Depression and suicidality in psoriasis: review of the literature including the cytokine theory of depression

Psoriasis Comorbidities and Their Treatment Impact

Psoriasis, a systemic inflammatory disease classically presenting with cutaneous lesions, has significant involvement in other organ systems. This article explores the prevalence, clinical manifestations, screening mechanisms, and laboratory testing by which to evaluate these comorbidities. Treatment approach for these comorbidities must combine patient preference with established treatment algorithms while recognizing innovative therapeutics currently under development.

The association between periodontitis and the impact of oral health on the quality of life of individuals with psoriasis and psoriatic arthritis

OBJECTIVE

To evaluate the association between psoriasis (PSO), psoriatic arthritis (PsA) and periodontitis (PE), and the Oral Health-Related Quality of Life (OHRQoL) impacts on individuals with psoriatic disease's daily activities compared to the non-psoriatic ones.

MATERIALS & METHODS

296 individuals with psoriatic disease (PSO n = 210, APS n = 86) (cases) and 359 without these diseases (controls) were included. Complete periodontal examinations and collection of variables of interest were performed. The Brazilian version of the Oral Impacts on Daily Performance (OIDP) instrument was applied.

RESULTS

The prevalence of PE was higher in PsA (57.0%; OR = 2.67 95%CI 1.65-4.32; p<0.001) than in PSO (34.3%; OR = 1.05 95% CI 0.73-1.51; p<0.001) compared to controls (33.1%). Both PsA and PSO groups showed more sites and teeth with 4-6mm probing depth (PD) and had higher OIDP scores than controls (p<0.001), thus indicating worse self-reported quality of life. PE, PSO+PE and consumption of alcohol/anxiolytics significantly influenced OHRQoL (p<0.05). The influence of periodontal parameters on OHRQoL was observed for the presence of PE; PD >6 mm; clinical attachment level >6 mm; higher plaque index, % sites and teeth with bleeding on probing (p<0.05).

CONCLUSION

Negative impacts of PE on the OHRQoL were demonstrated. The ones having PSO and especially PsA and PE presented significantly worse indicators.

Neuroticism and inflammatory skin diseases: a bidirectional Mendelian randomization study

Previous observational studies have linked inflammatory skin diseases with mental health issues and neuroticism. However, the specific impact of neuroticism and its subclusters (i.e. worry, depressed affect, and sensitivity to environmental stress and adversity) on these conditions remains underexplored. In this work, we explored causal associations between common inflammatory skin diseases and neuroticism. We conducted a two-sample, bidirectional Mendelian randomization (MR) analysis using data from genome-wide association studies in psoriasis, atopic dermatitis, neuroticism and relevant genetic subclusters conducted on participants of European ancestry. Corrections for sample overlap were applied where necessary. We found that psoriasis was causally associated with increased levels of worry (odds ratio, 95% confidence intervals: 1.011, 1.006-1.016, P = 3.84 × 10-6) while none of the neuroticism subclusters showed significant association with psoriasis. Sensitivity analyses revealed considerable evidence of directional pleiotropy between psoriasis and neuroticism traits. Conversely, genetic liability to atopic dermatitis did not exhibit any significant association with neuroticism traits. Notably, genetically predicted worry was linked to an elevated risk of atopic dermatitis (odds ratio, 95% confidence intervals: 1.227, 1.067-1.41, P = 3.97 × 10-3). Correction for overlapping samples confirmed the robustness of these results. These findings suggest potential avenues for future interventions aimed at reducing stress and worry among patients with inflammatory skin conditions.

Influence of stress resilience in adolescence on long-term risk of psoriasis and psoriatic arthritis among men: A prospective register-based cohort study in Sweden

BACKGROUND

Although stress is considered to be a negative factor for psoriasis, no convincing scientific evidence of this association exists, largely because of difficulties in measuring stress. Stress resilience is the ability to cope with and adapt to stressful events. Stress resilience can be measured in a standardized way and used as a marker for chronic stress.

OBJECTIVES

The objective of this study is to investigate whether low stress resilience in adolescence increases the risk for onset of psoriasis and psoriatic arthritis later in life.

METHODS

A cohort of Swedish men (mean age 18.3 years), enrolled in compulsory military service between 1968 and 2005, was created using data from the Swedish Military Service Conscription Register (n = 1,669,422). Stress resilience at conscription was estimated using standardized semi-structured interviews, and was divided into three categories: low, medium and high. The men were followed from conscription until new-onset psoriasis or psoriatic arthritis, death or emigration or at the latest until 31 December 2019. Cox regression models adjusted for confounders at conscription were used to obtain hazard ratios (HRs) with 95% confidence intervals (CIs) for incident psoriasis and psoriatic arthritis.

RESULTS

Men in the lowest stress resilience category had an increased risk of psoriasis and psoriatic arthritis (HR 1.31 (95% CI 1.26-1.36) and 1.23 (95% CI 1.15-1.32), respectively), compared with those in the highest stress resilience category. When including only hospitalized patients the HRs for psoriasis and psoriatic arthritis in the lowest stress resilience group were 1.79 (1.63-1.98) and 1.53 (1.32-1.77), respectively.

CONCLUSIONS

This large, prospective register study suggests that low stress resilience in adolescence is associated with an increased risk of incident psoriasis among men. The results indicate that patients with psoriasis have an inherent psychological vulnerability, and highlight the importance of addressing psychological well-being in the management of psoriasis.

Prevalence and risk of nonalcoholic fatty liver disease among adult psoriatic patients: A systematic review, meta-analysis, and trial sequential analysis

BACKGROUND

This systematic review and meta-analysis aimed to report the evaluation of the prevalence and risk of nonalcoholic fatty liver disease (NAFLD) among adult psoriatic patients in a systematic review and meta-analysis.

METHODS

A comprehensive search was conducted across 4 databases of PubMed, Scopus, Cochrane Library, and Web of Science to collect relevant studies until November 30, 2023, without any restrictions for finding observational studies. The comprehensive meta-analysis version 3.0 software was used to calculate effect sizes, showing the event rate (ER), odds ratio (OR), and a 95% confidence interval (CI) to evaluate NAFLD risk or prevalence in psoriatic patients and controls or psoriatic patients alone. The quality scoring was performed by 1 author based on the Newcastle-Ottawa Scale tool. Publication bias, meta-regression analysis, and sensitivity analyses were performed. Additionally, Trial Sequential Analysis (TSA) was performed using TSA software.

RESULTS

A total of 581 records were identified among the databases and electronic sources. At last, 41 studies involving 607,781 individuals were included in the meta-analysis. The pooled ER of NAFLD among psoriatic patients was 29.5% (95%CI: 19.6%-41.7%) and I2 = 99.79%. The pooled OR of NAFLD in psoriatic patients compared to controls was 1.685 (95%CI: 1.382-2.055; P < .001) and I2 = 87.96%.

CONCLUSIONS

The study found a significant link between psoriasis and NAFLD, with psoriatic patients having a higher chance of developing NAFLD compared to the controls. The study calls for regular NAFLD screening in psoriatic patients to prevent liver complications.

Experience and caring needs of patients with psoriasis: A qualitative meta-synthesis

BACKGROUND

As a chronic skin disease, psoriasis often affects the physical, psychological and social status of the patient, which in turn impacts on their experience of illness and needs. However, there is no review of qualitative research that integrates and analyses the experiences and needs of these three influences from a holistic perspective.

METHODS

This review follows the ENTREQ guidelines. Six English databases (JBI, Cochrane Library, PubMed, PsyINFO, CINAHL and Embase) and three Chinese databases (CNKI, VIP and Wanfang) were searched from January 2012 to October 2022. Literature was included if it was relevant to the experience of illness and caring needs of patients with psoriasis. The JBI-QARI was used to rate the quality of included studies.

RESULTS

Eleven studies were included in the meta-synthesis. Four analytical themes were identified for analysis: physical challenges, psychological discomfort, social phenomena and caring needs.

CONCLUSIONS

The combined physical, psychological and social effects of psoriasis and the consequent caring needs should be emphasised. Health professionals, including doctors and nurses, should be aware of the multiple changes in patients and their coping strategies, provide information about psoriasis, monitor and follow-up regularly over time and obtain feedback to inform further treatment and care so as to develop high-quality therapeutic interventions to help and guide patients with their coping strategies.

RELEVANCE TO CLINICAL PRACTICE

These findings describe the physical, psychological and social experiences of illness and caring needs of patients with psoriasis. Healthcare professionals should be more aware of patients' easily overlooked psychological and social distress, providing prompt attention and recognition of patients' experiences and needs, offering relevant assistance and support and enhancing daily, regular follow-up to help them improve their understanding of and ability to manage their illness.

NO PATIENT OR PUBLIC CONTRIBUTION

This is a meta-synthesis without direct patient involvement.

