Psoriasis: immunopathogenesis and evolving immunomodulators and systemic therapies; U.S. experiences

Improved Production of Anti-FGF-2 Nanobody Using Pichia pastoris and Its Effect on Antiproliferation of Keratinocytes and Alleviation of Psoriasis

Fibroblast growth factor 2 (FGF-2) is not only an angiogenic factor, but also a mitogen for epidermal keratinocytes. FGF-2 has been shown to be positively immunoreactive in the basal layer of psoriatic lesions. In previous work, we used the Escherichia coli (E. coli) expression system to biosynthesize a biologically active anti-FGF-2 nanobody (Nb) screened by phage display technology, but the low yield limited its clinical application. In this study, we aimed to increase the yield of anti-FGF-2 Nb, and evaluate its therapeutic potential for psoriasis by inhibiting FGF-2-mediated mitogenic signaling in psoriatic epidermal keratinocytes. We demonstrated a 16-fold improvement in the yield of anti-FGF-2 Nb produced in the Pichia pastoris (P. pastoris) compared to the  E. coli expression system. In vitro, the FGF-2-induced HaCaT cell model (FHCM) was established to mimic the key feature of keratinocyte overproliferation in psoriasis. Anti-FGF-2 Nb was able to effectively inhibit the proliferation and migration of FHCM. In vivo, anti-FGF-2 Nb attenuated the severity of imiquimod (IMQ)-induced psoriatic lesions in mice, and also improved the inflammatory microenvironment by inhibiting the secretion of inflammatory cytokines (IL-1β, IL-6, IL-23, and TNF-α), chemokines (CXCL1 and CCL20), and neutrophil infiltration in skin lesions. These were mainly related to the suppression of FGF-2-mediated mitogenic signaling in psoriatic keratinocytes. In conclusion, we have improved the production of anti-FGF-2 Nb and demonstrated the modality of attenuating the abnormal proliferative behavior of psoriatic keratinocytes by inhibiting FGF-2-mediated mitogenic signaling, which offers the possibility of treating psoriasis.

Strategies to Develop a Suitable Formulation for Inflammatory Skin Disease Treatment

Skin barrier functions, environmental insults, and genetic backgrounds are intricately linked and form the basis of common inflammatory skin disorders, such as atopic dermatitis, psoriasis, and seborrheic dermatitis, which may seriously affect one’s quality of life. Topical therapy is usually the first line of management. It is believed that successful topical treatment requires pharmaceutical formulation from a sufficient dosage to exert therapeutic effects by penetrating the stratum corneum and then diffusing to the target area. However, many factors can affect this process including the physicochemical properties of the active compound, the composition of the formulation base, and the limitations and conditions of the skin barrier, especially in inflammatory skin. This article briefly reviews the available data on these issues and provides opinions on strategies to develop a suitable formulation for inflammatory skin disease treatment.

Emerging Pathophysiological Targets of Psoriasis for Future Therapeutic Strategies

Psoriasis is a chronic autoimmune skin disorder which involves complex interactions between genes, keratinocytes, T-cells and inflammatory cells. It affects 2-3% population worldwide. Molecular biology and cellular immunology of psoriasis, when linked with biotechnology and genetic studies can help researchers to understand the pathophysiology of psoriasis. T-cells activation, keratinocyte hyperproliferation, and angiogenesis are the core mechanisms entailed in the development of psoriasis lesion. Investigators are trying to overcome the challenges of complex pathophysiology pathways involved in this disorder. The different possible hypotheses for its pathophysiology such as growth factors, enzymes, inflammation, and genetic factors mediated pathophysiology have been described in the present review paper in detail. Clinically available drugs only control the symptoms of psoriasis but are not effective for the treatment of the disorder completely and are also associated with some side effects such as itching, renal disorders, hematologic, nonmelanoma skin cancer, pulmonary, gastrointestinal toxicity, etc. This paper made an effort to understand the pathophysiological targets, discuss the research done so far and the treatments available for the effective management of psoriasis.

Dihydrochalcone Derivatives from Populus balsamifera L. Buds for the Treatment of Psoriasis

Psoriasis is a skin disorder characterized by epidermal hyperplasia, hyperkeratosis, and inflammation. The treatments currently available on the market only improve patients' quality of life and are associated with undesirable side effects. Thus, research leading to the development of new, effective, and safer therapeutic agents is still relevant. Populus balsamifera L. buds were used traditionally by Native Americans to treat various skin pathologies such as eczema and psoriasis. In this study, the antipsoriatic activities of dihydrochalcone derivatives from Populus balsamifera L. buds, known as balsacones, were investigated. The experiments were performed in vitro using a psoriatic skin substitute model. Also, anti-inflammatory and antioxidant activities were investigated. The tested balsacones showed promising antipsoriatic properties by slowing down cell growth and by regulating the expression of involucrin, loricrin, and Ki67 better than methotrexate in psoriatic substitutes. All five tested compounds could be an effective topical treatment for psoriasis, with promising anti-inflammatory and antioxidant actions that may contribute to clinical improvement in patients with psoriasis.

Kernel and regression spline smoothing techniques to estimate coefficient in rates model and its application in psoriasis

Background: Data types are recurrent events in studies in which each person may experience an event at different times. One of the most popular approaches to analyze recurrent event data is obtaining an estimate of the means/rate of events at different times. In this context, determining the variability over time can help better understand the effect of factor on the response. In this study, we applied smoothing methods to estimate coefficients in time-dependent rate model, and we also showed its application in data of psoriasis patients. Methods: In the present study, psoriasis patients who experienced relapse that led to hospitalization during 2005 and 2014 in the Dermatology Department of Imam Khomeini hospital in Tehran were examined. To investigate the rate of relapse during a year, time-dependent rate model was used and variability of the effects was assessed using Wald test. Both b-spline and kernel methods were used to estimate time varying coefficients in rates model. Finally, results from methods were compared based on the obtained estimates. Results: Based on the results of the Wald test, the effect of season on the occurrence of psoriasis was significantly different (p<0.01). Also according to the estimated coefficients from both b-spline and kernel methods, there was little difference between them. Conclusion: In situations in which the effect of a variable is different at different times, using time-dependent coefficients rate model can lead to a better estimate of the effect of variable on the response. On the other hand, smoothing methods can smooth the effects of the variables that vary over time.

