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Ito R, Hanai S, Watanabe M, Tanaka-Mabuchi N, Kubota S, Kobayashi Y, Nakagomi D. Generalized pustular psoriasis (von Zumbusch). Am J Med 2024:S0002-9343(24)00409-1. [PMID: 38969325 DOI: 10.1016/j.amjmed.2024.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/19/2024] [Accepted: 06/27/2024] [Indexed: 07/07/2024]
Affiliation(s)
- Ryosuke Ito
- Department of Rheumatology, University of Yamanashi Hospital, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan
| | - Shunichiro Hanai
- Department of Rheumatology, University of Yamanashi Hospital, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan
| | - Moe Watanabe
- Department of Rheumatology, University of Yamanashi Hospital, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan
| | - Nakako Tanaka-Mabuchi
- Department of Rheumatology, University of Yamanashi Hospital, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan
| | - Soichiro Kubota
- Department of Rheumatology, University of Yamanashi Hospital, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan.
| | - Yoshiaki Kobayashi
- Department of Rheumatology, University of Yamanashi Hospital, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan
| | - Daiki Nakagomi
- Department of Rheumatology, University of Yamanashi Hospital, 1110 Shimokato, Chuo-shi, Yamanashi 409-3898, Japan
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2
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Teshima R, Saito-Sasaki N, Sawada Y. Generalized Pustular Psoriasis and Systemic Organ Dysfunctions. Int J Mol Sci 2024; 25:6270. [PMID: 38892457 PMCID: PMC11172751 DOI: 10.3390/ijms25116270] [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: 04/29/2024] [Revised: 06/02/2024] [Accepted: 06/04/2024] [Indexed: 06/21/2024] Open
Abstract
This review explores the intricate relationship between generalized pustular psoriasis (GPP) and various systemic diseases, shedding light on the broader impacts of this severe skin condition beyond its primary dermatological manifestations. GPP is identified as not only a profound contributor to skin pathology but also a significant risk factor for systemic diseases affecting cardiovascular, hepatic, renal, pulmonary, and skeletal systems, as well as associated with an increased incidence of anemia, depression, anxiety, and arthritis. The research highlights the complex interplay of cytokines, particularly IL-17 and IL-36, which are central to the pathophysiology of GPP and implicated in the exacerbation of systemic conditions. Key findings indicate a higher incidence of cardiovascular events in GPP patients compared to those with other severe forms of psoriasis, notably with a stronger correlation between myocardial infarction history and GPP development. Liver disturbances, frequently reversible upon psoriasis remission, suggest a cytokine-mediated link to hepatic health. Renal dysfunction appears elevated in GPP sufferers, with IL-17 and IL-36 potentially driving renal fibrosis. Similarly, interstitial lung disease and osteoporosis in GPP patients underscore the systemic reach of inflammatory processes initiated in the skin. The associations with anemia, depression, anxiety, and arthritis further complicate the clinical management of GPP, requiring a multidisciplinary approach. The study concludes that managing GPP effectively requires a holistic approach that addresses both the cutaneous and systemic dimensions of the disease, advocating for continued research into the mechanisms that connect GPP with broader health implications to refine therapeutic strategies.
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Affiliation(s)
| | | | - Yu Sawada
- Department of Dermatology, University of Occupational and Environmental Health, Kitakyushu 807-8555, Japan
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Viguier M, Bentayeb M, Azzi J, de Pouvourville G, Gloede T, Langellier B, Massol J, Medina P, Thoma C, Bachelez H. Generalized pustular psoriasis: A nationwide population-based study using the National Health Data System in France. J Eur Acad Dermatol Venereol 2024; 38:1131-1139. [PMID: 38404163 DOI: 10.1111/jdv.19901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 01/24/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND GPP is a rare, chronic, neutrophilic skin disease, with limited real-world data characterizing patients with flares and the impact of flares on disease progression and morbidity. OBJECTIVE Describe the clinical characteristics of patients with GPP, comorbidities, disease epidemiology and frequency and severity of flares, and compare patients with GPP with a matched severe psoriasis population. METHODS In this population-based real-world cohort study an algorithm was developed to identify patients with GPP flares. Three cohorts were identified using the Système National des Données de Santé (SNDS) database covering almost the entire French population; a prevalent cohort (2010-2018), an incident cohort (2012-2015). A severe psoriasis cohort was compared with the GPP incident cohort using propensity score matching. RESULTS The prevalent and incident cohorts comprised 4195 and 1842 patients, respectively. In both cohorts, mean age was 58 years; 53% were male. Comorbidities were significantly more common in the incident cohort versus matched psoriasis cohort, respectively, including hypertension (44% vs. 26%), ischaemic heart disease (26% vs. 18%) and hyperlipidaemia (25% vs. 15%). In the incident cohort, the flare rate was 0.1 flares/person-year and 0.4 flares/person-year among the 569 out of 1842 patients hospitalized with flares. These patients had a mean (±SD) stay of 11.6 ± 10.4 days; 25% were admitted to the intensive care unit. In 2017, the cumulative incidence and cumulative GPP age-sex standardized prevalence were 7.1 and 45.2 per million, respectively. CONCLUSIONS Patients with GPP had a distinct comorbidity profile compared to patients with severe psoriasis, and GPP flares were associated with long hospitalizations.
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Affiliation(s)
- Manuelle Viguier
- Department of Dermatology-Venereology, Hôpital Robert Debré and Université Reims-Champagne Ardenne, IRMAIC, EA 7509, Reims, France
| | | | | | | | - Tristan Gloede
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Connecticut, USA
| | | | - Jacques Massol
- Aixial Consulting, Boulogne Billancourt, France
- Remede Consulting Group, Paris, France
| | | | | | - Hervé Bachelez
- Service de Dermatologie, Assistance Publique-Hôpitaux de Paris Hôpital Saint-Louis, and INSERM Unité 1163, Imagine Institute of Genetic Diseases, Université Paris Cité, Paris, France
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Frysz M, Patel S, Li MOY, Griffiths CEM, Warren RB, Ashcroft DM. Prevalence, incidence, mortality, and healthcare resource use for generalised pustular psoriasis, palmoplantar pustulosis, and plaque psoriasis in England: a population-based cohort study. Br J Dermatol 2024:ljae217. [PMID: 38775029 DOI: 10.1093/bjd/ljae217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/22/2024] [Accepted: 05/21/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Generalised pustular psoriasis (GPP) and palmoplantar pustulosis (PPP) are chronic, inflammatory skin conditions. Accumulating evidence shows that GPP and PPP have different characteristics compared with plaque psoriasis and are distinct clinical entities. OBJECTIVES To assess the epidemiology, comorbidities, mortality and healthcare use for patients with GPP and PPP compared with those with plaque psoriasis in England. METHODS A cohort study involving analyses of longitudinal electronic health record data in the Clinical Practice Research Datalink Aurum database and linked hospital and mortality data between 2008 and 2019. The primary study outcome was the incidence and prevalence rates for GPP, PPP and plaque psoriasis in England. Secondary outcomes included survival rates and healthcare resource use (HCRU) by disease type. RESULTS We identified 373 patients with GPP, 1,828 with PPP and 224,223 with plaque psoriasis. The mean age was 55.9 years (standard deviation [SD]: 18.6) for patients with GPP, 51.5 years (SD: 16.4) for those with PPP, and 48.5 years (SD: 19.1) for those with plaque psoriasis; 62.5% and 65.9% of patients with GPP and PPP, respectively, were women, compared with 49.4% of those with plaque psoriasis. About half of the patients were overweight or obese at baseline (GPP, 48.6%; PPP, 56.0%; and plaque psoriasis, 45.9%). The incidence rates for GPP, PPP and plaque psoriasis were 0.25 (95% CI: 0.21-0.28), 2.01 (95% CI: 1.92-2.11) and 103.2 (95% CI: 102.5-103.9) per 100,000 person-years, respectively. From 2008 to 2019, the prevalence rates per 100,000 persons ranged from 1.61 to 3.0 for GPP, 1.1 to 18.7 for PPP and 1771.0 to 1903.8 for plaque psoriasis. Survival rates were lower for patients with GPP, particularly those who were over 55 years old and those with a history of ≥1 comorbidity in each cohort. HCRU was lower in the plaque psoriasis cohort and highest in the GPP cohort, particularly among those who had ≥1 GPP flare. CONCLUSIONS Our results provide further evidence that GPP is a distinct disease with different epidemiology, lower survival and higher HCRU than plaque psoriasis in England.
