Psoriasis and uveitis: links and risks

Alterations in Retinal Vascularity in Severe Psoriasis

PURPOSE

To evaluate the changes in retinal vascularity in patients with severe psoriasis.

MATERIALS AND METHODS

Patients with severe psoriasis [psoriasis area-severity index (PASI) >10] who did not get any systemic treatment in the last year and do not have any ocular diseases were included. All patients underwent detailed ophthalmological examination, including optical coherence tomography (OCT) and OCT angiography (OCTA). Vessel densities (VD) of Superficial (SCP) and deep (DCP) capillary plexus, foveal avascular zone (FAZ) diameter, central retinal thickness (CRT) were analyzed and compared with age-sex matched healthy adults.

RESULTS

Fifty-three patients (13 F, 40 M) and 56 controls (16 F, 40 M) were included in the study. VD of SCP (50.4%±3.9 vs. 51.4%±3.2) and DCP (52.6%±6.4 vs. 55.4%±5.7) were lower in psoriasis group compared to controls (p < .05). Presence of psoriatic arthritis was related with an increased CRT (p = .000), larger FAZ and decreased foveal VD in SCP (p = .01, p = .02, respectively).

CONCLUSION

Severe psoriasis causes a decrease in retinal blood flow and presence of psoriatic arthritis is related with decreased foveal VD.

Diagnosis, Treatment, and Prevention of Noninfectious Acute Anterior Uveitis with or without Human Leukocyte Antigen B27 in Adults - Expert Consensus in Taiwan

BACKGROUND

Anterior uveitis is the most common anatomical type of uveitis. Patients with noninfectious anterior uveitis may develop various ocular complications and eventually visual impairment. Appropriately differentiating the etiologies can help clinicians to predict the outcome, arrange clinical follow-up, and decide the treatment or prevention strategy. Adequate treatment and effective prevention strategies can reduce the frequency of recurrence and the risk of developing complications. Human leukocyte antigen (HLA)-B27 is the most common positive finding in patients with noninfectious AAU in many countries including Taiwan.

PURPOSE

To report a consensus from experienced uveitis specialists and rheumatologists was made in Taiwan.

METHODS

A panel of nine ophthalmologists from nine different referral centers with expertise in the management of uveitis and an experienced rheumatologist was held on January 16, 2022. A comprehensive literature review was performed. Differential diagnoses for etiologies, general treatments, and prevention strategies were discussed. Each statement in the consensus was made only if more than 70% of the experts agreed.

RESULTS

A flow chart and seven statements regarding the differential diagnoses for etiologies, treatments and preventions, and co-management with rheumatologists were included in the consensus.

CONCLUSIONS

This article discusses the general diagnosis, treatment, and prevention of noninfectious acute anterior uveitis, with or without HLA-B27, in adults for general ophthalmologists to improve overall outcomes of these patients.

Association between immune checkpoint inhibitor medication and uveitis: a population-based cohort study utilizing TriNetX database

Objective

To explore the associations between the use of immune checkpoint inhibitors (ICIs) and the risk of developing uveitis among cancer patients.

Methods

Cancer patients who received ICI therapy and a comparison group of cancer patients who did not receive ICI therapy were retrospectively recruited from the TriNetX electronic heath-record registry. The outcome of interest was the development of new-onset uveitis. Propensity score matching based on a 1:1 ratio was conducted in order to reduce bias. Multi-variate cox proportional hazard models and Kaplan Meier method were also utilized to assess for the risk of uveitis among cancer patients who received ICI therapy.

