Application of Genetic Algorithm-Based Support Vector Machine in Identification of Gene Expression Signatures for Psoriasis Classification: A Hybrid Model

BACKGROUND

Psoriasis is a chronic autoimmune disease impairing significantly the quality of life of the patient. The diagnosis of the disease is done via a visual inspection of the lesional skin by dermatologists. Classification of psoriasis using gene expression is an important issue for the early and effective treatment of the disease. Therefore, gene expression data and selection of suitable gene signatures are effective sources of information.

METHODS

We aimed to develop a hybrid classifier for the diagnosis of psoriasis based on two machine learning models of the genetic algorithm and support vector machine (SVM). The method also conducts gene signature selection. A publically available gene expression dataset was used to test the model.

RESULTS

A number of 181 probe sets were selected among the original 54,675 probes using the hybrid model with a prediction accuracy of 100% over the test set. A number of 10 hub genes were identified using the protein-protein interaction network. Nine out of 10 identified genes were found in significant modules.

CONCLUSIONS

The results showed that the genetic algorithm improved the SVM classifier performance significantly implying the ability of the proposed model in terms of detecting relevant gene expression signatures as the best features.

Renal dysfunction in psoriatic patients

Psoriasis is a common chronic inflammatory disease of the skin that is increasingly being considered as a systemic inflammatory disorder due to its association with cardiovascular, metabolic, pulmonary, renal, liver, and neurologic diseases. Renal involvement is rare but well documented and psoriasis is recognized as an independent factor for CKD and ESKD. A careful monitoring of the urinalysis and of renal function is recommended in psoriatic patients, especially those with moderate-to-severe disease. In case of pathologic findings, the execution of a renal biopsy appears necessary to make an accurate diagnosis and to establish the most appropriate therapeutic strategies to prevent the progression of kidney damage. The mechanisms of kidney involvement are different and not yet fully clarified. We present here two case reports of renal dysfunction during psoriasis. In one case, we diagnosed IgA nephropathy with particularly severe clinical presentation; in the other, an advanced kidney injury due to nephrotoxicity after prolonged CNI treatment.

Translation and validation of the Simplified Psoriasis Index (SPI) into Brazilian Portuguese

BACKGROUND

The Simplified Psoriasis Index is a tool that assesses the current severity, psychosocial impact, past history and interventions in patients with psoriasis through separate components. Two versions are available, one in which the current severity of the disease is evaluated by the patient themselves and another by the physician.

OBJECTIVES

Translate the Simplified Psoriasis Index into Brazilian Portuguese and verify its validity.

METHODS

The study was conducted in two stages; the first stage was the translation of the instrument; the second stage was the instrument's validation.

RESULTS

We evaluated 62 patients from Complexo Hospitalar Santa Casa de Porto Alegre and Hospital Universitário de Brasília. The Simplified Psoriasis Index translated into Portuguese showed high internal consistency (Cronbach test 0.68).

STUDY LIMITATIONS

Some individuals, because of poor education, might not understand some questions of the Simplified Psoriasis Index.

CONCLUSIONS

The Brazilian Portuguese version of the Simplified Psoriasis Index was validated for our population and can be recommended as a reliable instrument to assess the patients with psoriasis.

DNA methylation-based subclassification of psoriasis in the Chinese Han population

Psoriasis (Ps) is an inflammatory skin disease caused by genetic and environmental factors. Previous studies on DNA methylation (DNAm) found genetic markers that are closely associated with Ps, and evidence has shown that DNAm mediates genetic risk in Ps. In this study, Consensus Clustering was used to analyze DNAm data, and 114 Ps patients were divided into three subclassifications. Investigation of the clinical characteristics and copy number variations (CNVs) of DEFB4, IL22, and LCE3C in the three subclassifications revealed no significant differences in gender ratio and in Ps area and severity index (PASI) score. The proportion of late-onset ( ≥ 40 years) Ps patients was significantly higher in type I than in types II and III (P = 0.035). Type III contained the smallest proportion of smokers and the largest proportion of non-smoking Ps patients (P = 0.086). The CNVs of DEFB4 and LCE3C showed no significant differences but the CNV of IL22 significantly differed among the three subclassifications (P = 0.044). This study is the first to profile Ps subclassifications based on DNAm data in the Chinese Han population. These results are useful in the treatment and management of Ps from the molecular and genetic perspectives.

A cross-sectional study of the distribution of psoriasis subtypes in different ethno-racial groups

Skin of colored patients with psoriasis are more likely to remain undiagnosed and experience a greater impact on quality of life than their white counterparts. A better understanding of the ethno-racial differences in the presentation of psoriasis can help address these disparities. To compare the prevalence of psoriatic subtypes (plaque, guttate, pustular, erythrodermic, palmoplantar, and inverse) and lesion locations in Caucasian, Asian, and Hispanic/Latino patients, we analyzed cross-sectional, patient-reported, physician-reviewed survey data from 882 adult and 16 pediatric psoriasis patients seen at the University of California, San Francisco Department of Dermatology between 2006 and 2016. Multivariate logistic regression was used to compare the prevalence of psoriasis subtypes and lesional distributions amongst the ethno-racial groups. Asians and Hispanics/Latinos had higher odds of having pustular psoriasis compared to Caucasians (OR=4.36 [95%CI: 1.24-17.62], P=0.026; and OR=5.94 [95%CI: 1.03-31.03], P=0.036, respectively). Asians also had a higher frequency of erythrodermic psoriasis (OR=5.56 [95%CI: 1.41-27.17], P=0.018), but a lower frequency of inverse psoriasis compared to Caucasians (OR=0.26 [95%CI: 0.06-0.80], P=0.036). These differences may relate to genetic or environmental factors or access to care. Clinician awareness of ethno-racial differences in psoriasis subtype and lesion location can facilitate earlier diagnosis and therapeutic intervention.

Indices of Disease Activity in Psoriatic Arthritis

Psoriatic arthritis (PA) may respond to disease-modifying antirheumatic therapy. The value of assessing disease activity with indices devised for rheumatoid arthritis (RA) was investigated in 72 patients with seronegative PA. Thirty patients had a peripheral polyarthritis including the distal inter-phalangeal joints (DIPJs) and 15 a symmetrical arthritis sparing DIPJs (RA-like). Significant correlations (Spearman rank test) were seen between the clinical variables (pain score, grip strength, Ritchie articular index and a summated index of disease activity) in these two groups. Ten patients with a markedly asymmetrical arthritis showed a poor correlation between clinical variables. Although the objective indices – erythrocyte sedimentation rate (ESR) and C-reactive protein – correlated together in the first two groups, the ESR correlated solely with clinical indices, and then only in RA-like patients.

These results cast some doubt on the value of assessment methods based on RA when evaluating subgroups of PA other than RA-like disease.