Evaluation of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in Turkish patients with chronic plaque psoriasis

INTRODUCTION

This study evaluates the relationship between disease activity and neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) in patients with chronic plaque psoriasis.

METHODS

Clinical and biochemical data were retrieved through retrospective examination of patients' and healthy subjects' medical records. NLR and PLR values were calculated from the hemogram results. This study included 46 patients (25 males, 21 females; 36.58 ± 9.82 years) diagnosed with chronic plaque psoriasis and a control group of 46 healthy volunteers (21 males, 25 females; 34.02 ± 8.41 years).

RESULTS

NLR and PLR were significantly elevated in patients with chronic plaque psoriasis (p = 0.0001 and p = 0.003, respectively). PASI was positively correlated with NLR, PLR, and serum CRP levels (r = 0.313, p = 0.034; r = 0.394, p = 0.017; r = 0.359, p = 0.014, respectively).

CONCLUSION

NLR and PLR are low-cost tests that can be used to determine the severity of current systemic inflammation in patients with chronic plaque psoriasis.

Evaluation of potent phytomedicine for treatment of psoriasis using UV radiation induced psoriasis in rats

The aim of present study was to determine the effect of newly formulated gels and suspensions of extractive Phytoconstituents of Woodfordia fructicosa flowers and Gardenia gummifera leaves by using UV Radiation induced psoriasis in rats. Both plants are traditionally claimed to be useful in treatment of number of skin diseases. However, there are no established scientific reports for their potential in psoriasis. Formulated Gels and Suspensions of ethanolic extract of both plants were tested for acute dermal and oral toxicity study respectively. The results of acute dermal toxicity at concentration 1% w/w and oral toxicity at dose 1000mg/kg showed that the gels and suspensions were safe. Psoriasis was induced in Wistar rats by espousing 10% area of total body by UV radiations. Anti-psoriatic activity was performed by applying 0.1% gel and orally at a dose 100mg/kg body weight in rats. Severity Index, histological study and biochemical estimation were analyzed. The results of our studies showed that the test formulations (Gels and Suspensions) of both plant extracts exhibited potential effect in anti-psoriatic activity.

IL-22/STAT3-Induced Increases in SLURP1 Expression within Psoriatic Lesions Exerts Antimicrobial Effects against Staphylococcus aureus

BACKGROUND

SLURP1 is the causal gene for Mal de Meleda (MDM), an autosomal recessive skin disorder characterized by diffuse palmoplantar keratoderma and transgressive keratosis. Moreover, although SLURP1 likely serves as an important proliferation/differentiation factor in keratinocytes, the possible relation between SLURP1 and other skin diseases, such as psoriasis and atopic dermatitis, has not been studied, and the pathophysiological control of SLURP1 expression in keratinocytes is largely unknown.

OBJECTIVES

Our aim was to examine the involvement of SLURP1 in the pathophysiology of psoriasis using an imiquimod (IMQ)-induced psoriasis model mice and normal human epidermal keratinocytes (NHEKs).

RESULTS

SLURP1 expression was up-regulated in the skin of IMQ-induced psoriasis model mice. In NHEKs stimulated with the inflammatory cytokines IL-17, IL-22 and TNF-α, which are reportedly expressed in psoriatic lesions, SLURP1 mRNA expression was significantly up-regulated by IL-22 but not the other two cytokines. The stimulatory effect of IL-22 was completely suppressed in NHEKs treated with a STAT3 inhibitor or transfected with siRNA targeting STAT3. Because IL-22 induces production of antimicrobial proteins in epithelial cells, the antibacterial activity of SLURP1 was assessed against Staphylococcus aureus (S. aureus), which is known to be associated with disease severity in psoriasis. SLURP1 significantly suppressed the growth of S. aureus.

CONCLUSIONS

These results indicate SLURP1 participates in pathophysiology of psoriasis by regulating keratinocyte proliferation and differentiation, and by suppressing the growth of S. aureus.

Anti-TNFα therapy in the management of psoriasis: experience of a state referral center

BACKGROUND

Psoriasis is a chronic immune-mediated disease, characterized by increased levels of TNFα. Anti-TNFα agents have revolutionized the treatment of severe psoriasis by targeting an important molecule involved in its pathogenesis.

OBJECTIVES

We report the experience of a state referral center that uses anti-TNFα agents for psoriasis.

METHODS

We conducted a retrospective case series. Seventy-four out of 120 patients met the inclusion criteria. Clinical and laboratory data was analyzed using the chi-squared, Wicoxon and McNemar's tests. Associations were considered statistically significant when p-value<0.05.

RESULTS

Forty-one subjects (55.40%) were male, with a mean age of 47.69 ± 14.99 years. Median disease duration and pre-treatment PASI were 14.0 months (IQR 9.0-20.0), and 13.55 points (IQR 8.5-20.32). Sixty patients (81.10%) had arthropathic psoriasis. Forty-six subjects (62.20%) had comorbidities; the most frequent was dyslipidemia (25.70%). In 55.40% of patients, insufficient response to conventional therapies was the principal indication for using anti-TNFα drugs. Clinical improvement occurred in 93.20% of cases, and the post-treatment PASI median was 0.0 points (IQR 0.0-0.0). Adverse effects occurred in 6.80% of patients. Infections and elevation of transaminases occurred in 28.40% and 8.10% of cases, respectively.

CONCLUSION

Post-treatment reduction in PASI was satisfactory and the occurrence of adverse effects was minor, mostly mild infusion effects and local reactions at drug administration sites.

