Does psychosocial stress play a role in the exacerbation of psoriasis?

Refugee healthcare: managing a chronic inflammatory skin condition through wartime and displacement

Refugee healthcare is largely emergency driven. However, chronic conditions are also common and managing these on the move is enormously challenging. Loss of access to medication, disruption of treatment, missing or incomplete medical records and psychological distress all contribute to poorer long-term outcomes. Europe is currently experiencing an unprecedented influx of refugees, asylum seekers and other migrants. With escalating conflict globally this number will continue to increase. It is essential that we as healthcare professionals in all specialties, including dermatology, appreciate the often arduous journey displaced people face to sit in front of us and that we are equipped to meet their needs.

Automated Machine Learning Predicts Necessary Upcoming Therapy Changes in Patients With Psoriasis Vulgaris et Arthritis And Uncovers New Influences On Disease Progression: Retrospective Study

BACKGROUND

Psoriasis vulgaris (PsV) and Psoriatic arthritis (PsA) are intertwined multifactorial diseases with significant impact on health and quality of life, which can be debilitating due to chronicity and treatment complexity. Predicting treatment response and disease progression in these conditions is challenging, but crucial for optimising therapeutic interventions. The advancing technology of automated machine learning (AutoML) holds great promise for rapidly building highly accurate predictive models based on patient features and treatment data.

OBJECTIVE

The study aimed to develop highly accurate ML models using AutoML to address key clinical questions in PsV and PsA patients, including predicting therapy changes and identifying reasons for therapy changes, factors influencing skin lesion progression or factors associated with an abnormal BASDAI score.

METHODS

After extensive dataset preparation of clinical study data from 309 PsV and PsA patients, a secondary dataset was created and ultimately analysed using AutoML to build a variety of predictive models and select the most accurate one for each variable of interest.

RESULTS

"Therapy change at 24 weeks follow-up" was modelled using the eXtreme Gradient Boosted Trees Classifier with Early Stopping model (AUC of 0.9078 and LogLoss of 0.3955 for the holdout partition) to gain insight into the factors influencing therapy change, such as the initial systemic therapeutic agent, the score achieved in the CASPAR classification criteria at baseline, and changes in quality of life. An AVG blender of 3 models (Gradient Boosted Trees Classifier, ExtraTrees Classifier, Eureqa Generalised Additive Model Classifier) with an AUC of 0.8750 and a LogLoss of 0.4603 was used to predict therapy changes on two hypothetical patients to highlight the importance of such influencing factors. Notably, treatments such as MTX or specific biologicals showed a lower propensity for change. A further AVG Blender of RandomForest Classifier, eXtreme Gradient Boosted Trees Classifier and Eureqa Classifier (AUC of 0.9241 and LogLoss of 0.4498) was then used to estimate "PASI change after 24 weeks" with the primary predictors being the initial PASI score, change in pruritus and change in therapy. A lower initial PASI score, and consistently low pruritus were associated with better outcomes. Finally, "BASDAI classification at baseline" was analysed using an AVG Blender of Eureqa Generalised Additive Model Classifier, eXtreme Gradient Boosted Trees Classifier with Early Stopping and Dropout Additive Regression Trees Classifier with an AUC of 0.8274 and LogLoss of 0.5037. Factors influencing BASDAI scores included initial pain, disease activity and HADS scores for depression and anxiety. Increased pain, disease activity and psychological distress were generally likely to lead to higher BASDAI scores.

CONCLUSIONS

The practical implications of these models for clinical decision making in PsV and PsA have the potential to guide early investigation and treatment, contributing to improved patient outcomes.

CLINICALTRIAL

Etiopathogenesis of Psoriasis: Integration of Proposed Theories

Psoriasis is a chronic inflammatory disease characterized by squamous and erythematous plaques on the skin and the involvement of the immune system. Global prevalence for psoriasis has been reported around 1-3% with a higher incidence in adults and similar proportions between men and women. The risk factors associated with psoriasis are both extrinsic and intrinsic, out of which a polygenic predisposition is a highlight out of the latter. Psoriasis etiology is not yet fully described, but several hypothesis have been proposed: 1) the autoimmunity hypothesis is based on the over-expression of antimicrobial peptides such as LL-37, the proteins ADAMTSL5, K17, and hsp27, or lipids synthesized by the PLA2G4D enzyme, all of which may serve as autoantigens to promote the differentiation of autoreactive lymphocytes T and unleash a chronic inflammatory response; 2) dysbiosis of skin microbiota hypothesis in psoriasis has gained relevance due to the observations of a loss of diversity and the participation of pathogenic bacteria such as Streptococcus spp. or Staphylococcus spp. the fungi Malassezia spp. or Candida spp. and the virus HPV, HCV, or HIV in psoriatic plaques; 3) the oxidative stress hypothesis, the most recent one, describes that the cell injury and the release of proinflammatory mediators and antimicrobial peptides that leads to activate of the Th1/Th17 axis observed in psoriasis is caused by a higher release of reactive oxygen species and the imbalance between oxidant and antioxidant mechanisms. This review aims to describe the mechanisms involved in the three hypotheses on the etiopathogeneses of psoriasis.

The skin-brain connection and pleasant touch as supportive care for psychocutaneous disorders

Psychodermatology is a subdiscipline of dermatology at the intersection of dermatology, psychiatry, and psychology. In dermatology clinical practice, patients may present with skin disease that affects their mental health, or skin disorders induced or worsened by psychological/psychiatric problems so there is a need for specialised education of dermatologists, as well as multidisciplinary teams, to achieve better management of these patients. Understanding the interaction between the central nervous system and the skin underlying psychocutaneous disorders could help identify alternative therapies that may improve patient well-being. The concept of pleasurable touch has received increasing attention following the discovery of C-tactile (CT) fibres. While afferent C-fibre stimulation is usually associated with pain, temperature, or itch, CT-fibres are stimulated optimally by a stimulus not in the nociceptor range but by a gentle, low-force stroking. As this affective touch may counteract unpleasurable sensations, such as pain and itch, and elicit positive feelings, the potential benefits of gentle touch and massage are interesting for dermatological, especially psychocutaneous, disorders. Here we provide an overview of the skin-brain connection to help understand the benefits of touch and massage, as illustrated with studies on atopic dermatitis and burns, as an adjunct to dermatological treatment for improving patient well-being and optimising treatment outcomes.

Association of psoriasis with depression, anxiety, and suicidality: A bidirectional two-sample Mendelian randomization study

Psoriasis is a chronic, refractory inflammatory skin disease, with a high prevalence of psychiatric comorbidities, including depression, anxiety, and even suicidality, which may in turn initiate or exacerbate skin inflammation. However, the causal relationships between these comorbidities remain unclear. To investigate the cause-effect relationships between psoriasis and mental disorders including depression, anxiety, and suicidality, we conducted a bidirectional two-sample Mendelian randomization (MR) study utilizing summary statistics from the most comprehensive genome-wide association studies of psoriasis (n = 306 123), broad depression (n = 500 199), major depressive disorder (n = 173 005), anxiety (n = 17 310), and suicide attempts (n = 50 264). Using the random-effects inverse-variance weighted method as primary method, the forward MR analyses indicated that psoriasis was significantly associated with higher odds of broad depression (odds ratio [OR] 1.030, 95% confidence interval [CI] 1.010-1.051, P = 0.003) and suggestively associated with an increased risk of major depressive disorder (OR 1.054, 95% CI 1.002-1.109, P = 0.040), but not with the risk of anxiety (P = 0.160) or suicide attempts (P = 0.648). In reverse MR analyses, significant causal impact of broad depression (OR 1.363, 95% CI 1.103-1.684, P = 0.004) and major depressive disorder (OR 1.890, 95% CI 1.285-2.781, P = 0.001), but not anxiety (P = 0.787) and suicide attempts (P = 0.961) on psoriasis risk was observed. In addition, the results of primary analysis are consistent across sensitivity analyses, albeit the MR-Egger regression model produced wide CIs and negative results in several analyses. In conclusion, this MR study indicates a bidirectional causal relationship between psoriasis and depression that was previously unrecognized, which highlights the significance of screening for depression in psoriasis patients and initiating appropriate interventions. Further studies are required to elucidate the pathophysiology of the bidirectional causal relationship between these two conditions.

