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Bhatia N, Heim J, Vasquez JG, Bhutani T, Schenkel B, Gogineni R, Koo J. Long-term quality of life outcomes from a phase 4 study of tildrakizumab in patients with moderate-to-severe plaque psoriasis in a real-world setting. J DERMATOL TREAT 2024; 35:2310631. [PMID: 39038815 DOI: 10.1080/09546634.2024.2310631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/12/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Tildrakizumab is an anti-interleukin-23 p19 monoclonal antibody approved for the treatment of moderate-to-severe plaque psoriasis. This report describes final primary results of a 64-week real-world study of the effect of tildrakizumab on patients' health-related quality of life (HRQoL). MATERIALS AND METHODS In this open-label phase 4 study (NCT03718299), patients with moderate-to-severe plaque psoriasis received tildrakizumab 100 mg at week 0, week 4, and every 12 weeks thereafter through week 52. The primary endpoint was improvement from baseline in HRQoL measured by Psychological General Well-Being Index (PGWBI) total score at weeks 28 and 52. Secondary HRQoL endpoints included change from baseline in Dermatology Life Quality Index (DLQI) score through week 64. Missing data were not imputed. RESULTS Of 55 patients enrolled, 45 were assessed at week 64. Mean ± standard deviation (SD) total PGWBI score improved from 78.1 ± 14.1 at baseline to 85.2 ± 12.0 at week 52 (p < .001). Mean ± SD DLQI score improved from 9.4 ± 5.2 at baseline to 2.0 ± 2.6 (p < .001) at week 64 with 62.2% of patients having a DLQI score of 0 or 1 at week 64. CONCLUSIONS Tildrakizumab improved long-term HRQoL in patients with psoriasis in a real-world setting.
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Affiliation(s)
- Neal Bhatia
- Therapeutics Clinical Research, San Diego, CA, USA
| | - Jayme Heim
- West Michigan Dermatology, Grandville, MI, USA
| | | | - Tina Bhutani
- University of California San Francisco Health, San Francisco, CA, USA
| | - Brad Schenkel
- Sun Pharmaceutical Industries, Inc., Princeton, NJ, USA
| | | | - John Koo
- University of California San Francisco Health, San Francisco, CA, USA
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Burlando M, Salvi I, Parodi A, Cozzani E. A 3-Year Experience with Tildrakizumab Treatment for Patients with Plaque Psoriasis in Clinical Practice. Dermatol Ther (Heidelb) 2024:10.1007/s13555-024-01252-7. [PMID: 39192037 DOI: 10.1007/s13555-024-01252-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Accepted: 08/05/2024] [Indexed: 08/29/2024] Open
Abstract
INTRODUCTION The efficacy and safety of tildrakizumab for the treatment of plaque psoriasis were demonstrated by randomized clinical studies, but the reappraisal of prolonged experiences in the clinical practice helps to optimize the use of this biologic drug. The aim of this study was to evaluate the long-term efficacy of tildrakizumab in patients with moderate-to-severe psoriasis in the real world. METHODS This is a long-term retrospective observational study in a real-life setting. Overall, 136 adult patients with moderate-to-severe plaque psoriasis and treated with tildrakizumab were included. RESULTS One hundred percent reduction of Psoriasis Area Severity Index (PASI100) was reached by 21.7% of patients at 4 weeks of therapy and by 51.2% at week 16, and the proportion of patients with this improvement was between 66.9% and 64.5% from 36 weeks to 3 years. The mean PASI of the cohort progressively improved from 12.6 at baseline to 1.8 at week 36 and was stable at 1 year, 2 years and 3 years. We could not confirm a previous observation that patients naïve to biologic had a better response, but we observed that those with a short history of psoriasis had a higher probability of 90% PASI reduction (PASI90) or PASI 100 within 36 weeks, suggesting that early treatment could be useful. CONCLUSION This long-term observation in the real life of patients with moderate-to-severe plaque psoriasis receiving tildrakizumab 100 mg showed that PASI100 can be obtained in a high proportion of patients by week 36 and be maintained for up to 3 years.
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Affiliation(s)
- Martina Burlando
- Division of Dermatology, Department of Health Sciences-DISSAL, University of Genoa, Genoa, Italy.
- IRCCS Policlinic Hospital San Martino, Largo Rosanna Benzi X, 16132, Genoa, Italy.
