Comparative assessment of biologics in treatment of psoriasis: drug design and clinical effectiveness of ustekinumab

A study of biophysical profile of inguinal skin: An implication for health and disease

Context:

Inguinal skin is prone to various infectious dermatological conditions such as erythrasma, intertrigo, hidradenitis suppurativa, folliculitis, dermatophytic infection, and various sexually transmitted diseases, as compared to the skin elsewhere.

Aim:

Our study attempts to compare the biophysical profile parameters (BPPs) of the genital skin with that of the rest of the body, while taking skin of the upper back as control. It also attempts to find out if there is a difference in BPPs of the two sites and that how the change in the BPPs, bring about change in microbiome and make inguinal skin more prone to infections.

Materials and Methods:

This was a hospital-based comparative study conducted over 976 patients (600 males and 376 females) of age group 18–60 years, where BPP parameters such as hydration, skin pH, transepidermal water loss (TEWL), and sebum content were measured over the skin of the upper back and right inguinal region, and the results were summarized and presented as proportions (%). Chi-square test was used to compare abnormal findings. P ≤ 0.05 was taken as statistically significant. MedCalc 16.4 version software was used for all statistical calculations.

Results:

Significant difference was noted in skin pH and TEWL, where P value came out to be <0.05, which was statistically significant, whereas there was minimal difference in sebum content and skin hydration in both the areas, in males and females.

Conclusion:

Raised skin pH disturbs organization of lipid bilayers (disturbed barrier), decreases lipid processing (impaired SC cohesion), and increases serine protease activity (reduced AMP). Increased TEWL (defect in physical barrier) and decreased hydration predispose the genital skin to infections. Use of pH buffered solutions (3–4), barrier repair creams containing ceramides, and barrier protective creams with dimethicone can help prevent these inguinal dermatoses.

Case Report: Paradoxical acrodermatitis of Hallopeau-like eruption following anti-IL-17 therapy

Psoriasis is a chronic immune-mediated inflammatory disease. Up to 40% of patients with psoriasis may develop psoriatic arthritis.  Currently, interleukin (IL)-17/IL-23 pathways are identified as key factors in the immunopathogenesis of both conditions. Here we describe the case of a patient who developed psoriasiform skin lesions 10 months after the initiation of anti-IL17 therapy for psoriatic arthritis. The underlying disease had responded well to the therapy, but the patient developed a striking pustular eruption at the fingers with nail involvement, onycholysis, yellow discoloration, and subungual keratosis. Clinical and histological findings were consistent with an acrodermatitis continua of Hallopeau-like eruption. Skin lesions subsided after discontinuation of the responsible anti-IL17 agent. The interpretation of this paradoxical side effect of biological therapies remains unclear but may relate to an unbalanced inflammatory cytokine response induced by the inhibition of TNF activity. It is likely that patients, who are genetically prone, may respond exaggeratedly to a cytokine imbalance. The identification of this kind of patient, in the future, could be useful in order to choose the correct therapy.

Biological products for the treatment of psoriasis: therapeutic targets, pharmacodynamics and disease-drug-drug interaction implications

Psoriasis is a chronic inflammatory skin disease condition that involves altered expression of a broad spectrum of proinflammatory cytokines which are associated with activation of T cells and proliferation of keratinocytes. Currently approved biological products for psoriasis treatment fall into two main classes: cytokine modulators and biologics targeting T cells. In psoriatic patients, elevated levels of proinflammatory cytokines are observed. Elevated proinflammatory cytokines can suppress some cytochrome P450 (CYP) enzymes, and the treatment of psoriasis with biological products can reduce proinflammatory cytokine levels. Therefore, the exposure of CYP substrate drugs is anticipated to be affected by the psoriasis disease resulting in a higher exposure than in healthy state (named disease-drug interaction) as well as by the biological treatments due to disease improvements resulting in a decrease in exposure (named disease-drug-drug interaction, disease-DDI). However, the quantitative impact on CYP substrate exposure due to disease or due to treatment with biological products remains to be evaluated. The objective of the current review is to provide an overview of the therapeutic targets and cytokine-related pharmacodynamic effects of biological products in psoriasis treatment with a particular focus on their implications for disease-DDI. The clinical study design considerations for psoriasis disease-DDI evaluation are also discussed.