Associations between symptoms, modern health worries, and somatosensory amplification in patients with building-related symptoms

OBJECTIVE

The objective of the present study was to investigate the associations between somatosensory amplification, modern health worries (MHWs), and symptoms among patients with building-related symptoms (BRS).

METHODS

Patients with self-reported and medically confirmed BRS (n = 83) were included in this cross-sectional study. The Somatosensory Amplification Scale (SSAS) was used to quantify the tendency to amplify somatic sensations and perceive them as unpleasant and dangerous. Concerns about harmful effects of modern technologies were assessed with the Modern Health Worries Scale (MHWS). Symptoms commonly found in different forms of environmental intolerance were assessed with the Environmental Hypersensitivity Symptom Inventory (EHSI).

RESULTS

Patients with BRS were characterized by more frequent and more severe environmental hypersensitivity symptoms compared to a reference population. Females and those with co-morbid self-reported chemical intolerance reported even more symptoms. MHWS and SSAS scores showed weak to moderate associations with symptoms, even after adjusting for socio-economic variables. However, neither the mean MHWS score or the SSAS score of our sample differed from normative scores.

CONCLUSION

Patients with BRS are not characterized by elevated levels of MHWs and somatosensory amplification, thus other, psychosocial and/or environmental, factors may have contributed to the development of the condition. However, the associations between severity of symptoms and MHWs and somatosensory amplification suggest that psychosocial characteristics may substantially influence symptom experience in this group.

Cutaneous neuropeptides: the missing link between psychological stress and chronic inflammatory skin disease?

A "brain-skin" connection has been long been observed between chronic stress and chronic inflammatory skin disease including urticaria, psoriasis, atopic dermatitis, and prurigo nodularis. The relationship appears to be bidirectional. Chronic psychological stress has been shown to sustain hyperactivity of the sympathetic branch of the autonomic nervous system. Chronic stress is proinflammatory and in the context of several dermatologic disorders may be associated with an increase in dermal nerve fiber density, mast cells, nerve growth factor and calcitonin-gene-related peptide (CGRP). Furthermore, CGRP elicits a TH2-polarized T-cell response that is a hallmark of chronic pruritic conditions such as atopic dermatitis and prurigo nodularis. This TH2 response contributes directly to acute pruritus as well as the sensitization of cutaneous sensory neurons that are critical for chronic pruritus. Prurigo nodularis is a debilitating skin disorder featuring prominent nerve structural, neuropeptide, and TH2 cytokine aberrations that is a model deserving of future study.

[Randomized clinical trial of compression therapy of the lower legs in patients with psoriasis]

BACKGROUND

Psoriatic plaques at the distal lower extremities are notoriously treatment resistant. Medical compression therapy could potentially be a useful supplementary therapeutic measure at this site. However, there is concern that the Koebner phenomenon may cause a worsening of the skin condition. Therefore, the purpose of this study was to investigate the effects of compression therapy on psoriatic plaques in the presence of coexisting edema of the lower legs.

PATIENTS AND METHODS

Compression therapy was performed in addition to standard of care on one lower leg for 4 weeks (half-side test) in patients with psoriatic plaques and edema on both lower legs. The primary endpoint of the study was clinical response of the psoriatic plaques on the lower legs measured with the lesion severity score (LSS) and the locally affected body surface area in a side-by-side comparison at week 4 compared with baseline. Secondary endpoints were related to patient-reported outcomes.

RESULTS

Data from 30 patients were included in the analysis. In the descriptive analysis, the mean LSS results and the subjective pain reported by the patients showed a slightly greater improvement on the compressed lower leg compared with the non-compressed lower leg. None of the patients showed evidence of the Koebner phenomenon induced by compression therapy.

CONCLUSION

This is the first clinical study that systematically investigated the impact of compression therapy on psoriatic plaques. During the study period of 4 weeks, there was no significant improvement in psoriatic plaques; however, there was also no evidence of worsening of the skin condition. Thus, anti-edematous compression therapy can be performed in psoriasis patients without causing complications if basic contraindications are considered.

Optimization of Monobenzone-Induced Vitiligo Mouse Model by the Addition of Chronic Stress

Vitiligo is a common primary, limited or generalized skin depigmentation disorder. Its pathogenesis is complex, multifactorial and unclear. For this reason, few animal models can simulate the onset of vitiligo, and studies of drug interventions are limited. Studies have found that there may be a pathophysiological connection between mental factors and the development of vitiligo. At present, the construction methods of the vitiligo model mainly include chemical induction and autoimmune induction against melanocytes. Mental factors are not taken into account in existing models. Therefore, in this study, mental inducement was added to the monobenzone (MBEH)-induced vitiligo model. We determined that chronic unpredictable mild stress (CUMS) inhibited the melanogenesis of skin. MBEH inhibited melanin production without affecting the behavioral state of mice, but mice in the MBEH combined with CUMS (MC) group were depressed and demonstrated increased depigmentation of the skin. Further analysis of metabolic differences showed that all three models altered the metabolic profile of the skin. In summary, we successfully constructed a vitiligo mouse model induced by MBEH combined with CUMS, which may be better used in the evaluation and study of vitiligo drugs.

Epidemiology of mental health comorbidity in patients with psoriasis: An analysis of trends from 1986 to 2019

BACKGROUND

The prevalence of mental disorders such as depression, anxiety, and suicide has increased in patients with psoriasis, although no study has systematically analyzed the epidemiology worldwide.

OBJECTIVE

To explore the prevalence and incidence of psoriasis with comorbid mental disorders (i.e., depression, anxiety, and suicide).

METHODS

Five databases from establishment through May 2022 were searched. Stata SE 15.1 was used for the data analysis. Subgroup, meta-regression, and sensitivity analyses were used to evaluate the heterogeneity of pooled studies.

RESULTS

We evaluated 56 studies in our research. The prevalence of depression, anxiety, and suicide in adults with psoriasis was 20%, 21%, and 0.77%. Patients with psoriasis in North America had a higher prevalence of depression and suicide, whereas those in South America had a higher prevalence of anxiety. The incidence of depression, anxiety, and suicide was 42.1, 24.7, and 2.6 per 1000 person-years in adults with psoriasis, respectively.

LIMITATIONS

All of the included studies were published in Chinese and English, causing a degree of selection bias.

CONCLUSION

These findings demonstrate the incidence and prevalence of comorbid mental disorders in patients with psoriasis, which may raise awareness among physicians and patients regarding the mental problems associated with psoriasis.

