The role of drugs in the induction and/or exacerbation of psoriasis

Risk Factors for Psoriasis Flares: A Narrative Review

Psoriasis is a chronic inflammatory cutaneous disease with multifactorial pathogenesis involving both genetic and environmental factors as well as the innate and acquired immune response. Several triggering factors may exacerbate or worsen the disease. In this context, we performed a review manuscript with the aim of investigating current literature on psoriasis risk factors, also showing possible mechanisms by which they act on psoriasis. Globally, risk factors can be divided in classic risk factors (eg, mechanical stress, infections and dysbiosis of the skin, common drugs, environment and pollution, lifestyle, psychological stress, hormonal and metabolic alterations) which have long been known to be responsible for worsening and/or reoccurrence of psoriatic manifestations, and emerging risk factors (eg, biological drugs, immunotherapy for oncologic disease, Covid-19, and vaccines) defined as those newly identified risk factors. Accurate patient information and monitoring of risk factors as well as planned follow-ups may help to prevent and treat the worsening of psoriasis and consequently improve the quality of life of psoriatic patients.

The Causal Association Between Medication Intake and Increased Risk of Psoriasis

INTRODUCTION

Psoriasis is a chronic, inflammatory, and papulo-squamous skin disorder without a radical cure. Although previous observational analyses have discovered a relationship between medication intake and increased risk of psoriasis, they are susceptible to confounders.

OBJECTIVES

We intend to ascertain if there is a causal association between specific medication intake and increased risk of psoriasis by utilizing the Mendelian randomization (MR) method.

METHODS

We obtained the genome-wide association study (GWAS) data for medication intake (23 types, N = 1809) from UK Biobank samples. And we sourced the GWAS data for psoriasis from the 8th release of the FinnGen database, which included 8,075 psoriasis cases and 330,975 healthy control cases. Then a two-sample MR study was performed to determine their causal association, and inverse-variance-weighted MR (IVW-MR) was applied to calculate the effect estimates.

RESULTS

The IVW-MR analysis uncovered a positive correlation between the intake of HMG CoA reductase inhibitors and the increased risk of psoriasis (odds ratio [OR] = 1.167, 95% confidence interval [CI] = 1.084-1.257). Similarly, the use of thyroid preparations (OR=1.080, 95% CI=1.026-1.138), nonsteroidal anti-inflammatory and antirheumatic products (OR=1.406, 95% CI=1.037-1.908), anilides (OR=1.379, 95% CI=1.004-1.894), antihistamines for systemic use (OR=1.341, 95% CI=1.104-1.630), and antihypertensives (OR=1.099, 95% CI=1.016-1.190) were associated with an increased risk of psoriasis. We did not find evidence from IVW-MR for other associations.

CONCLUSIONS

Our study offers a causal testimony that the intake of HMG CoA reductase inhibitors, thyroid preparations, nonsteroidal anti-inflammatory and antirheumatic products, anilides, antihistamines for systemic use, and antihypertensives will potentially increase the risk of psoriasis.

The Involvement of Semaphorins in the Pathogenesis of Skin Diseases

Semaphorins belong to a group of membrane and secretory proteins that act as ligands for several receptor families and are involved in modulating cell signaling pathways. They bind multimeric receptor complexes on the cell membrane to exert their effects and initiate unique intracellular signal transduction cascades. These proteins can influence several processes that are very important for cell function, such as cell division and differentiation. Semaphorins are involved in cell migration, apoptosis, cell adhesion, aggregation, and numerous immune processes due to their immunoregulatory effects. Semaphorins are expressed in keratinocytes, which is why they have become a target for studies on the pathogenesis of skin diseases. Most studies to date on the role of semaphorins in the pathogenesis of skin diseases have been carried out in cellular or animal models, and there are few clinical studies evaluating the role of semaphorins in the pathogenesis and therapy of skin diseases. In this narrative review, we summarized the current state of knowledge on the role of semaphorins in the pathogenesis of skin diseases and their potential importance as targets for therapy. We also tried to present the key findings and weaknesses of previous research in this field. The novelty of this article lies in the comprehensive presentation of the role of semaphorins in the pathogenesis of skin diseases, including the results of studies on cell cultures and animal models, elucidating the mechanisms and signaling pathways through which semaphorins affect the development of skin diseases, as well as on the presentation of the results of existing clinical trials evaluating the role of semaphorins in the pathogenesis of skin diseases, and as potential therapeutic targets.

Targeting cyclin-dependent kinases in rheumatoid arthritis and psoriasis - a review of current evidence

INTRODUCTION

Rheumatoid arthritis (RA) is a chronic inflammatory disease associated with synovial proliferation and bone erosion, which leads to the structural and functional impairment of the joints. Immune cells, together with synoviocytes, induce a pro-inflammatory environment and novel treatment agents target inflammatory cytokines. Psoriasis is a chronic immune-mediated skin disease, and several cytokines are considered as typical mediators in the progression of the disease, including IL-23, IL-22, and IL-17, among others.

AREA COVERED

In this review, we try to evaluate whether cyclin-dependent kinases (CDK), enzymes that regulate cell cycle and transcription of various genes, could become novel therapeutic targets in RA and psoriasis. We present the main results of in vitro and in vivo studies, as well as scarce clinical reports.

EXPERT OPINION

CDK inhibitors seem promising for treating RA and psoriasis because of their multidirectional effects. CDK inhibitors may affect not only the process of osteoclastogenesis, thereby reducing joint destruction in RA, but also the process of apoptosis of neutrophils and macrophages responsible for the development of inflammation in both RA and psoriasis. However, assessing the efficacy of these drugs in clinical practice requires multi-center, long-term clinical trials evaluating the effectiveness and safety of CDK-blocking therapy in RA and psoriasis.

