Association between palmoplantar pustulosis and cigarette smoking in Brazil: a case-control study

Effect of smoking cessation on psoriasis vulgaris, palmoplantar pustulosis and generalized pustular psoriasis

BACKGROUND

Smoking is a known risk factor for psoriasis; however, the impact of smoking cessation on psoriasis has seldom been evaluated.

OBJECTIVES

We aimed to examine the effects of smoking cessation on the development of psoriasis vulgaris (PsV), palmoplantar pustulosis (PPP) and generalized pustular psoriasis (GPP).

METHODS

Using the Korean National Health Insurance Service database, we retrospectively compiled a cohort of 5 784 973 participants without psoriasis, analysed their changes in smoking status from 2004 to 2007 and followed up new cases of psoriasis until 2021. The psoriasis risks were compared with those of sustained smokers, smoking quitters, sustained ex-smokers and never smokers using multivariate Cox proportional hazard models.

RESULTS

The mean age of the participants was 47.1 years (SD 13.5) and 3 092 426 (53.5%) were male. During 77 990 688 person-years, 67 364 psoriasis cases were identified. Compared with sustained smokers, smoking quitters showed a reduced risk of developing psoriasis [adjusted hazard ratio (aHR) 0.91; 95% confidence interval (CI) 0.87-0.95], specifically PsV (aHR 0.92; 95% CI 0.88-0.97) and PPP (aHR 0.71; 95% CI 0.63-0.79). The reduction in risk due to smoking cessation was more prominent in sustained ex-smokers (psoriasis: aHR 0.77, 95% CI 0.74-0.79; PsV: aHR 0.76, 95% CI 0.73-0.79; PPP: aHR 0.56, 95% CI 0.51-0.61; GPP: aHR 0.64; 95% CI 0.52-0.78). When conducting sensitivity analyses to address the potential for changes in smoking habits after 2007, the results and trends were consistent with the main findings, and a more pronounced significance was observed.

CONCLUSIONS

Compared with continuous smoking, smoking cessation was associated with a decreased risk of developing psoriasis. The risk-reducing effect of smoking cessation was more pronounced in those maintaining a smoke-free status. Smoking cessation and the maintenance of a smoke-free status should be encouraged to prevent the development of psoriasis and all other smoking-related diseases.

Clinical characteristics, quality of life and risk factors for severity in palmoplantar pustulosis: a cross-sectional, multicentre study of 263 patients

BACKGROUND

Palmoplantar pustulosis (PPP) is a rare, chronic, inflammatory skin disease characterized by sterile pustules on palmar or plantar areas. Data on PPP are scarce.

AIM

To investigate the clinical characteristics and risk factors for disease severity in a large cohort of Turkish patients with PPP.

METHODS

We conducted a cross-sectional, multicentre study of patients with PPP recruited from 21 tertiary centres across Turkey.

RESULTS

In total, 263 patients (165 women, 98 men) were evaluated. Most patients (75.6%) were former or current smokers. The mean Palmoplantar Pustulosis Area and Severity Index (PPPASI) was 8.70 ± 8.06 and the mean Dermatology Life Quality Index (DLQI) score was 6.87 ± 6.08, and these scores were significantly correlated (r = 0.52, P < 0.001). Regression analysis showed that current smoking was significantly associated with increased PPPASI (P = 0.03). Coexisting psoriasis vulgaris (PsV) was reported by 70 (26.6%) patients. Male sex prevalence, PPP onset incidence, disease duration, DLQI, and prevalence of nail involvement and psoriatic arthritis (PsA) were significantly increased among patients with PPP with PsV. Of the 263 patients, 18 (6.8%) had paradoxical PPP induced by biologic therapy, and these patients had significantly increased mean DLQI and prevalence of PsA (r = 0.03, P = 0.001).

CONCLUSION

Our data suggest that smoking is a risk factor for both PPP development and disease severity. Patients with PPP with PsV present distinct clinical features and patients with biologic therapy-induced paradoxical PPP have reduced quality of life and are more likely to have PsA.

Interventions for chronic palmoplantar pustulosis: abridged Cochrane systematic review and GRADE assessments

BACKGROUND

Palmoplantar pustulosis (PPP) is a chronic inflammatory disease in which sterile and relapsing pustules appear on the palms and soles.

