Metabolic syndrome in patients with psoriatic disease

Diabetes and obesity burden and improvements in cardiometabolic parameters in patients with psoriasis or psoriatic arthritis receiving apremilast in a real-world setting

Introduction

Patients with psoriasis and psoriatic arthritis have a higher prevalence of cardiometabolic comorbidities compared to the general population. Clinical data suggest apremilast may reduce weight and glycated hemoglobin (HbA1c).

Objective

To describe changes in cardiometabolic parameters among patients with psoriasis and psoriatic arthritis newly treated with apremilast by prediabetes/diabetes or obesity status.

Methods

This was a retrospective cohort study of electronic medical records from patients with psoriasis and/or psoriatic arthritis in the OM1 Real-World Data Cloud who newly initiated apremilast. Changes from baseline in body mass index, weight, HbA1c, and lipids were evaluated at 6 and 12 months using a multivariable linear regression model stratified by prediabetes/diabetes or obesity status.

Results

Of 8487 patients initiating apremilast, 24% had diabetes. Of 8250 patients with body mass index available, 27% were obese and 34% were severely obese. Patients experienced decreases in body mass index and weight at 6 and 12 months regardless of diabetes or obesity status, with the greatest reductions seen in those with diabetes and obesity. Reductions in HbA1c at 6 months were seen in patients without diabetes and patients with severe obesity.

Conclusions

Treatment with apremilast may provide the greatest cardiometabolic benefit to those with the greatest burden of cardiometabolic disease.

Clinical Implications of Metabolic Syndrome in Psoriasis Management

Psoriasis is an increasingly common chronic immune-mediated skin disease recognized for its systemic effects that extend beyond the skin and include various cardiovascular diseases, neurological diseases, type 2 diabetes, and metabolic syndrome. This study aimed to explore the complex relationship between psoriasis and metabolic syndrome by analyzing clinical, biochemical, and immunological parameters in patients with psoriasis alone and in patients combining psoriasis and metabolic syndrome. A total of 150 patients were enrolled, 76 with psoriasis only (PSO) and 74 with psoriasis and metabolic syndrome (PSO-MS). Data collected included anthropometric measurements, blood tests, and inflammatory markers. Statistical analysis was performed using the independent t-test, Mann-Whitney U test, Kruskal-Wallis test, and chi-square test to compare the two groups. Patients in the PSO-MS group had a significantly higher body weight, abdominal circumference, BMI, and inflammatory markers compared to patients with PSO. In addition, increased levels of IL-17A, cholesterol, triglycerides, and glucose were observed in the PSO-MS group. This study highlights the increased metabolic risk and exacerbated systemic inflammation associated with the coexistence of psoriasis and metabolic syndrome. These findings demonstrate the need for a comprehensive therapeutic approach and early intervention to manage metabolic complications in patients with psoriasis and metabolic syndrome.

Redefining Disease Severity with Special Area Involvement and Reflecting on Treatment Patterns in a Real-World Psoriasis Population

BACKGROUND

The International Psoriasis Council (IPC) recommends an approach that considers body surface area (BSA), involvement in special areas, and treatment history for classifying patients as candidates for topical or systemic treatment. This study aimed to quantify the burden of psoriasis by describing BSA distribution, special area involvement, and treatments in a real-world population.

METHODS

This retrospective cohort study included patients with psoriasis from the Optum® deidentified Electronic Health Records database with a BSA value (< 3%, 3-10%, and > 10%) recorded between 1 March 2014 and 1 September 2020. Treatments and special area involvement (face, scalp, palms/soles, nails, genitals) were identified within 90 days of the BSA value and stratified by BSA category.

RESULTS

Among eligible patients (N = 5120), mean age was 51.4 years and 49.3% were women. The majority of patients (78.9%) were treated with any topical. Proportions of patients with BSA < 3%, 3-10%, and > 10% were 23.4%, 41.9%, and 34.6%, respectively; proportions with 0, 1, and 2+ special areas were 21.6%, 31.6%, and 45.7%, respectively; and 44.4%, 45.7%, and 45.9% of patients with BSA < 3%, 3-10%, and > 10%, respectively, had 2+ special areas.

CONCLUSION

The IPC classification can likely identify many more patients who may benefit from systemic therapy than BSA alone.

The efficacy of metformin for the treatment of psoriasis: a meta-analysis study

Introduction

Metformin has potential in treating patients with psoriasis, and this meta-analysis aims to explore the impact of metformin supplementation on treatment efficacy for psoriasis.

Material and methods

The PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases were systematically searched, and we included randomized controlled trials (RCTs) assessing the effect of metformin on treatment efficacy for patients with psoriasis.

Results

Three RCTs were included in the meta-analysis. Overall, compared with control intervention for psoriasis, metformin intervention resulted in significantly increased psoriasis area severity index (PASI) 75% reduction (odds ratio (OR) = 22.02; 95% confidence interval (CI): 2.12 to 228.49; p = 0.01), and erythema, scaling and induration (ESI) 75% reduction (OR = 9.12; 95% CI: 2.13 to 39.02; p = 0.003), and was associated with substantially decreased fasting plasma glucose (FPG, standard mean difference (SMD) = -0.59; 95% CI: -0.92 to -0.26; p = 0.0005), triglycerides (SMD = -0.92; 95% CI: -1.38 to -0.47; p < 0.0001), total cholesterol (SMD = -0.77; 95% CI: -1.22 to -0.32; p = 0.00008), and low-density lipoprotein (LDL, SMD = -0.67; 95% CI: -1.12 to -0.23; p = 0.003).

Conclusions

Metformin supplementation effectively improves treatment efficacy and metabolic syndrome in psoriasis patients.

Metabolic Syndrome Screening and Nutritional Status of Patients with Psoriasis: A Scoping Review

Background: Patients with plaque psoriasis have an increased risk of metabolic syndrome. However, no studies have assessed the nutritional status or screening methods of this population. Aims: This review aimed to identify and summarise metabolic syndrome screening criteria and the tools/methods used in nutrition assessment in patients with plaque psoriasis. Data synthesis: PubMed, Web of Science, Ovid and Scopus were searched from inception to March 2023, following the Arkensey and O'Malley framework, to identify articles that report nutritional assessment methods/tools and metabolic screening criteria. Twenty-one studies were identified. Overall, these studies used four different screening criteria to define metabolic syndrome. Patients with psoriasis had a high prevalence of metabolic syndrome and had a poor nutritional status compared to controls. However, only anthropometric measures such as weight, height and waist circumference were employed to determine the nutritional status. Only two studies assessed the vitamin D status. Conclusions: Patients with psoriasis have a poor nutritional status, and they are at risk of nutrient deficiencies. However, these health aspects are not routinely assessed and may increase the risk of malnutrition among these patients. Therefore, additional assessments, such as body composition and dietary assessment, are needed to determine the nutritional status to provide a suitable intervention.

Retinal vascular assessment in psoriatic patients with and without metabolic syndrome using optical coherence tomography angiography

To evaluate the retinal vasculature in psoriasis patients and detect if metabolic syndrome is an additional risk factor. This cross-sectional analytic study was carried out on 80 eyes of 80 subjects; 28 eyes with psoriasis only (PS group), 12 eyes with additional metabolic syndrome to psoriasis (PMS group) and 40 eyes healthy controls (HS). The retinal capillary plexuses were evaluated by OCTA. The disease activity was evaluated by the Psoriasis Area and Severity Index (PASI) score and extent. The superficial capillary plexus (SCP) vascular density was significantly lower in PS group than HS while in PMS it was significantly lower only in whole image and superior and temporal perifoveal areas (p-value = 0.020, 0.030, 0.001 respectively). The changes correlated with the disease duration. The vascular density of the deep capillary plexus (DCP) was significantly lower in both PS and PMS groups (p-value < 0.001). Psoriatic patients are at a higher risk of developing retinal vascular complications even without evident clinical ocular disease. It was noted that the presence of metabolic syndrome contributes as an additional risk factor in possible visual loss secondary to ischemic changes that are likely to start in the DCP and progress to involve all levels.

