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James J, Otto T, Gao J, Porter ML. Oral Psoriasis Therapies. Dermatol Clin 2024; 42:357-363. [PMID: 38796267 DOI: 10.1016/j.det.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Oral psoriasis therapies include both older traditional immunosuppressants, such as methotrexate, cyclosporine, and acitretin, as well as newer, more targeted agents, such as apremilast, deucravacitinib, and oral interleukin-23 receptor antagonists. Patients may prefer oral therapies to injectable therapies based on the route of administration. Both older and newer oral psoriasis therapies can be utilized effectively in the treatment of psoriasis. Here, we will review oral agents used in the treatment of psoriasis as well as provide commentary on their role in our current, evolving psoriasis treatment paradigm.
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Affiliation(s)
- JaBreia James
- Harvard Combined Dermatology Residency Program, Department of Dermatology, Harvard Medical School, 55 Fruit Street, BH 616 Boston, MA 02114, USA
| | - Tracey Otto
- Department of Dermatology, Clinical Laboratory for Epidemiology and Applied Research in Skin (CLEARS), Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA
| | - Julia Gao
- Department of Dermatology, Clinical Laboratory for Epidemiology and Applied Research in Skin (CLEARS), Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA
| | - Martina L Porter
- Department of Dermatology, Clinical Laboratory for Epidemiology and Applied Research in Skin (CLEARS), Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02115, USA; Department of Dermatology, Harvard Medical School, 3 Blackfan Cir, Boston, MA 02115, USA.
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2
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Truong TM, Pathak GN, Singal A, Taranto V, Rao BK. Deucravacitinib: The First FDA-Approved Oral TYK2 Inhibitor for Moderate to Severe Plaque Psoriasis. Ann Pharmacother 2024; 58:416-427. [PMID: 37341177 DOI: 10.1177/10600280231153863] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
OBJECTIVE The objective of this study was to review the safety and efficacy of deucravacitinib, a tyrosine kinase 2 (TYK2) inhibitor for moderate to severe plaque psoriasis. DATA SOURCES Literature was reviewed from MEDLINE and Clinicaltrials.gov up to December 2022 using the terms "deucravacitinib" and "BMS-986165." STUDY SELECTION Relevant articles in English relating to the pharmacodynamics, pharmacokinetics, efficacy, and safety of deucravacitinib were included. A total of 6 trial results were included. STUDY SELECTION AND DATA EXTRACTION Deucravacitinib showed clinical efficacy across all the phase II and III clinical trials. Excluding the long-term extension study, there were 2248 subjects across all studies, with 63.2% of patients receiving deucravacitinib 6 mg daily. Of these subjects, the average proportion achieving a PASI 75 (a reduction of greater than 75% in the Psoriasis Area and Severity Index) at week 16 was 65.1%. Patients receiving deucravacitinib 6 mg once daily had a higher rate of achieving both PASI 75 response and a Static Physician's Global Assessment (sPGA) score of 0 or 1, compared with oral apremilast 30 mg twice daily. The safety profile of deucravacitinib includes mild adverse events (AEs), most commonly nasopharyngitis, with serious AEs reported ranging from 1.35% to 9.5%. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON WITH EXISTING MEDICATIONS While many available therapies for moderate to severe plaque psoriasis rely on an injectable dosage form or extensive monitoring, deucravacitinib can potentially reduce patient medication-related burden. This review summarizes the efficacy and safety of oral deucravacitinib for the treatment of severe plaque psoriasis. CONCLUSION Deucravacitinib shows a consistent efficacy and safety profile as the first oral TYK2 inhibitor approved for adult patients with moderate to severe plaque psoriasis who are eligible for systemic therapy or phototherapy treatment.
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Affiliation(s)
- Thu Minh Truong
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
- School of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Gaurav N Pathak
- School of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Amit Singal
- School of Medicine, Rutgers New Jersey Medical School, Newark, NJ, USA
| | | | - Babar K Rao
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
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3
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Kaczmarska A, Kwiatkowska D, Skrzypek KK, Kowalewski ZT, Jaworecka K, Reich A. Pathomechanism of Pruritus in Psoriasis and Atopic Dermatitis: Novel Approaches, Similarities and Differences. Int J Mol Sci 2023; 24:14734. [PMID: 37834183 PMCID: PMC10573181 DOI: 10.3390/ijms241914734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/24/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
Pruritus is defined as an unpleasant sensation that elicits a desire to scratch. Nearly a third of the world's population may suffer from pruritus during their lifetime. This symptom is widely observed in numerous inflammatory skin diseases-e.g., approximately 70-90% of patients with psoriasis and almost every patient with atopic dermatitis suffer from pruritus. Although the pathogenesis of atopic dermatitis and psoriasis is different, the complex intricacies between several biochemical mediators, enzymes, and pathways seem to play a crucial role in both conditions. Despite the high prevalence of pruritus in the general population, the pathogenesis of this symptom in various conditions remains elusive. This review aims to summarize current knowledge about the pathogenesis of pruritus in psoriasis and atopic dermatitis. Each molecule involved in the pruritic pathway would merit a separate chapter or even an entire book, however, in the current review we have concentrated on some reports which we found crucial in the understanding of pruritus. However, the pathomechanism of pruritus is an extremely complex and intricate process. Moreover, many of these signaling pathways are currently undergoing detailed analysis or are still unexplained. As a result, it is currently difficult to take an objective view of how far we have come in elucidating the pathogenesis of pruritus in the described diseases. Nevertheless, considerable progress has been made in recent years.
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Affiliation(s)
- Agnieszka Kaczmarska
- Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszów, Poland; (A.K.); (D.K.); (K.J.)
| | - Dominika Kwiatkowska
- Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszów, Poland; (A.K.); (D.K.); (K.J.)
| | | | | | - Kamila Jaworecka
- Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszów, Poland; (A.K.); (D.K.); (K.J.)
| | - Adam Reich
- Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszów, Poland; (A.K.); (D.K.); (K.J.)
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Sbidian E, Chaimani A, Guelimi R, Garcia-Doval I, Hua C, Hughes C, Naldi L, Kinberger M, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2023; 7:CD011535. [PMID: 37436070 PMCID: PMC10337265 DOI: 10.1002/14651858.cd011535.pub6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease with either skin or joints manifestations, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. The relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the benefits and harms of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their benefits and harms. SEARCH METHODS For this update of the living systematic review, we updated our searches of the following databases monthly to October 2022: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults over 18 years with moderate-to-severe plaque psoriasis, at any stage of treatment, compared to placebo or another active agent. The primary outcomes were: proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90; proportion of participants with serious adverse events (SAEs) at induction phase (8 to 24 weeks after randomisation). DATA COLLECTION AND ANALYSIS We conducted duplicate study selection, data extraction, risk of bias assessment, and analyses. We synthesised data using pairwise and network meta-analysis (NMA) to compare treatments and rank them according to effectiveness (PASI 90 score) and acceptability (inverse of SAEs). We assessed the certainty of NMA evidence for the two primary outcomes and all comparisons using CINeMA, as very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer treatment hierarchy, from 0% (worst for effectiveness or safety) to 100% (best for effectiveness or safety). MAIN RESULTS This update includes an additional 12 studies, taking the total number of included studies to 179, and randomised participants to 62,339, 67.1% men, mainly recruited from hospitals. Average age was 44.6 years, mean PASI score at baseline was 20.4 (range: 9.5 to 39). Most studies were placebo-controlled (56%). We assessed a total of 20 treatments. Most (152) trials were multicentric (two to 231 centres). One-third of the studies (65/179) had high risk of bias, 24 unclear risk, and most (90) low risk. Most studies (138/179) declared funding by a pharmaceutical company, and 24 studies did not report a funding source. Network meta-analysis at class level showed that all interventions (non-biological systemic agents, small molecules, and biological treatments) showed a higher proportion of patients reaching PASI 90 than placebo. Anti-IL17 treatment showed a higher proportion of patients reaching PASI 90 compared to all the interventions. Biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha showed a higher proportion of patients reaching PASI 90 than the non-biological systemic agents. For reaching PASI 90, the most effective drugs when compared to placebo were (SUCRA rank order, all high-certainty evidence): infliximab (risk ratio (RR) 49.16, 95% CI 20.49 to 117.95), bimekizumab (RR 27.86, 95% CI 23.56 to 32.94), ixekizumab (RR 27.35, 95% CI 23.15 to 32.29), risankizumab (RR 26.16, 95% CI 22.03 to 31.07). Clinical effectiveness of these drugs was similar when compared against each other. Bimekizumab and ixekizumab were significantly more likely to reach PASI 90 than secukinumab. Bimekizumab, ixekizumab, and risankizumab were significantly more likely to reach PASI 90 than brodalumab and guselkumab. Infliximab, anti-IL17 drugs (bimekizumab, ixekizumab, secukinumab, and brodalumab), and anti-IL23 drugs except tildrakizumab were significantly more likely to reach PASI 90 than ustekinumab, three anti-TNF alpha agents, and deucravacitinib. Ustekinumab was superior to certolizumab. Adalimumab, tildrakizumab, and ustekinumab were superior to etanercept. No significant difference was shown between apremilast and two non-biological drugs: ciclosporin and methotrexate. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. The risk of SAEs was significantly lower for participants on methotrexate compared with most of the interventions. Nevertheless, the SAE analyses were based on a very low number of events with very low- to moderate-certainty evidence for all the comparisons. The findings therefore have to be viewed with caution. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1), the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that, compared to placebo, the biologics infliximab, bimekizumab, ixekizumab, and risankizumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes measured from 8 to 24 weeks after randomisation), and is not sufficient for evaluating longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean 44.6 years) and high level of disease severity (PASI 20.4 at baseline) may not be typical of patients seen in daily clinical practice. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the safety evidence for most interventions was very low to moderate quality. More randomised trials directly comparing active agents are needed, and these should include systematic subgroup analyses (sex, age, ethnicity, comorbidities, psoriatic arthritis). To provide long-term information on the safety of treatments included in this review, an evaluation of non-randomised studies is needed. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Robin Guelimi
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Maria Kinberger
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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5
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Meena A, Sarkar R. Acitretin in dermatology. APOLLO MEDICINE 2023. [DOI: 10.4103/am.am_145_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Lé AM, Puig L, Torres T. Deucravacitinib for the Treatment of Psoriatic Disease. Am J Clin Dermatol 2022; 23:813-822. [PMID: 35960487 PMCID: PMC9372960 DOI: 10.1007/s40257-022-00720-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2022] [Indexed: 12/03/2022]
Abstract
Psoriasis is an immune-mediated disease, with the interleukin (IL)-23/IL-17 axis currently considered its main pathogenic pathway. Tyrosine kinase 2 (TYK2) is responsible for mediating immune signalling of IL-12, IL-23 and type I interferons, without interfering with other critical systemic functions as other JAK proteins do. This article aims to review the current knowledge on deucravacitinib, a new oral drug that selectively inhibits TYK2, granting it a low risk of off-target effects. After good efficacy and safety results in a phase II, placebo-controlled trial, two phase III, 52-week trials evaluated deucravacitinib 6 mg against placebo and apremilast—an active comparator. POETYK PSO-1 and PSO-2 involved 1688 patients with moderate-to-severe psoriasis. After 16 weeks, in both studies, over 50% of patients treated with deucravacitinib reached PASI75, which was significantly superior to placebo and apremilast. In POETYK PSO-1, these results improved until week 24 and were maintained through week 52, with over 65% of patients achieving PASI75 at this point. A reduction in signs and symptoms was also reported by patients, with greater impact on itch. Deucravacitinib was well tolerated and safe. There were no reports of serious infections, thromboembolic events, or laboratory abnormalities, which are a concern among other JAK inhibitors. Persistent efficacy and consistent safety profiles were reported for up to 2 years. Despite advances in the treatment of psoriasis, namely among biologic agents, an oral, effective and safe new drug can bring several advantages to prescribers and patients. Further investigation is required to understand where to place deucravacitinib among current psoriasis treatment options.