OBJECTIVES

To assess the effects of interventions for chronic PPP to induce and maintain complete remission.

METHODS

We searched for randomized controlled trials (RCTs), including people with PPP or chronic palmoplantar pustular psoriasis, in the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and eight trials registers up to July 2020. Study selection, data extraction and risk-of-bias assessment were carried out independently by two review authors. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method.

RESULTS

We included 37 RCTs (1663 participants, 76% women, mean age 50 years). Mean treatment duration was 11 weeks. Topical vitamin D derivative may be more effective than placebo in achieving clearance [risk ratio (RR) 7·83, 95% confidence interval (CI) 1·85-33·12; low-certainty evidence from two trials]. Concerning biological therapies, there was little or no difference between etanercept and placebo in achieving clearance (low-certainty evidence from one trial), ustekinumab is less effective than placebo in reducing severity (low-certainty evidence from one trial), and guselkumab (RR 2·88, 95% CI 1·24-6·69) and secukinumab (RR 1·55, 95% CI 1·02-2·35) are probably better in reducing disease severity (moderate-certainty evidence from two and one trial(s), respectively) but may cause more serious adverse events than placebo.

CONCLUSIONS

Evidence is lacking for or against major chronic PPP treatments. Risk of bias and imprecision limit our confidence in the results.

Cigarette Smoke Underlies the Pathogenesis of Palmoplantar Pustulosis via an IL-17A-Induced Production of IL-36γ in Tonsillar Epithelial Cells

Palmoplantar pustulosis (PPP) is characterized by sterile pustules on the palms and soles. A strong association between PPP and tobacco smoking has been reported, and it has been speculated that the IL-17A pathway may play an important role in PPP. Recent studies have suggested that IL-36 plays a pivotal role in the pathogenesis of psoriasis and its subtypes. The relationships among IL-36, smoking, and PPP have not been examined. Here, we investigated the relationships among the smoking index, severity of the clinical condition of PPP, and in vitro dynamics of IL-36 in human tonsillar epithelial cells under the condition of exposure to a cigarette smoke extract. The results demonstrated that the Palmoplantar Pustulosis Area and Severity Index was strongly and positively correlated with the smoking index in female patients. Immunohistochemical examinations showed that IL-36γ was highly expressed in tonsillar epithelial cells from patients with PPP but not in those from patients with recurrent tonsillitis without PPP. The in vitro study revealed that IL-17A synergistically induced a release of IL-36γ under cigarette smoke extract exposure. These results suggest that local production of IL-36γ by epithelial cells induced by cigarette smoke exposure plays an important role in the pathogenesis of PPP.

Smoking habits amongst patients with psoriasis and the effect of smoking on clinical and treatment-associated characteristics: A cross-sectional study

BACKGROUND

Psoriasis is a multifactorial, chronic inflammatory skin disease where genetic and environmental factors play a role in the pathogenesis. Smoking is one of the critical environmental factors triggering psoriasis.

OBJECTIVE

The purpose of the present study was to analyse the smoking habits of patients with psoriasis and the effect of smoking on disease characteristics.

METHODS

One hundred and thirty-three patients who applied to the department of Dermatological and Venereal Diseases, Ankara Numune Education and Research Hospital, between May 2018 and May 2019 and were diagnosed with psoriasis participated in the study. Clinical, demographical, and treatment-related characteristics, and smoking habits of patients were recorded.

RESULTS

Sixty-seven point six percent of psoriasis patients were smokers. The presence of moderate to severe psoriasis (P = .028), nail involvement (P = .004), administration of systemic treatment (P = .024) and additional cardiovascular disease (P = .038) frequencies was higher in smokers compared to non-smokers. Besides, a positive correlation was observed between the amount of smoking and psoriasis area and severity index (PASI) (P = .003; r = .32).

CONCLUSIONS

Smoking has many negative effects on patients with psoriasis including higher PASI levels, increased frequency of nail involvement, and cardiovascular diseases. Questioning cigarette smoking in psoriatic patients and supporting smoking cessation may contribute to reducing the adverse impact of smoking on psoriasis.