Results

71931 cancer patients (54.7% male; 76.5% white; mean age at index 63.6 ± 12.2 years) who received ICI treatment (ICI group) and 71931 cancer patients (54.7% male; 77% white; mean age at index 63.5 ± 12.4 years) who never received ICI (comparison group) were recruited. Associated Kaplan-Meier curves showed significantly increased uveitis risk among the ICI group for all follow-up years (p<0.001). The risk of uveitis was also higher among the ICI group during the 144-month follow-up period with a hazard ratio (HR) of 2.39 (95% CI: 2.07-2.75). Increased risk for specific uveitis diseases, such as iridocyclitis, chorioretinal inflammation, retinal vasculitis, unspecified purulent endophthalmitis, pan-uveitis and sympathetic uveitis were found. Subgroup analysis demonstrated an elevated hazard ratio for the development of uveitis among ICI recipients, spanning individuals below the age of 65 as well as those aged 65 and older. The elevated hazard ratio for uveitis development among ICI recipients was also observed across all genders, among those of white and Asian ethnicities, those with smoking history, and those with comorbid conditions such as hypertension and dyslipidemia, in comparison to their non-ICI counterparts. An additional subgroup analysis on monotherapy versus combinatory ICI regimens was also conducted. Individuals who received monotherapy from the class of anti-PD-1 (HR:1.98 [CI: 1.65-2.37]) and anti-CTLA-4 (HR:5.86 [CI:1.99-17.24]) exhibited elevated hazard ratios for uveitis development compared to their non-ICI comparators. Those exposed to combinatory ICI regimens, specifically a combination of anti-PD-1 and anti-CTLA4 (HR: 5.04 [CI:3.55-7.16]), showed increased hazard ratios for uveitis development compared to their non-ICI comparators. In contrast, individuals exposed to a combination of anti-PD-1 and anti-PD-L1 (HR: 2.47 [CI:0.81-7.50]) did not demonstrate an increased risk for uveitis compared to their non-ICI comparators.

Conclusion

A significantly increased risk for uveitis diseases was found among the ICI group from the first year of follow-up. Increased awareness should be promoted on the occurrence of uveitis among cancer patients receiving ICI therapy.

Long-Term Safety of Guselkumab in Patients with Psoriatic Disease: An Integrated Analysis of Eleven Phase II/III Clinical Studies in Psoriasis and Psoriatic Arthritis

INTRODUCTION

The benefit/risk profiles of biologics can be affected by comorbidities, certain demographic characteristics, and concomitant medications; therefore, it is important to evaluate the long-term safety profiles of biologics across broad patient populations. Guselkumab was well tolerated and efficacious across individual pivotal clinical studies in adults with moderate-to-severe psoriasis and/or active psoriatic arthritis (PsA).

OBJECTIVES

The objective of the current analysis was to evaluate guselkumab safety in a large population of patients with psoriatic disease by pooling adverse event (AE) data from 11 phase II/III studies (seven in psoriasis; four in PsA).

METHODS

Guselkumab was generally administered as 100 mg subcutaneous injections at Week 0, Week 4, then every 8 weeks (Q8W) in psoriasis studies and at Week 0, Week 4, then every 4 weeks (Q4W) or Q8W in PsA studies. Safety data were summarized for the placebo-controlled period (Weeks 0-16 in psoriasis; Weeks 0-24 in PsA) and through the end of the reporting period (up to 5 years in psoriasis; up to 2 years in PsA). Using the integrated data, incidence rates of key AEs were determined post hoc, adjusted for duration of follow-up, and reported per 100 patient-years (PYs). AE rates were also determined in subgroups of patients defined by sex, age, body mass index (BMI), and prior biologic use.

RESULTS

During the placebo-controlled period, 1061 patients received placebo (395 PYs) and 2257 received guselkumab (856 PYs). Through the end of the reporting period, 4399 guselkumab-treated patients contributed 10,787 PYs of follow-up. During the placebo-controlled period, in the guselkumab and placebo groups, respectively, rates of AEs were 281 versus 272/100 PYs, and infections were 76.0 versus 72.2/100 PYs. Rates of serious AEs (5.6 vs. 7.8/100 PYs), AEs leading to discontinuation (4.9 vs. 6.6/100 PYs), serious infections (1.0 vs. 2.3/100 PYs), malignancy (0.59 vs. 0.25 patients/100 PYs), and major adverse cardiovascular events (MACE; 0.35 vs. 0.25/100 PYs) were low and comparable between guselkumab and placebo. Among guselkumab-treated patients, safety event rates through the end of the reporting period were numerically lower than or comparable with rates observed during the placebo-controlled period: AEs, 164/100 PYs; infections, 61.2/100 PYs; serious AEs, 5.4/100 PYs; AEs leading to discontinuation, 1.8/100 PYs; serious infections, 1.0/100 PYs; malignancy, 0.6/100 PYs; and MACE, 0.3/100 PYs. No AEs of Crohn's disease, ulcerative colitis, or active tuberculosis were reported among guselkumab-treated patients. In the psoriasis studies, no opportunistic infections were reported among guselkumab-treated patients. Three AEs of opportunistic infections were reported in guselkumab-treated patients with PsA (0.14/100 PYs; all after Week 52 in DISCOVER-2). AE rates were largely consistent across subgroups of guselkumab-treated patients defined by sex, age, BMI, and prior biologic use.