The risk of herpes zoster during biological therapy for psoriasis and other inflammatory conditions

Recent advances in biological therapies have proved highly effective in treating psoriasis and other inflammatory conditions, including psoriatic arthritis, rheumatoid arthritis, inflammatory bowel disease and ankylosing spondylitis. However, adverse effects related to their immunosuppression have been observed, including an increased propensity to viral infections. This review evaluates the evidence of herpes zoster (HZ) risk from biologics based on clinical reports, cohort studies and randomized controlled studies. The risk of HZ associated with these agents remains controversial, especially when comparing their risk with non-biological therapy used to treat the same inflammatory conditions. This review specifically assesses the risk of the TNF inhibitors etanercept, adalimumab and infliximab, as well as interleukin-12/23 inhibitor ustekinumab. We found multiple cohort studies, randomized controlled trials and case reports that suggest infliximab increases risk of HZ, whereas adalimumab, etanercept and ustekinumab HZ risk remain controversial. Nevertheless, HZ vaccination should be considered prior to initiation of biological therapy, particularly infliximab.

Promising new treatments for psoriasis

Psoriasis is a chronic, proliferative, and inflammatory skin disease affecting 2-3% of the population and is characterized by red plaques with white scales. Psoriasis is a disease that can affect many aspects of professional and social life. Currently, several treatments are available to help control psoriasis such as methotrexate, ciclosporin, and oral retinoids. However, the available treatments are only able to relieve the symptoms and lives of individuals. The discovery of new immunological factors and a better understanding of psoriasis have turned to the use of immunological pathways and could develop new biological drugs against specific immunological elements that cause psoriasis. Biological drugs are less toxic to the body and more effective than traditional therapies. Thus, they should improve the quality of life of patients with psoriasis. This review describes new psoriasis treatments, which are on the market or currently in clinical trials that are being used to treat moderate-to-severe plaque psoriasis. In addition, this paper describes the characteristics and mechanisms in detail. In general, biological drugs are well tolerated and appear to be an effective alternative to conventional therapies. However, their effectiveness and long-term side effects need to be further researched.

Psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory spondyloarthritis that occurs in combination with psoriasis. The exact prevalence of PsA is unknown, and its pathogenesis has not yet been fully elucidated. Genetic, environmental, and immunologic factors have all been implicated. The appearance of arthritis might precede, succeed or occur concomitant with skin lesions. PsA is sometimes considered a benign form of arthritis, but it affects patient quality of life and also causes functional impairment. Up to 20% of affected patients exhibit extremely destructive and disfiguring forms of the disease, and PsA is associated with increased mortality. The treatment of PsA aims to provide relief from signs and symptoms of the disease, prevent structural damage to joints, improve patient quality of life and decrease mortality. The choice of treatment depends on the severity of clinical presentation. The use of immunobiological agents is restricted to cases that do not respond to conservative treatment.

Characterization of a psoriatic skin model produced with involved or uninvolved cells

Current knowledge suggests that uninvolved psoriatic skin could demonstrate characteristics associated with both normal and involved psoriatic skins. However, the triggering factor allowing the conversion of uninvolved skin into a psoriatic plaque is not fully understood. To counter this lack of information, we decided to develop pathological skin substitutes produced with uninvolved psoriatic cells, in order to better characterize the uninvolved psoriatic skin. Substitutes were produced using the self-assembly approach. Macroscopic, immunohistochemical, permeability and physicochemical results showed that involved substitutes had a thicker epidermis, higher cell proliferation, abnormal cell differentiation and a more permeable and disorganized stratum corneum compared with normal substitutes. Various results were observed using uninvolved cells, leading to two proposed profiles: profile 1 was suggested for uninvolved skin substitutes mimicking the results obtained with normal skin substitutes; and profile 2 was dedicated to those mimicking involved skin substitutes in all aspects that were analysed. In summary, uninvolved substitutes of profile 1 had a thin, well-organized epidermis with normal cell proliferation and differentiation, such as observed with normal substitutes, while uninvolved substitutes of profile 2 showed an inverse trend, i.e. a thicker epidermis, higher cell proliferation, abnormal cell differentiation and a more disorganized and more permeable stratum corneum, such as seen with involved substitutes. The results suggest that uninvolved substitutes could demonstrate characteristics associated with both normal or involved psoriatic skins.

Association between obesity measured by different parameters and severity of psoriasis

BACKGROUND

Obesity has been associated with the severity of psoriasis, but this relationship is not completely understood.

OBJECTIVES

This study aimed to evaluate associations between the severity of psoriasis and weight excess as determined using a variety of parameters.

METHODS

A cross-sectional study was performed in 296 psoriasis patients. Their body mass index (BMI), waist circumference (WC), and waist : hip ratio (WHR) values were compared with results on a psoriasis area severity index (PASI).

RESULTS

The frequency of severe psoriasis was higher in men (P < 0.05). Direct correlations were established between PASI scores and each of BMI (R = 0.0154, P = 0.01), WC (R = 0.207, P = 0.001), and WHR (R = 0.164, P = 0.007).

CONCLUSIONS

This study extends previous reports of an association between psoriasis and obesity and shows a direct correlation between obesity as measured according to different parameters and psoriasis severity.

The role of cytokines in the pathomechanism of cutaneous disorders

Cytokines are produced transiently by cutaneous cells in response to immune stimuli. They are non-immunoglobulin proteins and glycoproteins. Cytokines, which are signaling molecules, act by sending downstream signals to various cells through a number of signal transduction pathways and by binding to cytokine receptors on the surface of cells. Cytokines regulate immunity and inflammation and thus play an important role in the pathogenesis of various cutaneous disorders.

Atorvastatin for the treatment of plaque-type psoriasis

STUDY OBJECTIVE

To explore the efficacy and safety of oral atorvastatin for the treatment of plaque-type psoriasis.

DESIGN

Prospective, randomized, double-blind, placebo-controlled study.

SETTING

University-affiliated psoriasis outpatient clinic in Iran.

