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Gaspari V, Orioni G, Peron I, Misciali C, Bardazzi F. A case of guttate psoriasis after primary herpetic gingivostomatitis. Int J STD AIDS 2024:9564624241248873. [PMID: 38679796 DOI: 10.1177/09564624241248873] [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: 05/01/2024]
Abstract
Herpetic gingivostomatitis and anogenital herpes are widely known manifestations of sexually transmitted herpesvirus infections. What is less recognized is the potential causative role of such infections in triggering immune-mediated skin disorders such as guttate psoriasis. We describe the case of a 23-year-old man with an acute episode of guttate psoriasis related to primary herpetic gingivostomatitis. The diagnosis of guttate psoriasis was pathologically confirmed and the condition fully regressed after proper antiviral therapy. This case adds herpes simplex virus to the growing list of pathogens capable of acting as triggers for guttate psoriasis and highlights the need for better insight of the relationship between psoriasis and viral infections.
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Affiliation(s)
- Valeria Gaspari
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Gionathan Orioni
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S. Orsola Malpighi, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Isabella Peron
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S. Orsola Malpighi, Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Cosimo Misciali
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S. Orsola Malpighi, Bologna, Italy
| | - Federico Bardazzi
- Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna Policlinico S. Orsola Malpighi, Bologna, Italy
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2
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Hernandez-Nicols BF, Robledo-Pulido JJ, Alvarado-Navarro A. Etiopathogenesis of Psoriasis: Integration of Proposed Theories. Immunol Invest 2024; 53:348-415. [PMID: 38240030 DOI: 10.1080/08820139.2024.2302823] [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: 03/28/2024]
Abstract
Psoriasis is a chronic inflammatory disease characterized by squamous and erythematous plaques on the skin and the involvement of the immune system. Global prevalence for psoriasis has been reported around 1-3% with a higher incidence in adults and similar proportions between men and women. The risk factors associated with psoriasis are both extrinsic and intrinsic, out of which a polygenic predisposition is a highlight out of the latter. Psoriasis etiology is not yet fully described, but several hypothesis have been proposed: 1) the autoimmunity hypothesis is based on the over-expression of antimicrobial peptides such as LL-37, the proteins ADAMTSL5, K17, and hsp27, or lipids synthesized by the PLA2G4D enzyme, all of which may serve as autoantigens to promote the differentiation of autoreactive lymphocytes T and unleash a chronic inflammatory response; 2) dysbiosis of skin microbiota hypothesis in psoriasis has gained relevance due to the observations of a loss of diversity and the participation of pathogenic bacteria such as Streptococcus spp. or Staphylococcus spp. the fungi Malassezia spp. or Candida spp. and the virus HPV, HCV, or HIV in psoriatic plaques; 3) the oxidative stress hypothesis, the most recent one, describes that the cell injury and the release of proinflammatory mediators and antimicrobial peptides that leads to activate of the Th1/Th17 axis observed in psoriasis is caused by a higher release of reactive oxygen species and the imbalance between oxidant and antioxidant mechanisms. This review aims to describe the mechanisms involved in the three hypotheses on the etiopathogeneses of psoriasis.
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Affiliation(s)
- Brenda Fernanda Hernandez-Nicols
- Centro de Investigación en Inmunología y Dermatología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Juan José Robledo-Pulido
- Centro de Investigación en Inmunología y Dermatología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Anabell Alvarado-Navarro
- Centro de Investigación en Inmunología y Dermatología, Departamento de Fisiología, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
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3
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Olejnik-Wojciechowska J, Boboryko D, Bratborska AW, Rusińska K, Ostrowski P, Baranowska M, Pawlik A. The Role of Epigenetic Factors in the Pathogenesis of Psoriasis. Int J Mol Sci 2024; 25:3831. [PMID: 38612637 PMCID: PMC11011681 DOI: 10.3390/ijms25073831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/14/2024] Open
Abstract
Psoriasis is a chronic inflammatory skin disease, the prevalence of which is increasing. Genetic, genomic, and epigenetic changes play a significant role in the pathogenesis of psoriasis. This review summarizes the impact of epigenetics on the development of psoriasis and highlights challenges for the future. The development of epigenetics provides a basis for the search for genetic markers associated with the major histocompatibility complex. Genome-wide association studies have made it possible to link psoriasis to genes and therefore to epigenetics. The acquired knowledge may in the future serve as a solid foundation for developing newer, increasingly effective methods of treating psoriasis. In this narrative review, we discuss the role of epigenetic factors in the pathogenesis of psoriasis.