Identifying Psoriasis and Psoriatic Arthritis Patients in Retrospective Databases When Diagnosis Codes Are Not Available: A Validation Study Comparing Medication/Prescriber Visit-Based Algorithms with Diagnosis Codes

BACKGROUND

Using diagnosis code-based algorithms is the primary method of identifying patient cohorts for retrospective studies; nevertheless, many databases lack reliable diagnosis code information.

OBJECTIVES

To develop precise algorithms based on medication claims/prescriber visits (MCs/PVs) to identify psoriasis (PsO) patients and psoriatic patients with arthritic conditions (PsO-AC), a proxy for psoriatic arthritis, in Canadian databases lacking diagnosis codes.

METHODS

Algorithms were developed using medications with narrow indication profiles in combination with prescriber specialty to define PsO and PsO-AC. For a 3-year study period from July 1, 2009, algorithms were validated using the PharMetrics Plus database, which contains both adjudicated medication claims and diagnosis codes. Positive predictive value (PPV), negative predictive value (NPV), sensitivity, and specificity of the developed algorithms were assessed using diagnosis code as the reference standard. Chosen algorithms were then applied to Canadian drug databases to profile the algorithm-identified PsO and PsO-AC cohorts.

RESULTS

In the selected database, 183,328 patients were identified for validation. The highest PPVs for PsO (85%) and PsO-AC (65%) occurred when a predictive algorithm of two or more MCs/PVs was compared with the reference standard of one or more diagnosis codes. NPV and specificity were high (99%-100%), whereas sensitivity was low (≤30%). Reducing the number of MCs/PVs or increasing diagnosis claims decreased the algorithms' PPVs.

CONCLUSIONS

We have developed an MC/PV-based algorithm to identify PsO patients with a high degree of accuracy, but accuracy for PsO-AC requires further investigation. Such methods allow researchers to conduct retrospective studies in databases in which diagnosis codes are absent.

[Management of psoriasis]

Therapeutic procedures are dictated by burden and duration of disease, previous therapies and comorbidity. Possible triggers are to be taken into consideration and eliminate whenever possible.

Risankizumab versus Ustekinumab for Moderate-to-Severe Plaque Psoriasis

BACKGROUND

Interleukin-23 is thought to be critical to the pathogenesis of psoriasis. We compared risankizumab (BI 655066), a humanized IgG1 monoclonal antibody that inhibits interleukin-23 by specifically targeting the p19 subunit and thus prevents interleukin-23 signaling, and ustekinumab, an interleukin-12 and interleukin-23 inhibitor, in patients with moderate-to-severe plaque psoriasis.

METHODS

We randomly assigned a total of 166 patients to receive subcutaneous injections of risankizumab (a single 18-mg dose at week 0 or 90-mg or 180-mg doses at weeks 0, 4, and 16) or ustekinumab (45 or 90 mg, according to body weight, at weeks 0, 4, and 16). The primary end point was a 90% or greater reduction from baseline in the Psoriasis Area and Severity Index (PASI) score at week 12.

RESULTS

At week 12, the percentage of patients with a 90% or greater reduction in the PASI score was 77% (64 of 83 patients) for risankizumab (90-mg and 180-mg groups, pooled), as compared with 40% (16 of 40 patients) for ustekinumab (P<0.001); the percentage of patients with a 100% reduction in the PASI score was 45% in the pooled 90-mg and 180-mg risankizumab groups, as compared with 18% in the ustekinumab group. Efficacy was generally maintained up to 20 weeks after the final dose of 90 or 180 mg of risankizumab. In the 18-mg and 90-mg risankizumab groups and the ustekinumab group, 5 patients (12%), 6 patients (15%), and 3 patients (8%), respectively, had serious adverse events, including two basal-cell carcinomas and one major cardiovascular adverse event; there were no serious adverse events in the 180-mg risankizumab group.

CONCLUSIONS

In this phase 2 trial, selective blockade of interleukin-23 with risankizumab was associated with clinical responses superior to those associated with ustekinumab. This trial was not large enough or of long enough duration to draw conclusions about safety. (Funded by Boehringer Ingelheim; ClinicalTrials.gov number, NCT02054481 ).

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.

Evaluation of the Physician Global Assessment and Body Surface Area Composite Tool for Assessing Psoriasis Response to Apremilast Therapy: Results from ESTEEM 1 and ESTEEM 2

BACKGROUND

The Physician Global Assessment and Body Surface Area (PGAxBSA) composite tool is a simple, effective alternative for measuring psoriasis severity.

OBJECTIVE

To evaluate the product of PGAxBSA as a sensitive alternative to the Psoriasis Area and Severity Index (PASI) for assessing disease severity and therapeutic response with data collected from the phase 3 ESTEEM 1 and 2 trials.

METHODS

This post hoc analysis included 836 patients randomized to apremilast 30 mg BID at baseline (ESTEEM 1, n=562; ESTEEM 2, n=274). Spearman correlation coefficients were used to compare PGAxBSA, PASI, and the Dermatology Life Quality Index (DLQI). Concordance between PGAxBSA and PASI was evaluated for 50%/75%/90% improvement from baseline at week 16.

RESULTS

In ESTEEM 1 and 2, PGAxBSA and PASI exhibited significant positive correlations for measuring disease severity at baseline (r≥0.757) and week 16 (r≥0.807). At week 16, ≥79% concordance was observed between PGAxBSA and PASI for 75% and 90% improvement from baseline; greater concordance (>88.0%) was observed using 50% improvement from baseline. At week 16, PGAxBSA and PASI were moderately correlated with DLQI.

LIMITATIONS

Analysis was limited to patients with baseline BSA ≥10% and static PGA ≥3.

CONCLUSIONS

In patients with moderate to severe psoriasis, PGAxBSA is correlated with PASI and sensitive to therapeutic response. <p><em>J Drugs Dermatol. 2017;16(2):147-153.</em></p>.

Psoriatic arthritis and psoriasis: differential diagnosis

Psoriasis frequency ranges from 1 to 3 % in white population, and arthritis occurs in 10-40 % of psoriasis patients, representing a relevant health issue. Psoriatic arthritis (PsA) is an inflammatory arthropathy, associated with psoriasis, in which ocular-, intestinal-, metabolic-, and cardiovascular-related manifestations can variably coexist. In order to favor early PsA and psoriasis diagnosis, it is crucial to rule out other conditions that can resemble the disease and delay appropriate therapeutic approach. Therefore, the aim of this review is to focus on PsA and psoriasis differential diagnosis.

[Skin symptoms of psoriasis associated with spondylarthropathies]

The term spondylarthropathy summarizes a heterogenous group of diseases with spinal involvement as the common denominator. In this paper, we will primarily focus on cutaneous manifestations of psoriasis, as this dermatosis is associated with psoriatic artrhritis, one of the major diseases classified as spondylarthropathy. We will describe the clinical manifestations of psoriasis as well as the underlying pathophysiology, the latter allowing to understand the differences in efficacy of numerous Disease Modifying Anti-Rheumatic Drugs (DMARDs) on joint versus skin symptoms. Additionally, we address the exacerbation of pre-existing psoriasis under DMARD therapy.

