Diagnosis and Management of Cutaneous Psoriasis: A Review

Mesenchymal stem cell-derived exosomes decrease Hyperplasia in Psoriasis by inducing transforming growth factor β2 (TGF-β2)

BACKGROUND

Psoriasis, a chronic inflammatory skin disease, is increasingly effectively managed with the targeted immunotherapy; however, long-term immunotherapy carries health risks, and loss of response. Therefore, we need to develop the alternative treatment strategies. Mesenchymal stem/stromal cell (M.S.C.) exosomes stand out for their remarkable immunomodulatory properties, gaining widespread recognition. This study investigated whether M.S.C. exosomes can reduce psoriasis-induced hyperplasia by inducing Transforming Growth Factor beta 2 (TGF-beta2) signaling.

METHODOLOGY

Exosomes were isolated from M.S.C.s by ultracentrifugation. Then, scanning electron microscopy was used for the morphology of exosomes. To ascertain the exosome concentration, the Bradford test was used. To ascertain the cellular toxicity of exosomes in Human Umbilical Vein Endothelial Cells ( H.U.V.E.C), an MTT experiment was then conducted. Real-time PCR was used to quantify TGF beta2 expression levels, whereas an ELISA immunosorbent assay was used to determine the protein concentration of TGF beta2.

RESULTS

In this study, the exosomes of 15-30 nm in size that were uniform, and cup-shaped were isolated. Moreover, the IC50 value for this Treatment was calculated to be 181.750 µg/ml. The concentration of TGF-β2 gene in the target cells significantly increased following Treatment with the exosomes. Furthermore, the expression level of the studied gene significantly increased due to the Treatment.

CONCLUSION

Upregulating the expression of TGF-β2 in psoriatic cells via TGF-β2 signaling is one way exosomes can help reduce hyperplasia.

Reactive oxygen species-responsive supramolecular deucravacitinib self-assembly polymer micelles alleviate psoriatic skin inflammation by reducing mitochondrial oxidative stress

Introduction

The new topical formula is urgent needed to meet clinical needs for majority mild patients with psoriasis. Deucravacitinib exerts outstanding anti-psoriatic capacity as an oral TYK2 inhibitor; however, single therapy is insufficient to target the complicated psoriatic skin, including excessive reactive oxygen species (ROS) and persistent inflammation. To address this need, engineered smart nano-therapeutics hold potential for the topical delivery of deucravacitinib.

Methods

hydrophobic Deucravacitinib was loaded into polyethylene glycol block-polypropylene sulphide (PEG-b-PPS) for transdermal delivery in the treatment of psoriasis. The oxidative stress model of HaCaT psoriasis was established by TNF-α and IL-17A in vitro. JC-1 assay, DCFH-DA staining and mtDNA copy number were utilized to assess mitochondrial function. 0.75% Carbopol®934 was incorporated into SPMs to produce hydrogels and Rhb was labeled to monitor penetration by Immunofluorescence. In vivo, we established IMQ-induced psoriatic model to evaluate therapeutic effect of Car@Deu@PEPS.

Results

Deu@PEPS exerted anti-psoriatic effects by restoring mitochondrial DNA copy number and mitochondrial membrane potential in HaCaT. In vivo, Car@Deu@PEPS supramolecular micelle hydrogels had longer retention time in the dermis in the IMQ-induced ROS microenvironment. Topical application of Car@Deu@PEPS significantly restored the normal epidermal architecture of psoriatic skin with abrogation of splenomegaly in the IMQ-induced psoriatic dermatitis model. Car@Deu@PEPS inhibited STAT3 signaling cascade with a corresponding decrease in the levels of the differentiation and proliferative markers Keratin 17 and Cyclin D1, respectively. Meanwhile, Car@Deu@PEPS alleviated IMQ-induced ROS generation and subsequent NLRP3 inflammasome-mediated pyroptosis.

Conclusion

Deu@PEPS exerts prominent anti-inflammatory and anti-oxidative effects, which may offers a more patient-acceptable therapy with fewer adverse effects compared with oral deucravacitinib.

Effects of isometric training and R.I.C.E. treatment on the arm muscle performance of swimmers with elbow pain

The effects of IT and R.I.C.E. treatment on arm muscle performance in overhead athletes with elbow pain (EP) have been partially validated. However, there is a lack of research evidence regarding the efficacy of these two methods on arm muscle performance among swimmers with EP. The aim of this study was to investigate the trends and differences in the effects of IT and R.I.C.E. treatment on arm muscle performance among swimmers with EP. The main outcomes were the time effects and group effects of interventions on muscle voluntary contraction (MVC). Sixty elite freestyle swimmers from Tianjin, China, voluntarily participated in the study and completed a 10-week intervention program. Swimmers with EP in the IT group showed a positive trend in MVC, with an approximately 2% increase, whereas the MVC of subjects in the R.I.C.E. treatment group and control group decreased by approximately 4% and 5%, respectively. In comparison, the effects of the IT intervention on the MVC of the triceps and brachioradialis muscles in swimmers with EP were significant (p = 0.042 < 0.05, p = 0.027 < 0.05). The mean MVC value of the IT group (0.60) was greater than that of the other two groups (0.51, 0.50). IT has a beneficial impact on the MVC performance of the triceps and brachioradialis muscles in swimmers with EP. It is recommended that professionals consider incorporating IT into regular training routines to mitigate the risk of EP issues. Future research should examine the effectiveness of both interventions on hand-grip strength and completion time in 50-m freestyle swim drills in order for swimmers with EP to return to this sport.

