Erythrodermic psoriasis

Increased S. aureus colonization and reduced antimicrobial peptide expression in erythrodermic psoriasis

BACKGROUND

Erythrodermic psoriasis (EP) is a severe and rare condition characterized by prominent erythema and scaling over 75 % of the body surface area. Unlike psoriasis vulgaris (PV), EP carries high risk of systemic involvement, including superficial skin infections and sepsis, particularly those caused by Staphylococcus aureus.

OBJECTIVE

To explore the microecological characteristics of EP and detect the levels of antimicrobial peptides (AMPs) in both skin and serum of EP patients.

METHODS

In this study, skin microbiomes of 10 EP patients were analyzed through 16S rRNA gene sequencing. The expressions of AMPs, Interleukin-4/13 (IL-4/13), Interleukin-17 (IL-17) and Interferon-γ (IFN-γ) in skin were detected via immunohistochemical staining and serum levels of AMP were evaluated by ELISA. We also enrolled 10 AD and 10 PV patients as controls.

RESULTS

EP patients retained rich microbial diversity, dominated by S. aureus. The AMPs of hBD2, LL-37, and RNase7 in EP keratinocytes were significantly lower than those in PV, but higher than those in AD. The expression levels of IL-4, IL-13 and IFN-γ in lesions are similar between EP and AD, but quite different from PV. What's more, the serum AMP levels in EP were similar to those in PV while significantly lower than in AD.

CONCLUSION

We found EP patients have a rich microbial diversity dominated by S. aureus in lesions, while lower serum and skin AMPs expressions, which may account for the increased incidence of S. aureus cutaneous infections and sepsis in EP patients.

Integrative serum proteomics analysis reveals distinct immune and cardiovascular profile dysregulation in erythrodermic psoriasis

In-depth analysis of circulating proteome alterations identified that erythrodermic psoriasis (EP) presented a dysregulated serum proteome with distinct inflammation elevation, immune activation and metabolic disturbance. We found that EP harboured a blended immune milieu with distinct T helper (Th)17/Th1 skewing and mild Th2 activation. Additionally, atherosclerosis signalling were substantially increased in EP.

Heart failure in erythrodermic psoriasis: a retrospective study of 225 patients

Purpose

Erythrodermic psoriasis (EP) is a severe form of psoriasis that affects multiple organs, including the cardiovascular system. However, few studies have focused on this condition.This study is aimed to assess the prevalence and factors associated with heart failure in EP patient, and to the measure the serum concentrations of fibroblast growth factor 23 (FGF23), a potential predictor of chronic heart failure.

Methods

We retrospectively studied patients with EP hospitalized at Peking Union Medical College Hospital between January 2005 to October 2021. The prevalence of heart failure and associated factors was measured. In addition, peripheral blood samples were collected from 17 patients and matched with samples from eight healthy controls, and their serum concentrations of FGF23 were measured by ELISA.

Results

We studied 225 patients with EP, with a male: female ratio of 2.7:1 and a mean age of 47.6 ± 16.7 years. Twenty-five (11.1%) participants were diagnosed with heart failure during their hospital stay. The patients with EP and heart failure were older (58.2 years vs. 46.2 years, p = 0.001); had a higher prevalence of a history of coronary heart disease (32.0% vs. 21.5%, p < 0.001), fever (48.0% vs. 23.0%, p = 0.007), infection (56.0% vs. 35.5%, p = 0.046); higher hsCRP concentration (43.2 mg/L vs. 8.2 mg/L, p = 0.005); and higher prevalence of anemia (60.0% vs. 22.0%, p < 0.001), hypoalbuminemia (64.0% vs. 42.0%, p = 0.037), and hyperlipidemia (40.0% vs. 20.0%, p = 0.023) than those without heart failure. The serum FGF23 concentration was significantly higher in patients with EP than controls (493.1 pg/ml vs. 277.8 pg/ml, p = 0.027), and was significantly lower after treatment (395.7 pg/ml vs. 463.1 pg/ml, p = 0.022).

Conclusions

Clinicians should be aware of the risk of heart failure in patients with EP, and especially those of advanced age and with a history of coronary heart disease, severe systemic symptoms, high concentrations of inflammatory biomarkers, and poor nutritional status.

Systemic monotherapy with acitretin for erythrodermic psoriasis: results of a retrospective study of 81 patients

Background

Erythrodermic psoriasis (EP) remains challenging to manage because it is rare and has complex complications. Although acitretin is recommended as an appropriate choice for EP, there is a lack of large-scale evidence.

Objectives

This study aims to assess the efficacy and safety of acitretin as systemic monotherapy in EP patients.

Design

We retrospectively analyzed data from patients with EP who received at least 3 months of acitretin as systemic monotherapy during hospitalization and out-patient follow-up from January 2005 to May 2021 at the Peking Union Medical College Hospital, China.

Methods

The efficacy was clinically evaluated after 1, 2, 4, and 12 weeks of treatment, which was classified as a good response (>75% of lesions cleared), partial response (50%-75% cleared), moderate response (25-50% cleared), or no response (<25% cleared). Safety was assessed on the basis of physical examination results and significant changes in laboratory examination results after 12 weeks of treatment.

