Comparison of Skindex-29, Dermatology Life Quality Index, Psoriasis Disability Index and Medical Outcome Study Short Form 36 in patients with mild to severe psoriasis

Background Severity assessment of patients with psoriasis is a critical issue. Classical clinical assessment has recently been combined with quality of life (QoL) scores, but several instruments are used. Moreover, studies have focused on patients with moderate to severe psoriasis. Objectives To compare the characteristics of QoL instruments in patients with the full range of psoriasis severity attending dermatology clinics. Methods Observational, prospective, multicentre study. Patients completed Skindex‐29 (anchor) and a second instrument randomly selected from Dermatology Life Quality Index (DLQI), Psoriasis Disability Index (PDI) and Medical Outcome Study Short Form 36 (SF‐36). Results Demographic data, Psoriasis Area and Severity Index and affected body surface area were not different between the three groups. Skindex‐29 showed a weak but significant correlation with clinical severity; only PDI showed similar correlation. PDI, DLQI and SF‐36 showed a substantial floor effect in patients with mild to severe psoriasis. Skindex‐29 showed strong correlations with the other three QoL instruments. SF‐36 was more sensitive than the other instruments in detecting worse QoL in male patients. Conclusions Skindex‐29 has better sensitivity to clinical severity with minimal floor effect, and covers the main domains explored by the other three QoL instruments in patients with mild to severe psoriasis.     

Development and pilot-testing of a psoriasis screening tool

Background There is a need to validate psoriasis self‐reports in epidemiological studies, where individuals may not be seeing dermatologists or other health care providers. Objectives To develop and pilot test the Psoriasis Screening Tool (PST) in an ambulatory setting. Patients and methods The PST was designed with eight closed‐ended questions requiring a ‘yes’ or ‘no’ response. Typical images of skin, nail and scalp changes in psoriasis were included with respective questions. We administered the PST to 222 consecutive individuals being seen at a dermatology clinic. All English‐speaking subjects completed the PST without assistance. A board‐certified dermatologist established the diagnosis of psoriasis or excluded psoriasis in all participants. Results A total of 222 completed PST questionnaires were included for analysis. There were 111 individuals in the psoriasis group and 111 individuals in the nonpsoriasis group. A combination of three questions resulted in a sensitivity of 96·4% [95% confidence interval (CI) 93·2–98·0] and specificity of 97·3% (95% CI 94·1–98·9) for psoriasis. Adding a pictorial question increased the sensitivity of the screening tool to 98·2% (95% CI 95·0–99·5). Of the 111 individuals with psoriasis, 69% answered yes to having plaque‐type psoriasis, 50% answered yes to having nail involvement, 66% answered yes to having scalp involvement, and 59% answered yes to having inverse‐type psoriasis. Conclusions This pilot study suggests that the PST can distinguish individuals with psoriasis from individuals without psoriasis in an English‐speaking population being seen at an outpatient dermatology clinic. Furthermore, the PST may be used to identify psoriasis phenotypes. Although the PST may be limited by spectrum bias in this pilot study, we believe it remains a reliable tool to collect information on psoriasis in remote populations.     

Quality of life in Dutch women with lichen sclerosus

Background Lichen sclerosus (LS) is a chronic inflammatory skin disease. Earlier studies have shown an impaired health‐related quality of life (HRQoL), but more extensive research including generic questionnaires has not been reported. Objectives To investigate, in a cross‐sectional study, the HRQoL of a sample of Dutch women with LS; to compare the resulting HRQoL data with that available from other skin diseases and the general Dutch population; to explore factors that may influence the HRQoL. Methods Female members of the Dutch LS Foundation and Support Group filled out three questionnaires electronically: the Skindex‐29, the SF‐12 and the EQ‐5D visual analogue scale (VAS). We distinguished Skindex‐29 scores into groups with ‘little’ (score 0–24), ‘mild’ (25–31), ‘moderate’ (32–43) and ‘severe’ (44–100) impact on HRQoL. We compared differences using the Mann–Whitney U‐test and the Kruskal–Wallis test, and correlations using Spearman’s rank correlation coefficient. Results A total of 262 women with LS were included. The average diagnostic delay was 4·9 (SD 7·1) years. Patients had a mean total Skindex‐29 score of 38·4 (0–100, SD 17·2). Domain scores for symptoms, emotions and functioning were 46·8 (SD 19·0), 38·2 (SD 20·2) and 33·6 (SD 19·3), respectively. The SF‐12 showed average PCS‐12 (physical component) and MCS‐12 (mental component) scores of 47·7 and 48·5, respectively. For the Dutch population these scores were 49·3 and 52·3. The mean EQ‐5D VAS score was 74·1 (SD 15·4). Conclusions There is a considerable delay in diagnosis for female Dutch patients with LS. The Skindex‐29 domain scores showed a moderately impaired HRQoL. Women with LS reported a lower generic HRQoL than the average female Dutch population.     

