A review of the epidemiology of psoriasis vulgaris in the community

Multimorbidity of Psoriasis: A Large-Scale Population Study of Its Associated Comorbidities

INTRODUCTION

Psoriasis is a chronic disease of the skin with a prevalence of 2% in the general population. The high prevalence of psoriasis has prompted the study of its comorbidities in recent decades. We designed a study to determine the prevalence of psoriasis in a large-scale, population-based cohort, to exhaustively describe its comorbidities, and to analyze which diseases are associated with psoriasis.

METHODS

Retrospective, observational study based on the clinical information contained in the electronic health records of the individuals in the EpiChron Cohort with a diagnosis of psoriasis (31,178 individuals) in 2019. We used logistic regression models and calculated the likelihood of the occurrence of each comorbidity based on the presence of psoriasis (p-value < 0.05).

RESULTS

The prevalence of psoriasis was 2.84%, and it was more prevalent in men (3.31% vs. 2.43%). The most frequent chronic comorbidities were disorders of lipid metabolism (35.87%), hypertension (35.50%), and other nutritional-endocrine-metabolic disorders (21.79%). The conditions most associated with psoriasis were (odds ratio; 95% confidence interval) tuberculosis (2.36; 1.24-4.49), cystic fibrosis (2.15; 1.25-3.69), amongst others. We did not find a significant association between psoriasis and hypertension or neoplasms (0.90; 0.86-0.95).

CONCLUSIONS

This study revealed significant associations between psoriasis and cardiac, psychological, and musculoskeletal comorbidities.

Psoriasis and seasonal variation: A systematic review on reports from Northern and Central Europe-Little overall variation but distinctive subsets with improvement in summer or wintertime

BACKGROUND

Positive influence of the sun on psoriasis is a common assumption in dermatology. Other season-related factors such as mental health may interfere. However, the role of seasonal effects on psoriasis needs to be clarified. This review aims to systematically analyze the literature on seasonal variation on psoriasis with emphasis on Northern and Central Europe representing temperate climate conditions.

MATERIALS AND METHODS

Enrolled literature was identified through PubMed, EMBASE, and BIOSIS. An additional manual search of old reports before the introduction of efficient modern therapies, which can interfere with the spontaneous disease, was performed.

RESULTS

Thirteen studies were enrolled. About 50% of psoriasis patients were stable and showed no seasonal difference between seasons. Approximately 30% improved in summer, and 20% performed better in winter, some with marked summer worsening. European results matched international reports from different continents and hemispheres with climate extremes. The psychological effects could not be ruled out.

CONCLUSION

About 50% of psoriasis patients experience a season-independent disease, however, with a subset of patients who do better in summer. Others again do better in winter, with a few of these having marked worsening in warm periods. Individual season-related activity records should be paid proper attention to when considering light therapy or climatotherapy as a treatment.

Prevalence and Characteristics of Psoriasis in Romania-First Study in Overall Population

Background: Psoriasis is a chronic inflammatory disease characterized by an excessive hyperproliferation of keratinocytes and a combination of genetic, epigenetic, and environmental influences. The pathogenesis of psoriasis is complex and the exact mechanism remains elusive. Objectives: The study of the prevalence of psoriasis will allow the estimation of the number of people suffering from this condition at the national level, as well as the development and validation of a questionnaire to estimate the prevalence and the risk factors associated with the disease. Methods: A quantitative research was conducted at a national level among the target population in order to validate the questionnaire and estimate the national prevalence. Results: Declaratively, the prevalence of psoriasis in the studied group (N = 1500) is 4%, the first symptoms appearing around the age of 50, with a certified diagnosis being made on average at 55 years. The prevalence of psoriasis vulgaris was 4.99%. Conclusions: The results obtained will be useful in guiding future initiatives and communication campaigns related to this condition, and the methodological approach used will provide the opportunity to make recommendations for improving similar initiatives in the future.

Characteristics Associated with the Occurrence and Development of Acute Anterior Uveitis, Inflammatory Bowel Disease, and Psoriasis in Patients with Ankylosing Spondylitis: Data from the Chinese Ankylosing Spondylitis Prospective Imaging Cohort

Introduction

This study aimed to determine the association between extra-articular manifestations (EAMs) and baseline characteristics of patients with ankylosing spondylitis (AS) and identify their potential risk factors in an observational cohort.

Methods

We analyzed the data of consecutive patients with AS obtained between April 2016 and May 2019 from the ongoing Chinese Ankylosing Spondylitis Prospective Imaging Cohort.

Results

Among the 1414 patients with AS, 23.1% had experienced EAMs at baseline. The prevalence rates of acute anterior uveitis (AAU), inflammatory bowel disease, and psoriasis among patients with AS were 16.7, 6.9, and 2.6%, respectively, and the prevalence of AAU increased significantly with the disease duration. Patients with comorbidity of AAU and psoriasis had Ankylosing Spondylitis Disease Activity Score (ASDAS) than patients without EAMs (2.16 ± 0.984 vs. 1.99 ± 0.956 [p = 0.025] and 2.36 ± 1.01 vs. 1.99 ± 0.96 [p = 0.025]). Among the 1087 patients with AS without EAMs at baseline, 98 developed EAMs during follow-up. Long disease duration (> 10 years) and high disease activity at baseline (ASDAS > 2.1) were associated with the risk of new-onset EAMs (hazard ratio [HR] [95% confidence interval, CI], 2.150 [1.229–3.762] and 2.896 [1.509–5.561], respectively) and new-onset AAU (HR [95% CI], 2.197 [1.325–3.642] and 3.717 [1.611–8.574], respectively).

Conclusions

In Chinese patients with AS, patients with comorbidity of AAU and psoriasis had higher disease activity scores than patients without EAMs. Furthermore, the risk of AAU or combined EAMs increases with the duration of AS and appears to be associated with higher cumulative exposure to inflammation.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00293-0.

