Deutsche S3-Leitlinie zur Therapie der Psoriasis vulgaris, adaptiert von EuroGuiDerm - Teil 2: Therapiemonitoring, besondere klinische Situationen und Komorbidität

Discontinuation of Fumaric Acid Esters is Affected by Depressive Symptomatology: A Retrospective Analysis

Fumaric acid esters (FAEs) remain a widespread therapy option for moderate-to-severe psoriasis. However, drug survival of FAEs is limited by adverse events (AEs) or inadequate treatment response. Depressive disturbances are highly prevalent in psoriasis patients and are hypothesized to be associated with the reporting of AEs and therapy discontinuation. This study's aim was to analyze whether psoriasis patients with comorbid depressive symptomatology are more likely to discontinue treatment with FAEs due to AEs and/or inadequate treatment response. Data were retrospectively extracted from the records of patients starting therapy with FAEs in the Department of Dermatology, University Hospital Essen, Germany between 2017 and 2022, covering the first 52 weeks of treatment. Psoriasis severity and depressive symptomatology, as well as AEs and therapy discontinuation, were analyzed. Psoriasis patients (N = 95, 47.37% female) with depressive symptomatology (42.11%) were more likely to discontinue therapy due to patient-reported AEs, while the total number of reported AEs was not associated with depression. The results support the hypothesis that among psoriasis patients with depressive symptoms, the associated introspection and somatization may result in increased sensitivity for AEs and thus in quicker therapy discontinuation. In these patients, the occurrence of nocebo effects should be minimized, e.g. by special communication techniques.

Case Report: Paraneoplastic psoriasis in thymic carcinoma

Thymic carcinomas are exceedingly rare and very aggressive malignancies of the anterior mediastinum. While thymomas exhibit a high association with paraneoplastic syndromes, these phenomena are a rarity in thymic carcinomas. In general, acanthotic syndromes such as acroceratosis neoplastica and acanthosis nigricans maligna are commonly observed as paraneoplastic phenomena in patients with carcinomas. In contrast, psoriasis vulgaris, another acanthotic disease, rarely occurs as a paraneoplasia. We report the case of a 36-year-old patient with progressive thymic carcinoma (undifferentiated carcinoma, T3N2M1a) and paraneoplastic psoriasis occurring ten months before the initial diagnosis of the carcinoma. Over the course of the disease, new psoriatic flares heralded relapse or progression of the carcinoma. To our knowledge, this is the first reported case of paraneoplastic psoriasis in thymic carcinoma.

Interest in a short psychological intervention in patients with psoriasis: a cross-sectional observational study at a German clinic

Introduction

Utilization of health services is not only associated with the kind of illness one has, but also with patient characteristics like age, sex or psychological variables. Psoriasis (PS) is a chronic inflammatory skin condition, in which psychological interventions were shown to be beneficial regarding not only psychological variables, but also regarding the skin status. The present study investigated with regard to which patient characteristics PS-patients with interest in participation in a short psychological intervention differ from PS-patients without interest.

Methods

This cross-sectional questionnaire study was conducted at a German rehabilitation clinic. At the beginning of their stay at the clinic, 127 PS-patients filled in questionnaires to assess the severity of their PS, stress, illness perceptions, mindfulness, anxiety, and depression. Interest in taking part in a short psychological intervention was assessed using a dichotomous item. The statistical analysis comprised group comparisons using t-tests of patients with and without interest to take part in a short psychological intervention.

Results

Sixty-four of the participants were male (50.4%). Participants were 50.7 ± 10 years on average (range: 25-65). 50.4% of them had a mild, 37.0% a moderate, and 12.6% a severe PS. Results indicated that patients with interest in a short psychological intervention were younger, reported to have more skin symptoms due to their PS (higher skin-related illness identity), were more anxious and depressed, but less stressed and less mindful than patients without interest.

Conclusion

This study shows that in PS-patients with certain characteristics, it might help to raise awareness on the relationship between psychological factors and symptoms of the skin disease in order to motivate this group of patients to take part in psychological interventions to improve their skin condition. Further studies are needed to investigate whether patients who show interest in a psychological intervention also actually take part in the intervention and profit from it.Clinical Trial Registration: DRKS00017426.

Cardiovascular comorbidity in psoriasis - psoriatic inflammation is more than just skin deep

BACKGROUND

There is a growing understanding of inflammation in psoriasis beyond its dermatological manifestation, towards systemic inflammation. Management of possible comorbidities encompassing psychological, metabolic and cardiovascular disease is recommended in national and international dermatology guidelines for treatment of psoriasis patients. Vice versa, psoriasis is being recognized as a new risk factor for cardiovascular inflammation within the cardiological community.

METHODS

A review of the literature was conducted. Key points regarding epidemiological, mechanistic and management aspects were summarized and put into context for physicians treating psoriasis patients.

RESULTS

Efforts are currently being made to better understand the mechanistic underpinnings of systemic inflammation within psoriatic inflammation. Studies looking to "hit two birds with one stone" regarding specifically cardiovascular comorbidities of psoriasis patients using established systemic dermatological therapies have so far provided heterogeneous data. The diagnosis of psoriasis entails preventive and therapeutic consequences regarding concomitant diseases for the individual patient.

