Intralesional therapy for psoriasis

Current and emerging prospects in the psoriatic treatment

Psoriasis is an autoimmune chronic disorder that causes inflammation and a scaly epidermis. The exact pathogenesis of the disease is not known yet. According to the studies, psoriasis is considered an immune-mediated disease. Until now it is believed that genetic and environmental factors are responsible for the disease. There are many comorbidities associated with psoriasis which increases difficulties as patients in some cases get addicted to drugs, alcohol, and smoking which reduces their quality of life. The patient may face social ignorance or suicidal thoughts which may arise in the patient's mind. Due to the undefined trigger of the disease, the treatment is not fully established but by considering the severe impact of the disease researchers are focusing on novel approaches for successful treatment. which has succeeded to a large extent. Here we review pathogenesis, problems faced by psoriatic patients, the need for the development of new treatments over conventional therapies, and the history of psoriatic treatments. We thoroughly focus on emerging treatments like biologics, biosimilars, and small molecules which are now showing more efficacy and safety than conventional treatments. Also, this review article discusses novel approaches which are now in research such as drug repurposing, treatment by stimulation of the vagus nerve, regulation of microbiota, and autophagy for improving disease conditions.

Medical Aesthetics - Current Trends and a Review of Its Applications

Medical aesthetics is the use of a procedure or product for a therapeutic indication which is conventionally used for aesthetics. Several medical conditions are now being treated with products, procedures or equipment that are conventionally used for aesthetic indications. This has widened the scope of treatment modalities available for dermatologists to treat various indications that fall outside the purview of aesthetic dermatology. The authors present aesthetic treatment modalities and procedures which can be used for medical aesthetics, their present-day status and usefulness in field of therapeutics with a review of published literature from "Medline" (via "PubMed"), "Cochrane," the Virtual Health Library, and Google Scholar.

Comparative efficacy of intralesional 5 Flurouracil and intralesional Triamcinolone acetonide in localized plaque psoriasis

BACKGROUND

Psoriasis is a papulosquamous disorder that causes significant social and psychological trauma to the patient. It is characterized by the presence of erythematous, indurated plaques covered with silvery-white scales. Despite the availability of several systemic agents that have been approved for the treatment of psoriasis, usually there are some residual lesions and there is a need to treat them for cosmetic reasons or symptomatic control.

AIMS

1. Treatment of resistant localized psoriatic plaques or residuals after systemic treatment. 2. Recently, some intralesional agents have been used successfully for the treatment of psoriatic plaques as 5-FU, methotrexate, and botulinum toxin type-A, and nearly for 4 decades, no study focused on the effect of intralesional corticosteroids in the treatment of these psoriatic plaques. We decided to highlight their role and compare intralesional Triamcinolone to intralesional 5-FU regarding efficacy and safety in the treatment of plaque psoriasis.

METHODS

This study included 24 patients with localized plaque psoriasis. Each patient was treated by split-body therapy where one psoriatic plaque was treated with intralesional 5FU and another plaque with intralesional TAC. A total of three injections were given at two- week intervals and follow up was regularly every 2 weeks up to 12 weeks.

RESULTS

There was a statistically significant difference between both groups (p = 0.008) as the response rate on 5-FU side was 12.5% with no response, 29.2% with a moderate response, 41.7% with an excellent response, and 16.7% with a complete clearance, while on the TAC side it was16.7% with a moderate response, 20.8% with an excellent response and 62.5% with a complete clearance. Hyperpigmentation was the most irritating side effect of 5-FU that occurred. Pain, during and after injection, was greater in 5-FU group. Hypopigmentation and atrophy only occurred in TAC group in some patients but it seems to be reversible and not disfiguring.

CONCLUSION

1-Intralesional TAC injection may have more efficacy and less side effects than 5-FU injection in the treatment of localized plaque psoriasis. Hyperpigmentation and pain were the most irritating side effects of 5-FU 2-Intralesional TAC can be effective in the treatment of localized psoriatic plaques with minimal side effects, especially in patients not suitable for systemic agents.

cBleomycin restricts the glycolysis of lymphatic endothelial cells by inhibiting dimeric PKM2 formation: A novel mechanism for lymphatic malformation treatment

Glycolysis is activated in lymphatic endothelial cells and contributes to the development of lymphatic malformations (LMs). Bleomycin (BLM) is the most wildly used sclerosant for LMs, but its mechanisms are unknown. Here, our data showed that BLM suppressed the glycolysis of human dermal lymphatic endothelial cells (HDLECs) via inhibiting the expression and nucleus translocation of pyruvate kinase M2 isoform (PKM2) and inhibited dimeric PKM2 formation. Furthermore, the proliferation of LM lesions was inhibited by BLM through the down-regulation of nuclear PKM2 in the rat model. Additionally, PKM2, especially the nuclear PKM2 along with Ki-67, was inhibited in the lymphatic vessels of BLM-treated LMs. Our findings provide a new molecular mechanism of BLM in LM sclerotherapy treatment.

