Evidence-based recommendations to assess psoriasis severity: systematic literature review and expert opinion of a panel of dermatologists

The effect of IL17 and IL23 inhibitors on hematological parameters and C-reactive protein in psoriasis patients

INTRODUCTION

In the quest for objective biomarkers for psoriasis, the neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), C-reactive protein (CRP), and mean platelet volume (MPV) have been used to assess disease severity, treatment efficacy, and follow-up in psoriasis, and their relationship with the Psoriasis Area Severity Index (PASI) has been investigated.

PURPOSE

The evaluation of pre-treatment, 3rd and 6th-month levels of NLR, PLR, MPV, and CRP along with PASI scores in psoriasis patients treated with secukinumab, ixekizumab, risankizumab, and guselkumab.

MATERIALS AND METHODS

In our study, 83 patients aged 18 and over, who were followed up with moderate-severe plaque type psoriasis vulgaris and psoriatic arthritis and received secukinumab, ixekizumab, risankizumab, and guselkumab treatment in the chronic skin diseases clinic of Fırat University Faculty of Medicine Hospital between January 2019 and 2023, were evaluated retrospectively.

RESULTS

Post-treatment leukocyte, neutrophil, lymphocyte, platelet, CRP, and PASI values were statistically significantly lower in all biological agent groups and all patients. The post-treatment NLR value was statistically significantly higher in all patients and in the group using ixekizumab. The post-treatment PLR value was statistically significantly higher in the group using guselkumab and ixekizumab and in all patients. The post-treatment MPV was statistically significantly higher in all patients and in the group using secukinumab. No correlation was found between post-treatment PASI and other values (p > 0.05). There was no statistically significant difference between the post-treatment 6-month values among all biological agent groups. The effects of different drugs on outcomes after treatment were found to be similar (p > 0.05).

CONCLUSION

Our study supports the view that MPV and CRP can be used in patients with psoriasis using IL17 and IL23 inhibitors, while NLR and PLR parameters derived from blood count may not be used to evaluate treatment response, contrary to other studies.

Treatment guidelines for rare, early-onset conditions associated with epileptic seizures: a literature review on Rett syndrome and tuberous sclerosis complex

BACKGROUND

Rett syndrome (RTT) and tuberous sclerosis complex (TSC) are two rare disorders presenting with a range of different epileptic seizures. Seizure management requires careful therapy selection, thereby necessitating development of high-quality treatment guidelines. This targeted literature review (TLR) aimed to characterise country-specific and international treatment guidelines available for pharmacological management of seizures in RTT and TSC.

METHODS

A TLR was performed between 25-Jan and 11-Mar 2021. Manual searches of online rare disease and guideline databases, and websites of national heath technology assessment bodies were conducted for the following countries: Australia, Canada, France, Germany, Israel, Italy, Japan, Spain, Switzerland, UK, and US as defined by pre-specified eligibility criteria. Search terms were developed for each condition and translated into local languages where appropriate. Eligible publications were defined as guidelines/guidance reporting pharmacological management of seizures in patients with RTT and TSC. Guideline development methodology, geographical focus, author information and treatment recommendations were extracted from guidelines. An author map was generated using R version 3.5.1 to visualise extent of collaboration between authors.

RESULTS

24 total guidelines were included, of which three and six contained only recommendations for RTT and TSC, respectively (some provided recommendations for ≥ 1 condition). Guideline development processes were poorly described (50% [12 guidelines] had unclear/absent literature review methodologies); reported methodologies were variable, including systematic literature reviews (SLRs)/TLRs and varying levels of expert consultation. Most (83% [20/24]) were country-specific, with guideline authors predominantly publishing in contained national groups; four guidelines were classified as 'International,' linking author groups in the US, UK, Italy and France. High levels of heterogeneity were observed in the availability of treatment recommendations across indications, with 13 and 67 recommendations found for RTT and TSC, respectively. For RTT, all treatment recommendations were positive and sodium valproate had the highest number of positive recommendations (Khwaja, Sahin (2011) Curr Opin Pediatr 23(6):633-9). All TSC treatments (21 medications) received either exclusively negative (National Organization for Rare Disorders (2019)) or positive (Chu-Shore et al. (2010) Epilepsia 51(7):1236-41) recommendations; vigabatrin received the highest number of positive recommendations (Kaur, Christodoulou (2019)).

CONCLUSIONS

This review highlights the need for the development of international high-quality and comprehensive consensus-based guidance for the management of seizures with pharmacological therapy in RTT and TSC.

TRIAL REGISTRATION

Not applicable.

Examining the functions of the vascular endothelial growth factor/hypoxia-inducible factor signaling pathway in psoriatic arthritis

Objectives

The present study aimed to examine the roles of the vascular endothelial growth factor (VEGF), hypoxia-inducible factor (HIF), and heme oxygenase-1 (HO-1) in psoriatic arthritis (PsA).

Patients and methods

In this cross-sectional study conducted between November 2020 and May 2021, 64 patients (43 female, 21 male; mean age: 43.2±10.4 years; range, 22 to 60 years) with active PsA were included in the patient group, and 64 healthy volunteers (43 female, 21 male; mean age: 42.8±10.5 years; range, 23 to 61 years) were included in the control group. The demographic features of all cases were recorded. The following indices were used to assess the activity of PsA: Bath Ankylosing Spondylitis Disease Activity Index, Disease Activity Score in 28 joints (DAS28), and Visual Analog Scale. Additionally, Disease Activity in Psoriatic Arthritis (DAPSA) and Psoriasis Area and Severity Index (PASI) were used to evaluate the patients. The biochemical parameters of the patients were calculated. The serum levels of VEGF, HIF, and HO-1 were determined using an enzyme-linked immunosorbent assay.