Psychopathological symptoms in dermatology: A basic approach toward psychocutaneous disorders

Dermatological conditions impact not only an individual's physical body but also their psychological health. Similar to how cutaneous conditions can affect one's psychological health, worsening psychological conditions can exacerbate or even induce dermatological conditions. There are four common psychiatric pathologies typically found in dermatology practices: depressive symptoms, anxiety symptoms, obsessive-compulsive disorder behaviors, and psychosis. Common cutaneous disorders associated with these psychopathological symptoms include, but are not limited to, psoriasis, acne vulgaris, atopic dermatitis, urticaria, trichotillomania, excoriation disorder, and delusions of parasitosis. The goal of this review is to examine the relationship between these four psychopathological symptoms with common psychodermatological conditions and to help providers better diagnose and implement appropriate psychological support to treat their patients.

Effects of Neuropeptides on Dendritic Cells in the Pathogenesis of Psoriasis

Psoriasis is an autoimmune disease that is characterized by discolored, scaled patches of skin. Clinically, it is found that psychological factors often induce or aggravate the disease. Current research suggests that the pathogenesis of psoriasis involves the nervous and immune systems. This article reviews how neuropeptides secreted by nerve fibers affect dendritic cells in psoriasis. In this review, we describe that the neuropeptides calcitonin gene-related peptide, substance P, and vasoactive intestinal peptide can act on dendritic cells and participate in the pathogenesis of psoriasis. These neuropeptides can affect the secretion of interleukin (IL)-12 and IL-23 by dendritic cells, which stimulate T helper (Th)1, Th17, and Th22 cells to produce immune responses and cause the manifestation of psoriasis. The application of neuropeptide inhibitors can improve the skin lesions of psoriasis, which has been confirmed in clinical trials. Therefore, neuroimmune response may be a new direction to develop new drug treatments and perspectives in the development of psoriasis.

Perceived stress in patients with inflammatory and non-inflammatory skin conditions. An observational controlled study among 255 Norwegian dermatological outpatients

BACKGROUND

Inflammation may increase stress, while stress may promote inflammation. Most dermatological conditions are chronic and inflammatory, while some, such as cancer, naevi and tumours are non-inflammatory, but may cause stress because of the fear of malignancy and the necessity for surgical and other invasive treatments. Stress among patients with skin diseases is little explored.

OBJECTIVES

To assess perceived stress in patients with inflammatory and non-inflammatory skin conditions compared to healthy controls.

METHODS

Observational cross-sectional study. Consecutive outpatients (N = 255) visiting the Department of Dermatology, Stavanger University Hospital, Norway and 148 skin-healthy controls contributed by answering questionnaires on sociodemographics, stressful life events, economic difficulties, self-rated health and perceived stress. The validated Perceived Stress Scale10 was used to evaluate stress. A dermatologist examined patients and registered their diagnoses and comorbidities. Controls included in this study were not examined by a dermatologist and self-reported their comorbidities.

RESULTS

Patients with an inflammatory skin disease or psoriasis have a tripled risk of reporting moderate to high stress compared with controls when adjusted for relevant confounders, including having experienced a stressful life event recently or having a comorbidity. Patients with a purely non-inflammatory skin disease perceived stress no differently than controls.

CONCLUSION

Patients with inflammatory skin disease perceived higher stress than controls and patients with non-inflammatory skin conditions. Dermatologists may play a role in awareness of the importance of stress in skin disease.

The need for psychological support in routine dermatological care across the UK

This article presents a patient perspective on the importance of having psychological support for skin conditions available in the dermatological treatment pathway in the UK.

Brain structure and connectivity in psoriasis and associations with depression and inflammation; findings from the UK biobank

Background

Psoriasis is a chronic systemic inflammatory skin disease, coexisting with depression in up to 25% of patients. Little is known about the drivers of comorbidity, including shared neurobiology and depression brain imaging patterns in patients. An immune-mediated crosstalk between the brain and skin has been hypothesized in psoriasis. With the aim of investigating brain structure and connectivity in psoriasis in relation to depression comorbidity, we conducted a brain imaging study including the largest psoriasis patient sample to date (to our knowledge) and the first to investigate the role of depression and systemic inflammation in brain measures. Effects of coexisting psoriatic arthritis (PsA), which represents joint involvement in psoriasis and a higher putative inflammatory state, were further explored.

Methods

Brain magnetic resonance imaging (MRI) data of 1,048 UK Biobank participants were used (131 comorbid patients with psoriasis and depression, age-and sex-matched to: 131 non-depressed psoriasis patients; 393 depressed controls; and 393 non-depressed controls). Interaction effects of psoriasis and depression on volume, thickness and surface of a-priori defined regions of interest (ROIs), white matter tracts and 55x55 partial correlation resting-state connectivity matrices were investigated using general linear models. Linear regression was employed to test associations of brain measures with C-reactive protein (CRP) and neutrophil counts.

Results

No differences in regional or global brain volumes or white matter integrity were found in patients with psoriasis compared to controls without psoriasis or PsA. Thickness in right precuneus was increased in psoriasis patients compared to controls, only when depression was present (β = 0.26, 95% CI [Confidence Intervals] 0.08, 0.44; p = 0.02). In further analysis, psoriasis patients who had PsA exhibited fronto-occipital decoupling in resting-state connectivity compared to patients without joint involvement (β = 0.39, 95% CI 0.13, 0.64; p = 0.005) and controls (β = 0.49, 95% CI 0.25, 0.74; p < 0.001), which was unrelated to depression comorbidity. Precuneus thickness and fronto-occipital connectivity were not predicted by CRP or neutrophil counts. Precuneus thickening among depressed psoriasis patients showed a marginal correlation with recurrent lifetime suicidality.

Conclusions

Our findings provide evidence for a combined effect of psoriasis and depression on the precuneus, which is not directly linked to systemic inflammation, and may relate to suicidality or altered somatosensory processing. The use of the UK Biobank may limit generalizability of results in populations with severe disease.

Analysis of the effect of daily stress on the skin and search for genetic loci involved in the perceived stress of an individual

Background

Stress may have various effects on our bodies. In particular, the skin may be readily influenced by stress. In addition, there are individual differences in the way we feel stress, suggesting the involvement of genetic factors in such individual differences.

Objectives

In this study, we analysed the influence of stress on skin condition and ageing involving Japanese females, and investigated single nucleotide polymorphisms (SNPs) that influence perceived stress of an individual.

Methods

We collected genotype data from 1200 Japanese females. At the same time, a questionnaire was conducted on the degree of stress that each subject feels on a daily basis and the current skin condition. We analysed the effects of stress on skin condition and searched for SNPs related to individual stress susceptibility by genome‐wide association studies.

Results

Our data suggested that stress influences skin condition and ageing, as previously reported. And, we found rs74548608 as a SNP that affects perceived stress of an individual. This SNP is located on the upstream of Patched‐1, which is a gene that functions as a sonic hedgehog receptor.

Conclusions

Our study has identified new genetic factors for perceived stress of an individual in the Japanese female. The SNP found in this study may be a candidate factor important for understanding the perceived stress of an individual of Japanese.

Psychologic interventions in patients with the chronic dermatologic itch in atopic dermatitis and psoriasis: A step forward with family constellations seminars

Chronic itch is a complex psychophysiological sensation, which can severely affect the quality of life in patients with atopic dermatitis and psoriasis. Itch depends on the irritation of receptors in the skin and the processing of sensory information in the central nervous system. Severe itch leads to activation and later on to disruption of the stress response, resulting in disorders of skin repair, functional and microstructural changes in the areas of the central nervous system that are responsible for the perception of itch. Psychosocial stress can be an essential factor, activating neurohumoral mechanisms which lead to increased itch and scratch, exacerbating skin damage. Patients with chronic itch often have sleep disorders, increased irritability, and depletion of the nervous system. They are characterized by disrupting social relationships, high incidence of anxiety, depressive disorders, and suicidal tendencies. Psychological methods of intervention can effectively influence various mechanisms in the pathogenesis of itch and scratch and improve social functioning in patients with chronic dermatological itch. In this mini-review, we discuss family constellation seminars as an effective method of psychological intervention that can reduce the intensity of itch, and improve sleep and performance in patients with atopic dermatitis and psoriasis. This method is insufficiently described in previous reviews of psychological interventions in atopic dermatitis and psoriasis patients. The positive impact of family constellations seminars in patients with chronic dermatological itch may be related to reducing stress by improving understanding of the family situation, appropriate management of family secrets, and enhancing interactions with the social environment.