Impact of smoking on psoriasis risk and treatment efficacy: a meta-analysis

Objective

Psoriasis is an immune-mediated chronic inflammatory disease with skin and joint manifestations. Smoking is considered an unfavorable lifestyle factor for psoriasis. We aimed to explore the association between smoking, disease risk, and treatment efficacy in relation to psoriasis.

Methods

We searched the Cochrane Library, Embase, and PubMed databases for studies examining the relationship between smoking and psoriasis, up to 12 April 2020. We then conducted a meta-analysis using a fixed-effects model to obtain odds ratios (ORs) with 95% confidence intervals (CIs).

Results

Ever, current, and former smokers all had higher risks of developing psoriasis than non-smokers (pooled ORs (95% CIs): 1.60 (1.51–1.69), 1.63 (1.48–1.80), and 1.36 (1.13–1.64), respectively). Ever smokers were less likely to show disease improvement at 6 months following treatment with biologic agents than non-smokers (pooled OR (95% CI): 0.80 (0.67–0.95)).

Conclusions

Smoking increases psoriasis risk and negatively impacts the benefits of biologic agents. However, the number of reports is limited and more studies are needed to confirm the effects of smoking and smoking cessation on therapeutic response in patients with psoriasis. Education to encourage a healthy lifestyle remains a valuable approach in clinical practice.

"Autoinflammatory psoriasis"-genetics and biology of pustular psoriasis

Psoriasis is a chronic inflammatory skin condition that has a fairly wide range of clinical presentations. Plaque psoriasis, which is the most common manifestation of psoriasis, is located on one end of the spectrum, dominated by adaptive immune responses, whereas the rarer pustular psoriasis lies on the opposite end, dominated by innate and autoinflammatory immune responses. In recent years, genetic studies have identified six genetic variants that predispose to pustular psoriasis, and these have highlighted the role of IL-36 cytokines as central to pustular psoriasis pathogenesis. In this review, we discuss the presentation and clinical subtypes of pustular psoriasis, contribution of genetic predisposing variants, critical role of the IL-36 family of cytokines in disease pathophysiology, and treatment perspectives for pustular psoriasis. We further outline the application of appropriate mouse models for the study of pustular psoriasis and address the outstanding questions and issues related to our understanding of the mechanisms involved in pustular psoriasis.

Palmoplantar Pustulosis: Recent Advances in Etiopathogenesis and Emerging Treatments

Palmoplantar pustulosis (PPP) is a chronic, recurrent skin disease belonging to the spectrum of psoriasis. It is characterized by an eruption of sterile pustules on the palms and soles. Recent studies in PPP have focused on genetic differences between pustular phenotypes and the role of the innate immunological system and the microbiome in the etiopathogenesis of the disease. Mutations in IL36RN (a major predisposing factor for generalized pustular psoriasis) were found in selected patients with PPP and were associated with earlier disease onset. Studies have shown that the interleukin (IL)-17 and IL-36 pathways might be involved in the pathogenesis of PPP. A microbiome has been demonstrated in the vesicopustules of PPP, and an abundance of Staphylococcus appears to be increased by smoking. Improved understanding of the underlying etiopathogenesis of PPP has led to advances in treatment options, and targeted therapies for PPP have been evaluated or are under evaluation against more than 12 molecules in ongoing clinical trials. These targets include CXCR2 (IL-8 receptor type B), granulocyte colony-stimulating factor receptor, IL-1 receptor, IL-8, IL-12, IL-23, IL-17A, IL-17 receptor, IL-36 receptor, phosphodiesterase-4, and tumor necrosis factor-α.

Interventions for chronic palmoplantar pustulosis

BACKGROUND

Palmoplantar pustulosis is a chronic inflammatory disease in which sterile, relapsing pustules appear on the palms and soles, possibly in conjunction with other symptoms. The previous Cochrane Review on this topic was published in 2006, before biological treatments were extensively used.

OBJECTIVES

To assess the effects of interventions for chronic palmoplantar pustulosis to induce and maintain complete remission.