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Affiliation(s)
- Ana Maria Lé
- Department of Dermatology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Luis Puig
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Tiago Torres
- Department of Dermatology, Centro Hospitalar Universitário do Porto, Porto, Portugal. .,Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal.
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Sbidian E, Chaimani A, Garcia-Doval I, Doney L, Dressler C, Hua C, Hughes C, Naldi L, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2022; 5:CD011535. [PMID: 35603936 PMCID: PMC9125768 DOI: 10.1002/14651858.cd011535.pub5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease with either skin or joints manifestations, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. The relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS For this update of the living systematic review, we updated our searches of the following databases monthly to October 2021: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults over 18 years with moderate-to-severe plaque psoriasis, at any stage of treatment, compared to placebo or another active agent. The primary outcomes were: proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90; proportion of participants with serious adverse events (SAEs) at induction phase (8 to 24 weeks after randomisation). DATA COLLECTION AND ANALYSIS We conducted duplicate study selection, data extraction, risk of bias assessment and analyses. We synthesised data using pairwise and network meta-analysis (NMA) to compare treatments and rank them according to effectiveness (PASI 90 score) and acceptability (inverse of SAEs). We assessed the certainty of NMA evidence for the two primary outcomes and all comparisons using CINeMA, as very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer treatment hierarchy, from 0% (worst for effectiveness or safety) to 100% (best for effectiveness or safety). MAIN RESULTS This update includes an additional 19 studies, taking the total number of included studies to 167, and randomised participants to 58,912, 67.2% men, mainly recruited from hospitals. Average age was 44.5 years, mean PASI score at baseline was 20.4 (range: 9.5 to 39). Most studies were placebo-controlled (57%). We assessed a total of 20 treatments. Most (140) trials were multicentric (two to 231 centres). One-third of the studies (57/167) had high risk of bias; 23 unclear risk, and most (87) low risk. Most studies (127/167) declared funding by a pharmaceutical company, and 24 studies did not report a funding source. Network meta-analysis at class level showed that all interventions (non-biological systemic agents, small molecules, and biological treatments) showed a higher proportion of patients reaching PASI 90 than placebo. Anti-IL17 treatment showed a higher proportion of patients reaching PASI 90 compared to all the interventions, except anti-IL23. Biologic treatments anti-IL17, anti-IL12/23, anti-IL23 and anti-TNF alpha showed a higher proportion of patients reaching PASI 90 than the non-biological systemic agents. For reaching PASI 90, the most effective drugs when compared to placebo were (SUCRA rank order, all high-certainty evidence): infliximab (risk ratio (RR) 50.19, 95% CI 20.92 to 120.45), bimekizumab (RR 30.27, 95% CI 25.45 to 36.01), ixekizumab (RR 30.19, 95% CI 25.38 to 35.93), risankizumab (RR 28.75, 95% CI 24.03 to 34.39). Clinical effectiveness of these drugs was similar when compared against each other. Bimekizumab, ixekizumab and risankizumab showed a higher proportion of patients reaching PASI 90 than other anti-IL17 drugs (secukinumab and brodalumab) and guselkumab. Infliximab, anti-IL17 drugs (bimekizumab, ixekizumab, secukinumab and brodalumab) and anti-IL23 drugs (risankizumab and guselkumab) except tildrakizumab showed a higher proportion of patients reaching PASI 90 than ustekinumab and three anti-TNF alpha agents (adalimumab, certolizumab and etanercept). Ustekinumab was superior to certolizumab; adalimumab and ustekinumab were superior to etanercept. No significant difference was shown between apremilast and two non-biological drugs: ciclosporin and methotrexate. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. The risk of SAEs was significantly lower for participants on methotrexate compared with most of the interventions. Nevertheless, the SAE analyses were based on a very low number of events with low- to moderate-certainty for all the comparisons (except methotrexate versus placebo, which was high-certainty). The findings therefore have to be viewed with caution. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1), the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that, compared to placebo, the biologics infliximab, bimekizumab, ixekizumab, and risankizumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes measured from 8 to 24 weeks after randomisation), and is not sufficient for evaluating longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean 44.5 years) and high level of disease severity (PASI 20.4 at baseline) may not be typical of patients seen in daily clinical practice. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the safety evidence for most interventions was low to moderate quality. More randomised trials directly comparing active agents are needed, and these should include systematic subgroup analyses (sex, age, ethnicity, comorbidities, psoriatic arthritis). To provide long-term information on the safety of treatments included in this review, an evaluation of non-randomised studies and postmarketing reports from regulatory agencies is needed. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Liz Doney
- Cochrane Skin, Centre of Evidence Based Dermatology, University of Nottingham, Nottingham, UK
| | - Corinna Dressler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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Mascarenhas-Melo F, Carvalho A, Beatriz S. Gonçalves M, Cláudia Paiva-Santos A, Veiga F. Nanocarriers for the topical treatment of psoriasis - pathophysiology, conventional treatments, nanotechnology, regulatory and toxicology. Eur J Pharm Biopharm 2022; 176:95-107. [DOI: 10.1016/j.ejpb.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 04/24/2022] [Accepted: 05/17/2022] [Indexed: 11/24/2022]
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Reviewing the Etiologic Agents, Microbe-Host Relationship, Immune Response, Diagnosis, and Treatment in Chromoblastomycosis. J Immunol Res 2021; 2021:9742832. [PMID: 34761009 PMCID: PMC8575639 DOI: 10.1155/2021/9742832] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/30/2021] [Indexed: 01/19/2023] Open
Abstract
Chromoblastomycosis (CBM) is a neglected human disease, caused by different species of pigmented dematiaceous fungi that cause subcutaneous infections. This disease has been considered an occupational disease, occurring among people working in the field of agriculture, particularly in low-income countries. In 1914, the first case of CBM was described in Brazil, and although efforts have been made, few scientific and technological advances have been made in this area. In the field of fungi and host cell relationship, a very reduced number of antigens were characterized, but available data suggest that ectoantigens bind to the cell membrane of host cells and modulate the phagocytic, immunological, and microbicidal responses of immune cells. Furthermore, antigens cleave extracellular proteins in tissues, allowing fungi to spread. On the contrary, if phagocytic cells are able to present antigens in MHC molecules to T lymphocytes in the presence of costimulation and IL-12, a Th1 immune response will develop and a relative control of the disease will be observed. Despite knowledge of the resistance and susceptibility in CBM, up to now, no effective vaccines have been developed. In the field of chemotherapy, most patients are treated with conventional antifungal drugs, such as itraconazole and terbinafine, but these drugs exhibit limitations, considering that not all patients heal cutaneous lesions. Few advances in treatment have been made so far, but one of the most promising ones is based on the use of immunomodulators, such as imiquimod. Data about a standard treatment are missing in the medical literature; part of it is caused by the existence of a diversity of etiologic agents and clinical forms. The present review summarizes the advances made in the field of CBM related to the diversity of pathogenic species, fungi and host cell relationship, antigens, innate and acquired immunity, clinical forms of CBM, chemotherapy, and diagnosis.
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Belda W, Casolato ATS, Luppi JB, Passero LFD. Managing chromoblastomycosis with acitretin plus imiquimod: A case report on the improvement of cutaneous lesions and reduction of the treatment time. J Dermatol 2021; 48:1612-1615. [PMID: 34405444 DOI: 10.1111/1346-8138.16101] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/23/2021] [Accepted: 07/21/2021] [Indexed: 11/27/2022]
Abstract
Chromoblastomycosis (CBM) is an infectious disease caused by fungi that is prevalent in tropical and subtropical countries. Besides few therapeutic options, the classical treatment of CBM needs to be administrated for a long period of time, and unfortunately some patients do not show improvement of the lesions. Thus, it becomes urgent to develop new strategies for the treatment of CBM. This work reports a successful treatment, performed with the combination of oral acitretin (50 mg/kg, once a day) plus topical imiquimod (50 mg/g, five times per week) for 5 months in a patient with CBM. A significant improvement of the lesions was observed in the 1st month, and in the 5th a complete regression of lesions was recorded. Changes in the biochemical parameters were not observed. These data suggest that the combination of acitretin and imiquimod may be effective at treating CBM.
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Affiliation(s)
- Walter Belda
- Dermatology Department, Medical School, Clinics Hospital, University of São Paulo, São Paulo, Brazil
- Laboratory of Pathology of Infectious Diseases, Medical School, University of São Paulo, São Paulo, Brazil
| | | | - Juliana Bronzato Luppi
- Dermatology Division, Medical School, Clinics Hospital, University of São Paulo, São Paulo, Brazil
| | - Luiz Felipe Domingues Passero
- São Paulo State University (UNESP), Institute of Biosciences, São Vicente, Brazil
- São Paulo State University (UNESP), Institute for Advanced Studies of Ocean, São Vicente, Brazil
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Tseng JC, Chang YC, Huang CM, Hsu LC, Chuang TH. Therapeutic Development Based on the Immunopathogenic Mechanisms of Psoriasis. Pharmaceutics 2021; 13:pharmaceutics13071064. [PMID: 34371756 PMCID: PMC8308930 DOI: 10.3390/pharmaceutics13071064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 07/01/2021] [Accepted: 07/07/2021] [Indexed: 12/16/2022] Open
Abstract
Psoriasis, a complex inflammatory autoimmune skin disorder that affects 2–3% of the global population, is thought to be genetically predetermined and induced by environmental and immunological factors. In the past decades, basic and clinical studies have significantly expanded knowledge on the molecular, cellular, and immunological mechanisms underlying the pathogenesis of psoriasis. Based on these pathogenic mechanisms, the current disease model emphasizes the role of aberrant Th1 and Th17 responses. Th1 and Th17 immune responses are regulated by a complex network of different cytokines, including TNF-α, IL-17, and IL-23; signal transduction pathways downstream to the cytokine receptors; and various activated transcription factors, including NF-κB, interferon regulatory factors (IRFs), and signal transducer and activator of transcriptions (STATs). The biologics developed to specifically target the cytokines have achieved a better efficacy and safety for the systemic management of psoriasis compared with traditional treatments. Nevertheless, the current therapeutics can only alleviate the symptoms; there is still no cure for psoriasis. Therefore, the development of more effective, safe, and affordable therapeutics for psoriasis is important. In this review, we discussed the current trend of therapeutic development for psoriasis based on the recent discoveries in the immune modulation of the inflammatory response in psoriasis.