Discontinuation of Fumaric Acid Esters is Affected by Depressive Symptomatology: A Retrospective Analysis

Fumaric acid esters (FAEs) remain a widespread therapy option for moderate-to-severe psoriasis. However, drug survival of FAEs is limited by adverse events (AEs) or inadequate treatment response. Depressive disturbances are highly prevalent in psoriasis patients and are hypothesized to be associated with the reporting of AEs and therapy discontinuation. This study's aim was to analyze whether psoriasis patients with comorbid depressive symptomatology are more likely to discontinue treatment with FAEs due to AEs and/or inadequate treatment response. Data were retrospectively extracted from the records of patients starting therapy with FAEs in the Department of Dermatology, University Hospital Essen, Germany between 2017 and 2022, covering the first 52 weeks of treatment. Psoriasis severity and depressive symptomatology, as well as AEs and therapy discontinuation, were analyzed. Psoriasis patients (N = 95, 47.37% female) with depressive symptomatology (42.11%) were more likely to discontinue therapy due to patient-reported AEs, while the total number of reported AEs was not associated with depression. The results support the hypothesis that among psoriasis patients with depressive symptoms, the associated introspection and somatization may result in increased sensitivity for AEs and thus in quicker therapy discontinuation. In these patients, the occurrence of nocebo effects should be minimized, e.g. by special communication techniques.

Identification of potential crucial genes shared in psoriasis and ulcerative colitis by machine learning and integrated bioinformatics

BACKGROUND

Mounting evidence suggest that there are an association between psoriasis and ulcerative colitis (UC), although the common pathogeneses are not fully understood. Our study aimed to find potential crucial genes in psoriasis and UC through machine learning and integrated bioinformatics.

METHODS

The overlapping differentially expressed genes (DEGs) of the datasets GSE13355 and GSE87466 were identified. Then the functional enrichment analysis was performed. The overlapping genes in LASSO, SVM-RFE and key module in WGCNA were considered as potential crucial genes. The receiver operator characteristic (ROC) curve was used to estimate their diagnostic confidence. The CIBERSORT was conducted to evaluate immune cell infiltration. Finally, the datasets GSE30999 and GSE107499 were retrieved to validate.

RESULTS

112 overlapping DEGs were identified in psoriasis and UC and the functional enrichment analysis revealed they were closely related to the inflammatory and immune response. Eight genes, including S100A9, PI3, KYNU, WNT5A, SERPINB3, CHI3L2, ARNTL2, and SLAMF7, were ultimately identified as potential crucial genes. ROC curves showed they all had high confidence in the test and validation datasets. CIBERSORT analysis indicated there was a correlation between infiltrating immune cells and potential crucial genes.

CONCLUSION

In our study, we focused on the comprehensive understanding of pathogeneses in psoriasis and UC. The identification of eight potential crucial genes may contribute to not only understanding the common mechanism, but also identifying occult UC in psoriasis patients, even serving as therapeutic targets in the future.

The bidirectional causal association between psoriasis and psychological illnesses: a 2-sample Mendelian randomization study

There have been reports of association between psoriasis and psychological illnesses. Nevertheless, it is not easy to draw conclusions with high quality causality from conventional observational studies. The objective of this study was to evaluate the causality of psoriasis and psychological illnesses. All summary-level data from genome-wide association studies for psoriasis and psychological illnesses were collected from Neale Lab and MRC Integrative Epidemiology Unit. Bidirectional Mendelian randomization analysis was performed to determine the random orientation with an independent genetic variation. The main estimated effects are derived using Inverse-Variance Weighted, weighted median, and MR Egger methods. Multiple data sets were validated against each other, and a series of sensitivity studies were conducted to ensure the reliability of the results. Mendelian randomization analysis revealed a causal effect of psoriasis [odds ratio (OR) 1·34, 95% confidence interval (CI) 1·21-1·46, P < 0.001; and OR 1.28, CI 1.17-1.39, P < 0.001] on psychological illnesses, and vice versa (OR 1.23, CI 1.14-1.31, P < 0.001; and OR 1.21, CI 1.11-1.31, P < 0.001). The results were supported by a series of sensitivity analyses. The findings of this Mendelian randomization study support a causal effect between psoriasis and psychological illnesses, and vice versa.

Interleukin-17 and - 23 Inhibitors Associated with Direct Effects on Depressive Symptoms in Psoriasis: Results from a Register Study

Abstract is missing (Short communication)

"Mens Sana in Cute Sana"-A State of the Art of Mutual Etiopathogenetic Influence and Relevant Pathophysiological Pathways between Skin and Mental Disorders: An Integrated Approach to Contemporary Psychopathological Scenarios

The negative socioeconomic impact of mental health disorders and skin diseases has increased in part due to the conflict between Russia and Ukraine, which has been a fertile ground for the emergence of psychopathologies. It is firmly established that there is a direct thread of etiopathogenetic communication between skin diseases and neuropsychiatric disorders, and the literature has tried to reveal the pathophysiological mechanisms governing such bidirectionality. This paper discusses this complex network of molecular pathways that are targeted by conventional and biological pharmacological agents that appear to impact two pathological spheres that previously seemed to have little connection. This molecular discussion is supplemented with a literature review, from a clinical viewpoint, regarding skin-brain etiopathogenetic bidirectionality. We focus on post-traumatic stress disorder (PTSD), which can be considered for all intents and purposes a systemic inflammatory disease that also affects the skin. A brief overview is also provided on the diagnostic-therapeutic and follow-up potential of oxidative and inflammatory markers potentially involved in the pathophysiological mechanisms treated. The aim is to clarify how these mechanisms may be useful in defining different stress-coping strategies and thus individual phenotypes of stress sensitivity/resistance in order to promote personalized medicine in the field of psychodermatology.

Genomic, Epigenomic, Transcriptomic, Proteomic and Metabolomic Approaches in Atopic Dermatitis

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a high prevalence in the developed countries. It is associated with atopic and non-atopic diseases, and its close correlation with atopic comorbidities has been genetically demonstrated. One of the main roles of genetic studies is to comprehend the defects of the cutaneous barrier due to filaggrin deficit and epidermal spongiosis. Recently, epigenetic studies started to analyze the influence of the environmental factors on gene expression. The epigenome is considered to be a superior second code that controls the genome, which includes alterations of the chromatin. The epigenetic changes do not alter the genetic code, however, changes in the chromatin structure could activate or inhibit the transcription process of certain genes and consequently, the translation process of the new mRNA into a polypeptide chain. In-depth analysis of the transcriptomic, metabolomic and proteomic studies allow to unravel detailed mechanisms that cause AD. The extracellular space and lipid metabolism are associated with AD that is independent of the filaggrin expression. On the other hand, around 45 proteins are considered as the principal components in the atopic skin. Moreover, genetic studies based on the disrupted cutaneous barrier can lead to the development of new treatments targeting the cutaneous barrier or cutaneous inflammation. Unfortunately, at present, there are no target therapies that focus on the epigenetic process of AD. However, in the future, miR-143 could be an important objective for new therapies, as it targets the miR-335:SOX axis, thereby restoring the miR-335 expression, and repairing the cutaneous barrier defects.

Evidence for a causal association between psoriasis and psychiatric disorders using a bidirectional Mendelian randomization analysis in up to 902,341 individuals

BACKGROUND

The causal association between psoriasis and psychiatric disorders remains ambiguous.

OBJECTIVES

This study aimed to investigate the causal relationship between psoriasis and common psychiatric disorders using bidirectional Mendelian randomization (MR) analysis.

METHODS

Major depressive disorder (MDD) (N = 217,584), bipolar disorder (N = 51,710), schizophrenia (N = 77,096), and anxiety disorder (N = 218,792) were obtained as outcomes, and psoriasis (N = 337,159) were as exposure. Inverse variance weighting (IVW) was used as the main method, with other sensitivity methods as auxiliary methods. Sensitivity analysis and heterogeneity tests were performed to ensure the robustness of the results. We also performed a subgroup analysis of cases with psoriatic arthritis (PsA) (N = 213,879) by using the same testing methods.

RESULTS

MR showed that the genetic risk of psoriasis was positively associated with bipolar disorder (odds ratio (OR) = 13.54, 95 % confidence interval (95%CI): 2.43-75.37, P = 0.002) and MDD (OR = 1.08, 95%CI: 1.01-1.15, P = 0.027), which indicated possible causal relationships between psoriasis and these two diseases. Schizophrenia (OR = 3.52, 95%CI: 0.22-55.71, P = 0.372) and anxiety disorders (OR = 0.65, 95%CI: 0.16-2.63, P = 0.546) indicated no significant causal association. No reverse causal effects of psychiatric disorders on psoriasis were found. Subgroup analysis also suggested causal association of PsA with the bipolar affective disorder (OR = 1.05, 95%CI: 1.01-1.08, P = 0.005).

LIMITATIONS

Potential pleiotropic effects, restriction to European populations, and differences in diagnostic criteria.

CONCLUSIONS

This study has supported the causal association of psoriasis with MDD and bipolar disorder, and the subtype PsA with bipolar disorder, which informed the intervention for mental illnesses in patients with psoriasis.

Brief self-affirmation intervention for adults with psoriasis for reducing anxiety and depression and boosting well-being: Evidence from a randomized controlled trial

BACKGROUND

There are relatively few studies to address mental health implications of self-affirming, especially across groups experiencing a chronic health condition. In this study, short- and longer-term effects of a brief self-affirmation intervention framed in terms of implementation intentions (if-then plans with self-affirming cognitions; S-AII) were evaluated against an active control group (non-affirming implementation intentions; N-AII), matched to the target condition, and mere goal intention condition (a non-active control) in adults with psoriasis. The three pre-registered primary outcomes captured depression, anxiety, and well-being.

