the diagnosis and therapy of similar pathogenesis.

Phosphodiesterase-4 Inhibition Reduces Cutaneous Inflammation and IL-1β Expression in a Psoriasiform Mouse Model but Does Not Inhibit Inflammasome Activation

Apremilast (Otezla^®) is an oral small molecule phosphodiesterase 4 (PDE4) inhibitor approved for the treatment of psoriasis, psoriatic arthritis, and oral ulcers associated with Behçet’s disease. While PDE4 inhibition overall is mechanistically understood, the effect of apremilast on the innate immune response, particularly inflammasome activation, remains unknown. Here, we assessed the effect of apremilast in a psoriasis mouse model and primary human cells. Psoriatic lesion development in vivo was studied in K5.Stat3C transgenic mice treated with apremilast for 2 weeks, resulting in a moderate (2 mg/kg/day) to significant (6 mg/kg/day) resolution of inflamed plaques after 2-week treatment. Concomitantly, epidermal thickness dramatically decreased, the cutaneous immune cell infiltrate was reduced, and proinflammatory cytokines were significantly downregulated. Additionally, apremilast significantly inhibited lipopolysaccharide- or anti-CD3-induced expression of proinflammatory cytokines in peripheral mononuclear cells (PBMCs). Notably, inflammasome activation and secretion of IL-1β were not inhibited by apremilast in PBMCs and in human primary keratinocytes. Collectively, apremilast effectively alleviated the psoriatic phenotype of K5.Stat3 transgenic mice, further substantiating PDE4 inhibitor-efficiency in targeting key clinical, histopathological and inflammatory features of psoriasis. Despite lacking direct effect on inflammasome activation, reduced priming of inflammasome components upon apremilast treatment reflected the indirect benefit of PDE4 inhibition in reducing inflammation.

Topical Application of Vitamin D3-Loaded Hybrid Nanosystem to Offset Imiquimod-Induced Psoriasis

Lipid-polymer hybrid nanoparticles display several benefits over either lipid and/or polymer based systems with respect to enhanced drug loading, good colloidal stability, sustained release profile, and high cellular uptake. The present work rivets on development and evaluation of vitamin D₃-loaded monolithic lipid-polymer hybrid nanoparticles (VD3/LPHNPs) for their in vivo anti-psoriatic efficacy. These LPHNPs were prepared using a hot homogenization method and exhibited spherical morphology with a lower particle size (123.1 nm) with narrow PDI (0.234) and efficient encapsulation (76.80%). Further, these LPHNPs demonstrated a sustained release profile of VD3 for up to 3 days following a Korsemeyer-Peppas release model. Further, VD3/LPHNPs were formulated into a topical gel containing 0.005% w/w of VD3. Rheological data suggested that the product exhibited non-newtonian flow properties with characteristic shear-thinning and variable thixotropy features that are desirable for topical formulation. The successful formation of gel structure and its long-term stability were confirmed from the oscillatory studies such as amplitude and frequency sweep tests. In vivo efficacy assessment in imiquimod-induced psoriatic mouse model demonstrated enhanced anti-psoriatic activity of VD3 with improved PASI score when delivered as LPHNPs gel as compared to the free VD3 gel that were further supported by histopathology and immunohistochemistry.

A Novel Curcumin-Mycophenolic Acid Conjugate Inhibited Hyperproliferation of Tumor Necrosis Factor-Alpha-Induced Human Keratinocyte Cells

Curcumin (CUR) has been used as adjuvant therapy for therapeutic application in the treatment of psoriasis through several mechanisms of action. Due to the poor oral bioavailability of CUR, several approaches have been developed to overcome the limitations of CUR, including the prodrug strategy. In this study, CUR was esterified with mycophenolic acid (MPA) as a novel conjugate prodrug. The MPA-CUR conjugate was structurally elucidated using FT-IR, ¹H-NMR, ¹³C-NMR, and MS techniques. Bioavailable fractions (BFs) across Caco-2 cells of CUR, MPA, and MPA-CUR were collected for further biological activity evaluation representing an in vitro cellular transport model for oral administration. The antipsoriatic effect of the BFs was determined using antiproliferation and anti-inflammation assays against hyperproliferation of tumor necrosis factor-alpha (TNF-α)-induced human keratinocytes (HaCaT). The BF of MPA-CUR provided better antiproliferation than that of CUR (p < 0.001). The enhanced hyperproliferation suppression of the BF of MPA-CUR resulted from the reduction of several inflammatory cytokines, including IL-6, IL-8, and IL-1β. The molecular mechanisms of anti-inflammatory activity were mediated by an attenuated signaling cascade of MAPKs protein, i.e., p38, ERK, and JNK. Our results present evidence for the MPA-CUR conjugate as a promising therapeutic agent for treating psoriasis by antiproliferative and anti-inflammatory actions.

Dexamethasone and Fumaric Acid Ester Conjugate Synergistically Inhibits Inflammation and NF-κB in Macrophages

Macrophage-mediated inflammation drives autoimmune and chronic inflammatory diseases. Treatment with anti-inflammatory agents can be an effective strategy to reduce this inflammation; however, high concentrations of these agents can have immune-dampening and other serious side effects. Synergistic combination of anti-inflammatory agents can mitigate dosing by requiring less drug. Multiple anti-inflammatory agents were evaluated in combination for synergistic inhibition of macrophage inflammation. The most potent synergy was observed between dexamethasone (DXM) and fumaric acid esters (e.g., monomethyl fumarate (MMF)). Furthermore, this combination was found to synergistically inhibit inflammatory nuclear factor κB (NF-κB) transcription factor activity. The optimal ratio for synergy was determined to be 1:1, and DXM and MMF were conjugated by esterification at this molar ratio. The DXM-MMF conjugate displayed improved inhibition of inflammation over the unconjugated combination in both murine and human macrophages. In the treatment of human donor monocyte-derived macrophages, the combination of DXM and MMF significantly inhibited inflammatory gene expression downstream of NF-κB and overall performed better than either agent alone. Further, the DXM-MMF conjugate significantly inhibited expression of NOD-, LRR-, and pyrin domain-containing protein 3 (NLRP3) inflammasome-associated genes. The potent anti-inflammatory activity of the DXM-MMF conjugate in human macrophages indicates that it may have benefits in the treatment of autoimmune and inflammatory diseases.

Direct comparison of risankizumab and fumaric acid esters in systemic therapy-naïve patients with moderate-to-severe plaque psoriasis: a randomized controlled trial

Background

Fumaric acid esters (FAEs; Fumaderm^®) are the most frequently prescribed first‐line systemic treatment for moderate‐to‐severe plaque psoriasis in Germany. Risankizumab (Skyrizi^®) is a humanized IgG1 monoclonal antibody that specifically binds to the p19 subunit of interleukin 23.