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Affiliation(s)
- Jen-Chih Tseng
- Immunology Research Center, National Health Research Institutes, Zhunan, Miaoli 35053, Taiwan;
| | - Yung-Chi Chang
- Institute of Molecular Medicine, College of Medicine, National Taiwan University, Taipei 10002, Taiwan;
| | - Chun-Ming Huang
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan 32001, Taiwan;
| | - Li-Chung Hsu
- Institute of Molecular Medicine, College of Medicine, National Taiwan University, Taipei 10002, Taiwan;
- Center of Precision Medicine, College of Medicine, National Taiwan University, Taipei 10002, Taiwan
- Correspondence: (L.-C.H.); (T.-H.C.); Tel.: +886-2-2312-3456 (ext. 65700) (L.-C.H.); +886-37-246-166 (ext. 37611) (T.-H.C.)
| | - Tsung-Hsien Chuang
- Immunology Research Center, National Health Research Institutes, Zhunan, Miaoli 35053, Taiwan;
- Correspondence: (L.-C.H.); (T.-H.C.); Tel.: +886-2-2312-3456 (ext. 65700) (L.-C.H.); +886-37-246-166 (ext. 37611) (T.-H.C.)
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Sbidian E, Chaimani A, Garcia-Doval I, Doney L, Dressler C, Hua C, Hughes C, Naldi L, Afach S, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2021; 4:CD011535. [PMID: 33871055 PMCID: PMC8408312 DOI: 10.1002/14651858.cd011535.pub4] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS For this living systematic review we updated our searches of the following databases monthly to September 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase. We searched two trials registers to the same date. We checked the reference lists of included studies and relevant systematic reviews for further references to eligible RCTs. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults (over 18 years of age) with moderate-to-severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate-to-severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. The primary outcomes of this review were: the proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90 at induction phase (from 8 to 24 weeks after the randomisation), and the proportion of participants with serious adverse events (SAEs) at induction phase. We did not evaluate differences in specific adverse events. DATA COLLECTION AND ANALYSIS Several groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the PASI 90 score) and acceptability (the inverse of serious adverse events). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes and all comparisons, according to CINeMA, as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer on treatment hierarchy: 0% (treatment is the worst for effectiveness or safety) to 100% (treatment is the best for effectiveness or safety). MAIN RESULTS We included 158 studies (18 new studies for the update) in our review (57,831 randomised participants, 67.2% men, mainly recruited from hospitals). The overall average age was 45 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo-controlled (58%), 30% were head-to-head studies, and 11% were multi-armed studies with both an active comparator and a placebo. We have assessed a total of 20 treatments. In all, 133 trials were multicentric (two to 231 centres). All but two of the outcomes included in this review were limited to the induction phase (assessment from 8 to 24 weeks after randomisation). We assessed many studies (53/158) as being at high risk of bias; 25 were at an unclear risk, and 80 at low risk. Most studies (123/158) declared funding by a pharmaceutical company, and 22 studies did not report their source of funding. Network meta-analysis at class level showed that all of the interventions (non-biological systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in reaching PASI 90. At class level, in reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the non-biological systemic agents. At drug level, infliximab, ixekizumab, secukinumab, brodalumab, risankizumab and guselkumab were significantly more effective in reaching PASI 90 than ustekinumab and three anti-TNF alpha agents: adalimumab, certolizumab, and etanercept. Ustekinumab and adalimumab were significantly more effective in reaching PASI 90 than etanercept; ustekinumab was more effective than certolizumab, and the clinical effectiveness of ustekinumab and adalimumab was similar. There was no significant difference between tofacitinib or apremilast and three non-biological drugs: fumaric acid esters (FAEs), ciclosporin and methotrexate. Network meta-analysis also showed that infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab, and brodalumab outperformed other drugs when compared to placebo in reaching PASI 90. The clinical effectiveness of these drugs was similar, except for ixekizumab which had a better chance of reaching PASI 90 compared with secukinumab, guselkumab and brodalumab. The clinical effectiveness of these seven drugs was: infliximab (versus placebo): risk ratio (RR) 50.29, 95% confidence interval (CI) 20.96 to 120.67, SUCRA = 93.6; high-certainty evidence; ixekizumab (versus placebo): RR 32.48, 95% CI 27.13 to 38.87; SUCRA = 90.5; high-certainty evidence; risankizumab (versus placebo): RR 28.76, 95% CI 23.96 to 34.54; SUCRA = 84.6; high-certainty evidence; bimekizumab (versus placebo): RR 58.64, 95% CI 3.72 to 923.86; SUCRA = 81.4; high-certainty evidence; secukinumab (versus placebo): RR 25.79, 95% CI 21.61 to 30.78; SUCRA = 76.2; high-certainty evidence; guselkumab (versus placebo): RR 25.52, 95% CI 21.25 to 30.64; SUCRA = 75; high-certainty evidence; and brodalumab (versus placebo): RR 23.55, 95% CI 19.48 to 28.48; SUCRA = 68.4; moderate-certainty evidence. Conservative interpretation is warranted for the results for bimekizumab (as well as mirikizumab, tyrosine kinase 2 inhibitor, acitretin, ciclosporin, fumaric acid esters, and methotrexate), as these drugs, in the NMA, have been evaluated in few trials. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. Nevertheless, the SAE analyses were based on a very low number of events with low to moderate certainty for all the comparisons. Thus, the results have to be viewed with caution and we cannot be sure of the ranking. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1) the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that compared to placebo, the biologics infliximab, ixekizumab, risankizumab, bimekizumab, secukinumab, guselkumab and brodalumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes were measured from 8 to 24 weeks after randomisation) and is not sufficient for evaluation of longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean age of 45 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly-reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the evidence for all the interventions was of low to moderate quality. In order to provide long-term information on the safety of the treatments included in this review, it will also be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies. In terms of future research, randomised trials directly comparing active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between non-biological systemic agents and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve participants, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Clinical Investigation Centre, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Anna Chaimani
- Université de Paris, Centre of Research in Epidemiology and Statistics (CRESS), INSERM, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Ignacio Garcia-Doval
- Department of Dermatology, Complexo Hospitalario Universitario de Vigo, Vigo, Spain
| | - Liz Doney
- Centre of Evidence Based Dermatology, Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Corinna Dressler
- Division of Evidence Based Medicine, Department of Dermatology, Venerology and Allergology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Camille Hua
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Carolyn Hughes
- c/o Cochrane Skin Group, The University of Nottingham, Nottingham, UK
| | - Luigi Naldi
- Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Bergamo, Italy
| | - Sivem Afach
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
| | - Laurence Le Cleach
- Department of Dermatology, Hôpital Henri Mondor, Créteil, France
- Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Université Paris Est Créteil (UPEC), Créteil, France
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Griffiths CEM, Armstrong AW, Gudjonsson JE, Barker JNWN. Psoriasis. Lancet 2021; 397:1301-1315. [PMID: 33812489 DOI: 10.1016/s0140-6736(20)32549-6] [Citation(s) in RCA: 805] [Impact Index Per Article: 268.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/07/2020] [Accepted: 11/13/2020] [Indexed: 12/19/2022]
Abstract
Psoriasis is a common, chronic papulosquamous skin disease occurring worldwide, presenting at any age, and leading to a substantial burden for individuals and society. It is associated with several important medical conditions, including depression, psoriatic arthritis, and cardiometabolic syndrome. Its most common form, chronic plaque or psoriasis vulgaris, is a consequence of genetic susceptibility, particularly in the presence of the HLA-C*06:02 risk allele, and of environmental triggers such as streptococcal infection, stress, smoking, obesity, and alcohol consumption. There are several phenotypes and research has separated pustular from chronic plaque forms. Immunological and genetic studies have identified IL-17 and IL-23 as key drivers of psoriasis pathogenesis. Immune targeting of these cytokines and of TNFα by biological therapies has revolutionised the care of severe chronic plaque disease. Psoriasis cannot currently be cured, but management should aim to minimise physical and psychological harm by treating patients early in the disease process, identifying and preventing associated multimorbidity, instilling lifestyle modifications, and employing a personalised approach to treatment.
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Affiliation(s)
- Christopher E M Griffiths
- Dermatology Centre, Salford Royal NHS Foundation Trust, University of Manchester, Manchester, UK; NIHR Manchester Biomedical Research Centre, Manchester, UK.
| | - April W Armstrong
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Jonathan N W N Barker
- St John's Institute of Dermatology, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Belda W, Criado PR, Domingues Passero LF. Case Report: Treatment of Chromoblastomycosis with Combinations including Acitretin: A Report of Two Cases. Am J Trop Med Hyg 2020; 103:1852-1854. [PMID: 32815507 DOI: 10.4269/ajtmh.20-0471] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Chromoblastomycosis is a cutaneous fungal infection caused by dematiaceous fungi that belong to the order Chaetothyriales and family Herpotrichiellaceae. This infection is prevalent in tropical and subtropical areas and has been designated as a neglected tropical disease according to the WHO. Chromoblastomycosis infection is difficult to treat, and there are limited therapeutic options, making urgent the characterization of new medicines or approaches to treat such infection. In the present case report, two patients with extensive chromoblastomycosis lesions were treated with the combination of itraconazole, acitretin, and imiquimod. In the fourth month of treatment, both patients showed improvement of verrucous plates, suggesting that acitretin combined with drugs already used in chromoblastomycosis therapy can decrease the time of treatment, improving patient's quality of life.