Results

When the molecule levels and clinical features of the groups were evaluated, it was found that the VEGF and HIF-1 levels were higher in the patient group compared to the control group (p<0.05). No difference was observed in the comparison of the HO-1 levels of the patient group and the control group (p<0.05). A positive correlation was found between VEGF, HIF-1, and HO-1 (p<0.05). A positive relationship was found between VEGF and HIF-1 and erythrocyte sedimentation rate, C-reactive protein, DAPSA score, and PASI score (p<0.05). It was also determined that there was a positive relationship between the HIF molecule and DAS28 (p<0.05).

Conclusion

According to the results obtained in the present study, VEGF and HIF play a role in the etiology of PsA, and the observation of intermolecular correlation suggests that these molecules move together in pathogenesis.

A comprehensive investigation of novel and traditional inflammatory and metabolic markers as predictive indicators in psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory and papulosquamous dermatological disorder. While previous studies have discussed certain inflammatory markers for diagnosing and monitoring psoriasis, there is an absence of comprehensive research encompassing both novel and traditional inflammatory markers, as well as metabolic markers, in relation to psoriasis.

METHODS

A total of 209 individuals participated, including 54 psoriasis patients and 155 controls. Psoriasis Area Severity Index (PASI) was calculated for the patient group. Potential predictive markers for psoriasis were identified: Uric acid/HDL ratio (UHR), D-dimer/albumin ratio (DAR), fibrinogen/albumin ratio (FAR), erythrocyte sedimentation rate, CRP, WBC, HOMA-IR, and vitamin D levels. Differences between groups and correlations with PASI and each other were analyzed using the Mann-Whitney U test and Spearman correlation coefficient.

RESULTS

The results indicate that the patient group exhibited statistically significantly higher levels of UHR, FAR, CRP, WBC, and HOMA-IR. Upon analyzing the correlations between PASI and the identified markers, statistically significant positive correlation with WBC and negative correlation with vitamin D were observed. The correlations of PASI with other markers did not reach statistical significance. It should be underlined that our study was conducted in a predominantly mild-to-moderate patient population.

CONCLUSIONS

The absence of specificity of these markers for psoriasis limits their practical application. However, the development of new objective measures by using them in combination with specific data such as PASI will provide significant benefits in terms of disease diagnosis, follow-up, and treatment.

Neutrophil-to-Lymphocyte Ratio, Neutrophil-to-Monocyte Ratio, Platelet-to-Lymphocyte Ratio, and Systemic Immune-Inflammation Index in Psoriasis Patients: Response to Treatment with Biological Drugs

BACKGROUND

Psoriasis is a chronic immune-mediated skin disease in which systemic inflammation plays an important role in its pathogenesis. In recent years, the neutrophil-to-lymphocyte ratio (NLR), neutrophil-to-monocyte ratio (NMR), platelet-to-lymphocyte ratio (PLR), and systemic immune-inflammation index (SII) were shown to be important indicators of inflammation. This study aimed to investigate the NLR, NMR, PLR, and SII levels in psoriasis patients treated with biological agents.

METHOD

Clinical and biochemical data of 209 patients who received systemic therapy for psoriasis were obtained by retrospectively reviewing their medical records. The NLR, NMR, PLR, and SII values were calculated from the hemogram values of the patients.

RESULTS

In the third month of follow-up, the mean CRP, NLR, NMR, PLR, and SII values were significantly decreased compared with the baseline values. The SII values showed strong positive correlations with the NLR, NMR, and PLR. Adalimumab, etanercept, and infliximab, which are TNF-α blockers, were observed to be more effective on the PLR and NLR, and especially the NMR.

CONCLUSIONS

The NLR, NMR, PLR, and SII, which are data derived from routine blood tests, can be used in the monitoring of the treatment of psoriasis, especially with TNF-α blockers.

Translation and Validation of the Self-Assessment Psoriasis Area Severity Index

BACKGROUND

The self-assessment psoriasis area severity index (SAPASI) is a patient-administered psoriasis assessment tool for which we present a validated translation from English to Swedish.

METHODS

Validity was evaluated in this single-centre study using the psoriasis area severity index (PASI) as the standard. Test-retest reliability was assessed using repeated SAPASI measurements.

RESULTS

Significant correlations (p < 0.0001) using Spearman's correlation coefficient (r) were found between PASI and SAPASI scores (r = 0.60) for 51 participants (median baseline PASI 4.4, interquartile range [IQR]: 1.8-5.6) and repeated SAPASI measurements (r = 0.70) among 38 participants (median baseline SAPASI 4.0, IQR: 2.5-6.1). Bland-Altman plots showed generally higher SAPASI scores than PASI scores.

CONCLUSION

The translated version of SAPASI is valid and reliable, although patients generally tend to overrate their disease severity compared to PASI. Keeping this limitation in mind, SAPASI has the potential of being implemented as a time- and cost-efficient assessment tool in a Scandinavian context.