| | - Ilaria Salvi
- Division of Dermatology, Department of Health Sciences-DISSAL, University of Genoa, Genoa, Italy
- IRCCS Policlinic Hospital San Martino, Largo Rosanna Benzi X, 16132, Genoa, Italy
| | - Aurora Parodi
- Division of Dermatology, Department of Health Sciences-DISSAL, University of Genoa, Genoa, Italy
- IRCCS Policlinic Hospital San Martino, Largo Rosanna Benzi X, 16132, Genoa, Italy
| | - Emanuele Cozzani
- Division of Dermatology, Department of Health Sciences-DISSAL, University of Genoa, Genoa, Italy
- IRCCS Policlinic Hospital San Martino, Largo Rosanna Benzi X, 16132, Genoa, Italy
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Mansilla-Polo M, Morgado-Carrasco D. Biologics Versus JAK Inhibitors. Part II: Risk of Infections. A Narrative Review. Dermatol Ther (Heidelb) 2024; 14:1983-2038. [PMID: 39014279 PMCID: PMC11333430 DOI: 10.1007/s13555-024-01203-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 05/30/2024] [Indexed: 07/18/2024] Open
Abstract
INTRODUCTION The risk of infections associated with biological drugs (BD) and Janus kinase inhibitors (JAKi) has been extensively explored in the literature. However, there is a dearth of studies that evaluate both pharmacological groups together and, furthermore, compare them. Here, we review the risk of infections associated with BD and JAKi used in dermatology. METHODS A narrative review was performed. All relevant articles evaluating the risk of infection and opportunistic infections with BD and JAKi between January 2010 and February 2024 were selected. RESULTS Overall, the incidence of infections, serious infections, and opportunistic infections associated with BD and JAKi is low, but higher than in the general population. JAKi approved for dermatological disorders (abrocitinib, baricitinib, deucravacitinib, upadacitinib, ritlecitinib, and topical ruxolitinib) have been shown to be safe, and present a low rate of infections. We found an elevated risk, especially with anti-tumor necrosis factor (anti-TNF) agents, rituximab, and JAKi (particularly tofacitinib at high doses). Specific associations with infections include tuberculosis and tuberculosis reactivation with anti-TNF agents and tocilizumab; candidiasis with anti-interleukin (IL) 17 agents; hepatitis B virus reactivation with rituximab, anti-TNF, and JAKi; and herpes simplex and herpes zoster infections with JAKi (especially tofacitinib and upadacitinib at high doses). The incidence of infections with ustekinumab and anti-IL-23 was very low. Anti-IL-1, nemolizumab, tralokinumab, and omalizumab were not associated with an increased risk of infections. Dupilumab could decrease the incidence of cutaneous infections. CONCLUSIONS Anti-TNF agents, rituximab, and JAKi (particularly tofacitinib) can increase the risk of infections. Close monitoring of patients undergoing these therapies is recommended. Prospective studies with long-term follow-up are needed to comparatively evaluate the risks of infection deriving from treatment with BD and JAKi.
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Affiliation(s)
- Miguel Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria (IIS) La Fe, Valencia, Spain
- Department of Dermatology, Faculty of Medicine, Universitat de València, Valencia, Spain
| | - Daniel Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain.
- Department of Dermatology, Hospital de Figueres, Fundació Alt Empurdà, Gerona, Spain.
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Gebauer K, Spelman L, Yamauchi PS, Bagel J, Nishandar T, Crane M, Kopeloff I, Kothekar M, Yao SL, Sofen HL. Efficacy and safety of tildrakizumab for the treatment of moderate-to-severe plaque psoriasis of the scalp: A multicenter, randomized, double-blind, placebo-controlled, Phase 3b study. J Am Acad Dermatol 2024; 91:91-99. [PMID: 38554938 DOI: 10.1016/j.jaad.2024.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/27/2024] [Accepted: 03/10/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Scalp psoriasis is common and difficult to treat. OBJECTIVE To evaluate efficacy and safety of tildrakizumab for the treatment of scalp psoriasis. METHODS In this Phase 3b, randomized, double-blind, placebo (PBO)-controlled study (NCT03897088), patients with moderate-to-severe plaque psoriasis affecting the scalp (Investigator Global Assessment modified [IGA mod] 2011 [scalp] ≥3, Psoriasis Scalp Severity Index [PSSI] ≥12, ≥30% scalp surface area affected) received tildrakizumab 100 mg or PBO at W0 and W4. The primary endpoint was IGA mod 2011 (scalp) score of "clear" or "almost clear" with ≥2-point reduction from baseline at W16 (IGA mod 2011 [scalp] response). Key secondary endpoints were PSSI 90 response at W12 and W16 and IGA mod 2011 (scalp) response at W12. Safety was assessed from adverse events. RESULTS Of patients treated with tildrakizumab (n = 89) vs PBO (n = 82), 49.4% vs 7.3% achieved IGA mod 2011 (scalp) response at W16 (primary endpoint) and 46.1% vs 4.9% at W12; 60.7% vs 4.9% achieved PSSI 90 response at W16 and 48.3% vs 2.4% at W12 (all P < .00001). No serious treatment-related adverse events occurred. LIMITATIONS Only short-term data are presented. CONCLUSION Tildrakizumab was efficacious for the treatment of scalp psoriasis with no new safety signals.