Serum leptin levels, skin leptin and leptin receptor expression in psoriasis

Background Recent studies support the relation of psoriasis with obesity and cardiovascular disease. Leptin, a peptide hormone secreted predominantly from adipose tissue, is involved in the regulation of energy intake and expenditure. Recently, it has been shown to have several immunological effects including induction of proinflammatory cytokine production. Objectives To investigate the possible role of leptin in psoriasis pathogenesis. Methods Forty‐three patients with psoriasis, 10 diseased and 10 healthy controls with normal body mass index were included. Serum fasting leptin levels of the study group were examined by enzyme‐linked immunosorbent assay. Tissue leptin and leptin receptor expression of both patients and controls were investigated by immunohistochemistry. Results Serum leptin levels, tissue leptin and leptin receptor expression were significantly higher in patients with severe psoriasis than patients with mild–moderate psoriasis and controls (P < 0·05). Serum leptin levels showed a positive correlation with Psoriasis Area and Severity Index and involved body surface area in patients with psoriasis. In addition, serum leptin levels, tissue leptin and leptin receptor expression showed a positive correlation with disease duration in patients with psoriasis (P < 0·01, r = 0·979; P < 0·01, r = 0·691; P < 0·01, r = 0·428, respectively). Conclusions We assume that leptin might serve as a marker of severity in psoriasis and also may be a pathogenetic cofactor contributing to chronicity of the disease. Consequently, its role in obesity and cardiovascular disease in patients with psoriasis deserves to be studied. In addition, drugs targeting the proinflammatory effects of leptin may be a new adjuvant therapeutic approach in psoriasis.     

Ustekinumab does not increase body mass index in patients with chronic plaque psoriasis: a prospective cohort study

Background Chronic plaque psoriasis is frequently associated with metabolic disorders including obesity. Antitumour necrosis factor α treatments can induce body‐weight increase in patients with psoriasis. Information on the effect of ustekinumab on body weight is not available. Objectives To investigate whether therapy with ustekinumab is associated with changes in body mass index (BMI) in patients with chronic plaque psoriasis. Methods A prospective, multicentre study comparing the changes in BMI in two closed cohorts of patients with psoriasis during 7‐month treatment with ustekinumab (n = 79) or infliximab (n = 83). Results Patients treated for 7 months with infliximab showed a significant (P < 0·001) increase in mean BMI (2·1 ± 4·5%) and body weight (2·5 ± 3·3 kg) compared with patients treated with ustekinumab (0·1 ± 3·3%; 0·6 ± 1·1 kg). Some 45% of patients treated with infliximab had a BMI increase > 2%, compared with only 11% of those receiving ustekinumab (P = 0·01). In the multivariate analysis, all other clinical parameters predicted the BMI increase, except for the use of infliximab. At month 7, 96% of patients treated with infliximab and 82% of patients treated with ustekinumab achieved at least a 50% improvement from their baseline psoriasis area and severity index (PASI 50), and 69% of the infliximab group compared with 58% of the ustekinumab group achieved at least PASI 75. There was no difference in the proportion of PASI 50 and PASI 75 responders between the two groups. Conclusions In contrast to infliximab, ustekinumab does not increase BMI in patients with chronic plaque psoriasis. This difference could be taken into account in the selection of biologics when treating patients with psoriasis.     

Willingness-to-pay and quality of life in patients with vitiligo

Background Vitiligo is a chronic pigmentary disorder of the skin, affecting 1–2% of the general population. Although not life threatening, vitiligo may considerably influence patients’ health‐related quality of life (QoL) and psychological well‐being. Willingness‐to‐pay (WTP) is a construct reflecting disease burden and QoL reduction which has not yet been used in vitiligo. Objectives To assess the WTP and the QoL of patients with vitiligo. Methods Patients with vitiligo were included in a nationwide German postal survey. WTP was assessed by two standardized items, and QoL was evaluated using the Dermatology Life Quality Index (DLQI) and the EuroQol (EQ‐5D) questionnaire. QoL data were compared with n = 1511 patients from a national survey on psoriasis. Results The questionnaire was completed by 1023 patients (71·5% women, mean age 44·4 years, mean disease duration 20·3 years) with vitiligo. The mean DLQI was 7·0 (7·5 in women, 5·5 in men) compared with 8·6 in psoriasis. Of the patients with vitiligo, 24·6% had a DLQI > 10 which indicates severe QoL reductions, compared with 34·1% in patients with psoriasis. The highest mean DLQI value was observed in the patient group aged 20–29 years. EQ‐5D mean score was 83·6 compared with 75·3 in psoriasis. Of the patients with vitiligo, 32·9% would pay more than 5000 Euro in order to achieve complete disease remission. WTP was highest among middle‐aged patients (30–60 years). There was a significant correlation between DLQI scores and WTP (χ² = 65·43, P < 0·001). Moreover, WTP significantly correlated with duration of disease, and with body surface area affected (P < 0·001). Conclusions Vitiligo causes substantial disease burden as reflected by QoL impairment and high WTP, especially in women. These results should draw the attention of physicians to this disease, as appropriate education and treatment are likely to improve the QoL of patients with vitiligo and may support patients’ compliance and empowerment.     