2022 Taiwanese Dermatological Association (TDA), Taiwanese Association for Psoriasis and Skin Immunology (TAPSI), and Taiwan Society of cardiology (TSOC) joint consensus recommendations for the management of psoriatic disease with attention to cardiovascular comorbidities

Psoriatic disease is a chronic inflammatory disorder with skin and joint manifestations. Due to the persistent inflammatory state exhibited by patients with psoriasis, multiple systemic comorbidities occur more frequently in patients with psoriasis than in the general population, and the risk of cardiovascular (CV) diseases is significantly increased. As the pathophysiology of psoriatic disease is becoming better understood, the sharing of underlying pathogenic mechanisms between psoriatic and CV diseases is becoming increasingly apparent. Consequently, careful attention to CV comorbidities that already exist or may potentially develop is needed in the management of patients with psoriasis, particularly in the screening and primary prevention of CV disease and in treatment selection due to potential drug-drug and drug-disease interactions. Furthermore, as the use of effective biologic therapy and more aggressive oral systemic treatment for psoriatic disease is increasing, consideration of the potential positive and negative effects of oral and biologic treatment on CV disease is warranted. To improve outcomes and quality of care for patients with psoriasis, the Taiwanese Dermatological Association, the Taiwanese Association for Psoriasis and Skin Immunology, and the Taiwan Society of Cardiology established a Task Force of 20 clinicians from the fields of dermatology, cardiology, and rheumatology to jointly develop consensus expert recommendations for the management of patients with psoriatic disease with attention to CV comorbidities.

Case Report: Coexistence of bullous pemphigoid and psoriasis: Therapeutic challenge and IL17A-targeted parallel treatment strategy

Autoimmune blistering diseases of the skin have all been reported in patients with psoriasis, bullous pemphigoid (BP) being the most frequently observed. The pathophysiologic triggers for BP in psoriatic patients are unclear. Recent observational studies have suggested that chronic psoriatic inflammation may cause pathological changes to the basement membrane zone, thus inducing autoimmunity against BP antigens through cross reactivity and “epitope spreading.” The coexistence of BP and psoriasis poses challenging therapeutic dilemmas related to the incompatibility of their standard treatments. Considering the probable common immunologic mechanisms in the pathogenesis of these inflammatory skin disorders, a suitable treatment regimen should be applied for their parallel control. We report three patients, who developed BP in the course of preceding long-lasting psoriasis. Secukinumab was administered as first-line treatment with promising therapeutic effect for both skin disorders and long-term disease control in two of the cases. In the third case, parallel disease control was initially achieved with methotrexate. A few years later, secukinumab was used for the treatment of a relapse of both dermatoses but worsening of BP was observed and methotrexate was reintroduced. Our experience on the therapeutic potential of secukinumab in BP is supported by the data in the literature. Recently, it was demonstrated that the proinflammatory cytokine IL17A has a functional role in the process of skin inflammation in BP, similarly to psoriasis. IL17A inhibition has emerged as a promising therapeutic strategy in patients with extensive or refractory BP but paradoxical development of BP after secukinumab treatment for psoriasis has also been described. This controversy emphasizes the need for further investigation into the development of optimal treatment strategies and recommendations.

Lithium-Associated Generalized Ostraceous Psoriasis Treated with Adalimumab: A Case Report

Ostraceous psoriasis is a rare variant of psoriasis, characterized by severe hyperkeratotic lesions resembling an oyster shell. Adalimumab is a biological agent that antagonizes tumor necrosis factor (TNF) and is used clinically in plaque psoriasis. Some medications such as lithium carbonate (LC) may aggravate or trigger psoriasis. Here, we describe a case of generalized ostraceous psoriasis associated with lithium carbonate, whose lesions completely improved after discontinuing lithium carbonate and using adalimumab.

Antidepressants and the Risk of Psoriasis Induction: A Case-Control Study

Background

Psoriasis (PSO) is a common chronic autoimmune skin disease with a significant psycho-socio-economic burden. Some antidepressants (ADs) such as fluoxetine and bupropion can induce or exacerbate PSO. This study aimed to investigate the correlation between ADs history before PSO onset, and the risk of PSO induction, in Isfahan province, Iran.

Materials and Methods

In this case-control study, 80 patients with PSO were selected by non-probability sampling method, and 80 healthy individuals were selected using simple random sampling. They were interviewed and medical information was recorded. Chi-square, Mann-Whitney, and Kruskal-Wallis tests for dichotomous or categorical data, and independent-sample t test for continuous data were used. Statistical significance was taken as P ≤ 0.05.

Results

In this case-control study, a total of 160 individuals, 80 participants in each group, were included. The mean age of the total samples was 44.8 ± 16 years. Forty-three percent of the individuals were women. PSO familial history in the cases was significantly higher than the control group (OR = 11.94, P = 0.001). It was revealed that use of ADs by patients before PSO induction, was greater than the controls (OR = 2.78, P = 0.058).

Conclusions

Past history of ADs in the cases before PSO onset, was higher than the controls, indicating a possible association between ADs and the risk of PSO induction. This study can be effective to pay more attention to the possible complications of ADs and PSO risk factors. Accurate knowledge of PSO risk factors will be useful for better management and morbidity reduction.

The Intriguing Links between Psoriasis and Bullous Pemphigoid

The coexistence of psoriasis with autoimmune bullous diseases (AIBDs), particularly bullous pemphigoid (BP), has been documented in case reports and series, as well as in epidemiological studies. The onset of psoriasis precedes that of BP in the majority of cases. Patients with concomitant BP and psoriasis are generally younger at the onset of BP and present with fewer erosions and blisters as compared with patients suffering from isolated BP. Intriguingly, it has been speculated that some BP cases with comorbid psoriasis can actually correspond to anti-laminin gamma-1 pemphigoid, a rare form that was recently recognized as a distinct entity and which can mimic BP and/or other subepidermal AIBDs. The pathomechanisms underlying the BP-psoriasis association have not yet been identified, although several hypotheses have been proposed. The most credited among such hypotheses involves the so-called "epitope spreading" phenomenon, with tissue injury secondary to a primary inflammatory process (i.e., psoriasis) leading to the exposure of sequestered antigens evoking a secondary autoimmune disease (i.e., bullous pemphigoid). This narrative review aims to give a brief overview of the association between psoriasis and BP, examining epidemiological, clinical, and immunopathological features, the pathomechanisms underlying this association, the treatments for psoriasis incriminated as potential triggers of BP, and the therapeutic management of patients with psoriasis and BP.