Objectives

To compare risankizumab treatment to FAEs in patients with psoriasis.

Methods

This phase III randomized, active‐controlled, open‐label study with blinded assessment of efficacy was conducted in Germany. Patients were randomized (1 : 1) to subcutaneous risankizumab 150 mg (weeks 0, 4 and 16) or oral FAEs at increasing doses from 30 mg daily (week 0) up to 720 mg daily (weeks 8–24). Enrolled patients were adults naïve to and candidates for systemic therapy, with chronic moderate‐to‐severe plaque psoriasis. Phototherapy was not allowed within 14 days before or during the study.

Results

Key efficacy endpoints were met at week 24 for risankizumab (n = 60) vs. FAEs (n = 60) (P < 0·001): achievement of a ≥ 90% improvement in Psoriasis Area and Severity Index (PASI; primary endpoint 83·3% vs. 10·0%), ≥ 100% improvement in PASI (50·0% vs. 5·0%), ≥ 75% improvement in PASI (98·3% vs. 33·3%), ≥ 50% improvement in PASI (100% vs. 53·3%) and a Static Physician’s Global Assessment of clear/almost clear (93·3% vs. 38·3%). The rates of gastrointestinal disorders, flushing, lymphopenia and headache were higher in the FAE group. One patient receiving risankizumab reported a serious infection (influenza, which required hospitalization). There were no malignancies, tuberculosis or opportunistic infections in either treatment arm.

Conclusions

Risankizumab was found to be superior to FAEs, providing earlier and greater improvement in psoriasis outcomes that persisted with continued treatment, and more favourable safety results, which is consistent with the known safety profile. No new safety signals for risankizumab or FAEs were observed.

What is already known about this topic?

Risankizumab (Skyrizi^®) is approved as treatment for patients with moderate‐to‐severe plaque psoriasis who are candidates for systemic therapy.

Risankizumab is a humanized IgG1 monoclonal antibody that specifically binds to the p19 subunit of interleukin 23.

Fumaric acid esters (FAEs) are the most frequently prescribed first‐line systemic treatment for moderate‐to‐severe plaque psoriasis in Germany.

What does this study add?

In patients with psoriasis who were naïve to systemic treatment, risankizumab treatment was superior to FAEs, providing earlier and greater improvement in psoriasis outcomes that persisted to week 24.

Risankizumab showed more favourable safety results than FAEs and no new safety signals.

The results support risankizumab treatment for patients with moderate‐to‐severe plaque psoriasis who are naïve to systemic treatment.

Linked Comment: P. Fleming. Br J Dermatol 2022; 186:4–5.

Plain language summary available online

Functional study of TNF-α promoter polymorphisms in psoriasis

BACKGROUND

TNF-α is an important mediator in the pathogenesis of psoriasis and polymorphisms influence its transcription and could be implicated in psoriasis risk and modify certain aspects of disease, such as age at onset of psoriasis vulgaris and disease severity. Six TNF-α single nucleotide polymorphisms (SNPs) in promoter region has been identified and studied but with discordant results. The aim of this study was to evaluate whether the polymorphisms in TNF-α (-238 (rs361525), -308 (rs1800629), -857 (rs1799724), -1031 (rs1799964)) are associated with gravity, prurity, early onset or response to drug therapy in psoriasis in Caucasian Italian patients.

METHODS

58 psoriasis patients from Turin PSOCARE, 23 with psoriasis vulgaris and 35 with psoriatic arthritis were studied. Ready to used master mix for allelic discrimination of rs1800629, rs361525 and rs1799964 respectively.

RESULTS

Our data showed a significant association between the -857(G) variant and both VAS-itch (p=0,03) and VAS-pain index (p=0,006), OR=0,2 (0,04-0,98) and OR=0,12 (0,02-0,59). No significant association between the genotypes or alleles of TNF-α SNPs as been observed with other clinic-pathologic parameters or etanercept response.

CONCLUSIONS

Our data suggest that -857 CC genotype could be involved in pain and itch severity in psoriasis patients.

Polymeric Gels and Their Application in the Treatment of Psoriasis Vulgaris: A Review

Psoriasis is a chronic skin disease, and it is especially characterized by the occurrence of red, itchy, and scaly eruptions on the skin. The quality of life of patients with psoriasis is decreased because this disease remains incurable, despite the rapid progress of therapeutic methods and the introduction of many innovative antipsoriatic drugs. Moreover, many patients with psoriasis are dissatisfied with their current treatment methods and the form with which the drug is applied. The patients complain about skin irritation, clothing stains, unpleasant smell, or excessive viscosity of the preparation. The causes of these issues should be linked with little effectiveness of the therapy caused by low permeation of the drug into the skin, as well as patients’ disobeying doctors’ recommendations, e.g., concerning regular application of the preparation. Both of these factors are closely related to the physicochemical form of the preparation and its rheological and mechanical properties. To improve the quality of patients’ lives, it is important to gain knowledge about the specific form of the drug and its effect on the safety and efficacy of a therapy as well as the patients’ comfort during application. Therefore, we present a literature review and a detailed analysis of the composition, rheological properties, and mechanical properties of polymeric gels as an alternative to viscous and greasy ointments. We discuss the following polymeric gels: hydrogels, oleogels, emulgels, and bigels. In our opinion, they have many characteristics (i.e., safety, effectiveness, desired durability, acceptance by patients), which can contribute to the development of an effective and, at the same time comfortable, method of local treatment of psoriasis for patients.

Oral health status and dental treatment needs of psoriatic patients with different therapy regimes

The aim of the study was to investigate the dental treatment requirements and oral health status of psoriatic patients with different severities of the disease, managed by different methods, including biological therapies.

METHODS

One hundred and twenty-seven patients diagnosed with psoriasis were enrolled in this study. All subjects completed a general medical history and a Dermatology Life Quality Index (DLQI) questionnaire. The severity of the disease was assessed using the Psoriasis Area and Severity Index (PASI) scale and a DLQI questionnaire. In order to evaluate the oral health status, the following techniques were used: Approximal Plaque Index (API), the Community Periodontal Index (CPI) and the Decayed, Missing and Filled Teeth (DMFT) index.

RESULTS

Patients treated with biologicals presented a significantly lower mean CPI index and required no surgical interventions. Subjects managed with topical therapy had significantly more decayed teeth and higher treatment needs. Only 11.3% of patients did not require dental intervention.

CONCLUSIONS

The study revealed a high need for dental interventions in patients with psoriasis. The type of treatment used may affect the oral health status of patients. However, further investigations are required to explain the significantly lower CPI value in the group treated with biologicals.

How current biologic therapies affect the risk of major adverse cardiovascular events in patients with plaque psoriasis? A systematic review and meta-analysis of randomized controlled trials

Introduction

Concerns have been raised about an increased risk of major adverse cardiovascular events (MACEs) – stroke, myocardial infarction and sudden cardiac death – in patients with plaque psoriasis receiving biologic therapies.