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Affiliation(s)
| | | | | | - Christopher E M Griffiths
- Department of Dermatology, King's College Hospital, King's College London, London, UK
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Richard B Warren
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Dermatology Centre, Northern Care Alliance NHS Foundation Trust, Manchester, UK
| | - Darren M Ashcroft
- NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, Stopford Building, Manchester, UK
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Pathak GN, Wang E, Dhillon J, Parikh PN, Esseghir R, Rao BK, Feldman SR. Spesolimab: A Review of the First IL-36 Blocker Approved for Generalized Pustular Psoriasis. Ann Pharmacother 2024:10600280241252688. [PMID: 38755971 DOI: 10.1177/10600280241252688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
OBJECTIVE This article reviews clinical trial data that assesses the safety, efficacy, and clinical application of spesolimab, an interleukin-36 (IL-36) blocker, for the treatment of generalized pustular psoriasis (GPP). DATA SOURCES A review of the literature was conducted using the search terms: "spesolimab," "BI 655130," and "spevigo" in MEDLINE (PubMed) and Clinicaltrials.gov from January 1, 1950 to October 31, 2023. STUDY SELECTION AND DATA EXTRACTION Relevant articles in English relating to the pharmacodynamics, pharmacokinetics, efficacy, and safety of spesolimab were included. DATA SYNTHESIS In one phase 2 clinical trial evaluating single dose IV spesolimab for GPP flares at day 8, 54% of patients receiving spesolimab had a GPP physician global assessment (GPPGA) pustulation subscore of 0, and 43% had a GPPGA total score of 0 compared with 6% and 11% for the placebo group, respectively. Another phase 2 clinical trial assessing subcutaneous spesolimab found 23% of patients in low-dose, 29% in medium-dose, and 10% of high-dose spesolimab had flares by week 48 compared with 52% of the placebo group. Hazard ratios for time to GPP flare compared with placebo were 0.16 (P = 0.0005), 0.35 (P = 0.0057), and 0.47 (P = 0.027) for the spesolimab groups, respectively. Infection rates were similar across treatment and placebo groups, and severe adverse events such as drug reactions with eosinophilia and systemic symptom (DRESS), cholelithiasis, and breast cancer occurred with spesolimab. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING DRUGS Spesolimab is a first-in-class IL-36 monoclonal antibody receptor antagonist approved for the treatment of acute GPP flares. It is a safe and effective therapeutic agent in preventing future GPP flares, with no current comparator trials with other GPP agents. CONCLUSION Spesolimab is a safe and effective treatment for acute GPP flares in adults. Future clinical trials can establish safety and efficacy compared with other agents.
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Affiliation(s)
- Gaurav N Pathak
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
- Center for Dermatology Research, Department of Dermatology, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Emily Wang
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
| | - Jimmy Dhillon
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
| | - Prachi N Parikh
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
| | - Reem Esseghir
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
| | - Babar K Rao
- Department of Dermatology, Rutgers Robert Wood Johnson Medical School, Somerset, NJ, USA
- Department of Dermatology, Rao Dermatology, Atlantic Highlands, NJ, USA
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
- Department of Pathology, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
- Department of Social Sciences and Health Policy, School of Medicine, Wake Forest University, Winston-Salem, NC, USA
- Department of Dermatology, University of Southern Denmark, Odense, Denmark
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Vilarrasa E, Rivera R, Eiris N, Carretero G, de la Cueva P, Carrascosa JM. [Translated article] Approach to the Epidemiology, Disease Management, and Current Challenges in the Management of Generalized Pustular Psoriasis Through a Survey Conducted Among Spanish Dermatologists. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:T449-T457. [PMID: 38479699 DOI: 10.1016/j.ad.2024.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/22/2023] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Generalized pustular psoriasis (GPP) is a rare and severe inflammatory skin disease characterised by recurrent or intermittent flares. Epidemiological and disease management data in Spain are limited. Our goal was to estimate the epidemiology of GPP, explore its management, and reach consensus on the current challenges faced in Spain. METHODS An electronic survey was submitted to dermatologists from the Spanish Academy of Dermatology and Venereology Psoriasis Working Group. This group is experienced in the management of GPP. It included a Delphi consensus to establish the current challenges. RESULTS A total of 33 dermatologists responded to the survey. A 5-year prevalence and incidence of 13.05 and 7.01 cases per million inhabitants, respectively, were estimated. According to respondents, the most common GPP symptoms are pustules, erythema, and desquamation, while 45% of patients present > 1 annual flares. A total of 45% of respondents indicated that flares often require a length of stay between 1 and 2 weeks. In the presence of a flare, 67% of respondents often or always prescribe a non-biological systemic treatment as the first-line therapy [cyclosporine (55%); oral retinoid (30%)], and 45% a biological treatment [anti-TNFα (52%); anti-IL-17 (39%)]. The dermatologists agreed that the main challenges are to define and establish specific therapeutic goals to treat the disease including the patients' perspective on the management of the disease. CONCLUSION Our study describes the current situation on the management of GPP in Spain, increasing the present knowledge on the disease, and highlighting the current challenges faced at the moment.
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Affiliation(s)
- E Vilarrasa
- Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Universitat Autónoma de Barcelona, Barcelona, Spain.
| | - R Rivera
- Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, Spain; Universidad Complutense, Madrid, Spain
| | - N Eiris
- Servicio de Dermatología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - G Carretero
- Servicio de Dermatología, Hospital Universitario de Gran Canaria Doctor Negrin, Gran Canaria, Spain
| | - P de la Cueva
- Universidad Complutense, Madrid, Spain; Servicio de Dermatología, Hospital Infanta Leonor, Madrid, Spain
| | - J M Carrascosa
- Universitat Autónoma de Barcelona, Barcelona, Spain; Servicio de Dermatología, Hospital Germans Trias i Pujol, Barcelona, Spain; Instituto de Investigación Germans Trias i Pujol (IGTP), Barcelona, Spain
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7
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Vilarrasa E, Rivera R, Eiris N, Carretero G, de la Cueva P, Carrascosa JM. Approach to the Epidemiology, Disease Management, and Current Challenges in the Management of Generalized Pustular Psoriasis Through a Survey Conducted Among Spanish Dermatologists. ACTAS DERMO-SIFILIOGRAFICAS 2024; 115:449-457. [PMID: 37925068 DOI: 10.1016/j.ad.2023.10.022] [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: 07/31/2023] [Revised: 10/20/2023] [Accepted: 10/22/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Generalized pustular psoriasis (GPP) is a rare and severe inflammatory skin disease characterised by recurrent or intermittent flares. Epidemiological and disease management data in Spain are limited. Our goal was to estimate the epidemiology of GPP, explore its management, and reach consensus on the current challenges faced in Spain. METHODS An electronic survey was submitted to dermatologists from the Spanish Academy of Dermatology and Venereology Psoriasis Working Group. This group is experienced in the management of GPP. It included a Delphi consensus to establish the current challenges. RESULTS A total of 33 dermatologists responded to the survey. A 5-year prevalence and incidence of 13.05 and 7.01 cases per million inhabitants, respectively, were estimated. According to respondents, the most common GPP symptoms are pustules, erythema, and desquamation, while 45% of patients present > 1 annual flares. A total of 45% of respondents indicated that flares often require a length of stay between 1 and 2 weeks. In the presence of a flare, 67% of respondents often or always prescribe a non-biological systemic treatment as the first-line therapy [cyclosporine (55%); oral retinoid (30%)], and 45% a biological treatment [anti-TNFα (52%); anti-IL-17 (39%)]. The dermatologists agreed that the main challenges are to define and establish specific therapeutic goals to treat the disease including the patients' perspective on the management of the disease. CONCLUSION Our study describes the current situation on the management of GPP in Spain, increasing the present knowledge on the disease, and highlighting the current challenges faced at the moment.