METHODS

Adults with psoriasis (N = 175; M_age = 36.53, s.d. = 11.52) were randomized into S-AII, N-AII, or control. Participants' mental health outcomes were assessed prior to randomization (at baseline), at week 2 (post-intervention), and at a 1-month follow-up.

RESULTS

Linear mixed models were used and results were reported on the intention-to-treat principle. Analyses revealed that S-AII exerted significantly more improvement in the course of well-being (ds > 0.25), depressive symptoms (ds > -0.40), and anxiety (ds > -0.45) than the N-AII and control group at 2-week post-intervention. Though the differences between groups faded at 1-month follow-up, the within-group changes over time for S-AII in all mental health outcomes remained significant.

CONCLUSIONS

Brief and low-intensity S-AII intervention exerted in the short-term a considerable impact on mental health outcomes. The S-AII shows promising results as a relevant public mental health strategy for enhancing well-being and reducing psychological distress. Future studies could consider whether these effects can be further enhanced with booster interventions.

Clinical benefit and tolerance profile of a keratolytic and hydrating shampoo in subjects with mild to moderate psoriasis. Results from a double-blind, randomized, vehicle-controlled study

INTRODUCTION

Scalp psoriasis frequently goes with other disease location and may lead to a significant burden and impairment of quality of life (QoL). Adherence to local treatments is a frequent problem. A keratolytic and hydrating shampoo containing 2% salicylic acid, 5% urea, and 1% glycerin (active shampoo) has been developed for psoriasis-prone scalp.

OBJECTIVE

To assess the efficacy and tolerability of an active shampoo in subjects with mild to moderate scalp psoriasis.

MATERIALS AND METHODS

A single-center, randomized, double-blind, vehicle-controlled study was conducted on 67 adults with mild to moderate psoriasis. The active shampoo or its vehicle were applied daily for 14 days and 3 times/week for another 14 days. Assessments included the Psoriasis Scalp Severity Index (PSSI), Investigator Global Assessment (IGA), calculated total surface affected hair, scalp greasiness, irritation, and assessed scalp dermatitis-specific quality-of-life issues using SCALPDEX and product acceptability.

RESULTS

The active shampoo significantly (p < 0.05) reduced the PSSI by 39.0%, 37.2%, 63.0%, and 69.0% immediately after washing compared to a 22.8%, 5.5%, 19.6%, and 13.0% with the vehicle at Days 1, 8, 15, and 30, respectively. SCALPDEX items, IGA, and irritation significantly (p < 0.05) reduced with the active shampoo. Hair and scalp greasiness improved continuously with both products until Day 21. Subject-reported symptom scores paralleled the positive evolution of clinical signs. The active shampoo was well tolerated, subjects were highly satisfied and had an improved QoL.

CONCLUSION

The active shampoo significantly improved clinical signs, symptoms, and QoL of mild-to-moderate scalp psoriasis compared to the vehicle. It was very well tolerated and highly appreciated by the subjects.

Experiences and coping behaviours of patients with psoriasis: a qualitative study

BACKGROUND

Psoriasis is a complex, chronic, lifelong inflammatory skin disease characterized by the development of erythematous, indurated, scaly, pruritic and often painful skin plaques, and it is currently incurable. It profoundly affects psychological wellbeing and social functioning and has significant associated co-morbidities. To improve clinical approaches, understanding of the experiences of patients with psoriasis is needed.

OBJECTIVE

To explore the experiences and coping behaviours of patients with psoriasis.

METHODS

A qualitative study approach was conducted. Through semi-structured interviews, 20 patients with psoriasis were recruited from general practices and specialist dermatology practices in a regional teaching hospital in Taiwan. Recorded interviews were transcribed and analysed by content analysis.

RESULTS

Three themes and nine subthemes were identified: 1. Symptoms distress: (a) trouble with scaling, (b) bothersome itching, and (c) complex pain experiences; 2. Psychological distress: (a) encountering discrimination and (b) feeling stigmatised; 3. Managing psoriasis: (a) coping with symptoms, (b) seeking alternative methods, (c) using biologic agents, and (d) changing thinking and coexisting with the disease.

CONCLUSION

The experience of patients with psoriasis has significant negative impacts on their lives. The findings of this study can provide healthcare professionals with a reference for the care of patients with psoriasis.

COVID-19 vaccination in psoriasis patients receiving systemic treatment: A prospective single-center study

Background

The rate of seroconversion after COVID-19 vaccination in patients with moderate to severe psoriasis requiring systemic treatment is poorly understood.

Objectives

The aim of this prospective single-center cohort study performed between May 2020 and October 2021 was to determine the rate of seroconversion after COVID-19 vaccination in patients under active systemic treatment for moderate to severe psoriasis.

Methods

Inclusion criteria were systemic treatment for moderate to severe psoriasis, known COVID-19 vaccination status, and repetitive anti-SARS-CoV-2-S IgG serum quantification. The primary outcome was the rate of anti-SARS-CoV-2-S IgG seroconversion after complete COVID-19 vaccination.

Results

77 patients with a median age of 55.9 years undergoing systemic treatment for moderate to severe psoriasis were included. The majority of patients received interleukin- (n=50, 64.9%) or tumor necrosis factor (TNF)-α inhibitors (n=16, 20.8%) as systemic treatment for psoriasis; nine patients (11.7%) were treated with methotrexate (MTX) monotherapy, and one patient each received dimethyl fumarate (1.3%), respectively apremilast (1.3%). All included patients completed COVID-19 vaccination with two doses over the course of the study. Serum testing revealed that 74 patients (96.1%) showed an anti-SARS-CoV-2-S IgG seroconversion. While all patients on IL-17A, -12 or -12/23 inhibitors (n=50) achieved seroconversion, three of 16 patients (18.8%) receiving MTX and/or a TNF-α inhibitor as main anti-psoriatic treatment did not. At follow-up, none of the patients had developed symptomatic COVID-19 or died from COVID-19.

Conclusions

Anti-SARS-CoV-2-S IgG seroconversion rates following COVID-19 vaccination in psoriasis patients under systemic treatment were high. An impaired serological response, however, was observed in patients receiving MTX and/or TNF-α inhibitors, in particular infliximab.

Effectiveness of Long-Term Treatment with Brodalumab on Anxiety or Depressive Symptoms in Japanese Patients with Psoriasis: The ProLOGUE Study

INTRODUCTION

Evidence on treatment effectiveness in patients with psoriasis having anxiety or depressive symptoms helps shared decision-making. This single-arm, open-label, prospective study-ProLOGUE-was conducted to assess the effectiveness of brodalumab on self-assessed anxiety and depressive symptoms in Japanese patients with psoriasis.

METHODS

Patients aged ≥ 18 years with plaque psoriasis without peripheral arthritis symptoms who had responded inadequately to current therapies were enrolled at 15 Japanese facilities and received brodalumab 210 mg subcutaneously.

RESULTS

A total of 73 patients were enrolled (male, 82%; median age, 54 years). The proportion of patients without anxiety symptoms changed significantly from baseline (72.6%) to weeks 12 (88.9%, p = 0.008) and 48 (87.7%, p = 0.02); the proportion of patients without depressive symptoms did not change significantly. The Generalized Anxiety Disorder-7 score (median [quartile(Q)1-Q3], 1.0 [0.0-5.0] at baseline; 0.0 [0.0-2.0] at week 12, p = 0.008; and 0.0 [0.0-1.0] at week 48, p = 0.007) and Patient Health Questionnaire-8 score (median [Q1-Q3], 2.0 [0.0-4.0] at baseline; 1.0 [0.0-4.0] at week 12, p = 0.03; and 0.0 [0.0-2.0] at week 48, p = 0.004) significantly decreased after treatment. The median Psoriasis Area and Severity Index scores after treatment were < 1, irrespective of the presence of baseline anxiety or depressive symptoms. At week 12, the health-related quality of life was more impaired in patients with versus without baseline depressive symptoms, which largely resolved at week 48.

CONCLUSIONS

Brodalumab treatment resulted in the reduction of the levels of self-assessed anxiety and depressive symptoms in Japanese patients with psoriasis. Unlike anxiety symptoms, depressive symptoms did not resolve completely with brodalumab treatment. Patients with psoriasis having depressive symptoms may require long-term treatment.

TRIAL REGISTRATION

UMIN Clinical Trials Registry identifier: UMIN000027783, Japan Registry of Clinical Trials identifier: jRCTs031180037.

Mental health burden of patients with activity-limiting skin conditions: a national analysis

Cutaneous diseases are the fourth leading cause of nonfatal disease burden globally. In this study, we aimed to investigate the psychological symptom burden in patients with chronic activity-limiting cutaneous diseases. Our findings suggest that this patient population experience a wide range of interference with their daily lives and exhibit higher psychological burdens and lower quality of life. This study also identified that patients with activity-limiting skin conditions do not seem to seek more professional help or take more medications, which may suggest a potential gap in adequate mental health support and resources.