Results

Overall, 81 patients (79.0% men; mean age, 47.9 years) were included. The acitretin dose ranged from 20 to 60 mg/day (0.3 to 0.8 mg/kg/day). The rates of good, partial, and moderate responses were 0.0%, 2.5%, and 42.0% at 1 week; 3.7%, 34.6%, and 61.7% at 2 weeks; 29.6%, 58.0%, and 12.4% at 4 weeks; and 85.2%, 13.6%, and 1.2% at 12 weeks after treatment initiation, respectively. EP patients transformed from psoriasis vulgaris showed a higher good/partial response rate compared with that of EP patients that developed from pustular or articular psoriasis (44.6% vs. 14.3%, p = 0.035). Patients with concurrent infection showed a lower rate of good/partial response compared with that of those without concurrent infection (16.7% vs. 44.4%, p = 0.049). Adverse effects were seen in 45 (55.6%) patients in 12 weeks, and dyslipidemia (n = 31; 38.3%), xerosis (n = 24; 29.6%), and elevated liver enzymes (n = 6; 7.4%) were most commonly reported. Twenty-three patients were followed up for over 3 years, and six (26.1%) patients had EP recurrence.

Conclusions

Acitretin as a systemic monotherapy showed satisfactory effectiveness for EP, especially in patients developed from psoriasis vulgaris and without infection.

Case Report: Coexistence of bullous pemphigoid and psoriasis: Therapeutic challenge and IL17A-targeted parallel treatment strategy

Autoimmune blistering diseases of the skin have all been reported in patients with psoriasis, bullous pemphigoid (BP) being the most frequently observed. The pathophysiologic triggers for BP in psoriatic patients are unclear. Recent observational studies have suggested that chronic psoriatic inflammation may cause pathological changes to the basement membrane zone, thus inducing autoimmunity against BP antigens through cross reactivity and “epitope spreading.” The coexistence of BP and psoriasis poses challenging therapeutic dilemmas related to the incompatibility of their standard treatments. Considering the probable common immunologic mechanisms in the pathogenesis of these inflammatory skin disorders, a suitable treatment regimen should be applied for their parallel control. We report three patients, who developed BP in the course of preceding long-lasting psoriasis. Secukinumab was administered as first-line treatment with promising therapeutic effect for both skin disorders and long-term disease control in two of the cases. In the third case, parallel disease control was initially achieved with methotrexate. A few years later, secukinumab was used for the treatment of a relapse of both dermatoses but worsening of BP was observed and methotrexate was reintroduced. Our experience on the therapeutic potential of secukinumab in BP is supported by the data in the literature. Recently, it was demonstrated that the proinflammatory cytokine IL17A has a functional role in the process of skin inflammation in BP, similarly to psoriasis. IL17A inhibition has emerged as a promising therapeutic strategy in patients with extensive or refractory BP but paradoxical development of BP after secukinumab treatment for psoriasis has also been described. This controversy emphasizes the need for further investigation into the development of optimal treatment strategies and recommendations.

Biological treatment for erythrodermic psoriasis

INTRODUCTION

Erythrodermic psoriasis (EP) is an extreme and potentially life-threatening form of psoriasis in which most or all of the body surface area is affected by psoriasis. It occurs in 1-2% of patients with psoriasis and is less responsive to conventional therapies. Biologics have shown promise in the management of EP.

AREAS COVERED

This review briefly discusses the pathophysiology of EP. Current evidence on established and emerging targeted therapies for EP is covered, including anti-TNF-α biologics, IL-12/23, IL-17, and IL-23 inhibitors.

EXPERT OPINION

The need for rapidly acting, safe, and efficacious agents in EP has been met with advent of newer biologics, particularly IL-17 and IL-23 inhibitors. These targeted approaches warrant consideration as first-line management option for the management of EP; however, high-quality evidence regarding their long-term efficacy and safety in EP is lacking. Novel biologics such as bimekizumab and mirikizumab, and nanobodies such as netakimab and sonelokimab have shown promise in the management of plaque psoriasis, and potential of these molecules in management of EP should be explored. Management of patients with prior biologic failure remains a challenge. Guidelines for the management of EP need to be revisited in light of the recent advances.

Psoriatic erythroderma: comparative patient profile and association with psoriatic arthritis

Background: Psoriatic erythroderma is rare and the most severe form of psoriasis characterized by involvement of 80-90% of body surface area. Aims: to compare clinical and demographic characteristics of patients with psoriasis, depending on presence of psoriatic erythroderma in medical history; to assess the association between psoriatic arthritis and a history of psoriatic erythroderma. Materials and methods: patients aged 18 years and older with a duration of psoriasis of 10 years, from the psoriasis patients registry were included. Comparison of continuous quantitative variables was performed using t-test or Mann-Whitney U-test. The 2 test or Fisher's exact test was used to compare qualitative binary variables. The odds ratio of psoriatic arthritis in patients with and without a history of psoriatic erythroderma was calculated, unadjusted and adjusted for other independent variables. Results: The number of patients included in the analysis was 1,870. A history of psoriatic erythroderma (PE) had 227 (12.1%) of them. There were no significant differences in patient age at inclusion to the registry (47.113.1 years vs. 47.713.3 years), and prevalence of PE among men and women (12.6% vs. 11. 4%). Higher prevalence of arterial hypertension (47.9% vs 32.7%), angina pectoris (6.4% vs. 1.9%), myocardial infarction (3. 2% vs. 1.0%), biliary dyskynesia (14.3% vs. 3.9%), fatty liver (12.2% vs. 7.7%), cholelithiasis (8. 6% vs. 3.6%), and toxic liver disease (2.2% vs. 0.5%) among patients with vs without history of PE was found. Psoriatic arthritis was diagnosed in 67.0% patients with a history of psoriatic erythroderma. The odds of having psoriatic arthritis in patients with a history of psoriatic erythroderma were 4 times higher than in patients without erythroderma: 4.043 [2.975-5.493]. When adjusted for sex, age, duration of psoriasis, and body mass index, the odds ratio and statistical significance were maintained: 4.064 [2.939-5.619]. Conclusions: compared to patients without PE those with a history of psoriatic erythroderma have a greater comorbidity burden: a higher prevalence of cardiovascular diseases, diseases of the liver and biliary tract. A significant association between psoriatic arthritis and a history of PE was established.