Aim

This review and meta-analysis of randomized controlled trials (RCTs) was to evaluate the risk difference of MACEs between experimental and comparator interventions.

Material and methods

We searched MEDLINE database for suitable trials. Prior to that we identified the search strategy and eligibility criteria. Each RCT was double-blind, placebo controlled and scored five points in Jadad scale. We calculated risk difference (RD) with use of the Mantel-Haenszel fixed-effect method with 95% confidence intervals (CIs) and calculated i2 statistic to assess heterogeneity. A total of 43 RCTs were included, involving 19,161 patients. Overall, the risk of MACEs in the included studies was 0.1% (n = 21).

Results

There were no statistically significant risk differences in patients treated with biologic therapy vs. placebo (RD = 0.0; Z = 1.09; 95% CI: 0.0–0.0; p = 0.28); tumour necrosis inhibitors vs. placebo (RD = 0.0; Z = 0.47; 95% CI: –0.0–0.0; p = 0.64); anti-IL-17A agents vs. placebo (RD = 0.0; Z = 1.25; 95% CI: –0.0–0.01; p = 0.21); anti-IL-23 agents vs. placebo (RD = 0; Z = 0.36; 95% CI: –0.0–0.01; p = 0.72); anti-IL-12/23 agents vs. placebo (RD = 0.0; Z = 0.73; 95% CI: –0.0–0.0; p = 0.46).

Conclusions

Further trials are needed, including longer follow-up and patients with an increased cardiovascular risk, to assess the risk of MACEs.

Indoor balneophototherapy for chronic plaque psoriasis: Abridged Cochrane Review

Artificial exposure to ultraviolet B light (UVB) while soaking in an indoor salt bath, also called balneophototherapy, could simulate the natural exposure to the sun while bathing in the Dead Sea. We aimed to assess the effects of this intervention on patients with chronic plaque psoriasis. We searched CENTRAL, MEDLINE, Embase, and LILACS up to June 2019. We included randomized controlled trials (RCTs). The primary efficacy outcome was psoriasis area and severity index (PASI)-75 to detect people with a 75% or more reduction in the PASI score from baseline. The primary adverse outcome was treatment-related adverse events requiring withdrawal. We included eight RCTs (2105 participants; 1976 analyzed). With respect to PASI-75, two studies found that salt bath + UVB may improve psoriasis when compared to UVB alone (risk ratio 1.71, 95% confidence interval 1.24 to 2.35; 278 participants). With respect to treatment-related adverse events requiring withdrawal, two other studies found little to no difference when compared to UVB alone (risk ratio 0.96, 95% confidence interval 0.35 to 2.64; 404 participants). Salt bath + UVB could improve psoriasis when compared to UVB alone, though, results are based on a limited number of studies and provide low-certainty evidence.

Tumor Necrosis Factor-α 308 G/A polymorphism and psoriasis risk: A pooled analysis in different populations

More and more researches have been carried out on the association between the tumor necrosis factor-α (TNF-α) 308 G/A polymorphism and psoriasis, however, controversial results have emerged in these studies. This meta-analysis was performed to quantitatively clarify the relationship between TNF-α 308 G/A polymorphism and the risk of psoriasis in different populations. Databases of PubMed, Springer Link, Ovid, Chinese Wanfang Data Bases, Chinese National Knowledge Infrastructure and Chinese Biology Medicine were investigated until June 2019. The association between the TNF-α 308 G/A polymorphism and psoriasis was evaluated by calculating the pooled odds ratio (OR) and 95% confidence intervals (CIs). A total of 26 studies including 3657 patients and 3197 controls were screened out. In the overall population, the pooled results showed a reduced psoriasis risk with the TNF-α 308 G/A polymorphism (A vs G: OR = 0.77, 95% CI = 0.67-0.89; AA+GA vs GG: OR = 0.72, 95% CI = 0.61-0.86). In the subgroup analysis stratified by geographic locations, the TNF-α 308 G/A polymorphism was significantly associated with a reduced risk of psoriasis in Germany (A vs G: OR = 0.67, 95% CI = 0.57-0.78; AA+GA vs GG: OR = 0.62, 95% CI = 0.52-0.75), as well as in China (AA+GA vs GG: OR = 0.71, 95% CI = 0.52-0.98) and Poland (A vs G: OR = 0.61, 95% CI = 0.38-0.97; AA+GA vs GG: OR = 0.59, 95% CI = 0.35-0.99). This study indicated a significantly reduced psoriasis risk associated with the TNF-α 308 G/A polymorphism in Germans, as well as in Chinese and Poles populations compared with other populations. Ethnicity and geographic locations probably play a pivotal role in the genetic association of psoriasis.

Multi-component clobetasol-loaded monolithic lipid-polymer hybrid nanoparticles ameliorate imiquimod-induced psoriasis-like skin inflammation in Swiss albino mice

Lipid-polymer hybrid nanoparticles (LPNs) exhibit several advantages over polymeric and non-polymeric systems in terms of improved drug loading, controlled release, stability, and cellular uptake. Herein we report a scalable and stable monolithic lipid-polymer hybrid nanoparticles (LPNs) consisting of a combination of lipids (solid and liquid) and an amphiphilic copolymer, mPEG-PLA. Clobetasol propionate, a topical corticosteroid, was encapsulated in the hydrophobic core of these LPNs that showed spherical shaped particles with a z-average size of 94.8 nm (PDI = 0.213) and encapsulation efficiency of 84.3%. These clobetasol loaded LPNs (CP/LPNs) were formulated into a topical hydrogel using carbopol 974P. CP/LPNs gel showed a sustained in vitro clobetasol release for 7 days with no burst release and 6 month stability at 2-8°C and room temperature. Further, CP/LPNs showed an improved cellular uptake with significant growth inhibition of HaCaT cells. In ex vivo studies, these LPNs penetrated into the viable epidermis and dermis region of the psoriatic skin with undetectable quantities leaching to the reservoir. Further, the topical application of CP/LPNs gel on Swiss albino mice with psoriasis-like inflammation showed negligible leaching of clobetasol into the systemic circulation. Efficacy assessment showed significantly improved PASI score, reduced skin damage and proliferation after treatment with CP/LPNs gel as compared to marketed product (Clobetamos™). Collectively, the enhanced cellular uptake, high skin penetration with increased skin retention, and improved efficacy demonstrate the potential of these LPNs for future clinical application.

Oral mucosal lesions in psoriatic patients based on disease severity and treatment approach

BACKGROUND

This observational case-control study was designed to investigate the frequency of oral lesions in psoriatic patients and to identify an association between mucosal involvement, the severity of the disease, and a form of treatment.