Patient-reported well-being in value-based care using tildrakizumab in a real-world setting: protocol of a multinational, phase IV, 1-cohort prospective observational study (the POSITIVE study)

INTRODUCTION

Psoriasis is a chronic inflammatory skin disease that negatively impacts the quality of life of patients and their families. However, the most commonly used decision-making tools in psoriasis, Psoriasis Area and Severity Index (PASI), Physician Global Assessment (PGA) and Dermatology Life Quality Index (DLQI), do not fully capture the impact of psoriasis on patients' lives. In contrast, the well-established 5-item WHO Well-being Index (WHO-5) assesses the subjective psychological well-being of patients. Moreover, while drug innovations became available for psoriasis, data on the impact of these therapies on patients' lives and their closest environment (family, physicians) are limited. This study will assess the effect of tildrakizumab, an interleukin-23p19 inhibitor, on the overall well-being of patients with moderate-to-severe psoriasis. Moreover, the long-term benefit of tildrakizumab on physicians' satisfaction and partners' lives of patients with psoriasis will be evaluated.

METHODS AND ANALYSIS

This non-interventional, prospective, observational, real-world evidence study will involve multiple sites in Europe and approximately 500 adults with moderate-to-severe psoriasis treated with tildrakizumab. Each patient will be followed for 24 months. The primary endpoint is well-being measured by the WHO-5 questionnaire. Key secondary endpoints include Physician's Satisfaction and partner's quality of life (FamilyPso). Other endpoints will evaluate skin-generic quality of life (DLQI-R), Treatment Satisfaction Questionnaire for Medication (TSQM-9), Treatment-related Patient Benefit Index 'Standard', 10 items (PBI-S-10) and work productivity and activity impairment due to psoriasis (WPAI:PSO). Statistical analyses will be based on observed cases. Multiple imputations will be performed as a sensitivity analysis, and adverse events will be reported.

ETHICS AND DISSEMINATION

The study will be conducted according to the protocol, which received ethics committee approval and applicable regulatory requirements of each participating country. The results will be disseminated through scientific publications and congress presentations.

TRAIL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT04823247 (Pre-results).

Resveratrol exerts anxiolytic-like effects through anti-inflammatory and antioxidant activities in rats exposed to chronic social isolation

Emerging evidence has confirmed resveratrol's (RES) antioxidant, anti-inflammatory, and antidepressant effects. The beneficial effects of RES were confirmed for several emotional and cognitive deficits. This research aimed to assess the impacts of RES on behavior and hippocampal levels of anti-inflammatory and pro-inflammatory factors in rats exposed to chronic social isolation (SI) stress, which is known to induce mental disorders such as depressive-like behavior. The animals were treated by RES (20, 40, or 80 mg/kg/intraperitoneally) for 28 days following a 28-day exposure to stress. Behavioral tests, including the forced swim test (FST), open-field test (OFT), tail suspension test (TST), and sucrose preference test (SPT), assessed depressive symptoms. Finally, the animals were sacrificed, and molecular studies (qPCR and ELISA) were performed. Exposure of animals to SI dramatically increased the immobility of animals in TST and FST, enhanced the time spent in the open-field peripheral zone of the OFT, and reduced the sucrose preference rate. In addition, SI increased serum levels of corticosterone and hippocampal content of MDA, whereas it reduced hippocampal SOD and CAT activities. Moreover, SI upregulated the expression of IL-10, IL-18, and IL-1β and downregulated the expression of TGF-β in the hippocampus. RES treatment (40 & 80 mg/kg) significantly improved the behavioral alterations through the modulation of neuroinflammation and oxidative stress. The 20 mg/kg RES dose was inefficient for treating SI-induced depressive-like behavior. These results indicated that RES attenuated depressive-like behavior in prolonged stressed animals. These properties might be associated with RES-mediated improvements in serum corticosterone and hippocampal inflammatory and oxidative stress biomarkers.

Severe Mental Illness Among Adults with Atopic Eczema or Psoriasis: Population-Based Matched Cohort Studies within UK Primary Care

Background

Existing research exploring associations between atopic eczema (AE) or psoriasis, and severe mental illness (SMI - ie, schizophrenia, bipolar disorder, other psychoses) is limited, with longitudinal evidence particularly scarce. Therefore, temporal directions of associations are unclear. We aimed to investigate associations between AE or psoriasis and incident SMI among adults.

Methods

We conducted matched cohort studies using primary care electronic health records (January 1997 to January 2020) from the UK Clinical Practice Research Datalink GOLD. We identified two cohorts: 1) adults (≥18 years) with and without AE and 2) adults with and without psoriasis. We matched (on age, sex, general practice) adults with AE or psoriasis with up to five adults without. We used Cox regression, stratified by matched set, to estimate hazard ratios (HRs) comparing incident SMI among adults with and without AE or psoriasis.

Results

We identified 1,023,232 adults with AE and 4,908,059 without, and 363,210 with psoriasis and 1,801,875 without. After adjusting for matching variables (age, sex, general practice) and potential confounders (deprivation, calendar period) both AE and psoriasis were associated with at least a 17% increased hazard of SMI (AE: HR=1.17,95% CI=1.12-1.22; psoriasis: HR=1.26,95% CI=1.18-1.35). After additionally adjusting for potential mediators (comorbidity burden, harmful alcohol use, smoking status, body mass index, and, in AE only, sleep problems and high-dose glucocorticoids), associations with SMI did not persist for AE (HR=0.98,95% CI=0.93-1.04), and were attenuated for psoriasis (HR=1.14,95% CI=1.05-1.23).

Conclusion

Our findings suggest adults with AE or psoriasis are at increased risk of SMI compared to matched comparators. After adjusting for potential mediators, associations with SMI did not persist for AE, and were attenuated for psoriasis, suggesting that the increased risk may be explained by mediating factors (eg, sleep problems). Our research highlights the importance of monitoring mental health in adults with AE or psoriasis.

AIM2 and Psoriasis

Psoriasis is a chronic inflammatory skin disease occurring worldwide, with multiple systemic complications, which seriously affect the quality of life and physical and mental health of patients. The pathogenesis of psoriasis is related to the environment, genetics, epigenetics, and dysregulation of immune cells such as T cells, dendritic cells (DCs), and nonimmune cells such as keratinocytes. Absent in melanoma 2 (AIM2), a susceptibility gene locus for psoriasis, has been strongly linked to the genetic and epigenetic aspects of psoriasis and increased in expression in psoriatic keratinocytes. AIM2 was found to be activated in an inflammasome-dependent way to release IL-1β and IL-18 to mediate inflammation, and to participate in immune regulation in psoriasis, or in an inflammasome-independent way by regulating the function of regulatory T(Treg) cells or programming cell death in keratinocytes as well as controlling the proliferative state of different cells. AIM2 may also play a role in the recurrence of psoriasis by trained immunity. In this review, we will elaborate on the characteristics of AIM2 and how AIM2 mediates the development of psoriasis.

Adverse events associated with anti-IL-17 agents for psoriasis and psoriatic arthritis: a systematic scoping review

Background

Anti-interleukin (IL)-17 biological agents (BAs) have significant efficacy in the treatment of psoriasis and psoriatic arthritis; however, adverse events (AEs) are common, and their safety has not been systematically evaluated.

Objectives

The purpose of this systematic review and meta-analysis was to summarize the number and corresponding rates of AEs caused by anti-IL-17 BAs in patients with psoriasis and psoriatic arthritis to improve clinical decision-making regarding their use.

Methods

PubMed, Embase, Cochrane Library, and Web of Science databases were independently searched by three authors for articles on the treatment of psoriasis with anti-IL-17 BAs that were published before March 1, 2022, and included at least one AE. Dichotomous variables and 95% confidence intervals (CI) were analyzed using R software (version 4.1.3) and the Meta and Metafor software packages. Funnel plots and meta-regression were used to test for the risk of bias, I² was used to assess the magnitude of heterogeneity, and subgroup analysis was used to reduce heterogeneity.

Results

A total of 57 studies involving 28,424 patients with psoriasis treated with anti-IL-17 BAs were included in the meta-analysis. Subgroup analysis showed that anti-IL-17A (73.48%) and anti-IL-17A/F (73.12%) BAs were more likely to cause AEs than anti-IL-17R BAs (65.66%). The incidence of AEs was as high as 72.70% with treatment durations longer than one year, and long-term use of medication had the potential to lead to mental disorders. Infection (33.16%), nasopharyngitis (13.74%), and injection site reactions (8.28%) were the most common AEs. Anti-IL-17 BAs were most likely to cause type α (33.52%) AEs. Type δ AEs (1.01%) were rarely observed.

Conclusions

Anti-IL-17 BAs used for the treatment of psoriasis and psoriatic arthritis caused a series of AEs, but the symptoms were generally mild.