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Affiliation(s)
- Walter Belda
- Laboratory of Pathology of Infectious Diseases, Medical School, University of São Paulo, São Paulo, Brazil.,Dermatology Department, Clinics Hospital, Medical School, University of São Paulo, São Paulo, Brazil
| | - Paulo Ricardo Criado
- ABC School of Medicine, Fundação Universitária do ABC (FUABC), Santo André, Brazil.,Laboratory of Pathology of Infectious Diseases, Medical School, University of São Paulo, São Paulo, Brazil
| | - Luiz Felipe Domingues Passero
- Institute for Advanced Studies of Ocean, São Paulo State University (UNESP), São Vicente, Brazil.,Institute of Biosciences, São Paulo State University (UNESP), São Vicente, Brazil
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Tokuyama M, Mabuchi T. New Treatment Addressing the Pathogenesis of Psoriasis. Int J Mol Sci 2020; 21:ijms21207488. [PMID: 33050592 PMCID: PMC7589905 DOI: 10.3390/ijms21207488] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 10/06/2020] [Accepted: 10/08/2020] [Indexed: 12/14/2022] Open
Abstract
Psoriasis is an immune cell-mediated inflammatory skin disease. The interleukin (IL)23/IL17 axis plays an important role in the development of psoriasis. The effectiveness of biologic treatments such as tumor necrosis factor (TNF)α inhibitors (infliximab, adalimumab, certolizumab pegol), IL23 inhibitors (ustekinumab, guselkumab, tildrakizumab, risankizumab), and IL17 inhibitors (secukinumab, ixekizumab, brodalumab) have verified these findings. Immune-related cells such as dendritic cells (DCs) and macrophages, in addition to Toll-like receptors and cytokines such as interferon (IFN)α, TNFα, IFNɤ, IL12, IL22, IL23, and IL17, are related to the pathogenesis of psoriasis. Here, we first review new insights regarding the pathogenesis of psoriasis, as it relates to DCs, Langerhans cells, macrophages, the signal transducer and activator of transcription 3 pathway, and aryl hydrocarbon receptor in cutaneous vascular endothelial cells. Based on these findings, we summarize currently available oral treatments and biologics. Furthermore, we describe a new treatment option including Janus kinase inhibitor, tyrosine kinase 2 inhibitor, modulator of sphingosine 1-phosphate receptor 1, and Rho-associated kinase 2 inhibitor.
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16
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Schaap MJ, van Winden ME, Seyger MM, de Jong EM, Lubeek SF. Representation of older adults in randomized controlled trials on systemic treatment in plaque psoriasis: A systematic review. J Am Acad Dermatol 2020; 83:412-424. [DOI: 10.1016/j.jaad.2019.07.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/15/2019] [Accepted: 07/19/2019] [Indexed: 12/17/2022]
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Abstract
IMPORTANCE Approximately 125 million people worldwide have psoriasis. Patients with psoriasis experience substantial morbidity and increased rates of inflammatory arthritis, cardiometabolic diseases, and mental health disorders. OBSERVATIONS Plaque psoriasis is the most common variant of psoriasis. The most rapid advancements addressing plaque psoriasis have been in its pathogenesis, genetics, comorbidities, and biologic treatments. Plaque psoriasis is associated with a number of comorbidities including psoriatic arthritis, cardiometabolic diseases, and depression. For patients with mild psoriasis, topical agents remain the mainstay of treatment, and they include topical corticosteroids, vitamin D analogues, calcineurin inhibitors, and keratolytics. The American Academy of Dermatology-National Psoriasis Foundation guidelines recommend biologics as an option for first-line treatment of moderate to severe plaque psoriasis because of their efficacy in treating it and acceptable safety profiles. Specifically, inhibitors to tumor necrosis factor α (TNF-α) include etanercept, adalimumab, certolizumab, and infliximab. Other biologics inhibit cytokines such as the p40 subunit of the cytokines IL-12 and IL-13 (ustekinumab), IL-17 (secukinumab, ixekizumab, bimekizumab, and brodalumab), and the p19 subunit of IL-23 (guselkumab, tildrakizumab, risankizumab, and mirikizumab). Biologics that inhibit TNF-α, p40IL-12/23, and IL-17 are also approved for the treatment of psoriatic arthritis. Oral treatments include traditional agents such as methotrexate, acitretin, cyclosporine, and the advanced small molecule apremilast, which is a phosphodiesterase 4 inhibitor. The most commonly prescribed light therapy used to treat plaque psoriasis is narrowband UV-B phototherapy. CONCLUSIONS AND RELEVANCE Psoriasis is an inflammatory skin disease that is associated with multiple comorbidities and substantially diminishes patients' quality of life. Topical therapies remain the cornerstone for treating mild psoriasis. Therapeutic advancements for moderate to severe plaque psoriasis include biologics that inhibit TNF-α, p40IL-12/23, IL-17, and p19IL-23, as well as an oral phosphodiesterase 4 inhibitor.
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Affiliation(s)
- April W Armstrong
- Keck School of Medicine, Department of Dermatology, University of Southern California Los Angeles
| | - Charlotte Read
- Keck School of Medicine, Department of Dermatology, University of Southern California Los Angeles
- Department of Medicine, Imperial College London, London, United Kingdom
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Sbidian E, Chaimani A, Afach S, Doney L, Dressler C, Hua C, Mazaud C, Phan C, Hughes C, Riddle D, Naldi L, Garcia-Doval I, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2020; 1:CD011535. [PMID: 31917873 PMCID: PMC6956468 DOI: 10.1002/14651858.cd011535.pub3] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis. This is the baseline update of a Cochrane Review first published in 2017, in preparation for this Cochrane Review becoming a living systematic review. OBJECTIVES To compare the efficacy and safety of conventional systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis, and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS We updated our research using the following databases to January 2019: the Cochrane Skin Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and the conference proceedings of a number of dermatology meetings. We also searched five trials registers and the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) reports (until June 2019). We checked the reference lists of included and excluded studies for further references to relevant RCTs. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic treatments in adults (over 18 years of age) with moderate-to-severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate-to-severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. The primary outcomes of this review were: the proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90 at induction phase (from 8 to 24 weeks after the randomisation), and the proportion of participants with serious adverse effects (SAEs) at induction phase. We did not evaluate differences in specific adverse effects. DATA COLLECTION AND ANALYSIS Several groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the PASI 90 score) and acceptability (the inverse of serious adverse effects). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes, according to GRADE, as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. MAIN RESULTS We included 140 studies (31 new studies for the update) in our review (51,749 randomised participants, 68% men, mainly recruited from hospitals). The overall average age was 45 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo-controlled (59%), 30% were head-to-head studies, and 11% were multi-armed studies with both an active comparator and a placebo. We have assessed a total of 19 treatments. In all, 117 trials were multicentric (two to 231 centres). All but two of the outcomes included in this review were limited to the induction phase (assessment from 8 to 24 weeks after randomisation). We assessed many studies (57/140) as being at high risk of bias; 42 were at an unclear risk, and 41 at low risk. Most studies (107/140) declared funding by a pharmaceutical company, and 22 studies did not report the source of funding. Network meta-analysis at class level showed that all of the interventions (conventional systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in terms of reaching PASI 90. At class level, in terms of reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents. At drug level, in terms of reaching PASI 90, infliximab, all of the anti-IL17 drugs (ixekizumab, secukinumab, bimekizumab and brodalumab) and the anti-IL23 drugs (risankizumab and guselkumab, but not tildrakizumab) were significantly more effective in reaching PASI 90 than ustekinumab and 3 anti-TNF alpha agents: adalimumab, certolizumab and etanercept. Adalimumab and ustekinumab were significantly more effective in reaching PASI 90 than certolizumab and etanercept. There was no significant difference between tofacitinib or apremilast and between two conventional drugs: ciclosporin and methotrexate. Network meta-analysis also showed that infliximab, ixekizumab, risankizumab, bimekizumab, guselkumab, secukinumab and brodalumab outperformed other drugs when compared to placebo in reaching PASI 90. The clinical effectiveness for these seven drugs was similar: infliximab (versus placebo): risk ratio (RR) 29.52, 95% confidence interval (CI) 19.94 to 43.70, Surface Under the Cumulative Ranking (SUCRA) = 88.5; moderate-certainty evidence; ixekizumab (versus placebo): RR 28.12, 95% CI 23.17 to 34.12, SUCRA = 88.3, moderate-certainty evidence; risankizumab (versus placebo): RR 27.67, 95% CI 22.86 to 33.49, SUCRA = 87.5, high-certainty evidence; bimekizumab (versus placebo): RR 58.64, 95% CI 3.72 to 923.86, SUCRA = 83.5, low-certainty evidence; guselkumab (versus placebo): RR 25.84, 95% CI 20.90 to 31.95; SUCRA = 81; moderate-certainty evidence; secukinumab (versus placebo): RR 23.97, 95% CI 20.03 to 28.70, SUCRA = 75.4; high-certainty evidence; and brodalumab (versus placebo): RR 21.96, 95% CI 18.17 to 26.53, SUCRA = 68.7; moderate-certainty evidence. Conservative interpretation is warranted for the results for bimekizumab (as well as tyrosine kinase 2 inhibitor, acitretin, ciclosporin, fumaric acid esters, and methotrexate), as these drugs, in the NMA, have been evaluated in few trials. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. Nevertheless, the SAE analyses were based on a very low number of events with low to very low certainty for just under half of the treatment estimates in total, and moderate for the others. Thus, the results have to be viewed with caution and we cannot be sure of the ranking. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1) the results were very similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions. AUTHORS' CONCLUSIONS Our review shows that compared to placebo, the biologics infliximab, ixekizumab, risankizumab, bimekizumab, guselkumab, secukinumab and brodalumab were the best choices for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of moderate- to high-certainty evidence (low-certainty evidence for bimekizumab). This NMA evidence is limited to induction therapy (outcomes were measured from 8 to 24 weeks after randomisation) and is not sufficient for evaluation of longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean age of 45 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice. Another major concern is that short-term trials provide scanty and sometimes poorly-reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. Indeed, we found no significant difference in the assessed interventions and placebo in terms of SAEs, but the evidence for all the interventions was of very low to moderate quality. In order to provide long-term information on the safety of the treatments included in this review, it will also be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies. In terms of future research, randomised trials comparing directly active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between conventional systemic and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve participants, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.
