Tildrakizumab-induction therapy followed by as-needed dosing in patients with mild-to-moderate psoriasis

This retrospective real-world evidence study investigates the efficacy of as-needed dosing of tildrakizumab in patients with mild-to-moderate psoriasis. Patients received the first three standard doses of tildrakizumab, and thereafter used as-needed dosing over the course of 2.5 years, rather than the approved interval of every 12 weeks. Adequate disease control was achieved, reaching a mean Psoriasis Area and Severity Index at the end of follow-up of < 1.

Early Detection and Progression of Subclinical Atherosclerosis in Psoriasis (EDSAP): protocol for an observational, single-centre, prospective cohort study

INTRODUCTION

Life expectancy of patients with psoriasis is reduced by 4-5 years due to cardiovascular disease with an increased risk of myocardial infarction at an earlier age compared with the general population. This increased risk is independent of traditional cardiovascular risk factors and higher in moderate-to-severe forms of psoriasis. Inflammation may play a key role in the development of atherosclerosis in these patients.

METHODS AND ANALYSIS

A prospective cohort study, Early Detection and Progression of Subclinical Atherosclerosis in Psoriasis (EDSAP), was initiated in January 2020 to investigate the presence and progression of subclinical atherosclerosis in patients with psoriasis. 120 patients aged 30-65 years and eligible for biological treatment have been recruited at Hospital Ramón y Cajal in Madrid, Spain. Patients undergo a baseline visit, and 1-year follow-up visit after starting biological therapy. Each visit includes: assessment of cardiovascular risk factors, screening for subclinical atherosclerosis by two-dimensional/three-dimensional ultrasound of carotid and femoral arteries, cardiac CT of coronary arteries and blood sampling. All baseline visits were completed by December 2022, and the remaining follow-up visits will be concluded by the end of 2023. The EDSAP study aims to identify new molecular and imaging markers associated with the presence of atherosclerosis and its progression in a chronic inflammatory state such as psoriasis. This has the potential to: (1) help improve primary cardiovascular prevention strategies in these patients; (2) understand the effect of biological drugs on the cardiovascular system; and (3) serve as a model for understanding atherosclerosis in other chronic inflammatory diseases.

ETHICS AND DISSEMINATION

The study protocol has been approved by the Institutional Review Board of the Hospital Ramón y Cajal in Madrid. We will present our findings at national and international congresses, and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05858099.

Therapeutic Efficacy of a Plasma Rich in Growth Factors Gel Combined with Fractional Ablative Laser in the Management of Post-acne Scars

Background

Acne vulgaris is a common condition that often results in secondary cutaneous damage in the form of scarring. Scars require shape-specific scaffolds. Recently, a new 3D gel derived from plasma rich in growth factors technology (PRGF) has been developed with the aim of overcoming these limitations.

Objective

The aim of this study was to preliminarily assess the clinical performance of the combination therapy with PRGF-gel (PG) and fractional ablative laser for post-acne scar amelioration.

Materials and Methods

Nine patients suffering from post-acne scars received a combination of PG and fractional ablative laser therapy. Macrophotographs were taken and patients completed a satisfaction survey. Images were also analyzed following the ECCA score. Clinicians were also asked to fulfill a clinical improvement score and any undesired side effects were recorded.

Results

Patients were referred to be highly satisfied as an 8.7 ± 0.9 satisfaction score was achieved. Healthcare specialists objectivated that the scar reduction and overall skin quality at the end of the study had noticeably improved. The ECCA score showed a significant 55% of improvement compared with baseline. No major side effects were recorded, and the tolerance of the treatment was excellent.

Conclusion

The combined therapy with PG and fractional ablative laser might help in the management of post-acne scars and overall skin rejuvenation.

An Autologous Topical Serum Derived from Platelet-Rich Plasma Therapy for the Management of Sensitive Skin Alterations: A Case Series Report

Background

Although the underlying pathophysiology of sensitive skin remains unknown, it presents clinical symptoms like erythema, burning and dryness associated with other inflammatory dermatoses such as dermatitis or rosacea.

