1Albert Einstein College of Medicine, Bronx, NY; 2University of California, San Diego, La Jolla, CA; 3Rady Children’s Hospital, San Diego, CA Psoriasis is a common, chronic inflammatory skin disorder characterized by hyperkeratotic, scaly plaques often associated with pruritus, irritation, and decreased quality of life.1 Treatment is typically aimed at minimizing signs and symptoms. Topical agents are the mainstay of treatment and include corticosteroids, vitamin D analogues, and emollients or moisturizers. In severe cases, phototherapy, systemic immunosuppressants, and biologic agents also are utilized.1
Background/Objective Characterize gender differences in efficacy of psoriasis treatments, as this has not been well studied. Methods In this retrospective cohort study, data were collected on patients with psoriasis seen at Tufts Medical Center between 2008 and 2014. Treatment courses lasting ≥ 4 weeks in patients with baseline moderate to severe psoriasis were included. Clearance was defined as an S-MAPA (simple measure for assessing psoriasis activity, the product of body surface area and physician global assessment) ≤ 3. Results Of the 172 biologic treatment courses, 81 (47%) resulted in clearance, 56% of females and 39% of males (RR=1.43, p=0.032). Women were more likely to clear on infliximab (88% compared to 27% of males, RR=3.21, p=0.02) despite a significantly higher baseline S-MAPA in females in this subgroup (166.63 versus 94.86 in men, p=0.05). There was no statistically significant gender difference in clinical outcomes for patients on conventional systemics or combination treatment courses. Conclusion Clinical outcomes are better for biologics, especially infliximab, in females compared to males with moderate to severe psoriasis. Further investigation of possible biologic or pharmacokinetic explanations for this finding is warranted.
We report two cases of patients who endorsed hoarding prescription medications for the treatment of their psoriasis, at times utilizing long-expired medications or starting a second course of a biologic without the guidance of a physician. These behaviors represent risk factors for possible adverse medication-related outcomes. Dermatologists should be aware that patients may be hoarding medications and counsel them accordingly.
Palmoplantar psoriasis is a variant form of psoriasis that characteristically affects the skin of the palms and soles. It is chronic and inflammatory in nature and presents with hyperkeratotic, pustular, or mixed morphologies. Painful fissuring and bleeding may occur, which produces significant physical, functional, and social disability. Palmoplantar psoriasis is a therapeutically challenging condition and notoriously difficult to treat with topical therapy alone. Furthermore, limited data exist on treatment given that patients are typically excluded from clinical trials, which often require at least 10% body surface area (BSA) involved as an inclusion criterion. This article reviews the topical and systemic agents including biologics that have been investigated in the treatment of palmoplantar psoriasis. Combination therapy, comprising topical, systemic, and/or light treatments, with a particular focus on improvement in function and pain reduction, appears to be the most effective approach in treating these patients.
The International Dermatology Outcome Measures (IDEOM) group was created with the goal of establishing improved, as well as patient-centered, outcome measures. The effort involves the worldwide participation of those involved in the treatment of psoriasis, including dermatologists, rheumatologists, pharmaceutical and device company medical officers, payors, regulatory officers, patient advocacy groups including the National Psoriasis Foundation, and patients themselves. This review will outline the work done to date, the methodology utilized, and future planned action, including a worldwide search for patient representatives to this endeavor.
Psoriasis and psoriatic arthritis are chronic illnesses that are prevalent in women of childbearing age. The aim of this review is to bring to light data regarding the effect of pregnancy and the postpartum period on psoriasis and psoriatic arthritis and to discuss the major theories underlying these changes. To date, evidence indicates a tendency toward improvement of psoriasis and psoriatic arthritis during pregnancy and a flare in the postpartum period. This is likely a consequence of physiologic adaptations during pregnancy and the subsequent loss of these protective factors in the postpartum period. Most prominent among these adaptations are hormonally induced changes in helper T cell (Th1, Th2, and Th17) cytokines. However, alterations in proteins and cell surface molecules also have been implicated. The relatively high prevalence of psoriasis and psoriatic arthritis in women of childbearing age mandates that patients, dermatologists, and obstetricians alike be knowledgeable of the gestational and postpartum changes that occur in these diseases.
