Treatment of Psoriasis Vulgaris with Calcipotriol Betamethasone Dipropionate Combination Followed by Calcipotriol and Assessment of the Adjuvant Basic Use of Urea-Based Emollients

A new combination product containing betamethasone dipropionate and calcipotriol (Dovobet® ointment) has been proven very effective and well tolerated in patients with psoriasis vulgaris. Emollients are adjunctive modalities commonly used in psoriasis; however, their actual role in combination with topical drugs as well as well as their compatibility with these drugs have not been well elucidated. In 313 adult patients with psoriasis vulgaris, we studied the efficacy and tolerability of treatment with Dovobet® ointment combined with urea-based emollients (Excipial U®) for 4 weeks, followed by treatment with calcipotriol (Daivonex®) either alone (group A) or combined with urea-containing emollients (Excipial U®, group B) for 8 weeks. Clinical evaluations were performed at baseline, at 4 and 12 weeks, assessing the clinical score for erythema, scaling, infiltration and pruritus, graded on the basis of a 5-point scale. After the initial 4-week treatment, a significant improvement of all clinical parameters was observed (p<0.05). Overall, clinical results improved further during the maintenance treatment phase; significant changes (p<0.05) were observed in each group. Most patients considered treatment efficacy positively at both 4 weeks and 12 weeks. Interestingly, at the end of the study, a greater percentage of patients in group B than in group A judged the efficacy as excellent. Treatment was very well tolerated. Only two patients complained of mild and transient burning sensation during the first days of treatment. The results of this study confirm the great efficacy and tolerability of sequential treatment with Dovobet®, and Daivonex® in psoriasis vulgaris and show the enhanced acceptability of this treatment associated with urea-based emollients.

Re-Induction as a Possible Alternative Modality of Dose Escalation of Infliximab: A Prospective Evaluation in a Small Series of Psoriatic Patients

Infliximab is an anti-tumour necrosis factor-alpha chimeric monoclonal antibody which is highly effective in psoriasis, as well as in other indications. In clinical practice, some patients may require dose escalation to overcome a reduction of the extent and/or duration of response during regular maintenance treatment, possibly due to the loss of stable serum concentrations of the drug. Common strategies of dose escalation are the increase of dose per infusion and the decrease of interval between infusions. Here we report the results of re-induction therapy with infliximab used as a dose escalation strategy in 9 patients whose psoriasis relapsed during maintenance treatment with infliximab 5 mg/kg every 8 weeks. Re-induction was well tolerated and capable of restoring response in 8 of these patients.

Health-related quality of life in psoriasis: an analysis of Psocare project patients

AIM

Psoriasis is a common, chronic, immune-mediated skin disorder that may be complicated by psoriatic arthritis in up to one-third of patients. Psoriasis treatments are increasingly effective, yet more expensive, thus requiring rational decision-making on interventional priorities. The ability to perform cost-utility analyses is hindered by the lack of algorithms that allow the inference of utility measures, like QALY, from specific dermatological health-related quality-of-life (HR-QoL) measures (e.g. Dermatology Life Quality Index [DLQI]). This study aimed to assess whether psoriasis-related HR-QoL data (DLQI) could be used to obtain utility measures for use in economic analyses.

METHODS

Psoriasis patients attending 11 Italian Psocare project treatment centers over a 19-day period were enrolled and completed a questionnaire, including several HR-QoL scales and sociodemographic/clinical data, and underwent a clinical examination. Data were subjected to a Multiple Correspondence Analysis and multiple regression analysis to determine the contribution of single items to the HR-QoL.

RESULTS

DLQI and Psychological General Well-Being Index (PGWBI) scores were most closely correlated with the EuroQol health status index. Age and gender were considered confounding factors, while pain and arthritis contributed significantly to HR-QoL deterioration. For disease severity, the need for hospitalization and the number of examinations, but not the Psoriasis Area Severity Index (PASI), contributed to HR-QoL deterioration.

CONCLUSION

Recent historical clinical and HR-QoL data from psoriasis patients can reproducibly define a health status index, such as the EuroQol SD-5Q, that could be used reliably to estimate QALYs for use in cost-utility analyses to compare the cost-benefit profiles of competing therapies.

C-reactive protein and markers for thrombophilia in patients with chronic plaque psoriasis

Chronic plaque psoriasis is associated to an increased risk of cardiovascular events. The aim of our study is to test patients with psoriasis for common markers of acquired and inherited thrombophilia. A cross-sectional study on 172 patients with psoriasis and 198 controls was carried out. The plasma levels of coagulation protein C, coagulation protein S, homocysteine, folic acid, C-reactive protein (CRP) and fibrinogen as well as activated protein C resistance and antithrombin III activity, were measured. CRP and homocysteine levels were higher in patients with psoriasis than in controls (5.9 ± 7.1 vs 3.1 ± 2.4 mg/L, p=0.0003 and 16.3 ± 12.8 vs 10.4 ± 4.6 umol/L, p=0.0001; mean ± SD) whereas folic acid was lower in psoriatic patients compared to controls (4.3 ± 7.2 vs 12.6 ± 7.9 p=0.006). Levels of coagulation protein C, coagulation protein S, fibrinogen as well as activated protein C resistance, antithrombin III activity were within normal ranges both in cases and controls. In a multivariate regression analysis, psoriasis severity was an independent predictor of higher CRP. In conclusion, high levels of serum CRP and homocysteine were found in patients with psoriasis, related to the severity of the disease. These data suggest that the increased risk of thrombotic cardiovascular events observed in psoriasis patients should be ascribed to an acquired rather than inherited thrombophilic status.

