Psoriasis in solid organ transplant patients: best practice recommendations from The Medical Board of the National Psoriasis Foundation

Skin cancer prevention - Recent advances and unmet challenges

Cutaneous squamous cell carcinoma (cSCC) is the second most common malignancy in the world. Among many identified risk factors, immunosuppression is a major factor that contributes to cSCC development. Organ transplant recipients (OTRs) are at markedly increased risk of developing multiple cSCCs with a propensity for advanced metastatic disease, leading to significant morbidity and mortality. The severity of the cSCC phenotype in OTRs highlights the urgent need to identify effective preventive modalities in this population. Despite recent advances in skin cancer prevention (e.g., nicotinamide) and treatment (e.g., immune checkpoint blockade), these modalities have limited utility in OTRs due to the lack of efficacy or significant side effect. Topical treatments against precancerous skin lesions, actinic keratosis (AK), remain the primary strategy to prevent cSCC in OTRs, which also have significant deficiencies in this population. Herein, we review the epidemiology, risk factors, and current cSCC prevention strategies. We highlight the gaps and future clinical strategies to address cSCC risk in high-risk populations.

Psoriasis in the transplant population

Solid organ and stem cell transplants are increasingly common, and dermatologists will more frequently encounter and need to manage common skin diseases, such as psoriasis, in transplant patients. This review explores psoriasis remission and occurrence in recipients of solid organ and stem cell transplants. Hematopoietic and mesenchymal stem cell transplants may show potential for treating psoriasis in patients with leukemia or who have other medical conditions requiring stem cell transplant. The effects of solid organ transplant are less clear, partly due to limitations in the breadth of the literature. De novo psoriasis has been reported in recipients of solid organ transplants, but the reasons for this development have yet to be fully understood. Overall, the literature on this subject is limited to primarily case reports. Feasibility of studies on the subject may be a considerable barrier to further research assessing the use of transplant for treating psoriasis, but there is potential benefit from transplant for psoriasis patients. This subject should receive further exploration to fully understand these benefits.

Biologics recommendations for patients with psoriasis: a critical appraisal of clinical practice guidelines for psoriasis

PURPOSE

This review article serves to assess the consistency of recommendations from guidelines on biologic agents for psoriasis, based on the quality evaluation of psoriasis Clinical Practice Guidelines (CPGs).

METHODS

We conducted a systematic literature search to identify CPGs that provide recommendations on diagnosis and treatment for psoriasis. Four reviewers performed a quality assessment of the included CPGs with the Appraisal of Guidelines Research and Evaluation II (AGREE II) Instrument.

RESULTS

A total of 51 sets of CPGs from 22 medical societies or separate working groups fulfilled the inclusion criteria. The overall quality of the eligible sets of guidelines was moderate to high, with an overall average score of 55%The highest domain scores were Score and Purpose (70%) and Clarity of Presentation (68%). A total of 95 biologic agent recommendations were extracted from the 18 recommended CPGs.Three biologic agents (Etanercept, Adalimumab, Ustekinumab) were recommended for pediatric patients. Three biologic agents (Adalimumab, Ustekinumab, Secukinumab) were recommended as first-line biologic agents for adults with psoriasis.

CONCLUSION

The overall methodological quality of CPGs for psoriasis is medium to high. More attention should be paid to applicability in guideline development. The recommendations and the basis for them among various sets guidelines were almost consistent.

Oral Taodan granules for mild-to-moderate psoriasis vulgaris: protocol for a randomized, double-blind, multicenter clinical trial

Background

Psoriasis is a common chronic inflammatory skin disease with high recurrence rates and increasing incidence. Patients require long-term medication to reduce symptoms and prevent disease progression. Therefore, the development of treatments with high efficiency and low rate of adverse events is of utmost importance. Traditional Chinese medicine (TCM) plays an outstanding role in reducing disease symptoms and improving quality of life. The aim of this trial is to clarify the treatment efficacy, safety, and control of disease recurrence in patients with psoriasis with blood-stasis syndrome treated with Taodan granules (TDKL).

Methods

This trial is a five-center, randomized, double-blind, placebo-controlled study planned to transpire between September 1, 2019, and December 31, 2021. A sample size of 216 participants (108 per group) with mild-to-moderate psoriasis will be randomly assigned to receive TDKL or placebo twice per day, 7 days per week, for 8 weeks. The study duration will be 17 weeks, including a 1-week screening period, 8 weeks of intervention, and another 8 weeks of follow-up. The primary outcomes are improvement in the Psoriasis Area and Severity Index score and recurrence rate after 8 weeks of treatment. Secondary outcomes include body surface area affected and the scores for the Physician Global Assessment, Dermatology Life Quality Index, pain-related quality of life, pain on the visual analogue scale, and TCM syndromes. The number, nature, and severity of adverse events will be carefully recorded.

Discussion

The study results will help clarify the safety and efficacy of TDKL as treatment for psoriasis with respect to both disease regression and recurrence rate. We expect that this study will provide high-quality evidence with important public health implications that may alter the approach to psoriasis management in China.

Trial registration

The trial has been registered at ClinicalTrials.gov (ID: NCT03942198).

Treatment of severe psoriasis with ixekizumab in a liver transplant recipient with concomitant hepatitis B virus infection

Treatment of severe psoriasis (PsO) in organ transplant (OT) patients is difficult. In fact, systemic drugs used for PsO therapy can be detrimental to transplanted organs and/or can increase the risk of serious infections in subjects already taking antireject medicines. Current guidelines fail to give indications on how to manage PsO OT subjects. Moreover, only a few cases of patients with the above-cited characteristics treated with systemic therapies have been published so far. Here, we report our experience concerning a liver transplant patient successfully treated with ixekizumab for his psoriasis throughout 1 year.