Immunogenicity, efficacy, and safety of CoronaVac and Pfizer/BioNTech mRNA vaccines in patients with psoriasis receiving systemic therapies: A prospective cohort study

BACKGROUND AND OBJECTIVES

Evidence of immune response to COVID-19 vaccine in psoriasis patients on biological agents is lacking. This study aimed to evaluate SARS-CoV-2 antibody levels following vaccination with CoronaVac or Pfizer/BioNTech mRNA in patients using biological agents or methotrexate, high-titer antibody levels achievement rate, and impact of medications on immunogenicity.

METHODS

This noninterventional, prospective cohort study included 89 patients and 40 controls vaccinated with two doses of inactivated (CoronaVac) or Pfizer/BioNTech mRNA vaccines. Anti-spike and neutralising antibodies were analysed before and three to six weeks after the second dose. Adverse effects and symptomatic COVID-19 were assessed.

RESULTS

Median anti-spike and neutralising antibody titers after CoronaVac were significantly lower in patients than controls (57.92 U/mL vs 125.4 U/mL, and 1/6 vs 1/32, respectively, p < 0.05). Patients were less likely to achieve high-titer anti-spike antibody levels (25.6 % vs 50 %). Infliximab was associated with attenuated vaccine response. Pfizer/BioNTech vaccine induced comparable median anti-spike (2,080 U/mL vs 2,976.5 U/mL,) and neutralising antibody levels (1/96 vs 1/160) in patients and controls, respectively (p > 0.05). High-titer anti-spike and neutralising antibodies development rates were comparable among patients and controls (95.2 % vs 100 %, and 30.4 % vs 50.0 %, respectively, p > 0.05). Nine (10.1 %) COVID-19 cases- all mild - were identified. Psoriasis flare was seen in 6.74 %, mostly after Pfizer/BioNTech vaccine.

CONCLUSION

Psoriasis patients treated with biological agents and methotrexate developed similar response to mRNA vaccine but weaker response to inactivated vaccine. Infliximab reduced response to the inactivated vaccine. Adverse effects were more frequent with mRNA vaccine, but none was severe.

Treatment approaches in immunosuppressed patients with advanced cutaneous squamous cell carcinoma

Immunosuppression, both iatrogenic and disease-related, is associated with a greatly increased incidence of cutaneous SCC (cSCC) and with aggressive cSCC and worse disease outcomes. Consequently, rapid access to skin cancer services and prudent surgical choices, such as circumferential margin assessment, is essential when treating advanced cSCC in an immunosuppressed patient. For high-risk cancers and control of cSCC multiplicity, additional strategies should be actively considered within the multidisciplinary clinical care team. These include minimization or revision of immunosuppressive medications, systemic chemoprevention (including retinoids, nicotinamide, capecitabine) and adjuvant therapies such as radiotherapy. Unfortunately, there is a relative paucity of good evidence for many of these treatments in the immunosuppressed. Systemic treatments for metastatic cSCC are often contraindicated in organ transplant recipients, notably checkpoint inhibitor immunotherapy. There are also toxicity concerns with some conventional chemotherapies and EGFR inhibitors. Until recently, clinical trials have largely excluded immunosuppressed individuals. Development of more effective treatment for advanced cSCC in this high-risk group and prospective clinical trials are now research priorities.

Psoriasis and the liver: problems, causes and course

BACKGROUND/OBJECTIVES

Psoriasis patients have a higher risk of liver abnormalities such as non-alcoholic fatty liver disease (NAFLD), drug-induced hepatitis, alcoholic hepatitis and neutrophilic cholangitis, than the general population. Associated liver disease limits therapeutic options and necessitates careful monitoring. The aim of the study was to identify liver problems in psoriasis patients and to investigate the underlying causes as well as their course.

METHODS

The files of 518 psoriasis patients were retrospectively reviewed. Among these, 393 patients with relevant laboratory data were analysed for liver enzymes and their relation to the known risk factors for liver disease (obesity, diabetes mellitus, alcohol consumption, hepatotoxic medications, dyslipidemia, psoriatic arthritis and infectious hepatitis).

RESULTS

Among 393 patients, 24% and 0.8% developed liver enzyme abnormalities and cirrhosis, respectively. The most common factors associated with pathological liver enzymes were drugs (57%) and NAFLD (22%). Other rare causes were alcoholic hepatitis, viral hepatitis, neutrophilic cholangitis, autoimmune hepatitis and toxic hepatitis due to herbal therapy. Drug-induced liver enzyme abnormalities were reversible whereas in patients with NAFLD transaminases tended to fluctuate. One patient with herbal medicine-related cirrhosis died of sepsis.

