Liver test abnormalities in patients admitted for severe psoriasis: prevalence and associated risk factors

Gastrointestinal and hepatic manifestations in patients with generalised pustular psoriasis

Generalised pustular psoriasis (GPP) is a rare and severe form of pustular psoriasis. It is defined by persisting or relapsing macroscopically visible sterile primary pustules occurring on non-acral skin and not within psoriasis plaques. Due to its rarity, there is a lack of randomised controlled trials on GPP and its associated gastrointestinal (GI) and liver disorders. In this article, we present a review of the GI and hepatic disorders associated with GPP. GPP is known to be associated with extracutaneous manifestations such as neutrophilic cholangitis. Abnormal liver function tests are reported in up to 90% of patients with GPP upon diagnosis. Less commonly, pancreatitis and gastrointestinal bleeding have been attributed to GPP. While a psoriasis registry with 7.5% prevalence of pustular psoriasis reported an association with viral hepatitis B and C, the true relationship remains to be elucidated as hepatitis B is endemic in Asia where GPP prevalence is higher. Common genetic mutations between GPP and conditions such as hepatocellular carcinoma and inflammatory bowel disease have been identified, explaining their possible associations and providing answers to potential therapeutic options for these conditions. A lack of recognition of these association may result in unnecessary withdrawal of efficacious and definitive drugs for the treatment of GPP. Understanding the characteristics of the associated GI and hepatic disorders will have important implications for targeting the appropriate therapeutics.

Prevalence, comorbidities and mortality of generalized pustular psoriasis: A literature review

Generalized pustular psoriasis (GPP) is a rare auto-inflammatory skin disease characterised by acute episodes of sterile pustule formation. Diagnosis and treatment of the disease have historically been complicated by a lack of awareness, and no consistent global definition or clinical coding standards. Now acknowledged as a distinct clinical entity with a recognised genetic component, GPP can take a serious and life-threatening course due to systemic inflammatory complications and its association with various comorbidities. As with other rare diseases, there are significant challenges to understanding the epidemiology of GPP, notably a small patient population, non-standardised study methodologies and ethnic differences in its presentation. A clearer understanding of GPP is therefore required for clinicians to better manage patients with this rare condition. In this review article, we present an overview of the available data on GPP prevalence estimates in key demographics and report the frequency of genetic mutations associated with the disease. We detail the incidence of known comorbidities and summarise the data on mortality and assigned causes of death. Lastly, we discuss the various factors that impact the collection, interpretation and comparison of these data.

An analysis of psoriasis hospitalisation in Thailand

Psoriasis hospitalisation is not frequently reported. The objective of this study was to determine (1) the clinical, laboratory and treatment features of patients with psoriasis hospitalised due to flare-up and (2) other causes of admission of patients with psoriasis. We retrospectively reviewed data on 48 patients admitted due to psoriasis flare-up and 1908 patients with psoriasis admitted due to concomitant illnesses or comorbidities. The study period was 2005-2021. The latter group was compared with 821,804 patients without psoriasis admitted during the period. Of the 48 cases, 37.5% had erythroderma, and 62.5% had generalised pustular psoriasis (GPP). Women (68.8%) predominated, especially in the GPP group (76.7%). The mean age of admission with erythroderma (44.8 years) was higher than for GPP (32.1 years). Infection was the main trigger for psoriasis flare-up (46%). Abnormalities in liver function tests were found in 33.3% of the cases. These abnormalities usually subsided 1-2 months after skin improvement (83.4%). Acitretin was the most prescribed drug for GPP (81.4%), whereas topical treatment alone (50%) was the most frequent erythroderma therapy. Intensive care was needed by 9.3% of patients with GPP. In the psoriasis group admitted due to concomitant illnesses or comorbidities, admission due to digestive and infectious causes was significantly higher for psoriasis patients. Our study showed that trend of psoriasis admission due to disease flare-up was not significantly changed even in the era of biologics. We believed that patient education on avoiding the common precipitating factors of psoriasis flare-up and good self-care is mandatory to reduce the risk of hospitalisation.

Efficacy and Safety of Tripterygium Wilfordii Glycoside Tablets Combined with Acitretin Capsules in the Treatment of Moderate to Severe Plaque Psoriasis: A Randomized Controlled Trial

Objective

To probe into the clinical efficacy of tripterygium wilfordii glycoside (TWGs) tablets combined with acitretin capsules in the treatment of patients with moderate to severe plaque psoriasis (MSPP).

Methods

Thirty-six patients with MSPP were collected and divided into three groups, namely, group A (n = 12, TWG tablets + acitretin capsules), group B (n = 12, compound glycyrrhizin capsules + acitretin capsules), and group C (n = 12, acitretin capsules). The general data of the patients was recorded. In addition, a comparison was made before treatment, 4 weeks and 8 weeks after treatment in terms of the clinical efficacy, liver function indicators (alanine aminotransferase (ALT), aspartate transaminase (AST), and creatinine), psoriasis area, and severity index (PASI) scores. The incidence of adverse reactions after treatment and the recurrence rate during two months of follow-up was statistically analyzed.

