tree-in- bud and enlarged lymph nodes.

Psoriasis is a chronic inflammatory disease that can be triggered by injury, trauma, infection and medications. Genetic and immunologic studies have highlighted the importance of the interleukin (IL)-23/T-helper 17 (Th17) pathway in systemic psoriasis pathogenesis. Main IL-23 is an upstream regulatory cytokine with direct effects on epidermal keratinocytes and other resident skin cells while IL-17, a downstream molecule, can activate inflammatory responses in different cells across a diversity of organs. Disease modification could be achieved with drugs that can slow down the biological processes that cause the persistent inflammation in moderate to severe psoriasis. Early intervention with anti-IL-17 and anti-IL-23 agents in new-onset moderate to severe plaque psoriasis might modify the natural course of the disease. Perhaps we are not simply seeing a pharmacologic and mechanistic effect of new-generation biologics but eventually a disease modification process. In this short report we underline the main available data which supports an important role for IL-17 blockade and address whether these new drugs targeting the IL-23/IL-17 axis could be disease-modifying agents in plaque psoriasis. This type of data gains more relevance in the current pandemic era, where chronic patients undergoing earlier treatment may have better outcomes and consequently avoid constant hospital visits.

Psoriatic disease (Psoriasis and Psoriatic Arthritis, PsD) is a condition that affects the skin, the musculoskeletal system, and beyond, impairing patients' quality of life. A multidisciplinary approach of combined dermatology-rheumatology clinics is recommended and valuable to respond to PsD diagnosis, management, and treatment challenges. In Portugal, five Hospitals have implemented a multidisciplinary clinic for PsD assessment. This report aims to describe how these multidisciplinary clinics were developed, their characteristics, and the main obstacles to their implementation. Although the different hospitals adopted distinct functional models, a consensus respecting the minimal core set assessment for PsD in Multidisciplinary Dermatology/Rheumatology Clinics should comprise all disease manifestations and, if possible, quality of life. The main objective of these clinics is to achieve remission/minimal disease activity. Limitations to these multidisciplinary approaches are discussed, namely financial, time management, and human resources obstacles that can be a handicap in their implementation, despite the benefits of PsD integrated care.

Risankizumab is a new IL-23 inhibitor approved by EMA (April 2019), currently reimbursed in Portugal to treat adult patients with moderate-to-severe psoriasis. Psoriasis is a chronic inflammatory, immune mediated disease characterized by erythematous plaques covered with silvery-white scales, with a 2% prevalence in Portugal. Managing psoriasis is still challenging due to its chronicity and ability to relapse, being needed to assess the most cost-effective treatment sequences. The aim of this study was to evaluate the cost-effectiveness of therapeutic sequences initiating with risankizumab against other biologic treatment sequences used in clinical practice (biosimilars included), among the approved population in Portugal. An excel-based Markov model was adapted to simulate a cohort of patients over a lifetime horizon. The Portuguese NHS perspective was adopted, with a 4% annual discount rate for costs and effects. All the mathematically possible therapeutic sequences were analysed, being clinically plausible sequences subsequently identified through an expert panel for risankizumab and comparators. The model considered three lines of treatment, each one with induction and maintenance phases. Within each treatment-related state, patients were distributed by level of PASI response. Patients with PASI90 at the induction phase went through to the maintenance phase and continued receiving the same treatment. Remaining patients switched to the next treatment line. Discontinuation and effectiveness rates were assumed to vary by treatment and therapeutic line. Results suggest that risankizumab sequence is dominant versus all the sequences identified by the expert panel, allowing QALY gains between 0.01-0.45 and savings between 4,518€ and 21,965€ per patient. The probabilistic sensitivity analysis and the scenario analysis confirmed the dominance of risankizumab sequence across all the others. Risankizumab is expected to provide clinically meaningful benefit and quality of life increase, while allowing for expressive economic savings in the treatment of adults with moderate-to-severe psoriasis.

The broader use of anti-tumor necrosis factor (TNF) agents in inflammatory bowel disease (IBD) has been associated with a high rate of adverse reactions. Dermatological complications are among the most common adverse events. We assessed the incidence, risk factors, management, and outcome of anti-TNF-induced dermatological complications in a large cohort of IBD patients.