SEARCH METHODS

We searched the following databases up to March 2019: Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers and checked the reference lists of the included studies for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

We considered RCTs including people with palmoplantar pustulosis or chronic palmoplantar pustular psoriasis assessing topical therapy, systemic therapy, combinations of topical or systemic therapies, or non-pharmacological therapies compared with placebo, no intervention, or each other.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our outcomes included 'Proportion of participants cleared or almost cleared', 'Proportion of participants with adverse effects serious or severe enough to cause withdrawal', 'Proportion of participants with at least 50% improvement in disease severity', and 'Proportion of participants with adverse effects'.

MAIN RESULTS

We included 37 studies (1663 participants; mean age 50 years (range 34 to 63); 24% males). These studies reported condition severity differently. Around half of the included trials stated the setting (hospitals, community clinics, or both). More than half of the studies were at high risk of bias in at least one domain. Our included studies assessed mainly systemic treatments (retinoids, ciclosporin, biologics, etretinate + PUVA (combination of psoralens and long-wave ultraviolet radiation) therapy combined, and antibiotics), but also topical treatments (dermocorticoids, vitamin D) and phototherapy (PUVA, ultraviolet A1 (UVA1)). Other interventions were assessed by single studies. The most common comparator was placebo. All results presented in this abstract were assessed in the short term (mean treatment duration was 11 weeks (range 8 to 24 weeks)) and are based on participants with chronic palmoplantar pustulosis. All outcome time point measurements were taken from baseline and assessed at the end of treatment. Short-term and long-term outcomes were defined as measurement up to 24 weeks after randomisation and between 24 and 104 weeks after randomisation, respectively. One trial (188 participants) assessed the topical vitamin D derivative maxacalcitol versus placebo and found that maxacalcitol may be more effective than placebo in achieving clearance (risk ratio (RR) 7.83, 95% confidence interval (CI) 1.85 to 33.12; low-quality evidence), and the risk of adverse effects (such as mild local irritation, pruritus, and haematological or urinary test abnormalities) is probably similar in both groups (RR 0.87, 95% CI 0.64 to 1.19; moderate-quality evidence). Severity was not reported. Two trials (49 participants) assessed PUVA therapy versus placebo or no treatment, providing very low-quality evidence. Adverse effects were reported with oral PUVA (including nausea, ankle swelling, and non-purulent conjunctivitis) and with local PUVA (including blistering, erythema, and pruritus). With regard to the systemic retinoid alitretinoin, one trial (33 participants; moderate-quality evidence) showed that alitretinoin probably makes little or no difference in reducing severity when compared to placebo (RR 0.69, 95% CI 0.36 to 1.30). A similar number of adverse events were reported in both treatment groups, including headache, cheilitis, nausea, arthralgia, and nasopharyngitis (RR 0.84, 95% CI 0.61 to 1.17). Clearance was not reported. There may be little or no difference between etanercept and placebo in achieving clearance (RR 1.64, 95% CI 0.08 to 34.28; 1 study; 15 participants; low-quality evidence); however, the 95% CI was very wide, showing there may be a difference between groups. Severity was not measured. More patients treated with placebo may achieve reduced severity than those treated with ustekinumab, but the wide 95% CI indicates there might be little or no difference between groups and there might be greater effect with ustekinumab (RR 0.48, 95% CI 0.11 to 2.13; 1 study; 33 participants; low-quality evidence). Clearance was not reported. It is uncertain whether guselkumab increases clearance when compared to placebo (2 studies; 154 participants) because the quality of evidence is very low, but guselkumab probably better reduces disease severity (RR 2.88, 95% CI 1.24 to 6.69; 1 study; 49 participants; moderate-quality evidence). Secukinumab is probably superior to placebo in reducing severity (RR 1.55, 95% CI 1.02 to 2.35; 1 study; 157 participants; moderate-quality evidence), but our clearance outcome was not reported. None of these trials reported on occurrence of adverse effects. Only two of the studies discussed above reported adverse effects serious or severe enough to cause withdrawal. Guselkumab may cause more serious adverse events when compared to placebo, but there is uncertainty due to the very wide 95% CI showing there may be little or no difference and showing more events with placebo (RR 2.88, 95% CI 0.32 to 25.80; 1 study; 49 participants; low-quality evidence). Secukinumab probably causes more serious adverse events than placebo (RR 3.29, 95% CI 1.40 to 7.75; 1 study; 157 participants; moderate-quality evidence).