Systemic glucocorticoid use and the occurrence of flares in psoriatic arthritis and psoriasis: a systematic review

Objectives

The use of systemic glucocorticoids (SGCs) is traditionally discouraged in the treatment of PsA and psoriasis due to the risk of psoriatic flares. However, despite this recommendation, SGCs are frequently prescribed for these patients. In this study we reappraise the old paradigm that SGCs are contra-indicated in the treatment of PsA and psoriasis.

Methods

A systematic search of MEDLINE, EMBASE and the Cochrane Library databases was performed in November 2019 to identify articles on any SGC use compared with no use in the PsA and psoriasis population. Topical glucocorticoid treatment was excluded. Our two primary outcomes focused on the prescribing characteristics and the occurrence of any type of flare.

Results

Our search yielded 4922 articles, and of these 21 full-text articles were eligible for inclusion. There were 11 retro- and prospective cohorts involving a total of 4,171,307 patients. Of these, 6727 (37.82%) of the patients with PsA and 1 460 793 (35.17%) of the patients with psoriasis were treated with any type of SGC. Ten observational/interventional studies did not report an increased risk or occurrence of psoriatic flares related to SGC use.

Conclusion

Our results indicate that SGCs are frequently prescribed for PsA and psoriasis patients. The occurrence of psoriatic flares appears to be low upon SGC exposure. In patients with a clear indication for SGCs, e.g. in need of rapid anti-inflammatory therapy or bridging of therapies, the use of SGCs should be considered in view of the low risk of skin flaring. It remains of importance to weigh risks for short- and long-term SGC-related side effects in clinical decision making.

Erythrodermic Psoriasis and Staph-Infective Endocarditis—A Conundrum in Succession

Erythrodermic psoriasis is a rare subtype of psoriasis vulgaris that presents with diffuse erythema and desquamation over greater than 75% of the body’s surface area. We present a case of a 57-year-old male who was admitted with a diffuse, erythematous scaly rash covering his entire body, with associated subjective fevers. Skin biopsy revealed erythrodermic psoriasis, and blood cultures were positive for methicillin-sensitive Staphylococcus aureus. Echocardiogram revealed a mitral valve vegetation. Clinical improvement was achieved with intravenous antibiotic administration and topical corticosteroids without the use of immunomodulators.

Updates on the Treatment of Erythrodermic Psoriasis

Erythrodermic psoriasis (EP) is a rare variant of psoriasis, which is potentially life threatening and often resistant to conventional therapy. Biologics have revolutionized the treatment of plaque-type psoriasis, and shown promise in EP. However, due to the lack of head-to-head studies and the rarity of EP, no high level evidence-based treatment guidelines for EP have been established, and the evidence of treatment of EP is limited to case reports or small case series. Here, we present a narrative review focusing on the up-to-date information for the treatment of EP.

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.

Two cases of refractory erythrodermic psoriasis effectively treated with secukinumab and a review of the literature

Erythrodermic psoriasis (EP), which accounts for 1 to 2.25% of all psoriatic cases, typically occurs in patients with poor control of existing psoriasis. Secukinumab yields rapid and sustained improvements of signs and symptoms in patients with plaque psoriasis. Currently, clinical data on the treatment of EP with secukinumab are scarce. We describe two adult patients with severe EP, including one male and one female who were both ineligible for or resistant to acitretin or methotrexate treatment and had additional diseases. The patients underwent treatment with secukinumab using the standard regimen. After 4 weeks of treatment, a 75% reduction in the Psoriasis Area and Severity Index score (PASI 75) was achieved in both patients. Secukinumab was well tolerated and was continued for at least 32 weeks of treatment. We report the clinical use of secukinumab in the treatment of EP and review its potential role in the management of this severe condition.

Clinical Features and Genetic Polymorphism in Chinese Patients with Erythrodermic Psoriasis in a Single Dermatologic Clinic

BACKGROUND

Erythrodermic psoriasis (EP) is a rare variant of psoriasis that involves more complications and poorer biologic drug survival than plaque-type psoriasis vulgaris (PV). No prior study has explored human leukocyte antigen (HLA) or other genetic polymorphisms in patients with EP.

OBJECTIVES

Our objective was to describe the clinical features, comorbidities, and HLA polymorphisms among Chinese patients with EP.

METHODS

We enrolled consecutive patients with EP from our clinic, with EP defined as generalized confluent erythematous thin plaques covering at least 80% body surface area. Patients were categorized as having primary or secondary EP. Aggravating factors, comorbidities including psoriatic arthritis, family history of psoriasis, age of onset, and treatment history were also identified. Genetic studies were performed for HLA-C and HLA-DRB1, and the results were compared with those from a healthy population and patients with PV.

RESULTS

Of the 63 included patients, the male to female ratio was 2.71:1. Five (7.9%) patients had primary EP, and 58 (92.1%) had secondary EP. Genotyping of HLA-C and HLA-DRB1 was available in 61 and 58 subjects, respectively. HLA-C*0102 was the most frequent HLA-C allele (34.4%), followed by HLA-C*0702 (18.0%). The frequency of HLA-C*0602 allele (4.1%) was lower than in patients with plaque-type psoriasis (4.1 vs. 16.3%, corrected p value [P_c] = 0.02) and similar to that in the healthy population in Taiwan. The most frequent HLA-DRB1 allele was HLA-DRB1*0901 (20.7%), followed by HLA-DRB1*0803 (13.8%). An increased prevalence of psoriatic arthritis (61.9%) and higher male predominance were also noted in comparison with PV.