Activated protein C: A regulator of human skin epidermal keratinocyte function

Activated protein C (APC) is a physiological anticoagulant, derived from its precursor protein C (PC). Independent of its anticoagulation, APC possesses strong anti-inflammatory, anti-apoptotic and barrier protective properties which appear to be protective in a number of disorders including chronic wound healing. The epidermis is the outermost skin layer and provides the first line of defence against the external environment. Keratinocytes are the most predominant cells in the epidermis and play a critical role in maintaining epidermal barrier function. PC/APC and its receptor, endothelial protein C receptor (EPCR), once thought to be restricted to the endothelium, are abundantly expressed by skin epidermal keratinocytes. These cells respond to APC by upregulating proliferation, migration and matrix metalloproteinase-2 activity and inhibiting apoptosis/inflammation leading to a wound healing phenotype. APC also increases barrier function of keratinocyte monolayers by promoting the expression of tight junction proteins and re-distributing them to cell-cell contacts. These cytoprotective properties of APC are mediated through EPCR, protease-activated receptors, epidermal growth factor receptor or Tie2. Future preventive and therapeutic uses of APC in skin disorders associated with disruption of barrier function and inflammation look promising. This review will focus on APC’s function in skin epidermis/keratinocytes and its therapeutical potential in skin inflammatory conditions.

Experience of effective treatment for patients with severe psoriasis

In this study was summarized the clinical monitoring of 6 patients with a vulgar severe psoriasis receiving a short course of Ustekinumab — antagonist of IL 12/23. Clinical monitoring demonstrated high efficiency of treatment with achievement of clinical remission and appreciable improvement in all patients; conservation of remission of psoriasis process till 6 months with regress of PASI more than 75 % from initial point in 5 from 6 patients; improvement of quality of life, absence of complications and adverse events during the treatment and the subsequent observation.

Ustekinumab: a review of its use in the management of moderate to severe plaque psoriasis

Ustekinumab (Stelara™) is a human monoclonal antibody that binds to the p40 subunit common to both interleukin (IL)-12 and IL-23. It is indicated in the US for use in adult patients with moderate to severe plaque psoriasis who are candidates for phototherapy or systemic therapy. In the EU, it is indicated for those who failed to respond to, have a contraindication to or are intolerant of other systemic therapies or phototherapy. This article reviews the efficacy and tolerability of ustekinumab in patients with moderate to severe plaque psoriasis, as well as summarizing its pharmacological properties. Ustekinumab attenuates the immune cell activation properties of IL-12 and IL-23. It interrupts the abnormal activation of signalling and cytokine cascades that underlie the pathology of psoriasis by reducing the expression of IL-12- and IL-23-induced cell surface markers that mediate skin homing, activation and cytokine release. In well designed, randomized clinical trials, regimens of subcutaneous ustekinumab 45 or 90 mg provided a rapid and durable improvement in psoriasis area severity index (PASI) scores for patients with moderate to severe plaque psoriasis. A significantly greater proportion of patients receiving ustekinuman 45 or 90 mg compared with those receiving placebo achieved a ≥75% improvement from baseline in PASI score following 12 weeks' treatment (primary endpoint). Improvements in PASI scores were evident following 2 weeks' treatment with ustekinumab and were sustained for up to 3 years. Treatment with ustekinumab 45 or 90 mg also improved health-related quality-of-life scores from baseline. Following 12 weeks' treatment, ustekinumab 45 or 90 mg was more effective than etanercept 50 mg twice weekly in providing symptomatic relief for patients with moderate to severe plaque psoriasis. Furthermore, ustekinumab treatment provided effective symptomatic improvement for almost half of the patients who showed no response to 12 weeks' treatment with etanercept. More limited data indicate that ustekinumab also improves the symptoms of arthritis in patients with plaque psoriasis and psoriatic arthritis. Subcutaneous ustekinumab was generally well tolerated in clinical trials; most adverse events were mild in intensity and did not require dosage adjustment. A pooled analysis of clinical trial data indicated no specific patterns of infection for recipients of ustekinumab and that infection rates remained stable following cumulative exposure to the agent. In conclusion, subcutaneous ustekinumab provides an effective and well tolerated alternative for the symptomatic treatment of patients with moderate to severe plaque psoriasis.

