Consensus on the management of patients with psoriatic arthritis in a dermatology setting

BACKGROUND

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis (PsO). Early diagnosis and prompt therapeutic intervention are crucial for limiting PsA progression and prevention of disability. Dermatologists are in a privileged position to detect early PsA. The management of patients with PsA in the dermatology setting is widely variable.

OBJECTIVE

To provide practical recommendations for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

METHODS

A consensus document was written by an expert panel composed by dermatologists (n = 12) and rheumatologists (n = 6). Eleven highly relevant questions were selected and elaborated with answers/statements based on a narrative literature review. The resulting document was discussed in a face-to-face meeting adopting a nominal group technique to reach consensus (i.e. 100% agreement) using the Delphi method.

RESULTS

A consensus was achieved in defining the following: the clinical characteristics differentiating inflammatory and non-inflammatory signs and symptoms of joint disease; the most important differential diagnoses of PsA in clinical practice; the most useful screening questionnaires, serum laboratory tests and imaging techniques for the detection of early PsA; the criteria for dermatologist to refer patients with PsO to rheumatologist; the criteria for the diagnosis of PsA; the selection of the indices that the dermatologist could use for measuring the activity and severity of PsA in clinical practice; when systemic steroids and/or intra-articular steroid injections are indicated in the treatment of PsA. Finally, systemic treatments including synthetic and biologic disease-modifying antirheumatic drugs to be considered for the treatment of PsA have been reported.

CONCLUSIONS

The implementations of these practical recommendations could be very helpful for the management of patients with PsA in the dermatology setting including early diagnosis and treatment.

Italian guidelines on the systemic treatments of moderate-to-severe plaque psoriasis

Psoriasis is a common disease, which has a considerable impact on the healthcare system. Therefore, appropriate use of therapeutic resources is very important. Management of psoriasis in daily clinical practice is highly variable because many issues are still debated and not definitely addressed by the evidence-based medicine. Moreover, the different availability and reimbursability of drugs in each country justifies national guidelines. Expert consensus can provide helpful guidelines for optimizing patient care. A total of 20 dermatologists from different areas of Italy and with large experience in the treatment of psoriasis agreed to participate in the guidelines expert panel who aimed to reach consensus on the factors influencing psoriasis severity, the indications for systemic treatments, the parameters to be considered in the choice of treatment, and the factors to be considered in the choice of biological treatment. The recommendations for the use, screening and monitoring of systemic therapies were based on the 2015 S3 European Dermatology Forum/European Academy of Dermatology and Venereology psoriasis guidelines. Recommendations on the treatment of psoriasis in special patient populations were also agreed. The final document was discussed in a meeting moderated by a facilitator with participation of the entire group and adopting a nominal group technique to reach consensus. A statement was regarded as consented when agreement was achieved by at least 75% of the voting experts according to the Delphi procedure.

Anti-adalimumab antibodies in psoriasis: lack of clinical utility and laboratory evidence

OBJECTIVE

Adalimumab has proven effective in psoriasis; however, secondary failure may result from the drug's immunogenicity. Prevalence data on the immunogenicity of biologicals, and of adalimumab in particular, are highly variable. We investigated the prevalence of anti-adalimumab antibodies and the association with clinical indexes and tumour necrosis factor α (TNFα) serum levels in psoriatic patients.

DESIGN

Case-control, longitudinal.

SETTING

Single centre.

PARTICIPANTS

Patient groups: I (n=20) receiving biological therapies after switching from adalimumab; II (n=30) ongoing adalimumab therapy; III (n=30) novel adalimumab therapy; IV (n=15) biological therapies other than adalimumab.Healthy subjects: (group V; n=15) never treated with immunosuppressants or biologicals.

INTERVENTIONS

All groups were tested at enrolment. Group II was also tested at 12 months, and group III at 1, 3, and 6 months.

PRIMARY AND SECONDARY OUTCOME MEASURES

Standard clinical evaluations (Psoriasis Area Severity Index (PASI)), blood samples and two-site ELISA-based measurement of serum adalimumab trough levels, anti-adalimumab antibodies and TNFα.

RESULTS

The false-positive rate was 23% for adalimumab detection and 22% for anti-adalimumab antibodies in patients naïve to adalimumab. Spurious positivity for anti-adalimumab antibodies (one-time-point positivity in group III during follow-up) accounted for 33% of the total. The prevalence of anti-drug antibodies was highest (87%) in group I patients. No correlations were found between the presence of anti-adalimumab antibodies or adalimumab levels and changes in PASI scores.