Nail psoriasis in Germany: epidemiology and burden of disease

Background Although nail psoriasis affects a marked proportion of patients with psoriasis and causes significant psychological stress, only few epidemiological data characterizing patients with nail involvement are available. Objectives To gain robust data on the epidemiology and disease burden of nail psoriasis in Germany. Methods Two nationwide, noninterventional, cross‐sectional studies on psoriasis health care were conducted in 2005 and 2007, involving 48 (2005) and 130 (2007) German office‐based and clinic‐based dermatological centres. Data of n = 3531 patients with psoriasis were collected using standardized questionnaires and physical examinations by trained dermatologists. Patients with nail psoriasis were compared with patients without any nail involvement concerning sex, age, disease duration, family history, disease severity, presence of psoriatic arthritis (PsA), health‐related quality of life (HRQoL), number of inpatient therapies, and days off work. Results Nail psoriasis was diagnosed in 40·9% of the patients; prevalence was 11·2 percentage points higher in men than in women. Patients with nail involvement had a longer disease duration (21·9 vs. 18·1 years), higher disease severity (mean Psoriasis Area and Severity Index 12·7 vs. 9·3), higher frequency of PsA (26·0% vs. 12·7%), stronger impairment of HRQoL (mean Dermatology Life Quality Index 8·9 vs. 7·3), and a 2·5‐fold higher rate of inpatient treatments. Conclusions Nail involvement is a relevant manifestation of psoriasis and is associated with a higher disease severity and quality of life impairment. Accordingly, management of psoriasis should include a special focus on nail involvement.     

Quality of life in patients with epidermolysis bullosa

Background Epidermolysis bullosa (EB) is a rare, inherited group of disorders characterized by blistering of the skin following friction or mechanical trauma. EB has a clinical and socioeconomic impact on patients and their families. Objectives To assess the quality of life (QoL) in patients with EB and to determine disease burden. Methods The study was an observational, cross‐sectional postal survey. One hundred and eighty‐five patients were invited to participate. Different sets of questionnaires [Short Form‐36 (SF‐36), Skindex‐29, General Health Questionnaire‐12 (GHQ‐12), EuroQol 5 dimensions] were sent to patients according to age. The perceived severity of the disease was evaluated by patients or by the mothers of the younger children with EB, using the Patient Global Assessment five‐point scale. Carers received the Family Strain Questionnaire. Results One hundred and twenty‐five respondents were analysed. Patients with EB showed lower values in physical components of the SF‐36, while the mental components were not significantly impaired. Among EB types, patients with junctional EB and severe generalized recessive dystrophic EB reported lower values and their GHQ‐12 scores were significantly different from those of patients with EB simplex. There were no significant differences among EB types/subtypes for Skindex‐29 values. Women had a worse QoL compared with men in all Skindex‐29 and SF‐36 scales (P < 0·05). GHQ‐positive cases were more frequent among women (48%) compared with men (16%) (P = 0·003); GHQ‐positive cases had a worse QoL compared with GHQ‐negative patients. The patient QoL decreased and the family burden increased with increasing patient perceived disease severity and with increasing patient body surface involved. No differences were seen among EB types for the family burden. Conclusions In patients with EB mental components of SF‐36 scores are similar to the normal population. The perceived disease severity and skin area involved are relevant for QoL in all EB types/subtypes. EB imposes a heavy burden on the caregiver and the family. Psychological support and close monitoring of QoL may help patients with EB and their carers.     