Results

The therapeutic effect of group A was superior to the other two groups, with obviously more satisfactory results of serum parameters, clinical efficacy and PASI score, and incidence of adverse reactions.

Conclusions

TWGs combined with acitretin had better therapeutic effects and higher safety in the treatment of MSPP.

Elevated mean platelet volume in oral lichen planus and increased blood urea nitrogen level in its red-form: an observational study

Background

This retrospective observational study aims to assess platelet count, mean platelet volume (MPV), blood biochemical tests for liver and kidney function in Chinese oral lichen planus (OLP) patients.

Methods

Eighty pathologically confirmed OLP patients and 51 healthy controls were enrolled. Data on full blood count and biochemical tests were obtained from the electronic medical record system of the hospital.

Results

MPV was elevated in OLP patients compared to controls (10.68 ± 0.97 fL versus 10.33 ± 0.89 fL, P = 0.042) while platelet count showed no difference between them. Red-form OLP group had increased blood urea nitrogen (BUN, 5.24 ± 1.15 mmol/L versus 4.69 ± 0.98 mmol/L, P = 0.036) than white-form OLP group. By contrast, there were no differences between those two groups in the other variables including MPV, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and creatinine. In terms of C-reactive protein (CRP), 92.5% of the OLP patients had a value of less than 3.48 mg/L. Besides, 75% of the OLP patients were overweight with body mass index (BMI) more than 25 kg/m².

Conclusions

These findings indicate MPV might play roles in inflammation in OLP. The red-form OLP might be associated with damage or reduction of kidney function.

The risk of hepatic adverse events of systemic medications for psoriasis: a prospective cohort study using the BIOBADADERM registry

BACKGROUND

Limited information is available regarding the risk of incident liver disease in patients with psoriasis receiving systemic therapies.

OBJECTIVES

To describe the liver safety findings of conventional and modern systemic therapies for moderate-to-severe psoriasis, and to compare the relative incidence rates of hepatic adverse events (AEs) for each drug.

METHODS

All the patients on the BIOBADADERM registry were included. Crude and adjusted incidence rate ratios (cIRR and aIRR, respectively) of hepatic AEs, using anti-TNF drugs as reference, were determined. Outcomes of interest were hypertransaminasemia, nonalcoholic fatty liver disease (NADFLD) and a group of other, less represented, hepatic AEs.

RESULTS

Our study included 3,171 patients exposed to systemic drugs (6279 treatment cycles). Incident hypertransaminasemia was the most frequent hepatic AE (incidence rate of 21 per 1000 patients-years [CI 95% CI 18-23]), followed by NAFLD (8 cases per 1000 patients-years [95% CI 6-10]). Methotrexate (aIRR 3.06 [2.31-4.4]; p = 0.000) and cyclosporine (aIRR 2.37 [1.05-5.35]; p = 0.0378) were associated with an increased risk for hypertransaminasemia when compared to anti-TNF-α agents. No differences were observed between different groups of biologics. Conventional therapies were not associated with new incident NAFLD.

CONCLUSIONS

Comparative information of the incidence of hepatic AEs could facilitate drug selection in moderate-to-severe psoriasis.

Combination therapy with acitretin and glycyrrhizin in generalized pustular psoriasis with liver test abnormalities: A case series

Liver test abnormalities (LTA) are a frequent extracutaneous manifestation in generalized pustular psoriasis (GPP). Due to possible hepatotoxicity of systemic monotherapy, it is challenging to simultaneously achieve clinical remission and LTA normalization. However, evidence for therapy is lacking. The aim of this study was to assess the effectiveness of combination therapy of acitretin and glycyrrhizin in nine GPP patients with LTA. During the acute phase of GPP, a combination of acitretin (0.5 mg/kg/d PO) and glycyrrhizin (80 mg/d intravenous) was initiated. After 2 weeks, all the patients promptly achieved at least 77% improvement in the severity score of GPP, as well as a significant reduction of liver enzymes. The patients were continuously treated with tapered doses of acitretin (20-30 mg/d PO) and glycyrrhizin (150 mg/d PO), and presented stable conditions during the 12-month follow-up. In conclusion, we consider that the combination of acitretin plus glycyrrhizin is an effective and safe therapy in GPP patients with LTA.

Liver Abnormalities in Patients with Psoriatic Arthritis

OBJECTIVE

We aimed to determine the prevalence and incidence, and to identify the factors associated with liver abnormalities in patients with psoriatic arthritis (PsA).

METHODS

From a longitudinal cohort study, we identified PsA patients with either elevated serum transaminase or alkaline phosphatase levels or liver disease after the first visit to the PsA clinic (cases). Controls were subjects from the same cohort who never had such abnormalities or liver disease. Cases and controls were matched 1:1 by sex, age at the first clinic visit, and followup duration; variables at the onset of the first appearance of liver test abnormality associated with liver abnormalities were identified using univariate logistic and multivariate logistic regression analyses.