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Affiliation(s)
- Emilie Sbidian
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
- Hôpital Henri Mondor, Clinical Investigation Centre, Créteil, France, 94010
- Université Paris Est Créteil (UPEC), Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Créteil, France
| | - Anna Chaimani
- Université de Paris, Research Center in Epidemiology and Statistics Sorbonne Paris Cité (CRESS-UMR1153), Inserm, Inra, F-75004, Paris, France
- Cochrane France, Paris, France
| | - Sivem Afach
- Université Paris Est Créteil (UPEC), Epidemiology in dermatology and evaluation of therapeutics (EpiDermE) - EA 7379, Créteil, France
| | - Liz Doney
- Cochrane Skin Group, The University of Nottingham, Centre of Evidence Based Dermatology, A103, King's Meadow Campus, Lenton Lane, Nottingham, UK, NG7 2NR
| | - Corinna Dressler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Division of Evidence Based Medicine, Department of Dermatology, Venerology and Allergology, Charitéplatz 1, Berlin, Germany, 10117
| | - Camille Hua
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
| | - Canelle Mazaud
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
| | - Céline Phan
- Centre Hospitalier Victor Dupouy, Department of Dermatology, Argenteuil, France
| | - Carolyn Hughes
- The University of Nottingham, c/o Cochrane Skin Group, A103, King's Meadow Campus, Lenton Lane, Nottingham, UK, NG7 2NR
| | - Dru Riddle
- Texas Christian University (TCU), School of Nurse Anesthesia, Fort Worth, Texas, USA
| | - Luigi Naldi
- Padiglione Mazzoleni - Presidio Ospedaliero Matteo Rota, Centro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) - FROM (Research Foundation of Ospedale Maggiore Bergamo), Via Garibaldi 13/15, Bergamo, Italy, 24122
| | - Ignacio Garcia-Doval
- Complexo Hospitalario Universitario de Vigo, Department of Dermatology, Meixoeiro sn, Vigo, Spain, 36214
| | - Laurence Le Cleach
- Hôpital Henri Mondor, Department of Dermatology, 51 Avenue du Maréchal de Lattre de Tassigny, Créteil, France, 94000
- Université Paris Est Créteil (UPEC), Epidemiology in Dermatology and Evaluation of Therapeutics (EpiDermE) - EA 7379, Créteil, France
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Kogan N, Raimondo N, Gusis SE, Izcovich A, Abarca Duran JA, Barahona-Torres L, Blanco O, Quintana GB, Briones MC, Castro C, Castro Vargas EG, Criniti J, Diez de Medina JC, Franco M, Gómez M, Levrero VP, Martínez López JE, Valenzuela F. Latin American Clinical Practice Guidelines on the Systemic Treatment of Psoriasis SOLAPSO - Sociedad Latinoamericana de Psoriasis (Latin American Psoriasis Society). Int J Dermatol 2019; 58 Suppl 1:4-28. [PMID: 31282026 DOI: 10.1111/ijd.14471] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This Clinical Practice Guideline on the systemic treatment of Psoriasis includes the recommendations elaborated by a panel of experts from the Latin American Psoriasis Society SOLAPSO, who assessed the quality of the available evidence using the GRADE system and the PICO process to guide the literature search. To answer each question, the experts discussed the results of randomized controlled trials, observational studies and metanalysis evaluating the interventions identified (non-biologics, biologics and phototherapy) in different populations of patients with moderate to severe plaque-psoriasis, which was summarized in Tables ad-hoc. The main end-points considered to assess efficacy were PASI 50, 75, 90 and 100, PGA 0-1 and significant improvement of health-related quality of life. Specific adverse events, either severe or leading to treatment interruption, were also evaluated. The 31 recommendations included in this CPG follow the structure proposed by GRADE: direction (for or against) and strength (strong or weak). The goal of this CPG is to improve the management of patients with psoriasis by recommending interventions of proved benefit and providing a reference standard for the treating physician. Adhering to the contents of this CPG does not guarantee therapeutic success. The final decision on the specific treatment is the responsibility of the physician based on the individual circumstances and considering the values, the preferences and the opinions of the patient or caregivers.
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Affiliation(s)
- Nora Kogan
- Dermatology, Hospital Ramos Mejía, Buenos Aires, Argentina
| | | | - Simon E Gusis
- Rheumatology, Hospital Ramos Mejía, Buenos Aires, Argentina
| | - Ariel Izcovich
- Program on Evidence Based Medicine, Hospital Aleman, Buenos Aires, Argentina
| | | | | | - Orestes Blanco
- Parasitology, Institute of Tropical Medicine Pedro Kouri, La Habana, Cuba
| | | | - María C Briones
- Centro Privado de Piel "Dr. Enrique Uraga", Guayaquil, Ecuador
| | - Carla Castro
- Pediatric Dermatology, Hospital Universitario Austral, Pilar, Argentina
| | | | - Juan Criniti
- Program on Evidence Based Medicine, Hospital Aleman, Buenos Aires, Argentina
| | | | | | - Minerva Gómez
- Dermatology, University Hospital, Monterrey, Nueva León, Mexico
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20
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Arnone M, Takahashi MDF, Carvalho AVED, Bernardo WM, Bressan AL, Ramos AMC, Terena AC, Souza CDS, Nunes DH, Bortoletto MCDC, Oliveira MDFSPD, Neffá JM, Fieri LC, Azulay-Abulafia L, Felix PAO, Magalhaes RF, Romiti R, Jaime TJ. Diagnostic and therapeutic guidelines for plaque psoriasis - Brazilian Society of Dermatology. An Bras Dermatol 2019; 94:76-107. [PMID: 31166402 PMCID: PMC6544036 DOI: 10.1590/abd1806-4841.2019940211] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 01/28/2019] [Indexed: 02/07/2023] Open
Abstract
Psoriasis is a chronic inflammatory disease that affects 1.3% of the Brazilian
population. The most common clinical manifestations are erythematous, scaling
lesions that affect both genders and can occur on any anatomical site,
preferentially involving the knees, elbows, scalp and genitals. Besides the
impact on the quality of life, the systemic nature of the disease makes
psoriasis an independent risk factor for cardiovascular disease, especially in
young patients with severe disease. By an initiative of the Brazilian Society of
Dermatology, dermatologists with renowned clinical experience in the management
of psoriasis were invited to form a work group that, in a partnership with the
Brazilian Medical Association, dedicated themselves to create the Plaque
Psoriasis Diagnostic and Treatment Guidelines. The relevant issues for the
diagnosis (evaluation of severity and comorbidities) and treatment of plaque
psoriasis were defined. The issues generated a search strategy in the
Medline-PubMed database up to July 2018. Subsequently, the answers to the
questions of the recommendations were devised, and each reference selected
presented the respective level of recommendation and strength of scientific
evidence. The final recommendations for making up the final text were worded by
the coordinators.
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Affiliation(s)
- Marcelo Arnone
- Hospital das Clínicas, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | | | | | - Wanderley Marques Bernardo
- Center of Development of Medical Education, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Aline Lopes Bressan
- Service of Dermatology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Andrea Machado Coelho Ramos
- Service of Dermatology, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | | | - Cacilda da Silva Souza
- Department of Internal Medicine, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, SP, Brazil
| | - Daniel Holthausen Nunes
- Service of Dermatology, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | | | | | - Jane Marcy Neffá
- Department of Medicine, Dermatology Clinic, Universidade Federal Fluminense, Niterói, RJ, Brazil
| | | | - Luna Azulay-Abulafia
- Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | | | - Renata Ferreira Magalhaes
- Department of Internal Medicine, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, SP, Brazil
| | - Ricardo Romiti
- Hospital das Clínicas, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil
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21
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Arnone M, Carvalho AVED, Takahashí MDF, Bernardo WM. Moderate to severe plaque psoriasis - treatment with drugs of the classic scheme. ACTA ACUST UNITED AC 2019; 65:530-534. [PMID: 31066805 DOI: 10.1590/1806-9282.65.4.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2018] [Indexed: 11/22/2022]
Abstract
The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.
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Affiliation(s)
- Marcelo Arnone
- Brazilian Society of Urology, Rua Real Grandeza, 108 sala 101 - Botafogo, Rio de Janeiro - RJ, Brasil
| | | | | | - Wanderley M Bernardo
- Brazilian Medical Association, Rua São Carlos do Pinhal, 324 - Bela Vista, São Paulo - SP, Brasil
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22
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Pai VV, Phadke D, Shukla P, Naik K. Fixed Tapering Dosage of Acitretin in Patients with Psoriasis: A Short-Term Analysis of Clinical Efficacy and its Effects on Biochemical Parameters. Indian J Dermatol 2019; 64:213-216. [PMID: 31148860 PMCID: PMC6537684 DOI: 10.4103/ijd.ijd_300_18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Acitretin is a widely used systemic retinoid in the treatment of psoriasis. Dosage of acitretin in not weight adjusted due to certain interindividual variations. OBJECTIVE To evaluate the clinical efficacy and effects on biochemical parameters of fixed tapering dosage of acitretin in patients with psoriasis administered over a period of 4 weeks. MATERIALS AND METHODS This was an observational study. The study included patients of psoriasis vulgaris in the age group of 18 and 65 years with a psoriasis area severity index (PASI) score of >10 which was not responsive to topical therapy and phototherapy. Patients were given oral acitretin daily at a dose of 25 mg BD for 2 weeks, which was later tapered to 25 mg OD for another 2 weeks. The clinical efficacy and biochemical parameters were assessed. RESULTS Out of the 18 patients, PASI 75 was achieved in 66% of the patients by the end of the third week. Significant elevations were noted in serum lipids during 4 weeks, which returned to normal limits or near baseline levels at the end of 4 weeks. CONCLUSION Fixed tapering dose of acitretin is effective in psoriasis with minimal clinical and biochemical adverse events.
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Affiliation(s)
- Varadraj V Pai
- From the Department of Dermatology, Venereology and Leprosy, Goa Medical College, Bambolim, Goa, India
| | - Diksha Phadke
- From the Department of Dermatology, Venereology and Leprosy, Goa Medical College, Bambolim, Goa, India
| | - Pankaj Shukla
- From the Department of Dermatology, Venereology and Leprosy, Goa Medical College, Bambolim, Goa, India
| | - Krupeksha Naik
- From the Department of Dermatology, Venereology and Leprosy, Goa Medical College, Bambolim, Goa, India
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23
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Papp K, Gordon K, Thaçi D, Morita A, Gooderham M, Foley P, Girgis IG, Kundu S, Banerjee S. Phase 2 Trial of Selective Tyrosine Kinase 2 Inhibition in Psoriasis. N Engl J Med 2018; 379:1313-1321. [PMID: 30205746 DOI: 10.1056/nejmoa1806382] [Citation(s) in RCA: 257] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Tyrosine kinase 2 (TYK2) signaling pathways, which mediate cytokine signaling, are implicated in the pathophysiology of psoriasis. Selective inhibitors of TYK2 may be effective in treating psoriasis. METHODS We conducted a phase 2, double-blind trial of a TYK2 inhibitor, BMS-986165, in adults with moderate-to-severe psoriasis, excluding patients with a previous lack of response to agents targeting cytokine signaling through the same tyrosine kinase pathway. Patients were randomly assigned to receive the drug orally at a dose of 3 mg every other day, 3 mg daily, 3 mg twice daily, 6 mg twice daily, or 12 mg daily or to receive placebo. The primary end point was a 75% or greater reduction from baseline in the Psoriasis Area and Severity Index (PASI) score at week 12 (higher scores indicate greater severity of psoriasis). RESULTS A total of 267 patients received at least one dose in an intervention group of the trial. At week 12, the percentage of patients with a 75% or greater reduction in the PASI score was 7% (3 of 45 patients) with placebo, 9% (4 of 44 patients) with 3 mg of BMS-986165 every other day (P=0.49 vs. placebo), 39% (17 of 44 patients) with 3 mg daily (P<0.001 vs. placebo), 69% (31 of 45 patients) with 3 mg twice daily (P<0.001 vs. placebo), 67% (30 of 45 patients) with 6 mg twice daily (P<0.001 vs. placebo), and 75% (33 of 44 patients) with 12 mg daily (P<0.001 vs. placebo). There were three serious adverse events in patients receiving the active drug, as well as one case of malignant melanoma 96 days after the start of treatment. CONCLUSIONS Selective inhibition of TYK2 with the oral agent BMS-986165 at doses of 3 mg daily and higher resulted in greater clearing of psoriasis than did placebo over a period of 12 weeks. Larger and longer-duration trials of this drug are required to determine its safety and durability of effect in patients with psoriasis. (Funded by Bristol-Myers Squibb; ClinicalTrials.gov number, NCT02931838 .).