CONCLUSIONS

In this analysis of 4399 guselkumab-treated patients with psoriatic disease followed for 10,787 PYs, guselkumab had a favorable AE profile. AE rates were similar between guselkumab- and placebo-treated patients and were consistent throughout long-term guselkumab treatment and across broad subgroups of patients with psoriatic disease.

CLINICAL TRIALS REGISTRATIONS

Clinicaltrials.gov identifiers: NCT01483599, NCT02207231, NCT02207244, NCT02203032, NCT02905331, NCT03090100, NCT02325219, NCT02319759, NCT03162796, NCT03158285, and NCT03796858.

First contact investigations and compliance to treatment in patients with uveitis

AIM

To ascertain the pattern of investigations at first contact in uveitic patients and evaluate compliance to treatment.

METHODS

An observational study comprised of 201 uveitic patients presenting for the first time to our centre from January 2019 to June 2020. Detailed information regarding systemic investigations undertaken by specialists at the time of first contact and the cost of these investigations were reviewed on the first visit to our centre. Compliance with the treatment was determined and reasons behind non-compliance were evaluated on the first follow-up in patients who had no improvement in clinical signs and symptoms.

RESULTS

The mean age of the study group was 35.35±14.1y and gender composition was 59.7% males and 40.3% females. Anterior uveitis was observed in 45.3% of patients, intermediate uveitis in 31.8% of patients, posterior uveitis in 14.9% of patients and panuveitis in 8.0% of patients. Association with a systemic disease was evident in 17.9% of patients. When compared with standard guidelines and uveitis patterns, systemic investigations were identified to be relevant only in 38.3% of patients. Non-compliance to treatment was documented in 22.4% of patients. Common reasons for non-compliance were inadequate counselling by the treating physician about treatment in 26.7% of patients and a busy schedule at work/school in 22.2% of patients.

CONCLUSION

Significant number of investigations performed at first contact is found to be contrary to standard guidelines and are not contributory to the care. About a quarter of patients in this study are found to be non-compliant with the treatment. Compliance is more challenging to achieve in school-going children and working adults. The availability of comprehensive, periodically updated, evidence-based guidelines on the role of investigations and the use of trained counsellors may help to channelize proper evaluation and improve compliance to treatment, respectively, in patients with uveitis.

Prevalence of Cardiovascular Risk Factors in Saudi Patients With Psoriatic Arthritis: A Single-Center Retrospective Cohort Study

Background Psoriatic arthritis (PsA) is an extremely heterogeneous disease with numerous articular phenotypes and extra-articular manifestations. It is common for patients with PsA to have coexisting medical conditions. In recent studies, PsA patients were found to have a greater prevalence of cardiovascular risk factors when compared to non-PsA groups. Objectives This study aimed to describe the prevalence of cardiovascular risk factors among Saudi psoriatic arthritis patients treated at King Abdulaziz Medical City (KAMC), Riyadh. Methods A hundred and twenty-six patients with psoriatic arthritis diagnoses were enrolled in this study. Patients who were 18-years-old or older, had PsA diagnosed by a rheumatologist, and met the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria were included in the study population. Patients were excluded from the study if they were younger than 18, did not fulfill the CASPAR criteria, did not have a documented diagnosis by a rheumatologist, or had been diagnosed with any type of joint arthritis in the past. In this retrospective cohort article, we investigated the frequency of risk factors for cardiovascular disease such as [hypertension (HTN), dyslipidemia (DLP), diabetes mellitus (DM), obesity, and coronary heart disease (CHD)] and non-established risk factors such as [HbA1C, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)]. SPSS version 12.0 for Windows (SPSS Inc.) was used for statistical analysis. The threshold for statistical significance was set at 5%. Results A hundred and twenty-six PsA patients were enrolled in this study, 30 (24%) had PsA for less than two years (early), and 96 (76%) had PsA for more than two years (established). When the analysis was performed, the mean age was 47.5 years, and the mean age at diagnosis of PsA was 42.4 years. Of them, 89 (71%) were female while 37 (29%) were male. Established PsA patients were significantly older at the time of analysis than early PsA patients (49.2 vs. 41.8 years; P= 0.007). Furthermore, established PsA patients had a longer duration of PsA than those with early PsA (6.3 vs. 1.5 years; P= <0.001). The most frequently reported comorbidity was obesity (61%) followed by DLP (43%), HTN (34%), DM (30%), and CHD (11%). CV comorbidities did not differ between subgroups. However, patients with established PsA had a higher prevalence of DLP, especially females. Additionally, patients with early PsA had greater rates of HTN than those with established PsA, and patients with early PsA were more likely to have CHD. Conclusion This study confirms that PsA is linked with cardiovascular (CV) morbidity. When evaluating PsA, future studies should take these CV conditions into consideration.