CONCLUSIONS

There are HLA differences in Chinese patients with EP compared with patients with PV. The incidence of psoriatic arthritis is also higher. The implications of the above findings await further investigation.

Prevalence of Metabolic Syndrome in Chinese Patients With Erythrodermic Psoriasis: A Case-Control Study

Erythroderma psoriasis (EP) is a rare and severe form of psoriasis, which is a chronic inflammatory skin disease that usually occurs simultaneously with cardiovascular disease (CVD). Metabolic syndrome (MetS) is a significant precursor of CVD. This study was to investigate the association between EP and MetS in the Chinese population. We conducted a retrospective study on 86 consecutive patients with EP and 100 healthy controls from Huashan Hospital between 2013 and 2018. Demographic, biochemical parameters for MetS, and other relevant data including the severity of EP, family history of EP, age of onset, and treatment history involved in those individuals were recorded. The prevalence of MetS in erythrodermic psoriatic patients was 88.37%, which was significantly higher than that of controls (P < 0.0001). Erythrodermic psoriatic patients also had a higher prevalence of MetS components, including abdominal obesity, dyslipidemia and hypertension, whereas hyperglycemia was similar. Adjusted for confounding factors, MetS, abdominal obesity, hypertension, smoking and alcohol use were positive independent predictors of EP (odds ratio > 1, P < 0.05). The area under the receiver operating characteristic curve calculated from determined risk factors for predicting the EP's incidence was 0.934 (95% CI 0.902-0.966). There was no correlation between the severity of EP and the prevalence of MetS. Compared with patients with mild EP, patients with moderate-to-severe EP had higher body mass index, waist circumstance and blood pressure (P < 0.05). We concluded that the prevalence of MetS and its components was higher in patients with EP. MetS an independent predictor of EP, which can favor CVD and should be encouraged to correct these cardiovascular risk factors aggressively for managing EP.

The Management of Erythrodermic Psoriasis Complicated by Cyclosporine

We present a 64-year-old woman with past medical history of psoriasis and alcoholic liver cirrhosis who presented with a diffuse, erythematous, and scaly rash. Pertinent medications included topical triamcinolone 0.1% cream. She was started on oral prednisone 40 milligrams (mg) and oral cyclosporine 150 mg daily and was continued on topical triamcinolone. After the administration of two doses of this regimen, the serum creatinine increased to 1.76 mg/dL, and serum potassium increased to 6.7 mEq/L. The serum creatinine continued to uptrend to 2.42 mg/dL, and the glomerular filtration rate (GFR) decreased to 20 mL/min. The patient was emergently hemodialyzed. The patient was placed on an extended steroid taper, alleviating the psoriatic rash. However, the patient needed to be placed on a steroid-sparing regimen. Because of its rarity and ensuing complications, erythrodermic psoriasis must be identified and managed promptly. Cyclosporine is currently the first-line treatment. However, initiation of this therapy in our patient resulted in an acute kidney injury (AKI). Even though a steroid taper assisted in alleviating erythroderma, a steroid-sparing regimen needed to be started. This led to the consideration of alternate methods of therapy for further management of erythrodermic psoriasis with renal impairment.

Practical compendium for psoriasis management

Psoriasis management is complex and challenging. It should be tailored for each patient. Treatment strategy differs according to patient's age, sex, disease type, disease severity, burden on patient's quality of life, comorbidities, involvement of specific sites, and pregnancy. The choice of the appropriate therapeutic must take into consideration the availability, the price, and the patient's preferences. It is very important that the chosen treatment is not more unpleasant, intolerable, or dangerous than the disease itself. According to the disease type, severity, and effect on patient's quality of life, dermatologist chooses whether to start with topical therapy, phototherapy or systemic therapy, or a combination of two or more of them. Under each category, there are different types of therapies that can be the first line therapeutics, second line, or even contraindicated. In this compendium, we provide dermatologists with different treatment plans considering all the mentioned variables so that a dermatologist can choose the optimum plan for the patient.

Chrysin alleviates imiquimod-induced psoriasis-like skin inflammation and reduces the release of CCL20 and antimicrobial peptides

Psoriasis is a common non-contagious chronic inflammatory skin lesion, with frequent recurrence. It mainly occurs due to aberrant regulation of the immune system leading to abnormal proliferation of skin cells. However, the pathogenic mechanisms of psoriasis are not fully understood. Although most of the current therapies are mostly efficient, the side effects can result in therapy stop, which makes the effectiveness of treatment strategies limited. Therefore, it is urgent and necessary to develop novel therapeutics. Here, we investigated the efficacy of chrysin, a plant flavonoid, which we previously reported to possess strong antioxidant and anti-inflammatory effects, against psoriasis-like inflammation. Our results revealed that chrysin significantly attenuated imiquimod-induced psoriasis-like skin lesions in mice, and improved imiquimod-induced disruption of skin barrier. Moreover, the TNF-α, IL-17A, and IL-22-induced phosphorylation of MAPK and JAK-STAT pathways, and activation of the NF-κB pathway were also attenuated by chrysin pretreatment of epidermal keratinocytes. Most importantly, chrysin reduced TNF-α-, IL-17A-, and IL-22-induced CCL20 and antimicrobial peptide release from epidermal keratinocytes. Thus, our findings indicate that chrysin may have therapeutic potential against inflammatory skin diseases. Our study provides a basis for further investigating chrysin as a novel pharmacologic agent and contributes to the academic advancement in the field of Chinese herbal medicine.