Gallic Acid Alleviates Psoriasis Keratinization and Inflammation by Regulating BRD4 Expression

Psoriasis is a chronic non-contagious autoimmune disease. Gallic acid is a natural compound with potential health benefits, including antioxidant, anticancer, antiviral and antibacterial properties. Nevertheless, the influence of gallic acid on psoriasis has not been fully determined. This investigation aimed to discover the effect of gallic acid on psoriasis. Thirty-one pairs of psoriatic skin tissues and healthy adult human skin tissues were collected. Human keratinocytes (HaCaT cells) were transfected with interleukin 17A (IL-17A) to create the psoriatic keratinocyte model. The content of bromodomain-containing protein 4 (BRD4) microRNA was assessed using qRT-PCR testing. The content of BRD4 was detected by Western blotting. Cell migration was evaluated by conducting a wound healing assay. Cell proliferation was determined using an EdU assay. Apoptosis was detected by the TUNEL assay. The contents of interferon gamma (IFN-γ), IL-6, IL-8 and IL-17 were detected by ELISA. BRD4 was up-regulated in psoriatic skin tissues and in the IL-17A group compared to the healthy adult human skin tissues and the control group. Silencing BRD4 inhibited cell migration, proliferation and inflammatory response but induced apoptosis in IL-17A-treated HaCaT cells. Conversely, BRD4 over-expression promoted cell migration, proliferation and inflammatory response but suppressed apoptosis in IL-17A-treated HaCaT cells. Gallic acid repressed cell migration, proliferation and inflammatory response but indu-ced apoptosis in HaCaT cells transfected with IL-17A by down-regulating BRD4. Gallic acid represses cell migration, proliferation and inflammatory response but induces apoptosis in IL-17A-transfected HaCaT cells by down-regulating BRD4.

The Current Status and Future Direction of Extracellular Nano-vesicles in the Alleviation of Skin Disorders

Exosomes are extracellular vesicles (EVs) that originate from endocytic membranes. The transfer of biomolecules and biological compounds such as enzymes, proteins, RNA, lipids, and cellular waste disposal through exosomes plays an essential function in cell-cell communication and regulation of pathological and physiological processes in skin disease. The skin is one of the vital organs that makes up about 8% of the total body mass. This organ consists of three layers, epidermis, dermis, and hypodermis that cover the outer surface of the body. Heterogeneity and endogeneity of exosomes is an advantage that distinguishes them from nanoparticles and liposomes and leads to their widespread usage in the remedy of dermal diseases. The biocompatible nature of these extracellular vesicles has attracted the attention of many health researchers. In this review article, we will first discuss the biogenesis of exosomes, their contents, separation methods, and the advantages and disadvantages of exosomes. Then we will highlight recent developments related to the therapeutic applications of exosomes in the treatment of common skin disorders like atopic dermatitis, alopecia, epidermolysis bullosa, keloid, melanoma, psoriasis, and systemic sclerosis.

Lingua geographica: Welche Krankheit ist das?

Die Lingua geographica oder benigne migratorische Glossitis ist eine besondere und eigentümliche Zungenerkrankung, die zu einem landkartenartigen Aussehen mit Atrophie der filiformen Papillen an verschiedenen Stellen der Zunge führt. Die Form der Läsionen ändert sich mit der Zeit. Die genaue Ätiologie ist nach wie vor unbekannt, allerdings wird ein Zusammenhang mit der lingualen Mikrobiota des Patienten vermutet. Auch auf eine Assoziation zwischen Lingua geographica und Psoriasis wird seit langem hingewiesen, und es bestehen histologische Ähnlichkeiten zwischen beiden. Neuere Erkenntnisse deuten zunehmend auf eine Beteiligung bestimmter oraler Bakterien hin. Im Folgenden werden diese Befunde anhand eines Überblicks über die aktuelle Literatur diskutiert.

Geographic tongue: What is this disease?

Geographic tongue or benign migratory glossitis, is a unique and peculiar tongue condition, producing a map-like appearance with filiform papillae atrophy, on different parts of the tongue. The lesions change in shape with time. The exact etiology remains unknown, although it has been suggested relating the lingual microbiota of a patient. The association between geographic tongue and psoriasis has long been pointed out, and histological similarities existed between both as well. Increasingly, recent findings suggest the involvement of certain oral bacteria. Here, we discuss these findings with an overview of the recent literature.

Artesunate alleviates psoriasis-like dermatitis by reducing interleukin-23 expression in tumor necrosis factor-alpha-induced HaCaT cells

Artesunate (ART), an antimalarial drug with a multifunctional immunomodulatory effect, reduces psoriasis disease. ART can alleviate psoriasis-like dermatitis in mice but has no effect on proinflammatory cytokines in the blood. Thus, we hypothesized that the skin might be the target tissue of ART during the treatment of psoriasis. The interleukin (IL)-23/IL-17 axis has a key role in the pathogenesis of psoriasis. However, whether and how ART manipulates the IL-23 signal during psoriasis is unknown. This study found that IL-23 is highly expressed in the epidermis of psoriasis lesions and positively correlated with histological neutrophil infiltration and clinical psoriasis area and severity index (PASI) scores. Furthermore, ART inhibits the migration and cell cycle, as well as tumor necrosis factor-alpha (TNF-α)-induced IL-23 expression in HaCaT cells in a dose-dependent manner, probably through interference with the nuclear factor kappa B (NF-κB) signalling pathway. Animal experiments in imiquimod (IMQ)-induced psoriasis-like mice model also suggested that ART dose-dependently reduces IL-23 in the epidermis and ameliorates neutrophil infiltration. These findings thus provide further molecular evidence supporting ART as a promising drug for psoriasis in clinic.

