Update of calcineurin inhibitors to treat inverse psoriasis: A systematic review

Efficacy and Safety of Topical Tacrolimus Microemulsion Applied Twice Daily in Patients with Mild to Moderate Scalp Psoriasis

INTRODUCTION

Involvement of the scalp is common in psoriasis and severely affects the quality of life of those affected. It is difficult to treat and places special demands on the galenics of a drug formulation. Tacrolimus is a calcineurin inhibitor and is approved as an ointment formulation for the treatment of atopic dermatitis. The efficacy and safety of topically applied tacrolimus have also been studied and proven for psoriasis. However, no proprietary pharmaceutical product is currently approved for this indication.

METHODS

A multicenter, double-blind, vehicle-controlled phase 3 study was conducted to evaluate the efficacy and safety of 0.1% tacrolimus microemulsion when applied topically twice daily in 128 patients independently of sex with scalp psoriasis.

RESULTS

The primary efficacy analysis showed a scalp Investigator Global Assessment (s-IGA) of 0 (absence of disease) or 1 (very mild disease) at 8 weeks in 28.6% of subjects in the tacrolimus group, indicating a significantly better response (p = 0.0476, chi-square test) versus 12.7% of subjects in the placebo group (difference of 15.9%-points). The Dermatology Life Quality Index (DLQI) improved over time and was more pronounced in the group treated with tacrolimus-containing microemulsion than in the placebo group, but showed no statistically significant difference after 8 weeks of use (p = 0.193, ANCOVA). The safety analysis revealed no evidence of cutaneous side effects other than those known. Toxicologically relevant serum levels of tacrolimus could be excluded.

CONCLUSION

The study data show that 0.1% tacrolimus microemulsion has good efficacy and safety in the treatment of scalp psoriasis.

Efficacy and Microbiota Modulation Induced by LimpiAL 2.5%, a New Medical Device for the Inverse Psoriasis Treatment

(1) Inverse psoriasis (IP), also known as intertriginous, typically affects the groin, armpits, navel, intergluteal fissure, and external genitalia. Skin lesions are erythematous plaques of inflammatory nature, smooth, well-delimited, non-scaly, and non-infiltrated. Lesions may be accompanied by itching, pain, or burning sensation. The aim of this study is both to investigate the modulation of the skin microbiota induced by IP and, on the other hand, to test the effectiveness of the new biotechnological product LimpiAL 2.5%. (2) Patients affected by IP were recruited in a private practice and treated for 4 weeks with LimpiAL 2.5% exclusively. The clinical effects on the lesion skin were evaluated, and the skin microbiotas before and after treatment were compared. (3) The clinical outcomes reveled a significant beneficial effect of the tested product. At the same time, LimpiAL increased the biological diversity of the skin microbiota and exerted a significant decrease of some Corynebacterium species, and the increase of some Staphylococcus species. (4) Together, the clinical outcomes and the microbiota analysis suggest that LimpiAL treatment improves the skin condition of affected patients, basically restoring the eubiosis conditions of the affected sites and modulating the bacterial composition of the resident microbiota.

2022 European guideline for the management of balanoposthitis

BACKGROUND

This guideline is an update to the 2014 edition of the European guideline for the management of balanoposthitis. Balanoposthitis describes inflammation of the glans penis and prepuce and is caused by a range of disparate conditions including infection, dermatoses and premalignancy.

OBJECTIVE

The main objectives of this guideline are to aid recognition of the symptoms and signs and complications of penile skin conditions and to offer recommendations on the diagnostic tests and treatment for a selected group of these conditions.

METHODS

The previous guideline was updated following a literature review and priority was given to randomized controlled trial and systematic review evidence.

RESULTS

The updated guideline includes amended management for infective balanitis to provide clear guidance for Group A streptococcal infections, management of on going Lichen sclerosus (to include circumcision and supportive management to reduce the recurrence of genital herpes and warts), additional regimens for Zoonoid change, use of calcineurin inhibitors in management and risk of premalignancy and change of nomenclaturefrom Premalignant conditions to Penile Intraepithelial neoplasia (PeIN).

CONCLUSION

Balanoposthitis has a widerange of causes high quality evidence specific to the management of penile disease is not available for all the conditions described.

