Rethinking the Psoriasis Area and Severity Index: the impact of area should be increased

Quality of Life in Psoriasis: A Cross-Sectional Study from North India

Background

Psoriasis is a chronic inflammatory papulo-squamous disease characterized by multiple remissions and relapses. This study aimed to assess the impact of psoriasis on the quality of life of patients.

Materials and Methods

A hospital-based, cross-sectional study was conducted enrolling 198 adult patients of psoriasis. The STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for observational studies were followed. Clinical severity of psoriasis was measured using Psoriasis Area Severity Index (PASI), and quality of life was measured by EuroQoL 5D (EQ-5D-5L, EQ-VAS) and Psoriasis Quality-Of-Life-12 (PQOL-12) Questionniares.

Results

Of the 198 patients, 71.7% (n = 142/198) were males with a mean age of 41.65 ± 13.19 years. The mean PASI score was 12.46 ± 11.51, and the mean PQOL-12 score was 50.18 ± 23.36. Up to 22.7% (n = 45) cases had 'severe' and 6.1% (n = 12) cases has 'very severe' PQOL-12 scores. Statistically significant correlation (P < 0.05) was observed between PASI scores and almost all domains of EQ-5D-5L and PQOL-12.

Conclusion

Psoriasis affects most psycho-social domains of a patient's life. Coping with these QOL issues remains a challenge to the patients in everyday life. The goal of management of psoriasis therefore must include measures to improve quality of life along with long-lasting remittance of physical symptoms.

Psoriatic Foot Involvement is the Most Significant Contributor to the Inconsistency Between PASI and DLQI: A Retrospective Study from China

Background

The Psoriasis Area and Severity Index (PASI) and the Dermatology Life Quality Index (DLQI) are important evaluation tools for assessing psoriasis severity and guiding treatment options. However, the scores of PASI and DLQI are often inconsistent.

Objective

This study aimed to identify the factors affecting the consistency between PASI and DLQI.

Methods

The retrospective study was based on 4125 patients. We collected the PASI, DLQI, demographic and clinical characteristics data.

Results

DLQI has a weak correlation with PASI (r=0.37; P<0.001). For the DLQI >10 groups, DLQI has almost no correlation with PASI (r=0.16; P<0.001). There are 43.60% of mild-to-moderate patients (PASI<10) in the DLQI>10 groups. Our adjusted model showed that foot (OR=2.109; 95% CI:1.581-2.815) involvement led to the greatest impairment of QoL except for PASI≥10 (OR=5.547; 95% CI:3.477-8.845). Furthermore, DLQI impairment was associated with female (OR=1.336; 95% CI:1.071-1.667); the age of 20-39 subgroup (OR=1.795; 95% CI:1.100-2.930); psoriatic arthritis (OR=1.718; 95% CI:1.208-2.443); higher income (OR = 1.408; 95% CI: 1.067-1.858); family history of psoriasis (OR=1.460; 95% CI:1.131-1.885). Moreover, the influence of exposed lesions (such as scalp; face; neck; nails; and hands) were positively associated with severely impaired QoL.

Conclusion

Dermatologists should recognize the underestimated disease burden of psoriasis patients and actively identify and treat mild-to-moderate patients with high burden. In particular, the foot was a significant contributor to the burden.

Correlation of Psoriasis Disability Index and Psoriasis Area and Severity Index: A Study from Afghanistan

Background

Psoriasis is a common skin disease that affects physical, psychological, and social well-being of patients. Several studies have assessed health-related quality of life of patients with psoriasis in different populations with large variations.

Objective

To investigate, for the first time, the impact of psoriasis on quality of life of Afghan patients with psoriasis.

Methods

This is a prospective observational study conducted at the dermatology department of Maiwand Teaching hospital in Kabul City during April 2018 to May 2019. Patients with plaque psoriasis with age ≥16 years were included in the study. Psoriasis Disability Index was used for the assessment of health-related quality of life. Psoriasis Area and Severity Index was used to define the severity of disease. Appropriate tests were performed using Statistical Package for Social Science.

Results

A total of 174 patients with psoriasis were included in the study, 89 of them were male (51.1%) and 85 of them were female (48.9%). The mean age of the patients was 27.7 years with 13.2 years SD, and the average duration of the disease was 3.2 years with 4.7 years SD. The mean of PASI score was 13.3 with 7.8 SD, while the mean of total PDI was 9.6 with 3.7 SD; there was a strong correlation between total PDI and PASI score (r=0.751, p<0.001). The mean of total PDI was higher among moderate-to-severe psoriasis, female patients, younger age, and those who were single.

Conclusion

Our study highlighted that psoriasis disability index was highly correlated with psoriasis area and severity index. Furthermore, the quality of life was more affected among female patients, patients younger than 40 years, and those patients who were single.

Estimation error of the body surface area in psoriasis: A comparative study of physician and computer-assisted image analysis (Image J)

BACKGROUND

Assessing the area involved, i.e., the body surface area (BSA), is essential in diagnosing the disease severity of psoriasis. However, the BSA estimated by physicians tends to be over-estimated and has shown high inter- and intra-rater variabilities. Furthermore, no reports suggesting the cause and clinical significance of overestimating the BSA results exist in psoriasis patients.

OBJECTIVES

We aimed to investigate the errors in estimating the BSA affected by psoriasis by comparing the physicians' results with those of computer-assisted image analysis (CAIA) and provide suggestions regarding the clinical implications of such errors.