METHODS

One hundred twenty-seven patients diagnosed with psoriasis were enrolled in this study from November 2018 to September 2019. The oral mucosa evaluation was based on the clinical appearance, location, and morphology of the lesions. All patients completed a general medical history and a Dermatology Life Quality Index (DLQI) questionnaire. The severity of skin involvement was assessed using the Psoriasis Area and Severity Index (PASI) scale.

RESULTS

The most common oral lesions in patients with psoriasis were found to be fissured (FT), white coated (CT), and geographic tongue (GT). A significantly lower prevalence of GT was evident in the group managed with a new class of biological drugs and smokers. There appeared to be no association between the oral manifestation and the PASI score. FT appeared significantly more often in patients that experienced an extremely large effect of psoriasis on their quality of life as determined by the DLQI questionnaire and smokers. Only 25% of patients presented normal oral mucosa.

CONCLUSIONS

Tongue lesions seem to be associated with skin psoriasis regardless of the treatment. The severity of the disease, according to the PASI scale, does not influence mucosal involvement. The type of treatment may affect the prevalence of oral lesions. Further investigations are required to confirm the influence of biological therapies on mucosal improvement.

310 nm UV-LEDs attenuate imiquimod-induced psoriasis-like skin lesions in C57BL/6 mice and inhibit IL-22-induced STAT3 expression in HaCaT cells

Ultraviolet light-emitting diodes (UV-LEDs) are a novel light source for phototherapy. This study aimed to evaluate the therapeutic effects of UV-LEDs on psoriasis. Importantly, 310 nm UV-LEDs have not been studied in psoriasis in vitro and in vivo. Effects due to 310 nm UV-LED and 311 nm narrowband ultraviolet B (NBUVB) irradiation were compared for suppressing IL-22-induced activation of STAT3 expression using cell viability assay, western blotting, and immunocytochemistry. C57BL/6 mice were topically treated with imiquimod (IMQ) for 6 consecutive days and degenerative changes were observed. Test groups were irradiated with a 310 nm UV-LED and 311 nm NBUVB. Phenotypic observations, histopathological examinations, and ELISA were conducted with skin and blood samples. STAT3-dependent IL-22 signalling and effects in keratinocytes are negatively regulated by the 310 nm UV-LED, which significantly ameliorated IMQ-induced psoriasis-like dermatitis development and reduced Th17 cytokine levels (IL-17A, IL-22) in serum and dorsal skin. Histopathological findings showed decreases in epidermal thickness and inflammatory T-cell infiltration in the UV-LED-irradiated groups. Quantitative PCR confirmed a UV radiation energy-dependent decrease in IL-17A and IL-22 mRNA levels. The results demonstrated that UV-LEDs had anti-inflammatory and immunoregulatory effects. So, UV-LED phototherapy inhibits psoriasis development by suppressing STAT3 protein and inflammatory cytokines and could be useful in treating psoriasis.

A Systematic Literature Review and Bucher Indirect Comparison: Tildrakizumab versus Guselkumab

BACKGROUND

Psoriasis is a chronic inflammatory skin condition that impacts quality of life and requires long-term treatment and effective symptom management. Interleukin-23 (IL-23) has emerged as a key player in the pathogenesis of psoriasis and tildrakizumab and guselkumab are both immunomodulatory agents that inhibit the p19 subunit of IL-23. In its pivotal Phase III trial, tildrakizumab demonstrated greater efficacy than etanercept in moderate-to-severe psoriasis. However, there are no head-to-head trials comparing tildrakizumab with guselkumab.

METHODS

We conducted a systematic literature review and Bucher indirect comparison of tildrakizumab and guselkumab, using placebo as a common comparator. We searched MEDLINE, MEDLINE In-Process, MEDLINE(R) Daily Epub Ahead of Print, and Cochrane Central Register of Controlled Trials for Phase III randomized controlled trials between 1946 and November 2018. Inclusion criteria were adult patients ≥18 years with moderate-to-severe chronic plaque psoriasis, and intervention with tildrakizumab or guselkumab compared to placebo or best supportive care. Outcomes included were severity of psoriasis as defined by the Psoriasis Area and Severity Index (PASI) 75 and PASI 90, frequency of serious adverse events (SAEs), and treatment discontinuations. Outcomes were evaluated at Weeks 12 to 16 and 24 to 28. Analysis was based on the intent-to-treat population and, for all outcomes, the number of events reported were analyzed as a proportion of the number of patients randomized to ensure consistency across trials.

RESULTS

Overall, 154 unique records were identified. Five studies met the eligibility criteria and were included in the analysis; two tildrakizumab trials (reSURFACE 1 and reSURFACE 2) and three guselkumab trials (VOYAGE 1, VOYAGE 2, and a Japanese study). There was no statistically significant difference between guselkumab and tildrakizumab for PASI 75, PASI 90, SAEs, and rate of discontinuations at either timepoint.

CONCLUSION

This study assessed the comparative efficacy of tildrakizumab and guselkumab for the treatment of moderate-to-severe psoriasis. Limitations included the limited number of publications, imputation of placebo arm values for Weeks 24 to 28, and limited relevance of the Japanese study. This indirect comparison does not provide evidence that one treatment is superior to the other.

Indoor salt water baths followed by artificial ultraviolet B light for chronic plaque psoriasis

BACKGROUND

Chronic plaque psoriasis is an immune-mediated, chronic, inflammatory skin disease, which can impair quality of life and social interaction. Disease severity can be classified by the psoriasis area and severity index (PASI) score ranging from 0 to 72 points. Indoor artificial salt bath with or without artificial ultraviolet B (UVB) light is used to treat psoriasis, simulating sea bathing and sunlight exposure; however, the evidence base needs clear evaluation.

OBJECTIVES

To assess the effects of indoor (artificial) salt water baths followed by exposure to artificial UVB for treating chronic plaque psoriasis in adults.

SEARCH METHODS

We searched the following databases up to June 2019: the Cochrane Skin Group Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trial registers, and checked the reference lists of included studies, recent reviews, and relevant papers for further references to relevant trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of salt bath indoors followed by exposure to artificial UVB in adults who have been diagnosed with chronic plaque type psoriasis. We included studies reporting between-participant data and within-participant data. We evaluated two different comparisons: 1) salt bath + UVB versus other treatment without UVB; eligible comparators were exposure to psoralen bath, psoralen bath + artificial ultraviolet A UVA) light, topical treatment, systemic treatment, or placebo, and 2) salt bath + UVB versus other treatment + UVB or UVB only; eligible comparators were exposure to bath containing other compositions or concentrations + UVB or UVB only.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We used GRADE to assess the certainty of the evidence. The primary efficacy outcome was PASI-75, to detect people with a 75% or more reduction in PASI score from baseline. The primary adverse outcome was treatment-related adverse events requiring withdrawal. For the dichotomous variables PASI-75 and treatment-related adverse events requiring withdrawal, we estimated the proportion of events among the assessed participants. The secondary outcomes were health-related quality of life using the Dermatology Life Quality Index, (DLQI) pruritus severity measured using a visual analogue scale, time to relapse, and secondary malignancies.