AUTHORS' CONCLUSIONS

Evidence is lacking for major chronic palmoplantar pustulosis treatments such as superpotent corticosteroids, phototherapy, acitretin, methotrexate, and ciclosporin. Risk of bias and imprecision limit our confidence. Maxacalcitol may be more effective than placebo in achieving clearance in the short term (low-quality evidence), and the risk of adverse effects is probably similar (moderate-quality evidence). Oral alitretinoin is probably no more effective than placebo in reducing severity, with a similar risk of adverse effects (moderate-quality evidence). Regarding biological treatments, we are uncertain of the effect of etanercept on clearance and the effect of ustekinumab on severity (low-quality evidence). Secukinumab and guselkumab are probably superior to placebo in reducing severity (moderate-quality evidence). Adverse events not requiring withdrawal were not reported for these treatments. Reporting of serious adverse effects was incomplete: compared to placebo, secukinumab probably caused more participant withdrawals (moderate-quality evidence), but we are uncertain of the effect of guselkumab (low-quality evidence). Future trials should assess commonly used treatments using validated severity and quality of life scales.

Clinical Features, Etiologic Factors, Associated Disorders, and Treatment of Palmoplantar Pustulosis: The Mayo Clinic Experience, 1996-2013

OBJECTIVE

To further characterize clinical characteristics, etiologic factors, associated disorders, and treatment of palmoplantar pustulosis (PPP).

PATIENTS AND METHODS

We conducted a retrospective review of patients with PPP at Mayo Clinic between January 1, 1996, and December 31, 2013.

RESULTS

Of 215 patients with PPP identified, 179 (83%) were female, and the mean age at onset was 45.3 years. Most patients (n=165, 77%) were current or former smokers. At diagnosis, 15 patients (7%) had an anxiety diagnosis and 9 (4%) had an infection. Nineteen cases (9%) were drug induced. Comorbid conditions included thyroid disease in 18 patients (8%), gluten sensitivity in 3 (1%), and type 2 diabetes mellitus in 21 (10%). In all, 194 patients (90%) received topical corticosteroids, 55 (26%) received phototherapy, and 54 (25%) received systemic agents.

CONCLUSION

More than three-fourths of the patients in this study had a history of smoking, which is considered a triggering or aggravating factor for PPP. Regarding comorbid conditions, gluten sensitivity and thyroid disease were found less frequently than previously reported in the literature. Treatment regimens and responses in this cohort varied considerably.

Smoking and risk for psoriasis: a population-based twin study

BACKGROUND

Smoking is a potential risk factor for psoriasis. Both psoriasis and smoking habits are partly explained by genetic factors. However, twin studies investigating the association between these traits are limited.

METHODS

Questionnaire-based data on smoking habits and psoriasis were collected for 34,781 twins, aged 20-71 years, from the Danish Twin Registry. A co-twin control analysis was performed on 1700 twin pairs discordant for lifetime history of smoking. Genetic and environmental correlations between smoking and psoriasis were estimated using classical twin modeling.

RESULTS

After multivariable adjustment, age group (50-71 vs. 20-49 years) and childhood exposure to environmental tobacco smoke (ETS) were significantly associated with psoriasis in the whole population (odds ratio [OR] 1.15, 95% confidence interval [CI] 1.02-1.29 [P = 0.021] and OR 1.28, 95% CI 1.10-1.49 [P = 0.002], respectively). Risk for psoriasis increased substantially (OR 2.18, 95% CI 1.82-2.61; P < 0.001) for smokers with a history of >5 pack-years, even after adjusting for age, sex, and childhood ETS. Among twin pairs discordant for smoking, risk for psoriasis in the ever-smoking twin was lower among monozygotic twins (OR 1.23, 95% CI 0.59-2.56; P = 0.578) than among same-sex dizygotic twins (OR 2.21, 95% CI 1.36-3.58; P = 0.001). Genetic factors explained 20% (14-25%; P < 0.001) of the correlation between psoriasis and smoking, whereas non-shared environmental factors explained 8% (0-22%; P = 0.504).