Tryptanthrin ameliorates imiquimod-induced psoriasis in mice by suppressing inflammation and oxidative stress via NF-κB/MAPK/Nrf2 pathways

Nowadays, approximately 3% of the world's population suffers from psoriasis, an inflammatory dermatosis with high recurrence. Tryptanthrin (TRYP) is a natural alkaloid that possesses anti-inflammatory activities on multiple diseases. The present study aimed to unravel whether TRYP could relieve psoriasis and how it works. Imiquimod (IMQ)-induced psoriatic mouse models were administered saline (model), TRYP (25 and 100 mg/kg), or methotrexate (MTX, 1 mg/kg) and considered as the positive control. TNF-α-induced keratinocytes (HaCaT cells) with TRYP (0, 10, 20 and 50 nM) were used for in vitro verification. Psoriasis area severity index (PASI) and spleen index were evaluated. Th17 cell infiltration in both spleens and lymph nodes was detected by flow cytometry. The expression levels of inflammatory cytokines, glutathione (GSH), malondialdehyde (MDA) and catalase (CAT), as well as superoxide dismutase (SOD), were examined by ELISA, while the NF-κB/MAPK/Nrf2 pathways-related proteins were determined by western blot. TRYP significantly attenuated psoriatic skin lesions, increased GSH, SOD, and CAT levels, reduced spleen index, accumulation of MDA, the abundance of Th17 cells in both the spleen and lymph nodes, and secretion of inflammatory cytokines in IMQ-induced psoriatic mouse models. Mechanically, TRYP suppressed IMQ-activated NF-κB (IκB and p65), MAPK (JNK, ERK1/2, and p38), and activated Nrf2 signaling pathways. Similar alterations for inflammation and oxidative stress parameters and NF-κB/MAPK/Nrf2 pathways were also observed in TNF-α-treated HaCaT cells upon TRYP treatment. Our findings suggested TRYP is effective in protecting against inflammation and oxidative stress in psoriasis-like pathogenesis by modulating the NF-κB/MAPK/Nrf2 pathways.

The Impact of Psoriasis and Atopic Dermatitis on Quality of Life: A Literature Research on Biomarkers

Psoriasis (PSO) and Atopic dermatitis (AD) are common inflammatory skin diseases that affect people of all ages globally. They negatively impact the quality of life (QoL) of patients in health-related aspects such as physical, psychological and mental functioning. Here, we conducted a review of studies relating to candidate biomarkers and indicators associated with QoL impairment in PSO and AD. Data research was performed using PUBMED and SCOPUS databases from inception to September 2022. Most of the included studies reported genomic or proteomic biomarkers associated with disease activity and QoL outcomes. Sociodemographic, clinical and therapeutic factors have also been implicated in deterioration of life quality in these patients. The inclusion of clinical characteristics, QoL impairment and co-diagnosis should be considered in drug development programs, since processing biomarkers based on an increased number of features in addition to drug class and disease will intensify the value of the biomarker itself, thereby maximizing the future clinical utility as a stratification tool.

Aruncus dioicus var. kamtschaticus Extract Ameliorates Psoriasis-like Skin Inflammation via Akt/mTOR and JAK2/STAT3 Signaling Pathways in a Murine Model

Goat's beard (Aruncus dioicus var. kamtschaticus) is a traditional medicinal plant, widely used in Chinese and Korean traditional medicine because of its anti-inflammatory, anti-oxidant, antimicrobial, and anti-cancer activity. However, its effect on skin inflammatory diseases like psoriasis is unknown. The aim of this study was to investigate the therapeutic potency of A. dioicus extract (ADE) in in vitro and in vivo psoriasis models. ADE treatment significantly attenuated skin inflammation and improved skin integrity in imiquimod-treated mice by suppressing keratinocyte hyperproliferation, inhibiting the infiltration of immune cells, and downregulating the expression of psoriatic markers. Further, ADE treatment suppressed protein kinase B/mammalian target of rapamycin (Akt/mTOR) and Janus kinase 2/signal transducers and activators of transcription 3 (JAK2/STAT3) signaling in HaCaT cells. Overall, the application of ADE relieves psoriasis-like skin inflammation possibly by regulating the Akt/mTOR and JAK2/STAT3 signaling pathways, making it an effective alternative for psoriasis therapy.

Involvement of kynurenine pathway between inflammation and glutamate in the underlying etiopathology of CUMS-induced depression mouse model

Inflammation and glutamate (GLU) are widely thought to participate in the pathogenesis of depression, and current evidence suggests that the development of depression is associated with the activation of the kynurenine pathway (KP). However, the exact mechanism of KP among the inflammation, GLU and depression remain poorly understood. In this study, we examined the involvement of KP, inflammation and GLU in depressive phenotype induced by chronic unpredictable mild stress (CUMS) in C57B/6 J mice. Our results showed that CUMS caused depressive like-behavior in the sucrose preference test, tail suspension test and forced swimming test. From a molecular perspective, CUMS upregulated the peripheral and central inflammatory response and activated indoleamine 2,3-dioxygenase (IDO), the rate-limiting enzyme of KP, which converts tryptophan (TRP) into kynurenine (KYN). KYN is a precursor for QA in microglia, which could activate the N-methyl-D-aspartate receptor (NMDAR), increasing the GLU release, mirrored by increased IDO activity, quinolinic acid and GLU levels in the hippocampus, prefrontal cortex and serum. However, intervention with IDO inhibitor 1-methyl-DL-tryptophan (50 mg/kg/s.c.) and 1-methyl-L-tryptophan (15 mg/kg/i.p.) reversed the depressive-like behaviors and adjusted central and peripheral KP’s metabolisms levels as well as GLU content, but the inflammation levels were not completely affected. These results provide certain evidence that KP may be a vital pathway mediated by IDO linking inflammation and glutamate, contributing to depression.

Brain structure and connectivity in psoriasis and associations with depression and inflammation; findings from the UK biobank

Background

Psoriasis is a chronic systemic inflammatory skin disease, coexisting with depression in up to 25% of patients. Little is known about the drivers of comorbidity, including shared neurobiology and depression brain imaging patterns in patients. An immune-mediated crosstalk between the brain and skin has been hypothesized in psoriasis. With the aim of investigating brain structure and connectivity in psoriasis in relation to depression comorbidity, we conducted a brain imaging study including the largest psoriasis patient sample to date (to our knowledge) and the first to investigate the role of depression and systemic inflammation in brain measures. Effects of coexisting psoriatic arthritis (PsA), which represents joint involvement in psoriasis and a higher putative inflammatory state, were further explored.

Methods

Brain magnetic resonance imaging (MRI) data of 1,048 UK Biobank participants were used (131 comorbid patients with psoriasis and depression, age-and sex-matched to: 131 non-depressed psoriasis patients; 393 depressed controls; and 393 non-depressed controls). Interaction effects of psoriasis and depression on volume, thickness and surface of a-priori defined regions of interest (ROIs), white matter tracts and 55x55 partial correlation resting-state connectivity matrices were investigated using general linear models. Linear regression was employed to test associations of brain measures with C-reactive protein (CRP) and neutrophil counts.

Results

No differences in regional or global brain volumes or white matter integrity were found in patients with psoriasis compared to controls without psoriasis or PsA. Thickness in right precuneus was increased in psoriasis patients compared to controls, only when depression was present (β = 0.26, 95% CI [Confidence Intervals] 0.08, 0.44; p = 0.02). In further analysis, psoriasis patients who had PsA exhibited fronto-occipital decoupling in resting-state connectivity compared to patients without joint involvement (β = 0.39, 95% CI 0.13, 0.64; p = 0.005) and controls (β = 0.49, 95% CI 0.25, 0.74; p < 0.001), which was unrelated to depression comorbidity. Precuneus thickness and fronto-occipital connectivity were not predicted by CRP or neutrophil counts. Precuneus thickening among depressed psoriasis patients showed a marginal correlation with recurrent lifetime suicidality.

Conclusions

Our findings provide evidence for a combined effect of psoriasis and depression on the precuneus, which is not directly linked to systemic inflammation, and may relate to suicidality or altered somatosensory processing. The use of the UK Biobank may limit generalizability of results in populations with severe disease.

Abnormal functional connectivity in psoriasis patients with depression is associated with their clinical symptoms

Psoriasis is a chronic, autoimmune disorder that is related to mental health disorders such as depression. However, few studies have focused on the features of brain activity in psoriasis patients with depression (PPD) and the association between brain activity and disease severity. A total of 29 PPD and 24 healthy controls were involved in this study, and all participants underwent resting-state functional magnetic resonance imaging (fMRI) scanning. The psoriasis area and severity index (PASI) and the self-rating depression scale (SDS) were used to measure clinical symptoms. Compared with HCs, PPD patients showed increased fractional amplitude of low-frequency fluctuation (fALFF) in the Frontal_Mid_L and increased functional connectivity (FC) between the hypothalamus-R and the Cingulum_Mid_R. Correlation analysis suggested a positive correlation between PASI and SDS scores in PPD, while the fALFF and FC values were negatively correlated with their SDS and PASI scores. These brain regions may be associated with the development of depressive symptoms and disease severity in psoriasis patients.