Psoriasis is characterized by excessive growth and aberrant differentiation of keratinocytes and by dysregulation of immune cells. Topical vitamin D analogs and corticosteroids are commonly used for the treatment of mild-to-moderate plaque psoriasis. The effects of corticosteroids are predominantly anti-inflammatory and immunosuppressive, while those of vitamin D analogs have long been considered antiproliferative. Recent evidence suggests an independent role of vitamin D analogs and corticosteroids in cytokine modulation, an important factor in treatment efficacy. In vitro and in vivo studies show that the combination of a vitamin D analog and a corticosteroid produces effects on T-cell subsets that are involved in psoriatic skin inflammation. Based on the respective mechanisms of action of vitamin D analogs and corticosteroids, there is a biologic rationale for the enhanced clinical effect observed with the combination therapy. This article reviews current understanding of the pathogenesis of psoriasis and recent evidence for immunomodulatory mechanisms of vitamin D analogs and corticosteroids.
There is a well-known association between psychosocial stress and psoriasis. However, the underlying mechanism of stress-induced exacerbation of psoriasis is not well understood. Until recently, the majority of evidence has pointed to alterations of the endocrine and peripheral nervous systems, while less is known about changes in the immune system despite psoriasis being a chronic inflammatory skin disease. In the past few years, there has been an increase in data concerning evidence for the immune system as a mediator between stress and psoriasis, which we now review. Possible immunological mechanisms explored include increased leukocyte trafficking to the skin, elevations in proinflammatory cytokines, and reductions in anti-inflammatory cytokines in response to psychosocial stress.
Background Psoriasis is an inflammatory skin condition characterized by hyperproliferating keratinocytes, aberrant epidermal differentiation, and infiltrating inflammatory cells. Traditional herbal medicine has been used extensively to treat psoriasis with promising clinical results. Due to the vast number of herbal preparations used all over the world, we have focused on curcumin, indigo naturalis (IN), and aloe vera (AV) because they are the most commonly reported herbal therapeutics. Objective This review illustrates the beneficial effects of multiple herbal medications as a therapeutic alternative in the treatment of psoriasis. Methods A thorough literature search of the PubMed database was conducted to identify psoriasis studies utilizing these three herbs as therapeutics. Results Curcumin has been demonstrated to be a TNFα blocker. IN has been effective in treating plaque and nail psoriasis. AV-treated psoriasis also has shown clinical improvement. Conclusion Further studies are needed to back up these claims before these formulations can be accepted into the current treatment regimens.
Interleukin-17 (IL-17) has a complex, multifaceted role in the inflammatory and immune processes in both humans and mice. However, the research findings thus far on IL-17's role in the pathogenesis of atherosclerosis and psoriasis remain controversial. It is both atheroprotective and atherogenic in different studies. There are important clinical implications in the treatment of psoriasis with biologic therapies (i.e. IL-17 blockers and IL-12/23 blockers) and the occurrence of cardiac events. Further investigations are needed to elucidate the exact mechanisms of IL-17 and related cytokines, and the consequences of their inhibition.
SUMMER 2014 Varada et al. | PSORIASIS FORU M, VOL. 20, NO. 2 Sowmya Varada, B.S., Tufts Medical Center; Noori Kim, M.D., Tufts Medical Center; April Abernethy, N.D., National Psoriasis Foundation; April Armstrong, M.D., M.P.H., University of California Davis; Kristina Callis-Duffin, M.D., University of Utah; Amit Garg, M.D., Boston University; Alice Gottlieb, M.D., Ph.D., Tufts Medical Center IDEOM: International Dermatology Outcome Measures – Proceedings from the First Meeting
Psoriasis is a chronic immune-mediated disorder which, though not life-threatening, has a great impact on the quality of life. There are multiple therapeutic options available for the treatment of psoriasis based on the severity and percentage of body surface area involved which include topicals, systemic agents, and phototherapy. It is not uncommon for patients to become resistant to therapies and treatment failures can be frustrating for the physician as well as the patient. Mycophenolate mofetil, an antimetabolite and immunosuppressant, has been found to be effective and safe for treating moderate-to-severe psoriasis in several studies. It is a good alternative for patients who fail traditional systemic treatments or who have a contraindication for their use.
