Anti-Interleukin-17s for successful management of pustular psoriasis

Generalised pustular psoriasis (GPP) and acrodermatitis continua of Hallopeau (ACH) are two rare entities included in the spectrum of pustular psoriasis (PP). Due to the lack of randomised controlled clinical trials and standardized guidelines, their treatment remains a challenge for clinicians. Thus, herein we report our centre experience with the successful use of interleukin (IL)-17 inhibitors in three patients affected by PP. We also provide a brief overview of the current knowledge concerning the role of IL-17 in PP pathogenesis and of the use of IL-17 inhibitors in the treatment of PP. Based on our experience, anti-IL-17 molecules may represent a valuable therapeutical option for patients affected by different PP subtypes.

Clinical and Ultrasonographic Characterization of Hidradenitis Suppurativa in Female Patients: Impact of Early Recognition of the Disease

Hidradenitis suppurativa (HS) is considered a post-pubertal disease; however, earlier onset is not infrequent. The burden of HS on the female population is very relevant, and early identification might reduce the quality of life impairment and improve the therapeutic approach. In this study, we investigated clinical biomarkers of HS that could impact the management of patients affected by HS. Female patients affected by stable HS were prospectively included in this study. Anamnestic data, clinical and ultrasonographic features were collected and analyzed. Overall, 53 patients were included in this study. The median age of onset was 19 (IQR: 14-25). Early onset was reported by 22/53 patients (median age of onset: 14; IQR: 11-16). Four patients had pre-menstruation occurrence. Early-onset patients had an earlier first-menstrual-cycle age and more frequent genital localization of HS, and were more often treated with biologics. Patients with early-onset-HS and genital localization had more severe disease with a higher number of areas affected, Hurley, and IHS4 scores. Genital involvement might be prevalent in patients with early-onset HS, leading to a worse impact on the global severity of the disease and tailored treatment protocols, including multidisciplinary approaches, in order to improve the early recognition of hidden lesions.

Consistency of Bacterial Triggers in the Pathogenesis of Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is an inflammatory skin disease whose pathogenesis remains poorly defined. Over the past decades, the bacterial role in HS patients has been a focus of research. According to the literature, the HS skin (and probably gut) bacterial composition is different to that of healthy controls. To date, a key question is whether compositional changes in the microbial populations are responsible for the development of HS (primum movens), or only secondarily reflect the ongoing inflammatory process. The great diversity of methodologies that have been used to study microbial role in HS have led to an accumulation of conflicting results. Thus, in view of these considerations, the aim of this article is to provide the reader with an overview about different hypotheses proposed to explain the bacterial role in HS pathogenesis.

Targeting IL-17A for the treatment of pustular psoriasis: a comprehensive review

INTRODUCTION

Pustular psoriasis (PP) is a rare subtype of psoriasis. Overall, the growing evidence - in particular for acute generalized PP (GPP) - supports that it is a separate entity with a specific pathogenetic pathway. Interleukin (IL)-17/T-helper 17 (Th17) axis involvement may play an important role in the pathophysiology of PP. Biologicals, often required to achieve clinical remission, have changed the treatment of PP.

AREAS COVERED

We provide the reader with an overview of all the available evidence on the use of the antibody-based therapy targeting IL-17A in patients with PP.

EXPERT OPINION

Although papers reported in this review do not provide definitive evidence (due to methodological limitations) to support the use of IL-17 inhibitors as potential first-line for the treatment of PP, based on our own experience and according to most of the reported literature, targeting IL-17A, may represent the best therapeutical approach in this peculiar clinical spectrum of psoriasis.

Therapy of PsO in Special Subsets of Patients

Psoriasis is a chronic, inflammatory skin disease that may occur at any age, with a bimodal peak of incidence around the age of 16-20 years of age (early onset) and 57-60 years (late-onset). It is estimated that roughly 70% of patients develop the disease before the age of 40, which coincides with the reproductive years. Moreover, psoriasis is a chronic disease, meaning that, with increased life-duration expectancy, the number of patients affected with psoriasis aged over 65 years is going to increase and represent a big therapeutic challenge. Actually, no specific drug recommendation is available, based only on the age of the patients, while therapeutic prescription should take into account that elderly patients have more comorbidities than younger patients, with polypharmacy and an increased risk of drug interactions. Women with psoriasis are more likely to report a worse influence of the disease on their quality of life, and they are more susceptible to the development of depression. Furthermore, pregnancy and lactation represent a major contraindication to several systemic agents, and only a few studies exist providing the safety of certain drugs during these periods of life of a woman, such as certolizumab pegol. In this paper, we discuss systemic therapeutic strategies, including conventional and biological therapies, in a special subset of patients affected with moderate-to-severe psoriasis focusing on elderly patients and on female patients in fertile age, pregnancy, and lactation.