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Affiliation(s)
- E Vilarrasa
- Servicio de Dermatología, Hospital de la Santa Creu i Sant Pau, Barcelona, España; Universitat Autónoma de Barcelona, Barcelona, España.
| | - R Rivera
- Servicio de Dermatología, Hospital Universitario 12 de Octubre, Madrid, España; Universidad Complutense, Madrid, España
| | - N Eiris
- Servicio de Dermatología, Hospital Universitario Virgen Macarena, Sevilla, España
| | - G Carretero
- Servicio de Dermatología, Hospital Universitario de Gran Canaria Doctor Negrin, Gran Canaria, España
| | - P de la Cueva
- Universidad Complutense, Madrid, España; Servicio de Dermatología, Hospital Infanta Leonor, Madrid, España
| | - J M Carrascosa
- Universitat Autónoma de Barcelona, Barcelona, España; Servicio de Dermatología, Hospital Germans Trias i Pujol, Barcelona, España; Instituto de Investigación Germans Trias i Pujol (IGTP), Barcelona, España
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8
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Armstrong AW, Elston CA, Elewski BE, Ferris LK, Gottlieb AB, Lebwohl MG. Generalized pustular psoriasis: A consensus statement from the National Psoriasis Foundation. J Am Acad Dermatol 2024; 90:727-730. [PMID: 37838256 DOI: 10.1016/j.jaad.2023.09.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 09/11/2023] [Accepted: 09/24/2023] [Indexed: 10/16/2023]
Affiliation(s)
- April W Armstrong
- Division of Dermatology, Department of Medicine, David Geffen School of Medicine at University of California, Los Angeles, California.
| | - Carly A Elston
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Boni E Elewski
- Department of Dermatology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Laura K Ferris
- Department of Dermatology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alice B Gottlieb
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Mark G Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mount Sinai, New York, New York
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Prignano F, Atzori L, Bellinato F, Damiani G, Galeone C, Mariani P, Potenza C, Scopinaro A, Piaserico S, Fabbrocini G. Epidemiology, Characteristics of Disease, and Unmet Needs of Patients with Generalized Pustular Psoriasis: A Large Italian Delphi Consensus. Dermatology 2024; 240:414-424. [PMID: 38493762 PMCID: PMC11168448 DOI: 10.1159/000538072] [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: 06/20/2023] [Accepted: 02/26/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Generalized pustular psoriasis (GPP) is a rare and chronic, debilitating skin condition characterized, in its acute flare phase, by clinically severe and potentially life-threatening systemic manifestations. Data on GPP are still scanty, particularly in Europe and at a national level. The aim of this study was to provide expert indications on several disease-related and patient-related aspects of GPP, with specific focus to the Italian context. METHODS We conducted an iterative eDelphi study following the recommended criteria for reporting methods and results. After a thorough bibliographic review aimed to identify unknown or controversial issues in GPP, the following areas were investigated through a few specific questions/statements for each area: (1) disease epidemiology; (2) disease characteristics, with specific interest toward GPP flares; (3) diagnosis and diagnostic delay; (4) GPP treatment; (5) GPP patient journey and use of healthcare resources in Italy; (6) unmet needs and quality of life. An Executive Board of 9 principal investigators revised and approved the topics to be examined and overviewed the whole project. A total of 35 experts from different Italian areas, including 34 board-certified Italian dermatologists and 1 representative of patients' associations, took part in the study. RESULTS A high agreement in responses from Italian experts emerged during two eDelphi iterations on - among several other aspects - GPP prevalence and incidence in Italy, use of European Rare and Severe Psoriasis Expert Network diagnostic criteria, flare frequency and duration, best diagnostic and care pathway, and main unmet needs of Italian patients. On the other hand, a broad spectrum of treatments (of different drug classes) was reported both in the acute and chronic phases of GPP, and no consensus on the issue was thus achieved. CONCLUSIONS Consensus findings from this Delphi study of GPP experts may be useful to fill gaps of knowledge and improve awareness of this rare disease, as well as to help clinical and public health management of GPP in Italy.
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Affiliation(s)
- Francesca Prignano
- Section of Dermatology, Department of Health Sciences, University of Florence, Florence, Italy
| | - Laura Atzori
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesco Bellinato
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Damiani
- Unit of Dermatology, IRCCS San Raffaele Hospital, Milan, Italy
- Italian Center of Precision Medicine and Chronic Inflammation, University of Milan, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Carlotta Galeone
- Bicocca Applied Statistics Center (B-ASC), Department of Economics, Management and Statistics, University of Milano-Bicocca, Milano, Italy,
| | - Paolo Mariani
- Bicocca Applied Statistics Center (B-ASC), Department of Economics, Management and Statistics, University of Milano-Bicocca, Milano, Italy
| | - Concetta Potenza
- Department of Medico-surgical Sciences and Biotechnologies, Sapienza University of Rome, Polo Pontino, Italy
| | - Annalisa Scopinaro
- Italian Federation of Rare Diseases Patients Associations (UNIAMO FIMR), Rome, Italy
| | - Stefano Piaserico
- Section of Dermatology, Department of Medicine, University of Padua, Padua, Italy
| | - Gabriella Fabbrocini
- Section of Dermatology and Venereology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
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10
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Fujita H, Iwasaki R, Tsuboi S, Murashiuma Y, Akiyama M. Regional differences in the prevalence of generalized pustular psoriasis in Japan. J Dermatol 2024; 51:380-390. [PMID: 38292005 DOI: 10.1111/1346-8138.17089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/30/2023] [Accepted: 12/11/2023] [Indexed: 02/01/2024]
Abstract
Generalized pustular psoriasis (GPP), a rare form of psoriasis, is characterized by neutrophil-rich, sterile pustules. In Japan, GPP has intractable and rare disease designation, which allows patients to access support from national and local governments for medical expenses. Previously, similar numbers of patients in Tokyo and Hokkaido have been shown to have GPP designation, despite different population sizes. Here, we determine whether there are regional differences in the proportion of patients receiving GPP designation status in Japan and aim to identify causal factors. In this descriptive, retrospective cohort study, publicly available data were collected on the number of patients with intractable and rare disease designation for GPP in each prefecture and age classification (April 2018-March 2021). Three other designated intractable and rare disease cohorts were included: pemphigus, rare skin diseases, and all diseases. The primary outcome was the standardized morbidity ratio (SMR) of patients at prefecture level (observed numbers divided by expected). Regional differences were compared with the statistical expectation for the total population and age distribution of each prefecture. Regional differences were observed in all cohorts. Overall, 1910 patients had GPP as a designated intractable and rare disease in 2020. Regional differences in SMRs for GPP were observed with high SMRs (≥1.5) in Hokkaido, Tottori, Kagawa, and Miyazaki, and low SMRs (<0.6) in Gunma and Kanagawa. Regional differences in SMRs for GPP did not correlate with the number of medical doctors or dermatologists or internal migration. The number of medical doctors or dermatologists correlated with SMRs in the rare skin diseases and total cohorts. Regional differences in Japan exist in the number of patients with GPP who have an intractable and rare disease designation. Managing rare diseases is an important public health issue, and further research is required to elucidate the factors contributing to these differences.