Nanoscale Topical Pharmacotherapy in Management of Psoriasis: Contemporary Research and Scope

Psoriasis is a typical dermal condition that has been anticipated since prehistoric times when it was mistakenly implicit in being a variant of leprosy. It is an atypical organ-specific autoimmune disorder, which is triggered by the activation of T-cells and/or B-cells. Until now, the pathophysiology of this disease is not completely explicated and still, many research investigations are ongoing. Different approaches have been investigated to treat this dreadful skin disease using various anti-psoriatic drugs of different modes of action through smart drug-delivery systems. Nevertheless, there is no ideal therapy for a complete cure of psoriasis owing to the dearth of an ideal drug-delivery system for anti-psoriatic drugs. The conventional pharmacotherapy approaches for the treatment of psoriasis demand various classes of anti-psoriatic drugs with optimum benefit/risk ratio and insignificant untoward effects. The advancement in nanoscale drug delivery had a great impact on the establishment of a nanomedicine-based therapy for better management of psoriasis in recent times. Nanodrug carriers are exploited to design and develop nanomedicine-based therapy for psoriasis. It has a promising future in the improvement of the therapeutic efficacy of conventional anti-psoriatic drugs. The present manuscript aims to discuss the pathophysiology, conventional pharmacotherapy, and contemporary research in the area of nanoscale topical drug delivery systems for better management of psoriasis including the significance of targeted pharmacotherapy in psoriasis.

Psoriasiform Drug Eruption to Finasteride: Uncommon Side Effect of a Commonly Used Drug

Finasteride, a 5-α reductase inhibitor, is generally well tolerated on long-term use and cutaneous adverse events have rarely been observed with the drug. We present the case of a 25-year-old male who developed an extensive psoriasiform eruption within a week of starting finasteride 1 mg for androgenetic alopecia.

Updates and Proposed Diagnostic Approach to Psoriasiform Dermatoses

Psoriasiform dermatoses represent a wide array of skin diseases commonly encountered by clinicians and pathologists. While they may present a diagnostic challenge, thorough observation coupled with proper interpretation of subtle additional clinical or histopathologic features provide clues to the correct diagnosis. In this review, we provide updates on emerging entities and develop a systemic approach to establish the pathologic diagnosis, with emphasis on the importance of clinicopathologic correlation.

Long-Acting β2 Adrenergic Receptor Agonist Ameliorates Imiquimod-Induced Psoriasis-Like Skin Lesion by Regulating Keratinocyte Proliferation and Apoptosis

Psoriasis is a chronic inflammatory disease that affects approximately 1%–5% of the population worldwide. Considering frequent relapse, adverse drug reactions, and large costs of treatment, it is urgent to identify new medications for psoriasis. Keratinocytes play an essential role during psoriasis development, and they express high levels of β₂-Adrenergic receptor (β₂-AR), which increases intracellular cAMP levels when activated. Increased level of cAMP is associated with the inhibition of epidermal cell proliferation. In the present study, we observed the effect of salmeterol, a long-acting β₂-AR agonist, on the proliferation and apoptosis of keratinocytes as well as imiquimod-induced psoriasis-like skin lesions in mice. As phosphodiesterase 4 (PDE4) inhibitors increases intracellular cAMP concentration by inhibiting its inactivation, we further explored the synergetic effect of a PDE4 inhibitor and salmeterol on psoriasis-like skin lesions in mice. Our results indicated that salmeterol effectively inhibited the proliferation of HaCaT cells induced by TNF-α and serum, and this effect was accompanied by significantly increased apoptosis and CREB phosphorylation, which were reversed by the PKA inhibitor, H89. Salmeterol ameliorated imiquimod-induced psoriasis-like skin lesions in mice, but salmeterol combined with a PDE4 inhibitor had no synergetic effect in improving skin lesions in mice. Of note, the synergistic effects of anti-proliferation and induction of apoptosis in HaCaT cells appeared by inhibiting ERK signaling. In summary, salmeterol, a long-acting β₂-AR agonist, alleviates the severity of psoriasis via inhibiting the proliferation and promoting apoptosis of keratinocytes, partially by activating the cAMP/PKA signaling pathway.

Differences in Clinical Features and Comorbid Burden between HLA-C∗06:02 Carrier Groups in >9,000 People with Psoriasis

The identification of robust endotypes-disease subgroups of clinical relevance-is fundamental to stratified medicine. We hypothesized that HLA-C∗06:02 status, the major genetic determinant of psoriasis, defines a psoriasis endotype of clinical relevance. Using two United Kingdom-based cross-sectional datasets-an observational severe-psoriasis study (Biomarkers of Systemic Treatment Outcomes in Psoriasis; n = 3,767) and a large population-based bioresource (UK Biobank, including n = 5,519 individuals with psoriasis)-we compared demographic, environmental, and clinical variables of interest in HLA-C∗06:02-positive (one or two copies of the HLA-C∗06:02 allele) with those in HLA-C∗06:02‒negative (no copies) individuals of European ancestry. We used multivariable regression analyses to account for mediation effects established a priori. We confirm previous observations that HLA-C∗06:02-positive status is associated with earlier age of psoriasis onset and extend findings to reveal an association with disease expressivity in females (Biomarkers of Systemic Treatment Outcomes in Psoriasis: P = 2.7 × 10-14, UK Biobank: P = 1.0 × 10-8). We also show HLA-C∗06:02-negative status to be associated with characteristic clinical features (large plaque disease, OR for HLA-C∗06:02 = 0.73, P = 7.4 × 10-4; nail involvement, OR = 0.70, P = 2.4 × 10-6); higher central adiposity (Biomarkers of Systemic Treatment Outcomes in Psoriasis: waist circumference difference of 2.0 cm, P = 8.4 × 10-4; UK Biobank: waist circumference difference of 1.4 cm, P = 1.5 × 10-4), especially in women; and a higher prevalence of other cardiometabolic comorbidities. These findings extend the clinical phenotype delineated by HLA-C∗06:02 and highlight its potential as an important biomarker to consider in future multimarker stratified medicine approaches.