MAIN RESULTS

We included eight RCTs: six reported between-participant data (2035 participants; 1908 analysed), and two reported within-participant data (70 participants, 68 analysed; 140 limbs; 136 analysed). One study reported data for the comparison salt bath with UVB versus other treatment without UVB; and eight studies reported data for salt bath with UVB versus other treatment with UVB or UVB only. Of these eight studies, only five reported any of our pre-specified outcomes and assessed the comparison of salt bath with UVB versus UVB only. The one included trial that assessed salt bath plus UVB versus other treatment without UVB (psoralen bath + UVA) did not report any of our primary outcomes. The mean age of the participants ranged from 41 to 50 years of age in 75% of the studies. None of the included studies reported on the predefined secondary outcomes of this review. We judged seven of the eight studies as at high risk of bias in at least one domain, most commonly performance bias. Total trial duration ranged between at least two months and up to 13 months. In five studies, the median participant PASI score at baseline ranged from 15 to 18 and was balanced between treatment arms. Three studies did not report PASI score. Most studies were conducted in Germany; all were set in Europe. Half of the studies were multi-centred (set in spa centres or outpatient clinics); half were set in a single centre in either an unspecified settings, a psoriasis daycare centre, or a spa centre. Commercial spa or salt companies sponsored three of eight studies, health insurance companies funded another, the association of dermatologists funded another, and three did not report on funding. When comparing salt bath plus UVB versus UVB only, two between-participant studies found that salt bath plus UVB may improve psoriasis when measured using PASI 75 (achieving a 75% or more reduction in PASI score from baseline) (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.24 to 2.35; 278 participants; low-certainty evidence). Assessment was conducted at the end of treatment, which was equivalent to six to eight weeks after start of treatment. The two trials which contributed data for the primary efficacy outcome were conducted by the same group, and did not blind outcome assessors. The German Spas Association funded one of the trials and the funding source was not stated for the other trial. Two other between-participant studies found salt bath plus UVB may make little to no difference to outcome treatment-related adverse events requiring withdrawal compared with UVB only (RR 0.96, 95% CI 0.35 to 2.64; 404 participants; low-certainty evidence). One of the studies reported adverse events, but did not specify the type of events; the other study reported skin irritation. One within-participant study found similar results, with one participant reporting severe itch immediately after Dead Sea salt soak in the salt bath and UVB group and two instances of inadequate response to phototherapy and conversion to psoralen bath + UVA reported in the UVB only group (low-certainty evidence).

AUTHORS' CONCLUSIONS

Salt bath with artificial ultraviolet B (UVB) light may improve psoriasis in people with chronic plaque psoriasis compared with UVB light treatment alone, and there may be no difference in the occurrence of treatment-related adverse events requiring withdrawal. Both results are based on data from a limited number of studies, which provided low-certainty evidence, so we cannot draw any clear conclusions. The reporting of our pre-specified outcomes was either non-existent or limited, with a maximum of two studies reporting a given outcome. The same group conducted the two trials which contributed data for the primary efficacy outcome, and the German Spas Association funded one of these trials. We recommend further RCTs that assess PASI-75, with detailed reporting of the outcome and time point, as well as treatment-related adverse events. Risk of bias was an issue; future studies should ensure blinding of outcome assessors and full reporting.

Successful Treatment of Plaque Psoriasis with Allogeneic Gingival Mesenchymal Stem Cells: A Case Study

Plaque psoriasis is the most common type of psoriasis that manifests as red scaly patches with white scales affecting body areas including scalp, elbows, knees, trunk, and buttocks. Although many treatment options are available including novel biologics, no cure is available. Mesenchymal stem cells (MSCs) have been safely used to treat a variety of human diseases. Allogeneic MSCs possess unique characteristics including hypoimmunogenicity, immunomodulatory, and anti-inflammatory properties, and they are currently being explored for potential therapeutic use for many systemic inflammatory diseases. The human gingival tissue is an easily accessible and obtainable source for the isolation of MSCs. MSCs from adult human gingiva are of fetal-like phenotype, multipotent, and easy to isolate and expand in vitro. Herein, we report a case of a 19-year-old man with a 5-year history of severe plaque psoriasis refractory to multiple topical and systemic therapies who was treated with allogeneic human gingival MSCs. Complete regression was achieved after 5 infusions with no adverse reaction occurred. The patient has been followed for three years and has remained disease free.

Reliability, validity, and the ability to detect change of the Psoriasis Symptom Scale (PSS) in patients with plaque psoriasis

Introduction: The primary objective of the study was to evaluate the measurement properties of the patient-reported four-item Psoriasis Symptom Scale (PSS).Methods: Analysis of phase-III data on the efficacy of risankizumab to assess psychometric characteristics of the PSS in patients with moderate-to-severe psoriasis.Results: PSS items had a good range of symptom severity coverage. The PSS had good test-retest reliability (ICCs >0.90). Convergent and discriminant validity was indicated by moderate-to-strong correlations between the PSS and Dermatology Life Quality Index (DLQI), PSS pain item and EQ-5D pain/discomfort item at week 12 (0.63), and moderate negative correlation with EQ-Visual Analog Scale score at week 12 (-0.37). Known groups validity demonstrated as mean PSS total scores varied by Psoriasis Area and Severity Index (PASI) and Static Physician's Global Assessment (sPGA) defined groups (p < .0001). PSS total scores were responsive to changes in PASI score (p < .0001) and sPGA (p < .0001). PSS minimal, clinical, and meaningful change is estimated to be 1 to 2 points; a preliminary responder definition is a total change score of 3 to 4 points.Conclusions: The PSS is a short, valid unidimensional measure of psoriasis symptom severity, well suited for use in clinical trials.

How frequently does palmoplantar psoriasis affect the palms and/or soles? A systematic review and meta-analysis

Introduction

Palmoplantar psoriasis (PPP) is a variant of psoriasis that affects the palms and/or soles. Although PPP is a disabling and therapeutically challenging condition, its epidemiology is poorly defined.

Aim

To assess the prevalence of PPP locations (palms, soles or both), and to analyse epidemiological and clinical characteristics of the disease.

Material and methods

Two bibliographic databases (MEDLINE and SCOPUS) were used as data sources searched from inception to October 2017. The selection of articles was limited to human subjects and English or French languages.