Is the prevalence of psoriasis increasing? A 30‐year follow‐up of a population‐based cohort

Background  There is indication of an increasing prevalence of psoriasis in some western populations. However, the results are not conclusive. Objectives  To analyse trends in the prevalence of psoriasis over the past 30 years, separating age, birth cohort and time period effects. Methods  Five population‐based surveys in North Norway, the Tromsø Studies 2–6, collected between 1979 and 2008, were studied. Participants aged 20–79 years with self‐reported psoriasis data in at least one of the surveys were included, yielding a total of 69 539 observations from 33 387 unique individuals born between 1915 and 1977. Trends in psoriasis prevalence were examined using cross‐sectional, time lag and longitudinal designs of graphical plots. Observed trends were further evaluated in generalized linear‐regression models. Results  The self‐reported lifetime prevalence of psoriasis increased from 4·8% in 1979–1980 to 11·4% in 2007–2008. Graphical plots showed an increasing prevalence of psoriasis with each consecutive survey in all examined age groups and birth cohorts, leaving time period effects as the explanation for the increase. The odds for psoriasis in the cohort were 2·5 times higher in 2007–2008 than in 1979–1980 (adjusted odds ratio 2·49, 95% confidence interval 2·08–2·99). The prevalence of persons reporting a doctor’s diagnosis of psoriasis was 9·9% in the last survey. In subgroups of the study population, psoriasis was associated with higher body mass index, lower physical activity during work and leisure time, lower educational level and smoking. Conclusions  Our findings indicate an increasing prevalence of self‐reported psoriasis. This could represent a true increase in prevalence, possibly due to changes in lifestyle and environmental factors, or an increased awareness of the disease.     

Effect of narrowband ultraviolet B therapy on inflammatory markers and body fat composition in moderate to severe psoriasis

Background Previous studies have shown increased prevalence of metabolic syndrome in patients with psoriasis. Objectives To characterize the anthropometric and metabolic profile of Spanish patients with moderate to severe psoriasis compared with controls without psoriasis matched for gender, age and body mass index (BMI), and to evaluate the impact of narrowband ultraviolet B (NB‐UVB) therapy on patient profiles. Methods Baseline waist circumference, body fat composition, lipid, carbohydrate and calcium metabolism profile, inflammation markers, homocysteine, vitamins D, B₆ and B₁₂ and folic acid of 50 patients with psoriasis and 50 matched controls were recorded then evaluated after NB‐UVB in patients with psoriasis and correlated with clinical outcome. Results Despite very similar BMIs, 54% of patients met International Diabetes Foundation criteria for metabolic syndrome compared with 42% of controls (P = 0·01); body fat was 29·9% in patients and 28·0% in controls (P = 0·037), correlating with waist circumference; while patient atherogenic profiles were less favourable, with higher apolipoprotein B and low density lipoprotein cholesterol than controls, and both patients and controls showed insufficient vitamin D serum levels (< 20 ng mL^?1). Mean improvement of Psoriasis Area and Severity Index (PASI) after NB‐UVB was 78·2%. Ferritin, B₁₂ and C‐reactive protein decreased significantly after NB‐UVB therapy. Vitamin D levels reached adequate levels after phototherapy; however, no relationship with PASI improvement was observed. Conclusions We characterized inflammatory and atherogenic profiles of Spanish patients with psoriasis compared with matched controls. After NB‐UVB therapy we demonstrated improvement in psoriasis and some systemic inflammation markers, which were not mediated by enhancement of vitamin D synthesis.     

The effects of chronic periodontitis and its treatment on the subsequent risk of psoriasis

Background Although psoriasis and chronic periodontitis (CP) may share an underlying immune dysregulation as part of their pathologies, to date only one small‐scale cross‐sectional pilot study has investigated the potential association between CP and psoriasis. Objectives This study aimed to investigate the subsequent risk for psoriasis following a diagnosis of CP by utilizing a cohort study design and population‐based dataset in Taiwan. Methods In total, 115 365 patients with CP were included in the study cohort and 115 365 patients without CP were included in the comparison cohort. We individually tracked each patient for a 5‐year period to identify those who had subsequently received a diagnosis of psoriasis. A Cox proportional hazards regression was performed to compute the 5‐year risk of subsequent psoriasis following a diagnosis of CP. Results We found that the incidence rate of psoriasis during the 5‐year follow‐up period was 1·88 [95% confidence interval (CI) 1·77–1·99] per 1000 person‐years in patients with CP and 1·22 (95% CI 1·14–1·32) per 1000 person‐years in comparison patients. After censoring those who died during the follow‐up period, and adjusting for monthly income and geographical region, compared with comparison patients, the hazard ratio (HR) of psoriasis for patients with CP was 1·52 (95% CI 1·38–1·70). Furthermore, the study subjects who had undergone a gingivectomy or periodontal flap operation had only a slightly higher adjusted risk of psoriasis than comparison patients (HR 1·26). Conclusions This study detected an increased risk for psoriasis among patients with CP. Treatment for CP attenuated, but did not nullify, the risk for subsequent psoriasis.     