The link between psoriasis and other diseases based on epidemiological and genetic analyses

Psoriasis is a chronic disease, which is associated with numerous genetic and environmental factors. The high prevalence of psoriasis worldwide (2-3% of the general population) and its various comorbidities lead to research on its pathogenesis. The aim of this article is to describe the current state of knowledge on the potential links between psoriasis and other diseases, such as inflammatory bowel diseases, uveitis, arthritis, hypertension, metabolic syndrome, diabetes mellitus, atherosclerosis, fatty liver disease, dyslipidaemia, sleep apnoea, celiac disease, lymphoma, erectile dysfunction, Parkinson's disease, osteoporosis, chronic obstructive pulmonary disease, psychiatric disorders and substance use. Further research in this area may lead to better treatment options in the future.

Ocular manifestations of psoriasis: An inflammatory disease beyond the skin

Background

Psoriasis is a chronic inflammatory disorder, mainly involves skin.

Aims

To evaluate the prevalence of ocular manifestations in Iranian patients with psoriasis, compared to healthy controls.

Materials and methods

Forty psoriasis patients and 40 age- and gender-matched healthy controls were enrolled in the study and underwent a comprehensive ophthalmologic assessment.

Results

Only meibomian gland dysfunction was significantly more common among patients with psoriasis, compared to control group (p value: 0.011). Regarding intraocular pressure (IOP), the mean values for both patients and healthy controls were within the normal range and mean IOP in patients was even lower than normal controls, although this difference was significant only for left eye (p value: 0.049). A strong positive correlation between PASI and tear meniscus height for both right and left eyes (p value: 0.005, r: 0.44 for OD and p value: 0.003, r: 0.46 for OS.) was noted. Meibomian gland dysfunction was also positively correlated with disease duration for right and left palpebras (p: 0.04, r: 0.31 for both).

Conclusion

Psoriasis can lead to meibomian gland dysfunction, especially in patients with long-lasting disease. Hence, dermatologists and general practitioners should be vigilant in this regard when visiting psoriasis patients, especially those who have higher PASI values or long-lasting disease.

T cells in ocular autoimmune uveitis: Pathways and therapeutic approaches

Autoimmune uveitis is a non-infectious intraocular condition that affects the uveal tract of the eye and threatens vision if not treated properly. Increasing evidence suggests that activated CD4⁺ T cells are associated with progressive and permanent destruction of photoreceptors in ocular autoimmune diseases. As such, the purpose of this review is to offer an overview of the role of CD4⁺ T cells in autoimmune uveitis as well as a justification for the current development and assessment of innovative autoimmune uveitis medications targeting CD4⁺ T cells. With an emphasis on T helper (Th)17, Th1, and Th2 cells, follicular helper CD4⁺ T cells, and regulatory T cells, this review presents a summary of recent research related to the pathways and signaling that encourage CD4⁺ T cells to develop into specialized effector cells. We also describe immunotherapeutic approaches based on CD4⁺ T cell subsets and their potential as therapeutic agents for autoimmune disorders.

Epidemiology and clinical characteristics of psoriatic arthritis-related uveitis in Madrid, Spain

PURPOSE

To describe the epidemiology and clinical characteristics of psoriatic arthritis (PsA) related uveitis in Madrid, Spain.

METHODS

A case series nested in a retrospective single-center cohort of 494 patients with PsA was performed. Patients older than 18 years old whit a clinical diagnosis PsA-related uveitis who attended the Ramon y Cajal University Hospital in Madrid, Spain, between 1st January 2017 and 31st December 2019 were included in the study. Epidemiological and clinical data were retrieved from the electronic medical records.