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Affiliation(s)
- Kurt Gebauer
- Fremantle Dermatology, Fremantle, WA, Australia; Probity Medical Research, Waterloo, Ontario, Canada.
| | - Lynda Spelman
- Veracity Clinical Research, Brisbane, QLD, Australia; Probity Medical Research, Woolloongabba, QLD, Australia
| | - Paul S Yamauchi
- David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jerry Bagel
- Psoriasis Treatment Center of Central New Jersey, East Windsor, New Jersey
| | | | - Michael Crane
- Sun Pharmaceutical Industries, Inc., Princeton, New Jersey
| | - Iris Kopeloff
- Sun Pharmaceutical Industries, Inc., Princeton, New Jersey
| | | | - Siu-Long Yao
- Sun Pharmaceutical Industries, Inc., Princeton, New Jersey
| | - Howard L Sofen
- David Geffen School of Medicine at UCLA, Los Angeles, California
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Melgosa Ramos FJ, Mateu Puchades A, Matáix-Díaz J, Schneller-Pavelescu L, Belinchón-Romero I, Santos Alarcón S. 52-Week Mid-term Efficacy of Tildrakizumab in Moderate-to-severe Psoriasis: A Real-life Multicenter Experience. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:722-726. [PMID: 38556201 DOI: 10.1016/j.ad.2023.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/29/2023] [Accepted: 08/08/2023] [Indexed: 04/02/2024] Open
Abstract
Tildrakizumab is an IL-23-inhibitor that has been approved to treat plaque psoriasis. However, few reports have become available on its efficacy profile in the real-world. Our objective was to study the mid-term efficacy of tildrakizumab in patients with moderate-to-severe psoriasis in the Spanish routine clinical practice setting. This was a retrospective multicenter study that included a total of 91 psoriatic patients on tildrakizumab. The mean Psoriasis Area and Severity Index (PASI) was 9.09 (SD, 5.30). The overall tildrakizumab survival rate was 93.47% for a mean treatment exposure of 30.18 weeks (SD, 16.57). No drug discontinuation was associated with drug tolerability, or adverse reactions. Absolute PASI ≤3 was reached by 91.3% and 96.5% of the patients on weeks 28 and 52, respectively. Response was not impacted by weight, age (>65), metabolic syndrome, presence of arthritis, or previous number of biological therapies used. Based on our own experience tildrakizumab is an effective strategy to treat plaque psoriasis and difficult-to-treat-areas.
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Affiliation(s)
- F J Melgosa Ramos
- Department of Dermatology, University Hospital Doctor Peset of Valencia, Valencia, Spain.
| | - A Mateu Puchades
- Department of Dermatology, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - J Matáix-Díaz
- Department of Dermatology, Hospital Marina Alta, Vila-Joyosa, Alicante, Spain
| | | | - I Belinchón-Romero
- Department of Dermatology, General University Hospital of Alicante, Alicante, Spain
| | - S Santos Alarcón
- Department of Dermatology, University Hospital Virgen de los Lirios, Alcoy, Alicante, Spain
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Melgosa Ramos FJ, Mateu Puchades A, Matáix-Díaz J, Schneller-Pavelescu L, Belinchón-Romero I, Santos Alarcón S. 52-Week Mid-term Efficacy of Tildrakizumab in Moderate-to-severe Psoriasis: A Real-life Multicenter Experience. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:T722-T726. [PMID: 38777224 DOI: 10.1016/j.ad.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/08/2023] [Indexed: 05/25/2024] Open
Abstract
Tildrakizumab is an IL-23-inhibitor that has been approved to treat plaque psoriasis. However, few reports have become available on its efficacy profile in the real-world. Our objective was to study the mid-term efficacy of tildrakizumab in patients with moderate-to-severe psoriasis in the Spanish routine clinical practice setting. This was a retrospective multicenter study that included a total of 91 psoriatic patients on tildrakizumab. The mean Psoriasis Area and Severity Index (PASI) was 9.09 (SD, 5.30). The overall tildrakizumab survival rate was 93.47% for a mean treatment exposure of 30.18 weeks (SD, 16.57). No drug discontinuation was associated with drug tolerability, or adverse reactions. Absolute PASI ≤3 was reached by 91.3% and 96.5% of the patients on weeks 28 and 52, respectively. Response was not impacted by weight, age (>65), metabolic syndrome, presence of arthritis, or previous number of biological therapies used. Based on our own experience tildrakizumab is an effective strategy to treat plaque psoriasis and difficult-to-treat-areas.
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Affiliation(s)
- F J Melgosa Ramos
- Department of Dermatology, University Hospital Doctor Peset of Valencia, Valencia, España.
| | - A Mateu Puchades
- Department of Dermatology, University Hospital Doctor Peset of Valencia, Valencia, España
| | - J Matáix-Díaz
- Department of Dermatology, Hospital Marina Alta, Vila-Joyosa, Alicante, España
| | | | - I Belinchón-Romero
- Department of Dermatology, General University Hospital of Alicante, Alicante, España
| | - S Santos Alarcón
- Department of Dermatology, University Hospital Virgen de los Lirios, Alcoy, Alicante, España
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Hwang JK, Lipner SR. Treatment of Nail Psoriasis. Dermatol Clin 2024; 42:387-398. [PMID: 38796270 DOI: 10.1016/j.det.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2024]
Abstract
Nail psoriasis is associated with significant disease burden, negative impact on quality of life, and potential progression to psoriatic arthritis. Initiating timely and appropriate treatment is of the utmost importance, especially because nail disease may be more resistant to therapies than cutaneous psoriasis. This article reviews available intralesional, topical, and systemic treatment options for nail psoriasis, and discusses efficacy and safety of studied agents. Also reviewed are consensus treatment guideline recommendations. An updated algorithm to aid physicians in selection of specific treatment options is provided.
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Affiliation(s)
- Jonathan K Hwang
- Department of Dermatology, Weill Cornell Medicine, 1305 York Avenue, New York, NY 10021, USA
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, 1305 York Avenue, New York, NY 10021, USA.