METHODS

Using 43 images, 36 physicians visually estimated the BSA of psoriasis. Subsequently, the images were evaluated using CAIA (Image J). The BSA values determined by the physicians and CAIA were compared and matched. The BSA percentage was also graded from 0 to 6: no lesion (0), 1-9% (1), 10-29% (2), 30-49% (3), 50-69% (4), 70-89% (5), and 90-100% (6). Each grade range was divided, with the bottom and top 50% defined as the "first half" and "second half," respectively.

RESULTS

The average proportion of correct assessments by physicians was 49.4%. Physicians tended to overestimate the area involved by psoriatic lesions by 8.76%±8.82% compared to CAIA. The largest estimation error (proportion incorrect: 75.7%) was observed in Grade 3. Estimations located in the "second half" of the range demonstrated a higher proportion of inaccuracies compared to those in the "first half." An overestimating error occurred in certain morphological characteristics of the psoriatic lesions.

CONCLUSIONS

Inaccuracy of BSA estimation by physicians may be related that information from the human eye is perceived to be exaggerated compared to the actual size. Further research of using artificial intelligence (AI) technology is needed to reduce quantification error and develop an ideal BSA assessment system. Additionally, education and training are needed for physicians to accurately measure the BSA.

Application of the Statistical Method to Convert Published PASI 50/75/90/100 into Absolute PASI Response Rate in Patients with Moderate-to-Severe Plaque Psoriasis Treated with Tildrakizumab Based on Data from the Two Pivotal Phase 3 Studies reSURFACE 1 and reSURFACE 2

BACKGROUND

Absolute Psoriasis Area and Severity Index (PASI) is a key endpoint in psoriasis management. Petto et al. [Pharm Stat. 2019;18(1):4-21] developed a statistical method to estimate the proportion of patients reaching absolute PASI response given baseline PASI score and proportion of patients achieving relative improvements at predefined time points.

OBJECTIVES

To test this method on clinical data from two phase 3 tildrakizumab trials (reSURFACE 1/2) comparing estimated absolute PASI ≤1/≤2/≤3/≤5 responses with reference responses from clinical databases.

METHODS

Reference PASI responses of ≤1/≤2/≤3/≤5 were extracted from clinical databases. Estimation of absolute PASI ≤1/≤2/≤3/≤5 response rates at week (W) 12 and W28 by treatment and trial were performed. Differences between estimated and reference responses were analysed. Bland-Atman limits of agreement and Passing-Bablok regression to assess variations between estimated and reference responses were performed.

RESULTS

Differences between estimated and reference absolute PASI ≤1/≤2/≤3/≤5 responses at W12 and W28 by treatment and trial were of little clinical relevance with an overall mean difference in PASI response proportion of -2.2% (e.g., for the tildrakizumab 100-mg arm, original proportions of patients achieving PASI of ≤1/≤2/≤3/≤5 at W28 were 38.5%/52.2%/63.5%/73.9% and 39.8%/54.8%/63.6%/76.9% [reSURFACE 1 and 2, respectively] vs. estimated proportions of 33.2%/49.8%/62.5%/78.3% and 34.3%/51.6%/64.5%/79.9%). Limits of agreement were -7.1% to 1.4% at W12 and -6.8% to 4.3% at W28. Scatterplots revealed linearity that stood the cusum test in Passing-Bablok regression with slope 1.14 (95% confidence intervals: 1.06 to 1.20).

CONCLUSION

Good estimates of absolute PASI response rates were achieved with the application of the statistical method to tildrakizumab data reported in the phase 3 studies, in particular in the verum study arms. Our data support the method provided by Petto et al. [2019] to estimate proportions of psoriasis patients reaching absolute PASI value thresholds using relative PASI improvements.

Treatment Goals in Psoriasis: Which Outcomes Matter Most?

Psoriasis is a chronic immune-mediated inflammatory disease that predominantly affects the skin and joints. Its detrimental effects on the physical, psychosocial, and emotional well-being of patients leads to a significant reduction in quality of life (QoL). The goals of treatment focus on decreasing disease severity and improving QoL for patients; accomplishing these goals requires physicians to understand both the full impact of the disease on a patient's life and the outcomes that matter most to patients. The use of outcome measures, both physician- and patient-reported, can assist clinicians in evaluating the disease burden and its effect on QoL and in identifying patient preferences for treatment, ultimately enhancing quality of care. However, current outcome measures have many limitations and do not adequately capture patients' needs and priorities. Nevertheless, physicians treating patients with psoriasis are encouraged to utilize these instruments while remaining cognizant of each of their limitations. As there is no consensus on an outcome measure that fully encompasses the complexities of psoriasis and its impact on patients, instruments that are appropriate and applicable to dermatologists and their patients should be developed.

A Real-World, Non-interventional Indian Study Evaluating Intensive Plant-Based Butter Moisturizing Cream in Psoriasis

INTRODUCTION

Psoriasis is estimated to affect 0.44-2.8% of the Indian population. Moisturizers are a key adjuvant psoriasis treatment strategy, but data regarding their effectiveness, safety and compliance pattern in an Indian context are lacking. Hence, this real-world study on an intensive plant-based butter moisturizing cream (Venusia ® Max) was conducted among Indian patients with psoriasis.

