Psoriatic arthritis

The role of endothelial damage and dyslipidemia in the development of cardiovascular pathology in psoriatic arthritis

An increased risk of cardiovascular events has now been identified in patients with psoriatic arthritis. The chronic immune-mediated inflammation underlying psoriatic arthritis (PA) leads to the development of dyslipidemia, atherosclerosis and its complications, in particular, a high risk of cardiovascular complications. For PA, dyslipidemias are most characteristic, manifested by an increased level of low and very low density lipoproteins, triglycerides and total cholesterol, which correlates with the activity of the disease. The literature review studied the pathogenesis of dyslipidemias and vascular wall lesions in psoriatic arthritis, analyzed the literature on cardiovascular complications and mortality among patients with PA, studied the issues of total cardiovascular risk, presented the results of numerous clinical studies that allow PA to be considered a disease associated with increased the risk of cardiovascular complications. Considering the role of proinflammatory cytokines in the pathogenesis of psoriatic arthritis, early detection of endothelial lesions represents the most promising direction in the prevention of cardiovascular diseases, which are the main cause of mortality in this group of patients.

Psoriatic arthritis and COVID-19 pandemic: Consequences in medical treatment?

The COVID‐19 pandemic has a strong negative impact on human society worldwide. Patients with immune‐mediated disease may be prone to an increased risk of infection and/or more severe course. We review the available data for patients with psoriatic arthritis (PSA) and systemic treatments. Current treatment options are summarized. Based upon the experience with COVID‐19, the following problems are addressed: (a) Can systemic treatment reduce comorbidities of PsA that are also comorbidities for COVID‐19? Does systemic medical treatment pose an increased risk of infection with SARS‐CoV‐2? Does systemic drug therapy have an impact on the risk of pulmonary fibrosis—a factor with strong negative impact on COVID‐19 outcome? Small molecules, inhibitors of tumor necrosis factor alfa, interleukin, and JAK inhibitors are considered. The data are inhomogeneous for the multiple drugs used in PsA. Although the risk for severe upper airway tract infections during clinical controlled trials was mostly in the range of placebo, these data have been obtained before the COVID‐19 pandemic and should be interpreted with caution. Some biologics demonstrated an antifibrotic activity in vitro and in animal disease models. None of the biologics is indicated during an active infection with fever. In nonsymptomatic PsA patients, systemic drug therapy can be continued.

The Diagnosis and Treatment of Nail Disorders

BACKGROUND

Nail disorders can arise at any age. About half of all nail disorders are of infectious origin, 15% are due to inflammatory or metabolic conditions, and 5% are due to malignancies and pigment disturbances. The differential diagnosis of nail disorders is often an area of uncertainty.

METHODS

This review is based on publications and guidelines retrieved by a selective search in PubMed, including Cochrane reviews, meta-analyses, and AWMF guidelines.

RESULTS

Nail disorders are a common reason for derma - tologic consultation. They are assessed by clinical inspection, dermatoscopy, diagnostic imaging, microbiological (including mycological) testing, and histopathological examination. Some 10% of the overall population suffers from onychomycosis, with a point prevalence of around 15%. Bacterial infections of the nails are rarer than fungal colonization. High-risk groups for nail disorders include diabetics, dialysis patients, transplant recipients, and cancer patients. Malignant tumors of the nails are often not correctly diagnosed at first. For subungual melanoma, the mean time from the initial symptom to the correct diagnosis is approximately 2 years; this delay is partly responsible for the low 10-year survival rate of only 43%.

CONCLUSION

Evaluation of the nail organ is an important diagnostic instrument. Aside from onychomycosis, which is a common nail disorder, important differential diagnoses such as malignant diseases, drug side effects, and bacterial infections must be considered.

Role of mesenchymal stem cells in the pathogenesis of psoriasis: current perspectives

Mesenchymal stem cells (MSCs) are multipotent nonhematopoietic stromal cells studied for their properties and importance in management of several skin diseases. This review collects and analyzes the emerging published data, which describe the function of MSCs in the pathogenesis of psoriasis.

Economic Evaluation of Timely Versus Delayed Use of Tumor Necrosis Factor Inhibitors for Treatment of Psoriatic Arthritis in the US

INTRODUCTION

The present study aimed to evaluate clinical outcomes and costs associated with timely versus delayed use of tumor necrosis factor inhibitors (TNFis) among patients with moderately to severely active psoriatic arthritis (PsA) with and without moderate/severe psoriasis (Ps) from a US payer's perspective.

METHODS

An economic model evaluated PsA patients initially treated with a TNFi (timely TNFi use) or apremilast (delayed TNFi use). Patients without joint (American College of Rheumatology 20%, [ACR20]) improvement either switched TNFis or initiated one. ACR20 responses were evaluated for all patients and skin responses by Psoriasis Area Severity Index 75% (PASI75) for those with concomitant PsA and Ps. Published randomized controlled trials and publicly available databases provided model inputs. Effectiveness measures included 1-year responses and number needed to treat (NNT). Direct costs, costs per responder, and incremental costs per responder were calculated.