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Affiliation(s)
- Hideki Fujita
- Department of Dermatology, Nihon University School of Medicine, Tokyo, Japan
| | | | | | | | - Masashi Akiyama
- Department of Dermatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Cardenas-de la Garza JA, Zazueta-López RM, Garza-Elizondo AK, Flores-Gutierrez DP, Welsh E. Spesolimab treatment in a patient with generalized pustular psoriasis: a case report with 12-month follow-up and literature review. Clin Exp Dermatol 2024; 49:286-288. [PMID: 37966307 DOI: 10.1093/ced/llad389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023]
Abstract
This article explores the use of spesolimab in generalized pustular psoriasis (GPP) and presents the case of a Hispanic patient with GPP and plaque psoriasis treated with spesolimab and the 12-month follow-up presenting remission and significant improvement of their plaque psoriasis. A literature review identified limited cases of GPP treated with spesolimab with high response rates to the biologic and frequent mild adverse events. Most articles do not mention a previous history of plaque psoriasis and its response to spesolimab. This report highlights the efficacy of spesolimab in managing GPP, although further research is needed to assess the long-term effects of spesolimab in patients with GPP, particularly those with a history of plaque psoriasis.
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Affiliation(s)
| | | | - Angel Kevin Garza-Elizondo
- Rheumatology Department, Universidad Autónoma de Nuevo León, Hospital Universitario 'Dr José Eleuterio González', Monterrey NL, Mexico
| | - Diana Paola Flores-Gutierrez
- Rheumatology Department, Universidad Autónoma de Nuevo León, Hospital Universitario 'Dr José Eleuterio González', Monterrey NL, Mexico
| | - Esperanza Welsh
- Welsh Dermatology and Associates, Monterrey Nuevo León, Mexico
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12
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Choon SE, De La Cruz C, Wolf P, Jha RK, Fischer KI, Goncalves-Bradley DC, Hepworth T, Marshall SR, Gottlieb AB. Health-related quality of life in patients with generalized pustular psoriasis: A systematic literature review. J Eur Acad Dermatol Venereol 2024; 38:265-280. [PMID: 37750484 DOI: 10.1111/jdv.19530] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023]
Abstract
Generalized pustular psoriasis (GPP) is a rare, chronic, neutrophilic inflammatory skin disease characterized by episodes of widespread eruption of sterile, macroscopic pustules that can be accompanied by systemic inflammation and symptoms. A systematic literature review and narrative synthesis were conducted to determine the impact of GPP on patients' health-related quality of life (HRQoL) and patient-reported severity of symptoms and to compare its impact to patients with plaque psoriasis (plaque PsO). Searches were undertaken in Embase, MEDLINE and the Cochrane Library from 1 January 2002 to 15 September 2022. Screening was carried out by two reviewers independently. Outcome measures included generic (e.g. EQ-5D, SF-36) and dermatology-specific (e.g. DLQI) clinical outcome assessments, and other relevant patient-reported outcome measures (PROMs) (e.g. severity of pain measured by a numerical rating scale). Overall, 20 studies were found to be eligible for inclusion, of which seven also had data for plaque PsO. The DLQI was the most frequently reported outcome measure (16 out of 20 studies). When reported, mean DLQI (SD) scores varied from 5.7 (1.2) to 15.8 (9.6) across the studies, indicating a moderate to very large effect on HRQoL; the wide range of scores and large SDs were explained by the small population sizes (n ≤ 12 for all studies except two). Similar ranges and large SDs were also observed for other measures within individual studies. However, in general, people with GPP reported a greater impact of their skin condition on HRQoL, when compared to people with plaque PsO (i.e. higher DLQI scores) and higher severity for itch, pain and fatigue. This systematic review highlighted the need for studies with a larger population size, a better understanding of the impact of cutaneous and extracutaneous symptoms and comorbidities on HRQoL during and between GPP flares, and outcome measures specifically tailored to the unique symptoms and the natural course/history of GPP.
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Affiliation(s)
- S E Choon
- Hospital Sultanah Aminah Johor Bahru, Clinical School Johor Bahru, Monash University Malaysia, Johor Bahru, Malaysia
| | | | - P Wolf
- Department of Dermatology, Medical University of Graz, Graz, Austria
| | - R K Jha
- Boehringer Ingelheim International GmBH, Ingelheim am Rhein, Germany
| | - K I Fischer
- Boehringer Ingelheim International GmBH, Ingelheim am Rhein, Germany
| | | | | | - S R Marshall
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, USA
| | - A B Gottlieb
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
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13
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Bhutani T, Farberg AS. Clinical and Disease Burden of Patients with Generalized Pustular Psoriasis: A Review of Real-World Evidence. Dermatol Ther (Heidelb) 2024; 14:341-360. [PMID: 38363460 PMCID: PMC10891013 DOI: 10.1007/s13555-024-01103-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/17/2024] [Indexed: 02/17/2024] Open
Abstract
Generalized pustular psoriasis (GPP) is a chronic, rare, and potentially life-threatening disease. There is limited understanding of patient characteristics in GPP and their correlation with disease progression or healthcare resource utilization. Our review aims to examine real-world evidence on these characteristics and the associated disease burden as related to economic and quality of life factors. Results showed that most patients with GPP experienced flares once a year, lasting from 2 weeks to 3 months, with > 80% of patients having residual disease post-flare, with/without treatment, indicating the long-term nature of GPP. The impact of GPP on patients' daily activities was significant, even in the absence of a flare. GPP adversely affected mental health, and anxiety and depression were reported regularly. Patients with GPP had more comorbidities, were prescribed more medication, and had more inpatient and outpatient visits than in matched plaque psoriasis or general population cohorts. Improving the education of healthcare providers in diagnosing GPP, defining disease flares, and managing the disease, as well as making globally accepted clinical guidelines for GPP treatment available, could help to reduce the burden on patients with GPP. Effective therapies that control and prevent GPP flares and manage chronic disease are needed.
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Affiliation(s)
- Tina Bhutani
- Psoriasis and Skin Treatment Center, University of California at San Francisco, San Francisco, CA, 94118, USA.