Results

A search resulted in a total of 293 articles, out of which 24 were utilized for the current systematic review and 21 for meta-analysis. All listed studies comprised a total of 2083 patients with PPP, with more males than females. According to the results of meta-analysis, majority of patients had the highest prevalence of both palms and soles involvement (95% CI: 47-67), with an almost equal prevalence showing palmar (21%; 95% CI: 13-30) or plantar (20%; 95% CI: 12-29) involvement. The most prevalent type of PPP was plaque/hyperkeratotic, followed by the pustular type.

Conclusions

Almost three-fifths (59%) of all PPP patients had involvement of both palms and soles, while exclusive palmar or plantar involvement was seen in 21% and 20% of patients, respectively. Future research should be performed to elucidate basic epidemiological and clinical characteristics of PPP, which would be helpful for proper consideration of this condition.

Use of Ustekinumab in the Treatment of Libyan Psoriasis Vulgaris Patients

Introduction. Psoriasis is a relatively common chronic inflammatory disease. It clinically manifests as raised, well defined erythematous plaques with irregular borders and silvery scales. Psoriasis appears to be mediated by abnormal immune system functioning, including T lymphocyte and macrophage activation and release of various cytokins, such as interleukin 12 (IL-12) and IL-23. Recently a new biologic agent Ustekinumab has been used in the treatment of psoriasis. Our aim in this study was to assess the efficacy and tolerability of ustekinumab in moderate to severe psoriasis vulgaris and to observe and report any adverse reaction.

Material and Methods. Thirty five psoriatic patients above the age of 18 years having moderate to severe psoriasis were included in this study. Ustekinumab is available in pre-filled syringe 45mg/0.5ml, 90mg/1.0ml for subcutaneous injection according to body weight at the intervals of 0, 4 weeks, and then every 12 weeks. It is given in hospital by a doctor or specialist nurse. The assessment of the patients’ condition and improvement was carried out after administering each dose using PASI score.

Results. Thirty five patients were included in this study. Baseline PASI score of our patients ranged from 11.4 to 39.8 (mean: 21.1).There was a dramatic response to treatment with ustekinumab in which PASI decreased to 6.7 after the second dose, followed by subsequent responses that reached 2.6 after the 6th dose. After the second dose, 61% of the cases had marked improvement and 11% had clearance of their skin lesions. After the last, sixth dose there was a marked improvement in 65% of cases and the percentage of complete clearance increased to 24%. Ustekinumab had positive effect on psoriatic nail changes as well-there was a significant improvement in 50% of cases and complete clearance (cure) in 24% of cases.

Conclusion: Ustekinumab is effective in the treatment of severe and resistant cases of psoriasis vulgaris. It is well tolerated by the patients. No reactions or serious side effects have been reported.

Failure rates and survival times of systemic and biologic therapies in treating psoriasis: a retrospective study

BACKGROUND

Systemic and biologic therapies have varying failure rates and survival times in treating psoriasis.

OBJECTIVE

We aim to describe the patterns of therapy failure in psoriasis patients.

METHODS

A retrospective (January 2009 to May 2018) analysis of 250 psoriasis patients seen at a psoriasis referral center, and 806 treatment courses of several systemic and biologic therapies, was conducted to determine failure rates and survival times for systemic and biologic therapies.

RESULTS

Systemic therapies failed more often due to their adverse effects (16.4% vs 7.2%, p < .001). Biologics failed more often due to secondary failure (24.2% vs. 9.3%, p < .001). Biologics had a longer survival time (23.9 ± 22.2 vs. 12.6 ± 15.4 months, p < .001), even with early failures (≤6 months) removed (29.0 ± 22.5 vs. 21.1 ± 16.4 months, p = .014).

LIMITATIONS

Tertiary referral center, unreported causes of failure, sample size.

CONCLUSIONS

Systemic therapies fail more often due to adverse effects while biologics fail more often due to loss of efficacy. Biologic therapies have longer survival times than systemic therapies.

Occurrence and challenges in the management of severe chronic plaque type psoriasis in a limited resourced setting: a case report

Plaque-type psoriasis is a major dermatosis with significant effects on quality of life. Case complexity is often high in low-resourced settings such as in Africa where the incidence has been on the rise. Despite major advancements and newer therapeutic modalities over the last decade, an insight into the real-life, day to day challenges in low resourced settings reveal an interplay between the difficulty in obtaining these drugs and use of alternative traditional indigenous agents. We report the case of a 50 year old immunocompetent male who presented with chronic and extensive well demarcated plaques covered with silver-white scales occupying about 61% of his body surface area. Patient was however lost to follow up for about 8 months during which time, the lesions responded to some unknown homemade indigenous medications which was preferred to a systemic medication. Paramount importance on proper counselling and the need to retain patients in care is warranted by physicians and allied health personnel. Also, incentives aimed at subsidizing the newer systemic agents for patients in low resourced cohorts will go a long way to combat this multi-faceted disorder which is often unrecognized and under diagnosed.

Mesenchymal Stem Cell Conditioned Media Ameliorate Psoriasis Vulgaris: A Case Study

Psoriasis, an autoimmune disease, affects a vast number of peoples around the world. In this report, we discuss our findings about a scalp psoriasis suffering patient with a Psoriasis Scalp Severity Index (PSSI) score of 28, who was treated with Mesenchymal stem cell conditioned media (MSC-CM). Remarkably, complete regression was recorded within a treatment period of one month only (PSSI score of 0). A number of bioactive factors like cytokines and growth factors secreted by MSCs in the conditioned medium are very likely to be the principle molecules which play a vital role in skin regeneration. Treatment using MSC-CM appears to be an effective tool for tackling the psoriatic problem and, thus, may offer a new avenue of therapy which could be considered as an alternative approach to overcome the limitations of the cell-based therapy.

The Potential Benefits of Certolizumab Pegol in Patients with Concurrent Psoriatic Arthritis and Chronic Plaque Psoriasis: A Case Series and Review of the Literature

INTRODUCTION

We review the literature evaluating certolizumab in psoriasis and report our experience of treatment outcomes in a joint dermatology and rheumatology clinic.

METHODS

Patients with concomitant psoriatic arthritis (PsA) and psoriasis who had been commenced on certolizumab were included within our retrospective review. Data was collected for patient demographics, Patient Area and Severity Index (PASI), Dermatology Life Quality Index (DLQI) and previous treatments. The literature was systematically searched using Pubmed and Scopus.

RESULTS

Very recent results from the CIMPASI-1 and CIMPASI-2 studies have demonstrated the high efficacy of certolizumab in the treatment of psoriasis at both week 16 and 48. Pooled results from these studies showed a PASI75 at week 16 and week 48 of 82% and 83.6% respectively, in the certolizumab 400 mg group. In our cohort of eight patients (two female; six male; median age 49 and mean PASI of 20.8) all had failed at least two systemic non-biologic agents. Objective improvements were observed in seven patients, with five achieving PASI90 and two demonstrating either PASI75 or PASI50.