Insights into the Pathogenesis of HS and Therapeutical Approaches

Hidradenitis suppurativa (HS) is a debilitating, chronic, (auto)inflammatory disease primarily affecting apocrine gland-rich areas of the body. Although pathogenic mechanisms responsible for HS have not yet been fully elucidated, it is a multifactorial process whose main target is the terminal follicle. The role of the inflammatory process (and consequently of cytokine milieu) and of several other factors (genetics, lifestyle, hormonal status, microbiome, innate and adaptive immune systems) involved in HS pathogenesis has been investigated (and often defined) over the years with a view to transferring research results from bench to bedside and describing a unique and universally accepted pathogenetic model. This review will update readers on recent advances in our understanding of HS pathogenesis and novel (potential) medical therapies for patients with moderate-to-severe HS.

Long-term safety and efficacy of anti-tumor necrosis factor-alpha biosimilar agents in the treatment of psoriasis: a single Center study

Biosimilar anti-TNF-alpha drugs are widely used in the treatment of psoriasis, but only few studies reported the long term experience of the various biosimilar agents in the real world practice.A monocentric retrospective observational study was performed to assess the long term efficacy, tolerability and safety of biosimilars adalimumab (bADA), biosimilar etanercept (bETN) and biosimilar infliximab (bIFX) in psoriasis patients.A total of 73 patients (19 patient treated with bADA, 37 with bETN and 17 with bIFX) were enrolled and observed up to 48 months of follow-up. Regarding the efficacy, across all biosimilar treatments combined, the mean PASI score was ≤2 (1.2) after 12 months of treatments. Notably, the mean PASI score remaneid relatively stable during all 48 months of follow-up. With regard to tolerability and safety in the present study, 34 (28%) patients experienced adverse events during all biosimilar therapy, and 3 (4.3%) discontinued treatment. No severe adverse events, death or malignancy cases were recorded during the study period.Our results support that biosimilar anti TNF-alpha are effective and well tolerated drugs for the long-term treatment of psoriasis.

Clinical experience with adalimumab biosimilar imraldi in hidradenitis suppurativa

Adalimumab is the only biologic therapy approved for the treatment of patients with hidradenitis suppurativa, a chronic and disabling skin condition. To date, there are no studies in the literature about the effectiveness of adalimumab biosimilar SB5 in hidradenitis suppurativa. The aim of this study was to evaluate its efficacy and safety. A retrospective observational study was performed in hidradenitis suppurativa adalimumab naive patients and in patients who were switched from the adalimumab originator. Eleven patients were included in the study. Our results support adalimumab SB5 as an effective and well tolerated drug, with a good interchangeability with its originator also for the treatment of hidradenitis suppurativa.

Italian Guidelines in diagnosis and treatment of alopecia areata

Alopecia areata (AA) is an organ-specific autoimmune disorder that targets anagen phase hair follicles. The course is unpredictable and current available treatments have variable efficacy. Nowadays, there is relatively little evidence on treatment of AA from well-designed clinical trials. Moreover, none of the treatments or devices commonly used to treat AA are specifically approved by the Food and Drug Administration. The Italian Study Group for Cutaneous Annexial Disease of the Italian Society of dermatology proposes these Italian guidelines for diagnosis and treatment of Alopecia Areata deeming useful for the daily management of the disease. This article summarizes evidence-based treatment associated with expert-based recommendations.

Safety and efficacy of HCV eradication during etanercept treatment for severe psoriasis

Treatment of severe psoriasis in HCV positive patients is challenging, because several psoriasis medications have a toxic effect on the liver, and interferon alpha, used to treat hepatitis, can induce worsening of psoriatic lesions. TNF-alpha inhibitors seem to be a safe and effective option in HCV positive psoriatic patients, but there are concerns about long-term safety, impact on liver fibrosis progression and risk of immune-mediated liver injury. With regard to HCV treatment, new direct-acting antiviral therapies (DAA) seem to be extremely effective, with minimal side effects, but little is known about possible interactions with other medications, particularly with biologics. We report the case of a psoriatic patient, in treatment with Etanercept, who needed to undergo HCV eradication with Daclastavir and Sofosbuvir because of worsening liver fibrosis due to chronic hepatitis C. The present treatment produced excellent results in terms of HCV eradication and control of psoriatic lesions, without side effects.