PATIENTS

Forty-two patients aged 16-60 years with a diagnosis of acute or chronic plaque-type psoriasis with body surface area (BSA) involvement of greater than 10% were enrolled; 40 completed the study. Intervention. Oral atorvastatin 40 mg/day (20 patients) or placebo (20 patients) was administered for 12 weeks; patients' topical therapies with emollients, keratolytics, and/or class V corticosteroids were continued during the study period.

MEASUREMENTS AND MAIN RESULTS

The Psoriasis Area and Severity Index (PASI) and percentage BSA involvement were used to assess the efficacy of therapy. Mean ± SD baseline PASI scores were 7.42 ± 1.90 and 6.92 ± 1.76 in the atorvastatin and placebo groups, respectively. The primary outcomes were the degree of change in PASI scores and percentage BSA involvement from baseline to week 12. Significant improvement in psoriasis lesions was observed in both the atorvastatin and placebo groups (p<0.001 for both groups). A 75% improvement in PASI score (PASI 75) was achieved in 8 patients (40%) in the atorvastatin group and 7 patients (35%) in the placebo group. However, no statistically significant differences were noted between the two treatment groups in mean PASI score, percentage BSA involvement, and PASI 75. In terms of adverse effects, atorvastatin was well tolerated.

CONCLUSION

Oral atorvastatin 40 mg/day was not associated with therapeutic benefit when given to patients with baseline PASI scores less than 12 who were also treated with standard topical therapies. Additional trials are needed to elucidate the place of statins for the treatment of psoriasis. A larger follow-up study, as well as testing atorvastatin in patients with more intensive disease characterized by high PASI scores, is needed. Studies using higher atorvastatin doses or dose-ranging studies should also be performed.

Analysis of granulysin-mediated cytotoxicity in peripheral blood of patients with psoriatic arthritis

The objective of the present study was to investigate possible changes in granulysin (GNLY)-mediated cytotoxicity of peripheral blood lymphocytes in psoriatic arthritis (PsA) patients with respect to different phases of the disease. We prospectively enrolled 25 PsA patients in the active phase, 26 PsA patients in remission and 24 healthy controls. The simultaneous detection of intracellular GNLY and cell surface antigens (CD3 and CD56) was performed with flow cytometry. GNLY apoptotic protein was visualised by immunocytochemistry. Natural killer (NK) cell cytotoxicity was analysed with a cytotoxicity assay against human erythroleukaemia K-562 cells. The percentage of GNLY(+) cells did not differ significantly between PsA patients in the acute phase and those in remission; however, it was always higher than in healthy examinees due to the increased percentage of GNLY(+) cells within T cells, NKT cells, and both, and in the CD56(+dim) and CD56(+bright) NK subsets. The mean fluorescence intensity for GNLY was higher in all lymphocyte subpopulations in the acute phase than in remission and in healthy controls. Accordingly, GNLY-mediated NK cell cytotoxicity against K-562 cells of active phase PsA patients was significantly higher than that in patients in remission or in healthy controls. These findings demonstrated the involvement of GNLY in the worsening of PsA and suggested that GNLY mediated the development of joint lesions.

A pharmacoeconomic analysis of severe psoriasis therapy: a review of treatment choices and cost efficiency

INTRODUCTION

Psoriasis is a chronic, inflammatory disease afflicting 2% of the US population; it results in significant morbidity. The annual healthcare costs related to psoriasis are an estimated $11.3 billion and, with an expanding biologic market, an updated costs analysis is needed.

AREAS COVERED

Current treatments, including systemic agents (acitretin, cyclosporine, methotrexate), phototherapies and all available biologics (adalimumab, etanercept, infliximab, alefacept, ustekinumab) appropriate for severe psoriasis are described mechanistically and with regard to their efficacy, quality-of-life improvements and side effects. A cost-efficacy model considering US health-system-based annual costs, clinical and quality-of-life improvements was created. Reported Psoriasis Area and Severity Index improvement of 75% from baseline (PASI-75) scores, Dermatology Life Quality Index (DLQI) improvements and estimated costs of medications are described. Annual costs ranged from $1330 for methotrexate to $48,731 for high-dose etanercept. The lowest cost per achieving DLQI minimally important difference was from phototherapy; the highest was from alefacept. The lowest costs per patient achieving PASI-75 was from methotrexate and the highest was from alefacept.

EXPERT OPINION

Phototherapies and methotrexate offer high efficacy for their costs. Therapeutic approaches must be individualized for each patient given all considerations described.

Psoriasis and obesity: literature review and recommendations for management

Recent studies have found a relationship between obesity and chronic inflammation, confirmed by the association of high levels of tumor necrosis factor (TNF-_), interleukin six (IL-6,) and reactive C-protein with an increase in body mass index (BMI). In obese individuals, this inflammatory condition could contribute to the development or aggravation of psoriasis. Analogous phenomena have already been described in other inflammatory chronic diseases, such as rheumatoid arthritis and Crohn's disease. Epidemiological studies have identified a high prevalence of cardiovascular comorbidities, secondary to the metabolic alterations associated with psoriasis and obesity. A few aspects of this association remain unclear, such as the impact of obesity in the clinical forms of dermatoses, in the response to treatment, and its relationship with comorbidities.

Regulatory properties of polysaccharopeptide derived from Coriolus versicolor and its combined effect with ciclosporin on the homeostasis of human lymphocytes

OBJECTIVES

Lymphocyte homoeostasis is essential in inflammatory and autoimmune diseases. In search of natural fungal metabolites with effects on lymphocyte homoeostasis, we recently reported that polysaccharopeptide (PSP) from Coriolus versicolor exhibited ciclosporin-like activity in controlling aberrant lymphocyte activation. This object of this study was to investigate its effect on lymphocyte homoeostasis. This was done by investigating the mechanistic actions of PSP in relation to ciclosporin by performing cell cycle and cell death analysis of human lymphocytes in vitro.

METHODS

We investigated the effect of PSP in the presence and absence of ciclosporin on cell proliferation, cell cycle, cell death, immunophenotype and cell cycle regulatory proteins in human lymphocytes.