OA11 Treatment challenges and co-morbidity issues in a patient with Arthritis Mutilans

Introduction/Background

Psoriatic arthritis mutilans is known to be the most severe form of psoriatic arthritis¹ and reported to have a prevalence of 2-21%², depending on the classification used. Clinical features include shortening of the digits, telescoping and flail joints with radiographs showing severe osteolysis and bone resorption³. There is an increased prevalence of metabolic syndrome, cardiovascular disease and psychiatric illness among these patients⁴. Treatment of the disease is usually a stepwise approach starting with conventional synthetic disease modifying anti-rheumatic drug (csDMARD), combination csDMARD, biologic DMARD (bDMARD) or targeted synthetic DMARD (tsDMARD).

Description/Method

This 65-year-old gentleman has a diagnosis of psoriatic arthritis, mutilans type for more than 40 years. His other current co-morbidities include hypertension, hyperlipidaemia and depression. He was treated with methotrexate with good efficacy until this was stopped in 2012. Whilst on methotrexate, he had deranged liver function tests and the ultrasound scan of his abdomen showed fatty infiltration of the liver. Liver biopsy showed steato-hepatitis which was thought to be secondary to methotrexate and the drug was stopped. He was then started on Sulphasalazine, which was uptitrated to 1.5 g twice a day but with no benefit. He was having 12 swollen and 8 tender joints with a patient global score of 6/10 and physician global score of 7/10.

The patient was started on Golimumab in August 2013. He had four doses of 50 mg and two doses of 100 mg of the drug. Each dose had resulted in severe headaches which necessitated discontinuation of the treatment. He was then commenced on Adalimumab in August 2014, which also resulted in severe headaches and sweating with no efficacy otherwise. At that point, his Alanine Transaminase (ALT) levels continued to be fluctuating between 50 to 80 U/L and he was also noted to be hypertensive.

The patient was then started on Ustekinumab in October 2016 to which he tolerated well and had almost immediate noticeable improvement in his tender and swollen joints. The patient remained stable on this three monthly treatment till this day.

Interestingly, the erosive changes on the x-rays of his hands and feet has not progressed since 2010, despite tolerance and efficacy challenges of his treatment.

Despite stability of his disease and treatment, this gentleman sadly attempted suicide in March 2021 by consuming weed killer. He was informally admitted to a mental health ward.

Discussion/Results

We present a case of psoriatic arthritis mutilans which was complicated by side effects and lack of efficacy of several disease modifying treatment. He had methotrexate which had to be stopped due to steato-hepatitis. Both Golimumab and Adalimumab was stopped due to side effects characterised by headaches. Ustekinumab was started four years following the cessation of methotrexate which continues to be the most effective medication for this patient.

This patient also suffers with cardiovascular co-morbidities and depression. Tumour necrosis factor (TNF)-α associated endothelial dysfunction as well as interleukin (IL)-17A associated increased expression of adhesion and pro-inflammatory molecules may contribute to the association of psoriatic arthritis mutilans with cardiovascular disease^5,6. It is also known that there is a higher prevalence of mental health disease in patients with psoriasis. This is thought to be due to the involvement of the same inflammatory pathway as proinflammatory IL-1 and IL-6 are increased in both psoriatic arthropathy and depression⁷.

Key learning points/Conclusion

Based on our research, there is a lack of evidence for treatment specific to arthritis mutilans, due to the relatively rare nature of the disease. However, this case report has proved that treatment should be individualised to the patient, based on their response and tolerance to the medications.

It is also pertinent to be aware and manage co-morbidities associated with the disease which includes hypertension, hyperlipidaemia, diabetes mellitus and psychiatric illnesses. This requires close collaboration with the patient’s general practitioner.

Impact of Comorbidities of Patients with Psoriasis on Phototherapy Responses

A retrospective study of 200 psoriasis patients and 100 healthy donors in a Spanish cohort was carried out to study the comorbidities associated with psoriasis and their association with the response to phototherapy. The results showed a higher incidence of psychiatric disease, liver disease, kidney disease, hypertension, heart disease, vascular disease, diabetes, gastrointestinal disease, autoimmune and infectious diseases, dyslipidemia, and psoriatic arthritis in patients with psoriasis than in the control group. The incidence of comorbidities was higher in psoriasis patients over 40 years old than in the control individuals of the same age, which could be indicative of premature aging. Phototherapy was seen to be an effective treatment in cases of moderate-severe psoriasis, total whitening being achieved in more than 30% of patients, with women showing a better response than men. Narrow-band ultraviolet B was found to be the most effective type of phototherapy, although achievement of PASI100 was lower in patients with liver disease, hypertension, heart disease, vascular disease, or diabetes. Strikingly, liver disease and anemia comorbidities favored therapeutic failure. Finally, zebrafish and human 3D organotypic models of psoriasis point to the therapeutic benefit of inhibiting the glucose transporter GLUT1 and the major regulator of blood glucose dipeptidyl peptidase 4. Our study reveals that specific comorbidities of psoriasis patients are associated to failure of phototherapy and, therefore, need to be considered when planning treatment for these patients.

Serum interleukin-23 levels: relation to depression, anxiety, and disease activity in psoriatic arthritis patients

Objectives

Assessment of serum levels of IL-23 in PsA patients and its correlation with depression, anxiety, and disease activity.

Methods

Eighty psoriatic arthritis (PsA) patients and eighty healthy volunteers matched for age and gender were included in this observational case–control study. All participants suspected to detailed history, clinical assessment, PsA activity using Disease Activity Index for Psoriatic Arthritis (DAPSA) score, the severity and extent of psoriasis was assessed by the Psoriasis Area and Severity Index (PASI), and ultrasonographic assessments of the entheses were examined according to the Madrid Sonographic Enthesitis Index (MASEI). Depression and anxiety were assessed by Hospital Anxiety and Depression Scale (HADS). Serum IL-23 was measured and correlated with disease activity, depression, and anxiety.

Results

There was no significant difference between patients and controls regarding demographic data. Thirty-six PsA patients (45%) had anxiety and 28 patients (35%) had depression, while in the control group, 16 persons (20%) had anxiety and 12 (15%) had depression, with significant differences between the 2 groups (p < 0.0001). There were significant differences in HADS anxiety and depression scores between patients and controls with significant positive correlations between HADS depression, anxiety scores and IL-23, DAPSA, PASI, and MASEI scores (p < 0.05). IL-23 was positively correlated with DAPSA, PASI, and HADS scores; we observed that interleukin 23, higher DAPSA, and PASI were independently associated with depression and anxiety.

Conclusion

Serum interleukin-23 levels were elevated in PsA patients and were found to be correlated with depression, anxiety, and disease activity.

Key Points • Psoriatic arthritis is a multidimensional disorder with psychiatric drawbacks. • Interleukin-23 is a proinflammatory cytokines that was correlated with depression and anxiety in PsA patients. • Interleukin-23 was correlated with disease activity in PsA. • Depression and anxiety were positively correlated with disease activity in PsA.

Comorbidity in Adult Psoriasis: Considerations for the Clinician

Psoriasis is associated with several comorbidities ranging from cardiovascular comorbidity and mental disorders to other immune mediated inflammatory diseases. However, most of these co-morbidities are often overlooked or diagnosed late. Furthermore, evidence suggests that comorbidities are undertreated. Here, we provide an overview of comorbidities in psoriasis and present a simple rundown of considerations of relevance to the clinician. We hope that this review may raise clinicians' awareness of comorbidities in psoriasis and provide simple guidance regarding screening tools and treatment decisions in psoriasis with comorbidities.

Zugang und Inanspruchnahme psychosomatischer Versorgung aus ärztlicher Sicht: Eine qualitative Interviewstudie

Hintergrund Chronisch entzündliche Hauterkrankungen sind häufig mit psychosozialen Beeinträchtigungen und einer reduzierten Lebensqualität vergesellschaftet. Ziel dieser Studie war es zu erfassen, wie spezialisiertes medizinisches Personal eines universitären Haut-Entzündungszentrums die Zugangswege und die Inanspruchnahme psychosomatischer Sondierungsgespräche oder Kurzzeitinterventionen bei PatientInnen mit chronisch entzündlichen Hauterkrankungen wahrnimmt.

Methoden Es wurden qualitative Erhebungen in Form von 10 Einzelinterviews mit medizinischem Personal durchgeführt, das zum Zeitpunkt der Befragung im Zentrum für entzündliche Hauterkrankungen der Uni-Hautklinik tätig war. Die Daten wurden inhaltsanalytisch mithilfe einer qualitativen Analysesoftware ausgewertet.

Ergebnisse Die Ergebnisse aus den geführten Einzelinterviews ergaben, dass die Einbindung einer psychosomatischen Versorgung innerhalb eines dermatologischen Entzündungszentrums vom ärztlichen Personal als durchweg positiv bewertet wurde. Die Option auf ein zeit- und zentrumsnahes Gesprächsangebot nimmt dabei eine besondere Rolle ein. Experten fühlen sich mit der ortsnahen Einbindung psychosomatischer Expertise sicherer im Umgang mit belasteten Patient*innen. Der holistische Ansatz scheint einen positiven Einfluss auf die individuelle Behandlung und die Beziehungsgestaltung mit den Patient*innen zu nehmen. Dabei zeigten sich keine wesentlichen Unterschiede im Geschlecht und über verschiedene Altersgruppen hinweg.