RESULTS

Thirteen cases of psoriatic arthritis-related uveitis (6 men and 7 women) were included. PsA-related uveitis showed an incidence of 0.05 cases per 100,000 persons/year (CI95 0.00-0.35), and a prevalence of 2.19 cases per 100,000 persons (CI95 1.24-3.79). The prevalence of active uveitis in the cohort of PsA patients was 2.6%. The first episode of uveitis (mean age of 48.15 ± 15.41 years) was anterior and unilateral in 92.31% of the cases. Most of the patients had a recurrent course (69.2%) with 0.92 flare-ups per patient/year (CI95 0.85-0.96). The uveitis preceded the diagnosis of psoriatic arthritis in 62.5% of the patients. In patients with PsA-related uveitis, HLA-B27 was present in 23.1%, HLA-Cw6 in 7.7%.

CONCLUSIONS

Uveitis is a PsA manifestation that affects roughly 1 in 37 PsA patients, and that may precede the articular symptoms. It generally presents as a unilateral acute anterior uveitis and has a recurrent course. The most frequent observed complications are elevated intraocular pressure and cataracts.

Updated Perspectives on Keratinocytes and Psoriasis: Keratinocytes are More Than Innocent Bystanders

Psoriasis is a complex disease triggered by genetic, immunologic, and environmental stimuli. Many genes have been linked to psoriasis, like the psoriasis susceptibility genes, some of which are critical in keratinocyte biology and epidermal barrier function. Still, the exact pathogenesis of psoriasis is unknown. In the disease, the balance between the proliferative and differentiative processes of keratinocytes becomes altered. Multiple studies have highlighted the role of dysregulated immune cells in provoking the inflammatory responses seen in psoriasis. In addition to immune cells, accumulating evidence shows that keratinocytes are involved in psoriasis pathogenesis, as discussed in this review. Although certain immune cell-derived factors stimulate keratinocyte hyperproliferation, activated keratinocytes can also produce anti-microbial peptides, cytokines, and chemokines that can promote their proliferation, as well as recruit immune cells to help initiate and reinforce inflammatory feedback loops. Psoriatic keratinocytes also show intrinsic differences from normal keratinocytes even after removal from the in vivo inflammatory environment; thus, psoriatic keratinocytes have been found to exhibit abnormal calcium metabolism and possible epigenetic changes that contribute to psoriasis. The Koebner phenomenon, in which injury promotes the development of psoriatic lesions, also provides evidence for keratinocytes' contributions to disease pathogenesis. Furthermore, transgenic mouse studies have confirmed the importance of keratinocytes in the etiology of psoriasis. Finally, in addition to immune cells and keratinocytes, data in the literature support roles for other cell types, tissues, and systems in psoriasis development. These other contributors are all potential targets for therapies, suggesting the importance of a holistic approach when treating psoriasis.

Identifying and Treating Ocular Manifestations in Psoriasis

Psoriasis is a chronic immune-mediated inflammatory skin condition that commonly presents with red, thickened, and scaling plaques. Given the prominent cutaneous manifestations of psoriasis, more subtle ophthalmic findings of the disease may initially go undetected, with the potential for significant ocular morbidity. Associated ocular disease can involve nearly any structure of the eye, with the eyelids most commonly being affected, resulting in relatively common signs and symptoms of ocular surface discomfort. The presence of intraocular inflammation (i.e., uveitis) or retinal involvement carry a heightened risk of vision loss, and are often more difficult to diagnose outside of the ophthalmology clinic. Early detection and treatment of ocular disease can limit morbidity and are critical to the management of these patients, which requires coordination of care between dermatologists and ophthalmologists. The objective of this article was to review the most common ocular conditions that affect psoriatic patients, when to consider referral to an ophthalmologist, and to summarize the adverse ocular effects of current psoriasis treatments.

Epidemiology of Ocular Manifestations in Autoimmune Disease

The global prevalence of autoimmune diseases is increasing. As a result, ocular complications, ranging from minor symptoms to sight-threatening scenarios, associated with autoimmune diseases have also risen. These ocular manifestations can result from the disease itself or treatments used to combat the primary autoimmune disease. This review provides detailed insights into the epidemiological factors affecting the increasing prevalence of ocular complications associated with several autoimmune disorders.