Single-cell immune ecosystem and metabolism reprogramming imprinted by psoriasis niche

Background

A major challenge of psoriasis is its dysfunctional immune niche. Remarkable gaps remain in understanding how immune cell state transitions are linked to clinical outcomes in psoriasis. Thus, there is a pressing need to discover immunomodulatory programs governing psoriasis progression.

Methods

Here, by using the state-of-the-art single-cell RNA-sequencing (RNA-seq) data, we observed the unique immune cell profile inside the psoriasis niche compared with the normal skins.

Results

In detail, the immunosuppressive T cells such as regulatory T (Treg) cells and CTLA4⁺ CD8 T cells showed higher infiltration in the psoriasis niche, indicating the immunosuppressive state was imprinted by such disease. Interestingly, unbiased trajectory and pathway enrichment analysis showed that those suppressive T cells potentially showed developmental and metabolic abnormalities. Intercellular crosstalk modeling shows that exhausted CTLA4⁺ CD8 T cells can send out cytokine signaling via utilizing CXCL13-CXCR3 ligand-receptor pair. We finally quantified the metabolism profile of T cells and strikingly observed their enhanced metabolic activity.

Conclusions

Taken together, these data highlight cell-type specific reprogramming within the psoriasis microenvironment and provide evidence for immune-related biomarkers of psoriasis clinical outcome. Our work not only revealed the unique immune ecosystem of psoriasis, but also opened new opportunities for targeting immunometabolism in treating such skin diseases.

Comorbidity in Adult Psoriasis: Considerations for the Clinician

Psoriasis is associated with several comorbidities ranging from cardiovascular comorbidity and mental disorders to other immune mediated inflammatory diseases. However, most of these co-morbidities are often overlooked or diagnosed late. Furthermore, evidence suggests that comorbidities are undertreated. Here, we provide an overview of comorbidities in psoriasis and present a simple rundown of considerations of relevance to the clinician. We hope that this review may raise clinicians' awareness of comorbidities in psoriasis and provide simple guidance regarding screening tools and treatment decisions in psoriasis with comorbidities.

Oversight and Management of Women with Psoriasis in Childbearing Age

Psoriasis is a complex disease with many associated comorbidities, all of which have a negative impact on a patient's personal, social, and sexual life. There are some unique considerations in the effects of this disease among women. The average age of diagnosis in women with psoriasis is 28 years, and this onset corresponds to the fertile life of women. There is conflicting information about the effects of psoriasis on female fertility. Some studies suggest that this condition's associated comorbidities, personal behaviors, and reduced ovarian reserve, especially due to chronic inflammation, affect women's fertility. Another possible reason women with psoriasis are less likely to become pregnant is that their sexual intercourse frequency decreases after the condition's onset. The available information on the effects of pregnancy on women with psoriasis is limited. According to current evidence, most women will experience an improvement in their skin condition. Studies show that patients with moderate-to-severe psoriasis are more prone to experience pregnancy complications. The management of pregnant and lactating women with psoriasis is also difficult, as the safety profile of commonly used drugs in patients with psoriasis is not entirely known.

Psoriasis and metabolic syndrome: implications for the management and treatment of psoriasis

Psoriasis is a chronic systemic inflammatory disorder associated with several comorbidities in addition to the characteristic skin lesions. Metabolic syndrome (MetS) is the most frequent comorbidity in psoriasis and a risk factor for cardiovascular disease, a major cause of death among patients with psoriasis. Although the exact causal relationship between these two disorders is not fully established, the underlying pathophysiology linking psoriasis and MetS seems to involve overlapping genetic predispositions and inflammatory pathways. Dysregulation of the IL‐23/Th‐17 immune signalling pathway is central to both pathologies and may be key to promoting susceptibility to metabolic and cardiovascular diseases in individuals with and without psoriasis. Thus, biological treatments for psoriasis that interrupt these signals could both reduce the psoriatic inflammatory burden and also lessen the risk of developing atherosclerosis and cardiometabolic diseases. In support of this hypothesis, improvement of skin lesions was associated with improvement in vascular inflammation in recent imaging studies, demonstrating that the beneficial effect of biological agents goes beyond the skin and could help to prevent cardiovascular disease. This review will summarize current knowledge on underlying inflammatory mechanisms shared between psoriasis and MetS and discuss the most recent clinical evidence for the potential for psoriasis treatment to reduce cardiovascular risk.

Chronic Kidney Disease in Patients with Psoriasis -A Hospital Based Cross Sectional Study

Background:

Psoriasis is a multi-system inflammatory disease where skin and joints are the primary targets. Recently, some studies had shown the association of psoriasis with kidney disease.

Aims:

To study the association of psoriasis with chronic kidney disease (CKD) in a tertiary health care center.

Methodology:

The study was conducted in the Department of Dermatology in a tertiary care center in Kerala. The study was a descriptive cross-sectional study for 6 months from August 2017 to January 2018. A total of 104 patients with psoriasis were studied. Clinical data was collected. Glomerular filtration rate (GFR) and albumin creatinine ratio (ACR) were found out to know the presence of CKD. Descriptive and inferential statistical analysis has been carried out in the present study.

Observations:

Of the 104 patients, 14 were diagnosed as having CKD. Of the 14 CKD patients, 12 had severe psoriasis, 2 had moderate psoriasis, and none had mild psoriasis. The risk factors for CKD (presence of diabetes mellitus/hypertension or intake of drugs—non-steroidal anti-inflammatory drugs [NSAIDs]/cyclosporine) were present in 9 out of 14 CKD patients. The duration of psoriasis was more than 10 years in 10 CKD patients.

Conclusion:

Our study demonstrated that psoriatic patients have an increased risk of developing CKD and this risk is found to increase with the severity and duration of psoriasis. Our results require confirmation in large-patient populations in prospective studies or case-control studies.

Nutrition and psoriasis

Nutrition and dietary supplements are commonly used in the management of psoriasis; however, evidence of their efficacy is inconsistent. Although some dietary interventions have been shown to improve psoriasis consistently, others have little evidence supporting their use. We review common dietary interventions for the management of psoriasis and the evidence behind them. Caloric restriction, especially in overweight and obese individuals, has been shown to consistently diminish psoriatic activity. Evidence about other supplements and dietary interventions is inconsistent. Given the cost and side effects of pharmaceutical treatments for psoriasis, larger, long-term studies on the use of nutrition for the management of psoriasis are necessary.

Relationship between acanthosis nigricans, acrochordon and metabolic syndrome in patients with lichen planus

AIM

In the literature, there are no data examining the association with lichen planus with acanthosis nigricans and acrochordon, which are skin findings of metabolic syndrome (MS).

MATERIALS

A total of 108 lichen planus (LP) patients, age and sex-matched 109 controls, 217 patients in total were prospectively included in the study.

RESULTS

Metabolic Syndrome was found in 55 (50.9%) of 108 patients with lichen planus and 36.7% in the control group. The frequency of MS in the lichen planus group was found to be significantly higher than that in the control group (P = .03). The incidence of acanthosis nigricans (AN) was statistically higher in the LP group (P = .009). In addition, while 38 of 47 AN patients in the LP group had MS, 17 of 61 patients without AN had MS, and the presence of MS was found significantly higher in LP patients with AN (p˂0.001). The incidence of acrochordon was statistically higher in the LP group (P = .03). In addition, while 43 of 62 patients with acrochordon in the LP group had MS, 12 of 46 patients without acrochordon had MS, and the presence of MS was found significantly higher in patients with LP with acrochordon (P ˂ .001).