Objective

The aim of the present report was to provide preliminary data about the efficacy of Endoret-Serum (ES) as an autologous therapy for the topical management of sensitive skin alterations.

Materials and Methods

Five patients underwent a daily topical ES treatment that was maintained for three months. Clinical assessment was carried out using validated dermatological surveys (DLQI, IGA, Likert, PGI-I). Additionally, skin hydration measurement and high-resolution topographic and reflectance confocal imaging analysis were carried out.

Results

No adverse events were observed during the treatment. At the end of the follow-up period, surveys highlighted a significant therapeutic effect compared to baseline. Skin hydration was also improved, and topographic images showed a decrease in patient’s underlying inflammatory and vascular condition.

Conclusion

This preliminary report suggests that Endoret-Serum may be useful in the management of clinical symptoms derived from sensitive skin alterations.

Underperformance of clinical risk scores in identifying imaging-based high cardiovascular risk in psoriasis: results from two observational cohorts

AIMS

We aimed to evaluate whether traditional risk scores [short-term, 'psoriasis-modified' (multiplied by 1.5) and lifetime] were able to capture high cardiovascular disease (CVD) risk as defined by the presence of atherosclerotic plaques in coronary, femoral, or carotid arteries in psoriasis.

METHODS AND RESULTS

We used two prospectives obseravational cohorts. European cohort: femoral and carotid atherosclerotic plaques were evaluated by ultrasound in 73 psoriasis patients. Lifetime CVD risk (LTCVR) was evaluated with QRISK-LT; short-term CVD risk was evaluated with SCORE and psoriasis-modified SCORE. American cohort: 165 patients underwent coronary computed tomography angiography to assess presence of coronary plaques. LTCVR was evaluated with atherosclerotic cardiovascular disease (ASCVD-LT) lifetime; short-term CVD risk was evaluated with ASCVD and psoriasis-modified ASCVD. European cohort: subclinical atherosclerosis was present in 51% of patients. QRISK-LT identified 64% of patients with atherosclerosis missing a high proportion (35%) with atheroma plaque (P < 0.05). The percentage of patients with atherosclerosis identified by QRISK-LT was significantly higher than those detected by SCORE (0%) and modified SCORE (10%). American cohort: subclinical atherosclerosis was present in 54% of patients. ASCVD-LT captured 54% of patients with coronary plaques missing a high proportion (46%) with coronary plaque (P < 0.05). The percentage of patients with atheroma plaques detected with ASCVD and modified ASCVD were only 20% and 45%, respectively.

CONCLUSIONS

Application of lifetime, short-term and 'psoriasis-modified' risk scores did not accurately capture psoriasis patients at high CVD risk.

Daylight photodynamic therapy is an option for the treatment of actinic keratosis in patients with xeroderma pigmentosum in Africa

BACKGROUND

Xeroderma pigmentosum (XP) is a very rare and severe genetic disorder with a DNA repair defect of ultraviolet (UV)-induced damage. Photodynamic therapy (PDT) has been successfully used in XP patients to treat actinic keratosis (AK) and daylight PDT (DL-PDT) has demonstrated similar efficacy to conventional PDT (C-PDT) for AK.

OBJECTIVES

To assess DL-PDT for the treatment of AK in patients with XP.

METHODS

Patients with XP were evaluated by a group of Spanish and African dermatologists. Clinical characteristics of the patients were assessed and divided in mild, severe or moderate affectation of AK in the face. A topical photosensitizer was extended on the patients' faces and after two hours of indoor light exposure, fluorescence was assessed and the cream was removed. Patients were examined two and seven days later to assess the reaction to PDT and followed up three months later.

RESULTS

A total of 13 patients were treated on the whole face. Three were classified as severe AK, six as moderate AK and four as mild AK. Fluorescence assessment showed a soft yellow-green colour and a pink-color delineating the AK. Two days after treatment patients presented a scaly reaction. After one week the reaction healed, there was improvement and after three months no adverse events were noticed.

CONCLUSIONS

PDT is an option for treatment of AK in patients with XP.