It is believed that moisturizers can improve the efficacy of treatment for psoriasis. This study sought to analyze the active ingredients and properties of moisturizers that claimed to be suitable for psoriasis. Moisturizers for psoriasis were identified on electronic markets using the search terms “moisturizers” and “psoriasis.” Forty-seven moisturizers that claimed to be suitable for psoriasis were identified. Vitamin E was the most common ingredient used for emollient properties. Of the 47 moisturizers, 35 (74%) contained anti-inflammatory properties and 12 (26%) contained keratolytic properties. Coal tar, low-potency corticosteroids, and botanical extracts were added for anti-inflammatory properties while salicylic acid, lactic acid, and ≥ 10% urea cream were used for keratolytic effect. Although it seems that each active ingredient added into moisturizers for psoriasis can decrease the severity of psoriasis, there is a lack of well-done studies on the over-the-counter preparations. Therefore, the recommendations to use them are currently not evidence-based.
Erythrodermic psoriasis is a rare variant of psoriasis in which more than 75% of the patient's skin is inflamed and scaling. Patients with this condition can experience fevers, chills, malaise, and pruritus. Patients also have abnormal lab values that reflect the water and protein loss from the intense desquamation. In most cases, the histologic findings are consistent with those of classic plaque psoriasis. Systemic treatment recommendations include cyclosporine or biologics for severe, acute cases and acitretin or methotrexate for less severe cases. The prognosis for patients with this condition varies, but S. aureus colonization and subsequent bacteremia is more common in these patients and should be monitored carefully and treated promptly.
Treatment of psoriasis traditionally has been directed at epidermal symptoms. Recent findings from a prospective study have implicated a circulating cross-reactive T-cell population in psoriasis etiology. These T cells appear to originate from streptococcal infection in the tonsils, and the study showed that tonsillectomy may lead to stable clinical improvement in psoriasis. Here, we review previous case reports and retrospective studies of tonsillectomy in the treatment of psoriasis and discuss findings in relation to the prospective study.
Objectives The purpose of this study was to review evidence for the efficacy and safety of cyclosporine therapy in patients with psoriatic arthritis. Methods We performed a systematic literature review of available evidence using the electronic database PubMed. Results The available evidence suggests that cyclosporine may be an effective third-line treatment for psoriatic arthritis. However, its well-established side effect profile limits long-term use. Conclusion Cyclosporine may be an effective treatment option for psoriatic arthritis, but large randomized, placebo-controlled clinical trials with adequate sample sizes are needed to assess its impact on symptomatic control, inhibition of radiological disease progression, prevention of disability, and improvement of quality of life.
Background Oral acitretin 25 mg/day combined with a phototherapy regimen is a standard treatment for severe plaque-type psoriasis. Retinoid-related adverse events include alopecia, dry mucus membranes, pruritus, photosensitivity, elevation of liver enzymes, elevation of serum triglycerides and cholesterol and decrease of HDL, arthralgias, myalgias, eye irritation, blepharitis, photophobia, conjunctivitis, headaches, nausea, and anemia. Objective This single-center open label study evaluated the efficacy and tolerability of a reduced acitretin dose in patients with severe plaque-type psoriasis undergoing phototherapy treatment who were experiencing at least one retinoid-related adverse event. Results Of patients treated with 17.5 mg/day of acitretin, 89% demonstrated improved or comparable psoriasis area-and-severity index scores at week 12; 79% showed improvement in adverse events reported at baseline through week 12. Conclusion There is a role for a lower dose of acitretin in patients who are experiencing retinoid-related side effects and who are stabilized on a phototherapy regimen.