CONCLUSIONS

Tobacco consumption and childhood ETS are significantly associated with psoriasis. Results indicate shared genetic factors for smoking and psoriasis.

Infrared Saliva Analysis of Psoriatic and Diabetic Patients: Similarities in Protein Components

GOAL

Psoriasis is a chronic skin disease which is very common in the population and requires frequent clinical and pharmacological treatment. In the following, a study based on Fourier transform infrared spectroscopy analyzing saliva proteomic components in psoriatic patients against diabetic patients and a control group is presented. Clinical analysis showed a prominent amide II band, at around 1545 cm(-1), and the composition of the amide I band, at around 1647 cm(-1), allowing us to distinguish the infrared salivary signature of psoriatic and diabetic patients from the control group and even from patients with different kinds of psoriasis. Moreover, results highlighted existing differences in the secondary structure composition of proteins between psoriatic and diabetic patients as compared to the control group. In fact, the saliva spectra of the control group and that of the palmoplantar psoriatic patients differ from plaque psoriasis and diabetic patient spectra because of the absence of the amide II band and the presence of different secondary protein-structure conformations.

Increased numbers of tryptase-positive mast cells in the healthy and sun-protected skin of tobacco smokers

BACKGROUND

Tobacco smoking may cause skin aging through mast cell proteinases.

OBJECTIVE

To compare the numbers of mast cells showing tryptase and chymase in the healthy-looking skin of smokers and non-smokers.

METHODS

The study subjects consisted of 80 males, 42 of whom were smokers and 38 non-smokers. A skin biopsy from the medial arm was processed for immunohistochemical staining of tryptase and chymase, as well as chymase inhibitors alpha-1-proteinase inhibitor (alpha-1-PI) and alpha-1-antichymotrypsin (alpha-1-AC).

RESULTS

The number of tryptase(+) mast cells was significantly higher in the smoker group (84 ± 32 cells/mm(2)) than in the non-smoker group (70 ± 32 cells/mm(2)) (p = 0.044). Likewise, the number of chymase(+) mast cells was higher in the smoker group (89 ± 20 vs. 80 ± 22 cells/mm(2)), though statistical significance was not reached (p = 0.07). No significant difference was observed in alpha-1-PI(+) and alpha-1-AC(+) cells.

CONCLUSION

Especially tryptase, but probably also chymase, may have an influence on the skin of smokers, such as wrinkling and aging.

Clinical and epidemiological comparison of patients affected by palmoplantar plaque psoriasis and palmoplantar pustulosis: a case series study

BACKGROUND

In 2007 the International Psoriasis Council proposed that palmoplantar pustulosis (PPP) should be considered a separate condition from psoriasis, despite the presence of certain phenotypes common in both diseases.

OBJECTIVES

To describe and compare demographic and clinical characteristics among patients with PPP and palmoplantar plaque psoriasis.

METHODS

This was a retrospective case series study from 2005 to 2010. The following data were obtained: age, sex, family history, smoking habits, nail involvement, joint involvement, disease duration, lesion morphology (plaque or pustular), histological diagnosis, comorbidities, and Physician's Global Assessment (PGA) score for extrapalmoplantar lesions. The sample size calculation indicated that 80 patients, 40 patients for each group (palmoplantar plaque psoriasis and PPP) were needed to see clinically relevant differences between groups.

RESULTS

Ninety patients were selected, 51 with palmoplantar plaque psoriasis and 39 with PPP. No statistically significant differences were registered between patients affected by PPP and palmoplantar plaque psoriasis as regards age at onset of the disease (48 vs. 44 years; P=0·4), disease duration (6 vs. 10 years; P=0·1), family history of psoriasis (28% vs. 33%; P=0·7), concomitant arthritis (26% vs. 25%; P=1·0), or smoking habits (54% vs. 41%; P=0·2). We observed a female predominance (P=0·01) and a lesser frequency of nail involvement (P=0·03) in patients affected by PPP.

CONCLUSIONS

Our data suggest a close relationship between PPP and psoriasis. The existing data concerning epidemiology, clinical presentation, genetics, histopathology and pathogenesis do not permit a clear distinction between these two entities, which seem to coincide in many aspects. PPP appears to have a marked predilection among female smokers.