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Mansilla-Polo M, Morgado-Carrasco D. Biologics Versus JAK Inhibitors. Part I: Cancer Risk. A Narrative Review. Dermatol Ther (Heidelb) 2024; 14:1389-1442. [PMID: 38763966 PMCID: PMC11169156 DOI: 10.1007/s13555-024-01166-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/10/2024] [Indexed: 05/21/2024] Open
Abstract
INTRODUCTION Biological drugs (BD) and Janus kinase inhibitors (JAKi) have revolutionized the treatment of diverse dermatoses. However, there are concerns regarding their safety, especially the risk of cancer and opportunistic infections. Here, we discuss the risk of cancer associated with the BD and JAKi used in dermatology. METHODS A narrative review was carried out. All relevant articles evaluating the risk of cancer associated with BD or JAKi and published between January 2010 and February 2024 were selected. RESULTS Multiple large studies have evaluated the association between BD, JAKi and cancer risk. However, there is a lack of prospective, comparative studies. Overall, patients undergoing BD and JAKi present a cutaneous cancer incidence similar to that in the general population. The drugs more strongly associated with non-skin cancer risk were anti-tumor necrosis factor (anti-TNFs) agents and JAKi (especially tofacitinib and oral ruxolitinib). This risk appears to increase with age, the presence of other factors (such as chronic immunosuppression from previous drugs or other comorbidities), and specific diseases such as rheumatoid arthritis (RA) and myelodysplastic syndrome. Conversely, BD such as interleukin (IL)-17 and IL-23 inhibitors may even reduce the risk of some visceral and hematological malignancies. In patients with dermatological conditions such as psoriasis and atopic dermatitis, the risk of malignancies may be lower than in other subgroups, and probably comparable to the general population. CONCLUSIONS The incidence of cancer in patients undergoing BD or JAKi is generally low. This incidence can be higher in elderly patients with RA or myelodysplastic syndrome, and in those undergoing prolonged therapy with tofacitinib or ruxolitinib (oral), or anti-TNF agents.
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Affiliation(s)
- Miguel Mansilla-Polo
- Department of Dermatology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
- Instituto de Investigación Sanitaria (IIS) La Fe, Valencia, Spain
- Department of Dermatology, Faculty of Medicine, Universitat de València, Villarroel 170, 08036, Valencia, Spain
| | - Daniel Morgado-Carrasco
- Department of Dermatology, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain.
- Department of Dermatology, Hospital de Figueres, Fundació Alt Empurdà, Figueres, Spain.
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Torres T, Varela P, Mendes Bastos P, Magina S, Henrique M, Ferreira P. Tildrakizumab for the treatment of moderate-to-severe psoriasis: a 52-week, real-world Portuguese multicentric study. Drugs Context 2024; 13:2023-12-5. [PMID: 38510314 PMCID: PMC10954292 DOI: 10.7573/dic.2023-12-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/16/2024] [Indexed: 03/22/2024] Open
Abstract
Background Real-world evidence plays a pivotal role in validating the efficacy of biologic drugs beyond the controlled environment of randomized trials. This study aimed to evaluate the effectiveness of tildrakizumab in treating moderate-to-severe psoriasis within a real-world setting over a 52-week period in Portugal. Methods This multicentric, prospective, observational study included adult patients with moderate-to-severe psoriasis. All participants received tildrakizumab 100 mg at weeks 0 and 4, followed by a maintenance dose every 12 weeks, and were monitored for 52 weeks. Primary endpoints were determined based on Psoriasis Area and Severity Index (PASI) assessments at baseline, 16 (±2) weeks, 28 (±2) weeks and 52 (±2) weeks. Results A total of 54 patients were enrolled in the study (56% men, mean age of 50.3 ± 14.4 years). Half of the sample (n=27) had no prior experience with biologic treatments. About 74% of patients (n=40) presented at least one comorbidity during the study, with psoriatic arthritis being the most prevalent (29.6%). By week 52, there was a significant decrease in the mean PASI from 17.8±10.3 at baseline to 1.3±1.9 (p<0.001), indicating an overall improvement of 93%. By week 52, more than 85% of patients attained PASI ≤5, more than 80% reached PASI ≤3, and nearly 60% achieved PASI ≤1. Infections were observed in 9.3% of patients, and one patient required hospitalization (1.9%). The cumulative proportion of patients continuing treatment at 52 weeks was 88.9%. Conclusions This study demonstrates that tildrakizumab is an effective and safe agent for the treatment of moderate-to-severe psoriasis in a diverse, real-world setting.