| | - Aaron S Farberg
- Bare Dermatology, Dallas, TX, USA
- Baylor Scott and White Health System, Dallas, TX, USA
- University of North Texas Health Science Center, Fort Worth, TX, USA
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14
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Wolf P, Ceovic R, Conrad C, Falkensteiner K, Graier T, Kołt-Kamińska M, Marovt M, Mateeva V, Maul JT, Navarini AA, Nicolescu AC, Ratzinger G, Pavlovsky L, Sanzharovskaya M, Szegedi A, Reich A. Characteristics and management of generalized pustular psoriasis (GPP): Experience from the Central and Eastern Europe (CEE) GPP Expert Network. J Eur Acad Dermatol Venereol 2024. [PMID: 38279888 DOI: 10.1111/jdv.19808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 12/06/2023] [Indexed: 01/29/2024]
Abstract
BACKGROUND Generalized pustular psoriasis (GPP) is a rare, inflammatory skin disease characterized by widespread eruption of sterile pustules with or without systemic symptoms. OBJECTIVES This study aimed to describe the demographics of patients with GPP in Central and Eastern Europe (CEE), present the clinical characteristics of individual GPP flares and explore the current treatment landscape. METHODS Patient demographics were collected at the times of last observation and previous treatment. Characteristics of a patient's last (most recent) and most severe (from all documented episodes) flare were provided at clinician's discretion. RESULTS Fifty-eight patients were recruited from 12 centres in nine CEE countries; median (range) age was 61 (16-92) years and 60.3% (35 out of 58) were female. The most common comorbidities were hypertension (43.1% [25 out of 58]) and hyperlipidaemia (32.8% [19 out of 58]). Thirty-four patients (58.6%) presented with concomitant plaque psoriasis before or during the course of GPP. Data from two separate flares were recorded in 26 individuals; in 32 patients, the most recent flare was reported as the most severe. Over 90% of patients with a flare episode classified as most severe by clinicians were hospitalized, with >75% of these individuals having a Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) total score of 3 or 4. Systemic symptoms were more common in patients with a GPPGA score of 3 or 4 but were also manifest in individuals with a GPPGA score ≤2. A significant correlation was observed between a combined systemic disease score of clinical and laboratory features and both GPPGA total score (r = 0.385, p < 0.001) and GPPGA pustulation subscore (r = 0.305, p < 0.05). CONCLUSIONS Considerable heterogeneity in the presentation of GPP flares was observed, both between patients and within-patient. All GPP flares were associated with a significant clinical burden, highlighting the unmet need for accurate and early diagnosis.
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Affiliation(s)
- P Wolf
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - R Ceovic
- Department of Dermatology and Venereology, School of Medicine University of Zagreb, University Hospital Centre Zagreb, Zagreb, Croatia
| | - C Conrad
- Department of Dermatology, Lausanne University Hospital, Lausanne, Switzerland
| | - K Falkensteiner
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - T Graier
- Department of Dermatology and Venereology, Medical University of Graz, Graz, Austria
| | - M Kołt-Kamińska
- Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszów University, Rzeszów, Poland
| | - M Marovt
- Department of Dermatology, University Medical Centre Maribor, Maribor, Slovenia
| | - V Mateeva
- Department of Dermatology, Medical University of Sofia, Sofia, Bulgaria
| | - J-T Maul
- Department of Dermatology, University Hospital of Zürich, Zürich, Switzerland
- Faculty of Medicine, University of Zürich, Zürich, Switzerland
| | - A A Navarini
- Department of Dermatology, University Hospital of Basel, Basel, Switzerland
| | - A C Nicolescu
- Emergency Clinical Hospital Agrippa Ionescu, Bucharest, Romania
| | - G Ratzinger
- Department of Dermatology, Venereology and Allergology, Medical University of Innsbruck, Innsbruck, Austria
| | - L Pavlovsky
- Division of Dermatology, Rabin Medical Center, Tel Aviv University, Tel Aviv, Israel
| | | | - A Szegedi
- Department of Dermatology, University of Debrecen, Debrecen, Hungary
| | - A Reich
- Department of Dermatology, Institute of Medical Sciences, Medical College of Rzeszów University, Rzeszów, Poland
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15
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Garg A, Noe MH, Anadkat MJ, Armstrong A, Bhutani T, Farberg A, Han G, Hawkes JE, Lebwohl M, Rekhtman S, Song EJ, Strunk A, Duffin KC. Development of the Generalized Pustular Psoriasis Clinical Assessment Tool. J Am Acad Dermatol 2024; 90:192-195. [PMID: 37739266 DOI: 10.1016/j.jaad.2023.08.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/01/2023] [Accepted: 08/05/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Amit Garg
- Department of Dermatology, Northwell Health, New Hyde Park, New York.
| | - Megan H Noe
- Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Milan J Anadkat
- Division of Dermatology, Washington University School of Medicine, St. Louis, Missouri
| | - April Armstrong
- Division of Dermatology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Tina Bhutani
- Department of Dermatology, University of California San Francisco School of Medicine, San Francisco, California
| | | | - George Han
- Department of Dermatology, Northwell Health, New Hyde Park, New York
| | - Jason E Hawkes
- Department of Dermatology, University of California Davis, Sacramento, California
| | - Mark Lebwohl
- Department of Dermatology, Icahn School of Medicine at Mt Sinai, Manhattan, New York
| | - Sergey Rekhtman
- Department of Dermatology, Northwell Health, New Hyde Park, New York
| | | | - Andrew Strunk
- Department of Dermatology, Northwell Health, New Hyde Park, New York
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16
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Wei L, Zhang B, Wang L, Xu J, Liu A. Knowledge Mapping and Research Hotspots of Generalized Pustular Psoriasis: A Bibliometric Analysis from 2003 to 2023. Clin Cosmet Investig Dermatol 2023; 16:3629-3643. [PMID: 38144159 PMCID: PMC10749173 DOI: 10.2147/ccid.s440741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 12/09/2023] [Indexed: 12/26/2023]
Abstract
Background Generalised pustular psoriasis (GPP) is a chronic inflammatory skin disease. We aimed to visualize the research hotspots and trends of GPP using bibliometric analysis to enhance our comprehension of the future advancements in both basic science and clinical research. Methods Relevant publications from July 2003 to July 2023 were obtained from the Web of Science Core Collection on July 12, 2023. The analysis of countries, institutions, authors, references, and keywords associated with this subject was conducted through the utilisation of CiteSpace 6.2.R4, VOSviewer 1.6.18, and Microsoft Excel 2019. Results A total of 578 papers were analyzed, authored by 2758 researchers from 191 countries/regions and 1868 institutions, published in 174 academic journals. There was an overall upward trajectory in the volume of annual publications, accompanied by a gradual intensification of research interest in GPP. The United States, UDICE-French Research Universities, and Akiyama M of Nagoya University were the most productive and influential country, institution, and author, respectively. The Journal of Dermatology ranked first with the highest publications, and the Journal of the American Academy of Dermatology received the most citations. High-frequency keywords included "generalized pustular psoriasis", "psoriasis, interleukin-36", "plaque psoriasis", "skin-disease", and "antagonist deficiency". Recent research focuses have included "safety", "secukinumab", "spesolimab", "ap1s3 mutations", and "interleukin-36". Burst detection analysis of keywords showed that "moderate", "ixekizumab treatment", "mutations", "efficacy", and "safety" are current research frontiers in this field. Conclusion This bibliometric analysis delineated the landmark publications in GPP that have defined current research hotspots and development trends, notably the applications, efficacy, and safety of biological agents. Future research endeavors are warranted to explore other biological therapeutic options for both acute GPP and the long-term management of chronic GPP.
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Affiliation(s)
- Lu Wei
- Department of Dermatology, Henan University of Chinese Medicine, Zhengzhou, Henan, People’s Republic of China
| | - Buxin Zhang
- Department of Dermatology, Henan Province Hospital of Traditional Chinese Medicine, The Second Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, People’s Republic of China
| | - Li Wang
- Department of Dermatology, Henan Province Hospital of Traditional Chinese Medicine, The Second Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, People’s Republic of China
| | - Juntao Xu
- Department of Dermatology, Henan Province Hospital of Traditional Chinese Medicine, The Second Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, People’s Republic of China
| | - Aimin Liu
- Department of Dermatology, Henan University of Chinese Medicine, Zhengzhou, Henan, People’s Republic of China
- Department of Dermatology, Henan Province Hospital of Traditional Chinese Medicine, The Second Affiliated Hospital of Henan University of Chinese Medicine, Zhengzhou, Henan, People’s Republic of China
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17
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Haugaard JH, Thein D, Egeberg A. Characteristics and prognosis of first-time hospitalized patients with generalized pustular psoriasis: insights from national databases. Br J Dermatol 2023; 190:131-132. [PMID: 37804532 DOI: 10.1093/bjd/ljad384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/29/2023] [Accepted: 10/03/2023] [Indexed: 10/09/2023]
Abstract
In a Danish nationwide population-based study, we found that the mortality rate for patients with first-time hospitalization for generalized pustular psoriasis was zero during hospitalization but increased to 7% within the first 12 months following discharge. The study period spanned 2008–2017; in this period, the most frequently prescribed pharmacotherapy during hospitalization was acitretin, followed by methotrexate.