The skin in psoriasis: assessment and challenges

The coexistence of psoriasis arthritis (PsA) and psoriasis vulgaris in about 20% of patients with psoriasis leads to a need for rheumatologic-dermatologic team work. We summarise the role of dermatologists in assessment of the skin in psoriasis. Chronic plaque psoriasis must be differentiated from other subtypes such as generalised pustular psoriasis (GPP) or palmoplantar pustulosis (PPP). Therapeutic management is based on the evaluation of the disease severity. Quantitative scoring of skin severity includes calculation of the Psoriasis Area and Severity Index (PASI), body surface area (BSA) as well as the Dermatology Life Quality Index (DLQI). These scoring systems do not replace the traditional dermatologic medical history and physical examination of the patient. The skin should be examined for additional skin diseases; moreover, patients should be monitored for comorbidity, most importantly PsA and cardiovascular comorbidity.

[ASSOCIATION OF PSORIASIS WITH OTHER DISEASES]

Psoriasis is a chronic relapsing autoimmune disease with a multigenetic predisposition, which occurs in about 2% of patients in Croatia and shows variable occurrence in the world. Psoriasis can be associated with various diseases, including autoimmune diseases (pemphigus, pemphigoid, vitiligo), and slightly less with allergic diseases (atopic dermatitis, asthma, urticaria, allergic contact dermatitis). According to clinical manifestations, psoriasis appears as plaque psoriasis, erythrodermic form and pustular psoriasis. Provocative factors that encourage psoriasis are infections, endogenous factors, hypocalcemia, psychogenic factors and medications. Psoriasis may worsen other dermatoses such as contact dermatitis, inflammatory dermatoses and skin cancer, and the association of psoriasis with internal diseases is quite common (HIV, Crohn's disease, liver lesions, vascular diseases, amyloidosis and gout). Today, psoriasis is considered as a systemic inflammatory disease that can also affect the joints. Atypical localization of psoriasis, as well as resistant cases of psoriasis and other papulosquamous and eczematoid dermatoses require detailed work-up and confirming of diagnosis because of the possibility of the existence of other diseases. This paper discusses the association of psoriasis with rheumatic and other internal diseases.

Cost-of-illness in patients with moderate to severe psoriasis: a cross-sectional survey in Hungarian dermatological centres

BACKGROUND

Despite the widespread availability of biological drugs in psoriasis, there is a shortage of disease burden studies.

OBJECTIVES

To assess the cost-of-illness and quality of life of patients with moderate to severe psoriasis in Hungary.

METHODS

Consecutive patients with Psoriasis Area and Severity Index (PASI) > 10 and Dermatology Life Quality Index (DLQI) > 10, or treated with traditional systemic (TST) or biological systemic treatment (BST) were included. Demographic data, clinical characteristics, psoriasis related medication, health care utilizations and employment status in the previous 12 months were recorded. Costing was performed from the societal perspective applying the human capital approach. Quality of life was assessed using DLQI and EQ-5D measures.

RESULTS

Two-hundred patients were involved (females 32%) with a mean age of 51 (SD 13) years, 103 (52%) patients were on BST. Mean PASI, DLQI and EQ-5D scores were 8 (SD 10), 6 (SD 7) and 0.69 (SD 0.3), respectively. The mean total cost was €9,254/patient/year (SD 8,502) with direct costs accounting for 86%. The main cost driver was BST (mean €7,339/patient/year). Total costs differed significantly across treatment subgroups, mean (SD): no systemic therapy €2,186 (4,165), TST €2,388 (4,106) and BST €15,790 (6,016) (p < 0,001). Patients with BST had better PASI and DLQI scores (p < 0.01) than the other two subgroups.

CONCLUSIONS

Patients with biological treatment have a significantly better quality of life and higher total costs than patients with or without traditional systemic treatment. Our study is the largest in Europe and the first in the CEE region that provides cost-of-illness data in psoriasis involving patients with BST.

Exploring the relationship between EQ-5D, DLQI and PASI, and mapping EQ-5D utilities: a cross-sectional study in psoriasis from Hungary

BACKGROUND

There is a growing interest in policy making for using utility measures and identifying algorithms to convert disease-specific measures into utilities.

OBJECTIVES

To analyse the relationship between EQ-5D, Dermatology Life Quality Index (DLQI) and Psoriasis Area and Severity Index (PASI) in psoriasis. To transform DLQI scores, and key clinical, demographic and health service utilisation variables into utilities.

METHODS

A cross-sectional questionnaire survey of 200 consecutive adult patients with moderate to severe psoriasis was carried out in two Hungarian university clinics. The relationship between the outcome measures were analysed with correlations and with the known-groups method. Bivariate and multivariate regression algorithms on EQ-5D scores were formulated.

RESULTS

The mean age of respondents was 51 years (SD = 12.9), 68.5% were male, and 51.5% received biological therapy. Median EQ-5D, DLQI, and PASI scores were 0.73, 3.0, and 3.45, respectively. EQ-5D showed a moderate correlation with the DLQI and with the PASI (r s = -0.48 and -0.43, p < 0.05). Strong correlation was found between DLQI and PASI (r s = 0.81, p < 0.05). DLQI and PASI discriminated better among groups categorised by the localisation of the lesions than EQ-5D. Presence of psoriasis on the neck and/or décolletage was associated with the greatest health related quality of life (HRQOL) impairment. Ten variables were incorporated in a multivariate algorithm that accounted for 48.8% of EQ-5D variance (ANOVA p < 0.001).

CONCLUSIONS

This study provided the first evidence that patients with visible psoriatic lesions have significantly worse HRQOL compared to those with non-visible lesions, measured not only with DLQI but also with EQ-5D. In addition to demographic and clinical variables, our model included health service utilisation variables related to psoriasis, and explained higher proportion of EQ-5D variance than any previous findings in the literature.

Gene expression profile based classification models of psoriasis

Psoriasis is an autoimmune disease, which symptoms can significantly impair the patient's life quality. It is mainly diagnosed through the visual inspection of the lesion skin by experienced dermatologists. Currently no cure for psoriasis is available due to limited knowledge about its pathogenesis and development mechanisms. Previous studies have profiled hundreds of differentially expressed genes related to psoriasis, however with no robust psoriasis prediction model available. This study integrated the knowledge of three feature selection algorithms that revealed 21 features belonging to 18 genes as candidate markers. The final psoriasis classification model was established using the novel Incremental Feature Selection algorithm that utilizes only 3 features from 2 unique genes, IGFL1 and C10orf99. This model has demonstrated highly stable prediction accuracy (averaged at 99.81%) over three independent validation strategies. The two marker genes, IGFL1 and C10orf99, were revealed as the upstream components of growth signal transduction pathway of psoriatic pathogenesis.