The Brain-Skin Axis in Psoriasis-Psychological, Psychiatric, Hormonal, and Dermatological Aspects

Psoriasis is a chronic inflammatory skin disease with systemic manifestation, in which psychological factors play an important role. The etiology of psoriasis is complex and multifactorial, including genetic background and environmental factors such as emotional or physical stress. Psychological stress may also play a role in exacerbation of psoriasis, by dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis, sympathetic–adrenal–medullary axis, peripheral nervous system, and immune system. Skin cells also express various neuropeptides and hormones in response to stress, including the fully functional analog of the HPA axis. The deterioration of psoriatic lesions is accompanied by increased production of inflammatory mediators, which could contribute to the imbalance of neurotransmitters and the development of symptoms of depression and anxiety. Therefore, deregulation of the crosstalk between endocrine, paracrine, and autocrine stress signaling pathways contributes to clinical manifestations of psoriasis, which requires multidisciplinary approaches.

The hair follicle-psoriasis axis: Shared regulatory mechanisms and therapeutic targets

It has long been known that there is a special affinity of psoriasis for the scalp: Here, it occurs most frequently, lesions terminate sharply in frontal skin beyond the hair line and are difficult to treat. Yet, surprisingly, scalp psoriasis only rarely causes alopecia, even though the pilosebaceous unit clearly is affected. Here, we systematically explore the peculiar, insufficiently investigated connection between psoriasis and growing (anagen) terminal scalp hair follicles (HFs), with emphasis on shared regulatory mechanism and therapeutic targets. Interestingly, several drugs and stressors that can trigger/aggravate psoriasis can inhibit hair growth (e.g. beta-blockers, chloroquine, carbamazepine, interferon-alpha, perceived stress). Instead, several anti-psoriatic agents can stimulate hair growth (e.g. cyclosporine, glucocorticoids, dithranol, UV irradiation), while skin/HF trauma (Köbner phenomenon/depilation) favours the development of psoriatic lesions and induces anagen in "quiescent" (telogen) HFs. On this basis, we propose two interconnected working models: (a) the existence of a bidirectional "hair follicle-psoriasis axis," along which keratinocytes of anagen scalp HFs secrete signals that favour the development and maintenance of psoriatic scalp lesions and respond to signals from these lesions, and (b) that anagen induction and psoriatic lesions share molecular "switch-on" mechanisms, which invite pharmacological targeting, once identified. Therefore, we advocate a novel, cross-fertilizing and integrative approach to psoriasis and hair research that systematically characterizes the "HF-psoriasis axis," focused on identification and therapeutic targeting of selected, shared signalling pathways in the future management of both, psoriasis and hair growth disorders.

Alcohol in Psoriasis-From Bench to Bedside

Alcohol affects the symptoms, compliance and comorbidities as well as the safety and efficacy of treatments in psoriatic patients. In this review, we aim to summarize and link clinical observations with a molecular background, such as signaling pathways at the cellular level and genetic variations, and to provide an overview of how this knowledge could influence our treatment selection and patient management.

Recurrent radiation recall dermatitis 40 years after radiation therapy for breast cancer

Radiation recall dermatitis is an inflammatory reaction of the skin, which occurs at previously irradiated areas, usually following a subsequent exposure to an aggravating factor. Recall dermatitis can occur weeks to months after radiation, and the longest duration between radiation and dermatitis has been reported to be about 25 years. Here, we report a case of recurrent radiation recall dermatitis that developed spontaneously after 40 years following radiation for breast cancer. This case suggests that radiation recall dermatitis can occur much later than previously reported. In spite of this late presentation, topical anti-inflammatory agents managed the condition well.

Resolvin D3 controls mouse and human TRPV1-positive neurons and preclinical progression of psoriasis

Rationale: Psoriasis is a chronic inflammatory disease caused by a complex interplay between the immune and nervous systems with recurrent scaly skin plaques, thickened stratum corneum, infiltration and activation of inflammatory cells, and itch. Despite an increasing availability of immune therapies, they often have adverse effects, high costs, and dissociated effects on inflammation and itch. Activation of sensory neurons innervating the skin and TRPV1 (transient receptor potential vanilloid 1) are emerging as critical components in the pathogenesis of psoriasis, but little is known about their endogenous inhibitors. Recent studies have demonstrated that resolvins, endogenous lipid mediators derived from omega-3 fatty acids, are potent inhibitors of TRP channels and may offer new therapies for psoriasis without known adverse effects. Methods: We used behavioral, electrophysiological and biochemical approaches to investigate the therapeutic effects of resolvin D3 (RvD3), a novel family member of resolvins, in a preclinical model of psoriasis consisting of repeated topical applications of imiquimod (IMQ) to murine skin, which provokes inflammatory lesions that resemble human psoriasis. Results: We report that RvD3 specifically reduced TRPV1-dependent acute pain and itch in mice. Mechanistically, RvD3 inhibited capsaicin-induced TRPV1 currents in dissociated dorsal root ganglion (DRG) neurons via the N-formyl peptide receptor 2 (i.e. ALX/FPR2), a G-protein coupled receptor. Single systemic administration of RvD3 (2.8 mg/kg) reversed itch after IMQ, and repeated administration largely prevented the development of both psoriasiform itch and skin inflammation with concomitant decreased in calcitonin gene-related peptide (CGRP) expression in DRG neurons. Accordingly, specific knockdown of CGRP in DRG was sufficient to prevent both psoriasiform itch and skin inflammation similar to the effects following RvD3 administration. Finally, we elevated the translational potential of this study by showing that RvD3 significantly inhibited capsaicin-induced TRPV1 activity and CGRP release in human DRG neurons. Conclusions: Our findings demonstrate a novel role for RvD3 in regulating TRPV1/CGRP in mouse and human DRG neurons and identify RvD3 and its neuronal pathways as novel therapeutic targets to treat psoriasis.

The Role of Nociceptive Neurons in the Pathogenesis of Psoriasis

Psoriasis is a chronic inflammatory skin disease. Emerging evidence shows that neurogenic inflammation, induced by nociceptive neurons and T helper 17 cell (Th17) responses, has a fundamental role in maintaining the changes in the immune system due to psoriasis. Nociceptive neurons, specific primary sensory nerves, have a multi-faceted role in detecting noxious stimuli, maintaining homeostasis, and regulating the immunity responses in the skin. Therefore, it is critical to understand the connections and interplay between the nociceptive neurons and the immune system in psoriasis. Here, we review works on the altered innervation that occurs in psoriasis. We examine how these distinct sensory neurons and their signal transducers participate in regulating inflammation. Numerous clinical studies report the dysfunction of nociceptive neurons in psoriasis. We discuss the mechanism behind the inconsistent activation of nociceptive neurons. Moreover, we review how neuropeptides, involved in regulating Th17 responses and the role of nociceptive neurons, regulate immunity in psoriasis. Understanding how nociceptive neurons regulate immune responses enhances our knowledge of the neuroimmunity involved in the pathogenesis of psoriasis and may form the basis for new approaches to treat it.