Clinicopathologic Characteristics of PANDAS in a Young Adult: A Case Report

Pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) is an acute onset or exacerbation of neuropsychiatric symptoms following a group A streptococcus infection. It is believed to be a result of autoimmune response to streptococcal infection, but there is insufficient evidence to fully support this theory. Although this disease is primarily thought to be a disease of childhood, it is reported to occur also in adults. PANDAS is a well-defined clinical entity, but the neuropathology of this condition has not been established yet. We describe the clinical course of a 26-year-old female diagnosed with PANDAS. She committed suicide and her brain was biobanked for further studies. We examined the banked tissue and performed special stains, immunohistochemical, and immunofluorescence analyses to characterize the neuropathology of this condition. Histology of the temporal lobes, hippocampus, and basal ganglia shows mild gliosis and Alzheimer's type II astrocytes. Acute hypoxic ischemic changes were noted in hippocampus CA1 and CA2 areas. Immunostaining shows increased parenchymal/perivascular GFAP staining and many vessels with mild increases in CD3-, CD4-, and CD25-stained lymphocytes in the basal ganglia. The findings suggest that CD4- and CD25-positive T cells might have an important role in understanding the neuroinflammation and pathogenesis of this condition. The case represents the first neuropathological evaluation report for PANDAS.

Nano transdermal system combining mitochondria-targeting cerium oxide nanoparticles with all-trans retinoic acid for psoriasis

Psoriasis is an inflammatory skin disease that is intricately linked to oxidative stress. Antioxidation and inhibition of abnormal proliferation of keratinocytes are pivotal strategies for psoriasis. Delivering drugs with these effects to the site of skin lesions is a challenge that needs to be solved. Herein, we reported a nanotransdermal delivery system composed of all-trans retinoic acid (TRA), triphenylphosphine (TPP)-modified cerium oxide (CeO2) nanoparticles, flexible nanoliposomes and gels (TCeO2-TRA-FNL-Gel). The results revealed that TCeO2 synthesized by the anti-micelle method, with a size of approximately 5 nm, possessed excellent mitochondrial targeting ability and valence conversion capability related to scavenging reactive oxygen species (ROS). TCeO2-TRA-FNL prepared by the film dispersion method, with a size of approximately 70 nm, showed high drug encapsulation efficiency (>96%). TCeO2-TRA-FNL-Gel further showed sustained drug release behaviors, great transdermal permeation ability, and greater skin retention than the free TRA. The results of in vitro EGF-induced and H2O2-induced models suggested that TCeO2-TRA-FNL effectively reduced the level of inflammation and alleviated oxidative stress in HaCat cells. The results of in vivo imiquimod (IMQ)-induced model indicated that TCeO2-TRA-FNL-Gel could greatly alleviate the psoriasis symptoms. In summary, the transdermal drug delivery system designed in this study has shown excellent therapeutic effects on psoriasis and is prospective for the safe and accurate therapy of psoriasis.

Insights into Nutritional Strategies in Psoriasis

Psoriasis, an autoimmune chronic inflammatory skin condition, has a high incidence in the general population, reaching 2-4%. Its pathogenesis involves an interplay of genetic factors, immune disturbances, and environmental factors. Within the environmental factors that aid the appearance of this autoimmune skin disease, the Western lifestyle and overall diet play important roles in the steady growth in psoriasis prevalence. Furthermore, psoriasis is associated with comorbidities such as psoriatic arthritis, cardiovascular disease, metabolic syndrome, and obesity. Accumulating evidence suggests that obesity is an important risk factor for psoriasis. Moreover, obesity aggravates established psoriasis, and a reduction in the body mass index can improve the clinical outcomes of psoriasis and increase the efficacy of standard psoriasis therapies. The possible connection between this autoimmune disease and obesity relies on the fact that white adipose tissue is an essential endocrine organ that secretes an array of immune mediators and inflammatory and metabolic factors with pro-inflammatory action. Thus, immune-mediated mechanisms in both psoriasis and obesity conditions are common factors. This paper describes the factors that link obesity with skin autoimmune disease and highlights the importance of the stimulatory or regulatory effects of nutrients and food in psoriasis and the possible improvement of psoriasis through nutritional strategies.

Expert Consensus on Real-World Use and Consumption Patterns of a Fixed-Dose Combination Foam for Psoriasis as a Reactive Management (RM) and Proactive Management (PAM) Regimen

INTRODUCTION

Plaque psoriasis is a chronic skin disease characterised by periods of remission and relapse and associated with considerable burden to patients and healthcare systems. For most patients, standard-of-care is reactive management (RM) with topical therapies, but, more recently, the benefits of proactive management (PAM) have been recognised. This study aimed to gain consensus on real-world use and consumption in RM versus PAM regimens, based on fixed-dose combination calcipotriol and betamethasone dipropionate (Cal/BD) foam which, following a recent update, is currently the only topical therapy for psoriasis with a long-term maintenance regimen in its label.

METHODS

The modified-Delphi approach was used to gain insights and consensus on real-world views, use and consumption in RM versus PAM from a panel of dermatologists with experience prescribing Cal/BD foam as PAM. The panel included 16 dermatologists, 4 each from France, Germany, Italy, and Spain, and included two questionnaire rounds and a meeting to obtain final consensus.

RESULTS

The panel agreed that topicals are burdensome to apply in clinical practice and that poor patient adherence, particularly long-term, is a barrier to effective psoriasis management. The panel advised that, as they prescribe a similar number of cans for RM and PAM over a given period, consumption is not a key driver influencing future decisions to prescribe PAM, even in instances where prescribing differences could be observed. Instead, the panel agreed that patient- and disease-related factors better determine patient suitability for PAM.

CONCLUSION

This modified-Delphi study confirms that prescription of RM or PAM, with Cal/BD foam, is largely driven by patient-related factors and patient involvement is key to optimise outcomes. Real-world experiences captured in this study suggest that a PAM regimen does not increase overall consumption, and thus costs per patient for payers and prescribers, in comparison to RM.