Solid lipid nanoparticles and nanostructured lipid carrier-based nanotherapeutics for the treatment of psoriasis

INTRODUCTION

Psoriasis is an auto-immune inflammatory skin disease affecting people worldwide. Its topical therapy via different nanoformulations prevents the long-term side-effects of conventional formulations. Nanocarriers, especially solid lipid nanoparticles (SLNs) and nanostructured lipid carriers (NLCs), pose extra benefits in topical drug delivery due to their lipid constituents. Although both natural and synthetic anti-psoriatic drugs have been successfully incorporated in these nanoformulations, yet further studies including dual drug-loadings are being carried out for assessing their efficacy.

AREAS COVERED

This review aims at describing the different aspects of SLNs and NLCs in psoriasis, including their skin permeation behavior and the various drug molecules incorporated. The recent studies with single- and dual drug-loaded SLNs and NLCs have also been discussed in the review.

EXPERT OPINION

SLNs and NLCs have been very effective in mitigating psoriasis when compared to commercial formulations. They have also shown promising results when loaded with two drugs, thus overcoming drawbacks of traditional combination therapy. Therefore, various drug/antibody/siRNA combinations can be selected in the upcoming research works to evaluate their synergistic performance against psoriasis. However, the conclusions drawn so far are only based on the pre-clinical studies and hence further investigations are required to obtain their clinical trial outcomes.

Intradermal injection of incobotulinumtoxinA for face lifting

Intradermal injection of botulinumtoxinA (BoNT/A) has been used off-label by many clinicians for the purpose of face-lifting effect. Some studies on AbobotulinumtoxinA (AboA) demonstrated clinical efficacy on face-lifting effect when comparing to normal saline solution (NSS). So far, there is no split-face comparison study on face-lifting effect of IncobotulinumtoxinA (IncoA). The objective of this study was to compare the face-lifting effect of IncoA intradermal injection and NSS. Twenty-two subjects were enrolled and randomly injected with IncoA at 1:6 cc dilution (100 unit or 1 vial in 6 cc of NSS) on one side, and NSS on the other side by using intradermal injection technique. Standardized photographic documentation with 2-, and 3-dimentional imaging system (Vectra H1, Canfield Scientific, Inc., Fairfield, NJ) were obtained at baseline, and at 2 weeks after treatment. The face-lifting effect was graded by the subjects and two blinded dermatologists, using photographic comparison. Side effects were also recorded at the end of the study. Immediate face-lifting was identified on the side that was treated with IncoA by blinded injectors in 63.6% of patients. Of all subjects, 17 (77.3%) have noticed the improvement of skin laxity on the side that was treated with IncoA at 2 weeks after treatment. The difference in facial contouring volume measured by Vectra H1 imaging system on IncoA side was significantly higher (P = .033) when comparing to NSS side in patients aged <36 years old. However, there was no statistically significant difference in face-lifting when comparing between IncoA and NSS evaluated by two blinded dermatologists (P = 1.00). Facial asymmetry was found in 36.4% of subjects. This study demonstrated the face-lifting effect of IncoA intradermal injection. Further studies with larger number of subjects and proper method of evaluation should be done to verify these findings.

New trends in botulinum toxin use in dermatology

Background: Recent studies have highlighted new botulinum neurotoxin (BoNT) applications in the field of dermatology. Objective: To review current knowledge of BoNT use in dermatology. Methods: The literature of the last 5 years has been reviewed. Results: We describe interesting protocols of BoNT treatment for hyperhidrosis (HH), hypertrophic scars and keloids, Raynaud phenomenon, facial flushing, oily skin, psoriasis, Hailey-Hailey disease, and cutaneous lesions like painful lesions and periorbital syringomas. Conclusions: Several skin conditions eligible for BoNT treatment have been described. After the wide application for HH treatment, scars as well as vascular and inflammatory skin disorders, oily skin and cutaneous lesions represent fields of application of BoNT.

New trends in botulinum toxin use in dermatology

Background

Recent studies have highlighted new botulinum neurotoxin (BoNT) applications in the field of dermatology.

Objective

To review current knowledge of BoNT use in dermatology.

Methods

The literature of the last 5 five years has been reviewed.

Results

We describe interesting protocols of BoNT treatment for hyperhidrosis (HH), hypertrophic scars and keloids, Raynaud phenomenon, facial flushing, oily skin, psoriasis, Hailey-Hailey disease, and cutaneous lesions like painful lesions and periorbital syringomas.