CONCLUSIONS

High variability of results, high prevalence of false-positives and lack of association between anti-adalimumab antibodies and TNFα level/PASI score limit this assay's usefulness. Accurate clinical evaluation is key to early identification of treatment failures.

Biosimilar infliximab: an expert view

CT-P13, a biosimilar of infliximab, was the first biosimilar monoclonal antibody to be approved in both the European Union and Korea. As a monoclonal antibody, CT-P13 is a large molecule with a high molecular weight, and as such it differs from other biosimilars currently in the market. The comparability exercise for CT-P13, therefore, requires special consideration, as it was the first demonstration of biosimilarity between a biosimilar monoclonal antibody and its originator. This paper summarizes current regulations on the approval of biosimilars, describes the evidence leading to the approval of CT-P13, and discusses the potential role of this molecule in the Italian scenario on the basis of the view of a group of experts.

Consensus on the use of cyclosporine in dermatological practice. Italian Consensus Conference

Cyclosporine A (CsA) efficacy and safety have been proven in various dermatoses both in adults and in children even as long-term treatment. Over the last 25 years, Italian dermatologists have gathered relevant experience about CsA treatment for psoriasis and atopic dermatitis. This paper has been developed by an Italian Consensus Conference and it is aimed at providing recommendations based on real-world clinical experience in adult patients, consistent with efficacy and safety data arising from the scientific literature. The paper is mainly focused on the analysis of the optimal therapeutic schemes for psoriasis and atopic dermatitis, in terms of doses and treatment duration, according to individual characteristics and to the severity of the disease. Moreover, it overviews ideal management, taking into account pharmacological interactions, influence of comorbidities, and the most common adverse events related to CsA treatment.

The diagnosis of early psoriatic arthritis

Psoriatic arthritis (PsA) is a chronic inflammatory joint disease with heterogeneous clinical presentation and unpredictable course but often with a tendency to irreversible joint damage. Joint damage can occur early in the disease also in the absence of significant clinical signs of arthritis. These observations and the current availability of effective treatments in controlling skin and joint disease underline the importance of early diagnosis of PsA. The use of specific questionnaires for screening patients at risk of psoriatic arthritis, knowledge of new classification criteria for PsA and especially the proper use of new imaging techniques are all important steps in achieving the goal of early diagnosis of PsA. The dermatologist may play a key role in this regard supported, when necessary, by the collaboration of the rheumatologist and radiologist.

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.

Psoriasis Relapse Evaluation with Week-End Cyclosporine a Treatment: Results of a Randomized, Double-Blind, Multicenter Study

Cyclosporine A (CsA) effectively controls psoriasis, however, its long-term continuous use is not recommended. This study aims to evaluate the efficacy and tolerability of week-end CsA microemulsion for the reduction of relapse rate in patients with chronic plaque psoriasis who had achieved clinical remission following continuous CsA therapy. The PREWENT (Psoriasis Relapse Evaluation with Week-End Neoral Treatment) study was a 24-week, randomized, double-blind, multicenter study, carried out in 22 Italian hospital or university Dermatology units. CsA was discontinued for 8 days previous to the patients being randomized to oral CsA 5 mg/kg/day or placebo for two consecutive days/week, for a total period of 24 weeks. The primary endpoint was clinical success rate at week 24, defined as the proportion of patients with no clinical worsening (no relapse or a Psoriasis Area and Severity Index [PASI] <75% of pre-treatment PASI). A total of 162 patients were randomized to CsA and 81 to placebo. Clinical success rates at 24 weeks were 66.9% and 53.2% with CsA and placebo, respectively (p = 0.072). Time to first relapse was significantly prolonged with CsA versus placebo (p = 0.023), and PASI was significantly lower from weeks 4 to 16 in CsA recipients. In patients with moderate-severe psoriasis, the clinical success rate was significantly increased with CsA compared to placebo (69.9% vs 46.3%; p = 0.011), and significantly lower increases in PASI were observed from week 4 to week 24 (p < 0.05 vs placebo). CsA was well tolerated, with no differences in mean blood creatinine or blood pressure between CsA and placebo recipients. However, the high withdrawal rate (22.2% of randomized patients), which was not related to side effects, may have led to an overestimation of efficacy, but the study had a good statistical power (88% greater than that observed in similar studies, i.e. 80%). Week-end CsA administration was shown to prolong safely and effectively the time to first relapse in psoriasis patients.