Diskussion Die Möglichkeit zur zentrumsnahen Anbindung von belasteten Patient*innen in Form von zusätzlichen psychosomatischen Sondierungsgesprächen wie auch dem Einsatz von adaptierten Kurzzeitinterventionen trägt zur holistischen Behandlung bei, scheint einen günstigen Einfluss auf den somatischen Behandlungsverlauf zu nehmen und unterstützt Ärzt*innen in ihrer Behandlung.

[Translated article] Practical Update of the Guidelines Published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPs) on the Treatment of Psoriasis With Biologic Agents: Part 2-Management of Special Populations, Patients With Comorbid Conditions, and Risk

BACKGROUND AND OBJECTIVES

Since its inception, the Psoriasis Group (GPs) of the Spanish Academy of Dermatology and Venereology (AEDV) has worked to continuously update recommendations for the treatment of psoriasis based on the best available evidence and incorporating proposals arising from and aimed at clinical practice. An updated GPs consensus document on the treatment of moderate to severe psoriasis was needed because of changes in the treatment paradigm and the approval in recent years of a large number of new biologic agents.

METHODOLOGY

The consensus document was developed using the nominal group technique complemented by a scoping review. First, a designated coordinator selected a group of GPs members for the panel based on their experience and knowledge of psoriasis. The coordinator defined the objectives and key points for the document and, with the help of a documentalist, conducted a scoping review of articles in Medline, Embase, and the Cochrane Library up to January 2021. The review included systematic reviews and meta-analyses as well as clinical trials not included in those studies and high-quality real-world studies. National and international clinical practice guidelines and consensus documents on the management of moderate to severe psoriasis were also reviewed. The coordinator then drew up a set of proposed recommendations, which were discussed and modified in a nominal group meeting. After several review processes, including external review by other GPs members, the final document was drafted.

RESULTS

The present guidelines include updated recommendations on assessing the severity of psoriasis and criteria for the indication of systemic treatment. They also include general principles for the treatment of patients with moderate to severe psoriasis and define treatment goals for these patients as well as criteria for the indication and selection of initial and subsequent therapies Practical issues, such as treatment failure and maintenance of response, are also addressed.

Cognitive Functions Associated with Brain Imaging Markers in Patients with Psoriasis

Psoriasis is a severe inflammatory disease associated with a higher comorbidity of depression, cognitive dysfunction and brain atrophy. The association between psoriasis, magnetic resonance imaging (MRI) markers and cognitive impairment has rarely been investigated, and the existing results are conflicting. Methods. This study included 89 subjects (53 patients with psoriasis and 36 healthy controls). The severity of psoriasis was evaluated using the Psoriasis Area and Severity Index (PASI) score; for depression, the Hospital Anxiety and Depression Scale (HADS) scale was used. Neuropsychological tests were also applied, including a Trail Making Test (TMT) as well as Digit Span, Stroop, Verbal Fluency and Rey Auditory Verbal Learning tests. MRI scans were performed using a 1.5 T scanner. Brain volumetry, white matter lesions, grey matter and white matter were evaluated. The extent of these changes was assessed on the Fazekas scale. The differences between groups were evaluated using a Student’s t-test and a Mann-Whitney U test, and a Pearson correlation analysis was also performed. Results. Patients with psoriasis presented worse achievements on all the neuropsychological tests and showed more intense changes on MRI compared to healthy controls. The severity of psoriasis as determined by PASI scores was associated with depression, and a greater psychomotor slowness severity of changes in the brain was associated with poorer results on the neurological tests. Conclusions. Our results indicate the possibility of progressive brain atrophy related to cognitive decline in psoriasis.

Sodium Benzoate—Harmfulness and Potential Use in Therapies for Disorders Related to the Nervous System: A Review

Currently, due to the large number of reports regarding the harmfulness of food additives, more and more consumers follow the so-called “clean label” trend, i.e., prefer and choose the least-processed food products. One of the compounds known as a preservative with a high safety profile is sodium benzoate. While some studies show that it can be used to treat conditions such as depression, pain, schizophrenia, autism spectrum disorders, and neurodegenerative diseases, others report its harmfulness. For example, it was found to cause mutagenic effects, generate oxidative stress, disrupt hormones, and reduce fertility. Due to such disparate results, the purpose of this study is to comprehensively discuss the safety profile of sodium benzoate and its potential use in neurodegenerative diseases, especially in autism spectrum disorder (ASD), schizophrenia, major depressive disorder (MDD), and pain relief.

A Multivariate Analysis of Depression Prevalence in Psoriasis Patients: A Cohort Study

The literature reported higher depression rates in psoriasis patients compared to the general population. Our study aimed to verify whether variability in depression prevalence was due to using different diagnostic tools. We also aimed to determine whether dysfunctional coping strategies might increase the depression burden. We assessed psoriasis severity by the Psoriasis Area Severity Index (PASI) and PSOdisk. We analyzed mental alterations of 120 outpatients by Hamilton Depression and Anxiety Rating Scales (HAM-D and HAM-A), Symptom Checklist-90-Revised (SCL-90-R), plus coping strategies and quality of life by Coping Orientation to Problems Experienced (COPE) Inventory and 36-Item Short Form Health Survey (SF-36). We divided our cohort into five subgroups from minimal to severe psoriasis using the PSOdisk total score. Depression prevalence varied according to the assessment criteria for specificity, frequency, and severity. Different mood disorders other than major depression emerged when we used DSM-IV-TR criteria. Correlation analysis of the criteria we used to diagnose depression or depressed mood indicated that a dysfunctional coping strategy was highly and positively correlated only in patients of the severe subgroup. Differently, a negative correlation emerged between the SF-36 Mental Summary Component (MSC) and behavioral disengagement, thus suggesting that psychopathological distress might induce patients with a marked/severe psoriasis to adopt dysfunctional coping strategies. Dermatologists are fundamental in detecting comorbid depression, referring psoriasis patients to mental health specialists to achieve adequate treatments, and preventing suicide risk.

Oridonin Alleviates LPS-Induced Depression by Inhibiting NLRP3 Inflammasome via Activation of Autophagy

Objective: Oridonin (Ori) is a diterpene compound that has multiple biological properties. Here, our study was conducted to observe the therapeutic effect of Ori on depression as well as to uncover the mechanism.

Methods: Lipopolysaccharide (LPS)-induced depression models were established both in C57BL/6 mice and primary astrocytes, which were treated with Ori, autophagy agonist Rapamycin (Rap) and autophagy inhibitor 3-Methyladenine (3-MA). The depressive-like behaviors were assessed with behavioral tests. Autophagy was evaluated in the hippocampus and astrocytes by investigating autophagosomes under transmission electron microscope (TEM) and detecting LC3II/I, Beclin1 and P62 through western blotting. Astrocyte marker glial fibrillary acidic protein (GFAP) was investigated by immunofluorescence. NLRP3 inflammasome activation was evaluated by detecting IL-1β, NLRP3, ASC and Caspase-1 expression and reactive oxygen species (ROS) accumulation was quantified via DCFH-DA probe. Autolysosomes, autophagosomes and mitophagy were separately observed through mTag-Wasabi-LC3 plasmid, MitoTracker Deep Red staining, and TEM.

Results: Our results showed that Ori administration alleviated LPS-induced depressive-like behaviors and increased GFAP expression in the hippocampus. Furthermore, Ori treatment promoted autophagy activation and cell viability as well as weakened NLRP3 inflammasome activation and ROS accumulation both in LPS-induced mice and astrocytes. Ori promoted the autophagic flux unblocked through enhancing fusion of autophagosomes with lysosomes as well as enhanced mitophagy in LPS-treated astrocytes. The therapeutic effect of Ori was enhanced by Rap and weakened by 3-MA.

Conclusion: Collectively, our findings provided a promising antidepressant drug and uncovered that Ori alleviated LPS-induced depression by inhibiting NLRP3 inflammasome through activation of autophagy.

Three-Dimensional Skin CT Based on Intelligent Algorithm in the Analysis of Skin Lesion Sites Features in Children with Psoriasis

This research was to explore the application value of three-dimensional computed tomography (CT) based on artificial intelligent algorithm in analyzing the characteristics of skin lesions in children with psoriasis. In this study, 15 children with psoriasis were selected as the observation group, and 15 children with other skin diseases were selected as the control group. The CT images were optimized, and the feature selection was carried out based on artificial intelligent algorithm. Firstly, the results were compared with the results of simple skin three-dimensional CT to determine the effectiveness. Then, the two groups of three-dimensional skin CT image features of skin psoriasis-like hyperplasia, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium based on intelligent algorithms were compared. After comparison, the detection rate of psoriasis-like hyperplasia, Munro microabscess, dermal papillary vascular dilation, and squamous epithelium in the observation group was higher than that in the control group, with significant difference and statistical significance (P < 0.05). In addition, the sensitivity of psoriasis-like hyperplasia, Munro microabscess, dermal papilla vascular dilatation, and squamous epithelium in children with psoriasis was 80.0%, 86.7%, 80.0%, and 93.3%, respectively. The specificity of psoriasis-like hyperplasia, Munro microabscess, dermal papilla vascular dilatation, and squamous epithelium in children with psoriasis was 86.7%, 93.3%, 60.0%, and 73.3%, respectively. The results showed that Munro microabscess and psoriasis-like hyperplasia had high sensitivity and specificity in all diagnostic items, which could be used as important features of skin lesion sites in the diagnosis of psoriasis in children. The research provides a basis for the clinical diagnosis of psoriasis in children, which is worthy of clinical promotion.