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Affiliation(s)
- Kim Papp
- From K. Papp Clinical Research and Probity Medical Research, Waterloo (K.P.), the SKiN Centre for Dermatology and Probity Medical Research, Peterborough (M.G.), and Queen's University, Kingston (M.G.) - all in Ontario, Canada; Medical College of Wisconsin, Milwaukee (K.G.); the University of Luebeck, Luebeck, Germany (D.T.); Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan (A.M.); the University of Melbourne, St. Vincent's Hospital Melbourne, Skin and Cancer Foundation, and Probity Medical Research, Melbourne, VIC, Australia (P.F.); and Bristol-Myers Squibb, Princeton, NJ (I.G.G., S.K., S.B.)
| | - Kenneth Gordon
- From K. Papp Clinical Research and Probity Medical Research, Waterloo (K.P.), the SKiN Centre for Dermatology and Probity Medical Research, Peterborough (M.G.), and Queen's University, Kingston (M.G.) - all in Ontario, Canada; Medical College of Wisconsin, Milwaukee (K.G.); the University of Luebeck, Luebeck, Germany (D.T.); Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan (A.M.); the University of Melbourne, St. Vincent's Hospital Melbourne, Skin and Cancer Foundation, and Probity Medical Research, Melbourne, VIC, Australia (P.F.); and Bristol-Myers Squibb, Princeton, NJ (I.G.G., S.K., S.B.)
| | - Diamant Thaçi
- From K. Papp Clinical Research and Probity Medical Research, Waterloo (K.P.), the SKiN Centre for Dermatology and Probity Medical Research, Peterborough (M.G.), and Queen's University, Kingston (M.G.) - all in Ontario, Canada; Medical College of Wisconsin, Milwaukee (K.G.); the University of Luebeck, Luebeck, Germany (D.T.); Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan (A.M.); the University of Melbourne, St. Vincent's Hospital Melbourne, Skin and Cancer Foundation, and Probity Medical Research, Melbourne, VIC, Australia (P.F.); and Bristol-Myers Squibb, Princeton, NJ (I.G.G., S.K., S.B.)
| | - Akimichi Morita
- From K. Papp Clinical Research and Probity Medical Research, Waterloo (K.P.), the SKiN Centre for Dermatology and Probity Medical Research, Peterborough (M.G.), and Queen's University, Kingston (M.G.) - all in Ontario, Canada; Medical College of Wisconsin, Milwaukee (K.G.); the University of Luebeck, Luebeck, Germany (D.T.); Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan (A.M.); the University of Melbourne, St. Vincent's Hospital Melbourne, Skin and Cancer Foundation, and Probity Medical Research, Melbourne, VIC, Australia (P.F.); and Bristol-Myers Squibb, Princeton, NJ (I.G.G., S.K., S.B.)
| | - Melinda Gooderham
- From K. Papp Clinical Research and Probity Medical Research, Waterloo (K.P.), the SKiN Centre for Dermatology and Probity Medical Research, Peterborough (M.G.), and Queen's University, Kingston (M.G.) - all in Ontario, Canada; Medical College of Wisconsin, Milwaukee (K.G.); the University of Luebeck, Luebeck, Germany (D.T.); Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan (A.M.); the University of Melbourne, St. Vincent's Hospital Melbourne, Skin and Cancer Foundation, and Probity Medical Research, Melbourne, VIC, Australia (P.F.); and Bristol-Myers Squibb, Princeton, NJ (I.G.G., S.K., S.B.)
| | - Peter Foley
- From K. Papp Clinical Research and Probity Medical Research, Waterloo (K.P.), the SKiN Centre for Dermatology and Probity Medical Research, Peterborough (M.G.), and Queen's University, Kingston (M.G.) - all in Ontario, Canada; Medical College of Wisconsin, Milwaukee (K.G.); the University of Luebeck, Luebeck, Germany (D.T.); Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan (A.M.); the University of Melbourne, St. Vincent's Hospital Melbourne, Skin and Cancer Foundation, and Probity Medical Research, Melbourne, VIC, Australia (P.F.); and Bristol-Myers Squibb, Princeton, NJ (I.G.G., S.K., S.B.)
| | - Ihab G Girgis
- From K. Papp Clinical Research and Probity Medical Research, Waterloo (K.P.), the SKiN Centre for Dermatology and Probity Medical Research, Peterborough (M.G.), and Queen's University, Kingston (M.G.) - all in Ontario, Canada; Medical College of Wisconsin, Milwaukee (K.G.); the University of Luebeck, Luebeck, Germany (D.T.); Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan (A.M.); the University of Melbourne, St. Vincent's Hospital Melbourne, Skin and Cancer Foundation, and Probity Medical Research, Melbourne, VIC, Australia (P.F.); and Bristol-Myers Squibb, Princeton, NJ (I.G.G., S.K., S.B.)
| | - Sudeep Kundu
- From K. Papp Clinical Research and Probity Medical Research, Waterloo (K.P.), the SKiN Centre for Dermatology and Probity Medical Research, Peterborough (M.G.), and Queen's University, Kingston (M.G.) - all in Ontario, Canada; Medical College of Wisconsin, Milwaukee (K.G.); the University of Luebeck, Luebeck, Germany (D.T.); Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan (A.M.); the University of Melbourne, St. Vincent's Hospital Melbourne, Skin and Cancer Foundation, and Probity Medical Research, Melbourne, VIC, Australia (P.F.); and Bristol-Myers Squibb, Princeton, NJ (I.G.G., S.K., S.B.)
| | - Subhashis Banerjee
- From K. Papp Clinical Research and Probity Medical Research, Waterloo (K.P.), the SKiN Centre for Dermatology and Probity Medical Research, Peterborough (M.G.), and Queen's University, Kingston (M.G.) - all in Ontario, Canada; Medical College of Wisconsin, Milwaukee (K.G.); the University of Luebeck, Luebeck, Germany (D.T.); Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan (A.M.); the University of Melbourne, St. Vincent's Hospital Melbourne, Skin and Cancer Foundation, and Probity Medical Research, Melbourne, VIC, Australia (P.F.); and Bristol-Myers Squibb, Princeton, NJ (I.G.G., S.K., S.B.)
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Heath MS, Sahni DR, Curry ZA, Feldman SR. Pharmacokinetics of tazarotene and acitretin in psoriasis. Expert Opin Drug Metab Toxicol 2018; 14:919-927. [PMID: 30134735 DOI: 10.1080/17425255.2018.1515198] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Psoriasis is a prevalent cutaneous condition with severe physical and psychological manifestations. Since the advent of biologics, clinical outcomes in psoriasis have improved. However, retinoids are useful in the correct clinical context. Tazarotene and acitretin are currently the only US Food and Drug Administration approved retinoids for treatment of psoriasis. Both topical tazarotene and oral acitretin act on retinoic acid receptors and retinoid-X-receptors, resulting in altered gene expression of inflammatory cytokines and inhibition of keratinocyte proliferation. Areas covered: This article provides an in-depth pharmacologic and clinical review on the use of tazarotene and acitretin in psoriasis. The PubMed database was searched using combinations of keywords: acitretin, bioavailability, dosing, efficacy, etretinate, interactions, mechanism, pharmacodynamics, pharmacokinetics, pharmacogenetics, psoriasis, safety, tazarotene, tolerability, and toxicity. Expert opinion: Tazarotene and acitretin are effective treatments for psoriasis. Benefits include lack of immunosuppression and success treating inflammatory psoriasis. When combined with other topical and systemic agents, both retinoids improve clinical efficacy while lowering the treatment threshold. However, topical adherence and bothersome side effects can limit retinoid use. Acitretin and tazarotene both improve outcomes through a unique mechanism that especially benefits subsets of patients, despite side effects and limitations.
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Affiliation(s)
- Michael S Heath
- a Department of Dermatology, Center for Dermatology Research , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Dev R Sahni
- a Department of Dermatology, Center for Dermatology Research , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Zachary A Curry
- a Department of Dermatology, Center for Dermatology Research , Wake Forest School of Medicine , Winston-Salem , NC , USA
| | - Steven R Feldman
- a Department of Dermatology, Center for Dermatology Research , Wake Forest School of Medicine , Winston-Salem , NC , USA.,b Department of Pathology , Wake Forest School of Medicine , Winston-Salem , NC , USA.,c Department of Social Sciences & Health Policy , Wake Forest School of Medicine , Winston-Salem , NC , USA
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Amitay-Laish I, Reiter O, Prag-Naveh H, Kershenovich R, Hodak E. Retinoic acid receptor agonist as monotherapy for early-stage mycosis fungoides: does it work? J DERMATOL TREAT 2018; 30:258-263. [PMID: 29889596 DOI: 10.1080/09546634.2018.1487525] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Retinoids exert their biologic effects by binding to intracellular retinoic-acid receptors (RARs) and/or retinoid X receptors (RXRs). Early-stage mycosis fungoides (MF) has been effectively treated with bexarotene, an RXR-agonist, with overall response (OR) rates 54-67% and complete response (CR) rates 7-27%. Data on RAR-agonist monotherapy are limited. OBJECTIVE To analyze the effectiveness of RAR-agonist monotherapy for early-stage MF. METHODS Data on patients with early-stage MF treated with acitretin/isotretinoin monotherapy at a tertiary cutaneous lymphoma clinic in 2010-2017 were collected retrospectively from the medical files. RESULTS Thirty-five patients (26 males) of median age 50 years (range 8-83) with early-stage MF (IA 9, IB 26) underwent 37 treatment events: 25 acitretin and 12 isotretinoin at a median dosages of 0.3 mg/kg (range 0.2-0.9) and 0.2 mg/kg (range 0.1-0.7), respectively. Median time to maximal response was 6 months for both (range 1-10 for acitretin, 3-16 for isotretinoin); median treatment duration was 10 months (range 3-46) for acitretin, and 9 months (range 3-55) for isotretinoin. OR was 64% for acitretin and 80% for isotretinoin, and CR, 4% and 8%, respectively. Side-effect profiles were as previously reported for retinoids. CONCLUSIONS Early-stage MF patients may benefit from low dose RAR-agonist monotherapy, although the CR rate is low.