CONCLUSION

In our study, it was found that skin findings such as AN and acrochordon increased in patients with lichen planus. This increase was also observed in lichen planus patients with metabolic syndrome. Therefore, the association of acanthosis nigricans and acrochordon may be a predictive of metabolic syndrome in patients with lichen planus admitted to the dermatology outpatient clinic.

Methotrexate-Related Liver Cirrhosis in Psoriatic Arthritis: A Case Report and Review of the Literature

Methotrexate is an anchor-drug for the treatment of inflammatory arthritides affecting peripheral joints, such as rheumatoid and psoriatic arthritis (PsA), but also for other immune-mediated diseases like psoriasis. Although it is generally a well-tolerated drug, adverse effects often occur. Reversible derangement of liver function test is the most common laboratory adverse event. However, in some cases, liver cirrhosis and/or fibrosis can occur. Besides, many of these diseases like PsA and psoriasis are closely linked with clinical conditions and risk factors that also contribute to liver damage/cirrhosis, such as increased body mass index, dyslipidaemia and diabetes mellitus (DM). It has been hypothesised that the aforementioned risk factors along with methotrexate usage can act synergistically, causing liver damage in these patients. Herein, we describe a PsA patient with DM who developed fatal liver cirrhosis after 10 years of treatment with MTX. We also review the literature about the liver toxicity of MTX in the context of PsA and psoriasis, describing concurring risk factors and histopathological findings. PubMed and Scopus were searched, without date limits. The keywords "methotrexate" AND "psoriatic arthritis" OR "psoriasis" AND "Liver damage" OR "liver fibrosis" OR "cirrhosis" were used. We found that although fibrosis/cirrhosis is present in about 10-25% of the patients, MTX can rarely cause liver damage itself. However, it can exert its effect when other factors, like increased alcohol consumption and obesity coexist. Prospective studies are needed, specifically examining the hepatotoxicity of MTX in individuals with immune-mediated diseases.

Psoriatic Arthritis and Metabolic Syndrome: Is There a Role for Disease Modifying Anti-Rheumatic Drugs?

Although psoriatic arthritis (PsA) primarily leads to joint and skin damage, it is associated with higher prevalence of metabolic syndrome (MetS) and its components, namely hypertension, dyslipidemia, obesity, and type II diabetes. Additionally, chronic inflammation is known to aggravate these cardiometabolic factors, thus explaining the enhanced cardiovascular (CV) morbidity and mortality in RA. Furthermore, emerging evidence suggest that some risk factors can fuel inflammation, thus pointing to a bidirectional crosstalk between inflammation and cardiometabolic factors. Therefore, dampening inflammation by disease-modifying anti-rheumatic drugs (DMARDs) may be thought to ameliorate MetS burden and thus, CV risk and disease severity. In fact, recommendations for PsA management emphasize the need of considering comorbidities to guide the treatment decision process. However, the existing evidence on the impact of approved DMARDs in PsA on MetS and MetS components is far from being optimal, thus representing a major challenge for the clinical setting. Although a beneficial effect of some DMARDs such as methotrexate, TNF inhibitors and some small molecules is clear, no head-to-head studies are published and no evidence is available for other therapeutic approaches such as IL-23 or IL-17 inhibitors. This narrative review summarizes the main evidence related to the effect of DMARDs on MetS outcomes in PsA patients and identify the main limitations, research needs and future perspectives in this scenario.

Efficacy and safety of pioglitazone for treatment of plaque psoriasis: a systematic review and meta-analysis of randomized controlled trials

Background: A growing number of studies have shown that thiazolidinediones (TZD) can be antipsoriatic. Pioglitazone is a representative of the class of antidiabetic drugs known as TZD. TZD can activate nuclear peroxisome proliferator-activated receptors (PPAR)-c. PPARs are expressed on epidermal keratinocytes and exert their effects by promoting the terminal differentiation of keratinocytes, inhibiting epidermal growth, and reducing inflammatory responses. These observations suggest that TZD have potential benefits in the treatment of cutaneous and metabolic pathologies associated with psoriasis.Objective: A systematic review and meta-analysis was carried out to evaluate the efficacy of combined pioglitazone treatment. We point out three controversial side effects from administration of pioglitazone in psoriasis: elevated liver enzymes, weight gain, and nausea.Study selection: Randomized, single blind, or double blind, published studies of pioglitazone compared with placebo given to patients with plaque psoriasis for 10 weeks or 12 weeks were considered for inclusion in this review. The primary outcomes were 75% or greater improvement in the Psoriasis Area and Severity Index score from baseline (PASI 75) with pioglitazone.Data collection and analysis: The systematic literature search was conducted in the PubMed, Embase, Google Scholar, and Cochrane databases from inception up to December 20 2018. Data analysis was done using Revman 5.3 Haymarket, London, United Kingdom.Main results: We included six studies (three publications of pioglitazone only; three publications of pioglitazone combination therapy) comprising a total of 294 patients (n = 149 with pioglitazone only and n = 145 with pioglitazone combination therapy) in the analysis. There was a significant PASI 75 response, in the pioglitazone only subgroup as compared to placebo (OR = 8.74, 95% CI 3.76-20.31, p < .00001), and the pioglitazone combination subgroup as compared to placebo (OR = 4.64, 95% CI 2.03-10.60, p < .00001), others, the total of pioglitazone as compared to placebo (OR = 6.37, 95% CI 3.55-11.43, p < .00001), and tests of subgroup differences show: p = .29, I2 = 9.5%. The incidence rate of elevated liver enzymes (OR = 3.70, 95% CI 0.56-24.31, p = .99), weight gain (OR = 1.44, 95% CI 0.60-3.47, p = .41), and nausea (OR = 0.76, 95% CI 0.23-2.49, p = .65) were not significantly different compared with the control group.Conclusion: Pioglitazone has efficacy for the treatment of plaque psoriasis. There is no significant difference between patients treated with pioglitazone only or in combination with other therapies. The incidence rate of side effects associated with pioglitazone treatment such as elevated liver enzymes, weight gain, and nausea were not significantly different compared with the control group.

Interleukin-17A affects extracellular vesicles release and cargo in human keratinocytes

Psoriasis is a chronic inflammatory systemic disease caused by deregulation of the interleukin-23/-17 axis that allows the activation of Th17 lymphocytes and the reprogramming of keratinocytes proliferative response, thereby inducing the secretion of cyto-/chemokines and antimicrobial peptides. Beside cell-to-cell contacts and release of cytokines, hormones and second messengers, cells communicate each other through the release of extracellular vesicles containing DNA, RNA, microRNAs and proteins. It has been reported the alteration of extracellular vesicles trafficking in several diseases, but there is scarce evidence of the involvement of extracellular vesicles trafficking in the pathogenesis of psoriasis. The main goal of the study was to characterize the release, the cargo content and the capacity to transfer bioactive molecules of extracellular vesicles produced by keratinocytes following recombinant IL-17A treatment if compared to untreated keratinocytes. A combined approach of standard ultracentrifugation, RNA isolation and real-time RT-PCR techniques was used to characterize extracellular vesicles cargo. Flow cytometry was used to quantitatively and qualitatively analyse extracellular vesicles and to evaluate cell-to-cell extracellular vesicles transfer. We report that the treatment of human keratinocytes with IL-17A significantly modifies the extracellular vesicles cargo and release. Vesicles from IL-17A-treated cells display a specific pattern of mRNA which is undid by IL-17A neutralization. Extracellular vesicles are taken up by acceptor cells irrespective of their content but only those derived from IL-17A-treated cells enable recipient cells to express psoriasis-associated mRNA. The results imply a role of extracellular vesicles in amplifying the pro-inflammatory cascade induced in keratinocyte by pro-psoriatic cytokines.

Tildrakizumab efficacy, drug survival, and safety are comparable in patients with psoriasis with and without metabolic syndrome: Long-term results from 2 phase 3 randomized controlled studies (reSURFACE 1 and reSURFACE 2)

BACKGROUND

Data for the effect of metabolic syndrome (MetS) on the efficacy and safety of biologic agents for psoriasis treatment are limited.