CONCLUSION

Liver enzyme abnormalities are common in psoriasis patients and are mostly associated with drugs and NAFLD. Although most cases can be managed by avoiding hepatotoxic medications and close follow up, severe consequences like cirrhosis may develop.

Growth arrest-specific 6 and cardiometabolic risk factors in patients with psoriasis

OBJECTIVES

An increased risk for cardiovascular disease with psoriasis has been reported. Growth Arrest-Specific 6 (GAS6) amplifies pro-inflammatory endothelial cell activation via TAM receptors. However, it also inhibits inflammation by multiple mechanisms including phagocytosis. The objective of this study was to investigate whether plasma GAS6 levels are associated with conventional cardiometabolic (CM) risk factors in patients with psoriasis.

METHODS

Forty patients diagnosed with psoriasis (22 male, mean age: 43.3 ± 13.8 years) and 40 age-/sex-matched healthy controls (22 male, mean age: 39.3 ± 8.9 years) were included in the study. CM risk factors (hypertension, hyperlipidemia, diabetes mellitus, and cigarette smoking) were identified. GAS6 levels were measured by ELISA.

RESULTS

There were no significant differences between the plasma GAS6 levels of patients with psoriasis compared to the control group (6.6 ± 2.0 ng/mL, 7.6 ± 2.8 ng/mL, respectively, P > 0.05). However, GAS6 levels of patients with psoriasis having a smoking history (n = 11) were significantly lower than both patients with psoriasis who had no smoking history (n = 29) and controls (5.5 ± 1.7 ng/mL, 6.9 ± 1.9 ng/mL, 7.6 ± 2.8 ng/mL, respectively, P < 0.05). Similarly, psoriasis patients with at least one CM risk factor showed lower GAS6 levels compared to subjects without any CM risk factor (5.7 ± 1.7 ng/mL, 7.3 ± 2.0 ng/mL, P < 0.01). There was no correlation between the GAS6 level, disease duration or PASI score (r = 0.150, -0.150, and P = 0.310, 0.398, respectively).

CONCLUSIONS

This pilot study provides the first evidence in humans for an association between low plasma GAS6 levels and conventional risk factors in psoriasis. Further large scale, prospective studies are needed to confirm these results.

Erlotinib induced ectropion following papulopustular rash

BACKGROUND

Erlotinib is a targeted anti-cancer drug which acts through the inhibition of epidermal growth factor receptor (EGFR).

MAIN OBSERVATIONS

A 79-year-old developed bilateral ectropion after he received erlotinib treatment for lung adenocarcinoma. The ectropion completely resolved with symptomatic treatment without any modification in erlotinib therapy.

CONCLUSIONS

EGFR inhibitors are frequently associated with a variety of mucocutaneous adverse events. Ocular toxicity associated with these agents has been reported rarely. We present this case to underline the importance of recognition of newly reported cutaneous and ocular adverse events of targeted therapies.

The risk of tuberculosis in patients with psoriasis treated with anti-tumor necrosis factor agents

BACKGROUND

Tumor necrosis factor-alpha (TNF-α) antagonist treatment is associated with 1.6 to 27 times higher risk of tuberculosis (TB).

OBJECTIVE

To find TB incidence of psoriasis patients treated with TNF- α antagonists and define risk factors related with this condition in a country with moderately high risk of TB.

METHODS

Three hundred seventy psoriasis patients treated by anti-TNF agents in four referral centers were included. The data on the characteristics of the patients, TB history, tuberculosis skin test results, anti-TNF agent type and exposure time, localization of TB, and isoniazide prophylaxis state were analyzed.

RESULTS

Four patients (1.08%) developed TB, three pulmonary and one gastrointestinal, 2-23 months after initiating anti-TNF agents. Other than the patient with gastrointestinal TB, who was using methotrexate and corticosteroid concomitantly, none had contributing risk factors for TB. Two patients developed pulmonary TB in spite of chemoprophylaxis. Three patients with pulmonary TB completely recovered following antiTB treatment whereas patients with gastroinrestinal TB developed renal failure.

LIMITATIONS

The major limitation of the study is the lack of a diseased control group, which enables us to compare the risk of psoriatics with that of patients having other inflammatory diseases.

CONCLUSION

Tuberculosis is a rare but a severe complication of anti-TNF treatment and may develop in spite of chemoprophylaxis. The risk of TB in psoriasis patients in the present study is comparable to literature mostly based on rheumatology patients.