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Affiliation(s)
| | - David Thein
- Department of Dermatology, Bispebjerg Hospital
| | - Alexander Egeberg
- Department of Dermatology, Bispebjerg Hospital
- Department of Clinical Medicine, University of Copenhagen, Copenhagen , Denmark
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18
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Hayama K, Iwasaki R, Tian Y, Fujita H. Factors associated with generalized pustular psoriasis progression among patients with psoriasis vulgaris in Japan: Results from a claims database study. J Dermatol 2023; 50:1531-1538. [PMID: 37721393 DOI: 10.1111/1346-8138.16949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/24/2023] [Accepted: 08/17/2023] [Indexed: 09/19/2023]
Abstract
Of those patients diagnosed with generalized pustular psoriasis (GPP) in Japan, approximately 30% have a prior psoriasis vulgaris (PsV) diagnosis. Therefore, understanding factors associated with a GPP diagnosis is essential for early diagnosis of GPP in patients with PsV. This retrospective cohort study was conducted to identify associated factors for GPP diagnosis in patients with PsV. Eligible patients with two confirmed diagnoses of PsV with/without a confirmed GPP diagnosis (International Classification of Disease 10th revision codes L40.0 and L40.1, respectively) were identified from the Japanese Medical Data Center database (JMDC) (July 1, 2005-January 31, 2019). Weighted logistic regression was used to identify associated factors (based on recorded comorbidities) between the PsV only and PsV with GPP cohorts. Odds ratios (ORs) of ≥1.5, associated with a high probability of a GPP diagnosis, were reported for factors with ≥5 patients/cohort. The time from event to GPP diagnosis was evaluated. The highest associated factor for GPP diagnosis was psoriatic arthritis (OR 20.2, 95% confidence interval [CI] 17.06-23.92, P < 0.0001), which also had the shortest time from event to GPP diagnosis (median 119 days). Other comorbidities associated with GPP diagnosis were other psoriasis, tonsillitis, and sinusitis. Treatments associated with GPP diagnosis included systemic corticosteroids (OR 2.19, 95% CI 1.98-2.43, P < 0.0001; median time from treatment initiation to GPP diagnosis 180 days). Other associated treatments (other immunosuppressants, interleukin [IL]-17 or IL-23 inhibitors, and phototherapy) had a delay of ≥1 year from treatment initiation to GPP diagnosis. Back pain, headache, and fever were also identified as associated with a GPP diagnosis. Patients with PsV requiring systemic therapies are more likely to receive a GPP diagnosis than those not requiring systemic treatment. These data will help identify patients with PsV at high risk of developing GPP and potentially support early GPP diagnosis.
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Affiliation(s)
| | | | - Yahui Tian
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, USA
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19
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Hawkes JE, Visvanathan S, Krueger JG. The role of the interleukin-36 axis in generalized pustular psoriasis: a review of the mechanism of action of spesolimab. Front Immunol 2023; 14:1292941. [PMID: 38077370 PMCID: PMC10703363 DOI: 10.3389/fimmu.2023.1292941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 10/31/2023] [Indexed: 12/18/2023] Open
Abstract
Generalized pustular psoriasis (GPP) is a rare, chronic, inflammatory skin disorder characterized by recurrent flares associated with skin erythema, desquamation, and widespread superficial sterile pustules, which may be severe ("lakes of pus"). Systemic symptoms are often present, including malaise, fever, and skin pain. In GPP, innate immune responses are driven by abnormal activation of the interleukin (IL)-36-chemokine-neutrophil axis and excessive neutrophil infiltration. This review highlights the IL-36 pathway in the context of the IL-1 superfamily and describes how unopposed IL-36 signaling can lead to the development of GPP. Targeted inhibition of the IL-36 receptor (IL-36R) is an attractive therapeutic strategy in the treatment of GPP, including flare prevention and sustained disease control. Spesolimab is a first-in-class, humanized, monoclonal antibody that binds specifically to the IL-36R and antagonizes IL-36 signaling. Spesolimab was approved by the US Food and Drug Administration in September 2022 to treat GPP flares in adults and was subsequently approved for GPP flare treatment in other countries across the world. Anti-IL-36R therapy, such as spesolimab, can mitigate flares and address flare prevention in GPP, presumably through rebalancing IL-36 signaling and modulating the pro-inflammatory response of the downstream effectors.
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Affiliation(s)
- Jason E. Hawkes
- Integrative Skin Science and Research and Pacific Skin Institute, Sacramento, CA, United States
| | - Sudha Visvanathan
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, CT, United States
| | - James G. Krueger
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, NY, United States
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20
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Hawkes JE, Reisner DV, Bhutani T. Exploring the Quality-of-Life Impact, Disease Burden, and Management Challenges of GPP: The Provider and Patient Perspective [Podcast]. Clin Cosmet Investig Dermatol 2023; 16:3333-3339. [PMID: 38021429 PMCID: PMC10663504 DOI: 10.2147/ccid.s444238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/11/2023] [Indexed: 12/01/2023]
Abstract
Generalized pustular psoriasis (GPP) is a rare, chronic, and debilitating disease characterized by flares of widespread erythema, desquamation, and pustule formation. GPP flares can be accompanied by systemic symptoms including fever, fatigue, malaise, and skin pain; severe cases may be fatal if untreated. Although GPP may occur concurrently with plaque psoriasis, they represent two distinct inflammatory conditions. Patients with GPP experience a substantial burden of disease, and the impact of GPP on an individual's mental health and quality-of-life (QoL) goes far beyond skin pain and discomfort. The rarity of GPP may result in a misdiagnosis, as the sudden onset of skin pustules may be mistaken for a primary infection. Misdiagnosis with a subsequent delay in treatment has tremendous negative consequences for the affected patient. In September 2022, spesolimab became the first FDA-approved medication in the US for the treatment of GPP flares in adults. Spesolimab has since been approved by regulatory agencies in numerous countries, including Japan, Mainland China, and the EU. Prior to spesolimab, the clinical management of GPP relied on the off-label use of systemic or biologic therapies approved for plaque psoriasis or other inflammatory conditions. There is a need for increased education among healthcare providers regarding the clinical diagnosis, risk stratification, and therapeutic management of this rare disease, including the other novel GPP-specific therapies in development. In this podcast, two dermatologists and a patient who has plaque psoriasis and GPP discuss the clinical presentation, symptoms, disease burden, QoL impacts, diagnostic challenges, and therapeutic strategies for the management of GPP.