Microneedles as a momentous platform for psoriasis therapy and diagnosis: A state-of-the-art review

Psoriasis is a chronic, autoimmune, and non-communicable skin disease with a worldwide prevalence rate of 2-3%, creating an economic burden on global health. Some significant risk factors associated with psoriasis include genetic predisposition, pathogens, stress, medications, etc. In addition, most patients with psoriasis should also deal with comorbidities such as psoriatic arthritis, inflammatory bowel diseases, cardiovascular diseases, and psychological conditions, including suicidal thoughts. Based on its severity, the treatment approach for psoriasis is categorised into three types, i.e., topical therapy, systemic therapy, and phototherapy. Topical therapy for mild-to-moderate psoriasis faces several issues, such as poor skin permeability, low skin retention of drug formulation, greasy texture of topical vehicle, lack of controlled release, and so on. On the other arrow, systemic therapy via an oral or parenteral route of drug administration involves numerous drawbacks, including first-pass hepatic metabolism, hepatotoxicity, gastrointestinal disturbances, needle pain and phobia, and requirement of healthcare professional to administer the drug. To overcome these limitations, researchers devised a microneedle-based drug delivery system for treating mild-to-moderate and moderate-to-severe psoriasis. A single microneedle system can deliver the anti-psoriatic drugs either locally (topical) or systemically (transdermal) by adjusting the needle height without involving any pain. In this contemplate, the current review provides concise information on the pathophysiology, risk factors, and comorbidities of psoriasis, followed by their current treatment approaches and limitations. Further, it meticulously discusses the potential of microneedles in psoriasis therapy and diagnosis, along with descriptions of their patents and clinical trials.

A consensus-based approach on the management of patients with both psoriasis and psoriatic arthritis in the dermatological and rheumatological settings in Italy: The ADOI PSO-Amore Project

Psoriasis is a complex disease often needing a multidisciplinary approach. In particular, the collaboration between dermatologist and rheumatologist is crucial for the management of patients suffering from both psoriasis (PSO) and psoriatic arthritis (PsA). Here we report a series of recommendations from a group of experts, as a result of a Consensus Conference, defining the circumstances in which it is preferable or even mandatory, depending on the available settings, to rely on the opinion of the two specialists, jointly or in a deferred manner. Indications are given on how to organize a 3^rd level joint Dermatology- Rheumatology care unit, in connection with 1^st and 2^nd level clinicians of both specialties, GPs, and other specialists involved in the management of psoriasis. A potential patient journey is suggested, that can be used as a basis for future design and validation of national and/or local diagnostic therapeutic and assistance pathways.

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.

Human Mesenchymal Stem/Stromal Cells in Immune Regulation and Therapy

Studies of mesenchymal stem (or stromal) cells (MSCs) have moved from bedside to bench and back again. The stromal cells or fibroblasts are found in all tissues and participate in building the extracellular matrix (ECM). Bone marrow (BM)-derived MSCs have been studied for more than 50 years and have multiple roles. They function as stem cells and give rise to bone, cartilage, and fat in the BM (these are stem cells); support hematopoiesis (pericytes); and participate in sensing environmental changes and balancing pro- and anti-inflammatory conditions. In disease states, they migrate to sites of injury and release cytokines, hormones, nucleic acids depending on the microenvironment they find. Clinicians have begun to exploit these properties of BM, adipose tissue, and umbilical cord MSCs because they are easy to harvest and expand in culture. In this review, I describe the uses to which MSCs have been put, list ongoing clinical trials by organ system, and outline how MSCs are thought to regulate the innate and adaptive immune systems. I will discuss some of the reasons why clinical applications are still lacking. Much more work will have to be done to find the sources, doses, and culture conditions needed to exploit MSCs optimally and learn their healing potential. They are worth the effort.

Reconstruction Algorithm-Based Computed Tomography Image Feature for Evaluating the Effect of Internal Administration and Medicated Bath of Liangxue Xiaoyin Decoction on Psoriasis Vulgaris

Skin computed tomography (CT) image based on improved marching cubes (MC) algorithm was explored to evaluate the therapeutic effect of internal administration of Liangxue Xiaoyin decoction combined with medicated bath in the treatment of psoriasis vulgaris. 712 patients with psoriasis vulgaris blood heat syndrome in hospital were recruited as the research object, which were randomly divided into observation group (TCM oral therapy combined with medicinal bath) and control group (TCM oral therapy), each with 356 cases. Psoriasis area and severity index (PASI), pruritus degree, and clinical treatment effect were compared. The results showed that the reconstruction time of median method was greatly shorter, and the algorithm efficiency was improved by 40.6290%. After treatment, the psoriasis area and severity index (PASI) score of the observation group was 5.61 ± 1.15, ΔPASI = (22.64 ± 2.15). ΔPASI% = 80.14%, which were greatly higher than the control group ((9.41 + 1.56) points, ΔPASI = (18.84 + 1.65) points, ΔPASI% = 66.69%) (P < 0.05). After treatment, the itching degree of the observation group was 3.03 ± 1.01 points, which was lower than that of the control group ((3.71 ± 1.06) points), and the itching degree of the observation group was greater than that of the control group, with substantial difference (P < 0.05). The total effective rate of observation group (88.76%) was higher than that of control group (71.07%) (P < 0.05). Therefore, skin CT image based on the improved MC algorithm can evaluate the therapeutic effect of internal administration of Liangxue Xiaoyin decoction combined with medicated bath in the treatment of psoriasis vulgaris. The internal administration of Liangxue Xiaoyin decoction combined with medicated bath had a good effect on the treatment of psoriasis vulgaris and was of certain clinical application value.