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Affiliation(s)
- Joanna Olejnik-Wojciechowska
- Department of Physiology, Pomeranian Medical University, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland; (J.O.-W.); (D.B.); (M.B.)
| | - Dominika Boboryko
- Department of Physiology, Pomeranian Medical University, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland; (J.O.-W.); (D.B.); (M.B.)
| | | | - Klaudia Rusińska
- Department of General Pathology, Pomeranian Medical University, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland;
| | - Piotr Ostrowski
- Department of Nursing, Pomeranian Medical University, Żołnierska 48, 71-210 Szczecin, Poland
| | - Magdalena Baranowska
- Department of Physiology, Pomeranian Medical University, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland; (J.O.-W.); (D.B.); (M.B.)
| | - Andrzej Pawlik
- Department of Physiology, Pomeranian Medical University, al. Powstańców Wlkp. 72, 70-111 Szczecin, Poland; (J.O.-W.); (D.B.); (M.B.)
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4
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Liu S, He M, Jiang J, Duan X, Chai B, Zhang J, Tao Q, Chen H. Triggers for the onset and recurrence of psoriasis: a review and update. Cell Commun Signal 2024; 22:108. [PMID: 38347543 PMCID: PMC10860266 DOI: 10.1186/s12964-023-01381-0] [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: 08/15/2023] [Accepted: 11/02/2023] [Indexed: 02/15/2024] Open
Abstract
Psoriasis is an immune-mediated inflammatory skin disease, involving a complex interplay between genetic and environmental factors. Previous studies have demonstrated that genetic factors play a major role in the pathogenesis of psoriasis. However, non-genetic factors are also necessary to trigger the onset and recurrence of psoriasis in genetically predisposed individuals, which include infections, microbiota dysbiosis of the skin and gut, dysregulated lipid metabolism, dysregulated sex hormones, and mental illness. Psoriasis can also be induced by other environmental triggers, such as skin trauma, unhealthy lifestyles, and medications. Understanding how these triggers play a role in the onset and recurrence of psoriasis provides insights into psoriasis pathogenesis, as well as better clinical administration. In this review, we summarize the triggers for the onset and recurrence of psoriasis and update the current evidence on the underlying mechanism of how these factors elicit the disease. Video Abstract.
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Grants
- No.82173423, No.81974475, No.82103731 the National Natural Science Foundation of China
- No.82173423, No.81974475, No.82103731 the National Natural Science Foundation of China
- No.82173423, No.81974475, No.82103731 the National Natural Science Foundation of China
- Basic Research Project, No. JCYJ20190809103805589 Shenzhen Natural Science Foundation
- Basic Research Project, No. JCYJ20190809103805589 Shenzhen Natural Science Foundation
- Basic Research Project, No. JCYJ20190809103805589 Shenzhen Natural Science Foundation
- Key Project, No.2019003 Shenzhen Nanshan District Science and Technology Project
- Key Project, No.2019003 Shenzhen Nanshan District Science and Technology Project
- Key Project, No.2019003 Shenzhen Nanshan District Science and Technology Project
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Affiliation(s)
- Suwen Liu
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Mengwen He
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, 518052, China
| | - Jian Jiang
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaoru Duan
- Department of Rheumatology and Immunology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Bao Chai
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, 518052, China
- Department of Dermatology, The 6th Affiliated Hospital of Shenzhen University Medical School, Shenzhen, 518052, China
| | - Jingyu Zhang
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, 518052, China
- Department of Dermatology, The 6th Affiliated Hospital of Shenzhen University Medical School, Shenzhen, 518052, China
| | - Qingxiao Tao
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Hongxiang Chen
- Department of Dermatology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Department of Dermatology, Huazhong University of Science and Technology Union Shenzhen Hospital, Shenzhen, 518052, China.
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Schröder JM. Discovery of natural bispecific antibodies: Is psoriasis induced by a toxigenic Corynebacterium simulans and maintained by CIDAMPs as autoantigens? Exp Dermatol 2024; 33:e15014. [PMID: 38284202 DOI: 10.1111/exd.15014] [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: 09/25/2023] [Revised: 12/21/2023] [Accepted: 12/29/2023] [Indexed: 01/30/2024]
Abstract
The high abundance of Corynebacterium simulans in psoriasis skin suggests a contribution to the psoriasis aetiology. This hypothesis was tested in an exploratory study, where western blot (WB) analyses with extracts of heat-treated C. simulans and psoriasis serum-derived IgG exhibited a single 16 kDa-WB-band. Proteomic analyses revealed ribosomal proteins as candidate C. s.-antigens. A peptidomic analysis unexpectedly showed that psoriasis serum-derived IgG already contained 31 immunopeptides of Corynebacteria ssp., suggesting the presence of natural bispecific antibodies (BsAbs). Moreover, peptidomic analyses gave 372 DECOY-peptides with similarity to virus- and phage proteins, including Corynebacterium diphtheriae phage, and similarity to diphtheria toxin. Strikingly, a peptidomic analysis for human peptides revealed 64 epitopes of major psoriasis autoantigens such as the spacer region of filaggrin, hornerin repeats and others. Most identified immunopeptides represent potential cationic intrinsically disordered antimicrobial peptides (CIDAMPs), which are generated within the epidermis. These may form complexes with bacterial disordered protein regions, representing chimeric antigens containing discontinuous epitopes. In addition, among 128 low-abundance immunopeptides, 48 are putatively psoriasis-relevant such as epitope peptides of PGE2-, vitamin D3- and IL-10-receptors. Further, 47 immunopeptides originated from tumour antigens, and the endogenous retrovirus HERV-K. I propose that persistent infection with a toxigenic C. simulans initiates psoriasis, which is exacerbated as an autoimmune disease by CIDAMPs as autoantigens. The discovery of natural BsAbs allows the identification of antigen epitopes from microbes, viruses, autoantigens and tumour-antigens, and may help to develop epitope-specific peptide-vaccines and therapeutic approaches with antigen-specific regulatory T cells to improve immune tolerance in an autoimmune disease-specific-manner.