Relaxation therapy in the management of psoriasis

Several studies have demonstrated a direct link between psoriasis, stress and psychiatric comorbidity. We assessed the effect of relaxation therapy on psoriasis severity, quality of life, stress level and psychiatric comorbidity. Patients were assessed for stress, anxiety, depression, quality of life and severity of disease, using standard instruments. Patients were divided into two as cases and pair matched controls. The first group was given relaxation therapy in addition to the standard dermatology treatment and the second group was given only the standard dermatology treatment. The patients were followed up on first week, second week, first month and second month. Twenty one out of 30 cases (70%) achieved PASI 50 at the end of 2 months. While only 4 out of 30 (13.3%) of the control group achieved the same at the end of the study. There was statistically significant difference between cases and controls in PASI, DLQI, HADS scores with a P value of .000 each at the end of the study. But there was no statistically significant difference in perceived stress score between cases and controls. Psoriasis has significant impact in the quality of life and psychiatric comorbidity. Psychological interventions like relaxation therapy can decrease disease severity and improve quality of life.

The impact of perceived stress on skin ageing

Skin ageing can be divided according to phenotypical features into intrinsic (by the passage of time) and extrinsic (with the addition of the effects of environmental factors). Photoageing is by far the most researched factor of extrinsic ageing but the additional impact of other factors such as cigarette smoking and exposure to air pollution ought to be taken into account. One of the least researched topics in relation to extrinsic skin ageing is the impact of psychological stress. A contemporary review of response of human skin to stress describes the molecular mechanisms of extrinsic skin ageing, but has fallen short of explaining resilience to stress exhibited by people. Mechanisms to regulate gene expression, define cellular identity and promote functionality are responsible for the adaptive response to stressful events. Conversely, maladaptive response of human tissues to chronic stress appears to have an impact on gene regulation. Epigenetics is the study of heritable changes in organisms due to modifications in gene activity and expression, as opposed to the genetic code (DNA genome). Chronic stress appears to be an important factor in determining an individual's vulnerability to ageing and age-related comorbidities via epigenetic modifications. Forerunners in epigenetic research recognized the necessity of a reliable biomarker in order to develop a better understanding of the role of epigenomics in ageing. Genomic DNA methylation patterns (DNAm) appear to be valuable in age prediction but variability in specificity exists across species of mammals, human races and tissues. Neuroscience research appears to be leading the way in epigenomics whilst the lack of a valid and reliable DNAm-associated age predictor compatible with human skin tissue hinders research endeavours for the epigenetics of skin ageing.

Lifestyle changes for treating psoriasis

BACKGROUND

Psoriasis is an inflammatory skin disease that presents with itching, red, scaling plaques; its worsening has been associated with obesity, drinking, smoking, lack of sleep, and a sedentary lifestyle. Lifestyle changes may improve psoriasis.

OBJECTIVES

To assess the effects of lifestyle changes for psoriasis, including weight reduction, alcohol abstinence, smoking cessation, dietary modification, exercise, and other lifestyle change interventions.

SEARCH METHODS

We searched the following databases up to July 2018: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched the China National Knowledge Infrastructure, the Airiti Library, and five trials registers up to July 2018. We checked the references of included trials for further relevant trials, and we asked the authors of the included trials if they were aware of any relevant unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of lifestyle changes (either alone or in combination) for treating psoriasis in people diagnosed by a healthcare professional. Treatment had to be given for at least 12 weeks. Eligible comparisons were no lifestyle changes or another active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcome measures were 'Severity of psoriasis' and 'Adherence to the intervention'. Secondary outcomes were 'Quality of life', 'Time to relapse', and 'Reduction in comorbidities'. We used GRADE to assess the quality of the evidence for each outcome.

MAIN RESULTS

We included 10 RCTs with 1163 participants (mean age: 43 to 61 years; 656 men and 478 women were reported). Six trials examined the effects of dietary intervention (low-calorie diet) in 499 obese participants (mean age: 44.3 to 61 years; where reported, 395 had moderate-to-severe psoriasis). One trial assessed a combined dietary intervention and exercise programme in 303 obese participants with moderate-to-severe psoriasis who had started a systemic therapy for psoriasis and had not achieved clearance after four weeks of continuous treatment (median age: 53 years). Another trial assessed a walking exercise and continuous health education in 200 participants (mean age: 43.1 years, severity not reported). Finally, two trials included education programmes promoting a healthy lifestyle in 161 participants (aged 18 to 78 years), with one trial on mild psoriasis and the other trial not reporting severity.Comparisons included information only; no intervention; medical therapy alone; and usual care (such as continuing healthy eating).All trials were conducted in hospitals and treated participants for between 12 weeks and three years. One trial did not report the treatment period. Seven trials measured the outcomes at the end of treatment and there was no additional follow-up. In two trials, there was follow-up after the treatment ended. Five trials had a high risk of performance bias, and four trials had a high risk of attrition bias.We found no trials assessing interventions for alcohol abstinence or smoking cessation. No trials assessed time to relapse. Only two trials assessed adverse events; in one trial these were caused by the add-on therapy ciclosporin (given in both groups). The trial comparing two dietary interventions to a no-treatment group observed no adverse events.The results presented in this abstract are based on trials of obese participants.Outcomes for dietary interventions versus usual care were measured 24 weeks to six months from baseline. Compared to usual care, dietary intervention (strict caloric restriction) may lead to 75% or greater improvement from baseline in the Psoriasis Area and Severity Index (PASI 75) (risk ratio (RR) 1.66, 95% confidence interval (CI) 1.07 to 2.58; 2 trials, 323 participants; low-quality evidence). Adherence to the intervention may be greater with the dietary intervention than usual care, but the 95% CI indicates that the dietary intervention might also make little or no difference (RR 1.26, 95% CI 0.76 to 2.09; 2 trials, 105 participants; low-quality evidence). Dietary intervention probably achieves a greater improvement in dermatology quality-of-life index (DLQI) score compared to usual care (MD -12.20, 95% CI -13.92 to -10.48; 1 trial, 36 participants; moderate-quality evidence), and probably reduces the BMI compared to usual care (MD -4.65, 95% CI -5.93 to -3.36; 2 trials, 78 participants; moderate-quality evidence).Outcomes for dietary interventions plus exercise programme were measured 16 weeks from baseline and are based on one trial (303 participants). Compared to information only (on reducing weight to improve psoriasis), combined dietary intervention and exercise programme (dietetic plan and physical activities) probably improves psoriasis severity, but the 95% CI indicates that the intervention might make little or no difference (PASI 75: RR 1.28, 95% CI 0.83 to 1.98). This combined intervention probably results in a greater reduction in BMI (median change -1.10 kg/m², P = 0.002), but there is probably no difference in adherence (RR 0.95, 95% CI 0.89 to 1.01; 137/151 and 145/152 participants adhered in the treatment and control group, respectively). There were no data on quality of life. These outcomes are based on moderate-quality evidence.

AUTHORS' CONCLUSIONS

Dietary intervention may reduce the severity of psoriasis (low-quality evidence) and probably improves quality of life and reduces BMI (moderate-quality evidence) in obese people when compared with usual care, while combined dietary intervention and exercise programme probably improves psoriasis severity and BMI when compared with information only (moderate-quality evidence). None of the trials measured quality of life.We did not detect a clear difference in treatment adherence between those in the combined dietary intervention and exercise programme group and those given information only (moderate-quality evidence). Adherence may be improved through dietary intervention compared with usual care (low-quality evidence). Participants generally adhered well to the lifestyle interventions assessed in the review.No trials assessed the time to relapse. Trial limitations included unblinded participants and high dropout rate.Future trials should reduce dropouts and include comprehensive outcome measures; they should examine whether dietary intervention with or without an exercise programme is effective in non-obese people with psoriasis, whether an additional exercise programme is more effective than dietary intervention alone, whether the time to relapse prolongs in people who receive dietary intervention with or without exercise programme, and whether smoking cessation and alcohol abstinence are effective in treating psoriasis.