In vitro characterization and clinical use of platelet-rich plasma-derived Endoret-Gel as an autologous treatment for atrophic scars

BACKGROUND

Normal healing process becomes severely dysregulated in pathophysiological conditions such as inflammation, infection or underlaying diseases. These scenarios hamper the standard healing pattern and dermal fibrotic tissue develops.

OBJECTIVE

In the present study a novel three-dimensional formulation (Endoret-Gel) based on plasma rich in growth factors technology (Endoret-PRGF) has been assessed for atrophic scar management.

MATERIALS AND METHODS

Microstructure analysis, growth factor content, and projection capacity of both formulations (Endoret-Gel and Endoret-PRGF) was assessed. Additionally, a clinical evaluation of Endoret-Gel treatment was also performed in a case of an extense atrophic scar.

RESULTS

Endoret-Gel presented high molecular weight plasmatic proteins that formed solid thermal aggregates enclosed by a stable fibrin network. This formulation has a higher cutaneous projection capacity compared with Endoret-PRGF. Both formulations presented a high load of bioactive proteins such as EGF, PDGF-AB, and IGF-I being higher in liquid Endoret-PRGF. Clinical results evidenced that infiltrations of Endoret-Gel derived in an early volumetric disposal that was maintained for several months. The treatment provided and immediate soft tissue augmentation and scar amelioration effect that was translated into a noticeable clinical improvement of the injury. No side effects or adverse events were reported during ten-month follow-up period.

CONCLUSION

These preliminary findings suggest that Endoret-Gel may act not only as a temporary volumizer but also as soft tissue stimulator that might be used as a monotherapy for scar management.

Platelet rich plasma for the management of hair loss: Better alone or in combination?

Platelet-rich plasma (PRP) and autologous protein-based treatments have recently emerged as a potential therapeutic approach for hair loss-related disorders including androgenetic alopecia and alopecia areata. The safety and efficacy of repeated intradermal injections of PRP has proved to promote hair growth in a number of randomized clinical trials. Biologically active proteins and cytokines released upon platelet activation have shown to induce folliculogenesis and activate the anagen growing phase of dormant bulbs. Interestingly, further studies have revealed that combining PRP with other hair loss-related products may enhance the final performance of the treatment. These synergistic approaches include Food and Drug Administration (FDA) approved drugs such as finasteride or minoxidil, bioactive macromolecules and cell-based therapies. Here, recent research involving alone or combined therapy with platelet-rich plasma for the management of hair loss-related disorders are outlined and future prospects are discussed.

A novel personalized 3D injectable protein scaffold for regenerative medicine

Biomaterials should be designed to closely resemble the characteristics and functions of the native extracellular matrix to provide mechanical support and signals to direct biological events. Here we have developed a novel injectable plasma rich in growth factors (PRGF-Endoret)-based formulation that combines a thermal-denaturation step of plasma with an autologous fibrin crosslinking. Rheological and mechanical properties were evaluated. Additionally, the microstructure and biological capacity of the biomaterial was also characterized. This novel formulation exhibited ideal mechanical properties and a gel-like behavior with the ability to progressively release its growth factor load over time. The results also suggested that the novel injectable formulation is non-cytotoxic, biocompatible and suitable for cell ingrowth as it is deduced from the fibroblast proliferation within the scaffold. Finally, stimulation of both cell proliferation and matrix proteins synthesis demonstrated the regenerative potential of this autologous protein based injectable scaffold.

Beard alopecia areata: a multicentre review of 55 patients

BACKGROUND

Alopecia areata on the beard area (BAA) is a common clinical manifestation, but there are no studies about its characteristics.

OBJECTIVE

To describe the epidemiology, comorbidities, clinical presentation, evolution, diagnostic findings and therapeutic choices in a series of patients with BAA.

METHODS

This retrospective multicentre review included patients diagnosed with BAA as the first and unique clinical manifestation with at least 12 months of follow-up. Diagnosis was performed based on the typical clinical features. Extra-beard involvement was monitored in all cases.