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Affiliation(s)
- Jens-Michael Schröder
- Department of Dermatology, University-Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Falkenberg C, Bartholdy C, Koch J, Toft M, Skov S, Hansen CHF, Hansen A. Induction of CD8 + immune memory and enhanced inflammation in a skin inflammation model through pre-immunization with inactivated pathogens. Clin Transl Sci 2024; 17:e13697. [PMID: 38082552 PMCID: PMC10766028 DOI: 10.1111/cts.13697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 01/06/2024] Open
Abstract
Laboratory mice live in specific pathogen-free (SPF) conditions, resulting in an immature immune system comparable to that of newborns rather than adult humans or mice from pet shops. This condition may compromise their translational value. Reintroducing pathogens would lead to the uncontrolled spread of infections and associated diseases, so research facilities should seek safer alternatives. We immunized laboratory mice with a cocktail of pathogens, which were inactivated by ultraviolet irradiation and mixed with the adjuvant AddaVax. This immunization resulted in a higher percentage of CD8+ effector memory T cells compared to untreated mice, although the response was not as robust as in pet shop mice. In a model of skin inflammation, pre-immunization led to an increased skin inflammatory response compared to non-immunized mice. All immunized mice seroconverted to the pathogens in the mixture, while none of the non-immunized mice housed together seroconverted to the pathogens applied to the pre-immunized mice. In conclusion, pre-immunization of mice impacts the immune system, which includes increasing the levels of CD8+ effector memory T cells.
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Affiliation(s)
- Caroline Falkenberg
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical SciencesUniversity of CopenhagenFrederiksberg CDenmark
| | - Christina Bartholdy
- Translational Sciences, Research & Early Development, LEO Pharma A/SBallerupDenmark
| | - Janne Koch
- Translational Sciences, Research & Early Development, LEO Pharma A/SBallerupDenmark
| | | | - Søren Skov
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical SciencesUniversity of CopenhagenFrederiksberg CDenmark
| | - Camilla Hartmann Friis Hansen
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical SciencesUniversity of CopenhagenFrederiksberg CDenmark
| | - Axel Kornerup Hansen
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical SciencesUniversity of CopenhagenFrederiksberg CDenmark
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Man AM, Orăsan MS, Hoteiuc OA, Olănescu-Vaida-Voevod MC, Mocan T. Inflammation and Psoriasis: A Comprehensive Review. Int J Mol Sci 2023; 24:16095. [PMID: 38003284 PMCID: PMC10671208 DOI: 10.3390/ijms242216095] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 11/26/2023] Open
Abstract
Psoriasis is an immune-mediated disease with a strong genetic component that brings many challenges to sick individuals, such as chronic illness, and which has multiple associated comorbidities like cardiovascular disease, metabolic syndrome, inflammatory bowel disease, and psychological disorders. Understanding the interplay between the innate and adaptative immune system has led to the discovery of specific cytokine circuits (Tumor Necrosis Factor-alpha (TNF-α), IL-23, IL-17), which has allowed scientists to discover new biomarkers that can be used as predictors of treatment response and pave the way for personalized treatments. In this review, we describe the footprint psoriasis leaves on the skin and beyond, key pathophysiological mechanisms, current available therapeutic options, and drawbacks faced by existing therapies, and we anticipate potential future perspectives that may improve the quality of life of affected individuals.
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Affiliation(s)
- Alessandra-Mădălina Man
- Physiology Department, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400126 Cluj-Napoca, Romania; (A.-M.M.); (O.-A.H.); (M.-C.O.-V.-V.)
| | - Meda Sandra Orăsan
- Physiopathology Department, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400126 Cluj-Napoca, Romania;
| | - Oana-Alina Hoteiuc
- Physiology Department, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400126 Cluj-Napoca, Romania; (A.-M.M.); (O.-A.H.); (M.-C.O.-V.-V.)
| | - Maria-Cristina Olănescu-Vaida-Voevod
- Physiology Department, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400126 Cluj-Napoca, Romania; (A.-M.M.); (O.-A.H.); (M.-C.O.-V.-V.)
| | - Teodora Mocan
- Physiology Department, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400126 Cluj-Napoca, Romania; (A.-M.M.); (O.-A.H.); (M.-C.O.-V.-V.)