Nilotinib-induced elephantine psoriasis in a chronic myeloid leukemia patient: A rare case report and literature review

Tyrosine kinase inhibitors are anticancer drugs that disrupt signal transduction pathways in protein kinases by different mechanisms. This group of pharmacologic agents has significantly improved the outcome of patients with chronic myeloid leukemia. However, their effect is not limited to cancer cells, and various complications, particularly cutaneous reactions, have been reported. We report a very rare case of a 35-year-old female with a history of chronic myeloid leukemia who presented with elephantine psoriasis after the treatment with nilotinib.

Conclusions: This case highlights a critical side effect of tyrosine kinase inhibitors. Awareness of this subject can be useful for better management of similar patients.

Biologics for Psoriasis During the COVID-19 Pandemic

Coronavirus disease 2019 (COVID-19), a new form of acute infectious respiratory syndrome first reported in 2019, has rapidly spread worldwide and has been recognized as a pandemic by the WHO. It raised widespread concern about the treatment of psoriasis in this COVID-19 pandemic era, especially on the biologics use for patients with psoriasis. This review will summarize key information that is currently known about the relationship between psoriasis, biological treatments, and COVID-19, and vaccination-related issues. We also provide references for dermatologists and patients when they need to make clinical decisions. Currently, there is no consensus on whether biological agents increase the risk of coronavirus infection; however, current research shows that biological agents have no adverse effects on the prognosis of patients with COVID-19 with psoriasis. In short, it is not recommended to stop biological treatment in patients with psoriasis to prevent the infection risk, and for those patients who tested positive for SARS-CoV-2, the decision to pause biologic therapy should be considered on a case-by-case basis, and individual risk and benefit should be taken into account. Vaccine immunization against SARS-CoV-2 is strictly recommendable in patients with psoriasis without discontinuation of their biologics but evaluating the risk-benefit ratio of maintaining biologics before vaccination is mandatory at the moment.

Nevi, biologics for psoriasis and the risk for skin cancer: A real concern? (Case presentation and short review)

Psoriasis is a systemic inflammatory cutaneous disease that affects approximately 2% of the world's population. Systemic treatments and biologic treatment therapies are a powerful option for patients with moderate to severe psoriasis. Some studies from the literature indicate an overall small, but increased, risk of neoplasia in patients with psoriasis treated with phototherapy or systemic medication. The relationship between psoriasis and malignancy is not very well established; there are few studies with conflicting results. We present the case of a 31-year-old male patient, diagnosed with psoriasis, who was deemed eligible for systemic therapy. Treatment with methotrexate was initiated, but without a satisfactory outcome. Given the patient's resistant disease involving 15% of his body surface, his desire to have a clear skin, besides his being naïve to biologic therapy, he was proposed to start treatment with secukinumab 300 mg monthly. The patient experienced complete clearance of lesions and was followed-up on the basis of clinical and biological parameters. There are limited data concerning the relationship between melanocytic lesions, psoriasis and melanoma. Immunologic pathways implicated in psoriasis induce a reduction in the number of melanocytic nevi. Nevertheless, little is known concerning the association of melanocytic nevi with psoriasis. Thorough skin examination, meaning clinical and dermoscopic evaluation of melanocytic lesions, must be encouraged in patients treated with systemic therapies such as biologic agents.

Antihypertensive drug use and psoriasis: A systematic review, meta- and network meta-analysis

AIMS

Diverse genetic and/or external factors may induce psoriasis. Drug exposure is 1 such prominent external factor; antihypertensive drugs are reportedly associated with psoriasis, but study results have been inconsistent. In this context, we investigated the associations between antihypertensive drugs and incidence if psoriasis via a systematic literature review and meta-analysis.

METHODS

Literature search in databases such as PubMed, Embase and Web of Science was conducted on 8 January 2021, and obtained data were pooled for meta- and network meta-analysis. Fixed- or random effect models were used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for evaluating the strength of the associations between antihypertensive drugs and psoriasis incidence. In addition to meta-analysis, Bayesian network meta-analysis was performed. ResultsThirteen eligible studies were included for meta-analysis with 6 378 116 individuals and 8 studies for network meta-analysis with 5 615 918 individuals. All antihypertensive drugs were significantly associated with psoriasis incidence. In a meta-analysis, the pooled ORs were 1.67 (95% CI: 1.31-2.13) for angiotensin-converting enzyme (ACE) inhibitors, 1.40 (95% CI: 1.20-1.63) for β-blockers, 1.53 (95% CI: 1.23-1.89) for calcium-channel blockers (CCBs), and 1.70 (95% CI: 1.40-2.06) for thiazide diuretics. For the comparative risks of psoriasis among antihypertensive drugs in the network meta-analysis, ORs were 2.09 (95% CI: 1.39-3.18) for ACE inhibitors, 1.35 (95% CI: 0.99-1.91) for BBs, 1.53 (95% CI: 1.07-2.24) for CCBs and 1.80 (95% CI: 1.23-2.66) for thiazide diuretics.

CONCLUSION

This study confirmed the associations between antihypertensive drugs and psoriasis; ACE inhibitors, BBs, CCBs and thiazide diuretics increased the risk of psoriasis. Therefore, antihypertensive drug users should be carefully monitored for psoriasis.