Psoriasis as an Immune-Mediated and Inflammatory Systemic Disease: From Pathophysiology to Novel Therapeutic Approaches

Psoriasis is an immune-mediated inflammatory disease, with a chronic relapsing-remitting course, which affects 2–3% of the worldwide population. The progressive acquisitions of the inflammatory pathways involved in the development of psoriasis have led to the identification of the key molecules of the psoriatic inflammatory cascade. At the same time, psoriasis therapy has radically evolved with the introduction of target molecules able to modify the natural history of the disease, acting specifically on these inflammatory pathways. For these reasons, biologics have been demonstrated to be drugs able to change the disease’s natural history, as they reduce the inflammatory background to avoid irreversible organ damage and prevent systemic complications. However, several issues related to the use of biologics in patients with systemic comorbidities, remain open. All these data reflect the extraordinary potentiality of biologics, but also the unmet medical need to improve our knowledge on the long-term risk related to continuous use of these drugs, and their administration in special populations. This narrative review aims to highlight both the efficacy and safety profile of biologics in psoriasis, starting from pathophysiology and moving towards their clinical application.

Managing Psoriatic Arthritis With Inflammatory Bowel Disease and/or Uveitis

Psoriatic arthritis (PsA) is a chronic inflammatory disease that presents with psoriasis (PsO), peripheral and axial arthropathy. The heterogeneity of disease presentation leads to the term "psoriatic disease (PsD)" which is thought to better encompass the range of clinical manifestations. PsA is associated with several comorbidities such as cardiovascular diseases, metabolic syndrome and other extra-articular manifestations including uveitis, and inflammatory bowel disease (IBD). While novel therapeutics are being developed following advances in our understanding of the pathogenesis of the disease, the diverse combinations of PsA with its various comorbidities still pose a clinical challenge in managing patients with PsA. This article reviews our current understanding of the pathogenesis of PsA and how various pathways in the pathogenesis lead to the two comorbid extra-articular manifestations - uveitis and IBD. We also review current evidence of treatment strategies in managing patients with PsA with comorbidities of uveitis and/or IBD.

The risk of psoriasis in patients with uveitis: A nationwide population-based cohort study

Objective

To evaluate whether the risk of subsequent psoriasis and psoriatic arthritis development is increased in patients with uveitis.

Methods

In Taiwan’s national health insurance research database, we identified 195,125 patients with new-onset uveitis between 2001 and 2013. We randomly selected 390,250 individuals without uveitis who were matched 2:1 to uveitis cases based on age, sex and year of enrolment. The characteristics of the two groups were compared. Using multivariate Cox regression, hazard ratios (HRs) for psoriasis or psoriatic arthritis corresponding to uveitis were computed after adjustment for age, sex, insurance cost and comorbidities. In subgroup analyses, separate HRs for mild psoriasis, severe psoriasis and psoriatic arthritis were calculated.

Results

The mean age of the study cohort was 50.2 ± 17.2 years. Hypertension, diabetes, hyperlipidaemia and obesity were more prevalent in the uveitis group (all p < 0.0001). The hazard of psoriasis or psoriatic arthritis development was significantly greater in the uveitis group than in the non-uveitis group (p < 0.0001); this increased risk persisted after adjustment for confounders [adjusted HR = 1.41; 95% confidence interval (CI), 1.33–1.48]. Adjusted HRs showed an increasing trend from mild psoriasis (1.35; 95% CI, 1.28–1.44) to severe psoriasis (1.59; 95% CI, 1.30–1.94) and psoriatic arthritis (1.97; 95% CI, 1.60–2.42).

Conclusions

This nationwide population-based cohort study revealed that patients with uveitis have an increased risk of subsequent psoriasis or psoriatic arthritis development.