The prevalence of ADH1B and OPRM1 alleles predisposing for alcohol consumption are increased in the Hungarian psoriasis population

Alcohol intake affects in great the symptoms and life of  psoriasis patients, although the association of SNPs related to increased alcohol consumption with psoriasis has not been elucidated. Therefore, to investigate the association of psoriasis with established alcohol consumption and dependence-related gene variants we conducted a population-based case-control study including 3743 subjects (776 psoriasis cases and 2967 controls from the general Hungarian population). Genotyping of 23 SNPs at ADH1B, ADH1C, ALDH1A1, ALDH2, SLC6A3, DDC, GABRA2, GABRG1, HTR1B, MAOA, TPH2, CHRM2, GRIN2A, POMC, OPRM1, OPRK1 and BDNF were determined and differences in genotype and allele distributions were investigated. Multiple logistic regression analyses were implemented. Analysis revealed association between C allele of the rs1229984 polymorphism (ADH1B gene) and psoriasis risk (OR_additive = 1.58, 95% CI 1.23-2.03, p < 0.001, OR_recessive = 1.58, 95% CI 1.22-2.04, p = 0.001). Furthermore, the G allele of rs1799971 polymorphism (OPRM1 gene) increased the risk of familial aggregation (OR_additive = 1.99, 95% CI 1.36-2.91, p < 0.001 OR_dominant = 2.01, 95% CI 1.35-3.01, p < 0.001). In subgroups of psoriatic patients with history of early onset and familial aggregation effect allele 'C' of rs1229984 showed association in the additive and recessive models (OR_additive = 2.41, 95% CI 1.26-4.61, p < 0.01, OR_recessive = 2.42, 95% CI 1.26-4.68, p < 0.01). While effect allele 'G' of rs1799971 (OPRM1) also associated with increased risk of early onset and familial aggregation of psoriasis in the additive and dominant models (OR_additive = 1.75, 95% CI 1.27-2.43, p = 0.001, OR_dominant = 1.82, 95% CI 1.26-2.63, p = 0.001). Our results suggest that genetically defined high-risk individuals for alcohol consumption are more common in the psoriasis population.

Association of GA genotype of SNP rs4680 in COMT gene with psoriasis

Psoriasis is a multigene and multifactorial skin disease with heterogeneous genetic inheritance. Mental disorders participate in the development of psoriasis as predisposing factors; a correlation of dermatological diseases with pathological anxiety and stress was shown. Meanwhile, there are no studies describing molecular mechanisms of the linkages between psycho-emotional disorders and skin diseases. The aim of this study is to find the associations between SNP in genes COMT (rs4680), DBH (rs141116007), CCKAR (rs1800857) and CCKBR (rs1805002), and psoriasis. Patients were selected according to the 10th revision of International Classification of Diseases (L-40). The sample size was 88 patients. The size of the control sample (population control) was 365 people. Genotyping was performed using PCR-RFLP and real-time PCR. Statistical analysis was performed using WinPepi software. Identification of complex genotypes was performed by the Monte Carlo method using APSampler 3.6.1 algorithm. Among the studied genes, only GA genotype of COMT gene is significantly associated with psoriasis [χ² = 19.163 (p = 1.3E-5), F (p) = 1.2E-5, OR 3.47 (CI 99% = 1.61-7.91)]. At the moment, the functional significance of this phenomenon is difficult to explain.

TRPV1 mediates inflammation and hyperplasia in imiquimod (IMQ)-induced psoriasiform dermatitis (PsD) in mice

BACKGROUND

Transient Receptor Potential Vanilloid 1 (TRPV1) is known to mediate itch and neurogenic inflammation, but the role of TRPV1 in psoriasiform dermal inflammation is poorly understood.

OBJECTIVE

To investigate the function of TRPV1 in imiquimod (IMQ)-induced psoriasiform dermatitis (PsD) in mice.

METHODS

Following daily treatment of topical IMQ cream for consecutive 5 days in C57BL/6 wide-type (WT) and TRPV1 gene knockout (KO) mice, we assessed the psoriasis severity index (PSI) scores, transepidermal water loss (TEWL), dermal inflammatory infiltrates, as well as gene expression levels for psoriasis related genes in mouse skin lesions.

RESULTS

Compared with WT mice, the clinical and TEWL scores, the extent of skin hyperplasia, the area of Munro microabscesses (MM) and angiogenesis of psoriasis were all significantly decreased in TRPV1 KO mice triggered with IMQ, suggesting a reduction in skin inflammation and barrier defects. In addition, the infiltration of CD45⁺ leukocytes, mast cells as well as CD3⁺ T cells was all reduced in the IMQ-treated skin of TRPV1 KO mice. Quantitative Real-time PCR (RT-qPCR) revealed that expression levels of IL-1β, IL-6, IL-23, S100A8 were decreased while IL-10 was increased in TRPV1 KO mice.

CONCLUSIONS

In summary, key markers of psoriatic inflammation and epidermal hyperplasia are reduced in TRPV1 KO mice, indicating the involvement of TRPV1 in the psoriasiform inflammation and suggesting its potential as a therapeutic target.

Self-esteem is related to anxiety in psoriasis patients: A case control study

OBJECTIVE

In psoriasis, taking steps to improve emotional health is important to bring lasting benefits to patients' physical health and overall well-being. We aimed to identify factors that relate to anxiety in psoriasis and are potentially modifiable and that thus qualify as targets for future planned interventions for improving mental health. In this study, the importance of coping strategies and self-esteem as potential targets were tested.

METHODS

A total of 102 patients diagnosed with psoriasis, aged 26-65 years (M = 43.39 years, SD = 10.56) and 98 healthy controls (with an overall age, gender, educational attainment distribution similar to that of the cases) completed the Rosenberg's Self-Esteem Scale, the Coping Inventory for Stressful Situations, and the State-Trait Anxiety Inventory.

RESULTS

Patients with psoriasis compared to healthy controls reported significantly higher rates of anxiety and emotion- and avoidance-oriented coping strategies, presented lower rates of task-oriented coping strategies, and significantly lower levels of self-esteem. Importantly, our results revealed that self-esteem in psoriasis patients was strongly related to anxiety. Moreover, the increased rates of anxiety in psoriasis were not significantly associated with the coping strategies, suggesting that in patients with psoriasis coping strategies are secondary to other factors such as self-image and self-esteem.

CONCLUSIONS

The results identify self-esteem as a target to adopt in further interventions for psoriasis patients. Recommendations for future research and intervention development are discussed.