- Nanomedicine Department, Regional Institute of Gastroenterology and Hepatology, 400158 Cluj-Napoca, Romania
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Monteleone G, Moscardelli A, Colella A, Marafini I, Salvatori S. Immune-mediated inflammatory diseases: Common and different pathogenic and clinical features. Autoimmun Rev 2023; 22:103410. [PMID: 37597601 DOI: 10.1016/j.autrev.2023.103410] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 08/16/2023] [Indexed: 08/21/2023]
Abstract
The term "immune-mediated inflammatory diseases (IMIDs)" refers to several inflammatory pathologies of multifactorial etiology and involving either simultaneously or sequentially more organs. IMIDs share some common pathogenic mechanisms, which account for some similarities in the clinical course and the impact that these diseases may have on other organs and systems of the body. However, there are some differences in the IMID-associated pathological process, including the synthesis and function of multiple inflammatory cytokines, which are supposed to perpetuate the tissue-damaging inflammation. This justifies the different indications and responsiveness to corticosteroids, immunosuppressors, small molecules, and biologics. Many individuals with IMIDs are, however, intolerant, or unresponsive to the current drugs, thus suggesting the necessity of novel therapeutic approaches, such as the combination of compounds that either inhibit more immuno-inflammatory networks selectively or simultaneously suppress inflammatory signals and activate counter-regulatory pathways. In this article, we highlight the most relevant features of IMIDs and discuss how clinicians can combat the detrimental immune response in such disorders.
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Affiliation(s)
- Giovanni Monteleone
- Gastroenterology Unit, Azienda Ospedaliera Policlinico Tor Vergata, Rome, Italy; Department of Systems Medicine, University of "Tor Vergata", Rome, Italy.
| | | | - Alice Colella
- Gastroenterology Unit, Azienda Ospedaliera Policlinico Tor Vergata, Rome, Italy
| | - Irene Marafini
- Gastroenterology Unit, Azienda Ospedaliera Policlinico Tor Vergata, Rome, Italy
| | - Silvia Salvatori
- Gastroenterology Unit, Azienda Ospedaliera Policlinico Tor Vergata, Rome, Italy; Department of Systems Medicine, University of "Tor Vergata", Rome, Italy
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Jeong Y, Song J, Lee Y, Choi E, Won Y, Kim B, Jang W. A Transcriptome-Wide Analysis of Psoriasis: Identifying the Potential Causal Genes and Drug Candidates. Int J Mol Sci 2023; 24:11717. [PMID: 37511476 PMCID: PMC10380797 DOI: 10.3390/ijms241411717] [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: 05/31/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Psoriasis is a chronic inflammatory skin disease characterized by cutaneous eruptions and pruritus. Because the genetic backgrounds of psoriasis are only partially revealed, an integrative and rigorous study is necessary. We conducted a transcriptome-wide association study (TWAS) with the new Genotype-Tissue Expression version 8 reference panels, including some tissue and multi-tissue panels that were not used previously. We performed tissue-specific heritability analyses on genome-wide association study data to prioritize the tissue panels for TWAS analysis. TWAS and colocalization (COLOC) analyses were performed with eight tissues from the single-tissue panels and the multi-tissue panels of context-specific genetics (CONTENT) to increase tissue specificity and statistical power. From TWAS, we identified the significant associations of 101 genes in the single-tissue panels and 64 genes in the multi-tissue panels, of which 26 genes were replicated in the COLOC. Functional annotation and network analyses identified that the genes were associated with psoriasis and/or immune responses. We also suggested drug candidates that interact with jointly significant genes through a conditional and joint analysis. Together, our findings may contribute to revealing the underlying genetic mechanisms and provide new insights into treatments for psoriasis.
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Affiliation(s)
- Yeonbin Jeong
- Department of Life Sciences, Dongguk University, Seoul 04620, Republic of Korea
| | - Jaeseung Song
- Department of Life Sciences, Dongguk University, Seoul 04620, Republic of Korea
| | - Yubin Lee
- Department of Life Sciences, Dongguk University, Seoul 04620, Republic of Korea
| | - Eunyoung Choi
- Department of Life Sciences, Dongguk University, Seoul 04620, Republic of Korea
| | - Youngtae Won
- Department of Life Sciences, Dongguk University, Seoul 04620, Republic of Korea
| | - Byunghyuk Kim
- Department of Life Sciences, Dongguk University-Seoul, Goyang 10326, Republic of Korea
| | - Wonhee Jang
- Department of Life Sciences, Dongguk University, Seoul 04620, Republic of Korea
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Lupea-Chilom DS, Solovan CS, Farcas SS, Gogulescu A, Andreescu NI. Latent Tuberculosis in Psoriasis Patients on Biologic Therapies: Real-World Data from a Care Center in Romania. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1015. [PMID: 37374219 DOI: 10.3390/medicina59061015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/20/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023]
Abstract
Background and Objectives: Psoriasis is a chronic and inflammatory condition that has a huge impact on the patient's quality of life. Biological treatment improved psoriasis therapy, with impressive results seen in the evolution of the disease and the patient's quality of life. However, the risk of mycobacterium tuberculosis (MTB) infection reactivation is well-known to biological therapy, which raises problems especially in an endemic country. Materials and Methods: In this study, we followed moderate to severe psoriasis patients who had latent tuberculosis infection (LTBI) following treatment with a biological therapy approved in Romania. Results: The patients were evaluated at baseline and then followed-up with Mantoux tests and chest X-rays every year, resulting in 54 patients being diagnosed with LTBI. At the initial evaluation, 30 patients with LTBI were identified, and 24 more were identified during biological therapy. These patients were given prophylactic treatment. Out of the 97 participants in this retrospective study, 25 required association of methotrexate (MTX) alongside biological therapy. We compared the prevalence of positive Mantoux tests in patients with combined therapy with that of patients only on biological treatment, and the results were higher in the combined therapy group. Conclusion: All the patients in the study were vaccinated against tuberculosis (TB) after birth, and none were diagnosed with active tuberculosis (aTB) before or after the start of therapy according to the pulmonologist.