METHODS

This was an observational, patient-reported outcomes (PRO) study in patients with psoriasis aged 18-75 years who were prescribed the cream in routine clinical practice, as per clinician's discretion, over 4 weeks. The primary outcome measure was improvement from baseline in quality of life assessed using the Dermatology Quality of Life Index (DLQI) at 4 weeks of the study period. The secondary outcome measures were improvement in dryness using the Dry Skin/Ichthyosis Area and Severity Index (DASI) score at 4 weeks, safety and compliance. The DLQI and DASI scores were recorded by the clinicians at baseline and after 2 (optional) and 4 weeks of starting the cream. Safety was assessed throughout the study.

RESULTS

The study included 400 patients from 9 outpatient dermatology centers across India. Of 400 patients, 384 completed the study. A significant reduction in both the mean DLQI score (66.7%; p < 0.001) and mean DASI score (84.6%; p < 0.001) was observed at week 4 after starting the cream vs. baseline in the overall population. Overall, the cream showed a good safety and compliance profile during the study period. There were no serious adverse events or deaths.

CONCLUSIONS

The evidence from the PRO study suggests that use of the intensive plant-based butter moisturizing cream in a real-world scenario has a noticeable impact on improving the quality of life and reducing the skin dryness associated with psoriasis over 4 weeks. The moisturizing cream may serve as a valuable adjuvant treatment option for the management of psoriasis.

TRIAL REGISTRATION NUMBER

CTRI/2017/03/008023.

FUNDING

Dr. Reddy's Laboratories Ltd.

Severity and Area Score for Hidradenitis (SASH): a novel outcome measurement for hidradenitis suppurativa

BACKGROUND

Hidradenitis suppurativa (HS) is a chronic, inflammatory skin disease with a large impact on patients' health-related quality of life. However, reliable and consistent outcome measures to assess body surface area (BSA) of HS have not been established.

OBJECTIVES

To develop and assess the reliability and validity of a novel outcome instrument for assessment of HS BSA in a clinical trial setting.

METHODS

Qualitative interviews and focus groups were conducted from July to August 2015 and October 2017 to January 2018. Evaluation of the measurement was assessed during a single-day grading session with patients in April 2018. Participants, who included clinicians or patients, were recruited from academic medical centres in the U.S. mid-Atlantic region.

RESULTS

Concept elicitation included input from 10 providers, of which 60% (n = 6) were female, 80% (n = 8) dermatology specialists and 20% (n = 2) gynaecology specialists. Cognitive debriefing was conducted with 11 providers, of which 82% (n = 9) were dermatologists and 18% (n = 2) gynaecologists. The evaluation stage included 10 clinicians and 23 patients. The intraclass correlation coefficient (ICC) for inter-rater reliability was 0·60 [95% confidence interval (CI) 0·44-0·74]. The ICC for intrarater reliability was 0·98 (95% CI 0·94-1·00). Transformation of the BSA score resulted in an increase in inter-rater reliability to 0·75 (95% CI 0·62-0·85) or 0·76 (95% CI 0·62-0·85). Scores all demonstrated concurrent validity, with statistically significant correlations with extant scoring methods.

CONCLUSIONS

This novel scale is a reliable and valid HS outcome instrument and may capture a wide range of patients by assessing BSA. Future research is necessary to demonstrate its responsiveness. What's already known about this topic? The major HS disease activity scales rely on lesions counts and have moderate-to-good reliability. Body surface area (BSA) is one of the physical signs included in the Core Outcome Set for HS, but is not a part of existing HS disease activity scales. What does this study add? A novel disease severity scale, the Severity and Area Score for Hidradenitis (SASH), was developed and the psychometric properties assessed. There was high inter-rater reliability of 0·75 and 0·76 when BSA was scored on an ordinal scale, and an excellent intrarater reliability of 0·98. The SASH score also demonstrated convergent validity with extant instruments. What are the clinical implications of this work? The ability of clinicians to accurately assess disease status will be improved. Implementation of the SASH score will help guide and assess the effectiveness of appropriate treatment choice.

Subclinical atherogenesis in patients with mild psoriasis: A role for IL-6?

Summary Introduction: A link of psoriasis with subclinical atherosclerosis has been postulated and cytokine network might intermediate this association. Few data are available in patients with mild psoriasis. We evaluated carotid intima-media thickness (cIMT) in drug-free psoriatic individuals and controls. In parallel, we searched for associations of cIMT with disease activity indexes and serum interleukins (IL) in psoriatic patients. Method: An experienced radiologist performed the cIMT analyses. Cytokine concentrations were assessed by flow cytometry. Disease activity was evaluated based on psoriasis area and severity index (PASI) as well as body surface area (BSA). Results: Sixty-five (65) patients and 64 controls were studied. Mean age of patients (50.9 years) did not differ from controls (p=0.362). A low PASI and BSA (< 10) prevailed (69.2% and 56.9%, respectively). Median levels of IL-12p70, TNF-α, IL-1β and IL-10 were significantly lower in cases than in controls (adjusted p<0.05), while IL-6 and IL-8 medians did not differ between groups (adjusted p>0.05). Smoking habit and diabetes mellitus predominated in cases (p=0.002). An altered cIMT (≥ 0.9 mm) was more frequent in cases than in controls (23.8% versus 8.5%, adjusted p=0.045). Mean cIMT was higher in cases with a borderline significance (p=0.057). cIMT scores did not correlate to PASI (rs=0.066; p=0.250) or BSA (rs=0.175; p=0.185), but did correlate significantly with serum IL-6 (rs=0.26; p=0.005). Conclusion: Subclinical atherosclerosis was more frequent in patients with mild psoriasis than controls. cIMT in psoriatic individuals correlated with serum IL-6, pointing to an eventual proatherogenic role of IL-6 in these patients. Newer studies should clarify the connection of atherogenesis with cytokines in psoriasis.