OBJECTIVE

To evaluate long-term tildrakizumab efficacy, drug survival, and safety in patients with psoriasis by baseline MetS status.

METHODS

Post hoc analyses of up to 3 years of efficacy data and 5 years of safety data from the phase 3, double-blind, randomized controlled reSURFACE 1 and 2 trial (NCT01722331 and NCT01729754) base and extension studies were conducted for patients receiving continuous tildrakizumab 100 or 200 mg.

RESULTS

Of 338 (n = 124/214 in reSURFACE 1/2) and 307 (n = 147/160 in reSURFACE 1/2) patients continuously receiving tildrakizumab 100 and 200 mg, respectively, throughout the studies, 26/44 (21%/21%) and 34/30 (23%/19%) met MetS criteria. Proportions of patients who achieved a 75% improvement in the Psoriasis Area and Severity Index (PASI) in reSURFACE 1/2 were generally comparable among those with versus without MetS at week 52 (tildrakizumab 100 mg, 85%/86% vs 86%/94%; tildrakizumab 200 mg, 76%/87% vs 76%/87%) and through week 148. Results were similar for responders with 90% and 100% improvement in the PASI. Tildrakizumab's safety profile did not vary by MetS status.

LIMITATIONS

Small sample size and post hoc analysis limit interpretation.

CONCLUSION

Long-term tildrakizumab efficacy and safety were comparable between patients with and without MetS.

Recommendation for the Management of Spondyloarthritis Patients in Kuwait

OBJECTIVE

In 2016, ASAS and EULAR made joint recommendations for the management of patients with spondyloarthritis. Although Global and European perspectives are important, they cannot accurately reflect the situation for all patients in all countries and regions. As such, the group worked to tailor the existing international recommendations to suit the specific demographic needs of local populations in the Gulf region, with a specific focus on Kuwait.

METHODS

Recommendations drafted following a PubMed search for relevant literature were reviewed and then underwent Delphi vote to reach consensus on those to be included. Advice for newly approved agents, including targeted synthetic disease-modifying anti-rheumatic drugs, was included based on the group's clinical experience.

RESULTS

The resulting 41 recommendations are grouped into five categories covering key definitions and principles for the management and treatment of both axial and peripheral forms of spondyloarthritis.

CONCLUSION

Through adaptation of existing guidelines and incorporating the current evidence and clinical experience of the members of the group, these recommendations have been developed to reflect the unique situation in Kuwait with regard to differing patient profiles, local culture and approved therapeutic approaches, and are designed to aid in clinical decision-making.

Pulmonary function severity in relation to interleukin-23 levels in patients with psoriasis vulgaris

Background Interleukin-23 (IL-23), a key inflammatory regulator in the pathogenesis of psoriasis, is suspected to play a role in the onset of pulmonary dysfunction (chronic obstructive pulmonary disease) in psoriasis. Despite that, pulmonary function tests are rarely studied in these subjects. This study aims to seek a possible relation between pulmonary function in psoriasis patients serum IL-23. Methods For this analytical cross-sectional study, male psoriasis patients in the age group of 25-45 years were recruited from dermatology out patient department (n = 40). Age and BMI matched apparently healthy individuals were recruited as control group (n = 40). After obtaining demographic and personal details, anthropometric parameters and blood pressure were recorded. The severity of psoriasis was assessed using Psoriasis Area and Severity Index score. Pulmonary function was assessed using computerized spirometry, and serum IL-23 was measured using ELISA. Results Forced vital capacity, forced expiratory volume in 1 s, peak expiratory flow rate, and forced expiratory flow at 25%-75% of the pulmonary volume (FEF25%-75%) were significantly reduced in psoriasis. Based on the percentage of predicted values FEF25%-75% was significantly reduced in psoriasis. Serum IL-23 (pg/mL) was significantly higher in psoriasis. The increase in IL-23 in psoriasis subjects does not correlate with their pulmonary function. Conclusions Psoriasis may be associated with a reduced lung function even when the disease is in the mild stage. Increased IL-23 found in these subjects is suggestive of systemic inflammation, which indirectly lowers lung function.

Circulating Pro- and Anti-Inflammatory Metabolites and Its Potential Role in Rheumatoid Arthritis Pathogenesis

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that affects synovial joints, leading to inflammation, joint destruction, loss of function, and disability. Although recent pharmaceutical advances have improved the treatment of RA, patients often inquire about dietary interventions to improve RA symptoms, as they perceive pain and/or swelling after the consumption or avoidance of certain foods. There is evidence that some foods have pro- or anti-inflammatory effects mediated by diet-related metabolites. In addition, recent literature has shown a link between diet-related metabolites and microbiome changes, since the gut microbiome is involved in the metabolism of some dietary ingredients. But diet and the gut microbiome are not the only factors linked to circulating pro- and anti-inflammatory metabolites. Other factors including smoking, associated comorbidities, and therapeutic drugs might also modify the circulating metabolomic profile and play a role in RA pathogenesis. This article summarizes what is known about circulating pro- and anti-inflammatory metabolites in RA. It also emphasizes factors that might be involved in their circulating concentrations and diet-related metabolites with a beneficial effect in RA.

A Case Report of a Patient with Turner Syndrome, Multiple Comorbidities, and Pustular Psoriasis: Correlation or Coincidence?

Turner syndrome (TS) is one of the most common chromosomal abnormalities. Patients with TS are at an increased risk for the development of metabolic syndrome, hypertension (HTN), diabetes mellitus type II (DM2), hyperlipidemia (HLD), obesity, and cardiovascular disease. The association between psoriasis and the aforementioned conditions including metabolic syndrome, HTN, HLD, obesity, and cardiovascular disease has also been established. Although the mechanism for heightened risk in TS patients is yet to be elucidated, patients suffering from TS and cardiometabolic diseases are likely to be at an even higher risk for developing psoriasis than patients suffering from TS alone. We present a case of a 53-year-old Hispanic woman with a mosaic TS and multiple comorbidities who presented with pustular psoriasis. For this patient, management can be challenging considering her numerous medical comorbidities and the presence of both TS and psoriasis.

Systematic review of machine learning for diagnosis and prognosis in dermatology

Background: Software systems using artificial intelligence for medical purposes have been developed in recent years. The success of deep neural networks (DNN) in 2012 in the image recognition challenge ImageNet LSVRC 2010 fueled expectations of the potential for using such systems in dermatology.Objective: To evaluate the ways in which machine learning has been utilized in dermatology to date and provide an overview of the findings in current literature on the subject.Methods: We conducted a systematic review of existing literature, identifying the literature through a systematic search of the PubMed database. Two doctors assessed screening and eligibility with respect to pre-determined inclusion and exclusion criteria.Results: A total of 2175 publications were identified, and 64 publications were included. We identified eight major categories where machine learning tools were tested in dermatology. Most systems involved image recognition tools that were primarily aimed at binary classification of malignant melanoma (MM). Short system descriptions and results of all included systems are presented in tables.Conclusions: We present a complete overview of artificial intelligence implemented in dermatology. Impressive outcomes were reported in all of the identified eight categories, but head-to-head comparison proved difficult. The many areas of dermatology where we identified machine learning tools indicate the diversity of machine learning.

Risk and severity of psoriasis vulgaris in relation to angiotensin II type 1 receptor gene polymorphism and metabolic syndrome

Background

Psoriasis vulgaris is a chronic inflammatory and proliferative skin disease, characterized by the formation of itchy, erythematous skin patches or plaques. Patients with psoriasis are at an increased risk of developing metabolic syndrome, including obesity, hypertension, diabetes, and atherosclerosis. Recently, angiotensin II (Ang II) has been reported to be associated with the development of psoriasis. Ang II not only increases the blood pressure but is also a potent proinflammatory modulator and functions through interaction with angiotensin II type 1 receptor (AT1R). Moreover, it is hypothesized that the AT1R gene expression could be correlated with the severity of psoriasis and/or metabolic syndrome.