3D surface roughness measurement for scaliness scoring of psoriasis lesions

Psoriasis is an incurable skin disorder affecting 2-3% of the world population. The scaliness of psoriasis is a key assessment parameter of the Psoriasis Area and Severity Index (PASI). Dermatologists typically use visual and tactile senses in PASI scaliness assessment. However, the assessment can be subjective resulting in inter- and intra-rater variability in the scores. This paper proposes an assessment method that incorporates 3D surface roughness with standard clustering techniques to objectively determine the PASI scaliness score for psoriasis lesions. A surface roughness algorithm using structured light projection has been applied to 1999 3D psoriasis lesion surfaces. The algorithm has been validated with an accuracy of 94.12%. Clustering algorithms were used to classify the surface roughness measured using the proposed assessment method for PASI scaliness scoring. The reliability of the developed PASI scaliness algorithm was high with kappa coefficients>0.84 (almost perfect agreement).

Psoriasis

Psoriasis is a chronic inflammatory skin condition that is often associated with systemic manifestations. It affects about 2 percent of U.S. adults, and can significantly impact quality of life. The etiology includes genetic and environmental factors. Diagnosis is based on the typical erythematous, scaly skin lesions, often with additional manifestations in the nails and joints. Plaque psoriasis is the most common form. Atypical forms include guttate, pustular, erythrodermic, and inverse psoriasis. Psoriasis is associated with several comorbidities, including cardiovascular disease, lymphoma, and depression. Topical therapies such as corticosteroids, vitamin D analogs, and tazarotene are useful for treating mild to moderate psoriasis. More severe psoriasis may be treated with phototherapy, or may require systemic therapy. Biologic therapies, including tumor necrosis factor inhibitors, can be effective for severe psoriasis and psoriatic arthritis, but have significant adverse effect profiles and require regular monitoring. Management of psoriasis must be individualized and may involve combinations of different medications and phototherapy.

Transcriptome classification reveals molecular subtypes in psoriasis

BACKGROUND

Psoriasis is an immune-mediated disease characterised by chronically elevated pro-inflammatory cytokine levels, leading to aberrant keratinocyte proliferation and differentiation. Although certain clinical phenotypes, such as plaque psoriasis, are well defined, it is currently unclear whether there are molecular subtypes that might impact on prognosis or treatment outcomes.

RESULTS

We present a pipeline for patient stratification through a comprehensive analysis of gene expression in paired lesional and non-lesional psoriatic tissue samples, compared with controls, to establish differences in RNA expression patterns across all tissue types. Ensembles of decision tree predictors were employed to cluster psoriatic samples on the basis of gene expression patterns and reveal gene expression signatures that best discriminate molecular disease subtypes. This multi-stage procedure was applied to several published psoriasis studies and a comparison of gene expression patterns across datasets was performed.

CONCLUSION

Overall, classification of psoriasis gene expression patterns revealed distinct molecular sub-groups within the clinical phenotype of plaque psoriasis. Enrichment for TGFb and ErbB signaling pathways, noted in one of the two psoriasis subgroups, suggested that this group may be more amenable to therapies targeting these pathways. Our study highlights the potential biological relevance of using ensemble decision tree predictors to determine molecular disease subtypes, in what may initially appear to be a homogenous clinical group. The R code used in this paper is available upon request.

A case of verrucous psoriasis

Psoriasis is a common inflammatory disease with a range of clinical presentations and a chronic relapsing course. There have been few reports of verrucous psoriasis, which is distinguished by its warty appearance and characteristic histology. We report a case of this rare form of psoriasis in an elderly woman with a history of plaque-type psoriasis and and discuss the histopathologic findings.

Measures used in specifying psoriasis lesion(s), global disease and quality of life: A systematic review

OBJECTIVE

To assess which measures are utilized to quantify lesions, disease severity, and quality of life in the current literature on psoriasis vulgaris.

METHODS

A MEDLINE search was performed with the keyword 'psoriasis' and the following limits 'All Adult: 19+ years', 'published in the last 5 years', 'English', 'Randomized Controlled Trial', and 'Humans'. The 'Methods' section of the individual articles were reviewed for inclusion criteria that described the study participants' state of psoriasis or disease generalization at baseline, methods used to classify or measure psoriasis during the study, the primary and secondary endpoints, and the quality of life measures utilized in each study.

RESULTS

A search resulted in a total of 180 articles, out of which 134 were utilized for the review. The criteria most commonly utilized were 'moderate to severe psoriasis', 'BSA >/=10%', 'mild to moderate psoriasis', and 'severe psoriasis'. PASI was the most commonly used measure to describe the extent of psoriasis. The most common QoL measure used was DLQI, being used in 54.8% of the articles that used some form of QoL measure/s.

DISCUSSION

Various measures are being utilized for the same purpose of generalizing disease/lesion severity and determining 'quality of life'.

Drug-Induced Psoriasis: An Evidence-Based Overview and the Introduction of Psoriatic Drug Eruption Probability Score

Psoriasis is a common skin disorder that needs a long-term management, not only because, of its prevalence but also because of the profound impact it can have on patients quality of life. Drugs may result in exacerbation of a preexisting psoriasis, in induction of psoriatic lesions on clinically uninvolved skin in patients with psoriasis, or in precipitation of the disease in persons without family history of psoriasis or in predisposed individuals. The knowledge of the drugs that may induce, trigger, or exacerbate the disease is of primary importance in clinical practice. By reviewing the literature, there are many reports on drug-induced psoriasis, but the data are not univocal. We propose, when possible, the use of a probability score from the authors to obtain a better classification and further understanding of drug-induced psoriasis.

Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 52-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 2)

BACKGROUND

Ustekinumab, a human monoclonal antibody against interleukins 12 and 23, has shown therapeutic potential for psoriasis. This study assessed the efficacy and safety of ustekinumab in psoriasis patients and assessed dosing intensification in partial responders.

METHODS

In this multicentre, phase III, double-blind, placebo-controlled study, 1230 patients with moderate-to-severe psoriasis (defined by a psoriasis area and severity index [PASI] score > or =12, and at least 10% total body surface area involvement) were randomly assigned to receive ustekinumab 45 mg (n=409) or 90 mg (n=411) at weeks 0 and 4, then every 12 weeks, or placebo (n=410). Partial responders (ie, patients achieving > or =50% but <75% improvement from baseline in PASI) were re-randomised at week 28 to continue dosing every 12 weeks or escalate to dosing every 8 weeks. Both randomisations were done with a minimisation method via a centralised interactive voice response. The primary endpoint was the proportion of patients achieving at least 75% improvement in PASI (PASI 75) at week 12. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00307437.