Papulosquamous annular diseases

Papulosquamous diseases represent a commonly encountered group of cutaneous disorders in dermatology. Lesions can present with papules and plaques in various configurations, including annular forms. Some of these disorders are expected to appear in annular configurations, such as pityriasis rosea and subcorneal pustular dermatosis. Others may either begin as or even progress to annular configurations, including psoriasis vulgaris, seborrheic dermatitis, and nummular dermatitis. We have reviewed common papulosquamous diseases that can present with annular lesions, which includes psoriasis vulgaris, pityriasis rosea, subcorneal pustular dermatosis, contact dermatitis, seborrheic dermatitis, and nummular dermatitis. For each disorder, we have discussed the details of presentation and differential diseases to be considered.

Influence of psoriasis lesions' location and severity on psychosocial disability and psychopathology. Observational study and psychometric validation of the SAPASI Portuguese version

OBJECTIVES

The psychosocial impact of psoriasis is well documented. However, the contributing role of clinical disease characteristics is not satisfactorily explored. This study aimed to validate the Self-administered Psoriasis Area and Severity Index (SAPASI) to a Portuguese population (SAPASI-PT) and to perform its cross-validation, assessing how the results will generalize to an independent data set, with the Psoriasis Area and Severity Index (PASI), in order to assess the influence of psoriasis' severity on psychosocial disability and psychopathology.

METHODS

A cross-sectional study with 228 patients with psoriasis was carried out. Data was collected through a sociodemographic and clinical questionnaire, SAPASI-PT, the Psoriasis Disability Index (PDI) and the Brief Symptoms Inventory (BSI). The cultural and linguistic adaptation of SAPASI to a Portuguese version and the cross validation with PASI was carried out. Multiple associations between psychosocial disability, psychopathology and severity, discomfort and location of lesions were investigated through logistic regression models.

RESULTS

A good adjustment model for SAPASI-PT is found. Also, associations between psychosocial disability, psychopathology and the psoriasis severity and discomfort are found. The existence of lesions is positively associated with the severity of the disease. Patients with lesions in hands or genitals are those reporting a greater discomfort. The presence of lesions in hands is positively associated with PDI, i.e., with leisure and with treatment, marginally. Additionally, patients scoring higher in the personal dimension are found to have a significantly greater percentage of lesions in the genitals.

CONCLUSIONS

The psoriasis severity and location of lesions are important determinants of patients´ quality of life. Lesions on face, hands and genitals are associated with a higher impact on psychosocial wellbeing of patients. Psychological counselling should be considered within psoriasis treatment context in patients with the described disease manifestations.

An Analysis of IL-10, IL-17A, IL-17RA, IL-23A and IL-23R Expression and Their Correlation with Clinical Course in Patients with Psoriasis

Being one of the most common dermatological inflammatory disorders, psoriasis is a frequent subject of research. It is considered to be a T cell-dependent immune disease whose pathogenesis is influenced by cytokines, such as IL-10, IL-17A, IL-17RA, IL-23A and IL-23R. The present study examines whether the expression of selected genes is correlated with the clinical course of psoriasis, assessed by the PASI, BSA and DLQI scales. Skin biopsies and blood from 60 patients with psoriasis and 24 healthy controls were obtained for RNA isolation. These were subjected to RT-PCR for IL-10, IL-17A, IL-17RA, IL-23A and IL-23R genes. The results were presented as an RQ value. IL-17A and IL-23R expression levels were higher in psoriatic skin compared to controls, while IL-10 expression was lower. A positive correlation was also found between RQ for IL-23A and PASI index. Psoriatic skin is characterised by elevated expression of IL-17A and IL-23R and decreased expression of IL-10. This indicates that the selected cytokines may be one of the factors involved in the pathogenesis and pathomechanism of psoriasis, but more studies need to be made before we can elucidate the exact reason for the unbalance in cytokine expression levels.

Treatment Guidelines for Rare, Early-Onset, Treatment-Resistant Epileptic Conditions: A Literature Review on Dravet Syndrome, Lennox-Gastaut Syndrome and CDKL5 Deficiency Disorder

Background: Dravet syndrome (DS), Lennox-Gastaut syndrome (LGS) and CDKL5 deficiency disorder (CDD) are rare epileptic conditions, characterised by drug-resistant seizures. Seizure management in these patients requires careful therapy selection. This targeted literature review (TLR) aimed to collate and synthesise information from country-specific and international treatment guidelines for DS, LGS and CDD. Methods: A TLR was performed between 25th January and 11th March 2021. Online rare diseases and guideline databases were manually searched in addition to websites of national health technology assessment bodies for the following countries: Australia, Canada, France, Germany, Israel, Italy, Japan, Spain, Switzerland, UK and US, as defined by pre-specified eligibility criteria. Search terms, developed for each condition, were translated into local languages where appropriate. Descriptive analyses were performed to examine the geographical distribution of included guidelines; methodologies used to develop guidelines; cross-referencing of treatment recommendations made within other guidelines; patterns of treatment recommendations. An author map was created using R version 3.5.1, to visualise the extent of collaboration between authors. Results: Forty total guidelines were included, of which 29, 34 and 0 contained recommendations for DS, LGS and CDD, respectively (some provided recommendations for ≥1 condition). Most were country-specific, with guideline authors predominantly publishing in regional groups. Five guidelines were classified as "International" and displayed connections between author groups in the US, UK, France and Italy. Reported guideline development processes were lacking [43% (17 guidelines) had unclear/absent literature review methodologies] and those reported were variable, including both systematic and targeted literature reviews. Use of expert consultation was also variable. A high degree of heterogeneity was observed in the availability of treatment recommendations across disorders, with 271 and 190 recommendations for LGS and DS, respectively, and contradictory positive and negative treatment recommendations for several drugs in each indication [35% (11/31) and 22% (6/27) in LGS and DS, respectively]. Conclusions: This review highlights the need for further high-quality international consensus-based treatment guidelines for LGS, DS, and particularly for CDD (for which no treatment guidelines were identified). Supra-national consensus guidance based on findings from a wider geographical range may improve resource allocation and establish an improved world-wide standard of care.