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Affiliation(s)
- Tiago Torres
- Department of Dermatology, Centro Hospitalar Universitário de Santo António Porto, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, University of Porto, Porto, Portugal
| | - Paulo Varela
- Department of Dermatology, Centro Hospitalar VN Gaia/Espinho, VN Gaia, Portugal
| | | | - Sofia Magina
- Department of Dermatology, Centro Hospitalar S. João, Porto, Portugal
- Department of Pharmacology and Therapeutics, Faculdade de Medicina, University of Porto, Porto, Portugal
| | - Martinha Henrique
- Department of Dermatology, Centro Hospitalar de Leiria, Leiria, Portugal
| | - Paulo Ferreira
- Psoriasis Unit, Hospital CUF Descobertas, Lisbon, Portugal
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Hwang JK, Grover C, Iorizzo M, Lebwohl MG, Piraccini BM, Rigopoulos DG, Lipner SR. Nail psoriasis and nail lichen planus: Updates on diagnosis and management. J Am Acad Dermatol 2024; 90:585-596. [PMID: 38007038 DOI: 10.1016/j.jaad.2023.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/30/2023] [Accepted: 11/17/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND Inflammatory diseases of the nail, including nail psoriasis and nail lichen planus, are associated with significant disease burden and have a negative impact on quality of life. Diagnosis is often delayed, especially when patients present without cutaneous findings. Therefore, recognizing clinical signs and symptoms of inflammatory nail diseases, and initiating timely and appropriate treatment, is of utmost importance. OBJECTIVE We review recent studies on diagnostic techniques, discuss severity grading and scoring systems, and describe consensus treatment recommendations for nail psoriasis and nail lichen planus. METHODS An updated literature review was performed using the PubMed database on studies assessing diagnostic techniques or treatment modalities for nail psoriasis and nail lichen planus. RESULTS Recent studies on diagnostic techniques for inflammatory nail disease have focused on use of dermoscopy, capillaroscopy, and ultrasound modalities. Treatment of these conditions is dichotomized into involvement of few (≤3) or many (>3) nails. Recent psoriatic therapeutics studied for nail outcomes include brodalumab, tildrakizumab, risankizumab, deucravacitinib, and bimekizumab, while emerging treatments for nail lichen planus include JAK inhibitors and intralesional platelet rich plasma injections. CONCLUSIONS We emphasize the need for increased awareness and expanded management strategies for inflammatory nail diseases to improve patient outcomes.
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Affiliation(s)
- Jonathan K Hwang
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Chander Grover
- Department of Dermatology, University College of Medical Sciences, New Delhi, India
| | | | - Mark G Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Bianca M Piraccini
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Dimitris G Rigopoulos
- 1st Department of Dermatology-Venereology, National and Kapodistrian University of Athens, Athens, Greece
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York.
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Berenguer-Ruiz S, Aparicio-Domínguez M, Herranz-Pinto P, Ruíz-Villaverde R, López-Ferrer A, Santos-Juanes J, Rodríguez Fernández-Freire L, Hospital-Gil M, Arias-Santiago S, Carretero-Hernández G, Mateu-Puchades A, Ferran M, Del Alcázar E, Santos-Alarcón S, Garcia-Latasa de Aranibar FJ, Belinchón-Romero I, González-Cantero Á, Ruíz-Genao D, Eiris-Salvado N, Rocamora-Durán V, Rivera-Diaz R, de la Cueva P, Daudén E, Salgado-Boquete L, Llamas-Velasco M. Effectiveness and safety of tildrakizumab for the treatment of psoriasis in real-world settings at 24 weeks: A retrospective, observational, multicentre study by the Spanish Psoriasis Group. J Eur Acad Dermatol Venereol 2023; 37:2517-2525. [PMID: 37625815 DOI: 10.1111/jdv.19468] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 07/05/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND Tildrakizumab is a humanized, IgG1/κ antibody that interacts with the p19 subunit of interleukin 23. It is approved for the treatment of moderate-to-severe plaque psoriasis. Real-world evidence on the effectiveness and safety of tildrakizumab is limited. OBJECTIVES To assess the effectiveness and safety of tildrakizumab at 24 weeks in patients with moderate-to-severe plaque psoriasis in routine clinical practice. METHODS Retrospective, observational, multicentre study including adult patients with moderate-to-severe plaque psoriasis treated with tildrakizumab under real-life conditions. Patient data were extracted from anonymized electronic medical records. Statistical analysis was performed using SPSS22. RESULTS A total of 190 patients were included. About 53.9% were men with a mean age of 51.45 (SD 3.9) and a mean BMI of 29.13 (SD 6.21). About 79.8% (132 out of 190) of patients had previously received biological therapy (BT) and 17.3% (33 out of 191) had psoriatic arthritis. Baseline PASI was 10.7 (SD 6.53). Up to 109 patients reached Week 24 and at this point mean baseline PASI decreased to 1.7 (SD 4.8), representing an 88.79% mean PASI reduction. At 6 months, 87.1% and 40.3% of the treated patients achieved PASI ≤3 and ≤1, respectively. At Week 24 mean BSA decreased from 13.2 (SD 10.07) to 1.6 (SD 4.40) and mean DLQI went from 12.5 (SD 7.12) to 1.2 (SD 3.27). Multivariate analysis showed no differences when effectiveness was correlated with gender, obesity, psoriatic arthritis or prior exposure to BT. The rate of adverse events (AE) was 5.9% (11 out of 190), where infections were the most frequent AE (4 out of 11). One patient suffered a haemorrhagic ictus and one patient died due to causes unrelated to the study. CONCLUSION Tildrakizumab was effective and safe in a large cohort of patients with moderate-to-severe plaque psoriasis treated in a routine clinical setting.