FINDINGS

All randomised patients were included in the efficacy analysis. 273 (66.7%) patients receiving ustekinumab 45 mg, 311 (75.7%) receiving ustekinumab 90 mg, and 15 (3.7%) receiving placebo achieved the primary endpoint (difference in response rate 63.1%, 95% CI 58.2-68.0, p<0.0001 for the 45 mg group vs placebo and 72.0%, 67.5-76.5, p<0.0001 for the 90 mg group vs placebo). More partial responders at week 28 who received ustekinumab 90 mg every 8 weeks achieved PASI 75 at week 52 than did those who continued to receive the same dose every 12 weeks (22 [68.8%] vs 11 [33.3%]; difference in response rate 35.4%, 95% CI 12.7-58.1, p=0.004). There was no such response to changes in dosing intensity in partial responders treated with ustekinumab 45 mg. During the placebo-controlled phase, 217 (53.1%) patients in the 45 mg group, 197 (47.9%) in the 90 mg group, and 204 (49.8%) in the placebo group experienced adverse events; serious adverse events were seen in eight (2.0%) patients in the 45 mg group, five (1.2%) in the 90 mg group, and eight (2.0%) in the placebo group.

INTERPRETATION

Although treatment with ustekinumab every 12 weeks is effective for most patients with moderate-to-severe psoriasis, intensification of dosing to once every 8 weeks with ustekinumab 90 mg might be necessary to elicit a full response in patients who only partially respond to the initial regimen.

Efficacy and safety of ustekinumab, a human interleukin-12/23 monoclonal antibody, in patients with psoriasis: 76-week results from a randomised, double-blind, placebo-controlled trial (PHOENIX 1)

BACKGROUND

Interleukins 12 and 23 have important roles in the pathophysiology of psoriasis. We assessed ustekinumab, a human monoclonal antibody directed against these cytokines, for the treatment of psoriasis.

METHODS

In this phase III, parallel, double-blind, placebo-controlled study, 766 patients with moderate-to-severe psoriasis were randomly assigned to receive ustekinumab 45 mg (n=255) or 90 mg (n=256) at weeks 0 and 4 and then every 12 weeks; or placebo (n=255) at weeks 0 and 4, with subsequent crossover to ustekinumab at week 12. Patients who were initially randomised to receive ustekinumab at week 0 who achieved long-term response (at least 75% improvement in psoriasis area and severity index [PASI 75] at weeks 28 and 40) were re-randomised at week 40 to maintenance ustekinumab or withdrawal from treatment until loss of response. Both randomisations were done with a minimisation method via a centralised interactive voice response system. The primary endpoint was the proportion of patients achieving PASI 75 at week 12. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00267969.

FINDINGS

All randomised patients were included in the efficacy analysis. 171 (67.1%) patients receiving ustekinumab 45 mg, 170 (66.4%) receiving ustekinumab 90 mg, and eight (3.1%) receiving placebo achieved PASI 75 at week 12 (difference in response rate vs placebo 63.9%, 95% CI 57.8-70.1, p<0.0001 for 45 mg and 63.3%, 57.1-69.4, p<0.0001 for 90 mg). At week 40, long-term response had been achieved by 150 patients in the 45 mg group and 172 patients in the 90 mg group. Of these, 162 patients were randomly assigned to maintenance ustekinumab and 160 to withdrawal. PASI 75 response was better maintained to at least 1 year in those receiving maintenance ustekinumab than in those withdrawn from treatment at week 40 (p<0.0001 by log-rank test). During the placebo-controlled phase, adverse events occurred in 278 (54.5%) of the 510 patients receiving ustekinumab and 123 (48.2%) of the 255 receiving placebo. Serious adverse events occurred in six (1.2%) of 510 patients receiving ustekinumab and in two (0.8%) of 255 receiving placebo in this phase. The pattern of adverse events was much the same in the placebo crossover and randomised withdrawal phases as it was in the placebo-controlled phase.

INTERPRETATION

Ustekinumab seems to be efficacious for the treatment of moderate-to-severe psoriasis; dosing every 12 weeks maintains efficacy for at least a year in most patients.

Efficacy of ISA247 in plaque psoriasis: a randomised, multicentre, double-blind, placebo-controlled phase III study

BACKGROUND

The use of systemic calcineurin inhibitors for the treatment of patients with psoriasis is limited by toxicity, particularly nephrotoxicity. ISA247, a novel inhibitor, was effective and well tolerated in a phase II study of patients with plaque psoriasis. Therefore its efficacy was assessed in this phase III study.

METHODS

451 patients aged 18-65 years with plaque psoriasis involving at least 10% of the body surface area were randomly assigned in equal proportions to receive placebo or ISA247 at 0.2 mg/kg, 0.3 mg/kg, or 0.4 mg/kg orally twice a day in dermatology clinics. The primary endpoint was a 75% reduction in the psoriasis area and severity index (PASI 75) score at week 12. Treatment allocation was concealed from patient and physicians doing the assessments by use of sealed envelopes. The method of analysis was by modified intention to treat. The trial is registered at ClinicalTrials.gov, number NCT00244842.

FINDINGS

107, 113, and 116 patients were assigned to the ISA247 0.2 mg/kg, 0.3 mg/kg, and 0.4 mg/kg groups, respectively, and 115 to the placebo group. At week 12, PASI 75 scores were achieved in the ISA247 0.2 mg/kg, 0.3 mg/kg, and 0.4 mg/kg groups by 14 (16%; 95% CI 9-24) of 105, 26 (25%; 17-24) of 111, and 44 (47%; 27-57) of 113 patients, respectively, and in the placebo group by 4 (4%; 0-8) of 113 patients. Efficacy was maintained during 24 weeks. Mild to moderate glomerular filtration rate reductions were noted in seven patients in the ISA247 0.4 mg/kg group and in one in the ISA247 0.3 mg/kg group. ISA247 blood concentrations showed a strong correlation with mean percentage reduction in PASI.

INTERPRETATION

ISA247 was safe and effective in the treatment of patients with moderate to severe psoriasis during 24 weeks, with the highest dose providing the best efficacy. The strong correlation between ISA247 concentrations and efficacy might allow for accurate dosing of patients compared with existing calcineurin inhibitors.

Vascular endothelial growth factor, vascular endothelial growth factor receptor-3 and cyclooxygenase-2 expression in psoriasis

OBJECTIVE

To investigate expression patterns and relationship of vascular endothelial growth factor (VEGF), vascular endothelial receptor-3 (VEGF-R3) (FLT-4) and cyclooxygenase-2 (COX-2) in psoriasis.

STUDY DESIGN

Forty-three patients were included in this study. The clinical severity of psoriasis was assessed using the psoriasis area and severity index (PASI). Punch biopsy samples both from psoriatic and nonlesional skin were taken and VEGF, VEGF-R3 and COX-2 expressions determined.

RESULTS

VEGF, VEGF-R3 and COX-2 expressions were detected in 90.9%, 78.0% and 86.4% of psoriatic and 84.1%, 71.8%, and 84.1% of nonlesional skin, respectively. Epidermal VEGF, VEGF-R3 and COX-2 expressions were detected in 56.8%, 77.8% and 34.1 of psoriatic and 75%, 78.1% and 65.9% of nonlesional skin, respectively. In dermis, VEGF, VEGF-R3 and COX-2 expression was observed in 88.6%, 77.5% and 84.1% of psoriatic and 81.8%, 64.1% and 77.3% of nonlesional skin, respectively. Among the PASI subgroups no statistically significant differences were detected for VEGF, VEGF-R3 and COX-2 expression.