Associations between attention-deficit/hyperactivity disorder and autoimmune diseases are modified by sex: a population-based cross-sectional study

Several studies have demonstrated associations between neuropsychiatric disorders, such as attention-deficit/hyperactivity disorder (ADHD), and the immune system, including autoimmune diseases. Since ADHD and many autoimmune diseases show sex-specific properties, such associations may also differ by sex. Using Norwegian national registries, we performed a cross-sectional study based on a cohort of 2,500,118 individuals to investigate whether ADHD is associated with common autoimmune diseases. Associations between ADHD and autoimmune diseases in females and males were investigated with logistic regression and effect modification by sex was evaluated. Several subanalyses were performed. The strongest association was found between ADHD and psoriasis in females, adjusted odds ratio (adjOR) = 1.57 (95% confidence interval: 1.46-1.68) and males, adjOR = 1.31 (1.23-1.40); p value for interaction < 0.0001. Furthermore, among females, ADHD was associated with Crohn's disease, adjOR = 1.44 (1.16-1.79) and ulcerative colitis, adjOR = 1.28 (1.06-1.54). In contrast, males with ADHD had lower odds of Crohn's disease, adjOR = 0.71 (0.54-0.92), in addition to a trend for lower odds of ulcerative colitis, adjOR = 0.86 (0.71-1.03); p values for interaction < 0.0001 and 0.0023, respectively. In a group of females where information on smoking and body mass index was available, adjustment for these potential mediators did not substantially alter the associations. Our findings support previously reported associations between ADHD and diseases of the immune system. The associations differ by sex, suggesting that sex-specific immune-mediated neurodevelopmental processes may be involved in the etiology of ADHD.

The associations between psychological stress and psoriasis: a systematic review

Psoriasis is estimated to affect around 2-3% of the general population. More than one-third of Australians report having a significant level of distress in their daily lives. Psychological stress has long been shown to play an important role in the natural history of psoriasis, but the details of this relationship remain to be clearly defined. We performed a systematic review of the literature with the aim of determining whether there is a temporal association between psychological stress as the predictor and onset and/or exacerbation of psoriasis as the outcome measure. Our secondary aim was to establish whether there is a relationship between the degree of psychological stress and clinical severity of psoriasis. Our systematic review demonstrates a probable temporal association between different measures of psychological stress and onset, recurrence, and severity of psoriasis. In the light of this, we suggest clinicians include "stress" as a trigger factor in their psoriasis assessment and consider psychological interventions as adjuncts, particularly in those who identify as "stress-responders".

Psychosocial Distress of Patients with Psoriasis: Protocol for an Assessment of Care Needs and the Development of a Supportive Intervention

BACKGROUND

Psoriasis is a chronic inflammatory disease that is often associated with a number of somatic and mental comorbidity. Patients with psoriasis show an increased risk of depression and (social) anxiety.

OBJECTIVE

The aims of this study are 1) to explore the psychosocial distress of patients with psoriasis and to assess their care needs; and 2) to develop a supportive intervention based on the prior results.

METHODS

A multi-stage design with four phases combining quantitative and qualitative methodology will be used and conducted in two centers. 1) A scoping review and focus groups will be used to design a questionnaire to assess the psychosocial distress and care needs of the patients. 2) The questionnaire developed in phase 1 will be used in a cross-sectional survey to assess the extent of psychosocial distress and supportive care needs in 400 patients with psoriasis. 3) A systematic review and meta-analysis will be conducted to identify psychosocial and psychoeducational interventions for patients with psoriasis and to describe their effectiveness. 4) Based on the results of the phases 2 and 3 a manualized supportive intervention will be developed and the feasibility and acceptance of the intervention will be assessed.

RESULTS

Currently, phase 1 of the project has been completed and the recruitment for phase 2 has been started. The systematic review and meta-analysis of phase 3 are conducted simultaneously to phase 2 and results are expected soon. Phase 4 has not been started yet.

CONCLUSIONS

The expected results of this study will show the extent of psychosocial distress of patients with psoriasis in Germany and supplement previous research with findings about the supportive care needs of this patient group. Moreover, the developed intervention will help to address the psychosocial support needs of patients with psoriasis. Research shows that psychosocial support is strongly needed.

Psoriasis for the primary care practitioner

Primary care practitioners (PCPs) are playing an increasingly important role in the management and care of psoriasis. Thus, it is important for PCPs to be knowledgeable about the disease and to be able to differentiate between common myths and facts related to diagnosis and treatment. By building relationships with their patients and working collaboratively with dermatology health professionals and other specialists, PCPs can facilitate communication about the patient's treatment preferences and expectations for symptom relief, and they may be better able to work with the patient to optimize treatment adherence. This review aims to provide PCPs with a primer on psoriasis, its associated comorbidities, and its impact on patients' quality of life. Discussion topics include psoriasis epidemiology, triggering factors, clinical presentation, differential diagnosis, comorbidities, and approaches to treatment. This review also highlights the importance of staying abreast of advances in the understanding of psoriasis pathogenesis as well as emerging therapeutic treatment options, because these advances may change the treatment landscape and increase patients' expectations for skin clearance.

Screening for anxiety and depression in people with psoriasis: a cross-sectional study in a tertiary referral setting

BACKGROUND

National Institute for Health and Care Excellence guidance recommends assessment of psychological and social well-being in people with psoriasis.

OBJECTIVES

To screen systematically for depression and anxiety in patients with psoriasis in routine clinical practice and to identify at-risk groups for psychiatric morbidity.

METHODS

Consecutive patients attending a single, tertiary centre over a 10-month period were invited to complete the Patient Health Questionnaire Depression Scale (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7) and Dermatology Life Quality Index (DLQI) as part of IMPARTS: Integrating Mental and Physical Healthcare: Research, Training and Services. Information on demographics, treatment and clinical disease severity was collated from electronic patient records. Regression models were used to identify at-risk groups for psychiatric morbidity.

RESULTS

Of 607 patients included (56·2% on biologics), 9·9% (95% confidence interval 7·5-12·3%) screened positive for major depressive disorder (MDD) and 13·1% (79/604) (95% confidence interval 10·4-15·8%) for generalized anxiety disorder (GAD; GAD-7 score > 9). Suicidal ideation was reported in 35% of those with MDD; DLQI was < 10 in 38·3% and 45·6% cases of MDD and GAD, respectively. After adjusting for covariates, the risk of MDD or GAD was significantly higher in women and those with severe clinical disease, psoriatic arthritis and previous depression/anxiety. The risk of GAD was significantly increased with Asian ethnicity and use of topical treatments only.

CONCLUSIONS

Systematic screening for anxiety and depression identifies clinically important levels of depression and anxiety that may be missed using DLQI data alone. Women and those with severe disease, psoriatic arthritis and/or a prior history of psychiatric morbidity may be at particular risk.

Stressed skin?--a molecular psychosomatic update on stress-causes and effects in dermatologic diseases

A pathogenetically relevant link between stress, in terms of psychosocial stress, and disease was first described in the 1970s, when it was proven that viral diseases of mucous membranes (such as rhinovirus and Coxsackie virus infections) develop faster and more severe after stress exposure. Since then, there has been an annual increase in the number of publications which investigate this relationship and break it down to the molecular level. Nevertheless, the evidences for the impact of psychosocial stress on chronic inflammatory skin diseases and skin tumors are hardly known. In the present review, we outline current insights into epidemiology, psychoneuroimmunology, and molecular psychosomatics which demonstrate the manifold disease-relevant interactions between the endocrine, nervous, and immune systems. The focus is on stress-induced shifts in immune balance in exemplary disorders such as atopic dermatitis, psoriasis, and malignant melanoma. The objective of this article is to convey basic psychosomatic knowledge with respect to etiology, symptomatology, and therapeutic options for chronic skin diseases. Particular attention is directed towards the underlying molecular relationships, both from a somatic to mental as well as a mental to somatic perspective.