Aim

We examined the association of Ang II type 1 receptor (AT1R) A1166C gene polymorphisms and metabolic syndrome with the severity of psoriasis.

Patients and methods

The present case-control study included 25 patients with psoriasis vulgaris and 25 healthy subjects in Egypt. The psoriasis lesions in the patient group were assessed using the psoriasis area and severity index (PASI) score. The AT1R polymorphism A1166C (rs5186) was studied using restriction fragment length polymorphism (RFLP) and polymerase chain reaction (PCR) amplification of the gene from the whole blood sample in both groups. Serum lipid profile and blood sugar levels were assessed post 12 h and 8 h fasting, respectively, in both groups. The severity of metabolic syndrome was evaluated using the severity score.

Results

The results of the present study demonstrated that the AT1R A1166C gene polymorphisms increased the risk of developing psoriasis in the Egyptian population. We found that 70% of patients with AC genotype and 100% of patients CC genotype reported a PASI score >20 and were considered to be severe cases with a statistically significant difference as compared with patients with AA genotype (p=0.003). In addition, a high statistically significant difference (p=0.001) existed among AT1R genotypes with respect to the percentage of metabolic syndrome in psoriasis patients. Similarly, a statistically significant difference (p=0.004) among AT1R genotypes with respect to metabolic score was found, with the highest level of score and percentage observed in patients with CC genotype than in patients with AC genotype. The lowest level was present among those with AA genotype.

Conclusion

Patients with psoriasis expressing the C allele of AT1R1166 are susceptible to developing metabolic syndrome and have higher PASI scores as compared with patients carrying the A allele.

Malassezia and Parkinson's Disease

Parkinson's disease (PD) is a common debilitating neurodegenerative disease caused by a loss of dopamine neurons in the substantia nigra within the central nervous system (CNS). The process leading to this neuronal loss is poorly understood. Seborrheic dermatitis (SD) is a common benign inflammatory condition of the skin which mainly affects lipid-rich regions of the head and trunk. SD is caused by over proliferation of the lipophilic fungus Malassezia. PD and SD are strongly associated. The increased PD risk following an SD diagnosis (OR = 1.69, 95% CI 1.36, 2.1; p < 0.001) reported by Tanner and colleagues remains unexplained. Malassezia were historically considered commensals confined to the skin. However, many recent studies report finding Malassezia in internal organs, including the CNS. This raises the possibility that Malassezia might be directly contributing to PD. Several lines of evidence support this hypothesis. AIDS is causally associated with both parkinsonism and SD, suggesting that weak T cell-mediated control of commensal microbes such as Malassezia might contribute to both. Genetic polymorphisms associated with PD (LRRK2, GBA, PINK1, SPG11, SNCA) increase availability of lipids within human cells, providing a suitable environment for Malassezia. Four LRRK2 polymorphisms which increase PD risk also increase Crohn's disease risk; Crohn's disease is strongly associated with an immune response against fungi, particularly Malassezia. Finally, Malassezia hypha formation and melanin synthesis are stimulated by L-DOPA, which could promote Malassezia invasiveness of dopamine neurons, and contribute to the accumulation of melanin in these neurons. Although Malassezia's presence in the substantia nigra remains to be confirmed, if Malassezia play a role in PD etiology, antifungal drugs should be tested as a possible therapeutic intervention.

Choline metabolite, trimethylamine N-oxide (TMAO), is associated with inflammation in psoriatic arthritis

OBJECTIVES

Dietary intake of choline has been linked to systemic inflammation through the microbial production of two metabolites, trimethylamine (TMA) and trimethylamine-N-oxide (TMAO). Herein we explore the association between choline metabolites and inflammation in psoriatic arthritis (PsA) patients.

METHODS

Thirty-eight patients with PsA, all of whom satisfied the CASPAR classification criteria for PsA, were studied. Outcomes reflecting the activity of peripheral arthritis as well as skin psoriasis, Disease Activity Score (DAS)28, Clinical Disease Index (CDAI) and Body Surface Area (BSA) were assessed. Serum concentration of choline metabolites (choline, TMA, TMAO, betaine and carnitine) were determined by LC-MS, and metabolite levels associated with disease scores.

RESULTS

Among the 38 PsA patients included, the mean DAS28PCR was 2.74±1.29. Twenty-seven patients had active skin disease, with an average BSA of 7.2±16.22. TMAO, but not TMA or choline, significantly correlated with measures of disease activity for both skin and peripheral joints.

CONCLUSIONS

In our cohort, only TMAO, but not TMA, choline, betaine or carnitine, was associated with inflammation in PsA patients, establishing a mechanistic link between TMAO and PsA phenotypes. Future studies will explore the modulation of TMAO and disease severity in PsA.

Clinical characteristics and comorbidities of psoriatic arthritis (PsA) in Hong Kong

Aim

The primary objective of this study was to describe the clinical characteristics of psoriatic arthritis (PsA). The secondary objective was to evaluate the prevalence of various PsA comorbidities and their associated factors, with particular emphasis on metabolic syndrome (MetS).

Methods

Consecutive patients fulfilling the Classification Criteria for Psoriatic Arthritis (CASPAR) from two local hospitals were recruited between June 2016 and January 2018. Demographic data and related clinical parameters were collected and analyzed. MetS was defined by the International Diabetes Federation criteria for Asians.

Results

For the study, 201 eligible PsA patients were recruited: 124 were men and 77 were women. The mean age of onset of PsO and PsA was 36.6 ± 14.2 and 44.5 ± 12.6 respectively. Of the patients, 64.2% had central obesity, 18.4% had diabetes, 32.8% had hypertension and 35.8% had MetS.

Univariate analysis showed that the (1) age onset of PsA, (2) PsA duration, (3) PsO duration, and (4) tender joint-count were the potential associative factors of MetS. Subsequent regression model identified that both age onset and disease duration of PsA were significantly associated with MetS, with p-values of 0.02 and 0.018, respectively. Older age of onset (46.5 ± 12.2 vs 43.4 ± 12.7 years) or longer disease duration (9.8 ± 8.4 vs 7.0 ± 6.7 years) of PsA increased the likelihood of developing MetS.

No association of MetS was found with ESR or CRP levels, PASI, dactylitis count, enthesitis index, tender and swollen joint count, age onset of PsO and severe skin status.

Conclusion

PsA is a heterogeneous disease with an extremely diverse range of clinical features. It is also notably associated with other comorbidities, especially metabolic syndrome, in which it is closely related to arthritis onset and duration. In view of their common prevalence, regular screening of these PsA-related comorbidities is highly recommended.

Oxidized Low-Density Lipoprotein-Deteriorated Psoriasis Is Associated with the Upregulation of Lox-1 Receptor and Il-23 Expression In Vivo and In Vitro

Psoriasis is a chronic inflammatory skin disease. Even though scientists predict that abnormalities in lipid metabolism play an important role in the pathogenesis of psoriasis, the actual underlying mechanisms are still unclear. Therefore, understanding the possible relationship between mechanisms of the occurrence of psoriasis and dyslipidemia is an important issue that may lead to the development of effective therapies. Under this principle, we investigated the influences of hyperlipidemia in imiquimod (IMQ)-induced psoriasis-like B6.129S2-Apoe^tm1Unc/J mice and oxidized low-density lipoprotein (oxLDL) in tumor necrosis factor (TNF)-α-stimulated Hacat cells. In our study, we showed that a high-cholesterol diet aggravated psoriasis-like phenomena in IMQ-treated B6.129S2-Apoe^tm1Unc/J mice. In vitro analysis showed that oxLDL increased keratinocyte migration and lectin-type oxLDL receptor 1 (LOX-1) expression. Evidence suggested that interleukin (IL)-23 was a main cytokine in the pathogenesis of psoriasis. High-cholesterol diet aggravated IL-23 expression in IMQ-treated B6.129S2-Apoe^tm1Unc/J mice, and oxLDL induced IL-23 expression mediated by LOX-1 in TNF-α-stimulated Hacat cells. Therefore, it will be interesting to investigate the factors for the oxLDL induction of LOX-1 in psoriasis. LOX-1 receptor expression may be another novel treatment option for psoriasis and might represent the most promising strategy.

