Efficacy of guselkumab in difficult-to-treat psoriasis regions: Data from VOYAGE 1 and VOYAGE 2 Asian subpopulations

Patients with psoriasis were randomized to guselkumab, placebo or adalimumab in the VOYAGE 1 and VOYAGE 2 studies. In this post hoc analysis, difficult-to-treat psoriasis regions in the Asian subpopulation for both the guselkumab and adalimumab groups were compared with placebo at week 16 and the active treatment groups were compared at week 24. Endpoints included patients achieving scores of 0 or 1 (clear or near clear) or 0 (clear) on the scalp-specific Investigator's Global Assessment (ss-IGA), Physician's Global Assessment of the hands and/or feet (hf-PGA), and fingernail PGA (f-PGA), and percentage improvement in target Nail Psoriasis Severity Index (NAPSI) score through week 24. Efficacy was also assessed by prior biologic experience at baseline. A total of 199 eligible Asian patients were included. The proportion of patients achieving "clear" or "near clear" with guselkumab was superior to adalimumab at week 24 for scalp psoriasis ss-IGA (Asian patients, 72 [85.7%] vs 35 [67.3%], P = 0.004), hands and/or feet psoriasis hf-PGA (29 [82.9%] vs 16 [61.5%], P = 0.054), and similar for fingernail psoriasis f-PGA (28 [63.6%] vs 17 [54.8%], P = 0.412). Guselkumab mean improvements in NAPSI were comparable to adalimumab (39.9% vs 35.9%, P = 0.618). Overall, the complete clearance response of scalp, and hands and/or feet at week 24 occurred in a greater proportion of patients in the guselkumab group, irrespective of baseline biologic status (treatment-naïve or treatment-experienced). Guselkumab was superior to adalimumab for the treatment of scalp, and hands and/or feet psoriasis, and proportionally higher for fingernail psoriasis. Findings were comparable to the global study population.

Pustular psoriasis in Malaysia: A review of the Malaysian Psoriasis Registry 2007-2018

Pustular psoriasis (PP) is an uncommon subtype of psoriasis with distinct genetic features and clinical phenotypes. Patients with PP tend to experience frequent flares and significant morbidity. This study aims to determine the clinical characteristics, co-morbidities and treatment of PP patients in Malaysia. This was a cross-sectional study of patients with PP notified to the Malaysian Psoriasis Registry (MPR) between January 2007 and December 2018. Of 21 735 psoriasis patients, 148 (0.7%) had pustular psoriasis. Of these, 93 (62.8%) were diagnosed with generalized pustular psoriasis (GPP) and 55 (37.2%) with localized PP (LPP). The mean age for pustular psoriasis onset was 31.71 ± 18.33 years with a male to female ratio of 1:2.1. Patients with PP were more likely to have dyslipidaemia (23.6% vs. 16.5%, p = 0.022), severe disease (Body surface area >10 and/or Dermatology Life Quality Index [DLQI] >10) (64.8% vs. 50%, p = 0.003) and require systemic therapy (51.4% vs. 13.9%, p < 0.001) compared to non-PP patients. Patients with PP also suffered greater impairment to their quality of life (DLQI >10, 48.9% vs. 40.3%, p = 0.046), had more days off school/work (2.06 ± 6.09 vs. 0.5 ± 4.91, p = 0.004) and a higher mean number of hospitalizations (0.31 ± 0.95 vs. 0.05 ± 1.22, p = 0.001) in 6 months compared to non-PP patients. Overall, 0.7% of psoriasis patients in the MPR had pustular psoriasis. Patients with PP had a higher rate of dyslipidaemia, severe disease, greater impairment of quality of life and systemic therapy usage compared to other psoriasis subtypes.

Updates in treatment and impact of nail psoriasis

INTRODUCTION

Nail psoriasis is an inflammatory disorder without a potential scarring outcome, but the nail signs, even the milder ones, can cause discomfort to patients and severely affect their quality of life. Nail psoriasis may be associated with psoriatic arthritis and when it starts during infancy, it may be a predictor of a more severe disease course in adulthood. All these issues contribute to the high economic burden of psoriasis.

AREAS COVERED

Nail psoriasis is notoriously difficult to treat, even though new treatments are in continuous development. This paper provides an update on new treatments and address the current gaps in care of nail psoriasis.

EXPERT OPINION

A better understanding of the disease pathogenesis and more 'real-life' studies will definitely be helpful to improve treatment results. A lower level of heterogeneity should be advisable among trials when evaluating nail psoriasis. Moreover, the relationship between nail psoriasis and psoriatic arthritis should be the focus of unbiased studies in order to better define the real risk that nail psoriasis patients have to develop arthritis.

Treatment of nail psoriasis with pulsed dye laser versus combined pulsed dye and Nd:YAG lasers-An intrapatient left-to-right study

BACKGROUND AND OBJECTIVES

There are limited treatment options for nail psoriasis. It is important to find new therapies and improve existing ones. The aim of this study was to compare the effectiveness of pulsed dye laser (PDL) versus combined PDL and Nd:YAG lasers in patients with nail psoriasis.