Although the majority of patients with psoriasis vulgaris are treated exclusively with topical therapies, research to develop more effective topical therapies that are associated with higher patient satisfaction has lagged behind the development of systemic agents. The aim of this literature review was to determine whether there is documented evidence that applying an innovative approach to improving the formulation of active ingredients commonly used in the topical treatment of psoriasis can have a positive effect on clinical outcomes and patient-reported outcomes (PROs). The Embase and PubMed databases were searched for articles published between 2001 and 2016 that made direct head-to-head comparisons of different formulations of an active pharmaceutical ingredient (API), focusing on clinical outcomes and PROs. In total, 22 publications on APIs or API combinations met the eligibility criteria (19 head-to-head clinical trials, one pooled analysis, one health-economic modelling study and one systematic review). Significant clinical benefit associated with the use of a reformulated API over an older formulation was reported in three trials of clobetasol propionate, one trial of calcipotriol, three trials of betamethasone and five trials/pooled analyses of calcipotriol/calcipotriene + betamethasone dipropionate (Cal/BD) formulations. Significantly improved PROs associated with the use of a reformulated API over an older formulation were reported in three trials of clobetasol propionate, one trial of betamethasone valerate and two trials of Cal/BD formulations. These results demonstrate that the innovative reformulation of APIs used in the treatment of psoriasis can produce therapies that attain significantly improved clinical outcomes and PROs. This suggests that improvement in topical therapy for psoriasis need not only to be achieved by the identification of new targets and the development of new APIs, but that improvement in the vehicle used to deliver existing APIs has the potential to result in significant clinical and patient benefits.

We describe a patient with a generalized bullous form of Fixed Drug Eruption (FDE) induced by bromhexine, a commonly used drug for respiratory symptoms. This is a rare association and generalized bullous FDE is also very rare. We emphasize the importance of patch tests in identifying the culprit drug.

legend N2D N1D 2LPEG N2D vs. 2LPEG N1D vs. 2LPEG EFFICACY Primary analysis set, n1⁄4 275 Primary analysis set, n1⁄4 275 Primary analysis set, n1⁄4 272 Primary endpoint: Patients with successful overall bowel cleansing efficacy (HCS) [n] 253 (92.0%) 245 (89.1%) 238 (87.5%) -4.00%* [0.055] -6.91%* [0.328] Supportive secondary endpoint: Patients with successful overall bowel cleansing efficacy (BBPS) [n] 249 (90.5%) 243 (88.4%) 232 (85.3%) n.a. n.a. Primary endpoint: Excellent plus Good cleansing rate in colon ascendens (primary analysis set) [n] 87 (31.6%) 93 (33.8%) 41 (15.1%) 8.11%* [50.001] 10.32%* [50.001] Key secondary endpoint: Adenoma detection rate, colon ascendens 11.6% 11.6% 8.1% -4.80%; 12.00%** [0.106] -4.80%; 12.00%** [0.106] Key secondary endpoint: Adenoma detection rate, overall colon 26.6% 27.6% 26.8% -8.47%; 8.02%** [0.569] -7.65%; 9.11%** [0.455] Key secondary endpoint: Polyp detection rate, colon ascendens 23.3% 18.6% 16.2% -1.41%; 15.47%** [0.024] -6.12%; 10.82%** [0.268] Key secondary endpoint: Polyp detection rate, overall colon 44.0% 45.1% 44.5% -8.85%; 8.00%** [0.579] –7.78%; 9.09%** [0.478] Compliance rates (min 75% of both doses taken) [n] 235 (85.5%) 233 (84.7%) 245 (90.1%) n.a. n.a. SAFETY Safety set, n1⁄4 262 Safety set, n1⁄4 269 Safety set, n1⁄4 263 All treatment-emergent adverse events [n] 77 89 53 n.a. n.a. Patients with any related treatment-emergent adverse event [n] 30 (11.5%) 40 (14.9%) 20 (7.6%) n.a. n.a. *1⁄4 97.5% 1-sided CI; **1⁄4 95% 2-sided CI; n.a.1⁄4 not applicable. United European Gastroenterology Journal 4(5S) A219

cuits and the pacemaker defaults to 85 beats per minute. The devices return to normal operation once the magnetic field is removed. As can be seen in Table 1, no DC or AC magnetic fields of any significant level > 6 G or orientation were detected at the position of the patient or adjacent to the cubicle. The only reading > 6 G was measured next to, indeed virtually touching, the fan motor with the covers removed. It is unlikely that any patient would enter the cubicle with the covers removed. Our measurements indicate that treatment in these types of UV therapy cabinets is safe for patients fitted with electrical implanted devices, such as pacemakers. Additionally, it is safe for the operators of the cubicles and any person who may accompany the patient.

P346 Short term dose tailoring of anti TNF-a therapy delivers useful clinical efficacy in Crohn’s disease patients with secondary loss of response S. Ghaly1 *, S. Costello2, L. Beswick3, A. Pudipeddi4, A. Agarwal2, A. Sechi5, B. Headon3, R. Prosser6, S. Connor5, I.C. Lawrance7, M. Sparrow3, P. Bampton6, A. Walsh4, J. Andrews2. 1St. Vincent’s Hospital, University of New South Wales, Department of Gastroenterology, Sydney, Australia, 2Royal Adelaide Hospital, Department of Gastroenterology, Adelaide, Australia, 3The Alfred Hospital, Department of Gastroenterology, Melbourne, Australia, 4St. Vincent’s Hospital, Department of Gastroenterology, Sydney, Australia, 5Liverpool Hospital, Department of Gastroenterology, Sydney, Australia, 6Flinders Medical Centre, Department of Gastroenterology, Adelaide, Australia, 7Fremantle Hospital, Centre for Inflammatory Bowel Disease, Fremantle, Australia