Safe Psoriasis Control: A New Outcome Measure for the Composite Assessment of the Efficacy and Safety of Psoriasis Treatment

Background:

PASI is an inadequate outcome measure for the assessment of psoriasis treatments. No currently used endpoints provide a benefit: risk assessment of treatment taking into consideration all available efficacy and safety data.

Objective:

To propose a new outcome measure called “safe psoriasis control” (SPC), which assesses multiple dimensions of the disease in a clinically meaningful way through the combined use of appropriate efficacy, quality of life, and safety data.

Methods:

Data from 3,500 subjects were used for the purpose of derivation and validation of the SPC endpoint. Advanced statistical methodology was used to evaluate and validate important components in the assessment of therapeutic benefit.

Results:

SPC was shown to be a simple but meaningful combined endpoint showing the proportion of patients who had treatment benefit without major side effects.

Conclusion:

The SPC endpoint may be a step-forward in providing a composite tool for the evaluation of treatments for psoriasis.

PASI (Psoriasis Area and Severity Index) in the evaluation of the clinical manifestations of psoriasis

Psoriasis is one of the most prevalent chronic inflammatory skin diseases. The severity of its clinical manifestations can vary greatly. Objective assessment of psoriasis severity is required to select an adequate therapy. One of the simplest and most consistent methods used to determine psoriasis severity is to calculate the PASI (Psoriasis Area and Severity Index). This index is based on the doctor’s determination of the sum of indices showing the intensity of the main symptoms of psoriasis: erythema, infiltration and peeling in view of the affected skin area. The PASI can also be used to assess the efficacy of treatment for psoriasis patients.

Facial Psoriasis Log-based Area and Severity Index: A valid and reliable severity measurement method detecting improvement of facial psoriasis in clinical practice settings

Facial psoriasis is often observed in moderate to severe degrees of psoriasis. While we previously demonstrated construct validity of the facial Psoriasis Log-based Area and Severity Index (fPLASI) system for the cross-sectional evaluation of facial psoriasis, its reliability and accuracy to detect clinical improvement has not been confirmed yet. The aim of this study is to analyze whether the fPLASI properly represents the range of improvement for facial psoriasis compared with the existing facial Psoriasis Area and Severity Index (fPASI) after receiving systemic treatments in clinical practice settings. The changing severity of facial psoriasis for 118 patients was calculated by the scales of fPASI and fPLASI between two time points after systemic treatments. Then, percentage changes (ΔfPASI and ΔfPLASI) were analyzed from the perspective of both the Physician's Global Assessment of effectiveness (PGA) and patients' Subjective Global Assessment (SGA). As a result, the distribution of the fPASI was more heavily clustered around the low score range compared with the fPLASI at both first and second visits. Linear regression analysis between ΔfPASI and ΔfPLASI shows that the correlation coefficient was 0.94, and ΔfPLASI represented greater percentage changes than ΔfPASI. Remarkably, degrees of clinical improvement measured by the PGA matched better with ΔfPLASI, while ΔfPASI underestimated clinical improvements compared with ΔfPLASI from treatment-responding groups by the PGA and SGA. In conclusion, the fPLASI represented clinical improvement of facial psoriasis with more sensitivity and reliability compared with the fPASI. Therefore, the PLASI system would be a viable severity measurement method for facial psoriasis in clinical practice.

A Comprehensive Assessment Tool for Psoriasis — An Unmet Need: Report from the GRAPPA 2014 Annual Meeting

Psoriasis is a chronic inflammatory skin condition that has several distinct clinical subtypes, the most common of which is plaque psoriasis. Other non-plaque subtypes, however, including scalp, nail, inverse, and palmoplantar, have been demonstrated to be more common than previously believed, are associated with a significant burden of disease, and are likely underdiagnosed and undertreated. Understanding the effects of these non-plaque psoriasis subtypes can be challenging given that the gold standard psoriasis tool, the Psoriasis Area and Severity Index, is mostly directed at plaque psoriasis. Therefore, a tool that can more comprehensively assess the psoriasis patient represents an unmet need in dermatology. Herein we discuss the concept of an ideal tool that addresses both plaque and non-plaque subtypes, with equal contribution from physician and patient, as discussed at the 2014 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

Systematic review of cost-effectiveness analyses of treatments for psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease of the skin that has a major effect on an individual's physical and mental function. The disease is associated with increased healthcare resource use and costs, therefore cost-effectiveness analysis (CEA) can be used to assist decision makers with determining which treatments are optimal within a constrained healthcare system budget.

OBJECTIVES

Our aim was to systematically review the current literature on the CEA of existing treatment options for psoriasis, assess the quality of these studies, and summarize the evidence on the drivers of cost effectiveness.

METHODS

A literature search using Medical Subject Headings and keywords was performed in the MEDLINE, EMBASE and Health Technology Assessment databases, as well as the National Health Service Economic Evaluation Database; the CEA Registry was searched using keywords only. All references within the relevant review articles were examined manually. Two researchers independently determined the final articles and a third researcher resolved any discrepancies. We evaluated study quality in terms of the study perspective, effectiveness measures, cost measures, economic model, and time horizon. Any sensitivity analyses conducted in the studies were examined to identify the drivers of cost effectiveness, which included any variables leading to changes in the study conclusions.