Association of Benzodiazepine Receptor Agonist Use With Changes in Psoriasis Severity in Adult Population: A Population-Based Study

To date, it remains uncertain whether benzodiazepine receptor agonists (BZRAs) are aggravating factors even though these drugs can elevate the levels of biomarkers associated with the development of psoriasis. Therefore, this study aimed to investigate the association of BZRA use with changes in psoriasis severity. All data were sourced from the National Health Insurance system in Taiwan. We conducted a population-based retrospective cross-sectional study of 15,727 psoriasis patients who received BZRAs (BZRA users), and 18,856 psoriasis patients who did not receive BZRAs (nonusers). At least a 1-year washout period without any BZRA prescriptions was required. The main outcome was the change in psoriasis severity between before and after BZRA exposure. This study detected the exacerbation of psoriasis severity in mild psoriasis population by using a logistic model. Then, this study carried another logistic model among those patients who had severe psoriasis to calculate the odds ratios (ORs) for the improvement of the psoriasis severity. Among patients with mild psoriasis, BZRA users had a significantly higher probability of psoriasis severity exacerbation (IPTW-adjusted OR = 1.46). Mild psoriasis patients who received high and low doses of BZRAs had 1.70- and 1.39-fold higher probabilities of psoriasis severity exacerbation, respectively, than the non-users. Furthermore, in the severe psoriasis population, more low-dose BZRA users improved psoriasis severity than non-users. In conclusion, this study provided clinical evidence of the effects of BZRA use on patients with psoriasis severity. Among patients with mild psoriasis, high-dose BZRA users may be associated with the changes in psoriasis severity. However, low-dose BZRA exposure only slightly exacerbated disease severity among patients with mild psoriasis. Accordingly, clinicians should evaluate the risks and benefits of the BZRA usage.

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.

Addressing challenges associated with long-term topical treatment and benefits of proactive management in patients with psoriasis

The majority of patients with psoriasis vulgaris (chronic plaque psoriasis) can be treated successfully with short‐term topical therapies. However, long‐term management of psoriasis with topicals is challenging and tends to take a reactive approach to disease relapse, rather than a proactive approach aimed at maintaining disease remission. Patients are often dissatisfied with the delay in treatment response and inconvenience of applying topical treatments, and therefore frequently discontinue treatment leading to poor outcomes. Relapse is common, particularly with reactive management, as underlying residual disease can remain following initial skin clearance; some patients find that their disease at relapse may be worse than their initial symptoms. This can have a detrimental effect on patient quality of life (QoL) and increase the risk of psoriasis‐associated depression. A long‐term proactive management approach, with maintenance treatment following initial treatment success, could help sustain disease remission and improve clinical and QoL outcomes for patients. Treatment with fixed‐dose calcipotriol 50 µg/g betamethasone dipropionate 0.5 mg/g cutaneous foam (Cal/BD foam) is effective in the short term, providing a fast onset of action and improvements in disease at 4 weeks. Results from the Phase III PSO‐LONG study demonstrated that long‐term proactive management was superior to reactive management in prolonging time to first relapse, reducing number of relapses and increasing days in remission in adults with psoriasis vulgaris. Furthermore, Cal/BD foam was well tolerated in PSO‐LONG. No new safety concerns were identified over 52 weeks; the safety profile was consistent with that described previously. Given this, Cal/BD foam should be considered when prescribing topicals for the long‐term proactive management for patients with psoriasis.

Video abstract

Insights into interplay of immunopathophysiological events and molecular mechanistic cascades in psoriasis and its associated comorbidities

Psoriasis is an inflammatory skin disease with complex pathogenesis and multiple etiological factors. Besides the essential role of autoreactive T cells and constellation of cytokines, the discovery of IL-23/Th17 axis as a central signaling pathway has unraveled the mechanism of accelerated inflammation in psoriasis. This has provided insights into psoriasis pathogenesis and revolutionized the development of effective biological therapies. Moreover, genome-wide association studies have identified several candidate genes and susceptibility loci associated with this disease. Although involvement of cellular innate and adaptive immune responses and dysregulation of immune cells have been implicated in psoriasis initiation and maintenance, there is still a lack of unifying mechanism for understanding the pathogenesis of this disease. Emerging evidence suggests that psoriasis is a high-mortality disease with additional burden of comorbidities, which adversely affects the treatment response and overall quality of life of patients. Furthermore, changing trends of psoriasis-associated comorbidities and shared patterns of genetic susceptibility, risk factors and pathophysiological mechanisms manifest psoriasis as a multifactorial systemic disease. This review highlights the recent progress in understanding the crucial role of different immune cells, proinflammatory cytokines and microRNAs in psoriasis pathogenesis. In addition, we comprehensively discuss the involvement of various complex signaling pathways and their interplay with immune cell markers to comprehend the underlying pathophysiological mechanism, which may lead to exploration of new therapeutic targets and development of novel treatment strategies to reduce the disastrous nature of psoriasis and associated comorbidities.

Inflammatory versus Anti-inflammatory Profiles in Major Depressive Disorders-The Role of IL-17, IL-21, IL-23, IL-35 and Foxp3

Background: The authors of this research study intended to verify whether there are any changes in gene expression in depressed patients without coexisting inflammatory diseases for selected immune-inflammatory factors that are particularly important in autoimmune disease pathogenesis (IL-17, IL-21, IL-23, IL-35, Foxp3). Methods: The study was carried out on a group of 190 patients with depression and 100 healthy volunteers. The severity of depressive symptoms was assessed using the Hamilton Depression Scale. RT-PCR was used to evaluate mRNA expression and ELISA was used to measure protein expression of these genes. Results: The level of gene expression for IL-17, IL-21, IL-23, and IL-35 was substantially higher in the group of patients with depression compared to the control group. The mean mRNA expression of Foxp3 was considerably reduced in patients suffering from depressive disorders. There was a statistically significant correlation between the number of hospitalizations and the expression of specific inflammatory factors. Conclusions: Expression of specific inflammatory genes may be a factor in the etiopathogenesis of depressive disorders. The duration of the disease seems to be more important for the expression of the genes in question than the severity of depression. These cytokines may affect the metabolism of neurotransmitters and neuroendocrine functions in the brain as well as be a marker and a new potential therapeutic target for recurrent depressive disorders.