KEY FINDINGS

The data showed that PSP exhibited homoeostatic activity by promoting and inhibiting the proliferation of resting and phytohaemagglutinin (PHA)-stimulated lymphocytes, respectively. PHA-stimulated lymphocytes exhibited G0/G1 cell cycle arrest that was accompanied by a reduction of cyclin E expression with PSP treatment. Both PSP and ciclosporin blocked the reduction of the CD4/CD8 ratio in stimulated lymphocytes. PSP did not induce cell death in human lymphocytes, but the suppression of the Fasreceptor suggested a protective role of PSP against extrinsic cell death signals. These homoeostatic effects were more potent with combined PSP and ciclosporin treatment than with either fungal metabolite alone.

CONCLUSIONS

Collectively, the results reveal certain novel effects of PSP in lymphocyte homoeostasis and suggest potential as a specific immunomodulatory adjuvant for clinical applications in the treatment of autoimmune diseases.

TNFα and its Receptors in Psoriatic Skin, before and after Treatment with Etanercept

Psoriasis is a chronic inflammatory skin condition characterized by inflammatory dermal infiltrate and hyperproliferative keratinocytes. The pathogenesis of this disease is mediated by a dysregulation of the innate immunity and cytokine production. Tumor Necrosis Factor alpha (TNFα) is considered the most important cytokine involved in the pathological mechanism of psoriasis. Recently, several therapies have been introduced for the treatment of psoriasis that try to block TNF alpha activity. Among these treatments Etanercept is a fusion protein that specifically targets TNF alpha. We performed a study on twelve psoriatic patients aimed at evaluating the effect of Etanercept treatment on the production and expression of TNFα and its receptors, in lesional and uninvolved psoriatic skin. We demonstrated that after three month of Etanercept treatment at 50 mg/wk, TNF, TNF-RI and TNF-RII immunostaining in lesional and non-lesional skin samples of patients was greatly reduced, suggesting that this treatment not only acts on stable lesional plaques, but also at a very early stage of the disease.

Ultrastructural Findings and Tumor Necrosis Factor-alpha and Intercellular Adhesion Molecule-1 Expression in Psoriasis Patients Before and After Oral Cyclosporin A Therapy

Elevated levels of proinflammatory cytokines, including tumor necrosis factor-alpha, are found in skin lesions and plasma of patients with psoriasis. Clinical improvement of psoriasis with cyclosporin A treatment is accompanied by downmodulation of proinflammatory epidermal cytokines. In this study to determine the effects of cyclosporin A on the ultrastructural changes and tumor necrosis factor-alpha and intercellular adhesion molecule-1 expression in psoriasis, biopsy specimens before and after cyclosporin A treatment were evaluated ultrastructurally and immunohistochemically. Ten patients were given 3-7.5 mg/kg oral cyclosporin A for 6 months. Before and after treatment full thickness of 4-mm punch biopsies were obtained from patients and from 6 healthy volunteers. Samples were processed for electron microscopic and immunohistochemical evaluation. The treatment was well tolerated with complete clinical improvement. The ultrastructural changes such as reduction of tonofilaments, dilatation of intercellular space, and interruption in lamina densa were recovered by cyclosporin A treatment. The increased staining intensity of tumor necrosis factor-alpha and intercellular adhesion molecule-1 on epidermal keratinocytes and endothelial cells was reduced after cyclosporin A therapy. Cyclosporin A treatment results in total normalization of the electron microscopic picture of psoriasis and its beneficial effect depends on the direct inhibition of tumor necrosis factor-alpha and consequently intercellular adhesion molecule-1.

The safety and efficacy of high-dose alefacept compared with a loading dose of alefacept in patients with chronic plaque psoriasis

OBJECTIVES

Alefacept is a biologic response modifier indicated for moderate to severe psoriasis; it has been available since 2003. It is typically administered in a dosing regimen of 15 mg intramuscularly (IM) weekly for 12 weeks. The purpose of this study was to determine whether a higher dose may be more beneficial in achieving a 75% reduction in the Psoriasis Area and Severity Index (PASI 75). A secondary objective of this study was to examine whether increasing the dose during the initial course of alefacept would reduce the time to onset of efficacy and overall response rate. Two separate dosing regimens are evaluated in this study: 30 mg IM for 6 weeks followed by 15 mg IM for 6 weeks (group 1) and alefacept 30 mg IM weekly for 12 weeks (group 2).

METHODS

Efficacy was assessed using the PASI, Physician Global Assessment, body surface area, and photographic evaluation of a target lesion. A total of 20 patients enrolled and were randomized, 16 of whom completed the study. Data analyses were performed on a per-protocol basis.

RESULTS

Overall, the mean PASI scores progressively decreased, with 43.8% reaching a 50% reduction in the PASI (PASI 50) at week 14 evaluation. Of these participants, 37.5% were in group 1 and 50% were treated with alefacept 30 mg IM for 12 weeks (group 2). Although our sample size was small, 12.5% of patients (one patient in each treatment arm) reached PASI 75. The most common adverse events encountered in this trial were mild infection, headache, pruritus, and erythroderma. There were no infections associated with a CD4(+) cell count <250 cells/mm(3).

CONCLUSIONS

There was no difference between the treatment groups in achieving PASI 50 or PASI 75. In addition, in our small population, the higher doses of alefacept were associated with increased adverse effects, including erythroderma.

Pimecrolimus 1% cream in the treatment of facial psoriasis: a 16-week open-label study

BACKGROUND

Facial psoriasis requires a treatment approach other than topical corticosteroids which bear the risk of skin atrophy. Topical pimecrolimus has been shown to be effective in atopic eczema and recently in psoriasis.

OBJECTIVE

The aim of this open-label single-center investigator-initiated study was to evaluate the efficacy and safety of pimecrolimus 1% cream in patients with facial psoriasis.

METHODS

20 adults with facial psoriasis were enrolled. Pimecrolimus 1% cream was applied twice daily to psoriatic lesions of the face over an 8-week period. An 8-week follow-up was added.