CONCLUSIONS

The knowledge of comorbidities in psoriasis calls for pronounced interdisciplinary care of psoriasis patients, to which this article highlights efforts regarding vascular inflammation and cardiovascular disease.

[National consensus statement by the Austrian Societies for Rheumatology, Pulmonology, Infectiology, Dermatology and Gastroenterology regarding the management of latent tuberculosis and the associated utilization of biologic and targeted synthetic DMARDS (disease modifying antirheumatic drugs)]

This nationwide Austrian consensus statement summarizes the recommendations on the management of latent tuberculosis by treatment with biologic and targeted synthetic DMARDs. The essential questions with respect to screening and preventive treatment were discussed by experts from the disciplines of rheumatology, pneumology, infectious diseases, dermatology and gastroenterology, based on the available data, and then a joint consensus was formed by agreement. This involved a differentiated discussion on the various forms of treatment, and clear recommendations were formulated.

Immunologie in der dermatologischen Praxis – wieviel, warum, wann?

Die Haut als Grenzorgan zum Körperäußeren realisiert viele immunologische Abwehrfunktionen. Folglich sind Immunologie und Dermatologie eng miteinander verknüpft. Die Diagnostik immunologischer Hauterkrankungen und deren Immuntherapie, labormedizinische Analysen, Hyposensibilisierung – Begegnungen mit der Immunologie finden auch in einer dermatologischen Praxis im Alltag nahezu ständig statt. Ziel dieser Arbeit ist es, praxisnah aufzuzeigen, wie uns Dermatologen die Immunologie in unserer Fachdisziplin helfen kann.

Therapy of psoriasis during pregnancy and breast-feeding

There have been multiple systemic drugs approved for the therapy of psoriasis vulgaris and psoriasis arthritis (PsA) in the last decade. However, treatment decisions are difficult to make in women planning a pregnancy and in pregnant and lactating women due to the paucity of data for such cases. The strongest evidence for psoriasis therapy during pregnancy exists for topical corticosteroids. Medically controlled use of UVB-therapy is also considered safe. The best evidence regarding systemic therapy during pregnancy and lactation is available for the group of TNF-alpha inhibitors, which is also reflected in the respective medical product information. This is especially important in cases of psoriatic arthritis. Among traditional systemic therapeutics, the largest clinical experience exists for ciclosporin, which, if medically necessary, may be continued during gestation. However, TNF-alpha inhibitors, especially the pegylated form, should be preferred in case of pregnancy. Furthermore, an elective pregnancy termination is not necessary due to systemic therapy of psoriasis with many further substances during the first pregnancy weeks. The current work provides a comprehensive review of the scientific literature on treatment of psoriasis during pregnancy and lactation. Based on the available scientific information, severity of psoriasis and patient's comorbidities, the best possible therapeutic approach can be found in consensus with the patient.

Childhood Trauma and Psychosocial Stress Affect Treatment Outcome in Patients With Psoriasis Starting a New Treatment Episode

OBJECTIVE

Traumatic childhood experiences and psychosocial stress may predispose the evolvement of somatic diseases. Psoriasis is a multifactorial chronic inflammatory skin disease that often associates with current and past stress. Both may entail pathological alterations in major stress axes and a balance shift in the level of T helper type 1 (Th1) and 2 (Th2) cytokines, affecting the development and course of psoriasis. Until now, it is unclear whether traumatic stress experiences during the childhood or current stress are more frequent in psoriatic compared to skin-healthy individuals, and if they interact with treatment outcome.

METHOD

In a prospective cohort study, the impact of acute and early childhood stress on the course of dermatological treatment were studied in patients with moderate to severe psoriasis (PSO). Patients were examined before (T1) and about 3 months after (T2) the beginning of a new treatment episode. Assessments included clinical outcomes (Psoriasis Area and Severity Index-PASI, Structured Clinical Interview SCID-I) and patient-reported outcomes (PRO) (Childhood Trauma Questionnaire-CTQ, Perceived Stress Scale-PSS, itching/scratching, Dermatology Life Quality Index-DLQI, Hospital Anxiety and Depression Scale, Body Surface Area, Self-Administered PASI).

RESULTS

N = 83 PSO patients (median age 53.7, IQR 37.8, 62.5) and n = 66 skin-healthy control subjects (HC) (median age 51.5, IQR 33.3, 59.2) participated. PSO had higher CTQ physical neglect than HC, as well as higher PRO levels. The positive impact of improved skin on the skin-related quality of life was moderated by the perceived stress. Acute stress at T1 had a positive effect both on the skin severity and the skin-related quality of life. CTQ total closely interacted with baseline psoriasis severity, and was associated with higher improvement from T1 to T2.

CONCLUSION

One might tentatively conclude, that chronic psychosocial stressors like childhood maltreatment may predispose the manifestation of psoriasis. The latter may be amplified by acute psychological stressors. In addition, the present evidence suggests that systemic therapies work well in PSO, with childhood trauma and acute psychosocial stress. Both should therefore be routinely assessed and addressed in PSO.