Current treatment options for psoriatic arthritis: spotlight on abatacept

Psoriatic arthritis (PsA) is a chronic inflammatory disease of joints, tendon sheaths, and entheses affecting patients with established skin psoriasis, or, less frequently, patients without a personal history of psoriasis with a positive familial history. Many treatment options are now available to deal with the different aspects of the disease, including traditional and biological disease-modifying antirheumatic drugs and the recently released targeted synthetic disease-modifying antirheumatic drugs. However, ~40% of patients still fail to achieve a meaningful clinical response to first-line biologic therapy advocating the development of novel medications. It is now well accepted that T-cells participate in the immunopathogenesis of several autoimmune diseases. For this reason, the potential intervention on T-cells represented an attractive therapeutic target for a long time, becoming a clinical reality with the development of abatacept. Abatacept is a biologic agent selectively targeting the T-cell costimulatory signal delivered through the CD80/86-CD28 pathway and was approved in December 2005 by the US Food and Drug Administration and in May 2007 by European Medicines Agency for the treatment of patients with rheumatoid arthritis in combination with methotrexate. Based on the relevant role of T-cells in PsA pathogenesis and following the positive results obtained in a phase III clinical trial, abatacept recently received approval for treatment of patients with PsA. In this review, we will focus on the current knowledge about the emerging role of abatacept in treatment of PsA.

C10orf99 contributes to the development of psoriasis by promoting the proliferation of keratinocytes

Psoriasis is a chronic, relapsing inflammatory skin disease. The pathogenesis of psoriasis is complex and has not been fully understood. C10orf99 was a recently identified human antimicrobial peptide whose mRNA expression is elevated in psoriatic human skin samples. In this study, we investigated the functional roles of C10orf99 in epidermal proliferation under inflammatory condition. We showed that C10orf99 protein was significantly up-regulated in psoriatic skin samples from patients and the ortholog gene expression levels were up-regulated in imiquimod (IMQ)-induced psoriasis-like skin lesions in mice. Using M5-stimulated HaCaT cell line model of inflammation and a combinational approach of knockdown and overexpression of C10orf99, we demonstrated that C10orf99 could promote keratinocyte proliferation by facilitating the G1/S transition, and the pro-proliferation effect of C10orf99 was associated with the activation of the ERK1/2 and NF-κB but not the AKT pathways. Local depletion of C10orf99 by lentiviral vectors expressing C10orf99 shRNA effectively ameliorated IMQ-induced dermatitis. Taken together, these results indicate that C10orf99 plays a contributive role in psoriasis pathogenesis and may serve as a new target for psoriasis treatment.

Examining Dermatologist Use and Opinions of Ultraviolet Radiation for Cosmetic and Medical Purposes

BACKGROUND: The commercial tanning industry has opposed efforts to educate the public on the risks of tanning as well as attempts to restrict minors' access to tanning services. Despite a paucity of supporting literature, statements from the tanning industry claiming that dermatologists routinely use in-office phototherapy for cosmetic treatments and refer patients to tanning salons have successfully derailed and defeated legislation in many states. OBJECTIVE: This study aims to evaluate dermatologist referrals for ultraviolet radiation for cosmetic and medical purposes via tanning beds or phototherapy, as well as their opinions on tanning, legislation, and ultraviolet radiation counseling practices. DESIGN: The study was conducted using a 10-question anonymous survey. SETTING: The participants were surveyed during meetings of three regional dermatologic societies. PARTICIPANTS: One hundred and fifty-two dermatologists attending society meetings participated in the study. MEASURES: The authors measured physician referrals, opinions, and recommendations regarding ultraviolet exposure. RESULTS: Zero physicians (0/152) recommended tanning salons for cosmetic reasons. These 152 dermatologists referred 458 (417 adult, 41 pediatric) out of an estimated 809,369 patients (0.057%) to tanning salons for medical treatment. Of these physicians, 76 out of 152 and 15 out of 152 reported referring at least one adult or one pediatric patient, respectively, within the last year. All respondents supported ultraviolet tanning legislation and discouraged cosmetic tanning. CONCLUSION: These findings directly contradict the assertion that dermatologists use ultraviolet radiation for cosmetic purposes or routinely refer patients to tanning salons. This study underscores the complex nature of ultraviolet radiation, as dermatologists infrequently utilize ultraviolet radiation for medical purposes and unanimously support restrictive legislation. In addition, these dermatologists counsel against cosmetic tanning and list tanning bed use among their highest concerns with regard to the health of pediatric patients.

Real-world burden of comorbidities in US patients with psoriatic arthritis

Objectives

We assessed comorbidities associated with psoriatic arthritis in a broad cohort of US-insured adult patients using the Truven Health Analytics MarketScan Database.

Methods

Prevalence and incidence rates were assessed for 28 comorbid conditions among adult patients in the MarketScan database with a diagnosis of psoriatic arthritis and having two or more health claims for psoriatic arthritis between 1 July 2008 and 31 July 2015. Findings were compared with those of a similar, previously published analysis of patients with psoriasis.

Results

Among a total of 186 552 patients with a diagnosis of psoriatic arthritis, 94 302 had two or more health claims for psoriatic arthritis during the study period and were included in the comorbidity analysis. The prevalence and incidence rates of the most common comorbidities were 47.5% and 35.0% for hyperlipidaemia, respectively; 47.3% and 31.3% for hypertension; 21.2% and 15.4% for depression; 20.2% and 13.5% for type 2 diabetes mellitus; and 16.6% and 12.4% for fibromyalgia. Patients with psoriatic arthritis had notably higher incidence rates of uveitis, fibromyalgia, osteoporosis, Crohn’s disease and non-alcoholic liver disease than patients with psoriasis.

Conclusion

This observational retrospective analysis using the MarketScan database provides real-world health claims data on the prevalence and incidence of comorbidities in a large US patient population with psoriatic arthritis. The observed high cardiometabolic comorbidity rates align with those reported in the literature and may help healthcare providers in the comprehensive management of patients with psoriatic arthritis.

The impact of biologic agents on health-related quality of life outcomes in patients with psoriasis

INTRODUCTION

Psoriasis is a common, immune-mediated skin disease often associated with significant physical and psychosocial impairment. Antipsoriatic biologic agents offer patients unparalleled treatment potential in regard to greater skin clearance and overall improved quality of life. Evaluation of the therapeutic efficacy of biologic agents on the full psoriasis disease burden must account for their impact on both physical symptoms, as well as patient-reported, health-related quality of life (HRQoL) measurements. Areas covered: Results from numerous clinical trials demonstrate the significant clinical efficacy of biological agents targeting tumor necrosis factor-α (TNF-α) and the interleukin (IL)-12/23 and IL-17 immune pathways. However, relatively limited data is available evaluating their full effect on quality of life outcomes. This review will discuss the most relevant and up-to-date clinical data on HRQoL measurements related to treatment with these aforementioned biologic agents. Expert commentary: Patient-reported outcomes (i.e. Dermatology Life Quality Index) are being used with increasing frequency in clinical trials, and provide valuable information on the impact of psoriasis on numerous aspects of day-to-day living. These outcomes must also be incorporated in clinical practice, in addition to physical assessment of disease severity, treatment decisions, and therapeutic response in the psoriasis patient population.