Journal Article Narrowband ultraviolet B treatment for psoriasis increases serum vitamin A levels Get access S. Magina, S. Magina Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200‐319 Porto, PortugalInstitute for Molecular and Cell Biology, University of Porto, Rua do Campo Alegre 823, 4150‐180 Porto, PortugalDepartment of Dermatology and Venereology, University of Porto, Alameda Prof. Hernâni Monteiro, 4200‐319 Porto, Portugal E‐mail: smagina@med.up.pt Search for other works by this author on: Oxford Academic Google Scholar M.J. Cruz, M.J. Cruz Department of Dermatology and Venereology, University of Porto, Alameda Prof. Hernâni Monteiro, 4200‐319 Porto, Portugal Search for other works by this author on: Oxford Academic Google Scholar F. Azevedo, F. Azevedo Department of Dermatology and Venereology, University of Porto, Alameda Prof. Hernâni Monteiro, 4200‐319 Porto, Portugal Search for other works by this author on: Oxford Academic Google Scholar D. Moura, D. Moura Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200‐319 Porto, Portugal Search for other works by this author on: Oxford Academic Google Scholar E. Moura, E. Moura Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200‐319 Porto, PortugalInstitute for Molecular and Cell Biology, University of Porto, Rua do Campo Alegre 823, 4150‐180 Porto, Portugal Search for other works by this author on: Oxford Academic Google Scholar M.A. Vieira‐Coelho M.A. Vieira‐Coelho Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Porto, Alameda Prof. Hernâni Monteiro, 4200‐319 Porto, PortugalInstitute for Molecular and Cell Biology, University of Porto, Rua do Campo Alegre 823, 4150‐180 Porto, Portugal Search for other works by this author on: Oxford Academic Google Scholar British Journal of Dermatology, Volume 167, Issue 4, 1 October 2012, Pages 958–960, https://doi.org/10.1111/j.1365-2133.2012.11006.x Published: 01 October 2012

We describe 5 cases of anti-tumor necrosis factor-alpha (anti-TNF-α) induced psoriasiform eruptions with severe scalp involvement inducing inflammatory alopecia and review the literature on this subject. All our 5 patients were provided topical therapy, with good results in only 1 case. The remaining 4 were provided systemic therapy (methotrexate ± cyclosporine): 3 concomitantly suspended the anti-TNF-α treatment (2 are currently clear/almost clear but 1 has so far only observed mild improvement) and 1 switched anti-TNF-α (recurrent flare-ups of the disease continue). So far, no patient has developed scarring alopecia. To our knowledge, a total of 15 cases of anti-TNF-α induced psoriatic alopecia have been described. Anti-TNF-α was discontinued in 9 of the 15 patients and systemic therapy was provided to 9 of the 15 patients. Nonetheless, 2 patients developed scarring alopecia. We conclude that in anti-TNF-α induced psoriasiform eruptions some patients may respond to topical treatment, however in cases of severe scalp involvement anti-TNF-α suspension and systemic treatment should be considered in order to avoid scarring alopecia.

Background: Acne fulminans is a rare and exuberant variant of acne, mainly affecting young males with a previous history of acne vulgaris. It is a systemic disease of unknown etiology characterized by necrotizing acne associated with constitutional symptoms and laboratory abnormalities. Case report: Fourteen-year-old male adolescent with no previous history of acne, admitted to Paediatric Department of Hospital S. João - Porto for acne fulminans. Three weeks ago, he had consulted a Dermatologist due to the appearance of painful papular and pustular lesions on the face and anterior chest, along with low-grade fever. He was treated with amoxicillin/clavulanic acid, isotretinoin and prednisolone, with no improvement. Complementary exams showed leukocytosis with neutrophilia and elevated C-reactive protein and transaminases. In the dermatological exam, exuberant and exudative ulcerated and crusted lesions were observed localized on the trunk and, with less intensity, on the face and neck. Systemic prednisolone in higher doses, isotretinoin and topical treatment with polyurethane dressings were instituted, with clinical improvement and gradual involution of skin lesions. The therapy with isotretinoin was maintained for up to 4 months and the therapy with systemic glucocorticoid was maintained for 2 weeks and then progressively tapered. Comments: The authors describe a clinical case of acne fulminans in a male adolescent, with exuberant dermatological lesions and good therapeutic response to systemic corticoid, isotretinoin and topical treatment. Early diagnosis of acne fulminans and appropriate therapeutic intervention are essential for effective disease control to avoid deforming residual scars and to minimize the risk of recurrence.