RESULTS

Overall, 55 male patients with a mean age of 39.1 years (range 20-74) were included. Twenty-five patients (45.5%) developed alopecia of the scalp during follow-up and more than 80% of cases appeared in the first 12.4 months. Clinical presentation of AA on the scalp was patchy AA (less than 5 patches) (52%), multifocal AA (28%), AA totalis (12%) and AA universalis (8%). Multivariate analysis revealed a trend of association between scalp involvement and family history of AA without statistical significance.

CONCLUSIONS

According to this study, BAA may progress to scalp AA in a significant number of patients (45.5% of the patients with a follow-up interval of at least 12 months). In the group of patients who developed scalp AA, 80% of them did it within the first 12 months, so follow-up of patients with BAA is highly encouraged.

Histochemical Evaluation of the Vessel Wall Destruction and Selectivity After Treatment with Intense Pulsed Light in Capillary Malformations

BACKGROUND

Among the different approaches for improving the effectiveness in the treatment of Capillary Malformations type Port Wine Stain (CM type PWS) are the intense pulsed light sources. There are few clinical studies prove useful in the treatment of CM. Furthermore, no studies have been published yet demonstrating the histological effects of IPL in CM.

OBJECTIVES

To assess the histological effects of pulsed light in capillary malformations type port wine stain. We wanted to compare epidermal, dermal and vessel wall damage after treatment with different combinations of IPL parameters.

MATERIAL AND METHODS

Fifty-five post-treatment biopsies were performed in 15 consenting patients with CM and stained with nitroblue-tetrazolium chloride (NBTC). Patients had not been treated previously.

RESULTS

Fifteen patients with CM, with a median age of 39 years-old were enrolled in this study. In this series, the patients with the most severe epidermal damage were those with a darker phototype. Pink CM were especially resistant to treatment, even using high fluences, short pulse durations and stacking pulses. Longer intra- and interpulse delays were effective in purple CM, achieving adequate vessel destruction.

CONCLUSIONS

IPL devices provide a vast amount of treatment possibilities and further studies are necessary to optimize therapeutic approaches to CM. In this study we have observed the histological effects of different pulses on the MC type PWS.

Core Content for Undergraduate Medical Education in Spain: Recommendations of the Instructors' Group of the Spanish Academy of Dermatology and Venereology (AEDV)

BACKGROUND

Skin problems are among the most frequent reasons for seeking medical attention in primary care. In recent years, as a result of the process of adapting medical curricula to the requirements of the European Higher Education Area, the amount of time students spend learning the concepts of dermatology has been reduced in many universities.

MATERIAL AND METHODS

In order to reach a consensus on core content for undergraduate education in dermatology, we sent a survey to the 57 members of the instructors' group of the Spanish Academy of Dermatology and Venereology (AEDV), asking their opinions on what objectives should be set for a dermatology course in Spain. A total of 131 previously selected objectives were listed. We then applied the Delphi method to achieve consensus on which ones the respondents considered important or very important (score≥4 on a Likert scale).

RESULTS

Nineteen responses (33%) were received. On the second round of the Delphi process, 68 objectives achieved average scores of at least 4. The respondents emphasized that graduates should understand the structure and functions of the skin and know about bacterial, viral, and fungal skin infections, the most common sexually transmitted diseases (STDs), and the 4 main inflammatory dermatoses. Students should also learn about common complaints, such as itching and bald patches; the management of dermatologic emergencies; purpura and erythema nodosum as signs of internal disease; and the prevention of STDs and skin cancer. During clinical clerkships students should acquire the communication skills they will need to interview patients, write up a patient's medical history, and refer the patient to a specialist.

CONCLUSIONS

The AEDV's group of instructors have defined their recommendations on the core content that medical faculties should adopt for the undergraduate subject of dermatology in Spain.

Folliculitis decalvans: a multicentre review of 82 patients

BACKGROUND

Folliculitis decalvans (FD) is a rare neutrophilic scarring alopecia that represents a therapeutic challenge for dermatologists.