An update on psoriasis and metabolic syndrome: A meta-analysis of observational studies

The relationship between psoriasis and metabolic syndrome is not well understood. Though multiple epidemiologic studies have suggested a link between psoriasis and metabolic syndrome, there is a lack of a comprehensive meta-analysis synthesizing the results of all available observational studies to date. In this meta-analysis, we examined global data on the relationship between psoriasis and odds of metabolic syndrome by searching for studies published between 1946–2016. Specifically, we analyzed the results from 35 observational studies from 20 countries with 1,450,188 total participants, of which 46,714 were psoriasis patients. The pooled odds ratio based on random effects analysis was 2.14 (95% CI 1.84–2.48). Publication bias was present, as evidenced by an Egger test and graphical visualization through a funnel plot (p = 0.001). Based on this comprehensive meta-analysis, psoriasis patients have higher odds of having metabolic syndrome when compared with the general population.

Randomized Placebo Control Study of Metformin in Psoriasis Patients with Metabolic Syndrome (Systemic Treatment Cohort)

BACKGROUND

Psoriasis has been found to be associated with obesity, metabolic syndrome (MS), diabetes, and cardiovascular risk factors. Metformin treatment showed improvement in cardiovascular risk factors and hyperinsulinemia.

OBJECTIVE

To evaluate the efficacy and safety of metformin in psoriasis patients with MS.

MATERIALS AND METHODS

This was a single-center, parallel-group, randomized, open-label study with blinded end point assessment of metformin (1000 mg once daily for 12 weeks; n = 20) and placebo (n = 18) in psoriasis patients with MS. Total sample size was 38 participants.

RESULTS

Statistically significant improvement was observed in mean percentage change in erythema, scaling, and induration (ESI) (P = 0.048) in metformin as compared to placebo while mean percentage change in psoriasis area and severity index (PASI) and physician global assessment (PGA) scores was not significant (PASI - P = 0.215, PGA - P = 0.070). There was a statistically significant difference in percentage of parameters of MS improved following 12 weeks of treatment in metformin (19%) as compared to placebo (8.9%) group (P = 0.046). Statistically significant difference in percentage of patients achieving 75% reduction in ESI scores (P = 0.024). Significant improvement was observed in mean weight, body mass index (BMI), total cholesterol, and low-density lipoprotein (LDL) cholesterol in metformin group as compared to placebo. Improvement in BMI, fasting plasma glucose, serum triglycerides, high-density lipoprotein, LDL, systolic blood pressure, diastolic blood pressure, and total cholesterol was statistically significant in metformin group over the period of 12 weeks. There was no significant difference in adverse events in two groups except weight gain.

CONCLUSION

Metformin has shown improvement in psoriasis and parameters of MS, hence can be used for the benefit of psoriasis patients having MS. Large, controlled studies are needed to confirm.

Real-world burden of comorbidities in US patients with psoriasis

BACKGROUND

Understanding background comorbidity rates in psoriasis can provide perspective for adverse events associated with new therapies.

OBJECTIVE

We sought to assess the extent of comorbidities in psoriasis patients by use of the Truven Health Analytics MarketScan database.

METHODS

MarketScan, comprising commercial claims representative of a large US-insured population, had 1.22 million patients with ≥1 claim with a psoriasis diagnosis between January 1, 2008, and December 31, 2014. Patients ≥18 years of age who had ≥2 health claims in any diagnosis field for psoriasis (International Classification of Diseases, 9th Revision, Clinical Modification 696.1) with a psoriasis diagnosis (index) date between July 1, 2008, and June 30, 2014, were included to allow follow-up observation time.

RESULTS

Prevalence and incidence of 24 comorbidities were assessed in 469,097 psoriasis patients; the most common comorbidities were hyperlipidemia (45.64% and 30.83%, respectively), hypertension (42.19% and 24.19%), depression (17.91% and 12.68%), type 2 diabetes mellitus (17.45% and 8.44%), and obesity (14.38% and 11.57%).

LIMITATIONS

A limitation of the study was that only a certain insured population was represented.

CONCLUSIONS

Comorbidity rates align with those described in the literature and support the concept that psoriasis patients have high rates of cardiometabolic comorbidities. This analysis highlights the potential utility of very large insurance databases for determining comorbidity prevalence in psoriasis, which may aid health care providers in managing psoriasis.

Exploring the link between cadmium and psoriasis in a nationally representative sample

Psoriasis, a skin inflammatory disease, originates from dysregulated interactions of the immune system. Cadmium, an environment pollutant, increases the levels of inflammation markers and influences the immune system. To clarify the relationship between cadmium and psoriasis, 5,927 participants, ≥20 years, in the National Health and Nutrition Examination Survey (NHANES) 2003–2006 were studied. Psoriasis severity was assessed using self-reported dermatology questionnaires. Cadmium was measured using blood chemistry. Three adjusted models were applied for the interaction between serum cadmium and severity of psoriasis. Psoriasis patients had significantly higher blood cadmium (0.67 vs. 0.52 μg/L, p = 0.006). There was a strong linear increase in predicted blood cadmium values with an increase in severity of psoriasis (p for trend = 0.002). The β coefficient of the predicted serum cadmium in the “few patches to extensive psoriasis” group was 0.234 (p = 0.002) after adjusting covariates. Participants with severe psoriasis have higher blood cadmium. Environmental exposure to cadmium can predispose to the worsening of psoriasis. Although there are still limitations in this study, such as not included treatment data, these results have substantial public health implications for the general population, as they demonstrate the importance of cadmium exposure prevention, particularly among psoriasis patients.

The Role of the Skin and Gut Microbiome in Psoriatic Disease

PURPOSE

To understand the changes in the microbiome in psoriatic disease, we conducted a systematic review of studies comparing the skin and gut microbiota in psoriatic individuals and healthy controls.

FINDINGS

Our review of studies pertaining to the cutaneous microbiome showed a trend towards an increased relative abundance of Streptococcus and a decreased level of Propionibacterium in psoriasis patients compared to controls. In the gut microbiome, the ratio of Firmicutes and Bacteroidetes was perturbed in psoriatic individuals compared to healthy controls. Actinobacteria was also relatively underrepresented in psoriasis patients relative to healthy individuals.

SUMMARY

Although the field of the psoriatic microbiome is relatively new, these first studies reveal interesting differences in microbiome composition that may be associated with the development of psoriatic comorbidities and serve as novel therapeutic targets.

Diagnosis and management of psoriasis

OBJECTIVE

To provide primary care clinicians with an up-to-date and practical overview of the diagnosis and management of psoriasis.

QUALITY OF EVIDENCE

PubMed, MEDLINE, EMBASE, and Cochrane databases were searched for relevant meta-analyses, randomized controlled trials, systematic reviews, and observational studies about the diagnosis and management of psoriasis.

MAIN MESSAGE

Psoriasis is a chronic, multisystem inflammatory disease with predominantly skin and joint involvement. Beyond the physical dimensions of disease, psoriasis has an extensive emotional and psychosocial effect on patients, affecting social functioning and interpersonal relationships. As a disease of systemic inflammation, psoriasis is associated with multiple comorbidities, including cardiovascular disease and malignancy. The diagnosis is primarily clinical and a skin biopsy is seldom required. Depending on the severity of disease, appropriate treatment can be initiated. For mild to moderate disease, first-line treatment involves topical therapies including corticosteroids, vitamin D3 analogues, and combination products. These topical treatments are efficacious and can be safely initiated and prescribed by primary care physicians. Patients with more severe and refractory symptoms might require further evaluation by a dermatologist for systemic therapy.

CONCLUSION

Many patients with psoriasis seek initial evaluation and treatment from their primary care providers. Recognition of psoriasis, as well as its associated medical and psychiatric comorbidities, would facilitate timely diagnosis and appropriate management with effective and safe topical therapies and other medical and psychological interventions, as needed. More severe and refractory cases might warrant referral to a dermatologist for further evaluation and possible systemic therapy.