Characteristics associated with the presence and development of extra-articular manifestations in ankylosing spondylitis: 12-year results from OASIS

OBJECTIVE

The aim of this study was to identify characteristics associated with the presence and development of extra-articular manifestations (EAMs) in a prevalence cohort of patients with AS.

METHODS

Twelve-year follow-up data from the Outcome in Ankylosing Spondylitis International Study (OASIS) were used. In addition, medical charts were checked for the presence of acute anterior uveitis (AAU), IBD and psoriasis. Demographic, clinical and radiographic characteristics associated with the presence of (any) EAM at baseline or new development during follow-up were identified.

RESULTS

Two hundred and sixteen patients were included [mean age 43.6 years (s.d. 12.7), 154 (71%) men, mean symptom duration 20.5 years (s.d. 11.7), mean follow-up 8.3 years (s.d. 4.3)]. At baseline, 39 (18%) patients had AAU, 15 (7%) had IBD and 9 (4%) had psoriasis. The history of AAU was univariably associated with increased age [odds ratio (OR) 1.04 (95% CI 1.01, 1.07)], longer symptom duration [OR 1.05 (95% CI 1.02, 1.08)] and more radiographic damage [OR 1.02 (95% CI 1.00, 1.04)]. The history of psoriasis was associated with greater age [OR 1.05 (95% CI 1.00, 1.11)] and lower CRP [OR 0.77 (95% CI 0.59, 1.00)]. At follow-up, 27 patients developed a new EAM. Newly developed IBD was associated with a higher time-varying AS Disease Activity Score [hazard ratio (HR) 2.80 (95% CI 1.43, 5.52)], worse physical function [HR 1.40 (95% CI 1.09, 1.80)] and worse patient global well-being [HR 1.46 (95% CI 1.10, 1.93)]. Newly developed AAU was associated with an elevated time-varying CRP [HR 1.02 (95% CI 1.01, 1.04)].

CONCLUSION

Development of EAMs was infrequent in this cohort, despite relatively long follow-up. In particular, markers of disease activity were associated with the development of IBD.

Prevalence of extra-articular manifestations in patients with ankylosing spondylitis: a systematic review and meta-analysis

OBJECTIVES

Uveitis, psoriasis and inflammatory bowel disease (IBD) are common extra-articular manifestations (EAM) in patients with ankylosing spondylitis (AS); however, summary data of reported prevalence are lacking. The aim of the present study was to summarise the prevalence of EAMs among patients with AS and to identify underlying factors to explain potential heterogeneity of prevalence.

METHODS

A systematic literature search was performed (Medline, Embase and Cochrane Library) to identify relevant articles. Risk of bias was assessed and data were extracted. Pooled prevalences were calculated. Potential sources of any observed clinical or methodological heterogeneity in the estimates were explored by subgroup and metaregression analysis.

RESULTS

In the 156 selected articles, 143 reported the prevalence of uveitis (44 372 patients), 56 of psoriasis (27 626 patients) and 69 of IBD (30 410 patients). Substantial heterogeneity was observed in prevalence estimates among all EAMs (I(2)=84-95%). The pooled prevalence of uveitis was 25.8% (95% CI 24.1% to 27.6%), and was positively associated in multivariable metaregression with disease duration (β 0.05, 95% CI 0.03 to 0.08) and random selection of patients (β -0.24, 95% CI -0.43 to -0.04). The pooled prevalence of psoriasis was 9.3% (95% CI 8.1% to 10.6%). The pooled prevalence of IBD was 6.8% (95% CI 6.1% to 7.7%) and was positively associated with the percentage of women in the studies (β 0.02, 95% CI 0.00 to 0.03). Geographical area was associated in multivariable metaregressions with prevalence of all EAMs.

CONCLUSIONS

EAMs are common in patients with AS. The large heterogeneity between studies can be partly explained by differences in clinical as well as methodological characteristics.

Nail psoriasis: a review

Nail psoriasis is common, occurring in up to half of patients with psoriasis and in 90% of patients with psoriatic arthritis. Left untreated, it may progress to debilitating nail disease, which leads to significant functional impairment. The most common clinical signs of nail psoriasis are nail plate pitting and onycholysis. Other classical signs include oil drop discoloration, subungual hyperkeratosis, and splinter hemorrhages. The modified Nail Psoriasis Severity Index (mNAPSI) can be used to grade the severity of nail psoriasis, while the Nail Psoriasis Quality of Life Scale (NPQ10) is a questionnaire that evaluates the impact of nail psoriasis on the patient's functional status and quality of life. Treatment of nail psoriasis should be individualized according to the patient's preferences, severity of nail changes, and presence of skin and/or joint involvement. Both topical and intralesional therapies are safe and effective treatment modalities for nail disease, but are limited by poor adherence and pain, respectively. Systemic therapy such as oral retinoids may be considered for widespread nail disease causing significant morbidity. Among biologic agents, tumor necrosis factor-α inhibitors and T-cell-targeted therapies such as ustekinumab may be useful for refractory severe nail psoriasis.

Psoriasis incidence and prevalence in the Russian Federation

The article presents materials and analyzes the main trends in the epidemiology of psoriasis and follow-up of patients from this category in the Russian Federation for 2009—2011.

Global epidemiology of psoriasis: a systematic review of incidence and prevalence

The worldwide incidence and prevalence of psoriasis is poorly understood. To better understand this, we performed a systematic review of published population-based studies on the incidence and prevalence of psoriasis. Three electronic databases were searched from their inception dates to July 2011. A total of 385 papers were critically appraised; 53 studies reported on the prevalence and incidence of psoriasis in the general population. The prevalence in children ranged from 0% (Taiwan) to 2.1% (Italy), and in adults it varied from 0.91% (United States) to 8.5% (Norway). In children, the incidence estimate reported (United States) was 40.8/100,000 person-years. In adults, it varied from 78.9/100,000 person-years (United States) to 230/100,000 person-years (Italy). The data indicated that the occurrence of psoriasis varied according to age and geographic region, being more frequent in countries more distant from the equator. Prevalence estimates also varied in relation to demographic characteristics in that studies confined to adults reported higher estimates of psoriasis compared with those involving all age groups. Studies on the prevalence and incidence of psoriasis have contributed to a better understanding of the burden of the disease. However, further research is required to fill existing gaps in understanding the epidemiology of psoriasis and trends in incidence over time.