Erythrodermic psoriasis secondary to systemic corticosteroids

Erythroderma is an uncommon, potentially life-threatening condition, which has many causes, including uncontrolled psoriasis. We present a 58-year-old woman with psoriasis who, after an abrupt discontinuation of systemic corticosteroids, developed erythrodermic psoriasis with extensive body surface involvement requiring hospital admission. Erythrodermic psoriasis requires a high index of suspicion to diagnose it in a timely fashion and treat it to prevent complications.

Erythrodermic Psoriasis Causing Uric Acid Crystal Nephropathy

Background

Erythrodermic psoriasis is a rare and severe variant of psoriasis. It is characterized by widespread skin erythema, scaling, pustules, or exfoliation of more than 75% of the body's surface area. This condition has life-threatening complications to include hemodynamic, metabolic, immunologic, and thermoregulatory disturbances. One metabolic complication, hyperuricemia, occurs from rapid keratinocyte differentiation and infiltration of inflammatory cells into psoriatic lesions. Although renal injury caused by shunting of blood to the skin has been reported, there are no reports of erythrodermic psoriasis causing crystal-induced nephropathy. We present a case of erythrodermic psoriasis and hyperuricemia complicated by uric acid crystal nephropathy.

Case Presentation

A 57-year-old male with long-standing psoriatic arthritis presented with diffuse scaling of his skin. He was being treated with adalimumab, leflunomide, and topical clobetasol, but had recently stopped taking his medications. Physical exam revealed yellow scaling covering his entire body with underlying erythema and tenderness without mucosal involvement. Labs were notable for a creatinine of 3.3 mg/dL, with no prior history of renal disease, and uric acid of 12.7 mg/dL. He was admitted to the intensive care unit given >80% of body surface area involvement and acute renal failure. Despite aggressive fluid resuscitation, renal function did not improve, and creatinine peaked at 4.61 mg/dL. Urine microscopy showed diffuse polymorphic uric acid crystals, consistent with uric acid crystal-induced nephropathy. He was started on rasburicase, urinary alkalinization, and fluids. His renal function improved dramatically; urine output, uric acid, and electrolytes normalized. He was discharged on topical clobetasol and leflunomide and started on secukinumab with little to no skin involvement.

Conclusion

This case presents the rare complication of crystal-induced nephropathy in a patient with erythrodermic psoriasis. Uric acid crystal nephropathy is well described in diseases with rapid cell turnover such as tumor lysis syndrome. It is thought that rapid keratinocyte differentiation and inflammatory infiltration of psoriatic lesions produced life-threatening electrolyte abnormalities similar to tumor lysis syndrome. Early recognition of this rare complication is critical, and aggressive fluid resuscitation, urine alkalinization, and uric acid lowering agents should be administered immediately.

Complete resolution of erythrodermic psoriasis with first-line apremilast monotherapy

Erythrodermic psoriasis (EP) is the most serious type of psoriasis with high morbidity and mortality. First-line recommended therapies for EP, cyclosporine and infliximab have significant adverse effects. Cyclosporine increases the risk of hypertension, leucopenia, infections and renal failure. Infliximab increases the risk of reactivation of tuberculosis, hepatitis B and histoplasmosis, and increases risk for hepatitis, autoantibody formation, congestive heart failure, demyelinating disorders, pancytopenia, lymphoma and skin cancer. An effective drug with a much safer side effect profile will be of significant benefit in EP. The phosphodiesterase 4 inhibitor apremilast is U.S Food and Drug Administration (FDA) approved for plaque psoriasis and psoriatic arthritis. Adverse effects of apremilast reported are headache, nausea, diarrhoea, upper respiratory tract infection, potential for depression and weight loss. We report complete and long-standing resolution of EP with first-line apremilast monotherapy. Apremilast may be an effective option with comparatively minor side effects for EP.

The Tissue-Engineered Human Psoriatic Skin Substitute: A Valuable In Vitro Model to Identify Genes with Altered Expression in Lesional Psoriasis

Psoriasis is a chronic inflammatory skin disease for which no cure has emerged. Its complex etiology requires the development of an in vitro model representative of the pathology. In this study, we exploited gene profiling analyses on microarray in order to characterize and further optimize the production of a human psoriatic skin model representative of this in vivo skin disease. Various skin substitutes were produced by tissue-engineering using biopsies from normal, healthy donors, or from lesional or non-lesional skin samples from patients with psoriasis, and their gene expression profiles were examined by DNA microarray. We demonstrated that more than 3540 and 1088 genes (two-fold change) were deregulated between healthy/lesional and lesional/non-lesional psoriatic substitutes, respectively. Moreover, several genes related to lipid metabolism, such as PLA2G4E and PLA2G4C, were identified as repressed in the lesional substitutes. In conclusion, gene profiling analyses identified a list of deregulated candidate genes associated with various metabolic pathways that may contribute to the progression of psoriasis.

Erythroderma

Erythroderma, often described as generalized exfoliative dermatitis, is a condition in which erythema involves greater than 90% of the body surface, often as a result of an underlying inflammatory skin condition, which can result in a variety of systemic manifestations and potentially lead to life-threatening complications.