Psoriasis for the primary care practitioner

Primary care practitioners (PCPs) are playing an increasingly important role in the management and care of psoriasis. Thus, it is important for PCPs to be knowledgeable about the disease and to be able to differentiate between common myths and facts related to diagnosis and treatment. By building relationships with their patients and working collaboratively with dermatology health professionals and other specialists, PCPs can facilitate communication about the patient's treatment preferences and expectations for symptom relief, and they may be better able to work with the patient to optimize treatment adherence. This review aims to provide PCPs with a primer on psoriasis, its associated comorbidities, and its impact on patients' quality of life. Discussion topics include psoriasis epidemiology, triggering factors, clinical presentation, differential diagnosis, comorbidities, and approaches to treatment. This review also highlights the importance of staying abreast of advances in the understanding of psoriasis pathogenesis as well as emerging therapeutic treatment options, because these advances may change the treatment landscape and increase patients' expectations for skin clearance.

The metabolomics of psoriatic disease

Metabolomics is an emerging new "omics" field involving the systematic analysis of the metabolites in a biologic system. These metabolites provide a molecular snapshot of cellular activity and are thus important for understanding the functional changes in metabolic pathways that drive disease. Recently, metabolomics has been used to study the local and systemic metabolic changes in psoriasis and its cardiometabolic comorbidities. Such studies have revealed novel insights into disease pathogenesis and suggest new biochemical signatures that may be used as a marker of psoriatic disease. This review will discuss common strategies in metabolomics analysis, current findings in the metabolomics of psoriasis, and emerging trends in psoriatic metabolomics.

Prevalence of Metabolic Syndrome in Psoriasis and Levels of Interleukin-6 and Tumor Necrosis Factor-α in Psoriasis Patients with Metabolic Syndrome: Indian Tertiary Care Hospital Study

Background:

Psoriasis is a chronic inflammatory multisystem disease, found to be associated with metabolic syndrome (MS) and increased levels of cytokines. To evaluate the prevalence of MS in psoriasis and to determine the levels of interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in psoriasis patients with MS.

Methods:

Observational study on 334 psoriasis patients and 230 controls. MS was diagnosed by the presence of three or more criteria of original, revised, and modified National Cholesterol Education Program's Adult Treatment Panel III (NCEP ATP III).

Results:

MS was significantly more common in psoriasis patients than in controls (multivariate odds ratio [95% confidence interval] of original NCEP ATP III = 5.73 [2.99–10.99], revised NCEP ATP III = 4.44 [2.43–8.10], and modified NCEP ATP III = 6.00 [3.43–10.52]). Higher prevalence of abdominal obesity (66.2% vs. 47%, P < 0.001), hypertriglyceridemia (40.4% vs. 29.6%, P = 0.009), systolic blood pressure (BP) ≥130 mmHg (25.1% vs. 7.4%, P < 0.001), diastolic BP ≥85 mmHg (30.2% vs. 12.2%, P < 0.001), and fasting plasma glucose ≥100 mg/dl (17.4% vs. 9.1%, P = 0.005) among psoriasis patients as compared to controls. Mean (standard deviation) values of IL-6 and TNF-α were 76.7 (73.9) pg/ml and 234.3 (273.9) in subgroup of psoriasis patients with MS (n = 42), significantly higher than the normal population (P < 0.0001).

Conclusion:

MS is more common in psoriasis. IL-6 and TNF-α is significantly higher in psoriasis patients with MS, signifying their role in pathogenesis of psoriasis and MS.

Metabolic syndrome may be an important comorbidity in patients with seborrheic dermatitis

Introduction

Seborrheic dermatitis is a chronic inflammatory skin disease. One of the components of metabolic syndrome is inflammation, and many inflammatory cytokines play a critical role in the disease. The aim of this study is to investigate metabolic syndrome and to evaluate the relationship between the parameters of the disease and disease severity in patients with seborrheic dermatitis.

Material and methods

Forty-seven patients with seborrheic dermatitis and 36 healthy controls were included in the study. The parameters of metabolic syndrome were recorded in both groups. In the patient group, disease severity was determined with the seborrheic dermatitis area and severity index (SDASI). All the venous blood samples were taken at 8 a.m. after 10 h of fasting.

Results

High-density lipoprotein (HDL) levels in the patient group were statistically significantly lower than in the controls. There was no significant difference between groups according to other parameters. In terms of history of metabolic disease in first degree relatives (diabetes mellitus, cardiovascular disease, and dyslipidaemia), 78.7% of those in the patient group (n = 37) and 55.6% of those in the control group (n = 20) had a history of metabolic disease in their families, and the difference between the patient and control groups was found to be statistically significant (p < 0.05). There was a significant correlation between disease severity and plasma HDL levels (p = 0.033, r = –0.312).

Conclusions

The presence of seborrheic dermatitis may be a predictive factor for metabolic syndrome.

Psoriasis and autoimmunity

Psoriasis is one of the most common chronic inflammatory human skin diseases. Though clinically well characterized, the exact etiological and pathogenic mechanisms are still not known in detail. Current knowledge indicates distinct overlap to other inflammatory as well as autoimmune disorders. However, the one or more relevant autoantigens could not be characterized so-far. On the other side, several autoimmune diseases were shown to be associated with psoriasis. In addition, serological autoimmune phenomena, namely diverse circulating specific autoantibodies could be demonstrated in the past. A matter of current debate is if psoriasis is a primary autoimmune disease or secondarily evolving into autoimmunity as seen in other chronic inflammatory diseases. Related to this aspect is the concept of autoinflammation versus autoimmunity where psoriasis shares mechanisms of both entities. Though T-cells remain among the most important cellular players in the pathogenesis of psoriasis and current therapeutic strategies successfully target these cells or their products irrespective of these concepts, autoimmunity if relevant will add to the treatment armamentarium by using protective and prophylactic antigen-specific modalities.

Randomized placebo control study of insulin sensitizers (Metformin and Pioglitazone) in psoriasis patients with metabolic syndrome (Topical Treatment Cohort)

Background

Increased prevalence of metabolic syndrome (MS) is observed in psoriasis. Metformin has shown improvement in cardiovascular risk factors while pioglitazone demonstrated anti proliferative, anti-inflammatory and anti angiogenic effects. Study objective is to evaluate the efficacy and safety of Insulin sensitizers (metformin and pioglitazone) in psoriasis patients with metabolic syndrome (MS).

Methods

Single centre, parallel group, randomized, study of metformin, pioglitazone and placebo in psoriasis patients with MS.

Results

Statistically significant improvement was observed in Psoriasis Area and Severity Index (PASI), Erythema, Scaling and Induration (ESI) and Physician global assessment (PGA) scores in pioglitazone (p values – PASI = 0.001, ESI = 0.002, PGA = 0.008) and metformin groups (p values – PASI = 0.001, ESI = 0.016, PGA = 0.012) as compared to placebo. There was statistically significant difference in percentage of patients achieving 75 % reduction in PASI and ESI scores in metformin (p value – PASI = 0.001, ESI = 0.001) and pioglitazone groups (p vaue – PASI = 0.001, ESI = 0.001). Significant improvement was observed in fasting plasma glucose (FPG) and triglycerides levels in metformin and pioglitazone arms. Significant improvement was noted in weight, BMI, waist circumference, FPG, triglycerides and total cholesterol after 12 weeks of treatment with metformin while pioglitazone showed improvement in FPG, triglyceride levels, systolic blood pressure (SBP), diastolic blood pressure (DBP), total cholesterol and LDL cholesterol levels. There was no difference in pattern of adverse drug reaction in three groups.

Conclusion

Insulin sensitizers have shown improvement in the parameters of MS as well as disease severity in psoriasis patients.

Trial registration

CTRI Registration Number: CTRI/2011/12/002252. Registered on 19/12/2011.