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Affiliation(s)
| | | | | | | | - Anna López-Ferrer
- Department of Dermatology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jorge Santos-Juanes
- Department of Dermatology, Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | - Mercedes Hospital-Gil
- Department of Dermatology, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | | | | | | | - Marta Ferran
- Department of Dermatology, Hospital del Mar, Barcelona, Spain
| | - Elena Del Alcázar
- Department of Dermatology, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | | | | | | | | | - Diana Ruíz-Genao
- Department of Dermatology, Hospital Universitario Fundación Alcorcon, Madrid, Spain
| | - Noemí Eiris-Salvado
- Department of Dermatology, Complejo Asistencial Universitario de León, León, Spain
| | | | - Raquel Rivera-Diaz
- Department of Dermatology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Pablo de la Cueva
- Department of Dermatology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Esteban Daudén
- Department of Dermatology, Hospital Universitario de la Princesa, Madrid, Spain
| | | | - Mar Llamas-Velasco
- Department of Dermatology, Hospital Universitario de la Princesa, Madrid, Spain
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12
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Ter Haar ELM, Van den Reek JMPA, Gaarn Du Jardin K, Barbero-Castillo A, De Jong EMGJ, Lubeek SFK. Efficacy and Safety of Tildrakizumab in Older Patients: Pooled Analyses of Two Randomized Phase III Clinical Trials (reSURFACE 1 and reSURFACE 2) Through 244 Weeks. Acta Derm Venereol 2023; 103:adv17752. [PMID: 37877618 PMCID: PMC10614651 DOI: 10.2340/actadv.v103.17752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023] Open
Abstract
The evidence on treating older patients with psoriasis with modern biologics is scarce. This study compared the efficacy and safety of tildrakizumab among younger and older patients with psoriasis (< 65/≥ 65 years) in a post hoc analysis of 2 phase III trials (reSURFACE1/2, n = 1,862). Tildrakizumab 100 mg/200 mg was administered at weeks 0/4/every 12 weeks thereafter. At week 28, patients with ≥ 75% improvement in baseline Psoriasis Area and Severity Index (PASI75) in reSURFACE1 were re-randomized to the same tildrakizumab dose or placebo; in reSURFACE2, PASI75 responders to 200 mg were re-randomized to tildrakizumab 100 mg or 200 mg; PASI75 responders to 100 mg maintained their dose. At weeks 64/52 (reSURFACE1/2), PASI50 responders entered an extension period (weeks 256/244). Outcomes were proportion of patients with PASI < 3, Dermatology Life Quality Index (DLQI) 0/1, comorbidities, comedication, and side-effects. The proportion of patients with a PASI < 3 was similar and maintained (tildrakizumab 100 mg and 200 mg, week 244: 83.3% and 84.1%/92.3% and 100.0%); DLQI 0/1 proportions at week 52 were 66.8% and 72.0%/68.3% and 81.3%. Comorbidity and comedication were more common in older patients. The safety profile of tildrakizumab appeared favourable in both groups. Tildrakizumab in patients ≥ 65 years appears effective and safe in long-term psoriasis management. These findings might assist treatment selection and overcome treatment reluctance.
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Affiliation(s)
- Elke L M Ter Haar
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands.
| | - Juul M P A Van den Reek
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | | | | | - Elke M G J De Jong
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
| | - Satish F K Lubeek
- Department of Dermatology, Radboud University Medical Centre (Radboudumc), Nijmegen, The Netherlands
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13
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Griss J, Ratzinger G, Maul J, Weger W, Thaçi D, Carrascosa JM, Jonak C. No impact of disease duration on response to tildrakizumab treatment among patients with moderate-to-severe plaque psoriasis: Post hoc analyses from two phase 3 (reSURFACE 1 and reSURFACE 2) and one phase 4 (TRIBUTE) studies. SKIN HEALTH AND DISEASE 2023; 3:e263. [PMID: 37799374 PMCID: PMC10549803 DOI: 10.1002/ski2.263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
In the literature there is no consensus on the correlation between early systemic intervention and better treatment response in psoriasis. Here we present data on the impact of disease duration (<5 years, 5-<10 years, and ≥10 years) on response to tildrakizumab treatment among patients with moderate-to-severe plaque psoriasis from the reSURFACE 1 and reSURFACE 2 phase 3 trials and the TRIBUTE phase 4 study. Overall, there was no significant effect of disease duration on the Psoriasis Area and Severity Index ≤1, ≤3, and ≤5, or the Dermatology Life Quality Index 0-1 response rates. Tildrakizumab was highly effective regardless of the psoriasis disease duration.