Roles of the immune system in skin cancer

Over the past several decades, there has been increasing interest in understanding the roles of the immune system in the development and progression of cancer. The importance of the immune system in human skin cancer has been long recognized based primarily upon the increased incidence of skin cancers in organ transplant recipients and mechanisms of ultraviolet (UV) radiation-mediated immunomodulation. In this review, we integrate multiple lines of evidence highlighting the roles of the immune system in skin cancer. First, we discuss the concepts of cancer immunosurveillance and immunoediting as they might relate to human skin cancers. We then describe the clinical and molecular mechanisms of skin cancer development and progression in the contexts of therapeutic immunosuppression in organ transplant recipients, viral oncogenesis, and UV radiation-induced immunomodulation with a primary focus on basal cell carcinoma and squamous cell carcinoma. The clinical evidence supporting expanding roles for immunotherapy is also described. Finally, we discuss recent research examining the functions of particular immune cell subsets in skin cancer and how they might contribute to both antitumour and protumour effects. A better understanding of the biological mechanisms of cancer immunosurveillance holds the promise of enabling better therapies.

A pilot study of the association of tumor necrosis factor alpha polymorphisms with psoriatic arthritis in the Romanian population

Tumor necrosis factor alpha (TNF-alpha) is an important pro-inflammatory cytokine implicated in the pathogenesis of psoriatic arthritis. We have performed a case-control association study of three TNF-alpha gene polymorphisms in a group of Romanian psoriatic arthritis patients versus ethnically matched controls. A second group of patients with undifferentiated spondyloarthritis was used in order to look for similarities in the genetic background of the two rheumatic disorders. The −857C/T polymorphism was associated with susceptibility to psoriatic arthritis in our population at the individual level (p = 0.03, OR 1.65, 95% CI 1.05–2.57) and in combined haplotypes with the −238G/A and −308G/A SNPs. Regarding the investigated polymorphisms and derived haplotypes, no potential association was found with the susceptibility to undifferentiated spondyloarthritis in Romanian patients.

Computational approach to identify enzymes that are potential therapeutic candidates for psoriasis

Psoriasis is well known as a chronic inflammatory dermatosis. The disease affects persons of all ages and is a burden worldwide. Psoriasis is associated with various diseases such as arthritis. The disease is characterized by well-demarcated lesions on the skin of the elbows and knees. Various genetic and environmental factors are related to the pathogenesis of psoriasis. In order to identify enzymes that are potential therapeutic targets for psoriasis, we utilized a computational approach, combining microarray analysis and protein interaction prediction. We found 6,437 genes (3,264 upregulated and 3,173 downregulated) that have significant differences in expression between regions with and without lesions in psoriasis patients. We identified potential candidates through protein-protein interaction predictions made using various protein interaction resources. By analyzing the hub protein of the networks with metrics such as degree and centrality, we detected 32 potential therapeutic candidates. After filtering these candidates through the ENZYME nomenclature database, we selected 5 enzymes: DNA helicase (RUVBL2), proteasome endopeptidase complex (PSMA2), nonspecific protein-tyrosine kinase (ZAP70), I-kappa-B kinase (IKBKE), and receptor protein-tyrosine kinase (EGFR). We adopted a computational approach to detect potential therapeutic targets; this approach may become an effective strategy for the discovery of new drug targets for psoriasis.