Patient Satisfaction with Psoriasis Therapies: An Update and Introduction to Biologic Therapy

Background:

Psoriasis is a chronic, immune-mediated skin condition that often requires lifelong treatment. Many patients report dissatisfaction with traditional nonbiologic therapies because they are ineffective for their psoriasis, are associated with side effects, or impact negatively on quality of life.

Objectives:

The aim of this article is to review the effect on patient quality of life of traditional nonbiologic psoriasis therapies and to discuss the impact of biologic psoriasis therapies on patient satisfaction.

Methods:

A review of the literature is presented.

Results:

Traditional nonbiologic psoriasis therapies can negatively impact quality of life due to a variety of factors including inconvenience and toxicity. Biologic agents have been developed that target the immunopathogenesis of psoriasis. Based on favorable efficacy and safety results in clinical trials, some of these agents are now approved for clinical use. Evidence suggests that patients receiving biologic therapies experience significant improvements in health-related quality of life.

Conclusion:

Biologic agents offer new hope for patients with psoriasis that their chronic condition can be controlled in a manner that improves their quality of life and may lead to high levels of satisfaction with their treatment.

Erythrodermic psoriasis: current and future role of biologicals

Erythrodermic psoriasis (EP) is a severe form of psoriasis that may be associated with serious and sometimes fatal complications. The treatment of EP is often a challenge, since several factors, including treatment failure or possible complications, may limit favorable outcomes with traditional drugs. Recent evidence suggests that biological drugs, including both anti-tumor necrosis factor alpha agents and ustekinumab, may be useful in improving the management of EP. Unfortunately, since subjects with EP are usually excluded from pivotal trials involving biological agents, this evidence is currently dispersed in small case series and single case reports. In this paper, we briefly analyze conventional therapies for EP, before going on to critically evaluate the existing clinical evidence for the role of current biological drugs, namely infliximab, etanercept, adalimumab, and ustekinumab. Finally, we discuss the potential benefits that newer/developmental biological agents could bring to the management of EP.

Erythrodermic Psoriasis Treated with Golimumab: A Case Report

Erythrodermic psoriasis (EP) is a very severe variant of psoriasis whose management poses a challenge to physicians, as currently available therapies often provide unsatisfactory results. Many biologics have been used to treat chronic plaque psoriasis, the most common form of psoriasis; however, their effectiveness for EP is poorly understood. A recently developed biologic, golimumab, has been extensively studied for the treatment of moderate-to-severe active rheumatoid arthritis, psoriatic arthritis, active ankylosing spondylitis, and chronic plaque psoriasis. However, no clinical trials have been performed for EP. Here, we report the case of a 32-year-old man who presented with severe psoriasis that previously failed to respond satisfactorily to methotrexate, cyclosporine, retinoid, narrow-band ultraviolet B phototherapy, and topical agents (i.e., steroids and calcipotriol). Skin lesions worsened progressively and developed into erythroderma. Psoriatic arthritis was also detected. Conventional therapies lacked efficacy. Therefore, we administered golimumab 50 mg. The skin lesions improved significantly according to the Psoriasis Area and Severity Index score after the first administration; lesions improved further throughout the treatment course. Although additional studies are required to fully evaluate the efficacy and safety of golimumab, this agent may be an alternative treatment strategy for some patients with recalcitrant EP.

Infliximab treatment of psoriasis in supervised infusion centers: case management experience

Psoriasis is a systemic chronic inflammatory disease that affects 1-3% of the world's population. Knowledge of the pathogenesis of psoriasis, particularly in the understanding of the role of T cells and tumor necrosis factor α (TNFα), and advances in immunology have led to the development of biological agents, which, due to their great effectiveness, speed of response and good tolerability, have revolutionized patient management. One of these is infliximab, a human chimeric immunoglobulin G1 monoclonal antibody composed of human antibody constant regions and murine variable regions that was developed specifically to target TNFα. The six cases presented in this series highlight the feasibility, efficacy and safety of infliximab for psoriasis when administered in a variety of patients in several infusion centers across Spain. All six patients showed improvement in their psoriasis after the initiation of infliximab and no significant tolerability issues or injection site reactions were reported, despite the presence of several comorbid conditions or patient characteristics that traditionally reduce the efficacy of psoriasis treatments. This suggests that while the management of psoriasis patients with comorbid conditions and various unfavorable prognostic characteristics requires a multidisciplinary approach to ensure the patient obtains the best therapeutic response, infliximab is an effective and well tolerated treatment in these patients.

Effectiveness of conventional drug therapy of plaque psoriasis in the context of consensus guidelines: a prospective observational study in 150 patients

BACKGROUND

Evidence for superior outcome by adhering to therapy guidelines is imperative to their acceptance and adaptation for the optimal management of disease variants.

OBJECTIVE

Comparative study of prospective outcomes in simultaneous consideration of independent variables in groups of 150 patients of plaque psoriasis either treated adhering to or in digression of standard guidelines.

METHODS

The psoriasis area severity index (PASI) and the dermatology life quality index (DLQI), prior to and after three months of uninterrupted therapy were examined in treatment groups among 150 patients. Recovery rates of 75% or more in PASI were compared. Independent variables were also examined for their bearing on the outcome.

RESULTS

The vast majority was early onset disease phenotype. All three treatment regimens when administered in adherence to the guidelines yielded significantly superior rates of defined recovery both in PASI and DLQI. Compromise of the therapeutic outcome appeared in high stress profiles, obesity, female sex and alcohol, tobacco or smoking habit.

CONCLUSION

Conventional drug therapy of plaque psoriasis yields superior outcome by adhering to the consensus guidelines. Psychiatric address to stress must be integral and special considerations for phenotypic/syndromic variants is emphasized for effective therapy of psoriasis.