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Affiliation(s)
- Johannes Griss
- Department of DermatologyMedical University of ViennaViennaAustria
| | - Gudrun Ratzinger
- Department of DermatologyMedical University of InnsbruckInnsbruckAustria
| | - Julia‐Tatjana Maul
- Department of DermatologyUniversity Hospital ZurichZurichSwitzerland
- Faculty of MedicineUniversity of ZurichZurichSwitzerland
| | - Wolfgang Weger
- Department of Dermatology and VenereologyMedical University of GrazGrazAustria
| | - Diamant Thaçi
- Institute and Comprehensive Centre for Inflammation MedicineUniversity of LübeckLübeckGermany
| | - José Manuel Carrascosa
- Department of DermatologyHospital Universitari Germans Trias i Pujol, IGTP, UABBadalonaSpain
| | - Constanze Jonak
- Department of DermatologyMedical University of ViennaViennaAustria
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14
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Gao W, Wang Z, Li W, Li Y, Liu M. Biomarkers and biologics related with psoriasis and psoriatic arthritis. Int Immunopharmacol 2023; 122:110646. [PMID: 37454633 DOI: 10.1016/j.intimp.2023.110646] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/06/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
Over the past half century, psoriasis is considered as an immune-mediated inflammatory skin disease with the combined hallmarks of autoimmunity and autoinflammation, according to growing volumes of clinical and experimental findings. There is currently no cure for psoriasis, current treatment strategies focus on symptom control, disease minimization, and patient's quality of life enhancement. To meet these challenges, it keeps imperative to discover potential biomarkers, so that not only can they be used for the prediction and monitoring of psoriasis disease in clinic, but also can provide novel therapeutic targets or treatment strategies for psoriasis sufferers. This review systematically demonstrates the research progress of psoriasis-related biomarkers and elaborates their related mechanisms in the pathological development of psoriasis and psoriatic arthritis. In addition, we summarize the development of biologic therapies for psoriasis and psoriatic arthritis in order to drive the broader discussion of psoriasis as an autoimmune-mediated inflammatory skin disease.
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Affiliation(s)
- Weize Gao
- Department of Clinical Laboratory, Key Laboratory of Laboratory Medicine, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Zhan Wang
- Department of Clinical Laboratory, Key Laboratory of Laboratory Medicine, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Wenshuai Li
- Department of Clinical Laboratory, Key Laboratory of Laboratory Medicine, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Yongxin Li
- Department of Clinical Laboratory, Key Laboratory of Laboratory Medicine, The Affiliated Hospital of Qingdao University, Qingdao 266003, China
| | - Mingjun Liu
- Department of Clinical Laboratory, Key Laboratory of Laboratory Medicine, The Affiliated Hospital of Qingdao University, Qingdao 266003, China.
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15
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Blauvelt A, Chiricozzi A, Ehst BD, Lebwohl MG. Safety of IL-23 p19 Inhibitors for the Treatment of Patients With Moderate-to-Severe Plaque Psoriasis: A Narrative Review. Adv Ther 2023; 40:3410-3433. [PMID: 37330926 PMCID: PMC10329957 DOI: 10.1007/s12325-023-02568-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 05/25/2023] [Indexed: 06/20/2023]
Abstract
The approved biologics targeting interleukin (IL)-23 p19 for the treatment of moderate-to-severe plaque psoriasis, including guselkumab, tildrakizumab, and risankizumab, have generally favorable safety profiles. The aim of the current review is to describe in detail the safety of these selective inhibitors. A literature search was performed using PubMed from inception to 1 November 2022, to identify clinical trials and real-world evidence publications using the keywords "guselkumab," "tildrakizumab," and "risankizumab." Overall, the most common adverse events (AEs) associated with IL-23 p19 inhibitors in clinical trials were nasopharyngitis, headache, and upper respiratory tract infections. Rates of serious AEs and AEs of interest, including serious infections, nonmelanoma skin cancer (NMSC), malignancies excluding NMSC, major adverse cardiovascular events, and serious hypersensitivity reactions, were not increased with long-term use in clinical trials. Selectively targeting IL-23 p19 was also not associated with elevated risk of opportunistic infections, tuberculosis reactivation, oral candidiasis, or inflammatory bowel disease. Results from real-world studies were similar, supporting the safe long-term use of these biologics in a wider population of patients with psoriasis, including older patients, patients for whom multiple biologics failed, and those with comorbidities such as obesity, metabolic syndrome, cardiovascular disease, dyslipidemia, diabetes, hypertension, and psoriatic arthritis. This review is limited by the lack of direct comparisons among therapeutic agents due to differences among study designs and safety data reporting methods. In conclusion, the favorable safety profiles of IL-23 p19 inhibitors support their long-term use in the management of patients with moderate-to-severe psoriasis.
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Affiliation(s)
- Andrew Blauvelt
- Oregon Medical Research Center, 9495 SW Locust Street, Suite G, Portland, OR, 97223, USA.