CONCLUSION

Certolizumab is efficacious in both psoriasis and PsA, including in patients who are biologic failures, and could be considered as an alternative treatment modality.

Disrupting the IL-36 and IL-23/IL-17 loop underlies the efficacy of calcipotriol and corticosteroid therapy for psoriasis

Psoriasis is one of the most common skin inflammatory diseases worldwide. The vitamin D3 analog calcipotriol has been used alone or in combination with corticosteroids in treating plaque psoriasis, but how it suppresses psoriatic inflammation has not been fully understood. Using an experimental mouse psoriasis model, we show that topical calcipotriol inhibited the pivotal IL-23/IL-17 axis and neutrophil infiltration in psoriatic skin, and interestingly, such effects were mediated through the vitamin D receptor (VDR) in keratinocytes (KCs). We further reveal that IL-36α and IL-36γ, which have recently emerged as key players in psoriasis pathogenesis, were effectively repressed by calcipotriol via direct VDR signaling in mouse KCs. Accordingly, calcipotriol treatment suppressed IL-36α/γ expression in lesional skin from patients with plaque psoriasis, which was accompanied by a reduced IL-23/IL-17 expression. In contrast, dexamethasone indirectly reduced IL-36α/γ expression in mouse psoriatic skin through immune cells. Furthermore, we demonstrate that calcipotriol and dexamethasone, in combination, synergistically suppressed the expression of IL-36α/γ, IL-23, and IL-17 in the established mouse psoriasis. Our findings indicate that the combination of calcipotriol and corticosteroid efficiently disrupts the IL-36 and IL-23/IL-17 positive feedback loop, thus revealing a mechanism underlying the superior efficacy of calcipotriol and corticosteroid combination therapy for psoriasis.

Comparison of Management Guidelines for Moderate-to-Severe Plaque Psoriasis: A Review of Phototherapy, Systemic Therapies, and Biologic Agents

INTRODUCTION:

Many international guidelines for management of psoriasis exist and most have variations in grading evidence quality, strength of recommendations, and dosing. The objective of our review is to compare international guidelines published in the United Kingdom, Canada, Europe, and the United States for the management of moderate-to-severe plaque psoriasis.

METHODS:

We conducted a literature review on systemic therapies and phototherapy for moderate-to-severe plaque psoriasis in adult patients. The British, Canadian, European, and American guidelines served as the key comparators in our review. To identify relevant supporting clinical trials not referenced in the guidelines, we conducted literature searches in PubMed and EMBASE. Two authors independently extracted data on indications, dosing, efficacy, evidence grade, and strength of clinical recommendation for each therapy.

RESULTS:

Monoclonal antibodies directed toward tumour necrosis factor and interleukin (IL)-12/23 received the strongest recommendations for treatment of moderate-to-severe plaque psoriasis, supported by robust, high-quality randomized controlled trials (RCTs). Newer agents such as IL-17 and IL-23 inhibitors are not referenced in most guidelines. There are fewer RCTs for conventional therapies and few head-to-head comparisons with biologics, making it difficult to draw direct comparisons. Among older agents, methotrexate is most strongly recommended for long-term maintenance and cyclosporine is recommended for short-term control of flares.

CONCLUSION:

Physicians should individualize psoriasis-management strategies based on medication tolerance, efficacy, safety, patient comorbidities, availability of the medication, and patient preference.

Tildrakizumab for the treatment of psoriasis

Introduction: Psoriasis is an immune-mediated skin disease amenable to targeted immunotherapy. Tildrakizumab is a humanized IgG1 monoclonal antibody targeting interleukin-23 p19 and is approved for use in moderate to severe psoriasis. Areas covered: This article reviews the mechanism of action, pharmacokinetics, safety, tolerability, and clinical efficacy of tildrakizumab, administered subcutaneously every 12 weeks, in treatment of moderate to severe psoriasis. Expert commentary: In two phase 3 clinical trials, tildrakizumab showed a consistent low occurrence of adverse events, underlining safety and tolerance. The long half-life permits subcutaneous injections every 12 weeks. Seventy eight percent of patients achieved PASI 75 (a > 75% improvement from baseline PASI) at 28 weeks, 58% achieved PASI 90, 29% achieved PASI 100 and 70% achieved a Physician's Global Assessment score of clear or almost clear. A high proportion of patients maintained PASI response after 2 years of treatment. Tildrakizumab improved Dermatology Life Quality Index, psoriasis-related personal relationship problems and sexual difficulties. Baseline PASI score, PGA, and BMI were not predictive of PASI 90 response at week 12, however achievement of PASI 50 by week 8 was predictive of a PASI 90 response at week 12.

Japanese guidelines for the management and treatment of generalized pustular psoriasis: The new pathogenesis and treatment of GPP

Generalized pustular psoriasis (GPP) is a rare disease characterized by recurrent fever and systemic flushing accompanied by extensive sterile pustules. The committee of the guidelines was founded as a collaborative project between the Japanese Dermatological Association and the Study Group for Rare Intractable Skin Diseases under the Ministry of Health, Labour, and Welfare Research Project on Overcoming Intractable Diseases. The aim of the guidelines was to provide current information to aid in the treatment of patients with GPP in Japan. Its contents include the diagnostic and severity classification criteria for GPP, its pathogenesis, and recommendations for the treatment of GPP. Since there are few clinical trial data with high levels of evidence for this rare disease, recommendations by the committee are described in the present guidelines.

A clinical case of severe disease burden: an erythrodermic psoriatic patient treated with secukinumab

Erythrodermic psoriasis is a severe variant of psoriasis characterized by prominent erythema, affecting the entire body surface. Management of erythrodermic psoriasis is difficult, not standardized, and often ineffective. As clinical studies are lacking, reporting of clinical experience with secukinumab may help to gather insight in this field. Here, we describe the case of a 55-year-old man, with a 10-year history of moderate-to-severe plaque psoriasis. He presents a flare of erythroderma involving approximately 90% of his body surface area and a Psoriasis Area and Severity Index score of 42, with an important impact on his quality of life (DLQI score was 20.0; Skindex-29 score was 67.2). The patient presented also alexithymic features. Due to severity of clinical features and poor quality of life, the patient started secukinumab treatment; we observed a striking and rapid response to therapy with an excellent safety profile and a satisfactory compliance. Furthermore, therapy with secukinumab considerably enhanced patient's quality of life. Although further studies are needed to better understand the role of the IL-23/Th17 pathway, secukinumab can be an effective therapeutic option for patients affected by erythrodermic psoriasis.