RESULTS

All clinical parameters showed a significant improvement after 8 and 16 weeks compared to baseline. Pimecrolimus 1% cream was effective and well tolerated.

CONCLUSIONS

This is the first clinical study with a larger patient cohort reporting a relevant therapeutic effect and favorable safety profile of pimecrolimus 1% cream in facial psoriasis.

Therapeutic potential of selectin antagonists in psoriasis

Psoriasis is a systemic chronic inflammatory disorder. One of the major characteristics is an excess of infiltration of inflammatory cells, mainly lymphocytes, into the skin. Because the adhesion family of selectins is suggested to play a relevant role in this process, selectins have emerged as an interesting target for drug discovery and development in psoriasis. Different strategies targeting selectins have been described. This review discusses these approaches and summarises the current development of selectin antagonists for the treatment of psoriasis. An expert opinion will give the authors' personal opinion about selectin antagonism in psoriasis and which approach might be preferable.

XP-828L (Dermylex), a new whey protein extract with potential benefit for mild to moderate psoriasisThis article is one of a selection of papers published in this special issue (part 1 of 2) on the Safety and Efficacy of Natural Health Products

Natural health products (NHPs) or complementary and alternative medicine (CAM) are commonly used to prevent disorders or support the usual treatments of many diseases. XP-828L, a whey protein extract, has demonstrated potential benefits for the treatment of mild to moderate psoriasis. The aim of this study was to analyze further clinical data that demonstrated the clinical benefits and safety of the XP-828L in patients with psoriasis and the potential mechanism of action of this product in vitro. Oral administration (2.5 g, twice a day, over 112 days) of XP-828L in 42 human subjects with mild to moderate psoriasis improved their PGA scores (physician’s global assessment). Moreover, no significant changes in haematology or hepatic and renal parameters were observed throughout the study period, indicating the safety of the product. In vitro experiments showed that XP-828L decreased the proliferation of concanavalin A (ConA)-stimulated murine splenocytes and their production of interleukin (IL)-2 and interferon (IFN)-γ. Although the in vivo mechanism of action of XP-828L remains unknown, XP-828L represents an NHP to be used as an alternative or concomitant treatment for mild to moderate psoriasis and potentially for other immune-mediated diseases.

Effect of etanercept on insulin secretion and insulin sensitivity in a randomized trial with psoriatic patients at risk for developing type 2 diabetes mellitus

Tumor necrosis factor-alpha (TNF-alpha) inhibitors have been used in the treatment of psoriasis, which is associated with the insulin resistance syndrome. The purpose of this study was to determine the effect of etanercept, a TNF-alpha inhibitor, on insulin secretion and insulin sensitivity in psoriatic patients with high risk factors to develop type 2 diabetes mellitus. Randomized double blind clinical trial with 2 weeks of follow-up. The allocation was done by simple randomization. The investigation was performed in 12 psoriatic patients with indication of systemic treatment and 2 or more risk factors for type 2 diabetes mellitus. Patients with infections, topical corticosteroids or salicylic acid ointments for 6 weeks before the study, diabetes, acromegaly, cancer and other systemic diseases were excluded. All subjects gave written informed consent to participate in the study and the protocol was approved by the hospital-based Ethical Committee. Etanercept was injected in a subcutaneous dose of 25 mg in 1 ml twice by week for 2 weeks or 1 ml of saline solution as placebo. Insulin secretion was estimated with the formula for the homeostasis model analysis beta-cell function index and insulin sensitivity was assessed using the euglycemic-hyperinsulinemic clamp technique. There was no significant difference in insulin secretion and insulin sensitivity with etanercept. Fasting serum insulin levels were decreased in the etanercept group (146 +/- 117-111 +/- 87 pmol/l, P = 0.04). Etanercept did not modify insulin secretion and insulin sensitivity in psoriatic patients with risk factors for type 2 diabetes mellitus.

Adhesion of peripheral blood mononuclear cells and CD4+ T cells from patients with psoriasis to cultured endothelial cells via the interaction between lymphocyte function-associated antigen type 1 and intercellular adhesion molecule 1

BACKGROUND

The adhesion of CD4+ T cells to endothelial cells and their subsequent migration to skin tissue are essential to develop the psoriatic skin lesion. However, few studies have examined the role of adhesion molecules in the binding of T cells from patients with chronic plaque psoriasis to endothelial cells in vitro; thus, the adhesion molecules responsible for the development of skin lesions are still unclear.

OBJECTIVES

To identify the responsible adhesion molecules in the interaction between CD4+ T cells in patients with chronic plaque psoriasis and cytokine-stimulated endothelial cells.

METHODS

An in vitro adhesion assay between Calcein-labelled peripheral blood mononuclear cells (PBMC) and cytokine-stimulated human endothelial cultures, which exhibit a higher adhesion capacity to PBMC, was established, and the adhesion-inhibitory effects of a panel of antiadhesion molecule antibodies on the adhesion of PBMC from patients with psoriasis to endothelial cells were examined. Then, the inhibitory effects of selected antibodies acting on the interaction between CD4+ T cells from patients with psoriasis (purified by negative magnetic cell sorting) and cultured endothelial cells were examined.