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Affiliation(s)
- Doriana-Sorina Lupea-Chilom
- Department of Dermatology, University of Medicine and Pharmacy "Victor Babeş", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
| | - Caius Silviu Solovan
- Department of Dermatology, University of Medicine and Pharmacy "Victor Babeş", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
| | - Simona Sorina Farcas
- Department of Microscopic Morphology-Genetics, Center of Genomic Medicine, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
| | - Armand Gogulescu
- Department of Medical Rehabilitation, University of Medicine and Pharmacy "Victor Babeş", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
| | - Nicoleta Ioana Andreescu
- Department of Microscopic Morphology-Genetics, Center of Genomic Medicine, University of Medicine and Pharmacy "Victor Babes", Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania
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11
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Antonatos C, Asmenoudi P, Panoutsopoulou M, Vasilopoulos Y. Pharmaco-Omics in Psoriasis: Paving the Way towards Personalized Medicine. Int J Mol Sci 2023; 24:ijms24087090. [PMID: 37108251 PMCID: PMC10139144 DOI: 10.3390/ijms24087090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/04/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
The emergence of high-throughput approaches has had a profound impact on personalized medicine, evolving the identification of inheritable variation to trajectory analyses of transient states and paving the way for the unveiling of response biomarkers. The utilization of the multi-layered pharmaco-omics data, including genomics, transcriptomics, proteomics, and relevant biological information, has facilitated the identification of key molecular biomarkers that can predict the response to therapy, thereby optimizing treatment regiments and providing the framework for a tailored treatment plan. Despite the availability of multiple therapeutic options for chronic diseases, the highly heterogeneous clinical response hinders the alleviation of disease signals and exacerbates the annual burden and cost of hospitalization and drug regimens. This review aimed to examine the current state of the pharmaco-omic approaches performed in psoriasis, a common inflammatory disease of the skin. We sought to identify central studies that investigate the inter-individual variability and explore the underlying molecular mechanisms of drug response progression via biological profiling in psoriatic patients administered with the extended therapeutic armamentarium of psoriasis, incorporating conventional therapies, small molecules, as well as biological drugs that inhibit central pathogenic cytokines involved in the disease pathogenesis.
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Affiliation(s)
- Charalabos Antonatos
- Laboratory of Genetics, Section of Genetics, Cell Biology and Development, Department of Biology, University of Patras, 26504 Patras, Greece
| | - Paschalia Asmenoudi
- Laboratory of Genetics, Section of Genetics, Cell Biology and Development, Department of Biology, University of Patras, 26504 Patras, Greece
| | - Mariza Panoutsopoulou
- Laboratory of Genetics, Section of Genetics, Cell Biology and Development, Department of Biology, University of Patras, 26504 Patras, Greece
| | - Yiannis Vasilopoulos
- Laboratory of Genetics, Section of Genetics, Cell Biology and Development, Department of Biology, University of Patras, 26504 Patras, Greece
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12
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Psoriasiform Dermatitis in a COVID-19 Patient. Case Rep Dermatol Med 2022; 2022:1820673. [PMID: 36567752 PMCID: PMC9788876 DOI: 10.1155/2022/1820673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/11/2022] [Accepted: 11/14/2022] [Indexed: 12/23/2022] Open
Abstract
Psoriasis is a chronic inflammatory papulosquamous disorder which affects around 2% of the world's population. A peak exacerbation in psoriatic symptoms was noted during COVID-19 due to lack of access to dermatological care mixed with heightened emotional stress during the pandemic. This case report describes a 52-year-old admitted male patient who sustained a diffuse rash on multiple areas of his body a week prior to testing positive for COVID-19. We explore plausible causes for the occurrence of the rash, discuss our treatment plan, include relevant clinical pictures, and review published literature to examine conditions that present similarly to the rash seen in our patient. It is crucial for dermatologists to be able to discern various systemic manifestations associated with cutaneous lesions, such as the one seen in this patient, in order to make an accurate and prompt diagnosis. A better understanding of the association between COVID-19 infection and psoriasiform lesions is needed for improving the prognostic and therapeutic outcomes in patients.