RESULTS

Fifty-three articles were included in our final review: 70% did not explicitly include costs related to adverse events; approximately one-quarter used quality-adjusted life-years; and 34% applied a time horizon under 1 year. In 18 of the 38 studies that conducted a sensitivity analysis, the cost-effectiveness results were impacted by uncertainty. The main key drivers of cost effectiveness were the costs related to the treatment, values and choice of efficacy, utility values, hospitalization for non-responders, time horizon, model structure, and utility mapping method.

CONCLUSIONS

High-quality cost-effectiveness studies are required to facilitate resource allocation decision making. To improve study quality, future research should provide evidence on the long-term experience with psoriasis treatments, and resolve the uncertainty associated with key drivers of cost effectiveness.

Detection of Small Changes in Psoriasis Intensity with PrecisePASI

BACKGROUND

The Psoriasis Area and Severity Index (PASI) is the score of choice to grade psoriasis severity and detect clinical changes. Due to low resolution based on the calculation of the score by fixed area classes, PASI scores <10 have little value.

METHODS

At 756 patient examinations, psoriasis activity was measured with both PASI and PrecisePASI.

RESULTS

PrecisePASI has a linear increase while PASI has a staircase pattern. Both scores meet at the endpoint-relevant values of body surface area (BSA) 10, 30, 50, 70 and 90%. PASI and PrecisePASI correlate significantly over the whole range of BSA. In the region of BSA <5%, PrecisePASI shows a significantly higher resolution (p < 0.0001).

CONCLUSION

The calculation of PrecisePASI corrects the undesired inaccuracies of PASI in the lower BSA ranges and is a tool to use as an endpoint in trials aiming to detect differences in the lower ranges of BSA.

The Brigham Scalp Nail Inverse Palmoplantar Psoriasis Composite Index (B-SNIPI): a novel index to measure all non-plaque psoriasis subsets

Psoriasis is a chronic inflammatory disease that encompasses a large spectrum of clinically distinct subtypes. Although chronic plaque psoriasis is reported as the most common form of psoriatic skin disease, there is growing evidence that other variants including scalp, nail, inverse, and palmoplantar psoriasis are prevalent, undertreated, and associated with significant impairment in quality of life. Currently, the Psoriasis Area and Severity Index (PASI) is the standard to assess psoriasis severity as well as response to treatment; however, the PASI has several limitations. In response to this need and as a complementary objective measure to the PASI, we created the Brigham Scalp Nail Inverse Palmoplantar Psoriasis Composite Index (B-SNIPI), based on patient-surveyed, patient-reported outcomes equally weighted with physician assessment of disease activity. Herein we summarize the B-SNIPI as presented at the 2013 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

Computer-aided analysis with Image J for quantitatively assessing psoriatic lesion area

BACKGROUND/AIMS

Body surface area is important in determining the severity of psoriasis. However, objective, reliable, and practical method is still in need for this purpose. We performed a computer image analysis (CIA) of psoriatic area using the image J freeware to determine whether this method could be used for objective evaluation of psoriatic area.

METHODS

Fifteen psoriasis patients were randomized to be treated with adalimumab or placebo in a clinical trial. At each visit, the psoriasis area of each body site was estimated by two physicians (E-method), and standard photographs were taken. The psoriasis area in the pictures was assessed with CIA using semi-automatic threshold selection (T-method), or manual selection (M-method, gold standard). The results assessed by the three methods were analyzed with reliability and affecting factors evaluated.

RESULTS

Both T- and E-method correlated strongly with M-method, and T-method had a slightly stronger correlation with M-method. Both T- and E-methods had a good consistency between the evaluators. All the three methods were able to detect the change in the psoriatic area after treatment, while the E-method tends to overestimate.

CONCLUSION

The CIA with image J freeware is reliable and practicable in quantitatively assessing the lesional of psoriasis area.

Item-level psychometric properties for a new patient-reported psoriasis symptom diary

OBJECTIVES

This research evaluated the psychometric properties of a new Psoriasis Symptom Diary, identified diary responder definitions for use in determining whether a patient has experienced clinically meaningful change, and refined diary item content for use in future clinical trials.

METHODS

The Psoriasis Symptom Diary was administered in a phase 2 clinical trial of AIN457 to US adult outpatients (N = 172) with physician-diagnosed moderate to severe chronic plaque-type psoriasis. Participant compliance with daily diary administration and item score variability, reliability, construct and discriminant validity, sensitivity to change, and interpretation were all evaluated.

RESULTS

Participants completed 94% of scheduled diary assessments across 12 study weeks. Diary items were generally normally distributed, and no floor or ceiling effects were observed. Item reliability (reproducibility) was acceptable (intraclass correlation coefficients > 0.80), with an exception for one item (skin color). At week 12, items significantly related to criterion measures as predicted (Psoriasis Area and Severity Index r = 0.27-0.57; Investigator's Global Assessment r = 0.25-0.59), with the exception of items that measured skin color and difficulty using hands. Most items generated change scores that were synchronous to changes as measured by the Psoriasis Area and Severity Index, Investigator's Global Assessment, Dermatology Life Quality Index (r > 0.37), as well as the Patient Global Impression of Change. Responders experienced a 2- to 3-point and 3- to 5-point change in item scores for minimal and large improvements, respectively. Four items that did not perform well were dropped from the diary.

CONCLUSIONS

The 16-item Psoriasis Symptom Diary demonstrated favorable psychometric properties and is a brief, useful tool for measuring patient-based symptoms and the impact of chronic plaque psoriasis.