The Impact of Smoking on Psoriasis Patients with Biological Therapies in a Bucharest Hospital

Psoriasis is an immune-mediated chronic inflammatory skin disease with extracutaneous manifestations, that affects about 1–3% of the world’s population. The disease is not life-threatening, but the disability which comes with it is comparable to the disability caused by other serious chronic diseases, such as oncologic or cardiovascular disease. Several risk factors, such as infections, stress, smoking, excessive alcohol consumption and genetic predisposition have been involved in inducing psoriasis. Smoking status is a risk factor for many chronic diseases, including psoriasis. Moreover, recent studies have tried to answer the question of whether smoking also influences the response to biologic therapy in patients with psoriasis. Through the current study, our intention is to find out how smoking affects the response to biologic treatment. A hospital-based cross-sectional, observational, non-interventional, retrospective study of moderate and severe psoriasis patients receiving biologic treatment was developed. Two groups were defined based on smoking status: group 1 included smokers (more than 10 cigarettes/day) and former smokers, and group 2 included non-smokers. The data that resulted from the analysis of the cohort of patients demonstrate that smoking status does not affect the response of biologic therapy in patients with moderate and severe psoriasis.

Biologics recommendations for patients with psoriasis: a critical appraisal of clinical practice guidelines for psoriasis

PURPOSE

This review article serves to assess the consistency of recommendations from guidelines on biologic agents for psoriasis, based on the quality evaluation of psoriasis Clinical Practice Guidelines (CPGs).

METHODS

We conducted a systematic literature search to identify CPGs that provide recommendations on diagnosis and treatment for psoriasis. Four reviewers performed a quality assessment of the included CPGs with the Appraisal of Guidelines Research and Evaluation II (AGREE II) Instrument.

RESULTS

A total of 51 sets of CPGs from 22 medical societies or separate working groups fulfilled the inclusion criteria. The overall quality of the eligible sets of guidelines was moderate to high, with an overall average score of 55%The highest domain scores were Score and Purpose (70%) and Clarity of Presentation (68%). A total of 95 biologic agent recommendations were extracted from the 18 recommended CPGs.Three biologic agents (Etanercept, Adalimumab, Ustekinumab) were recommended for pediatric patients. Three biologic agents (Adalimumab, Ustekinumab, Secukinumab) were recommended as first-line biologic agents for adults with psoriasis.

CONCLUSION

The overall methodological quality of CPGs for psoriasis is medium to high. More attention should be paid to applicability in guideline development. The recommendations and the basis for them among various sets guidelines were almost consistent.

Joint AAD-NPF Guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the United States population. This guideline addresses important clinical questions that arise in psoriasis management and care and provides recommendations based on the available evidence. The treatment of psoriasis with topical agents and with alternative medicine will be reviewed, emphasizing treatment recommendations and the role of dermatologists in monitoring and educating patients regarding benefits as well as risks that may be associated. This guideline will also address the severity assessment methods of psoriasis in adults.

Safety and efficacy of Chinese herbal bath for psoriasis vulgaris: A protocol for systematic review and meta-analysis

BACKGROUND

Psoriasis is a common, chronic, and recurrent skin inflammatory disease, with psoriasis vulgaris considered as the most prevalent type of psoriasis. Chinese herbal bath, a type of traditional Chinese medicine, is an external therapy widely used to treat psoriasis vulgaris in China, and it has achieved satisfactory clinical effects. However, there are few studies evaluating the safety and efficacy of Chinese herbal bath compared with other external therapies administered under similar conditions. The purpose of this study is to comprehensively evaluate the clinical safety and efficacy of Chinese herbal bath in the treatment of psoriasis vulgaris through a systematic evaluation of the literature, so as to provide a reference basis for future clinical applications.

METHODS

PubMed, Embase, CENTRAL, the Web of Science, the China Biology Medicine Database (CBM), the China National Knowledge Database (CNKI), the Wan Fang Database, and the Chong Qing VIP Database will be searched to collect randomized controlled trials of Chinese herbal bath used to treat psoriasis vulgaris. The search time limits will be from the establishment of the database to December 2019. Two researchers will independently screen the studies, extract data, and evaluate the risk of bias of the studies. Meta-analysis will be carried out with the RevMan5.3 software. The mean difference will be used as the effect index for the measurement data, and the odds ratio will be used as the effect index for the enumeration data. The 95% confidence interval will be provided for each effect. Heterogeneity among the results of each study will be evaluated by the Chi-square test.

RESULTS

This study will comprehensively evaluate the clinical safety and efficacy of Chinese herbal bath in the treatment of psoriasis vulgaris, so as to provide a reference basis for future clinical applications.

CONCLUSION

This study will provide a theoretical basis for the standardized administration of Chinese herbal bath. OSF REGISTRATION NUMBER:: doi: 10.17605/OSF.IO/4HRPJ.