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Patrick MT, Li Q, Wasikowski R, Mehta N, Gudjonsson JE, Elder JT, Zhou X, Tsoi LC. Shared genetic risk factors and causal association between psoriasis and coronary artery disease. Nat Commun 2022; 13:6565. [PMID: 36323703 PMCID: PMC9630428 DOI: 10.1038/s41467-022-34323-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 10/20/2022] [Indexed: 11/06/2022] Open
Abstract
Psoriasis and coronary artery disease (CAD) are related comorbidities that are well established, but whether a genetic basis underlies this is not well studied. We apply trans-disease meta-analysis to 11,024 psoriasis and 60,801 CAD cases, along with their associated controls, identifying one opposing and three shared genetic loci, which are confirmed through colocalization analysis. Combining results from Bayesian credible interval analysis with independent information from genomic, epigenomic, and spatial chromatin organization, we prioritize genes (including IFIH1 and IL23A) that have implications for common molecular mechanisms involved in psoriasis and CAD inflammatory signaling. Chronic systemic inflammation has been associated with CAD and myocardial infarction, and Mendelian randomization analysis finds that CAD as an exposure can have a significant causal effect on psoriasis (OR = 1.11; p = 3×10-6) following adjustment for BMI and waist-hip ratio. Together, these findings suggest that systemic inflammation which causes CAD can increase the risk of psoriasis.
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Affiliation(s)
- Matthew T Patrick
- Department of Dermatology, Michigan Medicine, University of Michigan, Michigan, MI, USA
| | - Qinmengge Li
- Department of Biostatistics, School of Public Health, University of Michigan, Michigan, MI, USA
| | - Rachael Wasikowski
- Department of Dermatology, Michigan Medicine, University of Michigan, Michigan, MI, USA
| | - Nehal Mehta
- Section of Inflammation and Cardiometabolic Disease, National Heart, Lung, and Blood Institute, National Institutes of Health, Michigan, MD, USA
| | - Johann E Gudjonsson
- Department of Dermatology, Michigan Medicine, University of Michigan, Michigan, MI, USA
| | - James T Elder
- Department of Dermatology, Michigan Medicine, University of Michigan, Michigan, MI, USA
| | - Xiang Zhou
- Department of Biostatistics, School of Public Health, University of Michigan, Michigan, MI, USA
| | - Lam C Tsoi
- Department of Dermatology, Michigan Medicine, University of Michigan, Michigan, MI, USA.
- Department of Biostatistics, School of Public Health, University of Michigan, Michigan, MI, USA.
- Department of Computational Medicine and Bioinformatics, Michigan Medicine, University of Michigan, Michigan, MI, USA.
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Kapoor B, Gulati M, Rani P, Gupta R. Psoriasis: Interplay between dysbiosis and host immune system. Clin Exp Rheumatol 2022; 21:103169. [PMID: 35964945 DOI: 10.1016/j.autrev.2022.103169] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/07/2022] [Indexed: 11/30/2022]
Abstract
With advancement in human microbiome research, an increasing number of scientific evidences have endorsed the key role of both gut and skin microbiota in the pathogenesis of psoriasis. Microbiome dysbiosis, characterized by altered diversity and composition, as well as rise of pathobionts, have been identified as possible triggers for recurrent episodes of psoriasis. Mechanistically, gut dysbiosis leads to "leaky gut syndrome" via disruption of epithelial bilayer, thereby, resulting in translocation of bacteria and other endotoxins to systemic circulation, which in turn, results in inflammatory response. Similarly, skin dysbiosis disrupts the cutaneous homeostasis, leading to invasion of bacteria and other pathogens to deeper layers of skin or even systemic circulation further enhanced by injury caused by pruritus-induced scratching, and elicit innate and adaptive inflammation. The present review explores the correlation of both skin and gut microbiota dysbiosis with psoriasis. Also, the studies highlighting the potential of bacteriotherapeutic approaches including probiotics, prebiotics, metabiotics, and fecal microbiota transplantation for the management of psoriasis have been discussed.
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Affiliation(s)
- Bhupinder Kapoor
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India.
| | - Monica Gulati
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India; Faculty of Health, Australian Research Centre in Complementary and Integrative Medicine, University of Technology Sydney, NSW 2007, Australia.