Psoriasis Outcome Measures: A Report from the GRAPPA 2012 Annual Meeting

Psoriasis is a multisystem disease. The cutaneous and musculoskeletal manifestations (psoriatic arthritis) are well recognized. However, the other manifestations of psoriatic disease including metabolic syndrome, atherosclerotic cardiovascular disease, depression, poor self-esteem, and self-destructive habits including obesity, smoking and excess alcohol consumption are underappreciated. At the 2012 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members addressed the need to develop uniform, validated, standardized outcome measures for psoriatic disease, measures that are useful to all stakeholders including patients, physicians, regulators, and payers.

Application and Modifications of Minimal Disease Activity Measures for Patients with Psoriatic Arthritis Treated with Adalimumab: Subanalyses of ADEPT

Objective.

This posthoc analysis evaluated the percentage of patients with psoriatic arthritis (PsA) who achieved minimal disease activity (MDA) and compared the results with a modified MDA substituting the physician global assessment (PGA) for the Psoriasis Activity and Severity Index (PASI) using data from the ADalimumab Effectiveness in Psoriatic Arthritis Trial (ADEPT; NCT00646386).

Methods.

Patients with active PsA were randomized to receive adalimumab 40 mg or placebo every other week for 24 weeks. MDA was defined as achieving ≥ 5 of the following criteria: tender joint count ≤ 1; swollen joint count ≤ 1; PASI ≤ 1 or body surface area ≤ 3%; patient pain score ≤ 15 [1–100 mm visual analog scale (VAS)]; patient global assessment (PGA) of disease activity ≤ 20 (1–100 mm VAS); Health Assessment Questionnaire ≤ 0.5; and tender entheseal points ≤ 1 (only heels assessed). For modification of the MDA, PASI ≤ 1 was substituted with PGA “Clear” as MDAPGA1 and PGA “Clear” or “Almost clear” as MDAPGA2.

Results.

Sixty-seven patients were treated with adalimumab and 69 with placebo. At Week 24, MDA, MDAPGA1, and MDAPGA2 were achieved by 39%, 37%, and 39%, respectively, of patients treated with adalimumab versus 7%, 5%, and 8% of patients on placebo (p < 0.001). Kappa coefficients indicated good agreement between PASI and PGA at Week 24.

Conclusion.

ADEPT results indicated that significantly more patients treated with adalimumab achieved MDA by Week 24 compared with placebo. Modification of the MDA by replacing PASI ≤ 1 with PGA assessments did not alter the results, which may improve feasibility of practical use of the index.

Increased frequency of restless legs syndrome in atopic dermatitis

BACKGROUND

Restless legs syndrome (RLS) is characterized by an unpleasant sensation in the legs, which is difficult to describe, but produces an urge to move the legs frequently.

AIM

To assess the prevalence and severity of RLS in patients with atopic dermatitis (AD) and patients with psoriasis, and to investigate the factors potentially associated with RLS.

METHODS

In total, 253 people were enrolled (120 with AD, 50 with psoriasis and 83 healthy controls). A diagnosis of RLS was made according to the criteria of the International RLS Study Group (IRLSSG), and severity was assessed using the IRLSSG severity scale.

RESULTS

RLS was significantly more common in patients with AD (40.8%) than in patients with psoriasis (18.0%) or in controls (10.8%) (P<0.01 and P<0.001, respectively). Prevalence of RLS was higher in patients with active AD than in those with inactive AD (55.3% vs. 23.6%) or controls. There was a significant difference in RLS prevalence between patients with active and those with iactive AD, between patients with active AD and healthy controls, between patients with active AD and patients with psoriasis, and between patients with inactive AD and healthy controls (P<0.001, P<0.001, P<0.001, P=0.04, respectively). There was no significant difference in RLS prevalence between patients with active AD and patients with psoriasis, or between patients with psoriasis and healthy controls (P>0.05). Of patients who were positive for RLS, 56.9% had a family history of atopy and 40.3% had a family history of RLS, and there was a significant relationship between the presence of RLS and family history of atopy or RLS (P<0.001 for both).

CONCLUSIONS

RLS is common in patients with AD, particularly in those with active disease.

The investigation of autonomic functions in patients with psoriasis

BACKGROUND

Psoriasis is a common Th1-mediated skin disease whose etiology remains obscure. Loss of sweating caused by retention hyperkeratosis is seen in psoriasis plaques, which is likely to have resulted from autonomic dysfunction.

OBJECTIVE

In the present study, we aimed to evaluate autonomic nervous system (ANS) functions with regard to psoriasis and to examine whether there is an underlying ANS dysfunction.

MATERIALS AND METHODS

Fifty adult patients with plaque-type psoriasis and 20 healthy controls were enrolled in the present study. RESULTS  In this study, R-R interval variation (RRIV) was used to evaluate the parasympathetic system. No statistically significant difference was detected when RRIV values of the patient and the control groups were evaluated during normal and deep breathing (P > 0.05). It was determined that parasympathetic activity in the patient group remained unaffected. The sympathetic skin response (SSR) method was used for the evaluation of the sympathetic system. It was found that SSR latency and amplitude values of upper and lower extremities of the patient group were prolonged in comparison to those of the control group. The change in SSR latency of the upper extremity was found to be statistically significant (P < 0.05), whereas the changes in hand amplitude, foot latency, and foot amplitude values were not statistically significant (P > 0.05). It was determined that sympathetic activity in the patient group was affected.