CONCLUSION

Our study demonstrated that VEGF, VEGF-R3 and COX-2 expression in psoriatic and nonlesional skin is significantly high in epidermis and dermis. Although there was significant concordance between VEGF and VEGF-R3 expressions in psoriatic lesions, there seems to be no concordance between the others.

[Management of severe psoriasis: about 50 cases]

BACKGROUND

With its varied clinical presentation, psoriasis is actually considered as a public health care problem. Severe psoriasis remains difficult to treat.

METHODS

Our study was retrospective involving 50 patient with severe psoriasis treated in the dermatology unit of military hospital of Tunis from January 1990 to December 2003. Aim of our study was to evaluate actual different therapeutic attitudes and new treatments in case of severe psoriasis.

RESULTS

During the 14 years studied the frequency of severe psoriasis was about 19.5%. Extended psoriasis was noticed on 64% of the patients. Arthropatic psoriasis was found on only 6% of the patients. Erythrodermic psoriasis, pustular psoriasis and palmoplantar psoriatic keratoderma were equally noticed in 10% of the patients. PUVA-therapy was firstly prescribed on 96.6% of the patients with extended psoriasis, bettering was noticed on 71% of all them during the 3 first cures. From the 20 patients that have received acitretin, 65% have noticed improvement. Méthotrexate and Re-PUVA was secondarily used (only for the cases of psoriasic arthritis amd méthotrexate) on respectively 18% and 10% of the patients. All our patients reported worsening on thems quality of life.

CONCLUSION

Cyclosporin is more and more used initially in cases of rebellious psoriasis. Actually therapeutic hope leans on biological therapies.

[The treatment of psoriasis: basic principles and new options]

Psoriasis is a frequent chronic disease with a typical cutaneous expression described as erythemato-squamous lesions, and sometimes, joint involvement. This disorder rarely causes death in patients, but often alters their quality of life. A better understanding of the pathophysiology of psoriasis has led to the development of new therapeutic options among which are treatments targeted on blocking T-cell activation. Thanks to these therapies we can offer the patients long lasting remission, albeit not a curative approach. The therapeutic approach towards psoriasis will be selected in a multidisciplinary spirit, and after considering the patient himself, his disease and his lifestyle.

Treatment goals in psoriasis

The introduction of biologics has not only broadened the therapeutic armamentarium for psoriasis but also stimulated discussion about the treatment of this common skin condition. The recently presented German S3 psoriasis guideline contains detailed information on the efficacy of the different products and describes important safety and practical aspects of psoriasis treatments. Patient surveys and recent studies in Germany indicate a relatively high mean severity of skin symptoms and low quality of life among affected patients. One possible explanation is that the conventional traditional and new treatment options are not being used consistently. In this paper, minimum treatment goals for psoriasis that should be achieved by an individually selected treatment regimen are presented. If, after a defined period of time, an at least 50 % reduction of the baseline Psoriasis Area and Severity Index (PASI) and a Dermatology Life Quality Index of ( not less-than 5 is not reached, patients should be switched to another therapy, after a balanced discussion. Whenever necessary, a continuous maintenance therapy should be instituted with special attention to these goals. Patients should carefully be monitored for the presence of psoriatic arthritis and comorbidities because these may need to be integrated in the planning of treatment goals on an interdisciplinary basis.

Three retinoid X receptor gene polymorphisms in plaque psoriasis and psoriasis guttata

AIM

Polymorphisms in retinoid X receptors (RXRs) are very interesting from the point of view of a possible association of their variability with psoriasis.

METHODS

A total of 293 patients with plaque psoriasis, 82 patients with psoriasis guttata and 202 control subjects were enrolled in this study focused on 3 polymorphisms in RXRA and RXRB gene associations.

RESULTS

A marginally significant increase in AA allelic frequency of the RXRA A39526AA polymorphism in plaque psoriatic men compared to healthy men was proved. In women with psoriasis guttata, the higher risk for genotypes AA and TT in the RXRB 3'+140A/T polymorphism compared to healthy women was identified (p(corr) = 0.01). The genotypes A/A and AA/AA are more frequent in plaque psoriasis patients with a positive family history of psoriasis compared to the patients with a negative family history of psoriasis (p(corr) = 0.02). The A/A genotype is more frequent in patients with plaque psoriasis and repeated tonsillitis/tonsillectomy (p = 0.02). In the RXRB polymorphism, no genotype TT is observed in patients with psoriasis guttata with a positive personal history of repeated tonsillitis (p(corr) = 0.001).

CONCLUSION

Individual gene characteristics of patients with psoriasis improve the possibilities of pharmacotherapy using pharmacogenomic approaches which could be further stratified in future according to the subtypes of psoriasis.

Erythema-anulare-centrifugum-artige Psoriasis cum pustulatione

Erythema annulare centrifugum-type psoriasis with pustules represents a subtype of psoriasis pustulosa generalisata von Zumbusch. It presents with a typical morphology characterized by a lack of classical erythematosquamous skin lesions during its acute eruption phase. Diagnosis is usually established on the basis of clinical presentation and dermatopathology, which often shows a substrate typical for psoriasis, sometimes with spongiform pustules.

An attempt to formulate an evidence-based strategy in the management of moderate-to-severe psoriasis: a review of the efficacy and safety of biologics and prebiologic options

Psoriasis is a chronic skin disorder affecting up to 2.5% of the world's population. Despite the myriad treatment options available, there is no uniformly accepted therapeutic approach for moderate-to-severe psoriasis. The objective of this review is to evaluate the relative efficacy and safety of available therapeutic options and to formulate general recommendations for the treatment of moderate-to-severe psoriasis. MEDLINE and Evidence Based Medicine (Cochrane) were used to perform a comprehensive search of the literature from 1986 to 2006. The most scientifically rigorous clinical trial published in the literature was selected for Psoriasis Area and Severity Index (PASI 75) comparison. Only information from clinical trials, human subjects and English language journals are reported in this study. The percentage of PASI 75 reduction at approximately 12 weeks obtained by the following treatment options were: Goeckerman and RePUVA, 100%; calcipotriene plus PUVA, 87%; ciclosporin, 78.2-80.3%; infliximab, 80%; adalimumab 40 mg every other week, 53% and 40 mg/week, 80%; PUVA, 63%; methotrexate, 60%; NB-UVB, 55%; acitretin 52%; etanercept 50 mg twice weekly, 49% and 25 mg twice weekly, 34%; efalizumab, 31.4%; and alefacept 21%. Psoriatic treatments with safer profiles compared with other agents include bath PUVA, Goeckerman and RePUVA. Based on the literature review of efficacy and safety of biologics and prebiologic treatment options for moderate-to-severe psoriasis, the risk:benefit ratio seems most favorable for Goeckerman and RePUVA, followed by either etanercept or adalimumab.