| | - Andrea Chiricozzi
- Dermatologia, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Rome, Italy
- Dermatologia, Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Benjamin D Ehst
- Oregon Medical Research Center, 9495 SW Locust Street, Suite G, Portland, OR, 97223, USA
| | - Mark G Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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16
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Mastorino L, Burzi L, Frigatti G, Fazio A, Celoria V, Macagno N, Rosset F, Passerini SG, Roccuzzo G, Verrone A, Stroppiana E, Ortoncelli M, Dapavo P, Quaglino P, Ribero S. Clinical effectiveness of IL-17 and IL-23 inhibitors on difficult-to-treat psoriasis areas (scalp, genital, and palmoplantar sites): a retrospective, observational, single-center, real-life study. Expert Opin Biol Ther 2023; 23:929-936. [PMID: 37458181 DOI: 10.1080/14712598.2023.2236023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
INTRODUCTION Psoriasis affecting the genital, palmoplantar, and scalp regions is recognized as difficult-to-treat, and data on the efficacy of biologics in these areas remains limited. RESEARCH DESIGN AND METHODS This single-center study evaluated the effectiveness of anti-IL-17 and anti-IL-23 agents on scalp, genital, and palmoplantar psoriasis. We retrospectively analyzed data from all patients with psoriasis being treated with IL inhibitors at our clinic. Effectiveness was evaluated at 16, 28, and 52 weeks, according to the achievement of relative and mean PSSI, PGA-G, and ppPASI. RESULTS In all, 308 patients showed involvement of the scalp, 136 in the genital area, and 94 in the palmoplantar regions. On scalp psoriasis, anti-IL-17 agents demonstrated superiority in disease control compared to anti-IL-23 agents. PSSI100 at week 16 was reached by 59% of patients on an anti-IL17 vs 39.8% on an anti-IL-23 (p < 0.003). At genital sites, no significant differences between anti-IL-17 and anti-IL-23 agents were observed, and all classes achieved PGA-G 0/1. No significant differences between anti-IL-17 and anti-IL-23 agents were observed in palmoplantar areas. CONCLUSIONS The present data support the utility of both anti-IL-17 and anti-IL-23 agents for the treatment of difficult-to-treat areas in patients with psoriasis. Anti-IL-17 agents achieved better control of scalp psoriasis.
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Affiliation(s)
- Luca Mastorino
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Lorenza Burzi
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Giada Frigatti
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Alessandra Fazio
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Valentina Celoria
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Nicole Macagno
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Francois Rosset
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | | | - Gabriele Roccuzzo
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Anna Verrone
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Elena Stroppiana
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Michela Ortoncelli
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Paolo Dapavo
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Pietro Quaglino
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
| | - Simone Ribero
- Department of Medical Sciences, Section of Dermatology, University of Turin, Turin, Italy
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17
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Damsin T. A Case of Concurrent Psoriasis and Hidradenitis Suppurativa Successfully Treated with Tildrakizumab. Dermatol Ther (Heidelb) 2023:10.1007/s13555-023-00940-0. [PMID: 37266889 DOI: 10.1007/s13555-023-00940-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/11/2023] [Indexed: 06/03/2023] Open
Abstract
INTRODUCTION Plaque psoriasis and hidradenitis suppurativa are chronic inflammatory skin conditions with common pathogenetic pathways. METHODS We report the case of a 38-year-old man with 15-year history of psoriasis and hidradenitis suppurativa successfully treated with tildrakizumab for both conditions. After treatment failure to adalimumab, secukinumab, and guselkumab, tildrakizumab therapy was initiated and resulted in complete remission of psoriasis and the achievement of hidradenitis suppurativa clinical response after 40 weeks, without reporting adverse events. These responses were maintained at week 52. CONCLUSION Tildrakizumab may be an effective and safe therapeutic option for concomitant psoriasis and hidradenitis suppurativa.
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Affiliation(s)
- Thomas Damsin
- Department of Dermatology, CHU du Sart Tilman, Avenue de L'Hôpital 1, 4000, Liège, Belgium.
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18
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Ruggiero A, Fabbrocicni G, Cacciapuoti S, Potestio L, Gallo L, Megna M. Tildrakizumab for the Treatment of Moderate-to-Severe Psoriasis: Results from 52 Weeks Real-Life Retrospective Study. Clin Cosmet Investig Dermatol 2023; 16:529-536. [PMID: 36873660 PMCID: PMC9983574 DOI: 10.2147/ccid.s402183] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/22/2023] [Indexed: 03/03/2023]
Abstract
Background Tildrakizumab, an anti-IL-23, showed promising efficacy and safety profiles in two randomized clinical-trials (reSURFACE-1 and reSURFACE-2), comparing tildrakizumab superiority to placebo and etanercept. Due to its recent availability in clinical-practice, real-life data are still limited. Objective To assess the efficacy and safety of tildrakizumab in a real-world-practice in patients suffering from moderate-to-severe psoriasis. Methods A 52-week observational retrospective study enrolled patients suffering from moderate-to-severe plaque-psoriasis, starting tildrakizumab treatment. Results A total of 42 patients were included in the study. Mean PASI showed a significant reduction at each follow-up (p<0.001), reducing from 13.5±5.9 at baseline, 2.8±3.8 at week-28, resulting stable up to week-52. High rates of patients reached both PASI90 and PASI100 responses at both week 16 (PASI90: 52.4%, PASI100: 33.3%) and week 28 (PASI90: 76.1%, PASI100: 61.9%), maintaining these up to week 52 (PASI90: 73.8%, PASI100: 59.5%). The impact of treatment on patient's quality of life has been evaluated with DLQI, which showed a significant reduction during follow-ups. Conclusion Our data confirm tildrakizumab as an effective and generally safe treatment for the management of moderate-to-severe psoriasis, with high rates of both PASI90 and PASI100 responses, and very few reported adverse events, up to 52 weeks of follow-up.
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Affiliation(s)
- Angelo Ruggiero
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Gabriella Fabbrocicni
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Sara Cacciapuoti
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Luca Potestio
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Lucia Gallo
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Matteo Megna
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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