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Affiliation(s)
- Jason E Hawkes
- Department of Dermatology, University of California at Davis, Sacramento, CA, USA
| | | | - Tina Bhutani
- Psoriasis and Skin Treatment Center, Department of Dermatology, University of California at San Francisco, San Francisco, CA, USA
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21
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Wang HM, Xu JM, Jin HZ. Characteristics and Burdens of Disease in Patients from Beijing with Generalized Pustular Psoriasis and Palmoplantar Pustulosis: Multicenter Retrospective Cohort Study Using a Regional Database. Am J Clin Dermatol 2023; 24:991-1002. [PMID: 37386353 DOI: 10.1007/s40257-023-00807-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND OBJECTIVE Pustular psoriasis is a chronic and recurrent autoimmune disease, although little is known about the disease burden of pustular psoriasis in China. We analyzed the characteristics and disease burdens of patients from Beijing who had generalized pustular psoriasis (GPP) or palmoplantar pustulosis (PPP). METHODS This multicenter retrospective cohort study used a regional electronic health database that covered 30 public hospitals in Beijing. From June 2016 to June 2021, all patients with a diagnosis of GPP, PPP, or psoriasis vulgaris (PV) were identified by International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes. The GPP and PPP cohorts were separately matched with patients with PV in a 3:1 ratio for comparisons. Demographic data, clinical characteristics, healthcare resource utilization, and costs were collected. Descriptive and comparative analyses were used to compare the cohorts. RESULTS There were 744 patients with GPP (46.8% men; age 42.14 ± 21.47 years) and 4808 patients with PPP (35.5% men; age 51.65 ± 16.12 years); 14.5% of patients with GPP had concomitant PV and 7.5% of patients with PPP had concomitant PV. Relative to matched patients with PV, patients with GPP had a higher prevalence of erythrodermic psoriasis (5.9% vs 0.4%, p < 0.0001), psoriatic arthritis (3.1% vs 1.5%, p = 0.007), and organ failure (1.1% vs 0.2%, p = 0.002). Relative to matched patients with PV, patients with PPP had a higher prevalence of cerebrovascular disease (4.7% vs 1.2%, p < 0.0001), thyroid dysfunction (3.9% vs 3.3%, p = 0.035), and type 2 diabetes mellitus (6.8% vs 5.9%, p = 0.030). More patients with GPP than patients with PV received systemic non-biological agents (27.9% vs 3.3%, p < 0.0001) and biologic agents (4.8% vs 2.0%, p = 0.010). More patients with PPP than patients with PV received topical agents (50.9% vs 34.7%, p < 0.0001) and systemic non-biological agents (17.8% vs 2.7%, p < 0.0001). More patients with GPP than patients with PV required inpatient hospitalization (22.0% vs 7.8%, p < 0.0001). Hospitalization stay was longer in patients with GPP than patients with PV (11.72 ± 0.45 vs 10.38 ± 0.45 days, p = 0.022). More patients with PPP than patients with PV had emergency visits (16.3% vs 12.8%, p < 0.0001). The GPP and PPP cohorts and their matched PV cohorts had no significant differences in costs. However, patients with PPP had lower outpatient costs than patients with PV (368.20 ± 8.19 vs 445.38 ± 5.90 Chinese Yuan per patient per month, p < 0.0001). CONCLUSIONS Patients from Beijing with GPP and PPP had higher disease burdens than matched PV cohorts, including the prevalence of comorbidities, healthcare resource utilization, and medication burden. However, the economic burden of pustular psoriasis was similar to that of PV. Practical and specific therapies are needed to reduce the burdens of pustular psoriasis.
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Affiliation(s)
- Hai-Meng Wang
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (Dongdan campus), Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, No.1 Shuaifuyuan, Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Jia-Ming Xu
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (Dongdan campus), Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, No.1 Shuaifuyuan, Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Hong-Zhong Jin
- Department of Dermatology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital (Dongdan campus), Chinese Academy of Medical Sciences and Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases, No.1 Shuaifuyuan, Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
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22
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Jo SJ, Jaihyun Cho R. Preventing generalised pustular psoriasis. Lancet 2023; 402:1501-1503. [PMID: 37739000 DOI: 10.1016/s0140-6736(23)01480-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/13/2023] [Indexed: 09/24/2023]
Affiliation(s)
- Seong Jin Jo
- Department of Dermatology, Seoul National University College of Medicine, Seoul, South Korea
| | - Raymond Jaihyun Cho
- Department of Dermatology, University of California, San Francisco, CA 94115, USA.
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23
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Song EJ, Liu C. Exploring the Clinical Assessment, Guidelines, and Options for the Treatment of Generalized Pustular Psoriasis [Podcast]. Clin Cosmet Investig Dermatol 2023; 16:2911-2917. [PMID: 37915421 PMCID: PMC10616673 DOI: 10.2147/ccid.s442437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 09/28/2023] [Indexed: 11/03/2023]
Abstract
Acute episodes of generalized pustular psoriasis (GPP), known as "flares", are characterized by the widespread appearance of pustules with surrounding skin erythema, and are often accompanied by systemic symptoms. The clinical course of GPP is unpredictable, and symptoms vary in extent and severity; the disease may be relapsing-remitting with recurrent episodes of pustulosis, or be more persistent. The triggers that may lead to flares include withdrawal of corticosteroids, stress, pregnancy, and infections. GPP-specific assessment tools, such as the Generalized Pustular Psoriasis Physician Global Assessment (GPPGA) and the General Pustular Psoriasis Area and Severity Index (GPPASI), were developed to evaluate the severity of disease, and to monitor the patient's response to therapy during clinical trials. Spesolimab is the first GPP-specific treatment available in the United States for the treatment of GPP flares in adults, and was approved by the US FDA in September 2022. To date, spesolimab has been approved by regulatory agencies in almost 40 countries, including Japan, Mainland China, and the European Union. Spesolimab is a first-in-class humanized monoclonal antibody that targets the interleukin-36 receptor, and blocks the downstream effects of the interleukin-36 pathway, which is associated with GPP pathogenesis. Data from clinical trials demonstrate the safety and efficacy of spesolimab in providing rapid clinical improvement for patients with GPP flares. Standardized international guidelines for the diagnosis and management of GPP are needed, and no recent GPP guidelines are available in the US. This podcast discusses clinical assessment tools for GPP (GPPGA and GPPASI), the evolution of GPP management guidelines, the therapeutic landscape of GPP, efficacy and safety data for spesolimab, and examines important considerations for patients living with this condition.
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Affiliation(s)
| | - Clive Liu
- Bellevue Dermatology Clinic, Bellevue, Washington, USA
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Choon SE, Wright AK, Griffiths CEM, Wong KW, Tey KE, Lim YT, Chua KY, Ashcroft DM. Incidence and prevalence of generalized pustular psoriasis in multiethnic Johor Bahru, Malaysia: a population-based cohort study using routinely captured electronic health records in the Teleprimary Care (TPC®) clinical information system from 2010 to 2020. Br J Dermatol 2023; 189:410-418. [PMID: 37162007 DOI: 10.1093/bjd/ljad158] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 05/04/2023] [Accepted: 05/06/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND There is limited understanding of the epidemiology of generalized pustular psoriasis (GPP) internationally, with no population-based estimates of GPP in South East Asia. OBJECTIVES To determine the incidence and prevalence of GPP in the Malaysian population and characterize its flares and trigger factors. METHODS We conducted a population-based cohort study using the Teleprimary Care database between January 2010 and December 2020. We identified 230 dermatologist-confirmed GPP cases using International Classification of Diseases, 10th revision, diagnostic codes. Annual prevalence and incidence rates were stratified by age, sex and ethnicity. We compared data regarding flares and trigger factors for patients with GPP who had associated psoriasis vulgaris (PV) with those who did not have associated PV. RESULTS The prevalence of GPP was 198 per million (267 women, 127 men) and incidence was 27.2 per million person-years [95% confidence interval (CI) 22.8-31.6]; 35.3 (28.4-42.2) per million person-years for women and 18.3 (13.1-23.5) per million person-years for men. Rates were higher in Chinese individuals [prevalence 271 per million; incidence 41.6 per million person-years (28.9-54.3)] than in the Malay population [prevalence 186; incidence 24.6 (19.4-29.7)] or the Indian ethnic group [prevalence 179; incidence 25.0 (13.8-36.3)]. Annual prevalence was consistently higher in women than in men and highest among the Chinese population, followed by the Indian and Malay populations. Overall, 67% of patients with GPP had associated PV. The prevalence and incidence of GPP without PV were lower than GPP with PV at 66 vs. 132 per million and 19.3 (95% CI 15.6-23.0) vs. 8.0 (95% CI 5.6-10.3) per million person-years, respectively. The mean age at GPP onset was 42.7 years (SD 18.4). A bimodal trend in the age of GPP onset was observed, with first and second peaks at age 20-29 years and age 50-59 years, respectively. Disease onset was significantly earlier in patients with GPP without PV than in those with PV [mean age 37.5 years (SD 20.7) vs. 44.9 years (SD 17.0), P = 0.026]. Flares occurred more frequently in patients without PV than in those with PV [mean number of flares per patient per year was 1.35 (SD 0.77) vs. 1.25 (SD 0.58), P = 0.039]. Common triggers of flares in patients with GPP who did not have PV were infections, pregnancy, menstruation and stress, whereas withdrawal of therapy, particularly systemic corticosteroids, was a more frequent trigger in patients with GPP who also had PV. CONCLUSIONS Our findings contribute to the global mapping of GPP, which will help inform the management of this rare condition.