RESULTS

After 1 year, timely TNFi-treated patients had higher ACR20 responses (70.4% vs. 59.6%) and lower NNTs (1.42 vs. 1.68) compared with delayed use. Among PsA + Ps patients, timely TNFi use was associated with higher ACR20 + PASI75 responses (41.0% vs. 30.0%) and lower NNTs (2.44 vs. 3.33). Cost per ACR20 responder was higher ($56,492 vs. $52,835) among PsA patients without Ps; with concomitant Ps, cost per ACR20 + PASI75 responder was lower for timely TNFi use ($100,954 vs. $111,686). Incremental costs per responder for timely versus delayed TNFi were $76,823 in PsA and $71,791 in PsA and Ps.

CONCLUSION

Timely use of TNFis is a cost-effective strategy for the management of PsA based on improvements in both joint and/or skin disease.

FUNDING

AbbVie Inc.

A Rapidly Progressive Variant of Psoriatic Arthritis: Psoriatic Onycho-Pachydermo-Periostitis

We present a case with psoriatic onychodystrophy, onycholysis, connective tissue thickening above the distal phalanx as well as specific radiologic changes diagnosed as psoriatic onycho-pachydermo-periostitis who responded dramatically to methotrexate with current literature review. In this article, we report a 53-year-old male patient with psoriatic onycho-pachydermo-periostitis who responded dramatically to methotrexate.

Psoriatic arthritis for the dermatologist

Psoriatic arthritis (PsA) is a chronic, progressive, inflammatory spondyloarthropathy that affects approximately one-third of patients with all types of psoriasis. Dermatologists are in a unique position to recognize early symptoms of PsA, initiate appropriate therapy, and prevent development of further disability. The course of PsA can be modulated by immunosuppressive therapy; patients with moderate-to-severe disease require aggressive management with medications proven to halt disease progression. It is essential for the dermatologist to understand the safety, tolerability, efficacy, cost, and potential to halt disease progression with available medications for this relatively common and potentially disabling disease.

Fumaric acid esters in dermatology

Fumaric acid esters (FAE) are substances of interest in dermatology. FAE exert various activities on cutaneous cells and cytokine networks. So far only a mixture of dimethylfumarate (DMF) and three salts of monoethylfumarate (MEF) have gained approval for the oral treatment of moderate-to-severe plaque-type psoriasis in Germany. DMF seems to be the major active component. There is evidence that FAE are not only effective and safe in psoriasis but granulomatous non-infectious diseases like granuloma annulare, necrobiosis lipoidica and sarcoidosis. In vitro and animal studies suggest some activity in malignant melanoma as well.

[Psoriasis arthritis. An interdisciplinary challenge]

Psoriatic arthritis (PsA) is classified as a spondylarthropathy based on its clinical and serological characteristics. The clinical manifestations and the association with psoriasis or nail psoriasis have led, together with immunological characteristics, to a further differentiation. The pathophysiological and genetic understanding of this disease has advanced as a result of the development of new treatment strategies and targets in rheumatology and dermatology. Collaborative efforts and increasing multidisciplinary cooperation between rheumatologists and dermatologists have led to an increased awareness in early diagnosis and treatment. New treatment modalities have demonstrated significant efficacy in preventing radiologic progression resulting in amelioration of clinical symptoms, improvement of function and quality of life.

Antigens from Leishmania amastigotes inducing clinical remission of psoriatic arthritis

A first generation vaccine (AS100-1) was manufactured with protein from four cultured Leishmania species, which proved to be effective in the treatment of psoriasis. A single blind trial on 3,132 psoriasis patients revealed 508 (16.2%) subjects with psoriatic arthritis (PsA) that received AS100-1 antigens. The study group was distributed according to percent psoriasis area and severity index (PASI) reduction from PASI 10 to PASI 100. All groups decreased in arthritis score (AS), tender joints counts and nail changes after treatment; the highest decreased in the PASI 100 group. Relapses of psoriasis and PsA had PASI and AS lower than initial values before treatment. Clinical remissions were at lower doses and less time, after the second course of treatment. Peripheral blood mononuclear cells (PBMC) lymphocyte subsets (LS) varied with PASI range (1-10, 11-20 and 21-72). Pre-treatment, absolute values of gated LS: CD4+, CD8+HLA-, CD8+HLA+, CD8+CD3-, CD8+CD3+ decreased in PBMC as PASI increased, suggesting migration from the blood to the skin. In contrary to the previous finding, the following LS: CD8+CD4-, CD3+CD8-, HLA+CD8-, CD19, CD8+CD4+ and membrane surface immunoglobulin IgA+, IgD+, IgM+, IgE+, and IgG+ increased in PBMC as PASI increased suggesting activation and proliferation by unknown antigens creating a homeostatic cycle between skin/joints and peripheral blood. After nine doses of AS100-1, the following LS: CD8+CD3+, CD8+HLA+, CD3+CD8-, CD4+CD8-, CD8+HLA-, HLA+CD8-, CD8+CD3-, CD19+, CD8+CD4-, CD8+CD4+, IgA+, IgD+, IgM+, IgE+, and IgG+ decreased significantly as compared with values before treatment. The LS decreased stops the vicious cycle between skin/joints and blood explaining clinical remission of lesions.