Three-Dimensional Skin CT Based on Intelligent Algorithm in the Analysis of Skin Lesion Sites Features in Children with Psoriasis

This research was to explore the application value of three-dimensional computed tomography (CT) based on artificial intelligent algorithm in analyzing the characteristics of skin lesions in children with psoriasis. In this study, 15 children with psoriasis were selected as the observation group, and 15 children with other skin diseases were selected as the control group. The CT images were optimized, and the feature selection was carried out based on artificial intelligent algorithm. Firstly, the results were compared with the results of simple skin three-dimensional CT to determine the effectiveness. Then, the two groups of three-dimensional skin CT image features of skin psoriasis-like hyperplasia, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium based on intelligent algorithms were compared. After comparison, the detection rate of psoriasis-like hyperplasia, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium in the observation group was higher than that in the control group, with significant difference and statistical significance (P < 0.05). In addition, the sensitivity of psoriasis-like hyperplasia, Munro microabscess, dermal papilla vascular dilatation, and squamous epithelium in children with psoriasis was 80.0%, 86.7%, 80.0%, and 93.3%, respectively. The specificity of psoriasis-like hyperplasia, Munro microabscess, dermal papilla vascular dilatation, and squamous epithelium in children with psoriasis was 86.7%, 93.3%, 60.0%, and 73.3%, respectively. The results showed that Munro microabscess and psoriasis-like hyperplasia had high sensitivity and specificity in all diagnostic items, which could be used as important features of skin lesion sites in the diagnosis of psoriasis in children. The research provides a basis for the clinical diagnosis of psoriasis in children, which is worthy of clinical promotion.

The Digital Way to Intercept Psoriatic Arthritis

Psoriasis (PsO) and Psoriatic Arthritis (PsA) are chronic, immune-mediated diseases that share common etiopathogenetic pathways. Up to 30% of PsO patient may later develop PsA. In nearly 75% of cases, skin psoriatic lesions precede arthritic symptoms, typically 10 years prior to the onset of joint symptoms, while PsO diagnosis occurring after the onset of arthritis is described only in 15% of cases. Therefore, skin involvement offers to the rheumatologist a unique opportunity to study PsA in a very early phase, having a cohort of psoriatic “risk patients” that may develop the disease and may benefit from preventive treatment. Progression from PsO to PsA is often characterized by non-specific musculoskeletal symptoms, subclinical synovio-entheseal inflammation, and occasionally asymptomatic digital swelling such as painless toe dactylitis, that frequently go unnoticed, leading to diagnostic delay. The early diagnosis of PsA is crucial for initiating a treatment prior the development of significant and permanent joint damage. With the ongoing development of pharmacological treatments, early interception of PsA has become a priority, but many obstacles have been reported in daily routine. The introduction of digital technology in rheumatology may fill the gap in the physician-patient relationship, allowing more targeted monitoring of PsO patients. Digital technology includes telemedicine, virtual visits, electronic health record, wearable technology, mobile health, artificial intelligence, and machine learning. Overall, this digital revolution could lead to earlier PsA diagnosis, improved follow-up and disease control as well as maximizing the referral capacity of rheumatic centers.

Cutaneous and Systemic Psoriasis: Classifications and Classification for the Distinction

Psoriasis is a chronic multisystem inflammatory disease that affects ~0.1–1.5% of the world population. The classic cutaneous manifestation of psoriasis is scaly erythematous plaques, limited or widely distributed. Moreover, psoriasis could be associated with comorbidities like psoriatic arthritis, metabolic syndrome, diabetes, cardiovascular disease, nephropathy, bowel disease, and brain diseases. In this review, we suggest that psoriasis should be classified as cutaneous psoriasis or systemic psoriasis and propose the classification for distinction. This would help to better understand and manage psoriasis.

Analytical approaches to assess metabolic changes in psoriasis

Psoriasis is one of the most common human skin diseases, although its development is not limited to one tissue, but is associated with autoimmune reactions throughout the body. Overproduction of pro-inflammatory cytokines and growth factors systemically stimulates the proliferation of skin cells, which manifests as excessive exfoliation of the epidermis, and/or arthritis, as well as other comorbidities such as insulin resistance, metabolic syndrome, hypertension, and depression. Thus, there is a great need for a thorough analysis of the pathophysiology of psoriatic patients, including classical methods, such as spectrophotometry, chromatography, or Western blot, and also novel omics approaches such as lipidomics and proteomics. Moreover, the extensive pathophysiology forces increased research examining biological changes in both skin cells, and systemically. A wide range of techniques involved in lipidomic research based on a combination of mass spectrometry and different types of chromatography (RP-LC-QTOF-MS/MS, HILIC-QTOF-MS/MS or RP-LC-QTRAP-MS/MS), have allowed comprehensive assessment of lipid modification in psoriatic skin and provided new insight into the role of lipids and their mechanism of action in psoriasis. Moreover, proteomic analysis using gel-nanoLC-OrbiTrap-MS/MS, as well as MALDI-TOF/TOF techniques facilitates the description of panels of enzymes involved in lipidome modifications, and the response of the endocannabinoid system to metabolic changes. Psoriasis is known to alter the expression of proteins that are involved in the inflammatory and antioxidant response, as well as protein biosynthesis, degradation, as well as cell proliferation and apoptosis. Knowledge of changes in the lipidomic and proteomic profile will not only allow the understanding of psoriasis pathophysiology, but also facilitate proper and early diagnosis and effective pharmacotherapy.

Inhibition of BRD4 inhibits proliferation and promotes apoptosis of psoriatic keratinocytes

Background

Psoriasis is a common chronic recurrent inflammatory skin disease. The pathogenesis of psoriasis, such as other autoimmune diseases, is still unclear, which brings great difficulties to the treatment. This study aimed to investigate the role of bromine domain protein 4 (BRD4) in affecting the psoriatic keratinocytes.