Costs and quality of life in patients with moderate to severe plaque-type psoriasis in Germany: A multi-center study

BACKGROUND

This study evaluated costs, disease severity and health-related quality of life (QoL) in patients with moderate to severe plaque-type psoriasis.

PATIENTS AND METHODS

Patients with a 'psoriasis area and severity index' (PASI) > 12 and/or a body surface area (BSA) > 10 were enrolled in dermatological practices and hospital outpatient departments (n = 184) and the total costs of illness generated during the last 12 months were retrospectively calculated. QoL was assessed using the SF-36 and the DLQI. Participants were stratified into three subgroups according to the treatment received during the 1 year documentation period; a) patients without and b) patients with phototherapy or standard systemic therapy, and c) patients who had failed, were intolerant or had contraindications to at least two standard systemic therapies. The study was performed before biologics became available for the treatment of psoriasis in Germany.

RESULTS

Included patients had severe skin symptoms (mean PASI 18.2) and a highly impaired QoL (mean DLQI 10.6). Total annual costs amounted to euro 6,709. Patients belonging to subgroup C had the most severe skin symptoms (mean PASI 22.2), the lowest QoL (mean DLQI 12.6), the highest hospitalization rate and largest loss of productivity. These patients produced the highest total costs of 8.831 euro/y.

CONCLUSIONS

Patients who cannot (or can no longer) be adequately managed with standard treatments are characterized by high disease activity, high costs and reduced QoL. Improved treatment options particularly for these patients are medically necessary and appear economically sensible.

National Psoriasis Foundation clinical consensus on disease severity

OBJECTIVES

A task force of the National Psoriasis Foundation Medical Board was convened to evaluate the current severity criteria of mild, moderate, and severe psoriasis and to make recommendations concerning a 2-tiered categorization of severity based on current clinical practice and related to intent to treat.

PARTICIPANTS

This volunteer task force, led by David M. Pariser, MD, included Jerry Bagel, MD, Joel M. Gelfand, MD, MSCE, Neil J. Korman, MD, PhD, Christopher T. Ritchlin, MD, Bruce E. Strober, MD, PhD, Abby S. Van Voorhees, MD, and Melodie Young, MSN, RN, ANP. Meetings were held by teleconference and were coordinated and funded by the National Psoriasis Foundation.

EVIDENCE

This task force reviewed psoriasis severity criteria and other published psoriasis consensus statements. Current standards of care and expert opinion were used to inform the process.

CONSENSUS PROCESS

Based on meetings of the task force and under the guidance of David M. Pariser, MD, a statement was drafted by Elizabeth J. Horn, PhD, presented to the task force, and reviewed and approved by the task force. This statement was then reviewed and approved by Robert E. Kalb, MD, Gerald G. Krueger, MD, and Alan Menter, MD. The National Psoriasis Foundation Medical Board reviewed and endorsed this statement by a majority vote on March 2, 2006, at the medical board meeting.

CONCLUSIONS

This clinical consensus statement proposes a 2-tiered system for plaque psoriasis therapy that reflects more accurately than the current system how patients are treated in clinical practice. This statement, focused on plaque psoriasis, is intended to assist medical professionals and insurance payers in understanding these 2 categories of patients with psoriasis and choosing appropriate therapies for these patients.

A classification of psoriasis vulgaris according to phenotype

For nearly 200 years it has been appreciated that plaque psoriasis consists of a number of distinct clinical phenotypes. However, a reliable and simple stratification of clinical presentation of psoriasis is lacking. In the era of immunogenetic association studies and an advanced understanding of the pathomechanisms of psoriasis it is important that a classification of the disease according to phenotype is readily available. Such a classification would facilitate clinically relevant interpretation of investigational data. A meeting of the International Psoriasis Council produced a consensus on clinical phenotypes of psoriasis equally relevant to clinical practitioners and psoriasis researchers.

Incidence of infection during efalizumab therapy for psoriasis: analysis of the clinical trial experience

BACKGROUND

Because many therapies for psoriasis disrupt the normal inflammatory cascade and could theoretically impair the body's ability to respond to external pathogens, a possible increase in the incidence of infection is a concern with any new psoriasis therapy that affects the immune system. Efalizumab is a biologic therapy targeted to inhibit T cells. Its efficacy has been shown in clinical trials encompassing >3500 patients with psoriasis.

OBJECTIVES

The aims of this article were to review the incidence of infection observed in efalizumab-treated patients during 12-week, Phase III clinical trials, compare the incidence rate with that in patients receiving placebo, and evaluate the incidence of infection observed in patients with extended (>12-week) efalizumab use.

METHODS

Adverse events (AEs) of infection were tabulated from a pooled data set of 2335 patients enrolled to receive 12 weeks of subcutaneous (SC) efalizumab 1 or 2 mg/kg . wk or placebo in 4 randomized, double-blind, placebo-controlled, Phase III efalizumab clinical studies. The incidence of infection was further evaluated using pooled data from 1115 patients who received up to 24 weeks of efalizumab therapy during 5 clinical trials with treatment extension arms and from 170 patients who received up to 108 weeks (27 months) of continuous therapy in an open-label, Phase III efalizumab trial of 36 months' total duration.

RESULTS

The incidence and severity of AEs of infection during 12 weeks of efalizumab therapy were comparable to those observed in patients receiving placebo (overall, 28.6% vs 26.3%). Infections did not appear to increase with extended therapy of up to 27 months. Serious infections requiring hospitalization occurred in 1.1% of efalizumab-treated patients.

CONCLUSION

The present review of the available Phase III clinical trial suggests that efalizumab is not associated with an increased risk for infection in patients receiving initial or long-term (27-month) treatment for moderate to severe chronic plaque psoriasis.

Generalized pustular psoriasis (Zumbusch): a French epidemiological survey

A retrospective epidemiological survey of generalized pustular psoriasis (GPP) was carried out in France in 2005. 121 dermatological wards received a questionnaire concerning the patients treated in 2004. It related to demographic data, morbidity, mortality, failures and the therapeutic practices of each ward. CNAMTS, the main French health insurance, was also questioned about its registry concerning GPP.112 wards (92.5%) answered the questionnaire, totalling 99 cases (sex ratio male/female: 0.77, mean age 52.5 years +/- 18), which were handled by 46 wards. Incidence and prevalence were estimated in 2004 at a minimum of 0.64 and 1.76/million respectively. Incidence deduced from the CNAMTS data in 1998 and 2001 was similar. The treatment habits were the same in the 46 wards, which used acitretin as first line treatment (89%), followed by methotrexate (8%). High potency dermatocorticosteroids (DC) were most often used (87%). Complications and death were noted in 17% and 2% of the cases respectively, recalcitrant GPP in 42%. Immunobiologics were required in 13% of patients. Univariate analysis showed that treatment failure was related to: i) management in a university ward (OR: 2.9, p = 0.03) probably reflecting the management of the more severe cases ii) prescription of high or very high potency DC as first line local therapy (OR: 7.6, p = 0.05) iii) therapies other than retinoids as first line systemic therapy (OR: 5.5, p = 0.04). The systemic treatment is well codified but future studies will have to confirm the usefulness of DC in the management of GPP.