Nobiletin and 5-Hydroxy-6,7,8,3',4'-pentamethoxyflavone Ameliorate 12- O-Tetradecanoylphorbol-13-acetate-Induced Psoriasis-Like Mouse Skin Lesions by Regulating the Expression of Ki-67 and Proliferating Cell Nuclear Antigen and the Differentiation of CD4+ T Cells through Mitogen-Activated Protein Kinase Signaling Pathways

Psoriasis is a chronic and benign proliferative skin disease. Flavonoids in chenpi (aged tangerine peel) from tangerine ( Citrus reticulate Blanco), such as nobiletin (Nob), tangeretin, and 5-hydroxy-6,7,8,3',4'-pentamethoxyflavone (5-HPMF), possess anti-inflammation and regulation of immune activity among others. In this study, psoriasis-like skin lesions were induced by 12- O-tetradecanoylphorbol-13-acetate (TPA), and the preventive effect of Nob and 5-HPMF on psoriasis-like skin lesions was evaluated. Results showed that skin lesions were dramatically reduced by Nob and 5-HPMF. Levels of cytokines, including interleukin (IL)-1β, IL-17, IL-4, IL-6, tumor necrosis factor-α, and interferon-γ, were also reduced after Nob and 5-HPMF treatment. The expression levels of p-ERK1/2 and p-p38 mitogen-activated protein kinase (MAPK) in the TPA group were 5.3, 4.8, and 5.7 but downregulated to 2.7, 2.9, and 2.3 in the Nob group and 2.4, 2.7, and 1.2 in the 5-HPMF group, respectively ( p ≤ 0.05). The expression of transcription factors Ki-67 and proliferating cell nuclear antigen (PCNA) and the differentiation of CD4⁺ T cells were reduced by downregulating the expression of the MAPK signaling pathways. The expression levels in TPA, Nob, and 5-HPMF groups were 0.649 ± 0.094, 0.218 ± 0.034, and 0.193 ± 0.042 for Ki-67 and 0.753 ± 0.114, 0.315 ± 0.094, and 0.294 ± 0.035 for PCNA, respectively. Moreover, 5-HPMF showed stronger reduction activity in the prevention of psoriasis than Nob, indicating that the 5-hydroxyl group facilitated the suppression of psoriasis.

Effects of aloe polysaccharide, a polysaccharide extracted from Aloe vera, on TNF‑α‑induced HaCaT cell proliferation and the underlying mechanism in psoriasis

Aloe vera is a traditional wound‑healing medicine used for the treatment of skin disorders. Aloe polysaccharide (APS) is the main macromolecule of Aloe vera, which contributes to its function. Psoriasis is an immune‑mediated chronic inflammatory disease, which affects 2‑3% of the general population. The conventional remedies used to treat psoriasis demonstrate limited effects; therefore, natural products, including Aloe vera, are being taken into consideration. However, the effects of APS on the treatment of psoriasis and the underlying mechanisms remain to be elucidated. The human keratinocyte cell line HaCaT was used to determine the effects of APS on psoriasis. Cells were randomly divided into five groups: i) Negative control group; ii) tumor necrosis factor (TNF)‑α stimulated psoriasis model group; and iii) APS (20, 40 and 80 µg/ml) pretreated psoriasis groups. Cell viability and proliferation were investigated using the CCK‑8 assay. ELISA and western blotting were applied to study the abundance of interleukin (IL)‑8 and IL‑12 in TNF‑α‑incubated culture medium and APS‑treated HaCaT cells, respectively. In addition, the mRNA expression levels of p65, and the protein expression levels of nuclear factor (NF)‑κB inhibitor‑α (IκBα) and phosphorylated‑p65, were detected by reverse transcription‑quantitative polymerase chain reaction and western blotting, respectively. APS was revealed to significantly reduce TNF‑α‑stimulated elevation of HaCaT cell proliferation in a dose‑dependent manner. The expression levels of inflammatory factors, including IL‑8 and IL‑12, were increased in response to TNF‑α. In addition, the mRNA and protein expression levels of p65 were increased following treatment with TNF‑α. Notably, treatment with APS was demonstrated to significantly attenuate the aforementioned effects in a dose‑dependent manner. Furthermore, IκBα protein expression levels were significantly reduced following treatment with TNF‑α, which was significantly reversed following treatment with APS. In conclusion, these results suggested that APS inhibited TNF‑α‑induced proliferation of keratinocytes and overactivation of the NF‑κB signaling pathway.

A prospective 52-week randomized controlled trial of patient-initiated care consultations for patients with psoriasis

BACKGROUND

Treatment and care of moderate-to-severe psoriasis require lifelong consultations with a dermatologist with close monitoring of systemic treatment.

OBJECTIVES

To investigate the effect of patient-initiated care consultation (PICC) for patients with psoriasis in a dermatology outpatient clinic.

METHODS

A prospective randomized controlled trial with patients on well-controlled systemic treatment randomized to either (i) the PICC group, where they participated in one annual consultation with a dermatologist but were able to initiate consultations when needed; or (ii) routine care, where they participated in a consultation every 12-16 weeks. The primary outcome was the Dermatology Life Quality Index (DLQI). Other outcomes were safety, patient adherence and satisfaction with healthcare assessed at baseline and after 52 weeks. The study was registered with clinical trials number NCT02382081.

RESULTS

In total 150 patients were included, with 58·0% treated with biologics, 37·3% with methotrexate and 4·7% with acitretin. At week 52 no statistically significant mean difference between groups was detected in DLQI (0·28, 95% confidence interval -0·35 to 0·9) or Psoriasis Area and Severity Index (-0·24, 95% confidence interval -0·84 to 0·36). Patients in the PICC group requested 63% fewer consultations with a dermatologist: mean 2·5 ± 0·1 vs. 5·1 ± 0·6 (P = 0·001). Patient adherence and safety with treatment monitoring were equal between groups, but the PICC group was significantly better at attending consultations than the control group (P = 0·003).

CONCLUSIONS

PICC offers additional clinical benefits over routine care, making patients less dependent on clinical visits. The intervention adds no harm to monitoring systemic treatment, and patients report high quality of life and satisfaction with healthcare.

A Strategic Approach to Setting the Research Agenda in Psoriasis

Research into all the relevant facets of disease characteristics—including epidemiology, genetics, and pathogenesis—has historically yielded important insights that result in a progression of understanding as well as advances in treatment of disease. Certainly psoriasis can be highlighted as an example of a disease that through history has benefitted from the integration of serendipitous observation and defined research strategy, an interaction that has resulted in dramatically improved clinical comprehension and management of the condition. Despite this progress, major gaps still exist in our understanding of the different elements of the disease that could be used to guide the medical community's approach to research. Traditionally, medical research is organized along geopolitical and departmental divisions. This structure tends to impede collaboration in a multidisciplinary manner or by multiple organizations working congruently. To overcome this impediment, the objective of this International Psoriasis Council initiative was to leverage the available knowledge to highlight the key research needs in psoriasis and to convene appropriate experts, without regard for geography or research specialty, to make major strides in improving the overall outcomes for psoriasis patients.