Calcipotriol and betamethasone dipropionate in the treatment of mild-to-moderate psoriasis: a cost-effectiveness analysis of the ointment versus gel formulation

Background

Psoriasis is a chronic inflammatory skin disease with a major impact on the quality of life of affected individuals. Topical therapy has an important role in the treatment of psoriasis. Poor treatment outcomes from topical therapy regimens likely result from poor adherence and ineffective use of medication.

Methods

A cost-minimization analysis was performed with the purpose of assessing the use of a gel containing calcipotriol and betamethasone dipropionate (Dovobet^® gel) versus the ointment formulation (Dovobet ointment) in the treatment of psoriasis. The analysis was carried out using a Markov model with a one-year time horizon in a hypothetical cohort of patients with a Psoriasis Area and Severity Index score < 10. The model simulates different therapy adherence scenarios for the two different formulations.

Results

The Dovobet gel strategy allows a 5% reduction in the number of patients who could potentially be treated with more expensive therapies (biologics and conventional systemic drugs) in comparison with the Dovobet ointment strategy, with a consequent impact on costs for the National Healthcare Service. The total annual cost of Dovobet gel is about €407.00 per patient, ie, 19% less that the total cost of about €500.00 of the Dovobet ointment strategy. The base case results were then examined by sensitivity analysis and budget impact analysis to correlate the various scenarios of Dovobet gel use with cost savings to the National Healthcare Service.

Conclusion

The Dovobet gel strategy seems more acceptable to patients, shows better overall adherence, and appears to be favorable from the pharmacoeconomic point of view than the ointment formulation for treatment of patients with mild-to-moderate psoriasis.

Stress and quality of life in psoriasis: an update

Psoriasis is a chronic, relapsing, cutaneous condition with 1-2% prevalence in the general population. There are many factors involved in the induction and/or exacerbation of psoriasis of which stress is a well-known trigger factor in the appearance or exacerbation of psoriasis. Stress reaction in patients with psoriasis is probably mediated by the hypothalamic-pituitary-adrenal relationship with immunologic effects. Stress response involves increased levels of neuroendocrine hormones and autonomic neurotransmitters. Psychological stress or an abnormal response to stressors has been found to modify the evolution of skin disorders such as psoriasis. It can also have substantial psychological, and psychosocial impact on a patient's quality of life. Treatment regimens include stress-reduction strategies, such as biofeedback, meditation, yoga, and self-help approaches. This review focuses the relationship between psoriasis and stress, especially relating to psychosocial, psychological, and emotional stress aspects.

Association between psoriasis and incident cancer: the Iowa's Women's Health Study

INTRODUCTION

Studies have reported higher cancer risk in individuals with psoriasis, a chronic inflammatory autoimmune disease; however, adjustment for potential confounders was lacking.

METHODS

We examined the association of psoriasis with cancer incidence in 32,910 women after age 65 in the IWHS cohort linked to Medicare. Psoriasis was defined as: 2+ psoriasis claims from any Medicare file during 1991-2004 or 1+ psoriasis claim from a dermatologist (n = 719). Severe psoriasis was defined as 4+ psoriasis claims from a dermatologist in any year (n = 121). Cox proportional hazards regression, with psoriasis as a time-dependent variable was conducted to calculate hazard ratios (HR) and 95% confidence intervals (CI) of total (n = 6,488), breast (n = 2,066), lung (n = 742), and colon cancers (n = 947).

RESULTS

With age-adjustment, psoriasis (yes vs. no) was associated with increased risk of lung 1.9 (95% CI: 1.2-3.0), colon 1.6 (95% CI: 1.1-2.5), and total cancer 1.2 (95% CI, 1.0-1.4). After further adjustment for smoking, body mass index, education, physical activity, and hormone therapy use, only the association for colon cancer remained statistically significant (HR = 1.6, 95% CI: 1.0-2.4) and was stronger for severe psoriasis.

CONCLUSION

The observed association between psoriasis and colon cancer may reflect inflammatory or unidentified processes.

'Perfect skin', the media and patients with skin disease: a qualitative study of patients with acne, psoriasis and atopic eczema

The relationship of skin disease with societal ideals of beauty, and the role of the media in this relationship, has not previously been researched. The overall objective of this study was to explore the psychological effects of skin disease. The theme of the ideal of perfect skin and the role of the media in generating this ideal arose via an inductive study methodology and was explored in the context of respondents’ psychological morbidity. A qualitative study, 62 semi-structured interviews were conducted with respondents with acne, eczema or psoriasis recruited from both general practice and specialist dermatology practice in an Australian regional city. Interviews were audiotaped, transcribed and subjected to thematic analysis employing a process of constant comparison in which data collection and analysis were cumulative and concurrent. The themes of perfect skin, societal ideals and media influence emerged from this iterative process. Respondents identified a societal ideal of flawless skin, largely mediated by media portrayals of perfection. Failure to meet this ideal precipitated psychological morbidity in female, but not male, respondents. An appreciation of the pervasive pressures of society and media upon females with skin disease may inform management strategies, particularly psychological management strategies, in patients with skin disease.

Therapeutic moisturizers as adjuvant therapy for psoriasis patients

At any point in time, psoriasis affects 2-3% of the world's population and has one of the biggest impacts on quality of life of any dermatological disorder. Treatment is extremely costly and prevention of disease progression in severity and extent is crucial. Psoriasis treatment should include skin hydration (regular use of moisturizers and emollients), careful, gentle skin cleansing, and identification and avoidance of Koebner phenomenon triggers (excoriation, maceration) and infectious foci (Streptococcus pyogenes). Moisturizers have been shown to significantly improve skin conditions and quality of life for psoriasis patients. They are a valuable first-line treatment, as dry skin is common and adds to the irritability of the diseased skin. Most patients respond well to topical treatment with topical corticosteroids, emollients, coal tar, anthralin (dithranol) or calcipotriol. Emollients are the most prescribed products, providing transient relief from irritation and some possessing anti-inflammatory properties. Moisturizers and emollients should be used in the following cases: minimal psoriasis, napkin psoriasis, psoriasis of the folds, psoriatic skin damaged by previous local treatments, and in pregnancy or women of childbearing age.