To explore the clinical efficacy of Traditional Chinese Medicine bath in the treatment of psoriasis vulgaris with blood-heat syndrome and its effect on related cytokines based on different temperature and different concentration

BACKGROUND

Chinese herbal bath has long been used in the curative treatment of psoriasis vulgaris. However, there is no unified standard protocol for Chinese herbal bath. Many factors affect the curative effect of Chinese herbal bath, such as water temperature, bath concentration, and soaking time. Most studies involving Chinese herbal bath has described the bath generally, and few studies have investigated the factors that might contribute to the efficacy of Chinese herbal bath. Here we describe a protocol to evaluate the efficacy and safety of various bathwater temperatures and herbal concentrations on psoriasis vulgaris, and their effect on serum vascular endothelial growth factor (VEGF), tumor necrosis factor α (TNF-α), interleukin 23 (IL-23), and interleukin 17 (IL-17). These data could be useful for optimizing Chinese herbal bath treatments.

METHODS

In this randomized controlled trial, we planned to recruit 288 hospitalized atients with psoriasis vulgaris aged 18 to 65 years. All participants who meet the inclusion criteria will be randomly assigned to the observation group, the control group, or the basic treatment group. The observation group will be divided into 6 sub-groups according to water temperatures and bath concentrations, designated as observation groups 1 to 6. Thirty-six participants will be assigned to each group. The basic treatment group will be given co-qingdai capsule, po 2 g tid; compound glycyrrhizin tablet, po 75 mg tid; AA Skincare jojoba Oil, us.ext qd. The observation group will be given a Chinese herbal bath at the same time as the basic treatment. The control group will be given ozone hydrotherapy at the same time as the basic treatment. The entire treatment course will last for 2 weeks. The following parameters will be compared in each group, before and 2 weeks after treatment: the psoriasis area and severity index score (PASI), pruritus score, clinical efficacy, and dermatology life quality index score (DLQI); serum levels of serum VEGF, TNF-α, IL-23, and IL-17; and confocal laser scanning microscope images.

CONCLUSION

This study will evaluate the efficacy and safety of various Chinese herbal bath conditions (water temperatures and herbal concentrations) on the treatment of psoriasis vulgaris, which will provide an important reference for the operation of Chinese herbal bath.

TRIAL REGISTRATION NUMBER

ChiCTR1900027468.

Short-Term Correlation of the Psoriasis Area Severity Index, the Nail Psoriasis Area Severity Index, and the Dermatology Life Quality Index, before and after Treatment, in Patients with Skin and Nail Psoriasis

Background

The response to treatment in patients suffering from skin and nail psoriasis is quantitatively evaluated by monitoring clinical severity and quality of life indexes, especially in the context of clinical trials. Among them, the psoriasis area severity index (PASI), the nail psoriasis area severity index (NAPSI), and the dermatology life quality index (DLQI) are currently the most widely used indexes.

Objective

To study the short-term correlation between PASI, NAPSI, and DLQI in patients with skin and nail psoriasis at baseline and 3 months after treatment initiation.

Materials and Methods

This is a 2-center prospective, observational, cross-sectional study of 40 treatment-naive patients suffering from chronic plaque psoriasis with nail involvement and requiring systemic therapy. Disease activity and quality of life were assessed at baseline and 3 months after treatment initiation by measuring PASI, NAPSI, and DLQI scores. Statistical correlations between theses indexes were investigated using the appropriate statistical tests.

Results

A positive, strong correlation was observed between DLQI and NAPSI at baseline (r = 0.579, p <0.001) and at 3 months (r = 0.484, p = 0.002). Similarly, a strong correlation was noted between DLQI and PASI at baseline (r = 0.496, p = 0.001) and at 3 months (r = 0.401, p = 0.01). Moreover, we observed a positive strong correlation (r = 0.515, p = 0.001) between DLQI at baseline and NAPSI at 3 months and a moderate correlation (r = 0.433, p = 0.005) between DLQI at baseline and PASI at 3 months.

Conclusion

The observed positive correlations between PASI, NAPSI, and DLQI provide further evidence in support of their simultaneous utilization in clinical studies for skin and nail psoriasis. Moreover, the predictive value of DLQI at baseline emphasizes the importance of quality of life assessment when designing a therapeutic study as well as in the everyday clinical practice.

Investigation of Immunovascular Polymorphisms and Intersections in Psoriasis

Background:

Psoriasis is a chronic, inflammatory skin disease. The etiology of the disease is unknown. It is a polygenic and multifactorial disease, which interacts with genetic and environmental factors. Genetic factors (polymorphism/mutation) can alter the immune system and normal physiologically functioning keratinocytes to pathological or predisposition levels.

Aims:

We aimed to investigate psoriasis at a different and novel window by searching for vascular and immunological variations and intersections in psoriasis. We investigated the main vascular and hypoxic controlling factors, which are vascular endothelial growth factor (VEGF) and hypoxia inducible factor 1 alpha (HIF-1α), as well as immunological and serotonergic factors, such as TNF-α, IL-10, and 5HT2A, which could connect each other to the pathogenesis of psoriasis.

Subjects and Methods:

Nine single nucleotide polymorphisms (SNPs) in five genes were genotyped by mini-array format in 300 subjects: VEGF (rs2010963, rs833061, and rs1570360), HIF-1α (rs11549465), TNF-α (rs361525, rs1799964, and rs1800629), IL-10 (rs1800896), and 5HT2A (rs6311).