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Affiliation(s)
- Iris Amitay-Laish
- a Department of Dermatology , Rabin Medical Center, Beilinson Hospital , Petach Tikva, Israel.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Ofer Reiter
- a Department of Dermatology , Rabin Medical Center, Beilinson Hospital , Petach Tikva, Israel.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Hadas Prag-Naveh
- a Department of Dermatology , Rabin Medical Center, Beilinson Hospital , Petach Tikva, Israel
| | - Ruben Kershenovich
- a Department of Dermatology , Rabin Medical Center, Beilinson Hospital , Petach Tikva, Israel
| | - Emmilia Hodak
- a Department of Dermatology , Rabin Medical Center, Beilinson Hospital , Petach Tikva, Israel.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
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Whitlock SM, Enos CW, Armstrong AW, Gottlieb A, Langley RG, Lebwohl M, Merola JF, Ryan C, Siegel MP, Weinberg JM, Wu JJ, Van Voorhees AS. Management of psoriasis in patients with inflammatory bowel disease: From the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol 2018; 78:383-394. [PMID: 29332708 DOI: 10.1016/j.jaad.2017.06.043] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 06/13/2017] [Accepted: 06/20/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a significant association between psoriasis and inflammatory bowel disease (IBD). Many treatments for psoriasis and psoriatic arthritis are also used for IBD. OBJECTIVE To assess therapeutic options for patients with psoriasis and concurrent IBD. METHODS A systematic literature search was performed for clinical studies of biologic and systemic psoriasis medications in psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease, for the period from January 1, 1947, to February 14, 2017. Randomized, controlled, double-blinded studies were selected if available. If not, the next highest level of available evidence was selected. RESULTS Of the 2282 articles identified, 132 were selected. Infliximab and adalimumab have demonstrated efficacy in psoriasis, psoriatic arthritis, ulcerative; colitis, and Crohn's disease. Ustekinumab has demonstrated efficacy in psoriasis, psoriatic arthritis, and Crohn's disease. Certolizumab has demonstrated efficacy in psoriatic arthritis and Crohn's disease. Etanercept, secukinumab, brodalumab, and ixekizumab have demonstrated efficacy in psoriasis and psoriatic arthritis but may exacerbate or induce IBD. Guselkumab has demonstrated efficacy in psoriasis. LIMITATIONS There are no known clinical trials of treatment specifically for concurrent psoriasis and IBD. CONCLUSIONS Infliximab and adalimumab have demonstrated efficacy in psoriasis, psoriatic arthritis, ulcerative colitis, and Crohn's disease; other agents have demonstrated efficacy for some, but not all, of these indications.
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Affiliation(s)
- Scott M Whitlock
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Clinton W Enos
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia
| | - April W Armstrong
- Department of Dermatology, University of Southern California, Los Angeles, California
| | - Alice Gottlieb
- Department of Medicine, New York Medical College, Valhalla, New York
| | - Richard G Langley
- Division of Clinical Dermatology and Cutaneous Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mark Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Joseph F Merola
- Department of Dermatology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Caitriona Ryan
- Division of Dermatology, Baylor University Medical Center, Dallas, Texas
| | | | - Jeffrey M Weinberg
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jashin J Wu
- Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Abby S Van Voorhees
- Department of Dermatology, Eastern Virginia Medical School, Norfolk, Virginia.
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Narang T, Kumar S, Handa S, Dogra S. Hydroxyurea and acitretin as a novel combination therapy in severe plaque psoriasis. Br J Dermatol 2018; 179:1212-1213. [PMID: 29927478 DOI: 10.1111/bjd.16899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- T Narang
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
| | - S Kumar
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
| | - S Handa
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
| | - S Dogra
- Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160012, India
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Sbidian E, Chaimani A, Garcia‐Doval I, Do G, Hua C, Mazaud C, Droitcourt C, Hughes C, Ingram JR, Naldi L, Chosidow O, Le Cleach L. Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis. Cochrane Database Syst Rev 2017; 12:CD011535. [PMID: 29271481 PMCID: PMC6486272 DOI: 10.1002/14651858.cd011535.pub2] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Psoriasis is an immune-mediated disease for which some people have a genetic predisposition. The condition manifests in inflammatory effects on either the skin or joints, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. Several randomised controlled trials (RCTs) have compared the efficacy of the different systemic treatments in psoriasis against placebo. However, the relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head to head, which is why we chose to conduct a network meta-analysis. OBJECTIVES To compare the efficacy and safety of conventional systemic agents (acitretin, ciclosporin, fumaric acid esters, methotrexate), small molecules (apremilast, tofacitinib, ponesimod), anti-TNF alpha (etanercept, infliximab, adalimumab, certolizumab), anti-IL12/23 (ustekinumab), anti-IL17 (secukinumab, ixekizumab, brodalumab), anti-IL23 (guselkumab, tildrakizumab), and other biologics (alefacept, itolizumab) for patients with moderate to severe psoriasis and to provide a ranking of these treatments according to their efficacy and safety. SEARCH METHODS We searched the following databases to December 2016: the Cochrane Skin Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and LILACS. We also searched five trials registers and the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA) reports. We checked the reference lists of included and excluded studies for further references to relevant RCTs. We searched the trial results databases of a number of pharmaceutical companies and handsearched the conference proceedings of a number of dermatology meetings. SELECTION CRITERIA Randomised controlled trials (RCTs) of systemic and biological treatments in adults (over 18 years of age) with moderate to severe plaque psoriasis or psoriatic arthritis whose skin had been clinically diagnosed with moderate to severe psoriasis, at any stage of treatment, in comparison to placebo or another active agent. DATA COLLECTION AND ANALYSIS Three groups of two review authors independently undertook study selection, data extraction, 'Risk of bias' assessment, and analyses. We synthesised the data using pair-wise and network meta-analysis (NMA) to compare the treatments of interest and rank them according to their effectiveness (as measured by the Psoriasis Area and Severity Index score (PASI) 90) and acceptability (the inverse of serious adverse effects). We assessed the certainty of the body of evidence from the NMA for the two primary outcomes, according to GRADE; we evaluated evidence as either very low, low, moderate, or high. We contacted study authors when data were unclear or missing. MAIN RESULTS We included 109 studies in our review (39,882 randomised participants, 68% men, all recruited from a hospital). The overall average age was 44 years; the overall mean PASI score at baseline was 20 (range: 9.5 to 39). Most of these studies were placebo controlled (67%), 23% were head-to-head studies, and 10% were multi-armed studies with both an active comparator and placebo. We have assessed all treatments listed in the objectives (19 in total). In all, 86 trials were multicentric trials (two to 231 centres). All of the trials included in this review were limited to the induction phase (assessment at less than 24 weeks after randomisation); in fact, all trials included in the network meta-analysis were measured between 12 and 16 weeks after randomisation. We assessed the majority of studies (48/109) as being at high risk of bias; 38 were assessed as at an unclear risk, and 23, low risk.Network meta-analysis at class level showed that all of the interventions (conventional systemic agents, small molecules, and biological treatments) were significantly more effective than placebo in terms of reaching PASI 90.In terms of reaching PASI 90, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents. Small molecules were associated with a higher chance of reaching PASI 90 compared to conventional systemic agents.At drug level, in terms of reaching PASI 90, all of the anti-IL17 agents and guselkumab (an anti-IL23 drug) were significantly more effective than the anti-TNF alpha agents infliximab, adalimumab, and etanercept, but not certolizumab. Ustekinumab was superior to etanercept. No clear difference was shown between infliximab, adalimumab, and etanercept. Only one trial assessed the efficacy of infliximab in this network; thus, these results have to be interpreted with caution. Tofacitinib was significantly superior to methotrexate, and no clear difference was shown between any of the other small molecules versus conventional treatments.Network meta-analysis also showed that ixekizumab, secukinumab, brodalumab, guselkumab, certolizumab, and ustekinumab outperformed other drugs when compared to placebo in terms of reaching PASI 90: the most effective drug was ixekizumab (risk ratio (RR) 32.45, 95% confidence interval (CI) 23.61 to 44.60; Surface Under the Cumulative Ranking (SUCRA) = 94.3; high-certainty evidence), followed by secukinumab (RR 26.55, 95% CI 20.32 to 34.69; SUCRA = 86.5; high-certainty evidence), brodalumab (RR 25.45, 95% CI 18.74 to 34.57; SUCRA = 84.3; moderate-certainty evidence), guselkumab (RR 21.03, 95% CI 14.56 to 30.38; SUCRA = 77; moderate-certainty evidence), certolizumab (RR 24.58, 95% CI 3.46 to 174.73; SUCRA = 75.7; moderate-certainty evidence), and ustekinumab (RR 19.91, 95% CI 15.11 to 26.23; SUCRA = 72.6; high-certainty evidence).We found no significant difference between all of the interventions and the placebo regarding the risk of serious adverse effects (SAEs): the relative ranking strongly suggested that methotrexate was associated with the best safety profile regarding all of the SAEs (RR 0.23, 95% CI 0.05 to 0.99; SUCRA = 90.7; moderate-certainty evidence), followed by ciclosporin (RR 0.23, 95% CI 0.01 to 5.10; SUCRA = 78.2; very low-certainty evidence), certolizumab (RR 0.49, 95% CI 0.10 to 2.36; SUCRA = 70.9; moderate-certainty evidence), infliximab (RR 0.56, 95% CI 0.10 to 3.00; SUCRA = 64.4; very low-certainty evidence), alefacept (RR 0.72, 95% CI 0.34 to 1.55; SUCRA = 62.6; low-certainty evidence), and fumaric acid esters (RR 0.77, 95% CI 0.30 to 1.99; SUCRA = 57.7; very low-certainty evidence). Major adverse cardiac events, serious infections, or malignancies were reported in both the placebo and intervention groups. Nevertheless, the SAEs analyses were based on a very low number of events with low to very low certainty for just over half of the treatment estimates in total, moderate for the others. Thus, the results have to be considered with caution.Considering both efficacy (PASI 90 outcome) and acceptability (SAEs outcome), highly effective treatments also had more SAEs compared to the other treatments, and ustekinumab, infliximab, and certolizumab appeared to have the better trade-off between efficacy and acceptability.Regarding the other efficacy outcomes, PASI 75 and Physician Global Assessment (PGA) 0/1, the results were very similar to the results for PASI 90.Information on quality of life was often poorly reported and was absent for a third of the interventions. AUTHORS' CONCLUSIONS Our review shows that compared to placebo, the biologics ixekizumab, secukinumab, brodalumab, guselkumab, certolizumab, and ustekinumab are the best choices for achieving PASI 90 in people with moderate to severe psoriasis on the basis of moderate- to high-certainty evidence. At class level, the biologic treatments anti-IL17, anti-IL12/23, anti-IL23, and anti-TNF alpha were significantly more effective than the small molecules and the conventional systemic agents, too. This NMA evidence is limited to induction therapy (outcomes were measured between 12 to 16 weeks after randomisation) and is not sufficiently relevant for a chronic disease. Moreover, low numbers of studies were found for some of the interventions, and the young age (mean age of 44 years) and high level of disease severity (PASI 20 at baseline) may not be typical of patients seen in daily clinical practice.Another major concern is that short-term trials provide scanty and sometimes poorly reported safety data and thus do not provide useful evidence to create a reliable risk profile of treatments. Indeed, we found no significant difference in the assessed interventions and placebo in terms of SAEs. Methotrexate appeared to have the best safety profile, but as the evidence was of very low to moderate quality, we cannot be sure of the ranking. In order to provide long-term information on the safety of the treatments included in this review, it will be necessary to evaluate non-randomised studies and postmarketing reports released from regulatory agencies as well.In terms of future research, randomised trials comparing directly active agents are necessary once high-quality evidence of benefit against placebo is established, including head-to-head trials amongst and between conventional systemic and small molecules, and between biological agents (anti-IL17 versus anti-IL23, anti-IL23 versus anti-IL12/23, anti-TNF alpha versus anti-IL12/23). Future trials should also undertake systematic subgroup analyses (e.g. assessing biological-naïve patients, baseline psoriasis severity, presence of psoriatic arthritis, etc.). Finally, outcome measure harmonisation is needed in psoriasis trials, and researchers should look at the medium- and long-term benefit and safety of the interventions and the comparative safety of different agents.