Geoepidemiology and environmental factors of psoriasis and psoriatic arthritis

Psoriasis and Psoriatic Arthritis (PsA) are chronic inflammatory diseases that have a major impact on health. The prevalence and incidence estimates of these two closely related diseases show ethnic and geographic variations, being generally more common in the colder north than in the tropics. In Europe the prevalence of psoriasis varies anywhere from 0.6 to 6.5%. In the USA, the estimated prevalence of diagnosed psoriasis is 3.15%. The prevalence in Africa varies depending on geographic location, being lowest in West Africa. Psoriasis is less prevalent in China and Japan than in Europe, and is entirely absent in natives of the Andean region of South America. There are fewer reports on the incidence of psoriasis, but a recent study from Rochester, USA showed an increasing trend over the last 2 decades. The prevalence of PsA also shows similar variation, being highest in people of European descent and lowest in the Japanese. Although, study methodology and case definition may explain some of the variations, genetic and environmental factors are important. Genetic epidemiologic studies have shown that both diseases have a strong genetic component. The strongest association is with HLA-Cw*06. Associations with a number of genes including IL12B and IL23R have recently been confirmed. Environmental risk factors including streptococcal pharyngitis, stressful life events, low humidity, drugs, HIV infection, trauma, smoking and obesity have been associated with psoriasis and PsA. Here we have reviewed the current literature on the epidemiology and genetics of psoriasis and PsA.

Trends in incidence of adult-onset psoriasis over three decades: a population-based study

BACKGROUND

Incidence studies of psoriasis are rare, mainly due to lack of established epidemiological criteria and the variable disease course. The objective of this study is to determine time trends in incidence and survival of psoriasis patients over three decades.

METHODS

We identified a population-based incidence cohort of 1633 subjects aged > or = 18 years first diagnosed with psoriasis between January 1, 1970 and January 1, 2000. The complete medical records for each potential psoriasis subject were reviewed and diagnosis was validated by either a confirmatory diagnosis in the medical record by a dermatologist or medical record review by a dermatologist. Age- and sex-specific incidence rates were calculated and were age- and sex-adjusted to the 2000 US white population.

RESULTS

The overall age- and sex-adjusted annual incidence of psoriasis was 78.9 per 100,000 (95% confidence interval [CI]: 75.0-82.9). When psoriasis diagnosis was restricted to dermatologist-confirmed subjects, the incidence was 62.3 per 100,000 (95% CI: 58.8-65.8). Incidence of psoriasis increased significantly over time from 50.8 in the period 1970-1974 to reach 100.5 per 100,000 in the 1995-1999 time period (P = .001). Although the overall incidence was higher in males than in females (P = .003), incidence in females was highest in the sixth decade of life (90.7 per 100,000). Survival was similar to that found in the general population (P = .36).

LIMITATIONS

The study population was mostly white and limited to adult psoriasis patients.

CONCLUSION

The annual incidence of psoriasis almost doubled between the 1970s and 2000. The reasons for this increase in incidence are currently unknown, but could include a variety of factors, including a true change in incidence or changes in the diagnosing patterns over time.

Moderate and severe plaque psoriasis: cost-of-illness study in Italy

Psoriasis is a chronic inflammatory, immune-mediated skin disorder that affects 1.5-1.8 million people in Italy. The most common form of the disease is chronic plaque psoriasis, affecting about 90% of psoriasis patients, with about 20%-30% of them suffering from a moderate or severe condition. Little information is available about the economic impact of psoriasis in European countries. The primary objective of this study was to perform a cost-of-illness analysis of patients with moderate and severe plaque psoriasis in Italy. Therefore, direct, indirect costs, and intangible costs (quality of life - QoL) were assessed. In this national, multicenter, prospective, 3-month cost-of-illness study of moderate and severe plaque psoriasis, direct and indirect costs were assessed from the patient, third-party payer (National Health Service, NHS), and societal perspectives. From November 2003 to October 2004 consecutive patients were enrolled over a 1-year period, in order to minimize seasonal fluctuations in disease severity. 150 patients enrolled in 6 investigational sites in Italy, completed the study, and were eligible to be analyzed according to the study protocol. Intangible costs (QoL) were measured using SF36 and DLQI questionnaires. The mean total cost for psoriasis (average Psoriasis Area Severity Index [PASI] score 21.4), including direct and indirect items, was euro8,371.61 per patient per year. The mean cost for patients with moderate disease (PASI 20) was euro11,434.40 per year. Disease heavily affected QoL measured using SF36, and the impairment was greater in patients affected by a more severe form of disease. Moderate and severe plaque psoriasis is associated with extremely high costs, which are related to disease severity. Data from this study show that the more severe plaque psoriasis, the higher the direct and indirect costs for its management. Direct costs are higher than indirect costs; hospitalization represents the most significant item, accounting for 30% of the total expenses. QoL in moderate and severe plaque psoriasis is low compared with the population at large, confirming the high impact of plaque psoriasis on QoL. The relatively high average annual costs per patient point to the need for a more efficient and long-term control of psoriasis.

Calcipotriol/betamethasone dipropionate in the treatment of psoriasis vulgaris

Psoriasis is one of the most common skin diseases. The mainstay of treatment for the vast majority of patients is topical therapy. A rising first-line treatment modality for psoriasis vulgaris is the two-compound ointment containing calcipotriol 50 mug/g plus betamethasone dipropionate 0.5 mg/g (Dovobet((R)), Daivobet((R)), Taclonex((R))), which combines a vitamin D analog and a corticosteroid. This innovative formulation preserves the activity and bioavailability of the two components and many clinical studies have demonstrated that it has a greater efficacy, tolerability, and a rapid onset of action compared with its individual ingredients or tacalcitol.