RESULTS

A significant increase (P < 0.01) in the adhesion of psoriatic PBMC to both endothelial cultures, human skin microvascular endothelial cells from adults (HMVEC-Ad) and human coronary arterial endothelial cells (HCAEC), compared with healthy PBMC, was demonstrated in our in vitro cell adhesion assay. Pretreatment of both endothelial cultures with tumour necrosis factor (TNF)-alpha (1000 U mL(-1)) induced the most frequent adhesion of PBMC from patients with psoriasis among the three inflammatory cytokines examined, i.e. TNF-alpha, interleukin-1beta and interferon-gamma [TNF-alpha-treated vs. nontreated: P < 0.001 (in both HMVEC-Ad and HCAEC)]. In both endothelial cultures treated with TNF-alpha, PBMC from patients with psoriasis exhibited significantly more frequent adhesion compared with those from healthy individuals (P < 0.001). The TNF-alpha-stimulated HMVEC-Ad, which exhibited the most frequent adhesion of PBMC, were selected for adhesion-inhibition experiments using monoclonal antibodies (mAbs) to adhesion molecules that are upregulated in psoriatic lesions, and the combination of antilymphocyte function-associated antigen type 1 (LFA-1) and anti-intercellular adhesion molecule 1 (ICAM-1) mAbs gave the greatest reduction of adhesion of PBMC from patients with psoriasis (approximately 69% reduction; P < 0.01). This combination of mAbs significantly reduced also the adhesion of CD4+ T cells from patients with psoriasis to TNF-alpha-stimulated HMVEC-Ad (approximately 62% reduction), compared with pretreatment with isotype control mAbs (P < 0.01).

CONCLUSIONS

These findings indicate that the LFA-1/ICAM-1 interaction plays a major role in the adhesion of CD4+ T cells to endothelial cells and that TNF-alpha might play an important role for the induction of adhesion molecules on endothelial cells at psoriatic skin lesions.

What is a role of haeme oxygenase-1 in psoriasis? Current concepts of pathogenesis

The skin is constantly exposed to endogenous and environmental pro-oxidant agents, which lead to harmful generation of reactive oxygen species (ROS). Healthy skin, being a potential target for oxidative stress, is equipped with a large number of defence mechanisms including antioxidant systems. This protection can be corrupted by an imbalance between ROS and antioxidants with pathological level of oxidants prevailing. There is a great body of evidence indicating that some inflammatory skin diseases, such as psoriasis, are mediated by oxidative stress. Keratinocytes of normal skin, the primary target for pro-oxidant agents, show strong expression of ROS-detoxifying enzymes. In addition, normal keratinocytes express haeme oxygenase (HO), an enzyme which might be involved in the protection of cells against oxidative stress. HO (inducible HO-1, constitutive HO-2 and HO-3) is the rate-limiting enzyme in haeme catabolism, which leads to the generation of biliverdin, iron, and carbon monoxide. HO-1 is a stress-responsive protein whose expression is induced by various oxidative agents. HO-1 is known for its cytoprotective, antioxidant and anti-inflammatory properties. Interestingly, a strong overexpression of HO-1 was observed in psoriatic skin. However, the role of HO-1 in psoriasis remains unclear. In this review, we will discuss some current concepts concerning pathogenesis of psoriasis and the contribution of HO-1 in skin inflammation to show the relationships between HO-1, ROS and cytokine network in psoriatic skin. We will try to answer a question whether enhanced HO-1 expression in keratinocytes results in beneficial or detrimental effect on the development and severity of psoriatic lesions.

Clinical review of 202 patients with vulval lichen sclerosus: A possible association with psoriasis

Two hundred and two patients with clinically typical or biopsy-confirmed vulval lichen sclerosus were reviewed either at consultation (75%) or by retrospectively examining their chart. At diagnosis, 79% were 50 years or older. Ninety-six per cent complained of itching, pain and/or dyspareunia. Lichen sclerosus most often affected the labia minora and perineum but 50% had perianal and 13% had extragenital disease. Thirty-five patients gave a history of psoriasis (17%), which affected the vulval area in 10. Thyroid disease was reported in 39 patients (19%), and 33 gave a family history of thyroid disease. Of those tested (142), 20% had elevated thyroid antibodies. Topical clobetasol propionate was very effective but at least intermittent treatment was required long term in 85%. At follow up, 101 of 185 patients (56%) were asymptomatic but 22 (12%) continued to have moderate-to-severe symptoms. Thyroid disease and psoriasis are common associated conditions.

Pattern VEP alterations in psoriatic patients may indicate a sub clinic optic neuritis

We examined 44 subject (Group A) of both sexes (27 males and 17 females) aging between 16 and 80 (average: 45+/-16.6), divided into age bands, affected by mild-medium psoriasis with PASI (psoriasis area and severity index) between 1.2 and 48.6 (average: 11.2+/-9.7) without any other disease and we performed pattern transient VEP (Visual Evoked Potential) at the frequencies usually used in clinical experience (73', 36', 18' check size). For a good statistic comparison we choose 55 healthy subjects (group B) divided into age bands on which we performed the same test. Comparison of VEP parameters between psoriatic and healthy subjects, showed in group A 10 normal (22.7%) and 34 pathological (77.3%). In the latter group there are 16 subjects who show only a P100 reduced amplitude (36.3%), 3 with only increased latency (6.8%), 15 with alterations of both values (34%). The achieved data show that more than 3/4 of group A subjects have VEP alterations as index of the presence of a sub clinic optic neuritis with a probably toxic autoimmune origin due to the action of TNFalpha, of IgG, of ECP or of other cytokines (IL6, IL7, etc) that are increased in the blood of this patients. The electro physiologic monitoring of optic nerve seems to represent a good routine test to evaluate the global conditions of psoriatic patients.

Prospects for vaccines for allergic and other immunologic skin disorders

The human skin hosts a variety of immune response-associated components that together form the skin immune system. Any abnormality in the functioning of the skin immune system leads to a variety of dermatologic complications, including dermatitis, psoriasis, and eczema. Exposure to antigens/allergens can lead to allergic skin disorders such as atopic dermatitis, urticaria, and allergic contact dermatitis. Recent investigations have provided new insights into the immunologic processes leading to the development of skin diseases. T cells play a central role in the activation and regulation of immune responses by recognizing antigen and inducing cytokine production. Despite advances in the understanding of the immunologic events leading to the development of skin diseases, no effective prevention measure exists. Current therapeutic treatments are based on either alleviating the symptoms or suppressing the immune system with immunosuppressive drugs. Allergen-specific immunotherapy is expected to induce specific T cells that abolish allergen-induced proliferation of T helper cells, as well as their cytokine production. Recent approaches using recombinant protein, polycytosine guanine oligonucleotides, and plasmid DNA for vaccination suggest the possibility of protection against these skin disorders. The involvement of T cells in psoriasis indicates that the development of a T-cell receptor peptide vaccine may be beneficial. Dendritic cell-based vaccines using tolerogenic dendritic cells that can induce T-cell tolerance have been shown to be useful in dealing with autoimmune disorders and allergic conditions. In the light of these developments, this article presents the current status and prospects of developing vaccines for allergic and other immunologic skin disorders.