Results:

An association was found between rs1800629 (TNF-α) and Type I psoriasis, and rs833061 (VEGF) and Type II psoriasis. Haplotype analysis suggests that the coexistence of the polymorphisms rs1799964 (TNF-α), rs2010963 (VEGF), rs833061 (VEGF), and rs6311 (5HT2A) may be a protective factor for psoriasis.

Conclusion:

Our results suggest that the vascular component of the studied vasculo-immunologic variation is more relevant in the pathogenesis of psoriasis.

Compounded topical preparations in plaque psoriasis: Still a place for it in 2018?

Compounded topical preparations (CTP) were used to treat psoriasis until the last century and have disappeared from guidelines. The present authors report two severe psoriasis patients who were treated with CTP. A man had psoriasis with a PASI of 23 and a body surface area (BSA) of 43%. He had been using daily for several weeks a CTP including minoxidil, clobetasol propionate and hydroxyprogesterone formulated in an alcohol based vehicle. A woman suffered from psoriasis with an annular inflammatory pattern and a central healing. The PASI was 20 and the BSA was 30%. She had been using a CTP daily for 4 months including resorcinol, salicylic acid, 0.05% tretinoin cream, bethamethasone dipropionate cream. Until the 1970s, the dermatological textbooks recommended to treat severe psoriasis with CTP. Nowadays, CTP are considered outdated because of the large therapeutic armamentarium. The stability and benefit risks of the CTP used here were not documented. The use of CTP in psoriasis should be regulated and must be evidence based. Strict protocol and stability evaluation for preparations must be confirmed prior to compounding.

Evaluation of Erythroid Disturbance and Thiol-Disulphide Homeostasis in Patients with Psoriasis

This study aims to assess how mean corpuscular volume (MCV), red cell distribution width (RDW), and thiol-disulphide homeostasis are altered in psoriasis patients. This is a cross-sectional review of 76 healthy volunteers and 87 psoriasis patients who were consecutively admitted to the department of dermatology. Psoriasis patients and healthy controls were statistically similar with respect to age, sex, body mass index, blood pressures, and disease duration (p > 0.05 for all). When compared to healthy controls, psoriasis patients had significantly higher MCV, RDW, C-reactive protein (CRP), disulphide, disulphide/native thiol, and disulphide/total thiol (p < 0.001 for all). However, psoriasis patients had significantly lower native thiol and native thiol/total thiol (p = 0.009 and p < 0.001, respectively). When compared to healthy controls, the patients with Psoriasis Area Severity Index (PASI) ≤ 10 and patients with PASI > 10 had significantly higher MCV, disulphide, disulphide/native thiol, and disulphide/total thiol (p < 0.001 for all). The patients with PASI ≤ 10 and patients with PASI > 10 had significantly lower native thiol/native thiol than healthy controls (p < 0.001 for all). The psoriasis patients with PASI > 10 had significantly higher RDW and CRP than healthy controls and patients with PASI ≤ 10 (p < 0.001 for all). Disulphide, disulphide/native thiol, disulphide/total thiol, and native thiol/total thiol correlate significantly with both PASI scores and disease duration. Thiol-disulphide homeostasis is enhanced in psoriasis patients. Ongoing inflammation and increased oxidative stress in psoriasis patients also trigger the formation of prooxidants which are neutralized by antioxidants such as thiols. That is why plasma thiol levels are decreased in psoriasis patients.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Biologics and dermatology life quality index (DLQI) in the Australasian psoriasis population

BACKGROUND/OBJECTIVES

Psoriasis is a chronic condition that may require long-term treatment for disease control. This analysis utilizes data from the Australasian Psoriasis Registry with particular attention to the impact of biologic therapy on DLQI, and the differences between the biologics in terms of DLQI score change.

METHODS

A retrospective review of patients enrolled in the Australasian Psoriasis Registry from April 2008 to August 2016 was conducted. All subjects from the registry that had DLQI and Psoriasis Assessment Severity Index (PASI) scores recorded at a baseline time point of treatment commencement, in addition to week 12 and 24 post commencement were included in the study. A window of ±3 weeks was permitted at these time points. Multivariate linear regression analysis was undertaken to identify significant predictors associated with change in DLQI.

RESULTS

Significant predictors of reduction in DLQI and PASI score from baseline to week 24 include use of adalimumab, infliximab, secukinumab and ustekinumab. Other therapies, including etanercept and oral systemic agents did not show significant change. Each class of biologic showed significant reductions in DLQI score, with IL-12/23 blockade showing the greatest reduction. Significant predictors of lack of reduction in DLQI score include a baseline PASI score <16, and history of diabetes, alcoholism or uveitis.

CONCLUSIONS

Patients with moderate to severe chronic plaque psoriasis who are treated with biologics show the greatest reduction in DLQI score, compared with other treatments. Australian dermatologists are prescribing biologics when patients qualify for them in keeping with current guidelines.

Expert Recommendations on Treating Psoriasis in Special Circumstances (Part II)

BACKGROUND

There is insufficient information on how best to treat moderate to severe psoriasis in difficult clinical circumstances.

MATERIAL AND METHODS

We considered 5 areas where there is conflicting or insufficient evidence: pediatric psoriasis, risk of infection in patients being treated with biologics, psoriasis in difficult locations, biologic drug survival, and impact of disease on quality of life. Following discussion of the issues by an expert panel of dermatologists specialized in the management of psoriasis, participants answered a questionnaire survey according to the Delphi method.