Heart disease in psoriasis

Psoriasis has been traditionally viewed as an inflammatory skin disorder of unknown origin. Recent advances in the immunopathogenesis and genetics of psoriasis have broadened our understanding of psoriasis. Psoriasis is now considered a systemic inflammatory condition analogous to other inflammatory immune disorders. Patients with other immune disorders, such as systemic lupus erythematosus or rheumatoid arthritis, are known to be at increased risk of heart disease. Similarly, patients with psoriasis may carry an excess risk of heart disease, which would represent an important previously unrecognized cause of morbidity and mortality. This review summarizes the current evidence for an increased cardiovascular risk in patients with psoriasis and outlines deficits in our knowledge in this area.

Comparison of the efficacy of local narrowband ultraviolet B (NB-UVB) phototherapy versus psoralen plus ultraviolet A (PUVA) paint for palmoplantar psoriasis

Palmoplantar psoriasis is an idiopathic disabling condition, often resistant to conventional therapies. The purpose of this study was to evaluate the efficacy and safety of local narrowband ultraviolet B (NB-UVB) phototherapy and to compare it with local psoralen plus ultraviolet A (PUVA) paint in patients with palmoplantar psoriasis unresponsive to conventional therapies other than phototherapy. A cohort of 25 patients with palmoplantar psoriasis were included in this study, which was based on a left-to-right comparison pattern. The treatments were administered with local narrowband UVB irradiation on one side and local PUVA on the other side three times a week over 9 weeks. Clinical assessments were performed at baseline and every 3 weeks during the 9-week treatment. There was a statistically significant decrease in the mean clinical scores at the third, sixth and ninth week with both treatments. The difference in clinical response between the two treatment modalities was statistically significant at the end of the treatment period, with the percentage reduction in severity index scores with the PUVA-paint-treated side being 85.45% compared with 61.08% for the NB-UVB treated side (t = 5.379, P = 0.0001, Student's t-test for unpaired samples). Our results show that, although some clinical improvement was achieved with local NB-UVB phototherapy, the results were better with local PUVA, and such a treatment option may be reserved for patients with palmoplantar psoriasis who experience phototoxic reaction to psoralens.

Effect of psychological stress on salivary interleukin-1beta in psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory skin disease in which several Th1 cytokines such as interleukin-1 beta (IL-beta) have been shown to play a pivotal role. Psychological stress has also been implicated in triggering or exacerbating the disease.

METHODS

Salivary IL-1beta and cortisol levels of 25 patients with psoriasis were compared with those of 50 age- and sex-matched healthy controls under basal conditions and after a standardized stressful procedure including mental arithmetics and the Stroop Color-Word Naming Test.

RESULTS

At baseline, mean IL-1beta levels were higher in patients with psoriasis than controls (p <0.001), whereas mean cortisol levels did not differ significantly between groups. Although IL-1beta levels increased after stress among controls, they did not increase among patients with psoriasis, with a significant group-by-time interaction (p <0.01). After stress, cortisol levels were significantly increased in both groups as compared with baseline (p < or =0.001), without any group-by-time interaction. Perceived stress was similar among psoriatic patients and controls. There was no significant correlation between changes in IL-1beta and changes in cortisol.

CONCLUSIONS

The higher basal IL-1beta levels among psoriatic patients suggest that its production is increased. Changes in proinflammatory cytokine activity in psoriatic skin may play an important role in propagating inflammation. The blunted response of IL-1beta to stress observed in psoriatic patients may reflect a "ceiling effect", or be ascribed to a defective response of the immune system to adrenergic stimuli.

The association between psoriasis, diabetes mellitus, and atherosclerosis in Israel: a case-control study

BACKGROUND

Previous reports demonstrated an association between psoriasis and other diseases including heart failure and diabetes mellitus.

OBJECTIVES

Our aim was to describe the association between psoriasis, diabetes mellitus, and atherosclerosis in Israel.

METHODS

A cross-sectional study was performed utilizing the database of Maccabi Healthcare Services (MHS), a large health provider organization in Israel. Case patients were defined as subjects who were diagnosed with psoriasis. Patients with diabetes and atherosclerosis were identified by using the MHS diabetes and cardiovascular registries, respectively. The control group included MHS enrollees without psoriasis. The proportion of diabetes and atherosclerosis among case and control groups was compared. Chi-square tests were used to compare categorical parameters. Logistic regression models were used for multivariate analyses.

RESULTS

The study included 46,095 patients with psoriasis (case patients) and 1,579,037 subjects without psoriasis (control patients). The age-adjusted proportion of diabetes was significantly higher in psoriasis patients as compared with the control group (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.1-1.48). The age-adjusted proportion of atherosclerosis was significantly higher in psoriasis patients as compared with the control group (OR 1.28, 95% CI 1.04-1.59). In patients with psoriasis, a multivariate logistic regression model demonstrated an association between diabetes and the multiple use of very potent topical steroids (P < .05) or use of systemic medication for psoriasis (methotrexate, cyclosporine or acitretin) (P < .001). A similar model demonstrated an association between atherosclerosis and the use of phototherapy (P < .001).

LIMITATIONS

Our study was based on a computerized database. The diagnosis of psoriasis was based on digitally transmitted data. Therefore overestimation (false-positive cases) and underestimation (false-negative cases) of psoriasis patients may exist, thereby being a source for information bias. A second limitation is selection bias that may occur due to the possibility that reporting of both psoriasis and associated illnesses is higher in individuals who are seeking medical care. A third limitation concerns the causal effect between occurrence of psoriasis and atherosclerosis or diabetes. The dataset of MHS records diagnoses only from 1997 and does not record the date of disease onset.

CONCLUSIONS

Our study supports previous reports for an association between psoriasis and atherosclerosis and psoriasis and diabetes. Further study is needed to support this observation.