Etanercept Therapy in Patients with Psoriasis and Concomitant HCV Infection

Treatment of patients with psoriasis and/or psoriatic arthritis and concomitant hepatitis C infection remains difficult. Except for cyclosporine, other drugs have proved unacceptable because of hepatotoxicity in patients with HCV. With the advent of anti-TNF-alpha drugs, including etanercept, new therapeutic options have become available. Our study population was five patients with psoriasis and/or psoriatic arthritis and concomitant chronic HCV infection undergoing etanercept therapy. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and viral load were used as markers for liver damage and disease progression, respectively. The Psoriasis Area Severity Index (PASI) was used as a reference parameter for evaluating the therapeutic efficacy of etanercept therapy in improving the clinical skin picture. AST, ALT, viral load and PASI were monitored at 3-month intervals starting from the beginning of therapy up to two years after initiation of etanercept therapy. In four out of five patients, liver enzyme levels and viral load remained substantially unchanged during the course of therapy. In the one remaining patient, viral load and liver enzyme levels increased during etanercept therapy, and then decreased following the initiation of Peg-IFN/ribavirin in combination with anti-TNF-alpha therapy. PASI scores decreased in all five patients. Our data suggest that etanercept therapy is safe and provides an efficacious therapeutic alternative in patients with psoriasis and concomitant HCV infection.

Clinical Outcome Evaluation following Cyclosporine a Treatment in Moderate to Severe Psoriasis: A Retrospective Study

This retrospective study was conducted on 193 patients treated in three Italian Psoriasis Units with the aim of evaluating the evolution of psoriasis severity and the safety of cyclosporin A (Sandimmun Neoral®) in moderate to severe psoriasis, at the regimens usually employed in common clinical practice. Cyclosporin A (CyA) was administered for a mean period of 14 months, the mean number of treatment courses was 1.6 (range 1–4), and the mean dosage ranged from 1.5 to 3.1 mg/kg/die. Ninety percent of patients obtained complete therapeutic success or clinical remission, defined as complete clearance of lesions or clearance of lesions with residual minor pigmentations respectively, when treated with CyA in monotherapy. The mean Psoriasis Area and Severity Index (PASI) decreased from 23.31 before CyA administration to 5.64 at the end of treatment. The clinician's judgement on CyA tolerability was good/very good in 90% of cases. Adverse events occurred in 36% of patients, with hypertension being the most commonly reported (17.6%). The results of this study indicate that in the common clinical practice CyA in moderate to severe psoriasis is usually employed at low doses, resulting both safe and effective.

Successful Cyclosporine Treatment in a Case of Amicrobial Pustulosis Associated with Immunological Abnormalities

Amicrobial pustulosis associated with autoimmune diseases (APAD) is a clinical entity which was described only recently and few cases are reported in the literature. This condition is characterized by recurrent acute onset with pustular lesions predominantly involving skin folds, genitals, scalp and external auditory canals of young women. The etiopathogenesis of APAD is unknown and the most effective therapeutic treatment seems to be systemic corticosteroids. We describe the case of a 16-year old female patient suffering from APAD successfully treated with cyclosporine A.

A randomized trial of leukotriene receptor antagonist montelukast in moderate-to-severe atopic dermatitis of adults

Leukotriene receptor antagonists are recommended for the treatment of asthma, and have proved anecdotally successful even in atopic dermatitis. Standard treatments of atopic dermatitis are often unsatisfactory. Accordingly, we compared montelukast, 10 mg/day, with a combined regimen (orally administered cetirizine and clarythromycin, topical corticosteroids and hydrating preparations) for treatment of moderate-to-severe atopic dermatitis of adults. The trial was designed as a randomized single-blind study. SCORAD, eosinophilic cationic protein (ECP), eosinophilic protein X (EPX) serum levels were assessed at baseline and after 6 weeks in 32 adult patients with atopic dermatitis (16 treated with montelukast; 16 treated with the combined regimen). Similar improvements, evaluated in term of SCORAD reductions, were detected in both groups (Mann-Whitney, p < 0.05), while ECP and EPX levels significantly reduced within each group (Welch's approximate t, p < 0.05). We conclude that montelukast is as effective as the comparison combined regimen to treat atopic dermatitis of adults.

Sweet's syndrome in a patient with idiopathic myelofibrosis and thymoma-myasthenia gravis-immunodeficiency complex: efficacy of treatment with etretinate

Here we present the case of a patient affected with a unique association of Sweet's syndrome, idiopathic myelofibrosis, spindle-cell thymoma, myasthenia gravis and Good's syndrome (a rare form of thymoma-related, combined immunodeficiency presenting with recurrent respiratory infections). Conventional therapies (corticosteroids, colchicine, DDS, clofazimine) were ineffective or were contraindicated. Treatment with etretinate (50 mg/day) proved effective on skin lesions. Moreover, the patient's general condition unexpectedly improved, with long-lasting (11 months) suppression of respiratory infections and a slight but consistent improvement of hematological parameters such as Hct, MCV, Hb level, RBC, WBC and lymphocyte absolute counts.