Inorganic ions in the skin: Allies or enemies?

Skin constitutes a barrier protecting the organism against physical and chemical factors. Therefore, it is constantly exposed to the xenobiotics, including inorganic ions that are ubiquitous in the environment. Some of them play important roles in homeostasis and regulatory functions of the body, also in the skin, while others can be considered dangerous. Many authors have shown that inorganic ions could penetrate inside the skin and possibly induce local effects. In this review, we give an account of the current knowledge on the effects of skin exposure to inorganic ions. Beneficial effects on skin conditions related to the use of thermal spring waters are discussed together with the application of aluminium in underarm hygiene products and silver salts in treatment of difficult wounds. Finally, the potential consequences of dermal exposure to topical sensitizers and harmful heavy ions including radionuclides are discussed.

The role of Th17 cells in psoriasis

T helper 17 (Th17) cells have been involved in the pathogenesis of many autoimmune and inflammatory diseases, like psoriasis, multiple sclerosis (MS), rheumatoid arthritis (RA), and inflammatory bowel disease (IBD). However, the role of Th17 cells in psoriasis has not been clarified completely. Th17-derived proinflammatory cytokines including IL-17A, IL-17F, IL-21, IL-22, and IL-26 have a critical role in the pathogenesis of these disorders. In this review, we introduced the signaling and transcriptional regulation of Th17 cells. And then, we demonstrate the immunopathology role of Th17 cells and functions of the related cytokines in the psoriasis to get a better understanding of the inflammatory mechanisms mediated by Th17 cells in this disease.

The role of xenobiotics in triggering psoriasis

Psoriasis is a common inflammatory skin disease affecting approximately 2% of the world population. A complex interplay of genetic predisposition and risk factors contributes to the risk of its onset. Several xenobiotics have been implicated in the pathogenesis of psoriasis. Drugs are among the most investigated trigger factors; strong association with disease induction or exacerbation has been reported for β-blockers, lithium, NSAIDs and ACE inhibitors, all of which are commonly used in the management of various comorbidities in psoriasis patients. Furthermore, inhibitors of TNF have a well-documented potential for triggering new-onset psoriasis when used for other indications (e.g. Crohn's disease or rheumatoid arthritis), while post-marketing data have revealed the same association for ustekinumab. Several other drugs have been connected with psoriasis, but the evidence is less compelling. Smoking and alcohol have been reported to increase the risk for occurrence of psoriasis, but can also affect unfavorably the course of the disease and its response to treatment. Furthermore, exposure to secondhand smoke, especially in childhood, also mediates the risk. Emerging data now suggest that air pollution also has a detrimental effect on skin disease, including psoriasis, but this association needs further investigation. Understanding of the toxic effect of xenobiotics on the initiation and clinical course of psoriasis can contribute to its better control, as it can help with the avoidance of triggering factors and, in some cases, influence the success of pharmacological treatment. It, therefore, has an important place in the comprehensive management of psoriasis.

Mechanisms of Beta-Blocker Induced Psoriasis, and Psoriasis De Novo at the Cellular Level

Beta-blockers are a commonly prescribed medication, but the increase in use goes hand in hand with increasing side effects; one of particular interest lately has been its dermatological reactions. Although rare, beta-blockers can exacerbate pre-existing psoriasis and also cause de novo psoriasis in patients naïve to the disease. The mechanism by which this occurs is still unclear, although numerous articles have been published throughout the years as to how this unusual effect takes place. The most common mechanism suggests that beta-blockers cause intracellular changes in calcium, affecting both keratinocyte proliferation and granulocyte function via decreased cyclic adenosine monophosphate (cAMP) levels. Several inflammatory mediators are known to play a role, as well as reduced expression and desensitization of the beta-adrenergic receptor itself. We discuss these posed pathways in-depth and how each contributes to the worsening or formation of new psoriasis. With this knowledge, future physicians may be more mindful of this side effect should it occur, and why they occur, to better manage our patients on this widely used medication.

What makes an inflammatory disease inflammatory? An overview of inflammatory mechanisms of allergic contact dermatitis, atopic dermatitis and psoriasis

Inflammatory response in the skin is important for host defense against a broad spectrum of insults including microorganisms, chemicals, radiation and physical trauma. When the inflammatory process becomes prolonged and self-perpetuating, illness occurs. In this review, we discuss recent findings regarding the complex inflammatory mechanisms in allergic contact dermatitis, atopic dermatitis and psoriasis.

Digoxin use and following risk of psoriasis: A population-based cohort study in Taiwan

This study examined the association between digoxin use and subsequent psoriasis risk using a population-based database in Taiwan. This cohort study enrolled 15 545 digoxin users and 15 545 propensity score-matched non-users from the Taiwan National Health Insurance Research Database. Each patient was independently followed up for 5 years to confirm whether they had been diagnosed with psoriasis. Cox proportional hazard regression was used to estimate psoriasis risk among digoxin users. Subgroup and sensitivity analyses were also performed. The psoriasis incidence rates were 3.02 and 2.27 per 1000 person-years among digoxin users and non-users, respectively. After adjustment for confounders, psoriasis risk was significantly higher among digoxin users than among non-users. Notably, in most subgroup analyses, digoxin use tended to increase psoriasis risk, particularly among patients with heart failure, diabetes, hypertension and hyperlipidaemia. Moreover, significantly increased psoriasis risk was noted over 2, 3, 4 and 5 years of digoxin use. In conclusion, our findings confirm that digoxin use increases subsequent psoriasis risk. Thus, physicians should be aware of this association and accordingly estimate the risks and benefits of digoxin use. Nevertheless, some patient variables, such as body mass index and obesity, were unavailable in this study. The findings in this study should be elucidated carefully because the potential effects of these factors could not be considered.