Ocular Manifestations in Psoriasis Screening (OcMaPS) Questionnaire: A Useful Tool to Reveal Misdiagnosed Ocular Involvement in Psoriasis

Psoriasis is an immune-mediated, chronic inflammatory disease, which mainly affects the skin, although it has systemic pathological effects. Comorbidities of psoriasis include ocular disorders, which are often nonspecific or mildly symptomatic. The aim of this study was to show the importance of ocular-disease screening in psoriatic patients using the Ocular Manifestations in Psoriasis Screening (OcMaPS) questionnaire. Patients suffering from moderate-to-severe psoriasis referring at our outpatient-clinic were consecutively enrolled. Each patient was asked to complete a screening questionnaire (OcMaPS). Patients reporting ocular symptoms were referred for an ophthalmological examination. A total of 372 patients were enrolled in the study. Ocular symptoms were detected in 39 patients (10.5%), and 37 patients were referred to ophthalmological examination which confirmed the presence of ocular manifestation in 30 patients. There were three cases (10%) of uveitis, 14 (46.6%) of dry eye and 13 (43.3%) of cataract, in progress or already treated with surgery. In the remaining seven patients, no ocular manifestations were found. Ocular manifestations in psoriatic patients are not rare. It is important to be aware of ocular symptoms in psoriatic patients, screening patients (with a consultation or OcMaPS questionnaire), which leads to earlier diagnosis and treatment.

The Incidence and Prevalence of Uveitis in Psoriasis: A Systematic Review and Meta-Analysis

BACKGROUND

The systemic effects and comorbidities of psoriasis include ocular disorders, such as uveitis. Patients with psoriatic arthritis in particular have been demonstrated to have an elevated risk for developing uveitis. Presently, the risk of uveitis in psoriasis has yet to be fully elucidated and this systematic review seeks to address this gap.

OBJECTIVE

To examine the prevalence and incidence of uveitis in psoriasis patients compared to non-psoriasis patients.

METHODS

We conducted a systematic review search on MEDLINE, Embase, and CENTRAL electronic databases with no lower limit on year of publication.

RESULTS

Fourteen articles met our inclusion criteria, with a total of 234 143 psoriasis subjects. Two studies found that participants with severe psoriasis were at a greater risk of uveitis than those with mild psoriasis. A random-effects meta-analysis of the 3 studies, which reported risk of incidence of uveitis in psoriasis patients compared to non-psoriasis controls, found a pooled risk ratio of 1.29 (95% CI, 1.10-1.51), indicating an increased risk of uveitis in psoriasis. Three studies compared risk of uveitis in psoriatic arthritis with psoriasis-only participants, all finding that psoriatic arthritis was associated with a greater risk of uveitis.

CONCLUSIONS

In summary, our findings suggest that psoriasis is associated with an increased risk of uveitis, with or without psoriatic arthritis.

Psoriatic Arthritis and Diabetes Mellitus: A Narrative Review

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic immune-mediated inflammatory spondyloarthropathy associated with psoriasis. PsA is frequently associated with metabolic disorders including, obesity, metabolic syndrome, and diabetes mellitus (DM). Type 2 DM is among the most common metabolic disorders, with a prevalence ranging from 2.4 to 14.8% in the general population.

METHODS

We conducted a narrative review of the English-language studies from January 1989 to September 2019 investigating the risk of type 2 DM in patients with PsA, the pathogenic mechanism linking DM to PsA, and the effects on insulin sensitivity exerted by systemic therapies for PsA.

RESULTS

The prevalence of type 2 DM in patients with PsA ranges from 6.1 to 20.2%, generally higher when compared to the general population. The higher risk of DM is reported in women with more severe forms of PsA. Elevated serum levels of adipokines, including TNF-α, which inhibits the autophosphorylation of the insulin receptor and suppresses the expression of glucose transporter 4, favor insulin resistance and could partially explain the association between PsA and DM. Moreover, adiponectin and omentin, with insulin-sensitizing and anti-atherogenic properties, are decreased in patients with PsA. Some of the treatments for PsA could affect the glucose homeostasis. Systemic corticosteroids are known to impair insulin resistance, whereas apremilast (phosphodiesterase type 4 inhibitor) and TNF-α inhibitors could exert neutral effect or reduce the insulin-resistance. The role of IL-17 or IL-23 inhibitors has been marginally investigated.

CONCLUSIONS

Patients affected by PsA have a higher prevalence of type 2 DM compared with the general population. The mechanism linking PsA with DM has not been completely clarified, but some of the principal mediators could be TNF-α and adipokine, especially adiponectin and omentin. Apremilast and TNF-α inhibitor may have a favorable effect and could be safely used in patients with DM.