| | - Pooja Rani
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
| | - Reena Gupta
- School of Pharmaceutical Sciences, Lovely Professional University, Phagwara, Punjab, India
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15
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Paksoy T, Ustaoğlu G, Yaman D, Arıöz Ö, Demirci M, Ünlü Ö, Avcı E, Polat M. The link between total antioxidant status, total oxidant status, arylesterase activity, and subgingival microbiota in psoriasis patients. Int J Dermatol 2022; 61:1487-1496. [PMID: 35906956 DOI: 10.1111/ijd.16353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/15/2022] [Accepted: 06/24/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Studies focusing on the relationship between periodontitis and systemic diseases have suggested a possible association between these two chronic and inflammatory disorders. We aimed to comparatively investigate the salivary oxidative status, biomarker levels, clinical findings, and the microbial load on subgingival biofilm samples in psoriasis patients and controls. METHODS Forty participants were allocated into four groups as follows: (1) systemically and periodontally healthy (C group); (2) systemically healthy with periodontitis (P group); (3) psoriasis (Ps) and periodontally healthy (Ps-C group); and (4) Ps with periodontitis (Ps-P group). Subgingival biofilm samples were obtained to detect the periodontopathogenic agents by Real-time PCR (qPCR). The total antioxidant status (TAS) (mmol/l), total oxidant status (TOS) (μmol/l), and arylesterase (ARE) activity (U/L) were analyzed using saliva samples. RESULTS The level of TOS and oxidative stress index (OSI) were significantly higher in patients with Ps-P and P compared to controls (P = 0.001, and P ˂ 0.001, respectively). ARE levels were higher in controls compared to Ps and P (P ˂ 0.001). The prevalences of bacteria detected in subgingival biofilm samples were similar between all groups (P > 0.05). CONCLUSIONS This study reported that psoriasis may amplify TOS and OSI, and the co-existence of psoriasis and periodontitis may aggravate oxidative stress.
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Affiliation(s)
- Tuğçe Paksoy
- Istanbul Atlas University, Faculty of Dentistry, Department of Periodontology, Istanbul, Turkey
| | - Gülbahar Ustaoğlu
- Bolu Abant Izzet Baysal University, Faculty of Dentistry, Department of Periodontology, Bolu, Turkey
| | - Deniz Yaman
- Bolu Abant Izzet Baysal University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Bolu, Turkey
| | - Özkan Arıöz
- Bolu Abant Izzet Baysal University, Faculty of Dentistry, Department of Periodontology, Bolu, Turkey
| | - Mehmet Demirci
- Kırklareli University, Faculty of Medicine, Department of Medical Microbiology, Kırklareli, Turkey
| | - Özge Ünlü
- İstanbul Atlas University, Faculty of Medicine, Department of Medical Microbiology, İstanbul, Turkey
| | - Emre Avcı
- Health Sciences University, Gülhane Pharmacy Faculty, Basic Pharmaceutical Sciences Department, Department of Biochemistry, İstanbul, Turkey
| | - Mualla Polat
- Bolu Abant Izzet Baysal University, Faculty of Medicine, Department of Dermatology and Venerology, Bolu, Turkey
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16
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Zhou S, Yao Z. Roles of Infection in Psoriasis. Int J Mol Sci 2022; 23:ijms23136955. [PMID: 35805960 PMCID: PMC9266590 DOI: 10.3390/ijms23136955] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 06/22/2022] [Accepted: 06/22/2022] [Indexed: 02/08/2023] Open
Abstract
Psoriasis is a chronic, immune-mediated disorder with cutaneous and systemic manifestations. Genetic predisposition, environmental factors, and immune dysfunction all contribute to the pathogenesis of psoriasis with host-microbe interaction governing the progression of this disease. Emerging evidence has indicated that infection is an environmental trigger for psoriasis and plays multiple roles in its maintenance as evidenced by the frequent association between guttate psoriasis onset and acute streptococcal infection. Different infectious factors act on immune cells to produce inflammatory cytokines that can induce or aggravate psoriasis. In addition to bacterial infections, viral and fungal infections have also been shown to be strongly associated with the onset or exacerbation of psoriasis. Intervention of skin microbiota to treat psoriasis has become a hot research topic. In this review, we summarize the effects of different infectious factors (bacteria, viruses, and fungi) on psoriasis, thereby providing insights into the manipulation of pathogens to allow for the identification of improved therapeutic options for the treatment of this condition.
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Affiliation(s)
- Shihui Zhou
- Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China;
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
| | - Zhirong Yao
- Department of Dermatology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China;
- Institute of Dermatology, Shanghai Jiaotong University School of Medicine, Shanghai 200092, China
- Correspondence:
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Lalani A, Conrad C, Shahab S. Acute Psoriatic Exacerbation Secondary to Infected Pacemaker With Staphylococcus aureus and Candida lusitaniae? Cureus 2022; 14:e25078. [PMID: 35719758 PMCID: PMC9202648 DOI: 10.7759/cureus.25078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/28/2022] Open
Abstract
Psoriasis is a lifelong chronic hyperproliferative inflammatory immune-mediated disorder. There is a strong association of psoriasis exacerbation with infection of Staphylococcus and Streptococcus species. In the case of our patient, a psoriatic flare manifesting as dactylitis occurred secondary to methicillin sensitive Staphylococcus aureus bacteremia colonization of his pacemaker. If a patient is started on an antibiotic regimen, such as vancomycin, and has symptoms of rash, and swelling in the fingers, it is imperative to ask for a proper rheumatologic history, as vancomycin infusion reaction (previously known as Red Man Syndrome) may not be the cause of the flare-up, such as in the case of our patient. Inversely, patients with psoriasis are more likely to be colonized by S. aureus on the skin and in the nasal cavity, and this can lead to bacteremia and infection of hardware, such as an automatic implantable cardioverter-defibrillator (AICD).