Expression of IL-23/Th17-related cytokines in basal cell carcinoma and in the response to medical treatments

Several immune-related markers have been implicated in basal cell carcinoma (BCC) pathogenesis. The BCC inflammatory infiltrate is dominated by Th2 cytokines, suggesting a specific state of immunosuppression. In contrast, regressing BCC are characterized by a Th1 immune response with IFN-γ promoting a tumor suppressive activity. IL-23/Th17-related cytokines, as interleukin (IL)-17, IL-23 and IL-22, play a significant role in cutaneous inflammatory diseases, but their involvement in skin carcinogenesis is controversial and is poorly investigated in BCC. In this study we investigated the expression of IFN-γ, IL-17, IL-23 and IL-22 cytokines in BCC at the protein and mRNA level and their modulation during imiquimod (IMQ) treatment or photodynamic therapy (PDT). IFN-γ, IL-17, IL-23 and IL-22 levels were evaluated by immunohistochemistry and quantitative Real Time PCR in 41 histopathologically-proven BCCs (28 superficial and 13 nodular) from 39 patients. All BCC samples were analyzed at baseline and 19 of 41 also during medical treatment (9 with IMQ 5% cream and 10 with MAL-PDT). Association between cytokines expression and clinico-pathological variables was evaluated. Higher levels of IFN-γ, IL-17, IL-23 and IL-22 were found in BCCs, mainly in the peritumoral infiltrate, compared to normal skin, with the expression being correlated to the severity of the inflammatory infiltrate. IFN-γ production was higher in superficial BCCs compared to nodular BCCs, while IL-17 was increased in nodular BCCs. A significant correlation was found between IFN-γ and IL-17 expression with both cytokines expressed by CD4+ and CD8+ T-cells. An increase of all cytokines occurred during the inflammatory phase induced by IMQ and at the early time point of PDT treatment, with significant evidence for IFN-γ, IL-23, and IL-22. Our results confirm the role of IFN-γ and support the involvement of IL-23/Th17-related cytokines in BCC pathogenesis and in the inflammatory response during IMQ and MAL-PDT treatments.

The IL23R R381Q gene variant protects against immune-mediated diseases by impairing IL-23-induced Th17 effector response in humans

IL-23 and Th17 cells are key players in tissue immunosurveillance and are implicated in human immune-mediated diseases. Genome-wide association studies have shown that the IL23R R381Q gene variant protects against psoriasis, Crohn's disease and ankylosing spondylitis. We investigated the immunological consequences of the protective IL23R R381Q gene variant in healthy donors. The IL23R R381Q gene variant had no major effect on Th17 cell differentiation as the frequency of circulating Th17 cells was similar in carriers of the IL23R protective (A) and common (G) allele. Accordingly, Th17 cells generated from A and G donors produced similar amounts of Th17 cytokines. However, IL-23-mediated Th17 cell effector function was impaired, as Th17 cells from A allele carriers had significantly reduced IL-23-induced IL-17A production and STAT3 phosphorylation compared to G allele carriers. Our functional analysis of a human disease-associated gene variant demonstrates that IL23R R381Q exerts its protective effects through selective attenuation of IL-23-induced Th17 cell effector function without interfering with Th17 differentiation, and highlights its importance in the protection against IL-23-induced tissue pathologies.

Efficacy of photodynamic therapy with methyl aminolevulinate in the treatment of superficial and nodular basal cell carcinoma: an open-label trial

Photodynamic therapy with methyl aminolevulinate (MAL-PDT) is a non-invasive therapy for superficial and nodular basal cell carcinoma (BCC). We performed an open-label trial to evaluate efficacy, safety, tolerability and cosmetic outcome of MAL-PDT in selected patients with superficial and nodular BCCs. Ninety-four superficial and 24 nodular BCCs in 69 patients were treated with 2 to 8 MAL-PDT sessions. Efficacy, safety, tolerability and cosmetic outcome were evaluated at months 1, 3, 6 and 12 after the last MAL-PDT treatment and then every 3 months. One patient discontinued the study for reasons unrelated to study procedures. Complete clinical regression was detected in 84/94 (89.4%) superficial BCCs, and 12/23 (52.2%) nodular BCCs one month after 2 MAL-PDT sessions. No further clinical improvement was observed in either superficial or nodular BCCs with treatment continuation up to a maximum of 8 MAL-PDT sessions. Adverse effects were limited to mild local skin reactions, and cosmetic outcome was rated as excellent or good. Recurrence was observed in 2/84 (2.4%) successfully treated superficial BCCs at 6 and 12 months after treatment discontinuation. Based on the efficacy, tolerability, cosmetic outcome and recurrence rate, our results support the use of MAL-PDT for treatment of superficial BCC and for selected cases of nodular BCC.