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

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

Colchicine in Managing Skin Conditions: A Systematic Review

(1) Background: Colchicine is a natural alkaloid with anti-inflammatory properties used to treat various disorders, including some skin diseases. This paper aims to incorporate all the available studies proposing colchicine as a treatment alternative in the management of cutaneous conditions. (2) Methods: In this systematic review, the available articles present in various databases (PubMed, Scopus-Embase, and Web of Science), proposing colchicine as a treatment for cutaneous pathological conditions, have been selected. Exclusion criteria included a non-English language and non-human studies. (3) Results: Ninety-six studies were included. Most of them were case reports and case series studies describing colchicine as single therapy, or in combination with other drugs. Hidradenitis suppurativa, pyoderma gangrenosum, erythema nodosum, erythema induratum, storage diseases, perforating dermatosis, bullous diseases, psoriasis, vasculitis, acne, urticaria, stomatitis, actinic keratosis, and pustular dermatosis were the main diseases discussed in literature. Although the therapeutic outcomes were variable, most of the studies reported, on average, good clinical results (4) Conclusions: Colchicine could be, as a single therapy or in combination with other drugs, a possible treatment to manage several skin diseases.

Genetic Investigation of Inverse Psoriasis

Inverse psoriasis is considered to be a rare variant of plaque-type psoriasis and is associated with significantly impaired quality of life. Clinical manifestations and treatment options are somewhat different for each subtype. Identifying genetic variants that contribute to the susceptibility of different types of psoriasis might improve understanding of the etiology of the disease. Since we have no current knowledge about the genetic background of inverse psoriasis, whole exome sequencing was used to comprehensively assess genetic variations in five patients with exclusively inverse lesions. We detected six potentially pathogenic rare (MAF < 0.01) sequence variants that occurred in all investigated patients. The corresponding mutated genes were FN1, FBLN1, MYH7B, MST1R, RHOD, and SCN10A. Several mutations identified in this study are known to cause disease, but roles in psoriasis or other papulosquamous diseases have not previously been reported. Interestingly, potentially causative variants of established psoriasis-susceptibility genes were not identified. These outcomes are in agreement with our hypothesis that the inverse subtype is a different entity from plaque-type psoriasis.

Novel archetype in psoriasis management bridging molecular dynamics in exploring novel therapies

Psoriasis is an autoimmune chronic inflammatory condition of skin affecting 125 million populaces around the globe. It is implicated as a result of multifaceted phenomena involving various cell and subcell activities with the aid of numerous cellular and molecular components including signaling aisle and regulatory proteins owing to the development of such hyperproliferative dermatological conditions. This involves a deeply complex and conflicting pathology owing to genetic and immunological deviations resulting from the unusual presentation of different signaling pathways and regulatory proteins. Explorations of these biomarkers and intervention of molecular and cellular processes in psoriasis are yet to be investigated and could be an exceptional aspect for understanding pathology with successful targeting of disease. In the presented study, we have integrated molecular insights, including signaling molecules, pathways, and proteins implicated in pathogenesis, and we have attempted to link this knowledge to the targeting of these phenomena in order to manage the conditions precisely. Further, therapeutic delivery approaches for targeting distinct layers of skin have also been investigated based on the application of different nanocarriers for successful psoriasis treatment.

Polymeric Gels and Their Application in the Treatment of Psoriasis Vulgaris: A Review

Psoriasis is a chronic skin disease, and it is especially characterized by the occurrence of red, itchy, and scaly eruptions on the skin. The quality of life of patients with psoriasis is decreased because this disease remains incurable, despite the rapid progress of therapeutic methods and the introduction of many innovative antipsoriatic drugs. Moreover, many patients with psoriasis are dissatisfied with their current treatment methods and the form with which the drug is applied. The patients complain about skin irritation, clothing stains, unpleasant smell, or excessive viscosity of the preparation. The causes of these issues should be linked with little effectiveness of the therapy caused by low permeation of the drug into the skin, as well as patients’ disobeying doctors’ recommendations, e.g., concerning regular application of the preparation. Both of these factors are closely related to the physicochemical form of the preparation and its rheological and mechanical properties. To improve the quality of patients’ lives, it is important to gain knowledge about the specific form of the drug and its effect on the safety and efficacy of a therapy as well as the patients’ comfort during application. Therefore, we present a literature review and a detailed analysis of the composition, rheological properties, and mechanical properties of polymeric gels as an alternative to viscous and greasy ointments. We discuss the following polymeric gels: hydrogels, oleogels, emulgels, and bigels. In our opinion, they have many characteristics (i.e., safety, effectiveness, desired durability, acceptance by patients), which can contribute to the development of an effective and, at the same time comfortable, method of local treatment of psoriasis for patients.

Ixekizumab May Improve Renal Function in Psoriasis

Background: Psoriasis is a chronic dermatological condition characterized by lesions on extensor surfaces, hands, feet, and genital areas. Chronic renal failure is often associated with metabolic syndrome and inflammatory conditions, such as psoriasis. Case report: In this paper, we report a patient with stage-three chronic renal failure that improved his renal condition after treatment with ixekizumab, an anti-IL17A drug used in the treatment of various cutaneous and rheumatological conditions. Conclusions: IL17A blockage may help to treat various autoimmune and inflammatory conditions, such as psoriasis, that may lead to renal impairment. Further investigation is necessary in order to prove the effectiveness of this drug in renal conditions.