METHODS

Fourteen patients (with a total of 126 nails affected by nail psoriasis) were treated with PDL (6 J/cm2, 7 mm, 0.45 milliseconds) on both hands and additionally with Nd:YAG (10 J/cm² , 6 mm, 15 milliseconds) on the right hand. Three treatment sessions were applied at 4-week intervals and patients were followed up for 6 months after the last session. Disease severity was assessed using the Nail Psoriasis Severity Index, both 8- and 32-point variant. Additionally, Dermatology Life Quality Index was assessed before and after treatment.

RESULTS

Overall, there was a statistical difference in 8- and 32-point NAPSI score before and after treatment for both hands. However, there was no statistical difference between the score for the right and left hands based on both scale variants. Some aspects of patients' lives showed improvement due to the treatment.

CONCLUSIONS

Both PDL in monotherapy and combined Nd:Yag+PDL lasers are safe and effective in treatment of nail psoriasis, although combined therapy shows no advantage over the use of a single laser.

Concepts, Role, and Advances on Nail Imaging

This review discusses, from a practical point of view, the most common imaging techniques and their applications in nail pathologies with some technical considerations. There are several imaging techniques for studying the nail, and all of them require proper devices and trained operators. The highest axial resolution and a more extensive range of applications are provided by ultrasound, which currently is the first-choice imaging technique for evaluating nail conditions. A correlation of state-of-the-art clinical and imaging figures supports the review of this topic.

Toenail Psoriasis during Ustekinumab Therapy: Results and Limitations

Background

Nail psoriasis is a common clinically significant symptom of psoriasis. However, few studies have focused on the characteristics and course of toenail psoriasis.

Objective

To investigate the treatment response of toenail psoriasis during a 52-week period of ustekinumab use.

Methods

Patients were evaluated using the Nail Psoriasis Severity Index (NAPSI) at every injection visit. NAPSI score changes throughout the treatment were analyzed. The treatment response in each toenail and each NAPSI characteristic was also analyzed.

Results

A total of 22 patients with chronic plaque psoriasis with concomitant toenail psoriasis were examined. Several characteristics such as ridging or onychomycosis that mimic psoriasis or hinder the evaluation were identified. NAPSI significantly improved during the treatment (p<0.05). The big and second toes were significantly improved after 52 weeks of ustekinumab treatment (p<0.05). Pitting and oil-drop discoloration were the only two characteristics that showed significant changes post-treatment (p<0.05).

Conclusion

Ustekinumab proved to be efficacious in treating toenail psoriasis. Because of the factors that hinder the NAPSI scoring, only NAPSI scores of the first and second toes can be used.

Nail Dystrophy in Patients with Atopic Dermatitis and Its Association with Disease Severity

Background

Nail dystrophy arises from various inflammatory dermatologic diseases. However, there have been few reports on the prevalence of nail abnormality in atopic dermatitis (AD) or on the relationship of this condition with the severity of the disease.

Objective

This study was intended to determine the prevalence and types of nail abnormalities associated with AD and to evaluate the relation between nail abnormalities and the severity of AD.

Methods

AD patients aged 2 to 19 who visited the outpatient clinic were thoroughly examined for nail abnormalities. Demographic information was collected and eczema area and severity index (EASI) score for severity of AD were checked.

Results

A total of 235 AD patients (children and adolescents) were investigated. There were 24 (10.2%) patients with nail abnormalities: transverse groove (Beau's line) (25.0%), nail pitting (16.7%), koilonychia (16.7%), trachyonychia (12.5%), leukonychia (12.5%), brachyonychia (8.3%), melanonychia (8.3%), onychomadesis (8.3%), onychoschizia (8.3%), and onycholysis (8.3%). There was no statistically significant difference in the total EASI score associated with development of nail abnormalities (p=0.236). However, when the EASI score was confined to the lower extremities, it showed a relation to the prevalence of toe nail dystrophy (odds ratio, 1.115; 95% confidence interval, 1.014~1.316; p=0.030).

Conclusion

Nail abnormalities in AD are thought to be caused mainly by pathologic change in the nail matrix region, and the EASI score confined to lower limbs, might be used as a predictor of toe nail changes in patients with AD.

Differential efficacy of biologic treatments targeting the TNF-α/IL-23/IL-17 axis in psoriasis and psoriatic arthritis

Psoriasis and psoriatic arthritis cause significant physical and psychological burdens for afflicted individuals. An accelerated TNF-α/IL-23/IL-17 axis is their major pathomechanism; therefore, anti-TNF-α/IL-23/IL-17 biologics are very effective for the treatment of skin and joint lesions in psoriasis and psoriatic arthritis. Given that the IL-17 signature is more upregulated in the skin than in synovium in psoriatic arthritis, anti-IL-23/IL-17 agents seem to be superior to anti-TNF-α remedies in the treatment of skin lesions. In this review, we focus on the differential efficacy of anti-TNF-α/IL-23/IL-17 biologics in psoriasis and psoriatic arthritis.

Autoimmunity and autoimmune co-morbidities in psoriasis

Psoriasis is characterized by widespread scaly erythematous plaques that cause significant physical and psychological burdens for the affected individuals. Accelerated inflammation driven by the tumour necrosis factor-α/interleukin-23/interleukin-17 axis is now known to be the major mechanism in the development of psoriasis. In addition, psoriasis has an autoimmune nature that manifests as autoreactive T cells and is co-morbid with other autoimmune diseases, such as autoimmune bullous diseases, vitiligo, alopecia and thyroiditis. In this article, we review the recent topics on autoimmunity and autoimmune co-morbidities in psoriasis.