Methods

Imiquimod-induced psoriasis mice model and TNF-α or IL-17A induced HaCAT cells, an experimental model in vitro for psoriasis, were constructed. The pathological skin changes at the back of mice were observed by hematoxylin and eosin (H&E) assay and evaluated by psoriasis area and severity index (PASI). KI67 expression and keratinocyte apoptosis at the skin tissues were, respectively, detected by Immunohistochemical analysis and TUNEL assay. The inflammatory factors in mice serum and culture supernatant were determined by ELISA assay. The related proteins expression of proliferation, apoptosis and MAPK pathway were detected by Western blot analysis.

Results

BRD4 expression was upregulated in injured skin on the back of imiquimod-induced mice and (+)-JQ1 relieved the skin injury by suppressing the inflammation and promoting apoptosis of keratinocytes. Consistently, BRD4 expression was also increased in TNF-α or IL-17A induced HaCAT cells. (+)-JQ1 suppressed the viability and inflammation, and promoted apoptosis of TNF-α or IL-17A induced HaCAT cells. In addition, the MAPK signaling pathway was inhibited by (+)-JQ1 whether in mice or HaCAT cells.

Conclusions

Inhibition of BRD4 inhibited proliferation and inflammation and promoted apoptosis of psoriatic keratinocytes.

Are Patients with Psoriasis and Psoriatic Arthritis Undertreated? A Population-Based Study from Southern Italy

This study aimed to explore the pattern of use of different treatment lines in psoriasis (PsO) and psoriatic arthritis (PsA) patients from Southern Italy. A retrospective cohort study was performed during the years 2010–2018 using data from the Caserta Local Health Unit (LHU) claims database. All of the PsO or PsA patients were identified. The proportion of PsO/PsA patients untreated or treated with ≥1 drug classes (i.e., non-disease-modifying antirheumatic drugs (non-DMARDs), conventional synthetic DMARDs (csDMARDs), biological drugs (bDMARDs) or targeted synthetic small molecules (tsDMARDs)) was calculated in the years 2016–2018. Among the bDMARD users, the median times from the first registered PsO/PsA diagnosis/from the first csDMARD to the first bDMARD were calculated. Overall, 10,296 (1.1%) and 1724 (0.2%) PsO and PsA patients were identified. More than half of the PsO patients (N = 5301; 51.6%) and 15% of the PsA patients (N = 251) were not treated with any drug. A very low proportion of PsO patients (N = 121; 1.2%) received csDMARDs/bDMARDs dispensing. Instead, 538 (32.2%) PsA patients were treated with bDMARDs. The median times from the first diagnosis to the first bDMARD dispensing were 54.0 (Q1–Q3: 30.5–72.2) and 13.3 (Q1–Q3: 3.1–43.9) months in the PsO and PsA patients, respectively. The median time from the first csDMARD to the first bDMARD dispensing was shorter in the PsO [9.2 months (Q1–Q3: 5.5–30.0)] than in the PsA [14.5 months (Q1–Q3: 8.6–33.5)] patients. A potential undertreatment of PsO (much less for PsA) in an LHU from Southern Italy, with a particularly low use of more recently marketed drugs, such as biological ones, was shown.

Systematic literature review of long-term efficacy data for topical psoriasis treatments

OBJECTIVE

To identify long-term efficacy evidence that supports use of topical therapies as regular maintenance therapy in the prevention of psoriasis relapse.

METHODS

A systematic literature review identified clinical trials and observational studies that reported efficacy outcomes for topical psoriasis therapies with treatment durations of at least 12 weeks. For therapies with long-term data, the approved treatment schedules in product labels were reviewed.

RESULTS

Forty-six studies with at least 12-week efficacy outcomes were identified. Eight randomized controlled trials and six observational studies or single-arm open-label studies reported efficacy data for >12-week treatment periods. Most studies used treatment regimens that reflect current standard of care of repeated treatment of relapses. The PSO-LONG study is the only identified randomized controlled trial to have compared regular proactive maintenance use of a topical treatment (calcipotriol/betamethasone foam) with reactive management in response to psoriasis relapses.

CONCLUSIONS

Limited high-quality long-term efficacy data are available for topical psoriasis therapies. While some product labels mention clinical experience of up to 12 months, they do not provide specific recommendations on the optimal long-term regimen. Calcipotriol/betamethasone foam is the only treatment for which the approved label allows either reactive treatment of relapse or regular (twice weekly) maintenance use.

Guttate psoriasis: a case of unusual evolution of an occupation-related skin chemical burns

Introduction:

Chemical burns are a risk in domestic and occupational accidents due to the common use of caustic agents. Long-term sequelae are normally due to the amount of skin and underlying tissues damaged. We describe a case of work-related chemical burns with unusual evolution in guttate psoriasis.

Case Report:

A 36 years-old man was admitted to the Emergency Department (ED) three-hours after a work accident. During the cleaning of an industrial hydraulic system, a jet of hydrochloric acid 20% injured his face and upper limbs. At ED admission, he presented first and second-degree skin burns on the frontal region, on the scalp, on the right forearm, and earlobe. Plastic surgery management consisted in wound topical dressing with silver sulfadiazine and paraffin gauze twice a week for one month. Forty-eight hours after the latter topical treatment (45-days after the work accident), in the same anatomical regions of the previous burn scars, he developed a skin reaction with itchy erythema. The application of topical products was suspended without improvement, excluding an allergic reaction. Within few days, a generalized guttate psoriasis was evident on the whole body.