Densitometry of Pautrier's microabscess cells in cutaneous T cell lymphoma

BACKGROUND

Epidermotropic lymphoid T cell infiltrates are part of a continuous spectrum of lesions ranging from "benign" parapsoriasis to frank cutaneous T cell lymphoma (CTCL, mycosis fungoides). Either the clinical or histologic differentiation between these entities prove often difficult and the prognosis may be difficult to assess.

PATIENTS AND METHODS

We studied 15 patients, men aged 50 to 81 years, mean +/- SD 68 +/- 12 years, with patch-plague CTCL. Sections from punch biopsies from active lesions were stained with Feulgen reagent, coupled with a "twin" adjacent hematoxylin and eosin (H&E)-stained section and analyzed with a VIDAS Zeiss-Kontron Image Analyzer. At least 50 dermal infiltrating cells and 50 epidermotropic Pautrierian cells per specimen were counted and the biopsies were repeated periodically.

RESULTS

Nine patients with aneuploid Pautrierian cell DNA patterns dis well after conventional phototherapy (dermal cell ploidy was irrelevant), whereas six patients with euploid Pautrierian cell DNA patterns had to be treated aggressively (IFN + retinoids, COP). Clinical and histopathologic aspects of the first group were comparable to those of the second group.

CONCLUSIONS

The classical cytophotometric aphorism seems to be reversed in this sample: "The more abnormal the ploidy of epidermotropic Pautrierian cells, the better the prognosis." Euploid epidermotropic cell prove more efficient in invading the skin and other areas and this efficiency may be reflected in more aggressive trends in the evolution of the lymphoma. Thus, DSM analysis of epidermotropic cells could prove very useful as an inexpensive tool for routine CTCL grading.

Factors secreted by untreated psoriatic monocytes enhance neutrophil functions

Monocytes stimulated with bacterial lipopolysaccharides (LPS) release mediators that induce increased responses of human granulocytes. Recently we showed that psoriatic monocytes can stimulate neutrophil chemotaxis, phagocytosis, and O2- production without addition of LPS and this effect is inhibited by cyclosporin A. We have now investigated the presence of cytokines in supernatants from cultures of psoriatic monocytes (resting monocytes). These cells were cultured for 24 h in endotoxin-free medium. Normal human neutrophils were then incubated for 1 h with the resulting supernatants (sMS, or conditioned media). The sMS from unstimulated psoriatic monocytes significantly enhanced neutrophil chemotaxis and superoxide anion production. The enhancing factors are protein in nature and require ongoing protein synthesis, demonstrated by the facts that the activity in conditioned medium is labile to heat denaturation at 100 degrees C for 10 min, is not produced by monocytes cultured in the presence of puromycin, and is proteinase sensitive. Additional evidence suggested that extremes of pH inhibit activity. None of the conditioned media treated in these ways activated neutrophils. The neutrophil function-enhancing factors derived from psoriatic monocytes are in part cytokines, including TNF and GM-CSF. The support for this conclusion is the higher level of TNF and GM-CSF in media conditioned by psoriatic monocytes than in media conditioned by normal human monocytes, the inhibition of TNF production and neutrophil stimulating activity by cyclosporin A, and the inhibition of neutrophil stimulating activity in conditioned media preincubated with anti-TNF and anti-GM-CSF antibodies. It is concluded that psoriatic monocytes spontaneously produce higher than normal levels of TNF alpha, GM-CSF, and, perhaps, other cytokines that might be responsible for the enhanced activity of psoriatic neutrophils.

Nimodipine versus terfenadine in the treatment of physical stimulus-induced urticaria

Basophil and mastocyte degranulation is calcium-dependent. Calcium-antagonists can inhibit synthesis of and release in vitro some mediators in various types of cells. Both immunologically stimulated and non-immunologically stimulated release of material from basophils isolated from normal and allergic subjects can be antagonized by calcium blockers. The present study was aimed at testing the therapeutic effects and side effects of nimodipine therapy, a new dihydropyridine anti-calcium derivative for physical stimulus-induced urticaria, in comparison with a standard H1-antihistamine therapy. The study was done in 32 outpatients who had physical stimulus-induced urticaria: 20 patients received nimodipine three times a day in a daily dose of 180 mg, 12 patients were treated with terfenadine in a dose of 120 mg. In the majority of patients treated with both nimodipine and terfenadine, satisfactory clinical results were obtained after 3 weeks of therapy. There were, however significant (P less than 0.05) differences in responses. Complete clearance after 3 weeks was noted in 50% patients treated with nimodipine, whereas only 16% of patients on terfenadine were completely clear, and some showed only slight improvement. The treatment was easily manageable, and with few side effects.