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Huang YZ, Zheng YX, Zhou Y, Xu F, Cui YZ, Chen XY, Wang ZY, Yan BX, Zheng M, Man XY. OAS1, OAS2, and OAS3 Contribute to Epidermal Keratinocyte Proliferation by Regulating Cell Cycle and Augment Type I Interferon-Induced JAK1-STAT1 Phosphorylation in Psoriasis. J Invest Dermatol 2022; 142:2635-2645.e9. [PMID: 35305973 DOI: 10.1016/j.jid.2022.02.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 02/17/2022] [Accepted: 02/28/2022] [Indexed: 11/30/2022]
Abstract
Psoriasis is a systemic immune-mediated inflammatory disease characterized by hyperproliferation and abnormal differentiation of epidermal keratinocytes. Recent studies have identified IL-17 and IL-23 as key drivers of psoriasis pathogenesis, but the underlying molecular mechanisms remain unclear. The 2'-5'-oligoadenylate synthetases, namely, OAS1, OAS2, OAS3, and OASL, are a family of interferon-induced enzymes with multiple antiviral activities, but their role in psoriasis is unknown. Here, we identified overexpression of OAS1, OAS2, and OAS3 in human lesional psoriatic skin and serum and found that their expression was downregulated by biologics. Moreover, OASs were highly expressed in epidermal keratinocytes, epidermal dendritic cells, epidermal CD3+ T cells, dermal antigen-presenting cells, and dermal T cells from the psoriatic epidermis and dermis, as determined by flow cytometry. Additionally, OASs were upregulated by poly(I:C), poly(dA:dT), and type I IFNs but downregulated by JAK inhibitors in normal human epidermal keratinocytes. Furthermore, silencing of OASs inhibited the phosphorylation of JAK1 and STAT1. Knockdown of OASs suppressed keratinocyte proliferation by inhibiting cell cycle progression. Thus, OASs may be therapeutic biomarkers in psoriasis.
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Affiliation(s)
- Yan-Zhou Huang
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yu-Xin Zheng
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuan Zhou
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Fan Xu
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying-Zhe Cui
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xue-Yan Chen
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhao-Yuan Wang
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bing-Xi Yan
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zheng
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiao-Yong Man
- Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Liang X, Ou C, Zhuang J, Li J, Zhang F, Zhong Y, Chen Y. Interplay Between Skin Microbiota Dysbiosis and the Host Immune System in Psoriasis: Potential Pathogenesis. Front Immunol 2021; 12:764384. [PMID: 34733291 PMCID: PMC8558530 DOI: 10.3389/fimmu.2021.764384] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/27/2021] [Indexed: 12/12/2022] Open
Abstract
Psoriasis is a multifactorial immune-mediated disease. The highly effective and eligible treatment for psoriasis is limited, for its specific pathogenesis is incompletely elucidated. Skin microbiota is a research hotspot in the pathogenesis of immune-mediated inflammatory skin diseases nowadays, and it may have significant involvement in the provocation or exacerbation of psoriasis with broadly applicable prospects. It is postulated that skin microbiota alternation may interplay with innate immunity such as antimicrobial peptides and Toll-like receptors to stimulate T-cell populations, resulting in immune cascade responses and ultimately psoriasis. Achieving a thorough understanding of its underlying pathogenesis is crucial. Herein, we discuss the potential immunopathogenesis of psoriasis from the aspect of skin microbiota in an attempt to yield insights for novel therapeutic and preventive modalities for psoriasis.
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Affiliation(s)
- Xiaoqian Liang
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Caixin Ou
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Jiayi Zhuang
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Jinsheng Li
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Fangfei Zhang
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Yuanqiu Zhong
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
| | - Yongfeng Chen
- Department of Dermatology, Dermatology Hospital of Southern Medical University, Guangzhou, China
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Abstract
Psoriatic arthritis (PsA) is a complex inflammatory disease with heterogeneous clinical features, which complicates psoriasis in 30% of patients. There are no diagnostic criteria or tests available. Diagnosis is most commonly made by identifying inflammatory musculoskeletal features in joints, entheses or the spine in the presence of skin and/or nail psoriasis and in the usual absence of rheumatoid factor and anti-cyclic citrullinated peptide. The evolution of psoriasis to PsA may occur in stages, although the mechanisms are unclear. In many patients, there may be little or no relationship between severity of musculoskeletal inflammation and severity of skin or nail psoriasis. The reason for this disease heterogeneity may be explained by differences in genotype, especially in the HLA region. New targeted therapies for PsA have been approved with additional therapies in development. These developments have substantially improved both short-term and long-term outcomes including a reduction in musculoskeletal and skin manifestations and in radiographic damage. With efforts underway aimed at improving our understanding of the molecular basis for the heterogeneity of PsA, a personalized approach to treating PsA may become possible.
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