Conclusions

Several skin conditions eligible for BoNT treatment have been described. After the wide application for HH treatment, scars as well as vascular and inflammatory skin disorders, oily skin and cutaneous lesions represent fields of application of BoNT.

New Uses of AbobotulinumtoxinA in Aesthetics

BotulinumtoxinA (BoNT-A) is now widely established for the main approved indication of reducing glabellar lines, and is also widely used off-label to improve the appearance of wrinkles and lines in other parts of the face. The number of aesthetic procedures continues to increase as the patient population becomes more diverse, in particular with increasing numbers of people of color and men. Further developments in treatment may continue to expand the audience for BoNT-A by making procedures more comfortable and by delivering a more natural, less static appearance. These may be achieved through use of combinations of BoNT-A with other aesthetic procedures, tailoring the dose of toxin to the patient's muscle mass or by using novel injection and application techniques. Beyond amelioration of facial lines, encouraging results have been seen with the use of BoNT-A to improve the appearance of hypertrophic and keloid scars and even to prevent them. Studies have been conducted with scars in various parts of the body and further research is ongoing. Dermatological and other medical uses for BoNT-A are also active areas of research. Injections of BoNT-A have been shown to reduce signs and symptoms of acne, rosacea, and psoriasis, to reduce neuromuscular pain, and to bring about significant improvements in a number of rare diseases that are caused or exacerbated by hyperhidrosis. This paper reviews these new uses for BoNT-A, looking at the rationale for their use and discussing the results of published case studies and clinical trials. These areas have shown great promise to date, but more and larger clinical studies will be required before these treatments become a clinical reality. To this end details are also provided of clinical trials currently listed in the main clinical trials database to highlight research areas of particular interest.

Managing Scalp Psoriasis: An Evidence-Based Review

BACKGROUND

Scalp psoriasis is commonly the initial presentation of psoriasis, and almost 80 % of patients with psoriasis will eventually experience it.

OBJECTIVE

Although several systematic reviews and guidelines exist, an up-to-date evidence-based review including more recent progress on the use of biologics and new oral small molecules was timely.

METHODS

Of the 475 studies initially retrieved from PubMed and the 845 from Embase (up to May 2016), this review includes 27 clinical trials, four papers reporting pooled analyses of other clinical trials, ten open-label trials, one case series, and two case reports after excluding non-English literature.

RESULTS

To our knowledge, few randomized controlled trials (RCTs) are conducted specifically in scalp psoriasis. Topical corticosteroids provide good effects and are usually recommended as first-line treatment. Calcipotriol-betamethasone dipropionate is well tolerated and more effective than either of its individual components. Localized phototherapy is better than generalized phototherapy on hair-bearing areas. Methotrexate, cyclosporine, fumaric acid esters, and acitretin are well-recognized agents in the treatment of psoriasis, but we found no published RCTs evaluating these agents specifically in scalp psoriasis. Biologics and new small-molecule agents show excellent effects on scalp psoriasis, but the high cost of these treatments mean they may be limited to use in extensive scalp psoriasis.

CONCLUSIONS

More controlled studies are needed for an evidence-based approach to scalp psoriasis.

Novel factors in the pathogenesis of psoriasis and potential drug candidates are found with systems biology approach

Psoriasis is a multifactorial inflammatory skin disease characterized by increased proliferation of keratinocytes, activation of immune cells and susceptibility to metabolic syndrome. Systems biology approach makes it possible to reveal novel important factors in the pathogenesis of the disease. Protein-protein, protein-DNA, merged (containing both protein-protein and protein-DNA interactions) and chemical-protein interaction networks were constructed consisting of differentially expressed genes (DEG) between lesional and non-lesional skin samples of psoriatic patients and/or the encoded proteins. DEGs were determined by microarray meta-analysis using MetaOMICS package. We used STRING for protein-protein, CisRED for protein-DNA and STITCH for chemical-protein interaction network construction. General network-, cluster- and motif-analysis were carried out in each network. Many DEG-coded proteins (CCNA2, FYN, PIK3R1, CTGF, F3) and transcription factors (AR, TFDP1, MEF2A, MECOM) were identified as central nodes, suggesting their potential role in psoriasis pathogenesis. CCNA2, TFDP1 and MECOM might play role in the hyperproliferation of keratinocytes, whereas FYN may be involved in the disturbed immunity in psoriasis. AR can be an important link between inflammation and insulin resistance, while MEF2A has role in insulin signaling. A controller sub-network was constructed from interlinked positive feedback loops that with the capability to maintain psoriatic lesional phenotype. Analysis of chemical-protein interaction networks detected 34 drugs with previously confirmed disease-modifying effects, 23 drugs with some experimental evidences, and 21 drugs with case reports suggesting their positive or negative effects. In addition, 99 unpublished drug candidates were also found, that might serve future treatments for psoriasis.