Etanercept and efalizumab for the treatment of psoriasis: a systematic review

OBJECTIVES

To evaluate the clinical effectiveness, safety, tolerability and cost-effectiveness of etanercept and efalizumab for the treatment of moderate to severe chronic plaque psoriasis.

DATA SOURCES

Major electronic databases and several Internet resources were searched up to April 2004.

REVIEW METHODS

Systematic reviews were undertaken of the efficacy, safety and economic reviews of etanercept and efalizumab. An existing systematic review of the efficacy and safety of other treatments was also updated. Economic models supplied by the manufacturers of etanercept and efalizumab were critiqued. An economic model was then developed of etanercept and efalizumab in the treatment of moderate to severe chronic plaque psoriasis.

RESULTS

The review of the clinical evidence identified a total of 39 published and three unpublished studies: eight randomised controlled trials (RCTs) of the efficacy of etanercept (three trials) and efalizumab (five); 10 studies of the adverse effects of the interventions; and 24 RCTs of the efficacy of the other treatments for moderate to severe psoriasis. The trials of the efficacy of the interventions were all double-blind and placebo-controlled trials and generally of good quality, but three of the five efalizumab trials were poorly reported. A total of 1347 patients were included in the etanercept trials and 2963 in the efalizumab trials. Data on the efficacy of etanercept 25 mg twice a week for 12 weeks were available from three RCTs. On average, active treatment resulted in 62% of patients achieving a Psoriasis Area and Severity Index (PASI) 50, 33% achieving a PASI 75, 11% achieving a PASI 90 and 40% were assessed as clear or almost clear. These figures are not adjusted for changes relative to placebo. Improvement in quality of life as assessed by mean percentage change in Dermatology Life Quality Index (DLQI) was around 59% with etanercept 25 mg twice a week compared with 9% with placebo, and all mean differences that could be calculated were statistically significantly in favour of etanercept. Data on the efficacy of etanercept 50 mg twice a week for 12 weeks were available from two RCTs. Across the two trials, the proportion of patients achieving PASI 50, 75 and 90 was 76, 49 and 21%, respectively; the pooled relative risks were all statistically significantly in favour of etanercept. The findings for mean PASI after treatment, mean percentage change in PASI from baseline and mean percentage change in DLQI also demonstrated the efficacy of etanercept treatment. Evidence from one RCT indicates that the response to etanercept is maintained post-treatment, at least in the medium term, and data from uncontrolled follow-up phases reflect and extend these findings. Efalizumab at a dose of 1 mg/kg once a week subcutaneously was studied in five RCTs. Across these trials, 12 weeks of active treatment resulted in an average of 55% of patients achieving PASI 50, 27% PASI 75, 4.3% PASI 90 and 27% clear or minimal psoriasis status. These figures are not adjusted for changes relative to placebo. There is no evidence from RCTs that the response to efalizumab 1 mg/kg once a week is maintained when treatment continues beyond 12 weeks, and long-term follow-up data relate to a range of doses and are poorly reported and so cannot be used to draw even tentative conclusions regarding the long-term efficacy of efalizumab. Uncontrolled data from trial follow-up suggest that time to relapse may be around 60 days. No data indicating the existence or absence of any rebound in psoriasis after discontinuation of efalizumab were identified. There is no evidence relating to the efficacy of efalizumab upon retreatment. A mixed treatment comparison analysis found a higher response rate in terms of PASI 50, 75 and 90 with etanercept than with efalizumab. Injection site reactions appear to be the most common adverse effects of etanercept. Overall, etanercept appears to be well tolerated in short- and long-term use, although many of the long-term data are not from patients with psoriasis. Headache, chills and, to a lesser extent, nausea, myalgia, pain and fever are the common adverse events associated with efalizumab. Overall, withdrawal rates due to adverse events are low. Longer term data for efalizumab are not readily available for evaluation, but the adverse events data up to 3 years appear to reflect those over 12 weeks and to remain stable. Unfortunately, few data for serious infections and serious adverse events with efalizumab are available. For the primary analysis comparing etanercept, efalizumab and supportive care, the results of the York Model suggest that the biological therapies would only be cost-effective for all patients with moderate to severe psoriasis if the NHS were willing to pay over pound 60,000 per QALY gained. In patients with poor baseline quality of life (fourth quartile DLQI), efalizumab, etanercept 25 mg (intermittent), etanercept 25 mg (continuous) and etanercept 50 mg (intermittent) would be cost-effective as part of a treatment sequence if the NHS were willing to pay pound 45,000, pound 35,000, pound 45,000 and pound 65,000 per QALY gained, respectively. In patients who are also at high risk of inpatient hospitalisation (21 days per annum), these therapies would be cost-effective as part of a sequence as long as the NHS were willingness to pay pound 25,000, pound 20,000, pound 25,000 and pound 45,000 per QALY gained, respectively. As part of a secondary analysis including a wider range of systemic therapies as comparators, the York Model found that it would only be cost-effective to use etanercept and efalizumab in a sequence after methotrexate, ciclosporin and Fumaderm.

CONCLUSIONS

Clinical trial data indicate that both etanercept and efalizumab are efficacious in patients who are eligible for systemic therapy, but the economic evaluation demonstrates that these biological therapies are likely to be cost-effective only in patients with poor baseline QoL and who are at risk of hospitalisation. Efficacy trials conducted in the specific population for which etanercept and efalizumab are licensed are required, as are long-term comparisons of etanercept and efalizumab with other treatments for moderate to severe psoriasis. Long-term efficacy trials and safety/tolerability data for patients treated with etanercept or efalizumab are required, as are trials on the response of specific subtypes of psoriasis to different drugs. Research on the rate of inpatient hospitalisation in patients with moderate to severe psoriasis is warranted, and the effect of treatment on this rate.

[Efalizumab--therapy of moderately severe to severe plaque-psoriasis in the dermatologist's practice]

Psoriasis is a chronic immune-mediated skin disease with highly variable patterns of presentation, both between patients and in individuals over time. Its course can be influenced by various triggers. Since there is no cure for psoriasis, patients with moderate-to-severe plaque-type psoriasis often require lifelong therapy to control their disease. Traditional approaches such as cyclosporine or methotrexate are problematic for long-term use because of organ toxicity, other side effects, drug interactions and a loss of efficacy over time. Efalizumab is a recombinant monoclonal IgG1-antibody, approved in Germany for the management of moderate-to-severe plaque-type psoriasis. Its efficacy and safety have been demonstrated in clinical trials with thousands of patients,especially with regard to long-term therapy. Therefore, a change of paradigm from the traditional therapy of inflammatory episodes to continuous control of psoriasis seems possible. This supplement deals with practical aspects of using efalizumab in the outpatient setting.