OBJECTIVE

To describe the epidemiology, comorbidities, clinical presentation, diagnostic findings and therapeutic options in a large series of patients with FD.

METHODS

This retrospective multicentre review includes patients diagnosed with FD based on clinical and histopathologic findings. The clinical severity was determined by the maximum diameter of the largest alopecic patch (slight: <2 cm, moderate: 2-4.99 cm, severe: 5 cm or more). Response to therapy was assessed as improvement, worsening or stabilization depending on the clinical symptoms (pruritus and trichodynia), inflammatory signs (erythema, pustules and crusts) and the extension of the alopecic patch.

RESULTS

Overall, 82 patients (52 males and 30 females) with a mean age of 35 years were included. No significant comorbidities were present. A family history was present in three males. Severe FD was observed in 17 patients (21%). The independent factors associated with severe FD after multivariate analysis were: onset of FD before 25 years of age and presence of pustules. Oral antibiotics (tetracyclines and the combination of clindamycin and rifampicin) improved 90% and 100% of the patients, with a mean duration of response of 4.6 and 7.2 months respectively.

CONCLUSIONS

The onset of FD before 25 years of age and the presence of pustules within the alopecic patch were associated with severe FD. Tetracyclines and the combination of clindamycin and rifampicin were the most useful treatments.

Isolation and characterization of PDT-resistant cancer cells

Even though the efficacy of photodynamic therapy (PDT) for treating premalignant and malignant lesions has been demonstrated, resistant tumor cells to this therapy occasionally appear.

The effect of pulsed dye laser on high-risk basal cell carcinomas with response control by Mohs micrographic surgery

Several reports have shown the effectiveness of pulsed dye laser (PDL) for the treatment of basal cell carcinoma (BCC). Most studies have focused on low-risk BCCs, but an important limitation has been the lack of histologic confirmation of the treatment results. The aim of this study was to assess the effectiveness of PDL in high-risk BCCs with complete histologic evaluation with Mohs micrographic surgery (MMS). Seven patients with high-risk BCCs located on the face were included. All tumors were treated with three sessions of PDL (595 nm) at 4-week intervals. The tumor and 4 mm of peripheral skin were treated with two stacked pulses with a 1-s delay, a fluence of 15 J/cm(2), a pulse duration of 2 ms, and a spot size of 7 mm. MMS was performed at least 1 month after the last PDL session including excisional tumor debulking prior to the first stage of MMS for standard histologic evaluation. Apparent complete clinical response was achieved in five of seven patients. MMS was finally performed in six patients, and clear margins were achieved after one stage of MMS. The histologic evaluation of the tumor debulking specimens showed complete clearance in four of six cases. One patient who did not undergo MMS showed a recurrence after 14 months. This is the first pilot study that demonstrates that PDL can be effective for the treatment of high-risk BCCs. Until further scientific evidence is available, treatment of high-risk BCCs should include histologic confirmation of clearance.

New experimental models of skin homeostasis and diseases

Homeostasis, whose regulation at the molecular level is still poorly understood, is intimately related to the functions of epidermal stem cells. Five research groups have been brought together to work on new in vitro and in vivo skin models through the SkinModel-CM program, under the auspices of the Spanish Autonomous Community of Madrid. This project aims to analyze the functions of DNA methyltransferase 1, endoglin, and podoplanin in epidermal stem cell activity, homeostasis, and skin cancer. These new models include 3-dimensional organotypic cultures, immunodeficient skin-humanized mice, and genetically modified mice. Another aim of the program is to use skin-humanized mice to model dermatoses such as Gorlin syndrome and xeroderma pigmentosum in order to optimize new protocols for photodynamic therapy.

Erythematous nodular lesion on the chest of an infant

An 11-month-old girl presented with an erythematous nodule on the chest, which had been growing for 8 months. The tumor was composed of uniform polygonal and spindle-shaped cells, forming nodules and fascicles. The diagnosis of neurothekeoma was based upon the histology and immunohistochemistry.

Necrobiosis lipoidica

BACKGROUND

Necrobiosis lipoidica presents with a distinctive appearance making it an important clinical diagnosis.