CONCLUSION

In conclusion, we detected that a dysfunction was present in sympathetic nervous systems of patients with psoriasis. The parasympathetic nervous system functions were normal in patients with psoriasis.

Gender and the treatment of immune-mediated chronic inflammatory diseases: rheumatoid arthritis, inflammatory bowel disease and psoriasis: an observational study

BACKGROUND

Rheumatoid arthritis (RA), inflammatory bowel disease (IBD), and psoriasis are immune-mediated inflammatory diseases with similarities in pathophysiology, and all can be treated with similar biological agents. Previous studies have shown that there are gender differences with regard to disease characteristics in RA and IBD, with women generally having worse scores on pain and quality of life measurements. The relationship is less clear for psoriasis. Because treatment differences between men and women could explain the dissimilarities, we investigated gender differences in the disease characteristics before treatment initiation and in the biologic treatment prescribed.

METHODS

Data on patients with RA or IBD were collected from two registries in which patients treated with biologic medication were enrolled. Basic demographic data and disease activity parameters were collected from a time point just before the initiation of the biologic treatment. For patients with psoriasis, the data were taken from the 2010 annual report of the Swedish Psoriasis Register for systemic treatment, which included also non-biologic treatment. For all three diseases, the prescribed treatment and disease characteristics were compared between men and women.

RESULTS

In total, 4493 adult patients were included in the study (1912 with RA, 131 with IBD, and 2450 with psoriasis). Most of the treated patients with RA were women, whereas most of the patients with IBD or psoriasis were men. There were no significant differences between men and women in the choice of biologics. At treatment start, significant gender differences were seen in the subjective disease measurements for both RA and psoriasis, with women having higher (that is, worse) scores than men. No differences in objective measurements were found for RA, but for psoriasis men had higher (that is, worse) scores for objective disease activity measures. A similar trend to RA was seen in IBD.

CONCLUSIONS

Women with RA or psoriasis scored significantly higher on subjective, but not on objective, disease activity measures than men, and the same trend was seen in IBD. This indicates that at the same level of treatment, the disease has a greater effect in women. These findings might suggest that in all three diseases, subjective measures are discounted to some extent in the therapeutic decision-making process, which could indicate undertreatment in female patients.

Development of a preliminary US power Doppler composite score for monitoring treatment in PsA

OBJECTIVE

To develop a preliminary power Doppler (PD) US composite score for global assessment of PsA patients.

METHODS

Sixteen PsA patients receiving anti-TNF-α therapy were enrolled. All patients were involved in multiple psoriatic targets, including joints, tendon, enthesis, skin and nail. The target with the highest PD signal, one for each target area, was selected to be scanned at baseline and at follow-up visit 8 weeks after. For each target, PD was graded according to semi-quantitative scoring systems. Inter- and intra-observer reliability and feasibility was also investigated. The new PD composite score for PsA was called Five Targets PD for Psoriatic Disease (5TPD).

RESULTS

Sixty targets (16 joints, 9 tendons, 11 enthesis, 16 psoriatic plaques and 8 psoriatic onychopathies) were assessed. A significant improvement of the clinical scores was found at follow-up with respect to the baseline: HAQ modified for SpA (HAQ-S) (P = 0.0001); Psoriasis Area and Severity Index (P = 0.0001) and Nail Psoriasis Severity Index (P = 0.35). The 5TPD showed a significant change between baseline and follow-up (P = 0.0001). There was no significant correlation between HAQ-S and 5TPD findings. The inter- and intra-observer κ-values varied from good to excellent at baseline and follow-up. The time spent on baseline US examinations was mean (s.d.) 10.5 (2.0) min and no more than 7 min for follow-up assessment.

CONCLUSION

The present study provides a new working hypothesis that the sonographic core set may be useful to construct a PDUS composite score for the assessment of PsA. The 5TPD formula provides a feasible and reliable approach for multi-target monitoring of psoriatic disease.

Inter-rater concordance study of the PASI (Psoriasis Area and Severity Index)

BACKGROUND

Developed in 1978, the PASI (Psoriasis Area and Severity Index) is a method to rate psoriasis severity. Since then, it has been criticized for being extremely long, complex and for yielding significantly divergent interpretations.

OBJECTIVE

To determine the PASI inter-rater reliability among three independent evaluators examining the same patients.

METHODS

Cross-sectional study conducted in 2007 at a psoriasis treatment center, where 20 patients were selected. The patients were evaluated by three postgraduate students of Dermatology who independently determined the PASI of each patient. The inter-rater reliability coefficient was determined by employing intraclass correlation coefficients (ICC) and Bland & Altman plots.

RESULTS

An ICC of 0.729 (IC 95%: 0.440 - 0.882) showed a significant degree of concordance among evaluators. By graphic means, the Bland & Altman plot method presents concordance gap ranges. As shown in this study, narrow gap ranges indicate a good concordance degree. It was also observed that for high PASI values, wider concordance gap ranges predominate.

CONCLUSION

Based on this analysis, we may conclude that the PASI is a reliable indicator of psoriasis severity because it shows significant concordance when independent evaluations are performed.