Assessment of arterial stiffness and cardiovascular hemodynamics by oscillometric method in psoriasis patients with normal cardiac functions

Arterial stiffness is associated with increased cardiovascular risk. Pulse wave velocity (PWV) and augmentation index (AIx) are non-invasive markers for assessment of arterial stiffness. Increased arterial stiffness is associated with atherosclerosis in patients with psoriasis. Previous studies have shown that high neutrophil-to-lymphocyte ratio (NLR) predicts poor cardiovascular outcome. The aim of this study was to evaluate arterial stiffness and cardiovascular hemodynamics by oscillometric method in psoriasis patients with normal cardiac functions. Fifty consecutive patients with the diagnosis of psoriasis and 50 controls were included in the study. NLR was calculated as the ratio of neutrophil count to lymphocyte count. All patients underwent echocardiographic examination. Measurements of arterial stiffness were carried out using a Mobil-O-Graph arteriograph system. Fifty patients with psoriasis (26 male, mean age 43.3 ± 13.2 years) and 50 controls (33 male, mean age 45.0 ± 6.1 years) were included into the study. The distribution of cardiovascular risk factors was similar between the two groups, and NLR was significantly higher in patients with psoriasis (2.74 ± 1.78 versus 1.82 ± 0.52, p = 0.002). There was a weak correlation between NLR and PASI score without reaching statistical significance (r = 0.300, p = 0.060). While echocardiographic and hemodynamic parameters were comparable between psoriasis and control groups, heart rate was significantly higher in psoriasis group (81.5 ± 15.1 and 75.2 ± 11.8 beats/min, p = 0.021). Psoriasis patients had significantly higher AIx and PWV values as compared to controls (25.8 ± 13.1 versus 17.4 ± 12.3%, p = 0.001 and 6.78 ± 1.42 versus 6.18 ± 0.80 m/s, p = 0.011, respectively). AI and PWV were significantly associated with psoriasis when adjusted by heart rate (p = 0.005, odds ratio 1.04, 95% confidence interval 1.01-1.08 and p = 0.035, odds ratio 1.52, 95 % confidence interval 1.02-2.26, respectively). PWV significantly correlated with blood pressure, lipid levels, and several echocardiographic indices. AIx only correlated with left atrial diameter (r = 291, p = 0.040). Linear regression analysis was performed to find predictors of PWV. Central systolic blood pressure, left atrial diameter, and total cholesterol were independent predictors of PWV. PWV and AIx were significantly higher in patients with psoriasis. Assessment of arterial stiffness parameters may be useful for early detection of cardiovascular deterioration in psoriasis patients with normal cardiac functions. Novel inflammatory biomarkers such as NLR may elucidate the mechanism of vascular dysfunction in such patients.

Pain identifies squamous cell carcinoma in organ transplant recipients: the SCOPE-ITSCC PAIN study

Organ transplant recipients (OTR) are at high risk for cutaneous squamous cell carcinomas (SCC). We aimed to define clinically meaningful patient-reported warning signals predicting the presence of invasive SCC.Patient-reported signs and symptoms of 812 consecutively biopsied skin lesions from 410 OTR were determined by questionnaire and physical examination and related to the subsequent biopsy-proven diagnoses. Receiver-operating characteristic (ROC) curve analyses were used as a measure of distinction between the predictive values of patient-reported warning signals and the occurrence of SCC. Pain was an independent predictive patient-reported warning signal for a biopsy-proven invasive SCC. The odds ratio from the fully adjusted model predicting SCC was 4.4(95% confidence interval: 2.4–8.2). Higher scores on the visual analog scale (VAS) for pain were associated witha greater likelihood for the presence of SCC compared to none or mild pain. The for scores on the VAS from 1to 3, 4 to 6 and 7 to 10 were 4.9 (2.2–10.5), 2.3 (0.96–5.5)and 16.5 (3.6–75.8), respectively. Pain is the most powerful patient-reported warning signal for invasive cutaneous SCC in OTR. Empowerment of patients by education could accelerate diagnosis and treatment of cutaneous SCC.

Oxidant/antioxidant status in recurrent aphthous stomatitis

OBJECTIVE

Recurrent aphthous stomatitis (RAS) is a common oral mucosal disorder characterized by recurrent, painful oral aphthae, and oxidative stress presumably contributes to its pathogenesis. The study was performed to evaluate the involvement of oxidant toxicity in this disorder.

METHODS

Patients with RAS (n = 26) and age- and sex-matched healthy control subjects (n = 20) were included in this study. Following an overnight fast, blood specimens were obtained. Plasma malondialdehyde concentrations and erythrocytes glutathione peroxidase activities were determined. Also, plasma vitamin E and selenium levels were detected. Mann-Whitney U-test was performed for statistical evaluation.