RESULTS

Among 1061 patients followed in the PsA clinic, 343 had liver abnormalities. Two hundred fifty-six patients who developed liver abnormalities after the first visit were identified as cases, and 718 patients were identified as controls. The prevalence of liver abnormalities was 32% and the incidence was 39/1000 patient-years where there were 256 cases over 6533 total person-years in the PsA cohort. Liver abnormalities were detected after a mean (SD) followup duration of 8.3 ± 7.8 years. The common causes of liver abnormalities were drug-induced hepatitis and fatty liver. Independent factors associated with liver abnormalities were higher body mass index (BMI), daily alcohol intake, higher damaged joint count, elevated C-reactive protein, and use of methotrexate, leflunomide, or tumor necrosis factor inhibitors.

CONCLUSION

Liver abnormalities are common among patients with PsA and are associated with higher BMI, more severe disease, and certain therapies.

Prevalence of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational and clinical studies

BACKGROUND

Wide-ranging prevalence estimates of psoriatic arthritis (PsA) in patients with psoriasis have been reported.

OBJECTIVES

To assess the prevalence and incidence of PsA in patients with psoriasis.

METHODS

Two authors independently searched 3 databases for studies reporting on the prevalence or incidence of PsA in patients with psoriasis. A proportion meta-analysis was performed to calculate the pooled proportion estimates of PsA in patients with psoriasis.

RESULTS

A total of 266 studies examining 976,408 patients with psoriasis were included. Overall, the pooled proportion (95% confidence interval [CI]) of PsA among patients with psoriasis was 19.7% (95% CI, 18.5%-20.9%). In children and adolescents (<18 years of age), the pooled prevalence was 3.3% (95% CI, 2.1%-4.9%). The PsA prevalence was 22.7% (95% CI, 20.6%-25.0%) in European patients with psoriasis, 21.5% (95% CI, 15.4%-28.2%) in South American patients with psoriasis, 19.5% (95% CI, 17.1%-22.1%) in North American patients with psoriasis, 15.5% (95% CI, 0.009%-51.5%) in African patients with psoriasis, and 14.0% (95% CI, 95% CI, 11.7%-16.3%) in Asian patients with psoriasis. The prevalence of PsA was 23.8% (95% CI, 20.1%-27.6%) in studies in which the Classification Criteria for Psoriatic Arthritis were applied. The incidence of PsA among patients with psoriasis ranged from 0.27 to 2.7 per 100 person-years.

LIMITATIONS

Between-study heterogeneity may have affected the estimates.

CONCLUSIONS

We found that 1 in 4 patients with psoriasis have PsA. With the growing recognition of the Classification Criteria for Psoriatic Arthritis, more homogenous and comparable prevalence estimates are expected to be reported.

Up-regulated expression of CD86 on circulating intermediate monocytes correlated with disease severity in psoriasis

BACKGROUND

The number of intermediate monocytes (CD14⁺⁺CD16⁺) increases in many inflammatory conditions. However, it is not yet known which functional markers expressed by these populations are linked to the pathogenesis of psoriasis.

OBJECTIVES

We evaluated the expression of functional markers on circulating intermediate monocytes. Our goal was to correlate specific populations and their markers with the clinical severity of psoriasis.

METHODS

A cohort of 43 psoriatic patients was subjected to analysis. The proportion of intermediate monocytes with CD86 expression was evaluated by flow cytometry. Serum beta defensin-2 levels were measured by ELISA. Immunofluorescent staining was performed in order to identify the presence of CD14⁺CD16⁺ cells that co-expressed CD86 in affected skin tissues.

RESULTS

Upregulated expression of CD86 on the intermediate subset (but not the number of intermediate monocytes) correlated with clinical severity as measured by PASI scores and serum beta defensin-2 levels. Immunostaining also showed the presence of CD86⁺CD14⁺CD16⁺ cells in the epidermis and dermis of psoriatic plaques, which was associated with increased epidermal proliferation.

CONCLUSION

These results suggest that the expression of CD86 on circulating intermediate monocytes could be used as an index in clinical practice and provide novel insights into how these cells join a complex immune network under the pathological conditions of psoriasis.

[What's new in clinical dermatology?]

In addition to continuous medical education, medical journals offer to dermatologists a huge variety of news that differ by their content, validity, originality and clinical relevance. I collected here various articles relative to clinical dermatology that have been published between September, 2016 and September, 2017. These papers have been chosen in the aim of reflecting such diversity. I just excluded, as far as possible, articles dealing with other issues that the reader will find further in this booklet (such as research, pediatric, instrumental, oncologic or therapeutic dermatology, or dermatology and internal medicine). Space restriction required to skip some commentaries while keeping the references to the selected papers, which the reader will be able to read carefully in its original form.