Clinical improvement in psoriasis with treatment of associated hyperlipidemia

Psoriasis is associated with an increased risk of cardiovascular disease, a principal cause of which is atherosclerosis caused by hyperlipidemia. However, it is not known whether treatment of hyperlipidemia in patients with psoriasis lead to clinical improvement in psoriasis condition. In this study, the authors summarize the existing literature relevant to this inquiry. They also describe the potential pathways believed to link psoriasis with atherosclerosis and the role of hyperlipidemia therapy in this setting. A few studies indicated clinical improvement in psoriasis with treatment of associated hyperlipidemia. Some studies showed that a low-fat diet improved psoriasis. Others indicated a decreased risk of psoriasis associated with intake of cholesterol-lowering drugs such as "statins." Treatment with statins increased lactate dehydrogenase level and diminished Psoriasis Area and Severity Index score, ie, reduced cutaneous lesion in psoriasis. Beneficial effects of statin therapy on psoriasis included downregulation of lymphocyte function-associated antigen-1, inhibition of leukocyte endothelial adhesion, extravasation and natural killer cell activity, inhibition of proinflammatory cytokines such as tumor necrosis factor-alpha and interleukin 1 and 6, lowering of C-reactive protein, promotion of a T(H)1 to T(H)2 cells and inhibition of T(H)1 cytokine receptors on T cells, leading to inhibition of activation of lymphocytes and infiltration into the inflammation sites. Taken together, current literature indicates clinical improvement in psoriasis condition with treatment of associated hyperlipidemia, particularly with statins of which the mechanisms could be attributed to immunomodulatory and anti-inflammatory effects.

Disease measurement--enthesitis, skin, nails, spine and dactylitis

Outcome measurement is a key part of study design but presents particular challenges in spondyloarthropathy. Enthesitis and dactylitis are typical features of spondyloarthropathy and validated scoring systems for both are available, although the majority of enthesitis outcome measures are validated in ankylosing spondylitis (AS) only. Assessment of axial disease is well researched in AS and composite outcome measures are routinely used. However, assessment of axial disease in predominantly peripheral arthritis, such as psoriatic arthritis, is problematic and under-researched. Extensive research in dermatology has provided multiple outcome measures for skin psoriasis. The psoriasis area and severity index (PASI) remains the most common outcome measure used, despite the fact that significant problems exist with this scale and that newer scoring methods and modifications of the PASI show better validity. Nail psoriasis is accurately measured by detailed scoring systems but these can be time-consuming.

Clinically validated approaches to the treatment of autoimmune diseases

IMPORTANCE OF THE FIELD

Autoimmune diseases are pathological conditions in which "self-tolerance" has been broken, and an immune response has been mounted against the body's own tissues. More than seventy autoimmune diseases have been described, some of which are systemic and others of which are organ-specific. Although many of these diseases are rare, the collective prevalence of autoimmune diseases in the United States alone is between 5 and 8%, and is increasing.

AREAS COVERED IN THIS REVIEW

Herein, we review the exciting advances made during the past decade (1999 - 2009) in the development of clinically-validated agents for the treatment of autoimmune disease. We focus on five of the most prevalent conditions: rheumatoid arthritis, psoriasis, multiple sclerosis, Crohn's disease, and systemic lupus erythematosus. The discussion is largely restricted to agents - both small molecules and macromolecules - that have advanced through randomized, controlled clinical trials.

WHAT THE READER WILL GAIN

An overview of the pathogenesis of each disease is provided, along with a description of the therapies. Results from pivotal clinical trials are tabulated for four of the disease areas. We also provide summaries of experiences with both failed clinical trials and side effects observed during the course of clinical investigations. We conclude the review with thoughts on current challenges in the field and the prospect for future innovations.

TAKE HOME MESSAGE

During the past decade, some of the largest advances in the treatment of autoimmune disease have arisen from highly potent and selective macromolecule-based therapies (e.g. antibodies, recombinant proteins and fusion proteins). Together, these clinical experiences have provided insight into the critical mechanisms in autoimmune pathogenesis, including inflammatory cytokine release, T-cell migration and co-stimulation, and B-cell function.

The role of host and environmental factors in the epidemiology of rumpwear in brushtail possums

Rumpwear is a common, but poorly defined and understood disease of brushtail possums (Trichosurus spp.) in Australia and New Zealand, resulting in varying degrees of fur loss. Populations of Trichosurus cunninghami (mountain brushtail possum) and T. vulpecula (common brushtail possum) were studied over two years at Boho South (Victoria), to describe the disease, investigate its prevalence and explore its epidemiology. The main type of lesion observed was coat damage in the lumbo-sacral region, and increased severity of rumpwear was related to decreased coat length and increased hair breakage. Significant skin lesions were rare and hair breakage patterns suggested mechanical damage. Rumpwear was very prevalent in both T. cunninghami and T. vulpecula, but very severe rumpwear was rare. There was no true seasonal pattern to the prevalence of rumpwear in T. cunninghami and sex and habitat did not affect prevalence or severity. Prevalence and severity of rumpwear did, however, increase with age. There were no significant relationships between the number of previous captures or body condition index with rumpwear.

[Psoriatic arthritis. Treatment outcome parameters]

Psoriatic arthritis (PsA) has increasingly attracted the attention of clinical research in recent years with regard to long-term clinical registries, studies on epidemiology, genetics, and therapy. However, the methodology for assessing disease activity, damage and progression, as well as the resulting definition of treatment outcome parameters have progressed far less in PsA as compared to other rheumatic diseases such as rheumatoid arthritis (RA). Most of the assessment methodologies have been adapted from clinical trials on RA, ankylosing spondylitis, or psoriasis, but have not yet been validated for use in PsA. This article gives an overview of general rheumatological and PsA-specific assessment methods and outcome parameters of PsA therapy.