Discussion:

Despite many prevention actions, work-related burns are a relatively common cause of hospitalization and may involve up to 80% of patients admitted to a burn unit. Guttate psoriasis has not been described as a sequelae of chemical burns. In our case, the others most frequent factors causing guttate psoriasis have been ruled out. Considering the temporal link between the development of guttate psoriasis and the work accident, hydrochloric acid skin burns might have promoted the systemic inflammatory mediators’ mechanism involved in the development of guttate psoriasis lesion’s after the dermal injury.

Effect of Very-Low-Calorie Ketogenic Diet on Psoriasis Patients: A Nuclear Magnetic Resonance-Based Metabolomic Study

Psoriasis is an inflammatory disease of the epidermis based on an immunological mechanism involving Langerhans cells and T lymphocytes that produce pro-inflammatory cytokines. Genetic factors, environmental factors, and improper nutrition are considered triggers of the disease. Numerous studies have reported that in a high number of patients, psoriasis is associated with obesity. Excess adipose tissue, typical of obesity, causes a systemic inflammatory status coming from the inflammatory active adipose tissue; therefore, weight reduction is a strategy to fight this pro-inflammatory state. This study aimed to evaluate how a nutritional regimen based on a ketogenic diet influenced the clinical parameters, metabolic profile, and inflammatory state of psoriasis patients. To this end, 30 psoriasis patients were subjected to a ketogenic nutritional regimen and monitored for 4 weeks by evaluating the clinical data, biochemical and clinical parameters, NMR metabolomic profile, and IL-2, IL-1β, TNF-α, IFN-γ, and IL-4 concentrations before and after the nutritional regimen. Our data show that a low-calorie ketogenic diet can be considered a successful strategy and therapeutic option to gain an improvement in psoriasis-related dysmetabolism, with significant correction of the full metabolic and inflammatory status.

Topical Application of Mesenchymal Stem Cell Exosomes Alleviates the Imiquimod Induced Psoriasis-Like Inflammation

Severe psoriasis, a chronic inflammatory skin disease is increasingly being effectively managed by targeted immunotherapy but long-term immunotherapy poses health risk and loss of response. Therefore, there is a need for alternative therapy strategies. Mesenchymal stem/stromal cell (MSC) exosomes are widely known for their potent immunomodulatory properties. Here we investigated if topically applied MSC exosomes could alleviate psoriasis-associated inflammation. Topically applied fluorescent exosomes on human skin explants were confined primarily to the stratum corneum with <1% input fluorescence exiting the explant over a 24-h period. Nevertheless, topically applied MSC exosomes in a mouse model of imiquimod (IMQ) psoriasis significantly reduced IL-17 and terminal complement activation complex C5b-9 in the mouse skin. MSC exosomes were previously shown to inhibit complement activation, specifically C5b-9 complex formation through CD59. Infiltration of neutrophils into the stratum corneum is characteristic of psoriasis and neutrophils are a major cellular source of IL-17 in psoriasis through the release of neutrophil extracellular traps (NETs). We propose that topically applied MSC exosomes inhibit complement activation in the stratum corneum and this alleviates IL-17 release by NETS from neutrophils that accumulate in and beneath the stratum corneum.

Efficacy of psychological intervention for patients with psoriasis vulgaris: a prospective study

Objective

The study aim was to examine the effect of a psychological intervention on patients with psoriasis vulgaris.

Methods

Participants in this prospective study were 205 patients with psoriasis vulgaris, 104 who received a psychological intervention (study group) and 101 who received routine nursing care (control group). An additional 291 healthy subjects formed a non-psoriasis group. The Symptom Checklist-90 (SCL-90), Generic Quality of Life Inventory (GQOLI), Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) were used to evaluate psychological status and quality of life.

Results

There were significant differences in SCL-90 and GQOLI scores between the study and non-psoriasis groups. After treatment, the study group showed significantly improved scores on the SCL-90 and GQOLI compared with the control group. Scores on the SDS (mean ± standard deviation: 31.99 ± 4.54 vs. 44.08 ± 4.52) and SAS (28.36 ± 4.52 vs. 40.14 ± 6.33) were improved in the study group. In addition, patients in the study group showed higher satisfaction rate and compliance rate than those in the control group.

Conclusion

Psychological intervention may be beneficial for improving quality of life and the therapeutic efficacy of drugs in patients with psoriasis.

Discovering novel hub genes and pathways associated with the pathogenesis of psoriasis

In-depth analysis on the rambling genes of psoriasis may help to identify the pathologic mechanism of this disease. However, this has seldom been performed. Using bioinformatic approaches, we analyzed four gene expression profiles in gene expression omnibus (GEO) database, identified the differentially expressed genes (DEGs), and found out the overlapping DEGs (common DEGs, CDEGs) in the above four profiles. The CDEGs were further subjected to Gene Ontology (GO) enrichment analysis, Kyoto encyclopedia of genes and genomes (KEGG) pathway analysis and protein-protein interaction (PPI) network analysis, and hub genes were ranked. We identified 139 CDEGs associated with a variety of GO processes including keratinization, immune and inflammatory responses, and type 1 interferon signaling pathway. These CDEGs were enriched in a variety of KEGG processes, including cytokine-cytokine receptor interaction and chemokine signaling. PPI analysis showed that seven genes (HERC6, ISG15, MX1, RSAD2, OAS2, OASL, and OAS3) were likely the novel hub genes of psoriasis. RT-qPCR identified that five (ISG15, MX1, OAS2, OASL, and OAS3) of the seven predicted hub genes were overexpressed in TNF-α stimulated HaCaT cell lines, a result quite consistent with the predictions. The study provides new information in exploring the mechanisms and therapeutic targets of psoriasis.