Anti-TNF-α Drugs Differently Affect the TNFα-sTNFR System and Monocyte Subsets in Patients with Psoriasis

TNF-α has a central role in the development and maintenance of psoriatic plaques, and its serum levels correlate with disease activity. Anti-TNF-α drugs are, however, ineffective in a relevant percentage of patients for reasons that are currently unknown. To understand whether the response to anti-TNF-α drugs is influenced by the production of anti-drug antibodies or by the modulation of the TNFα-TNFα receptor system, and to identify changes in monocyte phenotype and activity, we analysed 119 psoriatic patients who either responded or did not respond to different anti-TNF-α therapies (adalimumab, etanercept or infliximab), and measured plasma levels of TNF-α, TNF-α soluble receptors, drug and anti-drug antibodies. Moreover, we analyzed the production of TNF-α and TNF-α soluble receptors by peripheral blood mononuclear cells (PBMCs), and characterized different monocyte populations. We found that: i) the drug levels varied between responders and non-responders; ii) anti-infliximab antibodies were present in 15% of infliximab-treated patients, while anti-etanercept or anti-adalimumab antibodies were never detected; iii) plasma TNF-α levels were higher in patients treated with etanercept compared to patients treated with adalimumab or infliximab; iv) PBMCs from patients responding to adalimumab and etanercept produced more TNF-α and sTNFRII in vitro than patients responding to infliximab; v) PBMCs from patients not responding to infliximab produce higher levels of TNF-α and sTNFRII than patients responding to infliximab; vi) anti- TNF-α drugs significantly altered monocyte subsets. A complex remodelling of the TNFα-TNFα receptor system thus takes place in patients treated with anti-TNF-α drugs, that involves either the production of anti-drug antibodies or the modulation of monocyte phenotype or inflammatory activity.

Hypothalamic-Pituitary-Adrenal Hypofunction in Myalgic Encephalomyelitis (ME)/Chronic Fatigue Syndrome (CFS) as a Consequence of Activated Immune-Inflammatory and Oxidative and Nitrosative Pathways

There is evidence that immune-inflammatory and oxidative and nitrosative stress (O&NS) pathways play a role in the pathophysiology of myalgic encephalomyelitis (ME)/chronic fatigue syndrome (CFS). There is also evidence that these neuroimmune diseases are accompanied by hypothalamic-pituitary-adrenal (HPA) axis hypoactivity as indicated by lowered baseline glucocorticoid levels. This paper aims to review the bidirectional communications between immune-inflammatory and O&NS pathways and HPA axis hypoactivity in ME/CFS, considering two possibilities: (a) Activation of immune-inflammatory pathways is secondary to HPA axis hypofunction via attenuated negative feedback mechanisms, or (b) chronic activated immune-inflammatory and O&NS pathways play a causative role in HPA axis hypoactivity. Electronic databases, i.e., PUBMED, Scopus, and Google Scholar, were used as sources for this narrative review by using keywords CFS, ME, cortisol, ACTH, CRH, HPA axis, glucocorticoid receptor, cytokines, immune, immunity, inflammation, and O&NS. Findings show that activation of immune-inflammatory and O&NS pathways in ME/CFS are probably not secondary to HPA axis hypoactivity and that activation of these pathways may underpin HPA axis hypofunction in ME/CFS. Mechanistic explanations comprise increased levels of tumor necrosis factor-α, T regulatory responses with elevated levels of interleukin-10 and transforming growth factor-β, elevated levels of nitric oxide, and viral/bacterial-mediated mechanisms. HPA axis hypoactivity in ME/CFS is most likely a consequence and not a cause of a wide variety of activated immune-inflammatory and O&NS pathways in that illness.

Life events and escape in conversion disorder

BACKGROUND

Psychological models of conversion disorder (CD) traditionally assume that psychosocial stressors are identifiable around symptom onset. In the face of limited supportive evidence such models are being challenged.

METHOD

Forty-three motor CD patients, 28 depression patients and 28 healthy controls were assessed using the Life Events and Difficulties Schedule in the year before symptom onset. A novel 'escape' rating for events was developed to test the Freudian theory that physical symptoms of CD could provide escape from stressors, a form of 'secondary gain'.

RESULTS

CD patients had significantly more severe life events and 'escape' events than controls. In the month before symptom onset at least one severe event was identified in 56% of CD patients - significantly more than 21% of depression patients [odds ratio (OR) 4.63, 95% confidence interval (CI) 1.56-13.70] and healthy controls (OR 5.81, 95% CI 1.86-18.2). In the same time period 53% of CD patients had at least one 'high escape' event - again significantly higher than 14% in depression patients (OR 6.90, 95% CI 2.05-23.6) and 0% in healthy controls. Previous sexual abuse was more commonly reported in CD than controls, and in one third of female patients was contextually relevant to life events at symptom onset. The majority (88%) of life events of potential aetiological relevance were not identified by routine clinical assessments. Nine per cent of CD patients had no identifiable severe life events.

CONCLUSIONS

Evidence was found supporting the psychological model of CD, the Freudian notion of escape and the potential aetiological relevance of childhood traumas in some patients. Uncovering stressors of potential aetiological relevance requires thorough psychosocial evaluation.

Urinary Biopyrrins: A New Marker of Oxidative Stress in Psoriasis

Background:

Psoriasis is a common chronic, relapsing, immune-mediated disease involving skin and joints of genetically predisposed individuals. Oxidative stress has been found to play many important roles in cellular damage and loss of function in a number of tissues and organs and is believed to contribute to the pathogenesis of a variety of diseases. Urinary biopyrrin levels have gained attention as an indicator of oxidative stress.

Aim and Objective:

To measure urinary biopyrrins excretion as a marker of oxidative stress in psoriasis.

Patients and Methods:

This case–control study was carried out on 85 subjects; 55 cases with chronic plaque psoriasis and 30 age, gender and body mass index-matched normal subjects as a control group. Urinary biopyrrin levels were measured using enzyme immunoassay.

Results:

There was a highly significant difference between cases and controls regarding urinary biopyrrins level (P < 0.001). There was significant positive correlation between biopyrrins level and both the age of cases (r = 0.28, P = 0.01) and psoriasis area and severity index score (r = 0.99, P < 0.001).

Conclusion:

Urinary biopyrrins are increased in patients with psoriasis, and the level is correlated with disease severity. Further large-scale studies involving different ages and different clinical varieties of the disease are needed to expand and validate current findings. The clinical usefulness of antioxidants in psoriasis treatment needs to be evaluated in future research. Furthermore, the value of biopyrrins as biomarkers for monitoring response to therapy needs to be evaluated.

Absence of Koebnerization Following Ablative and Nonablative Laser Therapy in Patients With Plaque Psoriasis

BACKGROUND

The adverse effects of laser procedures performed in patients with psoriasis have not been reported to date.

OBJECTIVE

The authors report the incidence of koebnerization in patients with psoriasis who underwent laser treatment with different devices over the past 12 years.

MATERIALS AND METHODS

The medical records of 38 patients with psoriasis treated with laser therapy were reviewed. Patient characteristics, including duration and severity of psoriasis, baseline psoriasis treatment, laser modality and settings, facial areas treated, and number of sessions, were collected. The primary outcome of interest was incidence of koebnerization.

RESULTS

None of the 38 patients with psoriasis treated with laser therapy experienced subsequent koebnerization. Seven patients were on oral systemic medications, 14 were on biologic agents, and 3 were on combination therapy. None of the patients experienced skin infections, delayed healing, or scarring, irrespective of their psoriasis therapy.

CONCLUSION

Koebnerization did not occur on the face, neck, or scalp of patients with psoriasis who underwent laser therapy, irrespective of psoriasis severity or types of psoriasis medications they were receiving. Although these results are encouraging, the risk of koebnerization should be discussed with patients with psoriasis who wish to undergo laser procedures.