Emerging role of anti-IL23 in the treatment of psoriasis: When humanized is very promising

Risankizumab is a novel anti-interleukin 23 humanized antibody developed to treat severe psoriasis. In this paper, we analyze the key information about this new drug and the results of phase 3 clinical trials already present in literature in order measure its safety and effectiveness in every day practice. Risankizumab seems to be one of the best performing drugs in the treatment of psoriasis, with a good safety profile and a dosage regimen less frequent than all other biologic agents, although head-to-head randomized clinical trials with other anti-interleukin treatments will be necessary in order to confirm these preliminary results.

Successful treatment of erythematous-squamous disorders of the external auditory canal with tacrolimus and clotrimazole in otic oil: Our experience in 25 patients

The external auditory canal (EAC) comprises a special area where erythematous-scaly diseases are located. Among the main dermatoses that can affect EAC seborrheic dermatitis, psoriasis, irritant or allergic contact dermatitis, chronic external otitis (atrial eczematoid dermatitis) and cutaneous lupus should be considered. In this study, 25 consecutive patients were recruited on our dermatological outpatient clinic, 9 men and 16 women, with a clinical diagnosis of localized erythematous-squamous dermatoses in EAC. The mean age was 48.8 years (16-83). The mean time of evolution of the dermatoses was 11.44 months (2-36). Regarding the diagnosis, 14 patients were diagnosed with seborrheic dermatitis (56%), 9 patients with psoriasis (36%), 1 patient with subacute cutaneous lupus (4%), and 1 patient with allergic contact dermatitis to corticosteroids (4%). The indicated treatment was tacrolimus 0.1% and clotrimazole 1% in otic oil, twice a day, for 1 month. The EAC had to be cleaned initially with saline solution impregnated on a swab from the ears. The IGA score and pruritus showed a high results, with important improvement of almost all patients. The satisfaction of the patients obtained with the TSQM-9 questionnaire was 95.2. Retreatment showed an equal efficacy observed during the first treatment period. The efficacy and the absence of side effects with the treatment make this magistral formula an adequate therapeutic option for these dermatoses.

Diaper rashes can indicate systemic conditions other than diaper dermatitis

Background

Although the majority of rashes in the diaper area are caused by irritation from urine and feces, irritant diaper dermatitis; IDD, there are some less common but potentially serious cutaneous eruptions associated with systemic diseases that should not be discounted.

Methods

This prospective descriptive study aimed to explore variation in cutaneous disease in the diaper area. It was conducted as a prospective descriptive study between October 2016 and November 2019 in the pediatric department of a tertiary-level hospital.

Results

Three hundred consecutive patients with rashes in the diaper area were enrolled. The most common diagnosed was IDD (125 cases; 41.7%), followed by rashes exacerbated by the diaper (101 cases; 33.67%) and non-diaper-related rashes (74 cases; 24.67%).

Conclusions

Our finding suggests that when diagnosing rashes that occur in the diaper area, general pediatricians should consider, in addition to IDD, the possibility of less-common conditions. The simultaneous presence of cutaneous lesions at other sites was linked to diagnoses of systemic diseases other than IDD, (P < 0.001).

Use of a new cold plasma tool for psoriasis treatment: A case report

Cold atmospheric plasma sources are emerging as new potent tools in different fields of medicine, from oncology to dermatology. Psoriasis is a chronic inflammatory disease characterized by the presence of itchy red plaque on skin, known as psoriatic plaques. In this case report, we evaluate the effectiveness of a cold atmospheric plasma treatment on a psoriatic plaque on the hand of a 20-year-old woman. Two quick applications of the procedure led to a complete disappearance of the cutaneous lesion in 14 days. The results of this case show a potential application of this new technique in the dermatological field, as palmo-plantar psoriasis is usually resistant to traditional treatments. A clinical trial would be necessary in order to evaluate the real effectiveness of this plasma.

[Intertriginous psoriasis]

Intertriginous psoriasis is a variant of psoriasis that is associated with inflammatory lesions in skin folds. Patients often feel ashamed, are subjected to stigmatization, social isolation, or experience mental health issues. There is no general consensus on the definition of intertriginous psoriasis. Depending on the definition used, the prevalence varies substantially. Due to the particular location of skin lesions, therapeutic management is very challenging. Mild symptoms can be treated with topical corticosteroids or topical immunomodulators. There are encouraging data demonstrating the efficacy of ixekizumab, possibly charting the way for it to become a systemic treatment option.