Epidemiology of psoriasis. Review and the German perspective

According to population-based European studies, 2-3% of the population are affected by psoriasis. However, commonly accepted and validated diagnostic criteria are lacking. Psoriasis patients, compared to those with other dermatological disorders, are among those who suffer the highest impact on their quality of life, and this affection is comparable to other common diseases. Several lifestyle factors including alcohol and smoking have been associated with psoriasis. There is also evidence for associations with other diseases including cancer. Treatment of psoriasis engenders considerable costs, which should always be taken into account together with the relevant clinical outcome parameters. Prevention of psoriasis is crucial, as in the case of other common chronic diseases where causative treatments are lacking, but has barely been studied.

Calcipotriol/betamethasone dipropionate for the treatment of psoriasis

The two-compound product calcipotriol/betamethasone dipropionate is arising as a first-line treatment for mild-to-moderate plaque psoriasis. Its beneficial action is attributed to the synergistic effect of its components on keratinocyte proliferation and differentiation, and on inflammation. The good tolerability of the two-compound product is thought to be due to the anti-inflammatory effect of betamethasone. Evidence from short-term (4-12 weeks) and long-term use (> 1 year) has shown a good safety profile. Areas such as the face or skin folds, which are sensitive to the components of the combination, should be avoided. Finally, it is unsuitable for use in unstable psoriasis, in which potent steroids may lead to an increased inflammatory response.

Rheumatic manifestations of psoriasis

Psoriatic arthritis was described as a distinct rheumatic disease in the 1960s, and subsequently grouped among the spondyloarthropathies. Recently, other rheumatic manifestations of psoriasis, such as enthesopathy and osteoperiostitis, were recognized. This study attempts to examine the rheumatological and radiological manifestations of Psoriasis and their association with skin and nail disease. Eighty-one psoriatic outpatients were interviewed consecutively during 6 months. Questionnaires and indices were carried out to assess the extent and severity of skin and nail involvement, as well as the activity and severity of peripheral and axial rheumatic manifestations. Radiological examination of the hands, feet, spine and pelvis was also done for all patients. Fifty-nine psoriatic outpatients (73%) had rheumatic manifestations clinically and/or radiologically (Psoriatic arthropathy "PsA"). Clinical peripheral arthritis was found in 14 (23.7%) of the patients with PsA, being oligoarticular in 11, polyarticular in two, and exclusively of the distal interphalangeal (DIP) joints in one patient. Sacroiliitis and/or spondylitis were found in 38 (64.4%), enthesopathy in 36 (61%), dactylitis in two (3.3%), radiological DIP involvement in 24 (40.6%), and radiological osteoperiostitis in 49 (83%) of patients with PsA. Most PsA patients had more than one rheumatic manifestation, while four patients (6.7%) had isolated enthesopathy without any other rheumatic manifestations. Subungual hyperkeratosis of the nails was significantly correlated with PsA (p<0.05), as well as with clinical arthritis, enthesopathy, and DIP involvement (p<0.01), while other types of skin and nail lesions were correlated with selected rheumatic manifestations. The performance of existing criteria for PsA was poor, as individual sets favored either sensitivity or specificity. Psoriatic arthropathy (PsA), occurring in about three-quarters of hospital outpatients with psoriasis, is more common than previously thought. More sensitive and specific criteria for the diagnosis and classification of PsA need to be developed, taking into account the recently described clinical and radiological manifestations.

An Italian Study on Psoriasis and Depression

BACKGROUND

Psoriasis is often associated with the risk of physical disability, social discomfort and psychological disorders.

OBJECTIVES

The aim of this study was to investigate the prevalence of depressive symptomatology among Italian patients with psoriasis vulgaris, in order to better evaluate the disease severity in this patient population.

METHODS

Five thousand Italian patients with psoriasis were mailed the Center for Epidemiological Studies-Depression Scale (CES-D) questionnaire, a 20-item instrument developed to perform epidemiological studies of depressive symptomatology in the general population. Questionnaires with responses to 16 or more items were considered evaluable.

RESULTS

We received evaluable questionnaires from 2,391 patients, including 1,528 men (63.9%) and 863 women (36.1%). Depressive symptomatology was observed in 1,482/2,391 patients (62% overall; females, 63%; males, 61%). Men < 40 years of age were significantly more likely to report depressive symptoms than were men > or =40 years of age (67 vs. 58%, respectively; p = 0.002). Depressive symptomatology was more prevalent in psoriatic patients with only primary or secondary education than in psoriatic patients with higher education (51 vs. 32%, respectively; p < 0.02).

CONCLUSION

Our results are consistent with previous studies showing that psoriasis is associated with profound psychological morbidity, in particular with depression in a large number of patients. It is important to consider this association in the overall management of psoriasis.

Stress, social support, emotional regulation, and exacerbation of diffuse plaque psoriasis

The authors' aim was to investigate the role of stressful events, perceived social support, attachment security, and alexithymia in triggering exacerbations of diffuse plaque psoriasis. Inpatients experiencing a recent exacerbation of diffuse plaque psoriasis (N=33) were compared with inpatients with skin conditions believed to have a negligible psychosomatic component (N=73). Stressful events during the last year were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia, and perceived social support were assessed with the Experiences in Close Relationships questionnaire, the Toronto Alexithymia Scale, and the Multidimensional Scale of Perceived Social Support, respectively. Multiple logistic regression analysis was used to control for age, gender, education, marital status, and alcohol consumption. In relation to comparison subjects, the patients with psoriasis had lower perceived social support and higher attachment-related avoidance. Also, they were more likely to have high alexithymic characteristics. There were no differences between the patients with psoriasis and the comparison subjects in scores on the Experiences in Close Relationships anxiety scale, the total number of stressful events, and the number of undesirable, uncontrollable, or major events. Although caution should be applied in generalizing these findings to outpatients, this study suggests that alexithymia, attachment-related avoidance, and poor social support might increase susceptibility to exacerbations of diffuse plaque psoriasis, possibly through impaired emotional regulation. Several physiological mechanisms involving the neuroendocrine and the immune system might mediate the interplay between stress, personality, and diffuse plaque psoriasis.