Lysosomotropic drugs enhance pro-inflammatory responses to IL-1β in macrophages by inhibiting internalization of the IL-1 receptor

Interleukin (IL)-1 signaling leads to production of pro-inflammatory mediators and is regulated by receptor endocytosis. Lysosomotropic drugs have been linked to increased pro-inflammatory responses under sterile inflammatory conditions but the underlying mechanisms have not been fully elucidated. Here, we report that lysosomotropic drugs potentiate pro-inflammatory effects in response to IL-1β via a mechanism involving reactive oxygen species, p38 mitogen-activated protein kinase and reduced IL-1 receptor internalization. Chloroquine and hydroxychloroquine increased IL-1β-induced CXCL8 secretion in macrophages which was critically dependent on the lysosomotropic character and inhibition of macroautophagy but independent from the NLRP3 inflammasome. Co-stimulation with the autophagy inducer interferon gamma attenuated CXCL8 release. Other lysosomotropic drugs like bafilomycin A₁, fluoxetine and chlorpromazine but also the endocytosis inhibitor dynasore showed similar pro-inflammatory responses. Increased cell surface expression of IL-1 receptor suggests reduced receptor degradation in the presence of lysosomotropic drugs. Our findings provide new insights into a potentially crucial immunoregulatory mechanism in macrophages that may explain how lysosomotropic drugs drive sterile inflammation.

Psoriasis precipitated by timolol eye drops. A series of eight cases

Induction of psoriasis following administration of beta blocker containing eye drops has rarely been documented. We report eight cases of psoriasis triggered by timolol eye drops. Since the clinical and histopathological features of this drug reaction are indistinguishable from those of idiopathic psoriasis, a thorough drug history should be taken in all patients, especially elderly ones, with recent onset of psoriasis.

Apoptotic or Antiproliferative Activity of Natural Products against Keratinocytes for the Treatment of Psoriasis

Natural products or herbs can be used as an effective therapy for treating psoriasis, an autoimmune skin disease that involves keratinocyte overproliferation. It has been demonstrated that phytomedicine, which is used for psoriasis patients, provides some advantages, including natural sources, a lower risk of adverse effects, and the avoidance of dissatisfaction with conventional therapy. The herbal products’ structural diversity and multiple mechanisms of action have enabled the synergistic activity to mitigate psoriasis. In recent years, the concept of using natural products as antiproliferative agents in psoriasis treatment has attracted increasing attention in basic and clinical investigations. This review highlights the development of an apoptotic or antiproliferatic strategy for natural-product management in the treatment of psoriasis. We systematically introduce the concepts and molecular mechanisms of keratinocyte-proliferation inhibition by crude extracts or natural compounds that were isolated from natural resources, especially plants. Most of these studies focus on evaluation through an in vitro keratinocyte model and an in vivo psoriasis-like animal model. Topical delivery is the major route for the in vivo or clinical administration of these natural products. The potential use of antiproliferative phytomedicine on hyperproliferative keratinocytes suggests a way forward for generating advances in the field of psoriasis therapy.

Defective Induction of COX-2 Expression by Psoriatic Fibroblasts Promotes Pro-inflammatory Activation of Macrophages

Fibroblasts play an important role as members of the innate immune system through the secretion of COX-2-derived inflammatory mediators such as prostaglandin E₂ (PGE₂). However, it has been described that dermal fibroblasts behave like mesenchymal stem cells reducing lymphocyte recruitment and dendritic cell activation through PGE₂ release. As the role of fibroblasts in psoriasis remains poorly characterized, in the present study we have evaluated the possible influence of PGE₂ derived from dermal fibroblasts as modulator of the immune response in psoriatic skin. Our results indicate that under inflammatory conditions, psoriatic fibroblasts showed defective induction of COX-2, which resulted in diminished production of PGE₂, in contrast to healthy fibroblasts. This phenotype correlated with deficient c-Jun N-terminal kinase (JNK) activation, in accordance with the hypothesis that alterations in members of the JNK pathway are associated with psoriasis. Furthermore, conditioned medium from psoriatic fibroblasts promoted the polarization of monocytic cells toward a pro-inflammatory profile, effect that was mimicked in healthy fibroblasts after pre-incubation with indomethacin. These results are consistent with a prominent role of dermal fibroblasts in the regulation of inflammatory response through the participation of COX-derived metabolites. This resolutive behavior seems to be defective in psoriatic fibroblasts, offering a possible explanation for the chronification of the disease and for the exacerbation triggered by nonsteroidal anti-inflammatory drugs (NSAIDS) such as indomethacin.

Metabolic syndrome in dermatology: Treatment and Management for Dermatologists

Metabolic syndrome, a commonly observed pathology and a global health issue, is closely related to the skin and thus dermatologists. The skin contributes to the development of metabolic syndrome and it is an end organ for it. Metabolic dysfunction is related to many skin disorders, some of which with high association and some of which with lower association. The diseases of highest association will be discussed in this article. These diseases are acne vulgaris, acanthosis nigricans, hidradenitis suppurativa, and psoriasis vulgaris.