RESULTS

Oxidative stress was confirmed by the significant elevation in plasma malondialdehyde levels and by the significant decrease in glutathione peroxidase activities, vitamin E and selenium levels (P < 0.001).

CONCLUSIONS

Our results indicated that lipid peroxidation and the inadequacy of the defense system seem to play a crucial role in the pathogenesis of recurrent aphthous stomatitis.

Can topical calcipotriol be a treatment alternative in actinic keratoses? A preliminary report

BACKGROUND

Recent research demonstrated that vitamin D, apart from calcium-related actions, has antiproliferative, prodifferentia-tive and immunomodulatory activities.

OBJECTIVE

To determine whether actinic keratoses may benefit from the antiproliferative and prodifferentiative effects of topical vitamin D.

MATERIALS AND METHODS

The study was an investigator-blinded, half-side comparison trial. Patients applied calcipotriol cream to one side and Ultrabase cream as placebo to the other side of the scalp and/or face for 12 weeks. The total number of actinic keratoses (AKs), diameters and total scores of the target lesions were determined at each visit.

RESULTS

Nine patients were included, eight of whom completed the treatment. There was a statistically significant difference between the total number of AKs at baseline and at week 12 on calcipotriol applied side whereas no difference was detected on placebo applied side (p = 0.028 vs p = 1.00). The mean total score of the target lesions reduced significantly at week 12 on calcipotriol side; however, no significant reduction was found on placebo side (p = 0.017 vs p = 0.056). Although side effects were more common on calcipotriol side, the difference was not statistically significant.

CONCLUSION

Topical calcipotriol may show promise in the treatment of actinic keratoses. More studies are needed to confirm its efficacy.

Erosive Pustular Dermatosis of the Leg: An Overlooked Entity?

Background:

Erosive pustular dermatosis is a distinctive clinical entity that has been described on either the scalp or legs. Chronic, shallow erosions covered by yellow crusts develop in atrophic or fibrotic skin. The scalp is the most commonly encountered localization, whereas erosive pustular dermatosis of the leg has also been reported in several cases. The histopathologic picture is nonspecific, and the disease is usually considered as a diagnosis of exclusion.

Objective and Conclusion:

We report two patients with erosive pustular dermatosis of the leg who were unresponsive to antibacterial and antifungal medications but were successfully treated with systemic steroids in combination with topical pimecrolimus in one of them and topical clobetasol in the other. The condition is simply overlooked, which accounts for its rare description in literature.

Melanoma in organ transplant recipients: clinicopathological features and outcome in 100 cases

Organ transplant recipients have a higher incidence of melanoma compared to the general population but the prognosis of this potentially fatal skin cancer in this group of patients has not yet been established. To address this, we undertook a multicenter retrospective analysis to assess outcome for 100 melanomas (91 posttransplant and 9 pretransplant) in 95 individuals. Data were collected in 14 specialist transplant dermatology clinics across Europe belonging to the Skin Care in Organ Transplant Patients, Europe (SCOPE) Network, and compared with age, sex, tumor thickness and ulceration status-matched controls from the American Joint Committee on Cancer (AJCC) melanoma database. Outcome for posttransplant melanoma was similar to that of the general population for T1 and T2 tumors (< or = 2 mm thickness); but was significantly worse for T3 and T4 tumors (> 2 mm thickness); all nine individuals with a pretransplant melanoma survived without disease recurrence following organ transplantation. These data have implications for both cutaneous surveillance in organ transplant recipients and management of transplant-associated melanoma.

A case of Schamberg's disease responding dramatically to PUVA treatment

Pigmented purpuric dermatoses are a group of chronic, recurrent disorders characterized by purpuric lesions mainly involving the lower extremities. Their etiology is unknown. Treatment options are limited and none of them have proven benefit. Phototherapy has been reported to be effective in a small number of patients in the literature. We present a case of Schamberg's disease showing a dramatic response to psoralen plus ultraviolet A therapy and discuss the current therapeutic options focusing mainly on phototherapy. We believe that phototherapy is a valuable alternative, especially for patients with long-standing and widespread pigmented purpuric dermatitis.

Phacomatosis pigmentovascularis type IIIb

Phacomatosis pigmentovascularis (PPV) is a group of syndromes comprising coexistent vascular and pigmentary nevi, which is first classified into five subtypes and then further categorized according to the absence or presence of associated systemic findings as type (a) and (b), respectively. This case report is of an 11-year-old Turkish girl with extensive vascular nevus and nevus spilus. Because of coexistent scoliosis, the patient represents an example of PPV type IIIb. Including the present case, a total of eight cases of PPV type IIIb have been reported to date. The case is discussed in view of the new classification proposed by Happle.