Adalimumab: Psoriatic Arthritis

Off-Label Drug Uses

This Hospital Pharmacy feature is extracted from Off-Label DrugFacts, a quarterly publication available from Wolters Kluwer Health. Off-Label DrugFacts is a practitioner-oriented resource for information about specific FDA-unapproved drug uses. This new guide to the literature will enable the health care professional/clinician to quickly identify published studies on off-label uses and to determine if a specific use is rational in a patient care scenario. The most relevant data are provided in tabular form, so the reader can easily identify the scope of information available. A summary of the data—including background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations—precedes each table of published studies. References direct the reader to the full literature for more comprehensive information prior to patient care decisions. Direct questions or comments regarding “Off-Label Drug Uses” to hospitalpharmacy@drugfacts.com .

Cytokine and Anti-Cytokine Therapies for Psoriasis and Atopic Dermatitis

Since the discovery of cytokines as key mediators in inflammation, targeting the cytokine network has represented a promising therapeutic approach. Psoriasis and atopic dermatitis, as T cell-mediated diseases with a strong cytokine component and a high unmet medical need, have moved into the focus of experimental therapies. Whereas pro-inflammatory cytokines such as tumor necrosis factor (TNF)-alpha are overexpressed in both diseases, a type 1 cytokine pattern predominates in psoriasis and a type 2 cytokine pattern is of pathophysiological importance at least in the initial stages of atopic dermatitis. Strategies for intervention into the cytokine network have included antagonism of pro-inflammatory cytokines (e.g. TNFalpha, interleukin [IL]-1, IL-8, IL-12, IL-18, IL-23) with neutralizing antibodies and soluble receptors, application of recombinant cytokines (e.g. IL-4, IL-10, IL-11, interferon [IFN]-gamma) to shift the cytokine balance, and administration of small molecules to modulate cytokine expression or signaling. Results from the clinic have led to novel therapeutic options as well as a better understanding of the pathophysiology of inflammatory skin diseases. This review highlights the various therapeutic strategies, results from the clinic (that are in some cases preliminary), and insights that can be drawn from the more advanced clinical studies and the use of approved cytokine-directed therapies.

Immunomodulatory effects of a set of amygdalin analogues on human keratinocyte cells

Peptide T (PT) is an octapeptide shown to resolve psoriatic lesions. Our previous investigations suggest that keratinocytes play an important role in conditioning the therapeutic effects of the PT in psoriasis. However, peptides are not good therapeutic agents, because they exhibit poor absorption, are easily metabolized and are immunogenic. Using computational methods, the natural product amygdalin was identified as peptidomimetic of PT. However, amygdalin exhibits a toxic profile due to its cyanide group. To overcome this deleterious effect, we synthesized analogues lacking the cyanide group. Human keratinocytes were treated with PT or with three different peptidomimetics of PT. To study its effects on the expression of HSP-70, TGF-beta, alpha-v integrin, ICAM-1 and cytokines, we analysed the protein levels by Western blot and ELISA. Our results show that the different peptidomimetics of PT tested exhibit a similar biological behaviour in regard to the overexpression of HSP-70, TGF-beta and alpha-v integrin than the native peptide. TNF-alpha is overexpressed by PT and SVT-03018; between the other two analogs, SVT-03016 do not produce any significant change in regard to the control, while SVT-03017 shows only a moderate increase in regard to control. SVT-03018 provokes a remarkable upregulation of IL-10, stronger than SVT-03016, SVT-03017 and PT. All the other three analogues reduce comparably to the PT, the expression of ICAM-1 and do not increase the release of proinflammatory cytokines. The results highlighted that the three analogues of amygdalin with the cyanide group removed exhibit the same biological effects of PT. Therefore, they can be considered peptidomimetics, suggesting their possible use in the treatment of psoriasis.

Tratamiento de la psoriasis refractaria con etanercept

BACKGROUND AND OBJECTIVES

Etanercept is a dimeric fusion protein that binds to tumor necrosis factor and blocks inflammatory response. The purpose of this study was to assess the effects of etanercept and its maintenance in patients with severe and refractory psoriasis.

PATIENTS AND METHOD

Twenty two patients with severe and refractory psoriasis in an open-label clinical trial were studied. Patients received etanercept 50 mg/week subcutaneously during 6 months. PASI (Psoriasis Assessment and Severity Index) was used to monitor disease activity in each month of treatment and in the follow up. Results at weeks 12 and 24 are shown.

RESULTS

96% of patients improved their PASI basal score early at week 12. This improvement was maintained until week 24. Etanercept was well tolerated without any significant adverse reaction. Time until relapse was 2.27 +/- 0.59 months (CI 95%: 1.94-2.60).

CONCLUSION

Etanercept seems an effective therapy for severe and refractory psoriasis yet long-term dosing and safety studies of etanercept in psoriasic patients are needed.

Psoriasis vulgaris flare during efalizumab therapy does not preclude future use: a case series

Background

Severe psoriasis vulgaris can be extremely difficult to treat in some patients, even with the newer biological therapies available today.

Case presentations

We present two patients with severe chronic plaque psoriasis who received numerous systemic anti-psoriatic therapies with varied results. Both responded well to initial treatment with efalizumab (anti-CD11a), but then experienced a flare of their disease after missing a dose. However, after disease stablization, both patients responded well to re-introduction of efalizumab, one patient requiring concurrent treatment with infliximab (anti-TNF-α).

Conclusion

These cases are presented to characterize this "flare" reaction, and to inform health care providers that efalizumab can still be administered after disease flare, and again may be a successful therapy.