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Affiliation(s)
| | | | - Ignacio Garcia‐Doval
- Complexo Hospitalario Universitario de VigoDepartment of DermatologyTorrecedeira 10, 2º AVigoSpain36202
| | - Giao Do
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Camille Hua
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Canelle Mazaud
- Hôpital Henri MondorDepartment of Dermatology51 Avenue du Maréchal de Lattre de TassignyCréteilFrance94000
| | - Catherine Droitcourt
- Université de Rennes 1Department of Dermatology2 rue Henri le GuillouxRennesFrance35000
| | - Carolyn Hughes
- The University of Nottinghamc/o Cochrane Skin GroupA103, King's Meadow CampusLenton LaneNottinghamUKNG7 2NR
| | - John R Ingram
- Cardiff UniversityDepartment of Dermatology & Wound Healing, Cardiff Institute of Infection & Immunity3rd Floor Glamorgan HouseHeath ParkCardiffUKCF14 4XN
| | - Luigi Naldi
- Padiglione Mazzoleni ‐ Presidio Ospedaliero Matteo RotaCentro Studi GISED (Italian Group for Epidemiologic Research in Dermatology) ‐ FROM (Research Foundation of Ospedale Maggiore Bergamo)Via Garibaldi 13/15BergamoItaly24122
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Chiricozzi A, Panduri S, Dini V, Tonini A, Gualtieri B, Romanelli M. Optimizing acitretin use in patients with plaque psoriasis. Dermatol Ther 2016; 30. [PMID: 27998019 DOI: 10.1111/dth.12453] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 10/23/2016] [Accepted: 10/31/2016] [Indexed: 11/27/2022]
Abstract
Acitretin is one of the systemic agents used for the treatment of psoriasis. Because different acitretin dosages resulted therapeutically successful, there is no general agreement on the optimal dose regimen. To report acitretin efficacy and safety in a real-life setting, wherein patient-tailored dose regimen is usually prescribed, a retrospective analysis evaluating charts of all plaque-type psoriasis patients treated with acitretin from the clinic database was performed. PASI score improvement, as well as PASI 50, 75, 90, and 100 responses were assessed throughout the observational period. Overall, 52% PASI score reduction and a satisfactory safety profile were detected. PASI 50, 75, 90, and 100 response was achieved by 53%, 48%, 28%, and 14%, respectively. Treatment consisted on a mean daily acitretin dose of 25.01 mg. The initial dose was increased (51.2% of cases) or decreased (48.8%) prescribing a mean daily dose of 29.8 mg and 20.02 mg, respectively. This study proposed a dose regimen customized on clinical response and patient's needs, to optimized acitretin benefit.
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Affiliation(s)
- Andrea Chiricozzi
- Dermatology Department, University of Pisa, Via Roma 67, Pisa, 56126, Italy
| | - Salvatore Panduri
- Dermatology Department, University of Pisa, Via Roma 67, Pisa, 56126, Italy
| | - Valentina Dini
- Dermatology Department, University of Pisa, Via Roma 67, Pisa, 56126, Italy
| | - Annalisa Tonini
- Dermatology Department, University of Pisa, Via Roma 67, Pisa, 56126, Italy
| | - Bruno Gualtieri
- Dermatology Department, University of Pisa, Via Roma 67, Pisa, 56126, Italy
| | - Marco Romanelli
- Dermatology Department, University of Pisa, Via Roma 67, Pisa, 56126, Italy
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Ergun T, Seckin Gencosmanoglu D, Alpsoy E, Bulbul-Baskan E, Saricam MH, Salman A, Onsun N, Sarioz A. Efficacy, safety and drug survival of conventional agents in pediatric psoriasis: A multicenter, cohort study. J Dermatol 2016; 44:630-634. [PMID: 27943425 DOI: 10.1111/1346-8138.13713] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 10/28/2016] [Indexed: 12/18/2022]
Abstract
The data on long-term efficacy, safety and drug survival rates of conventional systemic therapeutics in pediatric psoriasis is lacking. The primary aim of this study is to investigate acitretin, methotrexate, cyclosporin efficacy, safety and drug survival rates in pediatric patients as well as predictors of drug survival. This is a multicenter study including 289 pediatric cases being treated with acitretin, methotrexate and cyclosporin in four academic referral centers. Efficacy, adverse events, reasons for discontinuation, 1, 2- and 3-year drug survival rates, and determinants of drug survival were analyzed. A 75% reduction of Psoriasis Area and Severity Index score or better response rate was obtained in 47.5%, 34.1% and 40% of the patients who were treated with acitretin, methotrexate and cyclosporin, respectively. One-year drug survival rates for acitretin, methotrexate and cyclosporin were 36.3%, 21.1% and 15.1%, respectively. The most significant determinant of drug survival, which diminished over time, was treatment response whereas arthritis, body mass index and sex had no influence. Although all three medications are effective and relatively safe in children, drug survival rates are low due to safety concerns at this age group. Effective disease control through their rational use can be expected to improve survival rates.
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Affiliation(s)
- Tulin Ergun
- Department of Dermatology, Marmara University School of Medicine, Istanbul, Turkey
| | | | - Erkan Alpsoy
- Department of Dermatology, Akdeniz University School of Medicine, Antalya, Turkey
| | - Emel Bulbul-Baskan
- Department of Dermatology, Uludag University School of Medicine, Bursa, Turkey
| | | | - Andac Salman
- Department of Dermatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Nahide Onsun
- Department of Dermatology, Bezm-i Alem University School of Medicine , Istanbul, Turkey
| | - Abdullah Sarioz
- Department of Public Health, Marmara University School of Medicine, Istanbul, Turkey
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Di Lernia V, Bonamonte D, Lasagni C, Belloni Fortina A, Cambiaghi S, Corazza M, Di Nuzzo S, Gisondi P, Panzone M, Guarneri C, Neri I. Effectiveness and Safety of Acitretin in Children with Plaque Psoriasis: A Multicenter Retrospective Analysis. Pediatr Dermatol 2016; 33:530-5. [PMID: 27443789 DOI: 10.1111/pde.12940] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acitretin is licensed for and is most commonly used to treat psoriasis. Little information exists about its efficacy and safety in childhood and adolescent psoriasis. METHODS Retrospective analysis of a group of children and adolescents (<17 years of age) with moderate to severe plaque psoriasis treated with acitretin between 2010 and 2014 at Italian dermatology clinics. Patients were identified through databases or registries. RESULTS The study population consisted of 18 patients with a median age of 9.5 years at the start of therapy. The median maintenance dosage per day was 0.41 mg/kg. Eight patients (44.4%) achieved complete clearance or good improvement of their psoriasis, defined as improvement from baseline of 75% or more on the Psoriasis Area and Severity Index at week 16. Three had three or more courses of treatment with short disease-free intervals. In three patients, acitretin treatment was ongoing at the time of data collection. The mean total duration of treatment in responders was 22.7 months. One patient discontinued treatment because of arthralgia. The remaining nine patients (50%) discontinued treatment because it was ineffective. Mucocutaneous adverse effects occurred in all patients, but did not affect therapy maintenance. CONCLUSIONS In this retrospective case series, acitretin was a moderately effective, well-tolerated treatment in children with moderate to severe plaque psoriasis. Given the small number of patients, statements about long-term safety are not possible.
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Affiliation(s)
- Vito Di Lernia
- Dermatology Unit, Arcispedale Santa Maria Nuova IRCCS, Reggio Emilia, Italy.
| | - Domenico Bonamonte
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Claudia Lasagni
- Dermatology Unit, Department of Head and Neck Surgery, University of Modena, Modena, Italy
| | - Anna Belloni Fortina
- Pediatric Dermatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Stefano Cambiaghi
- UOC Dermatologia Pediatrica, Ospedale Maggiore, Policlinic of Milan, Milan, Italy
| | - Monica Corazza
- Section of Dermatology, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Sergio Di Nuzzo
- Section of Dermatology, Department of Clinical and Experimental Medicine, Parma University Hospital, Parma, Italy
| | - Paolo Gisondi
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - Michele Panzone
- Department of Dermatology, University of Turin, Turin, Italy
| | - Claudio Guarneri
- Department of Clinical and Experimental Medicine, Section of Dermatology, University of Messina, Messina, Italy
| | - Iria Neri
- Division of Dermatology, Department of Experimental, Diagnostic, and Specialty Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Rob F, Fialová J, Brejchová M, Džambová M, Sečníková Z, Zelenková D, Jiráková A, Hercogová J. Drug fever as an adverse effect of acitretin in complicated psoriasis patient. Dermatol Ther 2015; 28:366-8. [PMID: 26133643 DOI: 10.1111/dth.12263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We present a case of a 63-year old man with severe chronic plaque psoriasis and a recent history of lung cancer, wherein fever appeared suddenly after initiation of treatment with low dose acitretin. Tumor recurrence or infection was not found during extensive examinations, nevertheless the patient was empirically treated with broad-spectrum antibiotics without any effect on fever. Immediately after discontinuation of acitretin therapy, the fever disappeared. The patient was followed for next 2 years, during this period similar problems did not reappear, although there has been a relapse of psoriasis and the patient was switched later on biological treatment.
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Affiliation(s)
- Filip Rob
- Dermatovenereology Department, 2nd Medical faculty, Charles University, Bulovka Hospital, Prague, Czech Republic
| | - Jorga Fialová
- Dermatovenereology Department, 2nd Medical faculty, Charles University, Bulovka Hospital, Prague, Czech Republic
| | - Miroslava Brejchová
- Dermatovenereology Department, 2nd Medical faculty, Charles University, Bulovka Hospital, Prague, Czech Republic
| | - Martina Džambová
- Dermatovenereology Department, 2nd Medical faculty, Charles University, Bulovka Hospital, Prague, Czech Republic
| | - Zuzana Sečníková
- Dermatovenereology Department, 2nd Medical faculty, Charles University, Bulovka Hospital, Prague, Czech Republic
| | - Darina Zelenková
- Dermatovenereology Department, 2nd Medical faculty, Charles University, Bulovka Hospital, Prague, Czech Republic
| | - Anna Jiráková
- Dermatovenereology Department, 2nd Medical faculty, Charles University, Bulovka Hospital, Prague, Czech Republic
| | - Jana Hercogová
- Dermatovenereology Department, 2nd Medical faculty, Charles University, Bulovka Hospital, Prague, Czech Republic
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