RESULTS

Consensus was reached on 66 (70.9%) of the 93 items analyzed; the experts agreed with 49 statements and disagreed with 17. It was agreed that body mass index, metabolic comorbidities, and quality of life should be monitored in children with psoriasis. The experts also agreed that the most appropriate systemic treatment for this age group was methotrexate, while the most appropriate biologic treatment was etanercept. Although it was recognized that the available evidence was inconsistent and difficult to extrapolate, the panel agreed that biologic drug survival could be increased by flexible, individualized dosing regimens, continuous treatment, and combination therapies. Finally, consensus was reached on using the Dermatology Quality of Life Index to assess treatment effectiveness and aid decision-making in clinical practice.

CONCLUSIONS

The structured opinion of experts guides decision-making regarding aspects of clinical practice for which there is incomplete or conflicting information.

Consensus document on the evaluation and treatment of moderate-to-severe psoriasis: Psoriasis Group of the Spanish Academy of Dermatology and Venereology

Psoriasis is a highly prevalent disease with a major impact on quality of life; therefore, appropriate patient management is mandatory. Given that many issues in psoriasis are controversial and not clearly defined by evidence-based medicine, management of psoriasis is very variable. Expert consensus can generate practical guidelines for optimization of patient care. Much has changed since 2009, when the Consensus Document on the Evaluation and Treatment of Moderate to Severe Psoriasis was published by the Spanish Psoriasis Group (GEP) of the Spanish Academy of Dermatology and Venereology (AEDV). The objective of the present consensus document is to provide the dermatologist with updated recommendations for the evaluation and treatment of patients with moderate-to-severe plaque psoriasis. All active members of the GEP of the AEDV were invited to participate in the survey. The final group comprised 46 members from various areas of Spain and with substantial experience in managing psoriasis. A 3-round Delphi process was used to reach consensus. Consistent agreement and consistent disagreement (consensus) required the achievement of at least two of the following three criteria: Criterion 1, which was based on the position occupied by the mean on a scale of 1-9 and an SD <2; Criterion 2, which was based on the median and interquartile range (IQR) on a scale of 1-9; Criterion 3, which considered the percentage of the voting experts on a scale of 1-9. The items studied were definition of severity, therapeutic objectives, indications for systemic treatment and biologic therapy, induction and maintenance periods, therapeutic failure, loss of response, relapse and rebound, continuous and intermittent therapy, screening of patients before treatment, adherence to therapy, follow-up of treatment outcome, combination of drugs, transitioning and associated comorbidities. Consistent agreement or disagreement (consensus) was achieved for 198 items (agreement, 3 criteria 146 items, 2 criteria 43 items; disagreement, 3 criteria 9 items, 2 criteria 0 items) based on the criteria described above. Completion of the Delphi consensus process enabled a broad and experienced group of Spanish psoriasis experts to provide useful and practical guidelines for the management and treatment of patients with moderate-to-severe psoriasis, particularly in areas where evidence is lacking.

Evidence-based recommendations on the role of dermatologists in the diagnosis and management of psoriatic arthritis: systematic review and expert opinion

BACKGROUND

Psoriatic arthritis (PsA) can develop at any time during the course of psoriasis.

AIMS

The aims of these practical recommendations are to help dermatologists identify patients at risk of PsA, to diagnose PsA in collaboration with rheumatologists and to gain a better understanding of initial PsA management.

MATERIALS AND METHODS

A scientific committee consisting of 10 dermatologists and a rheumatologist selected clinically relevant questions to be addressed by evidence-based recommendations using the DELPHI method. For each question, a systematic literature review was performed in Medline, Embase and the Cochrane Library databases. The levels of evidence of all selected and reviewed articles were appraised according to the Oxford levels of evidence.

RESULTS

An expert board of 30 dermatologists reviewed and analysed the evidence and developed recommendations for the selected questions. Agreement among participants was assessed on a 10-point scale, and the potential impact of the recommendations on clinical practice was evaluated. Among the 6960 references identified, 190 relevant articles were included in the reviews. Three recommendations regarding risk factors for PsA and one regarding PsA prevalence were issued. The mean agreement score between participants varied from 7.8 to 9.6. Three recommendations on PsA screening tools that can be used by dermatologists were issued. The mean agreement score between participants varied from 7.7 to 9.4. Initial PsA treatment options according to published guidelines were critically appraised for axial and peripheral involvement and enthesitis/dactylitis. Three recommendations were issued. The mean agreement score between participants varied from 7.6 to 8.7.

DISCUSSION

The systematic literature research and meta-analyses did not provide high-quality evidence to support recommendations regarding PsA screening. Conversely, PsA treatment options were supported by strong evidence.

CONCLUSION

Cooperation between dermatologists and rheumatologists should be emphasized to better identify and manage PsA patients.