[Exfoliative cytology of psoriasis: effects of cyclosporin A]

The cytological modifications of the horny layer cell population in psoriatic subjects during treatment with Cyclosporin A are described. They are studied by means of the cytoexfoliative method. The value of this technique is discussed, using it either for diagnosis, or for evaluating therapeutic efficacy of various treatments. The cytological findings are respectively compared with those of other psoriasis therapies, such as Methotrexate and RO 10-9359 (etretinate).

Increased plasma levels of platelet-derived growth factor activity in patients with progressive systemic sclerosis

We measured mitogenic activity of whole blood serum and platelet-poor plasma-derived serum of a group of 10 patients with progressive systemic sclerosis and of 8 controls. Mitogenic activity of plasma-derived serum was greater in patients than in controls, in the absence of other signs of platelet activation. This increased activity was inhibited by specific antibodies, anti-platelet derived growth factor, suggesting that circulating levels of platelet-derived growth factor may be present in progressive systemic sclerosis patients. Platelet-derived growth factor, released either by platelets or by monocytes, might play a role in the pathogenesis of scleroderma.

Role of the polymorphonuclear neutrophils in the phototoxic reaction in porphyria cutanea tarda

We have compared the superoxide production of polymorphonuclear cells (PMNLs) from healthy donors, when incubated with either control or porphyria cutanea tarda (PCT) sera at 4, 24 and 48 hours after exposure in vivo to UVA light. Serum from UVA-irradiated (1-5 J/cm2) PCT patients generated significantly greater amounts of superoxides from PMNLs than serum from UVA-irradiated (8-12 J/cm2) normal controls. This indicates that serum factors activated by porphyrin plus UVA stimulate neutrophilic granulocytes to liberate superoxides, triggering a series of events that cause tissue damage. The vascular lesions in patients with PCT could be, at least in part, due to this cytotoxic effect.

Circadian rhythm of the in vivo migration of neutrophils in psoriatic patients

Neutrophil chemotaxis in ten subjects with psoriasis was evaluated in vivo by the quantitative skin-window technique using autologous serum and in vitro using a modified Boyden technique. The in vitro chemotaxis values of the psoriatics were significantly lower (P less than 0.01) than those of healthy controls. When measured in vivo, however, we found that, after 9, 12, and 24 h, the values of the migrating polymorphonuclear leukocytes (PMNL) of psoriasis patients were only slightly and non-significantly lower than normal values. Analysing the in vivo chemotaxis data by a chronobiological method, we demonstrated statistically significant circadian rhythms in nine of the ten psoriasis patients. In seven of the patients, we found that the population had a significant rhythm, with the acrophase at -328 degrees. Our in vitro and in vivo values are in agreement with previously published values. However, there was a definite circadian rhythm of migration that we could not demonstrate in normal controls. We consider that our data reveal a significant and important difference between neutrophil chemotaxis in vivo in normal subjects and that in patients with psoriasis.

Pityriasis rubra pilaris and and retinol-binding protein

Serum levels of retinol-binding protein (the specific carrier of vitamin A) were measured in eleven patients with pityriasis rubra pilaris and in some of their close relatives. The level of retinol-binding protein was markedly reduced in every patient, and in some of the relatives. It is postulated that defective synthesis of retinol-binding protein is a biochemical marker for pityriasis rubra pilaris, probably transmitted as a Mendelian dominant.

[Multiple cutaneous neoplasms following repeated fluoroscopic examinations. (A case of clear-cell malignant hidradenoma associated with intra-epidermal epitheliomas of the Bowen type)]

A case of some neoplastic lesions of the skin of the back, arisen on undamaged skin, in a patient who underwent therapeutic pneumothorax and was submitted to several fluoroscopic examinations for pulmonary tuberculosis many years ago, is reported and discussed. An attempt of evaluation of the exposure to the ionizing radiations received by the interscapular region of the patient is made. The malignant clear-cell hidradenoma is a very rarely observed carcinoma: nine cases have been so far described.