Topical treatment of psoriasis: questionnaire results on topical therapy as long-term continuous treatment and use on specific body sites

Background: Currently, no formalized international consensus guidelines exist to direct optimal topical treatment including long-term treatment.Objective: In this survey, we aim to examine if and which topicals are used in clinical practice in long-term continuous treatment of psoriasis and how topicals are used in treating specific sites of the body.Methods: A questionnaire was distributed electronically to dermatologists from the International Psoriasis Council (IPC) representing 26 countries.Results: The top three topicals used across all severities of disease were topical corticosteroids, vitamin D analogs, and potent topical corticosteroids in combination with vitamin D analogs. On locations where the skin is thin, flexural and genital psoriasis, lower potency topical corticosteroids were used, whereas on other sites, in particular in palmoplantar psoriasis, superpotent topical corticosteroids and combination vitamin D analogs/corticosteroids were used.Conclusions: It is relevant to optimize localized therapy for all severities of psoriasis reconciling disease activity (stable vs. unstable disease), localization of the lesions and the individual patient and his/her perspectives on disease control. Topical therapies are valuable treatments for classical mild disease and may have a position in some patients with more severe manifestations.

Hailey-Hailey Disease: An Update Review with a Focus on Treatment Data

Hailey-Hailey disease is a rare blistering dermatosis first described in 1939 by the brothers Howard and Hugh Hailey. Its incidence is estimated at 1/50,000. The inheritance is autosomal dominant with complete penetrance, but a variable expressivity in affected family members. Clinically, Hailey-Hailey disease presents between the third and fourth decade as flaccid vesicles and blisters on erythematous skin, giving rise to erosions, fissures, and vegetations. Maceration and superinfections are frequent. The lesions are typically distributed symmetrically within intertriginous regions such as the retroauricular folds, lateral aspects of the neck, axillae, umbilicus, inguinal, and perianal regions. The disease is characterized by a chronic relapsing course with spontaneous remissions and multiple recurrences. Severe disease can be very frustrating and have a major psychological and social impact. Given the dearth of evidence-based guidelines and large clinical trials, the assessment of the efficacy and safety of treatments is difficult. Treatments include topical and systemic agents, and procedural therapy such as lasers and surgery. This review provides a systematic search of the literature with a focus on classical and emerging treatment options for Hailey-Hailey disease.

Inverse Psoriasis: From Diagnosis to Current Treatment Options

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

A novel vehicle for the treatment of psoriasis

This study evaluates the effectiveness of the topical use of an aerosol foam combination of calcipotriol 50 μg/g plus betamethasone dipropionate 0.5 mg/g (Cal/BD foam, Enstilar®) in adults with moderate plaque psoriasis. A total of 120 male and female adult psoriasis patients (53.3% male) from two Italian dermatological units were enrolled in an 8-week prospective study performed between November 2018 and January 2019. Psoriasis Area and Severity Index (PASI) was evaluated at baseline (T0) and 4 weeks (T4) of daily application, and a further evaluation was carried out 4 weeks after suspension (T8). Furthermore, the Dermatology Life Quality Index (DLQI) was evaluated at baseline and after 4 weeks of treatment (T4). At baseline, patients presented a mean PASI of 7 (7.0 ± 2.1). After 4 weeks (T4) of once-daily application, an important improvement in PASI was observed (1.1 ± 0.3). At Week 4, DLQI was reduced by 5.5 points from baseline (mean: 12 ± 3.1 at T0 vs 6.5 ± 1.8 at T4). Four weeks after suspension (T8), mean PASI was 2.6 ± 1.9, which was stable compared to the previous evaluation; only 8.3% of the treated patients showed worsening of plaque psoriasis. This study suggested that the Cal/BD aerosol foam is an effective topical therapy to treat plaque psoriasis.

The Skin in Celiac Disease Patients: The Other Side of the Coin

Celiac disease (CD) is an autoimmune enteropathy that primarily affects the small intestine and is characterized by atrophy of intestinal villi. The manifestations of the disease improve following a gluten-free diet (GFD). CD is associated with various extra-intestinal diseases. Several skin manifestations are described in CD patients. The present paper reviews all CD-associated skin diseases reported in the literature and tries to analyze the pathogenic mechanisms possibly involved in these associations. Different hypotheses have been proposed to explain the possible mechanisms involved in every association between CD and cutaneous manifestations. An abnormal small intestinal permeability seems to be implicated in various dermatological manifestations. However, most of the associations between CD and cutaneous diseases is based on case reports and case series and a few controlled studies. To better assess the real involvement of the cutaneous district in CD patients, large multicentric controlled clinical trials are required.