Generalized pruritus treated with narrowband UVB

BACKGROUND

Narrowband UVB phototherapy has been increasingly used in a variety of dermatological diseases. We planned to evaluate its efficacy in generalized pruritus in this prospective study.

METHODS

Forty-six patients were included and then divided into two groups: group 1 and group 2 consisted of patients with uremic pruritus and "idiopathic pruritus", respectively. Phototherapy was given three times a week. Efficacy assessments were made by means of visual analog scale (VAS) and pruritus grading score.

RESULTS

Thirty-five patients completed the treatment. Mean VAS decreased from 8.2 +/- 1.5 to 3.6 +/- 3 in group 1 and from 7.1 +/- 2.3 to 2.3 +/- 2.8 in group 2 (P < 0.0001). Mean percentage of change in VAS was 54.2% (95% CI 32.6-75.9) and 67.9% (95% CI 53.8-81.9) in group 1 and group 2, respectively. Mean number of treatments was 22 in both groups. Mean cumulative UVB dose was 24,540 mJ/cm(2) and 20,801 mJ/cm(2) in group 1 and group 2, respectively.

CONCLUSION

Narrowband UVB is an effective and well-tolerated treatment option for patients with generalized pruritus.

Metronidazole 0.75% gel vs. ketoconazole 2% cream in the treatment of facial seborrheic dermatitis: a randomized, double-blind study

BACKGROUND

Recently, two placebo-controlled studies have shown that topical metronidazole was effective in the treatment of seborrheic dermatitis.

OBJECTIVE

To compare the efficacy and safety of metronidazole 0.75% gel with that of ketoconazole 2% cream in the treatment of facial seborrheic dermatitis.

METHODS

A total of 60 consecutive patients with facial seborrheic dermatitis were included. Patients were randomized into two groups. One group used ketoconazole 2% cream with metronidazole gel as vehicle; the other group used metronidazole 0.75% gel with ketoconazole cream as vehicle for a 4-week treatment period. Main outcome measures were change in clinical severity scores, patients' and investigator's global evaluation of improvement and frequency of side-effects.

RESULTS

All the assessments were made by an investigator who was unaware of which group the patients were allocated to. Mean percentage decrease in clinical severity scores from baseline to last available visit was 63.4% (95% CI 57.7-69) and 54.4% (95% CI 47.9-61) in the ketoconazole- and metronidazole-treated patients, respectively (P = 0.31). Eighty-two per cent of patients in the ketoconazole group vs. 79% of patients in the metronidazole group rated their global improvement as significant or moderate (P > 0.05). No statistically significant difference in the frequency of side-effects was detected between the two groups. The results of this study need to be confirmed in further studies involving large numbers of patients.

CONCLUSION

Our data demonstrated that metronidazole 0.75% gel had a comparable efficacy and safety profile with that of ketoconazole 2% cream in the treatment of facial seborrheic dermatitis.

Neutral endopeptidase expression and distribution in human skin and wounds

Cutaneous sensory nerves mediate inflammation and wound healing by the release of neuropeptides such as substance P. Neutral endopeptidase is a cell surface enzyme that degrades substance P and thereby terminates its biologic actions. The distribution of neutral endopeptidase in normal skin and wounded human skin, however, has not been examined. The objectives of this study were to evaluate neutral endopeptidase expression in wounded and unwounded skin as well as in cells derived from human skin. Neutral endopeptidase was strikingly localized in normal skin by immunohistochemistry to keratinocytes of the epidermal basal layer, to hair follicles, eccrine and sebaceous glands as well as to endothelium of blood vessels and to large nerves. Standard incisional human wounds were studied at several time points between 1 h and 28 d after wounding. Staining for neutral endopeptidase was noted in the wound bed 6 h after wounding. In contrast to normal skin, staining of all the epidermal cell layers was noted in the migrating tongue of epithelium in l d wounds. Similar full-thickness staining was noted in 3 d and 7 d wounds in all layers of the new wound epithelium and in a "transition epithelium" near the wound edge. By 28 d post wounding neutral endopeptidase staining again was detected only in the basal layer of the epidermis. Neutral endopeptidase mRNA was detected in normal skin and wounds as well as cultured keratinocytes, fibroblasts and endothelial cells. Neutral endopeptidase enzymatic bioactivity was demonstrated in cultured keratinocytes. While it is known that several metalloproteinases important to tissue repair are produced by keratinocytes, this is the first evidence that keratinocytes produce neutral endopeptidase. Neutral endopeptidase may terminate the proinflammatory and mitogenic actions of neuropeptides in normal skin and wounds.