Systemic steroids in the treatment of psoriasis: what is fact, what is fiction?

BACKGROUND

The use of systemic steroids in the treatment of psoriasis is not recommended by dermatological textbooks and guidelines because of the risk of disease deterioration after dose reduction or withdrawal. In contrast to these recommendations, a recent analysis using data from a German nationwide healthcare insurance revealed that systemic steroids were the most frequently prescribed drugs for psoriasis by general practitioners, internal medicine physicians and dermatologists.

OBJECTIVE

As there is an obvious discrepancy between the use of systemic steroids for psoriasis and the reported adverse effects, a non-systematic literature search starting 1950 until today was performed to address beneficial and adverse effect of systemic steroids in psoriasis.

METHODS

Non-systematic literature search.

RESULTS

Regarding the widespread use of systemic steroids in psoriasis and other medical conditions taking the high prevalence of psoriasis of 2-3% at least in Caucasians into consideration, there is a remarkable lack of literature addressing adverse effects such as rebound, pustular or erythrodermic flares or even new occurrence of psoriasis in patients with a negative disease history.

CONCLUSION

A re-evaluation of the treatment of psoriasis and/or psoriatic arthritis with systemic steroids is necessary.

Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In the first 5 parts of the American Academy of Dermatology Psoriasis Guidelines of Care, we have presented evidence supporting the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis. In this sixth and final section of the Psoriasis Guidelines of Care, we will present cases to illustrate how to practically use these guidelines in specific clinical scenarios. We will describe the approach to treating patients with psoriasis across the entire spectrum of this fascinating disease from mild to moderate to severe, with and without psoriatic arthritis, based on the 5 prior published guidelines. Although specific therapeutic recommendations are given for each of the cases presented, it is important that treatment be tailored to meet individual patients' needs. In addition, we will update the prior 5 guidelines and address gaps in research and care that currently exist, while making suggestions for further studies that could be performed to help address these limitations in our knowledge base.

Evaluation and management of psoriasis: an internist's guide

Psoriasis is a debilitating chronic skin condition that afflicts millions of patients worldwide. Patients experiencing psoriasis report a magnitude of impaired quality of life that is often similar to that of patients who have heart failure and cancer. Many patients who have psoriasis are even themselves at risk for developing heart disease, metabolic syndrome, certain cancers, and psychiatric illness. Therefore, primary care physicians must appreciate the current psoriatic disease model and share a basic understanding of psoriasis management. This article reviews the epidemiology, clinical features, pathogenesis, comorbidities, and treatment of psoriasis, with special emphasis placed on the new class of medications, biologics, which are revolutionizing the management of the disease.

Treatment of erythrodermic psoriasis: from the medical board of the National Psoriasis Foundation

BACKGROUND

Erythrodermic psoriasis is a severe form of psoriasis that can arise acutely or follow a chronic course. There are a number of treatment options, but overall there are few evidence-based data to guide clinicians in managing these challenging cases.

OBJECTIVE

Our aim was to create treatment recommendations to help dermatologists treat patients with erythrodermic psoriasis.

METHODS

A task force of the National Psoriasis Foundation Medical Board was convened to evaluate treatment options for erythrodermic or exfoliative psoriasis. Meetings were held by teleconference and were coordinated and funded by the National Psoriasis Foundation. Consensus on treatment of erythrodermic psoriasis was achieved. A literature review was conducted to examine treatment options for erythrodermic psoriasis and the strength of the evidence for each option.

RESULTS

There is no high-quality scientific evidence on which to base treatment recommendations. Treatment should be dictated by the severity of disease at time of presentation and the patient's comorbidities. Cyclosporine and infliximab appear to be the most rapidly acting agents for the treatment of erythrodermic psoriasis. Acitretin and methotrexate are also appropriate first-line choices, although they usually work more slowly. Treating physicians can consider a number of second-line agents, including etanercept or combination therapy, in the treatment of patients with erythrodermic psoriasis. Combination therapy may be more effective than a single-agent approach; there is a paucity of scientific data in this area. All patients should be evaluated for underlying infection. Supportive care can help control disease and patient symptoms if instituted appropriately. Physicians should avoid potential exacerbating agents when managing this challenging disease.

LIMITATIONS

There are few high-quality studies examining treatment options for erythrodermic psoriasis.

CONCLUSION

Treatment of patients with erythrodermic psoriasis demands a thorough understanding of the treatment options available. Therapy should be based on acuity of disease and the patient's underlying comorbidities. There are limited data available to compare treatment options for erythrodermic psoriasis. Further studies are necessary to explore the optimal treatment algorithm for these patients.

Psoriasis comorbidities

Psoriasis is a chronic and debilitating inflammatory disease associated with serious comorbidities. Psoriasis can have a significant impact on a patient's quality of life and is associated with loss of productivity, depression, and an increased prevalence of malignancy. Emerging comorbidities of psoriasis include cardiovascular disease and metabolic syndrome. Psoriasis patients have an increased prevalence of the core components of metabolic syndrome, including obesity, dyslipidemia, and insulin resistance. The relationship between psoriasis and comorbidities such as metabolic syndrome and cardiovascular disease is likely linked to the underlying chronic inflammatory nature of psoriasis. The molecular mechanisms involved in psoriasis-associated dysregulation of metabolic function are believed to be due, in large part, to the action of increased levels of proinflammatory factors, such as tumor necrosis factor-alpha, that are central to the pathogenesis of psoriasis. Recent studies investigating the effects of tumor necrosis factor antagonists on the treatment of cardiovascular disease and metabolic syndrome support this concept.