Relationship between patient acceptable symptom state and disease scores in psoriasis

Patient acceptable symptom state (PASS) is a patient-reported outcome that reflects patients' perspective well. The relationship between the PASS and disease scores in psoriasis has not been described. The aim of the present study was to investigate the association of PASS with Psoriasis Area and Severity Index (PASI) and body surface area (BSA) affected by lesions in patients with psoriasis. A sectional study was conducted. PASS was evaluated by a binary question on the patient's feeling that they have about their symptoms. Clinical data including PASI, BSA, and other patient characteristics were collected. Logistic regression was used to investigate the associations. Receiver-operator curve (ROC) analysis was utilized to determine the PASI/BSA thresholds for PASS. A total of 198 participants (27.8% female, mean age 41.9 ± 12.6 years, mean disease duration 10.2 ± 8.6 years) completed this study. Of patients with mild psoriasis, 71.4% based on PASI and 76.3% based on BSA considered their symptom state acceptable. Female sex (adjusted odds ratio [OR] = 0.47; 95% confidence interval [CI = 0.42-0.92) and patients with exposed skin involved (adjusted OR = 0.38; 95% CI = 0.19-0.76) were less likely to report acceptable symptom state. The threshold for differentiating psoriasis patients in PASS was 3.85 (area under the curve [AUC], 0.67; sensitivity, 0.67; specificity, 0.60) for PASI and 2.85% (AUC, 0.66; sensitivity, 0.79; specificity, 0.54) for BSA, respectively. These results showed that mild psoriasis based on PASI/BSA score align well with PASS status. Female and exposed skin involved are risk factors for acceptable status. Both PASI and BSA have limited capability in differentiating acceptable symptom state in psoriasis.

The Brain-Skin Axis in Psoriasis-Psychological, Psychiatric, Hormonal, and Dermatological Aspects

Psoriasis is a chronic inflammatory skin disease with systemic manifestation, in which psychological factors play an important role. The etiology of psoriasis is complex and multifactorial, including genetic background and environmental factors such as emotional or physical stress. Psychological stress may also play a role in exacerbation of psoriasis, by dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis, sympathetic–adrenal–medullary axis, peripheral nervous system, and immune system. Skin cells also express various neuropeptides and hormones in response to stress, including the fully functional analog of the HPA axis. The deterioration of psoriatic lesions is accompanied by increased production of inflammatory mediators, which could contribute to the imbalance of neurotransmitters and the development of symptoms of depression and anxiety. Therefore, deregulation of the crosstalk between endocrine, paracrine, and autocrine stress signaling pathways contributes to clinical manifestations of psoriasis, which requires multidisciplinary approaches.

The Global, Regional, and National Burden of Psoriasis: Results and Insights From the Global Burden of Disease 2019 Study

Background: Psoriasis is a common, chronic, inflammatory, debilitating, systemic disease with a great impact on healthcare systems worldwide. As targeted therapies have transformed the therapeutic landscape, updated estimates of the Global Burden of Disease (GBD) imposed by psoriasis are necessary in order to evaluate the effects of past health care policies and to orient and inform new national and international healthcare strategies. Methods: Data were extracted from the GBD 2019 study, which collates a systematic review of relevant scientific literature, national surveys, claims data, and primary care sources on the prevalence of psoriasis. Prevalence data were combined with disability weight (DW) to yield years lived with disability (YLDs). Measures of burden at global, regional, and national levels were generated for incidence, prevalence, and YLDs, due to psoriatic disease. All measures were reported as absolute numbers, percentages, and crude and age-adjusted rates per 100,000 persons. In addition, psoriasis burden was assessed by socio-demographic index (SDI). Findings: According to the GBD 2019 methodology, there were 4,622,594 (95% uncertainty interval or UI 4,458,904-4,780,771) incident cases of psoriasis worldwide in 2019. The age-standardized incidence rate in 2019 was 57.8 (95% UI 55.8-59.7) per 100,000 people. With respect to 1990, this corresponded to a decrease of 20.0% (95% UI -20.2 to -19.8). By sex, the age-standardized incidence rate was similar between men [57.8 (95% UI 55.8-59.8) per 100,000 people] and women [(57.8 (95% UI 55.8-59.7) per 100,000 people]. With respect to 1990, this corresponded to a decrease by 19.5% (95% UI -19.8 to -19.2) and by 20.4% (95% UI -20.7 to -20.2) for men and women, respectively. The age-standardized incidence rate per 100,000 persons was found to vary widely across geographic locations. Regionally, high-income countries and territories had the highest age-standardized incidence rate of psoriasis [112.6 (95% UI 108.9-116.1)], followed by high-middle SDI countries [69.4 (95% UI 67.1-71.9)], while low SDI countries reported the lowest rate [38.1 (95% UI 36.8-39.5)]. Similar trends were detected for prevalence and YLDs. Conclusion: In general, psoriasis burden is greatest in the age group of 60-69 years, with a relatively similar burden among men and women. The burden is disproportionately greater in high-income and high SDI index countries of North America and Europe. With advances in psoriasis therapeutics, objective evaluation of psoriasis disease burden is critical to track the progress at the population level.

The Role of Interleukins in the Pathogenesis of Dermatological Immune-Mediated Diseases

Autoimmune inflammatory diseases are primarily characterized by deregulated expression of cytokines, which drive pathogenesis of these diseases. A number of approved and experimental therapies utilize monoclonal antibodies against cytokine proteins. Cytokines can be classified into different families including the interleukins, which are secreted and act on leukocytes, the tumor necrosis factor (TNF) family, as well as chemokine proteins. In this review article, we focus on the interleukin family of cytokines, of which 39 members have been identified to this date. We outline the role of each of these interleukins in the immune system, and various dermatological inflammatory diseases with a focused discussion on the pathogenesis of psoriasis and atopic dermatitis. In addition, we describe the roles of various interleukins in psychiatric, cardiovascular, and gastrointestinal comorbidities. Finally, we review clinical efficacy and safety data from emerging late-phase anti-interleukin therapies under development for psoriasis and atopic dermatitis. Collectively, additional fundamental and clinical research remains necessary to fully elucidate the roles of various interleukin proteins in the pathogenesis of inflammatory dermatologic diseases, and treatment outcomes in patients.

Common Fundamentals of Psoriasis and Depression

Psoriasis is an inflammatory, immune-mediated disease that is frequently associated with psychological comorbidities such as depression. The stigma patients feel because of the appearance of their skin may contribute to the high psycho-social burden of psoriasis. However, there is emerging evidence that overlapping biological mechanisms are, to a substantial degree, responsible for the close interaction between psoriasis and depression. Increased proinflammatory mediators, such as C-reactive protein or interleukin-6, are present in both psoriasis and depression, indicating that inflammation may represent a pathophysiological link between the diseases. Anti-inflammatory biologic therapies treat the clinical manifestations of psoriasis, but might also play a significant role in reducing associated depressive symptoms in patients with psoriasis. Comparison between single studies focusing on the change in depressive symptoms in psoriasis is limited by inconsistency in the depression screening tools applied.

The Effects of Vitamin D on the Expression of IL-33 and Its Receptor ST2 in Skin Cells; Potential Implication for Psoriasis

Interleukin 33 (IL-33) belongs to the IL-1 family and is produced constitutively by epithelial and endothelial cells of various organs, such as the skin. It takes part in the maintenance of tissue homeostasis, repair, and immune response, including activation of Th2 lymphocytes. Its involvement in pathogenesis of several inflammatory diseases including psoriasis was also suggested, but this is not fully understood. The aim of the study was to investigate expression of IL-33 and its receptor, ST2, in psoriasis, and the effects of the active form of vitamin D (1,25(OH)₂D₃) on their expression in skin cells. Here we examined mRNA and protein profiles of IL-33 and ST2 in 18 psoriatic patients and healthy volunteers by qPCR and immunostaining techniques. Potential effects of 1,25(OH)₂D₃ and its receptor (VDR) on the expression of IL-33 and ST2 were tested in cultured keratinocytes, melanocytes, fibroblasts, and basal cell carcinoma cells. It was shown that 1,25(OH)₂D₃ effectively stimulated expression of IL-33 and its receptor ST2’s mRNAs in a time-dependent manner, in keratinocytes and to the lesser extends in melanocytes, but not in fibroblasts. Furthermore, the effect of vitamin D on expression of IL-33 and ST2 was VDR-dependent. Finally, we demonstrated that the expression of mRNA for IL-33 was mainly elevated in the psoriatic skin but not in its margin. Interestingly, ST2 mRNA was downregulated in psoriatic lesion compared to both marginal tissue as well as healthy skin. Our data indicated that vitamin D can modulate IL-33 signaling, opening up new perspectives for our understanding of the mechanism of vitamin D action in psoriasis therapy.