Classification and diagnostic criteria for psoriatic arthritis

BACKGROUND

The study of psoriatic arthritis is difficult and has lagged behind the study of other arthropathies in that there are no universally agreed or properly validated case definitions.

METHOD

This paper examined the validity and practicality of the original Moll and Wright criteria and subsequent criteria sets. Key features discriminating between psoriatic and other arthropathies were reviewed. A comparative study involving patients with psoriatic arthritis and rheumatoid arthritis was used to contrast the different classification methods.

RESULTS

Although the Moll and Wright criteria continue to be widely used, they have been shown to discriminate poorly between psoriatic and rheumatoid arthritis. In comparison, the most sensitive criteria were those of Vasey and Espinoza, McGonagle et al, and Gladman et al (99%), whereas the others were significantly less sensitive (between 56% and 94%). The specificity of all methods was high and statistically similar (between 93% and 99%). Models that had reasonably good accuracy even without such key variables as psoriasis or rheumatoid factor were developed. Spinal involvement continues to be a key feature of psoriatic arthritis, but dissimilarities with classic ankylosing spondylitis have been highlighted.

CONCLUSIONS

Further work is required to produce classification criteria for psoriatic arthritis. A prospective study collecting clinical, radiological, human leucocyte antigen (HLA) and immunological data from both psoriatic and non-psoriatic cases should provide agreed criteria for use in psoriatic arthritis studies in the future.

Fixed-dose combination therapy for psoriasis

Fixed-dose combination therapy offers stable products containing two or more medications with different mechanisms of action and safety profiles. It is also convenient for patients since only one product rather than two or more needs to be applied. Topical corticosteroids are often the mainstay of therapy in psoriasis. Diprosalic and Nerisalic contain a topical corticosteroid (betamethasone dipropionate and diflucortolone, respectively) and salicylic acid. A left/right study showed that both products have comparable efficacy. It has also been shown that betamethasone dipropionate + salicylic acid ointment has similar efficacy to clobetasol and calcipotriene (calcipotriol) ointments. Betamethasone dipropionate + salicylic acid lotion has similar efficacy to clobetasol lotion. Faster improvement of scaling, itching, and redness was noted with betamethasone dipropionate + salicylic acid lotion compared with betamethasone dipropionate alone. Dovobet (Daivobet) ointment is a fixed-dose combination product containing betamethasone dipropionate and calcipotriene. Clinical studies have shown that it has greater efficacy and a faster speed of onset than the individual components or tacalcitol. Once daily and twice daily treatments have similar efficacy. Psoriasis Area and Severity Index reductions of approximately 40% after 1 week and 70% after 4 weeks of therapy were consistently noted in six large international studies involving >6000 patients. Betamethasone dipropionate + calcipotriene treatment is associated with approximately 75% less adverse cutaneous events as compared with tacalcitol, 50% less compared with calcipotriene, and a similar number as treatment with betamethasone dipropionate.

Only limited support for a role of psychosomatic factors in psoriasis. Results from a case-control study

OBJECTIVE

To investigate the role of stressful events, social support, attachment security and alexithymia in triggering or exacerbating psoriasis.

METHODS

Outpatients experiencing a recent onset or exacerbation of psoriasis (n=40) were compared with outpatients with skin conditions in which psychosomatic factors are regarded as negligible (n=116). Stressful events during the last year were assessed with Paykel's Interview for Recent Life Events. Attachment style, alexithymia and perceived social support were assessed with the ECR questionnaire, the TAS-20 and the MSPSS, respectively.

RESULTS

The mean number of recently experienced life events, or of undesirable, uncontrollable or major events was not different between psoriatic patients and controls. The only stress measure that showed a slight trend towards an association with psoriasis was having experienced four or more stressful events in the preceding year. There was a statistical trend towards an association between alexithymia and psoriasis, whereas there were no significant differences between patients with psoriasis and controls with respect to perceived social support and attachment security. Subgroup analysis suggested that the role of all psychosomatic factors studied might be more important in certain clinical types, such as guttate and diffuse plaque psoriasis.

CONCLUSIONS

Our findings provide only limited support for a role of psychosomatic factors in psoriasis. Future studies should investigate chronic and daily stressors in addition to major life events, include measures of stress appraisal and include specifically patients with a recent onset of disease.

Efficacy and safety of a new combination of calcipotriol and betamethasone dipropionate (once or twice daily) compared to calcipotriol (twice daily) in the treatment of psoriasis vulgaris: a randomized, double-blind, vehicle-controlled clinical trial

BACKGROUND

Calcipotriol and betamethasone dipropionate are both widely used, effective treatments for psoriasis. Vitamin D analogues and topical corticosteroids have different mechanisms of action in the treatment of psoriasis. A new vehicle has been developed in order to contain both calcipotriol (50 micro g g-1) and betamethasone dipropionate (0.5 mg g-1) in an ointment form. By using calcipotriol and a corticosteroid together, greater efficacy may be achieved than by using either compound alone.

OBJECTIVES

The present study was conducted in order to compare the clinical efficacy and safety of the combined ointment formulation used once daily with the vehicle ointment used twice daily, calcipotriol ointment used twice daily and the combined formulation used twice daily in psoriasis vulgaris.

METHODS

This was an international, multicentre, prospective, randomized, double-blind, vehicle-controlled, parallel group, 4-week study in patients with psoriasis vulgaris amenable to topical treatment. Patients were randomized to one of four treatment groups: combined formulation once daily, combined formulation twice daily, calcipotriol twice daily or vehicle twice daily. Efficacy and safety were assessed.