A Multicenter Open-Label Experience on the Response of Psoriasis to Adalimumab and Effect of Dose Escalation in Non-Responders: The Aphrodite Project

There is much evidence to show the efficacy of adalimumab, a human monoclonal antibody targeting tumour necrosis factor-alpha, in the treatment of plaque psoriasis. In this open-label experience, 147 high-need patients suffering from plaque psoriasis, with a mean Psoriasis Area and Severity Index (PASI) of 18.8, and concomitant psoriatic arthritis (PsA) received subcutaneous injections of 40 mg of adalimumab every other week (EOW). This was actually the dosage regimen recommended for PsA, as the drug had not then been approved for psoriasis at the time of the patients' enrolment. At week 12, an improvement of at least 50% of the PASI (PASI-50) was observed in 111 (77%) patients. Continuation of treatment in responders with adalimumab 40 mg EOW led to a sustained response, with the PASI-50 achieved by 97% of patients in the as-treated analysis at week 24 (PASI-75 in 82% and PASI-90 in 45% out of 109 patients who received EOW injections up to week 24). Thirty subjects who failed to attain the PASI-50 response at week 12 were treated with adalimumab 40 mg every week for a further 12 weeks. At week 24, 80% of these patients obtained a PASI-50 response after dose escalation. Tolerability was good in the majority of patients. Only two patients discontinued treatment because of an adverse event (repeated flu-like episodes and a pleuropericarditis of unknown origin, respectively).

308 nm monochromatic excimer light in dermatology: personal experience and review of the literature

For over five years, we have been using a new ultraviolet B ray source, a Xenon-Chloride lamp emitting non-coherent, monochromatic 308-nm light that represents the natural evolution of the excimer laser. A source of monochromatic excimer light (MEL) produces 50 mW/cm(2) power density at a distance of 15 cm from the source and has a maximum irradiating area of 504 cm(2), this feature representing the greatest therapeutic advantage offered by 308 nm sources. On the other hand, the benefits offered by the MEL compared to traditional phototherapies are essentially correlated to the fact that there is no need to administer oral psoralens (PUVA therapy) and that sessions need to be repeated only every 7-15 days, an important condition for the improvement of the patient's quality of life (since at least 2-3 weekly sessions are required with the traditional UVB therapy). Using MEL, UV B light can be applied on the entire body, with partial subintrant skin irradiations, or on one or just a few individual patches, taking care to accurately protect the healthy surrounding skin and allowing for a phototherapy exclusively targeted onto the lesion to be treated. Clinical indications and the reasons for choosing MEL for the treatment of photosensitive skin disorders are virtually identical to those stated for PUVA therapy or narrowband UV B light. Due to the absence of photosensitizing substances and drug-induced toxicity, patients who work in the open air, pregnant women and patients suffering from liver or kidney failure can also be treated. Furthermore, the short time required for sessions, the duration of cycles and the selective exposure of the skin areas to be treated undoubtedly represent significant benefits for patients in terms of safety and efficacy. In addition to psoriasis, the use of MEL can also be extended to other pathologies such as vitiligo, alopecia areata, atopic dermatitis and patch-stage IA mycosis fungoides with encouraging

Influence of body mass index, comorbidities and prior systemic therapies on the response of psoriasis to adalimumab: an exploratory analysis from the APHRODITE data

Adalimumab is a fully human monoclonal antibody directed against tumor necrosis factor (TNF)-alpha, which is effective for the treatment of psoriasis and psoriatic arthritis (PsA). The aim of this study is to determine whether the response of psoriasis to adalimumab treatment might be influenced by certain particular factors, such as body mass index (BMI), history of biologic therapy, blood hypertension and metabolic comorbidities. For this reason, an exploratory analysis was conducted on 144 patients with psoriasis and concomitant PsA treated with adalimumab 40 mg every other week, evaluating the influence of such factors on the Psoriasis Area and Severity Index (PASI) response rate at week 12. Our preliminary results suggest that the response rate at week 12, in terms of both PASI-50 and PASI-75, appeared to be independent of the presence of hypertension and/or metabolic comorbidities. The PASI-50 response was observed more frequently in patients with BMI less than 30 as compared to obese patients (79% vs 58%, p = 0.02). Previous use of anti-TNF biologics did not appear to affect per se the rate of responders, although it was associated with a lower PASI-75 rate among responders.

[Comparative evaluation of fluconazole 50 mg and 100 mg versus itraconazole 100 mg in the treatment of dermatomycoses]

In the above double-blind multicenter study the efficacy and tolerability of 50 and 100 mg doses of fluconazole were compared with 100 mg itraconazole in 178 patients with T. corporis, T. cruris, and T. pedis infections. All patients were submitted to clinical and mycological examination before starting, at weekly intervals during treatment, and 4 and 8 weeks after its conclusion. Duration of the three therapeutic regimes was 15 days for T. corporis and T. cruris, and 30 days for T. pedis infection. The percentage of symptomatic cure was 85% and 86.5%, respectively for 50 and 100 mg fluconazole, and 83% for itraconazole. Mycologic cure was achieved in 81.4% of patients treated with 50 mg fluconazole, 83.3% in those treated with 100 mg fluconazole, and 67.9% in those treated with 100 mg itraconazole. None of the groups showed changes in laboratory parameters. It is concluded that all three treatment schemes had high antimycotic activity, but fluconazole both 50 and 100 mg daily was superior. Both drugs were well tolerated and compliance was good.