Associations between the neutrophil-to-lymphocyte and the platelet-to-lymphocyte ratios and the presence and severity of psoriasis: a systematic review and meta-analysis

The diagnosis of psoriasis, an immune-mediated disease that affects 2% of the population in Western countries, is largely based on history and clinical examination. The aim of this systematic review and meta-analysis was to investigate the associations between the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) and the presence and clinical severity of psoriasis. A systematic literature search was conducted in PubMed, Web of Science, and Scopus, from inception to January 2018. Twelve case-control studies enrolling 1067 psoriasis patients (537 males and 530 females) and 799 healthy controls (404 males and 395 females) were included in the meta-analysis. The NLR was evaluated in all the studies, while the PLR was assessed in four studies. Pooled results showed that both the NLR and the PLR values were significantly higher in patients with psoriasis (SMD = 0.69, 95% CI 0.53-1.85, p < 0.001, and SMD = 0.40, 95% CI 0.12-0.68, p = 0.006, respectively). There were no significant differences in NLR values according to the severity of disease (p = 0.52). The NLR and the PLR are significantly associated with the presence, but not with the severity, of psoriasis. Further studies are required to determine the additional utility of these haematological indexes in the diagnosis of psoriasis.

Psoriasis and cardiovascular disease: the elusive link

Psoriasis, an autoimmune inflammatory disease, with its most common coexisting condition, psoriatic arthritis, seem to be more than just a local skin or joint disease, as evidence has accumulated over the years that it is associated with cardiovascular disease (CVD), which may confer an increased cardiovascular event and death rate. The data come mostly from observational studies and meta-analyses and indicate a potential pathogenetic link between these two systemic diseases, however definite proof of this detrimental relationship awaits further prospective studies. Newer anti-psoriatic biologic therapies seem to confer a cardiovascular benefit, but this needs future randomized controlled studies to confirm. All these intricate issues of a potential link between psoriasis and CVD are discussed and elaborated in this overview, in an attempt to shed further light on pivotal aspects of the association between psoriasis and CVD.

Risk of Psoriasis Following Terbinafine or Itraconazole Treatment for Onychomycosis: A Population-Based Case-Control Comparative Study

INTRODUCTION

Several case studies have reported an association between antifungal drug use and psoriasis risk.

OBJECTIVE

The objective of this study was to investigate the association between terbinafine/itraconazole exposure and psoriasis incidence.

METHODS

Among patients with onychomycosis in the Taiwan National Health Insurance Research Database, 3831 incident psoriasis cases were identified during 2004-2010 and compared with 3831 age- and sex-matched controls with the same look-back period. Multivariate conditional logistic regression was used for the analysis.

RESULTS

The psoriasis cases were significantly more likely than matched controls to have used terbinafine or itraconazole (59.85 vs. 42.70%, respectively; p < 0.0001). After adjusting for potential confounders and cumulative duration of antifungal drug prescription, terbinafine/itraconazole use was associated with an increased psoriasis risk (adjusted odds ratio 1.33, 95% confidence interval 1.15-1.54). The association was stronger for more recent drug exposure (adjusted odds ratio 2.96, 95% confidence interval 2.25-3.90 for ≤ 90 days before the sampling date; adjusted odds ratio 1.04, 95% confidence interval 0.89-1.22 for > 360 days). In a comparison of patients receiving terbinafine or itraconazole only, psoriasis risk was higher for itraconazole (adjusted odds ratio 1.21, 95% confidence interval 1.05-1.40).

CONCLUSION

This large population-based case-control analysis showed that exposure to terbinafine or itraconazole is associated with an increased risk of incident psoriasis. The finding of an increased psoriasis risk for antifungal drug users, particularly for itraconazole, deserves attention in clinical practice although further prospective studies are necessary to confirm our findings and clarify the biological mechanisms that underlie these associations.

A Review of Drugs that Induce or Exacerbate Psoriasis

Background

Psoriasis is a common disorder of the skin, immune system, and joints that is influenced by genetic and environmental factors. It can be aggravated or induced by drugs.

Objectives

To identify the major drugs implicated in inducing or exacerbating psoriasis and to discuss their characteristics.

Methods

We performed a PubMed literature search for reviews and case reports on drugs that exacerbate or induce psoriasis. Articles were screened by title and abstract and then examined for their findings and references.

Results

Drugs most often reported to exacerbate or induce psoriasis were β-blockers, lithium, synthetic antimalarials, nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, interferons, tetracyclines, tumor necrosis factor-α inhibitors, and steroid withdrawal.

Conclusions

Characterizing drugs that induce or exacerbate psoriasis by latency and type of psoriatic eruption can help guide clinical reasoning. Although a relatively uncommon occurrence, psoriatic lesions can be caused by drugs, allowing astute physicians to recognize and change their management plans accordingly.

Oral vitamin D3 supplementation for chronic plaque psoriasis: a randomized, double-blind, placebo-controlled trial

PURPOSE

The management of psoriasis remains a challenge for dermatologist and patient. This study aimed to determine whether vitamin D₃ supplementation improves psoriasis compared to placebo.

MATERIALS AND METHODS

In a randomized, doubled-blind, placebo-controlled trial, 101 participants ≥18 years with psoriasis were grouped by severity and allocated to 100,000 International Units (IU) vitamin D₃/month for 12 months (200,000 IU at baseline; n = 67) or an identical placebo (n = 34). Psoriasis Area and Severity Index (PASI) and serum 25(OH)D concentrations were assessed at 3-monthly intervals. The primary outcome was the difference in PASI between groups over time. The relationship between 25(OH)D and PASI across the sample was also considered in a post hoc analysis.

RESULTS

PASI did not differ between groups at any time (group F(1, 104) = 0.48, p = .49; group*time F(4, 384) = 0.26, p = .90). However, 25(OH)D increased in both groups, rendering these findings inconclusive. A significant inverse relationship existed between PASI and 25(OH)D, with elevation of 25(OH)D by up to 125 nmol/L associated with mild decreases in PASI (estimated range of decrease 0-2.6; p = .002).

CONCLUSIONS

A direct benefit of vitamin D₃ supplementation for psoriasis could not be determined. However, these findings suggest a relationship between 25(OH)D and psoriasis severity, at least in some subgroups. Australian New Zealand Clinical Trials Registry #12611000648921.