Patient satisfaction with psoriasis therapies: an update and introduction to biologic therapy

BACKGROUND

Psoriasis is a chronic, immune-mediated skin condition that often requires lifelong treatment. Many patients report dissatisfaction with traditional nonbiologic therapies because they are ineffective for their psoriasis, are associated with side effects, or impact negatively on quality of life.

OBJECTIVES

The aim of this article is to review the effect on patient quality of life of traditional nonbiologic psoriasis therapies and to discuss the impact of biologic psoriasis therapies on patient satisfaction.

METHODS

A review of the literature is presented.

RESULTS

Traditional nonbiologic psoriasis therapies can negatively impact quality of life due to a variety of factors including inconvenience and toxicity. Biologic agents have been developed that target the immunopathogenesis of psoriasis. Based on favorable efficacy and safety results in clinical trials, some of these agents are now approved for clinical use. Evidence suggests that patients receiving biologic therapies experience significant improvements in health-related quality of life.

CONCLUSION

Biologic agents offer new hope for patients with psoriasis that their chronic condition can be controlled in a manner that improves their quality of life and may lead to high levels of satisfaction with their treatment.

Relapse, rebound, and psoriasis adverse events: An advisory group report

Psoriasis is a chronic disease, the severity of which varies among patients and changes unpredictably over time in individual patients. Psoriasis can be exacerbated during treatment by infection, endocrine factors, hypocalcemia, medications, psychologic stress, skin trauma, or other factors. Patients who discontinue treatments may experience a return of disease--relapse--or worsening of disease--rebound. The National Psoriasis Foundation (NPF) proposed standardized definitions of relapse and rebound. Efalizumab, a recombinant humanized immunoglobulin G-1 monoclonal antibody, is approved for the management of psoriasis. During efalizumab clinical trials, a small percentage of patients experienced protocol-defined adverse events related to psoriasis. After publication of the NPF definition of rebound, post hoc exploratory analyses of the efalizumab clinical trial data were performed. The efalizumab clinical trial investigators discussed their observations, the analyses, and their individual approaches to the treatment of patients receiving or discontinuing efalizumab therapy, the conclusions of which are described herein.

Treatment of erythrodermic psoriasis with etanercept

BACKGROUND

Severe variants of psoriasis, such as erythrodermic psoriasis, may be associated with serious morbidity and mortality. Current treatment options for erythrodermic psoriasis are limited, unsatisfactory and potentially associated with organ-specific toxicity. Recently, a new class of agents, targeted biological therapies, has emerged. Etanercept is a recombinant human fusion protein acting as a competitive inhibitor of tumour necrosis factor-alpha. The safety and efficacy of etanercept have been widely demonstrated in psoriatic arthritis and moderate to severe plaque-type psoriasis.

OBJECTIVES

To assess the efficacy and tolerability of etanercept in the treatment of erythrodermic psoriasis over a period of 24 weeks.

METHODS

Ten patients, eight men and two women, were selected to receive etanercept 25 mg subcutaneously twice weekly. The Psoriasis Area and Severity Index (PASI) score, ranging from 0 to 72, was used to assess the severity of disease.

RESULTS

Etanercept was well tolerated and led to a significant reduction in the severity of disease over the period of treatment. After 24 weeks, the mean PASI score decreased from 39.1 (baseline) to 5.1. At week 12, five of 10 (50%) patients achieved an improvement of PASI score from baseline exceeding 75%. At week 24, six of 10 patients (60%) achieved or maintained an improvement of PASI score from baseline exceeding 75% while two patients (20%) maintained an improvement of between 50% and 75%.

CONCLUSIONS

In this study, etanercept has been demonstrated to be an effective treatment for erythrodermic psoriasis, providing a safe and convenient alternative to current therapies.

Psoriasis-Induced Postoperative Cardiac Failure

Erythroderma-induced cardiogenic shock is a rare but known manifestation of erythrodermic psoriasis. Erythrodermic psoriasis is an aggressive form of the disease and can be precipitated by numerous factors including stress to the body. In this article we present a case of persistent severe vasodilatation after coronary artery bypass surgery that required prolonged epinephrine administration. This was caused by a flareup of erythrodermic psoriasis that was previously only controlled by methotrexate. This drug was omitted in the perioperative phase. Vasodilatation disappeared after treatment was reinstituted.

Life-threatening erythroderma: diagnosing and treating the “red man”

Exfoliative erythroderma, or diffuse erythema and scaling of the skin, may be the morphologic presentation of a variety of cutaneous and systemic diseases. Establishing the diagnosis of the underlying disease is often difficult and, not uncommonly, erythroderma is classified as idiopathic. Several cases are presented to demonstrate the diversity of presentation of this disease. Laboratory findings are typically unhelpful in establishing the etiology of erythroderma. Clinical data combined with multiple skin biopsies over time are necessary. Systemic complications of erythroderma include infection, fluid and electrolyte imbalances, thermoregulatory disturbance, high output cardiac failure, and acute respiratory distress syndrome. The initial approach to the management of erythroderma of any etiology includes attention to nutrition, fluid and electrolyte replacement, and the institution of gentle local skin care measures. Oatmeal baths and wet dressings to weeping or crusted sites should be followed by application of bland emollients and low-potency topical corticosteroids. Systemic dermatologic therapy may be required to maintain improvement achieved with local measures or to control erythroderma refractory to local measures. The prognosis of erythroderma is dependent on the underlying etiology.