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Affiliation(s)
- Siew Eng Choon
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Alison K Wright
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health
| | - Christopher E M Griffiths
- Centre for Dermatology Research, NIHR Manchester Biomedical Research Centre, University of Manchester, Manchester, UK
- Department of Dermatology, King's College Hospital, King's College London, London, UK
| | - Kit Wan Wong
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Kwee Eng Tey
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Yee Ting Lim
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Keow Yin Chua
- Department of Dermatology, Hospital Sultanah Aminah, Johor Bahru, Malaysia
- Clinical School Johor Bahru, Jeffrey Cheah School of Medicine & Health Sciences, Monash University, Selangor, Malaysia
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health
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Ericson O, Löfvendahl S, Norlin JM, Gyllensvärd H, Schmitt-Egenolf M. Mortality in generalized pustular psoriasis: A population-based national register study. J Am Acad Dermatol 2023; 89:616-619. [PMID: 37230364 DOI: 10.1016/j.jaad.2023.04.066] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/24/2023] [Accepted: 04/27/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Oskar Ericson
- The Swedish Institute for Health Economics, Lund, Sweden
| | - Sofia Löfvendahl
- The Swedish Institute for Health Economics, Lund, Sweden; Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Faculty of Medicine, Lund University, Lund, Sweden
| | - Jenny M Norlin
- The Swedish Institute for Health Economics, Lund, Sweden
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Kodali N, Blanchard I, Kunamneni S, Lebwohl MG. Current management of generalized pustular psoriasis. Exp Dermatol 2023; 32:1204-1218. [PMID: 36779681 DOI: 10.1111/exd.14765] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/06/2023] [Accepted: 02/08/2023] [Indexed: 02/14/2023]
Abstract
Generalized pustular psoriasis (GPP) is a rare subset of psoriasis involving episodes of sterile pustules accompanied by inflammation and, often, systemic involvement. The inflammatory nature of GPP has potential for severe multisystem complications including high-output cardiac failure, infections, digestive system issues, and disfiguring or lethal acute flare episodes. The disease tends to have higher prevalence in females and Asians. The IL-1/IL-36 inflammatory pathway is a critical facet of GPP's pathology. Genetic mutations that are associated with GPP include modifications of Interleukin 36 Receptor Antagonist (IL36RN), Caspase Recruitment Domain Family Member 14 (CARD14), Adaptor Related Protein Complex 1 Subunit Sigma 3 (AP1S3), Myeloperoxidase (MPO) and Serpin Peptidase Inhibitor Clade A Member 3 (SERPINA3) genes. Treatment guidelines for GPP are not well-entrenched. Currently, only one GPP-specific treatment, the interleukin-36 receptor antagonist (IL-36Ra) spesolimab, has been approved for use in the United States. Additional anti-IL-36 pathway therapies are currently being developed. Other treatment options include other biologic therapies such as IL-17 inhibitors, IL-23 inhibitors and TNFα inhibitors. Non-biologic therapeutic options include retinoids, cyclosporine and methotrexate. Treatment options differ throughout the world; most countries utilize retinoids, cyclosporine and methotrexate as first-line non-biologic options. China and United Kingdom have no GPP-specific biologic therapies approved for use, while several biologic therapies are approved for use in Japan. This review aims to serve as an update on the current global management of GPP while also including relevant aspects of disease pathogenesis, diagnosis, clinical presentation, histopathology, aetiology and epidemiology.
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Affiliation(s)
- Nilesh Kodali
- Department of Education, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Isabella Blanchard
- Department of Education, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Sruthi Kunamneni
- Department of Education, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Mark G Lebwohl
- Dermatology, The Icahn School of Medicine at Mount Sinai, New York City, New York, USA
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Nunziato M, Balato A, Ruocco A, D’Argenio V, Di Caprio R, Balato N, Ayala F, Salvatore F. A Familial Novel Putative-Pathogenic Mutation Identified in Plaque-Psoriasis by a Multigene Panel Analysis. Int J Mol Sci 2023; 24:ijms24054743. [PMID: 36902182 PMCID: PMC10003515 DOI: 10.3390/ijms24054743] [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: 01/17/2023] [Revised: 02/14/2023] [Accepted: 02/24/2023] [Indexed: 03/06/2023] Open
Abstract
Psoriasis is a chronic multifactorial skin disorder with an immune basis. It is characterized by patches of skin that are usually red, flaky and crusty, and that often release silvery scales. The patches appear predominantly on the elbows, knees, scalp and lower back, although they may also appear on other body areas and severity may be variable. The majority of patients (about 90%) present small patches known as "plaque psoriasis". The roles of environmental triggers such as stress, mechanical trauma and streptococcal infections are well described in psoriasis onset, but much effort is still needed to unravel the genetic component. The principal aim of this study was to use a next-generation sequencing technologies-based approach together with a 96 customized multigene panel in the attempt to determine if there are germline alterations that can explain the onset of the disease, and thus to find associations between genotypes and phenotypes. To this aim, we analyzed a family in which the mother showed mild psoriasis, and her 31-year-old daughter had suffered from psoriasis for several years, whereas an unaffected sister served as a negative control. We found variants already associated directly to psoriasis in the TRAF3IP2 gene, and interestingly we found a missense variant in the NAT9 gene. The use of multigene panels in such a complex pathology such as psoriasis can be of great help in identifying new susceptibility genes, and in being able to make early diagnoses especially in families with affected subjects.
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Affiliation(s)
- Marcella Nunziato
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via Gaetano Salvatore, 486, 80145 Naples, Italy
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Anna Balato
- Dermatology Unit, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy
| | - Anna Ruocco
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via Gaetano Salvatore, 486, 80145 Naples, Italy
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Valeria D’Argenio
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via Gaetano Salvatore, 486, 80145 Naples, Italy
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Via Sergio Pansini, 5, 80131 Naples, Italy
- Department of Human Sciences and Quality of Life Promotion, San Raffaele Open University, 00166 Roma, Italy
| | - Roberta Di Caprio
- Microbiology and Virology Unit, Cotugno Hospital, AORN Dei Colli, Via Gaetano Quagliariello, 54, 80131 Naples, Italy
| | - Nicola Balato
- Italian “School of Psoriasis” Association, 81031 Aversa, Italy
| | - Fabio Ayala
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Via Sergio Pansini, 5, 80131 Naples, Italy
| | - Francesco Salvatore
- CEINGE-Biotecnologie Avanzate Franco Salvatore, Via Gaetano Salvatore, 486, 80145 Naples, Italy
- Department of Molecular Medicine and Medical Biotechnologies, University of Naples Federico II, Via Sergio Pansini, 5, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-081-3737-826 or +39-081-3737-758
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