OBJECTIVE

To describe a case of necrobiosis lipoidica in a patient with type 1 diabetes mellitus, and to discuss differential diagnoses and management.

DISCUSSION

Necrobiosis lipoidica is most commonly found on the shins, presenting as a well-defined plaque. Management is challenging and options are discussed. Avoiding ulceration is a key concern.

Frontal fibrosing alopecia: a multicenter review of 355 patients

BACKGROUND

To our knowledge, there are no large multicenter studies concerning frontal fibrosing alopecia (FFA) that could give clues about its pathogenesis and best treatment.

OBJECTIVE

We sought to describe the epidemiology, comorbidities, clinical presentation, diagnostic findings, and therapeutic choices in a large series of patients with FFA.

METHODS

This retrospective multicenter study included patients given the diagnosis of FFA. Clinical severity was classified based on the recession of the frontotemporal hairline.

RESULTS

In all, 355 patients (343 women [49 premenopausal] and 12 men) with a mean age of 61 years (range 23-86) were included. Early menopause was detected in 49 patients (14%), whereas 46 (13%) had undergone hysterectomy. Severe FFA was observed in 131 patients (37%). Independent factors associated with severe FFA after multivariate analysis were: eyelash loss, facial papules, and body hair involvement. Eyebrow loss as the initial clinical presentation was associated with mild forms. Antiandrogens such as finasteride and dutasteride were used in 111 patients (31%), with improvement in 52 (47%) and stabilization in 59 (53%).

LIMITATIONS

The retrospective design is a limitation.

CONCLUSIONS

Eyelash loss, facial papules, and body hair involvement were associated with severe FFA. Antiandrogens were the most useful treatment.

Congenital smooth muscle hamartoma on the face treated using vascular laser

A congenital smooth muscle hamartoma is a rare, benign proliferation of smooth muscle bundles in the dermis that is usually diagnosed in the neonatal period or infancy. Surgical excision is the first-line therapeutic option, but in certain areas such as the face, surgery may be too aggressive, and different treatments should be considered. We present the case of a congenital smooth muscle hamartoma on the face treated using pulsed dye laser with good response.

Congenital plaque-like glomangioma treated successfully with dual wavelength pulsed-dye and neodymium:yttrium-aluminum-garnet laser

Glomovenous malformations are disseminated variants of cutaneous glomus tumors. These malformations are subdivided into regional or localized, disseminated, and congenital plaque-like forms. The congenital plaque-like form is the rarest variant. Most treatment modalities have been disappointing in the treatment of large glomangiomas, leading to high recurrence rates. We report a case of a 34-year-old man with a congenital plaque-like glomangioma on his left arm and forearm treated successfully with sequential pulsed-dye neodymium yttrium aluminum garnet laser.

Patchy hair loss on the pubis--a case study

A female, aged 17 years and with a history of anorexia nervosa, presented with a 3 month history of a large, irregular area of hair loss over the pubis. Physical examination revealed scattered short hairs of varying length, follicular hyperkeratosis and hyperpigmentation throughout the area of alopecia (Figure 1a). A magnified view revealed decreased hair density, broken hairs with different shaft lengths, short vellous hairs and signs of recent haemorrhage (Figure 1b). The remainder of the hairs appeared normal, and her nails did not show any pathological changes. The hair-pull test was negative. Potassium hydroxide (KOH) examination and fungal culture were negative. Biochemical studies, abdominal X-ray and ultrasonography were normal.

Perforating dermatosis in a patient receiving azathioprine

Azathioprine (AZA) is an imidazole derivative of mercaptopurine. It antagonizes purine metabolism, and it may inhibit synthesis of DNA, RNA, and proteins. The 6-thioguanine nucleotides appear to mediate the majority of AZAs immunosuppressive and toxic effects. While cutaneous adverse side-effects are not uncommon, perforating dermatosis has not been reported in association to AZA. We speculate that immunological disorders induced by AZA in susceptible individuals could be related to perforating dermatosis.