Pustulotic arthro-osteitis associated with palmoplantar pustulosis

Palmoplantar pustulosis (PPP) is a chronic inflammatory disorder characterized by sterile pustules predominantly involving the palms and soles of middle-aged women. PPP frequently develops or exacerbates following focal infections, such as tonsillitis, odontogenic infection and sinusitis, either with or without arthralgia and/or extra-palmoplantar lesions. Pustulotic arthro-osteitis (PAO) is a joint comorbidity of PPP, most often affecting the anterior chest wall. PAO is sometimes regarded as the same entity as synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome, and may be a subtype or incomplete type of SAPHO syndrome; however, there are several differences. In Japanese patients, PPP with PAO is frequently seen, whereas SAPHO syndrome in the true meaning is rare. A difference of incidence depending on race suggests that different genetic backgrounds may be responsible for susceptibility to these disorders. Bacterial infection, especially Propionibacterium acnes, is suggested to play an important role in the pathogenesis of SAPHO syndrome. P. acnes is responsible for acne, however, bacterium is unassociated with PPP skin lesions which are characterized by sterile pustules. On the other hand, PAO is frequently triggered by focal infection, and treatment of focal infection results in dramatic effects on the release of joint pain. This paper reviews current insights into the clinicopathophysiology of PAO, and discusses its possible mechanisms in comparison with SAPHO syndrome.

Psoriasis and vascular disease-risk factors and outcomes: a systematic review of the literature

BACKGROUND

Psoriasis afflicts 2-3% of the world's population. Affected patients commonly have risk factors for cardiovascular disease (CVD). In addition, psoriasis is independently associated with CVD and mortality.

PURPOSE

To determine which CVD risk factors are associated with psoriasis independent of confounders, whether psoriasis is associated with CVD independent of CVD risk factors, and whether there is increased mortality among patients with psoriasis.

DATA SOURCES

MEDLINE, Embase, and Cochrane Collaborations from inception through October 2009. We reviewed bibliographies of retrieved articles for additional references.

STUDY SELECTION

Cross-sectional, cohort-based, case-control, and randomized controlled trials which involved patients with psoriasis.

DATA EXTRACTION

Two investigators independently reviewed studies and resolved any discrepancies by consensus.

DATA SYNTHESIS

Of the 2,303 articles identified by literature search, 90 studies met inclusion criteria for this review; 15 were cohort-based studies, 45 were case-control, and 30 were cross-sectional.

LIMITATIONS

The quality of evidence was limited by study heterogeneity and lack of large scale prospective studies with long-term follow-up.

CONCLUSIONS

Patients with psoriasis demonstrate a higher prevalence of cardiovascular risk factors and appear to be at increased risk for ischemic heart disease, cerebrovascular disease, and peripheral arterial disease. This increase in vascular disease may be independent of shared risk factors and may contribute to the increase in all-cause mortality. Future research should aim to more confidently distinguish between a true causal relationship or merely an association resulting from multiple shared risk factors. Physicians should screen for and aggressively treat modifiable risk factors for CVD in patients with psoriasis.

Dermatoses neutrofílicas: parte II

Neste artigo são abordadas as dermatoses neutrofílicas, complementando o artigo anterior (parte I). São apresentadas e comentadas as seguintes dermatoses: pustulose subcórnea de Sneddon-Wilkinson, dermatite crural pustulosa e atrófica, pustulose exantemática generalizada aguda, acroder matite contínua de Hallopeau, pustulose palmoplantar, acropustulose infantil, bacteride pustular de Andrews e foliculite pustulosa eosinofílica. Uma breve revisão das dermatoses neutrofílicas em pacientes pediátricos também é realizada.

Tobacco and the skin

Smoking negatively impacts the health of the skin as it does every organ system. This contribution reviews the effect of cigarette smoking on wound healing, wrinkling, and aging of the skin, skin cancer, psoriasis, and other inflammatory skin diseases, hidradenitis suppurativa, acne, alopecia, lupus erythematosus, polymorphous light eruption, and tobacco-associated oral lesions. Dermatologists need to encourage their patients to discontinue this deleterious habit.