Pharmacotherapy and inappropriate prescriptions in patients with psoriasis

Background Psoriasis is a chronic inflammatory and systemic disease that primarily affects the skin, nails, and joints. Some medications have been linked to worsening clinical manifestations of cutaneous psoriasis. Objective To identify pharmacological treatments and drugs related to worsening dermatological lesions in patients with psoriasis. Setting Patients diagnosed with psoriasis or psoriatic arthritis between November 1, 2018, and October 30, 2019. Methods This was a cross-sectional study from a population database that identified the prescriptions of patients with psoriasis during 2019. All medications prescribed for the treatment of psoriasis and other comorbidities were investigated. Main outcome measure Potentially inappropriate medications. Results We identified 2088 patients with psoriasis, with a mean age of 53.6 ± 15.5 years, and 52.9% were men. A total of 92.6% received pharmacological treatment, and of these, topical corticosteroids were the most commonly used group (76.6%). A total of 55.3% of patients with cutaneous psoriasis received at least one drug associated with worsening dermatological lesions. The most frequent were naproxen (25.5%), diclofenac (14.7%), and dexamethasone (10.8%). Residing in Barranquilla (odds ratio 1.27, 95%confidence interval 1.009-1.607), having any chronic comorbidities (odds ratio 1.94, 95%confidence interval 1.566-2.402), and having a history of coronary heart disease (odds ratio 6.25, 95%confidence interval 1.895-20.645) increased the probability of receiving these prescriptions. Conclusions The pharmacological treatment of psoriasis was in accordance with the recommendations of the clinical practice guidelines, but the high proportion of potentially inappropriate prescriptions makes it necessary to promote educational and pharmacovigilance strategies that improve the formulation habits of the physicians involved in the treatment of these patients.

Inverse Psoriasis: From Diagnosis to Current Treatment Options

Inverse psoriasis represents a clinical variant of psoriasis that is sometimes difficult to diagnose due to its clinical similarity with other skin disorders involving the folds, mainly including mechanical intertrigo, fungal and bacterial infections, contact dermatitis, seborrheic dermatitis, and lichen planus. Dermoscopy represents a useful tool for an enhanced non-invasive diagnosis. The treatment of inverse psoriasis may be challenging and include topical corticosteroids, topical calcineurin inhibitors, vitamin D analogs, traditional oral systemic therapies such as cyclosporine and methotrexate, and biologic therapies.

Expressive Suppression and Negative Affect, Pathways of Emotional Dysregulation in Psoriasis Patients

The main goal of this study was to assess the emotion regulation (ER) mechanisms, such as expressive suppression and cognitive reappraisal, in patients with psoriasis, as compared with healthy persons not afflicted by dermatological diseases. Moreover, the study intended to carry on a multidimensional assessment of emotional mechanisms in persons with psoriasis, highlighting the differences between psoriasis patients and healthy participants, in order to identify the specific patterns of emotion dysregulation (ED) in psoriasis. Another goal of the study was to investigate the predictors of ED among different emotional patterns. We presumed that the maladaptive ER mechanisms are higher in psoriasis patients than in the control group and there are specific dysregulation patterns in psoriasis patients as negative emotions tendency. This cross-sectional study was performed on 192 individuals aged between 35 and 75 years (mean age 59). The sample was divided in two groups: the clinical group including 91 patients with a diagnosis of psoriasis vulgaris and the control group including 101 healthy persons. The results of the present study suggest that psoriasis patients more frequently used emotional suppression - a maladaptive ER mechanism - as well as ED patterns - i.e., impulse control difficulties, and nonacceptance of emotional responses. They also displayed trait tendency to a negative emotional response. In fact, in people with psoriasis, the presence of suppression mechanism and negative affect of trait could predict that 35% of patients will show emotional dysregulated patterns, while living with higher levels of ED. The results of our study are important in the clinical practice, helping clinicians to better understand the emotional vulnerability of people that live with psoriatic disease, and to optimize the disease management and patient care in an interdisciplinary approach.

Acute onset of psoriatic spondyloarthritis as a new manifestation of post-streptococcal reactive arthritis: a case series

Streptococcus is well associated with a myriad of inflammatory diseases. Among others, this bacterium is linked to the triggering of psoriasis and to post-streptococcal reactive arthritis (PSRA), an arthritis which is typically confined to peripheral joints. Three patients who developed acute psoriatic spondyloarthritis (SpA) following a recent streptococcal infection are described in this article. We searched the existing literature for cases of axial involvement in PSRA and reviewed the association between streptococcal infection and psoriasis or psoriatic arthritis )PsA). In all patients, psoriatic SpA occurred within 7-10 days of a confirmed streptococcal infection. The main presenting syndrome was inflammatory back pain with evidence of acute axial spondyloarthritis on magnetic resonance imaging. One patient had guttate psoriasis, the second patient developed pustular psoriasis, and the third patient had exacerbation of pustular palmoplantar psoriasis. Two patients required treatment with tumor necrosis factor alpha (TNF-α) blockers. Axial involvement in PSRA is very rare. A potential association of streptococcal infection and development of PsA has been explored in several articles. However, to the best of our knowledge, acute psoriatic SpA as a manifestation of PSRA has yet to be described. Acute psoriatic SpA should be considered in the differential diagnosis of new-onset inflammatory back pain followed by psoriasis in young adults who had a recent throat infection. KEY POINTS: • Our case series describes three cases of acute psoriatic spondyloarthritis that occurred within 7--10 days of a confirmed streptococcal infection and progressed to full blown chronic disease. • Acute psoriatic spondyloarthritis as a manifestation of post streptococcal reactive arthritis should be considered in the differential diagnosis of new onset inflammatory back pain followed by psoriasis in young adults who had a recent throat infection.