RESULTS

There was no statistically significant difference in the mean percentage change in the Psoriasis Area and Severity Index (PASI) from baseline to end of treatment between the two combined formulation groups, but the difference in PASI reduction was significantly higher in the combined formulation groups (68.6% once daily, 73.8% twice daily) than in both the twice daily calcipotriol group (58.8%) and the vehicle group (26.6%). Safety data showed the frequency of adverse events to be less in the combined formulation groups than in both the calcipotriol group and the vehicle group. The proportion of patients with lesional/perilesional adverse reactions was less in the combined formulation groups and vehicle group than in the calcipotriol group (9.9% combined formulation once daily, 10.6% combined formulation twice daily, 19.8% calcipotriol, 12.5% vehicle).

CONCLUSIONS

No statistically significant nor clinically relevant difference in efficacy was seen between the combined formulation used once daily and twice daily. When compared to vehicle ointment or calcipotriol ointment alone, the combined formulation was shown to be clearly more efficacious.

Psoriasis of early and late onset: a clinical and epidemiologic study from Spain

BACKGROUND

The existence of 2 distinct forms of psoriasis related to age at onset has been postulated. However, precise data regarding the clinical and epidemiologic characteristics of psoriasis depending on the age at onset are still lacking.

OBJECTIVE

The purpose of this study was to define the clinical and epidemiologic features of this disease in Spain and to compare patients with psoriasis of early and late onset.

METHODS

An observational, analytic, cross-sectional, multicenter study was carried out. From January 1999 to November 1999, 179 participating dermatologists completed a questionnaire detailing the clinical and epidemiologic features of the first 10 consecutive patients with psoriasis seen in their clinical practice. The sample distribution was proportional to the Spanish population. Both statistical and descriptive analyses were performed.

RESULTS

Available data were obtained from 1774 patients. The onset of the disease before 30 years of age was significantly associated with a higher incidence of family history of psoriasis, a more severe and extensive cutaneous involvement, and greater psychosocial impact. Guttate psoriasis, nail involvement, evidence of precipitating factors, and a recurrent clinical course were more frequent in this group of patients. Patients with psoriasis of late onset had a less severe clinical course and a more continuous evolution. Palmoplantar pustulosis was more frequent in this group of patients. No significant relationship was detected between the age at onset and development of joint involvement.

CONCLUSION

Patients with early and late onset psoriasis often show different clinical and evolutionary features. From the analysis of our data, it seems that 2 different groups of patients with psoriasis related to age at onset can be defined.

The effects of 17 August Marmara earthquake on patient admittances to our dermatology department

On 17 August 1999 a devastating earthquake with a magnitude of 7.4 on the Richter scale occurred in Marmara region of Turkey and the epicentre of the earthquake was our city. In this study we aimed to determine the influence of a major earthquake on patient admittance's to the outpatient clinic of our dematology department. All the registrations of the outpatient clinic of our dermatology department in a period of 6 months after the earthquake and the same period last year were revised retrospectively and categorized into 15 subgroups. The first 3 months registrations (earthquake group 1) and the second 3 months registrations (earthquake group 2) after the earthquake were compared with those of the same periods in last year, respectively (control group 1 and control group 2). Also the earthquake group 1 was compared with the earthquake group 2. When the results were evaluated, it was seen that the incidence of infections-infestations was significantly higher in the earthquake group 1 when compared with the control group 1. When the earthquake group 2 and the control group 2 were compared with each other regarding the incidences of the skin diseases, no statistically significant difference was found. The incidences of erythematous-squamous skin diseases, pruritus and neurocutaneous dermatoses and eczemas were significantly higher in the earthquake group 2 when compared with the earthquake group 1. On the other hand, the incidences of infections-infestations and dermatoses due to physical factors were significantly lower in the earthquake group 2 when compared with the earthquake group 1. We think that the alteration in the admittance's to outpatient clinic of our dermatology department in the first 3 months after the earthquake is due to the damaged infrastructures and unhygienic life conditions and in the second 3 months is due to psychoemotional factors related to earthquake.

Immunologic features of chromosome 22q11.2 deletion syndrome (DiGeorge syndrome/velocardiofacial syndrome)

OBJECTIVES

To characterize immunologic function and clinical characteristics in patients with chromosome 22q11.2 deletion syndrome and determine whether there was significant change over time.

METHODS

This study characterized the laboratory and clinical features of the immunodeficiency in a cohort of 195 patients with chromosome 22q11.2 deletion syndrome and used cross-sectional and analysis of variance to compare the findings in different age groups with control patients. Changes over time were also characterized by a model effect method in a subset of patients who were studied serially.

RESULTS

Diminished T cell counts in the peripheral blood are common in patients with chromosome 22q11.2 deletion syndrome. The pattern of changes seen with aging in normal control patients was also seen in patients with chromosome 22q11.2 deletion syndrome, although the decline in T cells was blunted. Autoimmune disease was seen in most age groups, although the types of disorders varied according to age. Infections were also common in older patients, though they were seldom life threatening.

CONCLUSIONS

Slow declines in T cell populations are seen in chromosome 22q11.2 deletion syndrome. Clinical manifestations of immunodeficiency, such as recurrent infection and autoimmune disease, were common in this population but had little relationship to specific immunologic laboratory features.

Prevalence of psoriasis in Spain (Epiderma Project: phase I)

BACKGROUND

Various national and international studies are under way to obtain reliable data on the epidemiological features of psoriasis.

OBJECTIVES

The purpose of this study was to determine the prevalence of psoriasis in the general population in Spain as well as its variations according to sex, age and distribution in different geographical areas.

MATERIAL AND METHODS

A random sample (12,938 subjects from 4027 households), representative of the general population, was the basis for a cross-sectional survey through telephone calls performed by trained non-medical interviewers using a specific questionnaire.

RESULTS

The prevalence of psoriasis, similar in both sexes, was estimated to be 1.17-1.43%. The highest prevalence rates were shown among 20-50-year-old subjects. Distribution of psoriatic patients was not homogeneous throughout the country and prevalence was shown to be higher in the central dry region of the country.

CONCLUSIONS

In a population of about 40 million inhabitants, 470,000-570,000 psoriatic subjects constitute an important target for health care issues and further epidemiological studies.