Psoriasis, cardiovascular events, cancer risk and alcohol use: evidence-based recommendations based on systematic review and expert opinion

The relationship between psoriasis, chronic inflammation, cardiovascular risk and risk of cancer has long been debated. In addition, it has been suggested that alcohol consumption may be a risk factor for psoriasis onset and severity. The aim of this study was to develop evidence-based recommendations on the risk of comorbidities and its management for daily clinical use, focusing on cardiovascular risk, risk of cancer and alcohol use in psoriasis. A scientific committee identified and selected through the Delphi method clinically relevant questions about cardiovascular risk, risk of cancer and alcohol use in psoriasis. To address these questions, a systematic literature search was performed in Medline, Embase and the Cochrane Library databases. Systematic literature reviews including meta-analysis whenever possible were performed. Subsequently, an Expert board meeting involving 39 dermatologists took place to analyse the evidence and to elaborate recommendations on the selected questions. Recommendations were graded according to the Oxford level of evidence grading system. The degree of agreement of these recommendations was assessed on a 10-point scale, as well as their potential impact on daily clinical practice. A total of 3242 articles were identified through the systematic literature searches, among which 110 were included in the systematic reviews. Overall, 12 recommendations were elaborated regarding comorbidities management in psoriasis patients. A moderate increased risk of cardiovascular diseases (CVD), mainly myocardial infarction (MI) [meta-analysis of cohort studies: OR = 1.25 (95% CI 1.03-1.52) and of cross-sectional studies: OR = 1.57 (95% CI 1.08-2.27)], and coronary artery disease (CAD) [meta-analysis of cross-sectional: OR = 1.19 (95% CI 1.14-1.24), of cohort studies: OR = 1.20 (95% CI 1.13-1.27) and of case-control studies: OR = 1.84 (95% CI 1.09-3.09)] was acknowledged. This increased cardiovascular risk requires appropriate prevention measures. There was a lack of substantial evidence that conventional systemic treatment has any effect on cardiovascular risk although methotrexate might be cardioprotective. An increased risk of solid cancer potentially associated with smoking and alcohol use was identified. The role of systemic treatment on cancer risk could not be assessed thoroughly due to limited long-term follow-up data. A higher risk of non-melanoma skin cancers especially squamous cell carcinoma was shown, mainly due to previous exposure to oral 8-methoxypsoralen-ultraviolet-A (PUVA), ciclosporin and possibly methotrexate. No firm conclusion could be drawn regarding alcohol and psoriasis due to high variability in alcohol usage assessment in studies. Clinical experience suggests higher alcohol consumption among psoriasis patients compared to the general population. The mean expert participants' level of agreement on these recommendations varied from 6.8 to 9.4. These 12 recommendations are evidence based and supported by a panel of expert dermatologists. The next step is now to disseminate these recommendations to dermatologists who did not participate in the Expert board meeting and to assess their opinion about the recommendations.

Automatic segmentation of scaling in 2-D psoriasis skin images

Psoriasis is a chronic inflammatory skin disease that affects over 3% of the population. Various methods are currently used to evaluate psoriasis severity and to monitor therapeutic response. The PASI system of scoring is widely used for evaluating psoriasis severity. It employs a visual analogue scale to score the thickness, redness (erythema), and scaling of psoriasis lesions. However, PASI scores are subjective and suffer from poor inter- and intra-observer concordance. As an integral part of developing a reliable evaluation method for psoriasis, an algorithm is presented for segmenting scaling in 2-D digital images. The algorithm is believed to be the first to localize scaling directly in 2-D digital images. The scaling segmentation problem is treated as a classification and parameter estimation problem. A Markov random field (MRF) is used to smooth a pixel-wise classification from a support vector machine (SVM) that utilizes a feature space derived from image color and scaling texture. The training sets for the SVM are collected directly from the image being analyzed giving the algorithm more resilience to variations in lighting and skin type. The algorithm is shown to give reliable segmentation results when evaluated with images with different lighting conditions, skin types, and psoriasis types.

Measuring disease activity in psoriatic arthritis

Over the past decade, the assessment of the disease activity in psoriatic arthritis (PsA) has rapidly evolved in view of the need for valid, feasible, and reliable outcome measures that can be ideally employed in longitudinal cohorts, clinical trials, and clinical practice as well as the growing paradigm of tight disease control and treating to target in the management of PsA. This paper reviews the currently available measures used in the assessment of the disease activity in PsA. The composite measures for PsA that are under development are also discussed.

Disease severity and therapy as predictors of cardiovascular risk in psoriasis: a population-based cohort study

BACKGROUND

Previous studies suggest an increased risk of cardiovascular disease in psoriasis, but the relative contributions of traditional risk factors and markers of disease severity are unclear. We examined the effect of psoriasis disease characteristics on cardiovascular risk after adjusting for traditional cardiovascular risk factors.

METHODS

Study populations included (a) case-cohort sample of 771 patients nested within a population-based psoriasis incidence cohort, and (b) cohort of 1905 patients with incident and prevalent psoriasis patients. Both cohorts were followed-up to ascertain disease and treatment characteristics, traditional cardiovascular risk factors and cardiovascular outcomes. Cox proportional hazards regression models were used to identify predictors of cardiovascular outcomes.

RESULTS

After adjusting for traditional risk factors, increasing number of psoriasis-affected body sites at disease onset (HR: 1.53 per additional site, 95% CI: 1.20, 1.95) was significantly associated with an increased risk of cardiovascular outcomes. Phototherapy (HR: 3.76, 95% CI: 2.45, 5.77) and systemic therapy (HR: 2.17, 95% CI: 1.50, 3.13) were associated with a higher risk of cardiovascular outcomes in univariate analyses, but these relatively strong associations disappeared after adjusting for cardiovascular risk factors.

CONCLUSIONS

Increasing number of psoriasis-affected body sites may be a severity indicator in psoriasis and is associated with an increased cardiovascular risk. Due to low number of patients exposed to systemic therapy, this study had limited power to examine the effect of treatment on cardiovascular risk. Strong associations with phototherapy and systemic therapy suggest that the cardiovascular risk in psoriasis is confined to patients with severe disease.