A prospective case‐controlled cohort study of endothelial function in patients with moderate to severe psoriasis

Background There is well‐documented evidence that patients with moderate and severe psoriasis have a significantly increased risk of cardiovascular disease (CVD). While this risk can, at least in part, be attributed to the high prevalence of traditional risk factors in the population with psoriasis, some epidemiological evidence suggests it may be independent of these. Objectives This prospective, case‐controlled study investigates whether psoriasis is a risk factor for CVD using two, validated, sensitive markers of CVD, endothelial dysfunction and high‐sensitivity C‐reactive protein (hsCRP). Methods Patients were recruited from a tertiary referral psoriasis clinic and exclusion criteria included established CVD and/or conventional risks for CVD. Preclinical CVD was assessed using flow‐mediated brachial artery dilatation, which measures endothelial dysfunction, and hsCRP, a serological marker of atherosclerosis. Results Sixty‐four patients (22%) out of a total of 285 consecutive patients attending the severe psoriasis clinic were entered into the study. One hundred and sixty‐one (56%) were excluded following identification of cardiovascular risk; 39 of the 161 (24%) had at least two cardiovascular risk factors. A further 16 (6%) patients were excluded because of established CVD. No statistically significant difference in endothelial dysfunction was observed between patients with psoriasis (n = 60) and healthy controls (n = 117) (P = 0·508). The hsCRP level was, however, significantly elevated in the psoriasis group (2·828 mg L^?1, SEM 0·219; controls 0·728 mg L^?1, SEM 0·142; P < 0·05). Conclusion This large, investigative study is the first to assess endothelial function in patients with psoriasis after exclusion of traditional risk factors for CVD. These data suggest that psoriasis per se is not a risk factor for CVD and that elevated hsCRP is possibly independent of atheroma risk. There was a high prevalence of traditional risk factors in our population with severe psoriasis.     

Itch Severity Scale: a self-report instrument for the measurement of pruritus severity

Background Assessing pruritus severity is difficult because of its subjective nature. A questionnaire that takes into account how the symptom is perceived by the patient may provide a more accurate representation of the pruritus. However, recently developed questionnaires do not specifically quantify severity of the symptom. Objectives To develop a self‐report questionnaire to measure pruritus severity and to provide initial evidence of its validity and reliability. Methods We modified a previously developed interview for the characterization and evaluation of pruritus, which was completed along with the RAND‐36 Health Status Inventory and Dermatology Life Quality Index by patients with psoriasis‐associated pruritus. Exploratory factor analysis, studies of internal consistency, and correlation analyses with health‐related quality of life scores were used to help determine which components of the modified pruritus interview to include in the new questionnaire, the Itch Severity Scale (ISS). The ISS was then assessed for construct validity, internal consistency reliability and test–retest reliability. Results Seven of the initial 11 components of the modified pruritus interview were included in the ISS. ISS scores correlated moderately with physical (r = −0·483) and mental (r = −0·492) health composite scores of the RAND‐36 and strongly with Dermatology Life Quality Index scores (r = 0·628), evidence of construct validity. It had an internal consistency reliability of 0·80 and a test–retest reliability of 0·95. Conclusions Based on this preliminary evidence of validity and reliability, this new seven‐item ISS may be useful in comparing pruritus severity among different disease populations or in assessing pruritus treatment effectiveness.     

Medium-dose ultraviolet (UV) A1 vs. narrowband UVB phototherapy in atopic eczema: a randomized crossover study

Background Ultraviolet (UV) A1 and narrowband (NB)‐UVB have been reported to be effective treatments for atopic eczema (AE). Objectives We aimed to compare the efficacy of medium‐dose UVA1 and NB‐UVB mono‐phototherapy in patients with AE. Methods A randomized double‐blind controlled crossover trial (ClinicalTrials.gov Identifier: NCT00419406) was conducted in which patients with AE received a 6‐week course of both medium‐dose UVA1 and NB‐UVB. Clinical efficacy was assessed using the Six Area, Six Sign, Atopic Dermatitis (SASSAD) score and a visual analogue scale for pruritus. Assessment of health‐related quality of life was performed using the Skindex‐29. Total immunoglobulin E (IgE) and eosinophilic cationic protein (ECP) were evaluated at baseline and after each phototherapy course. Results Twenty‐eight patients who completed both UVA1 and NB‐UVB phototherapy courses on an intention‐to‐treat basis were analysed according to the crossover design. Both interventions were associated with significant clinical improvement but there was no significant difference between treatments with respect to the mean ± SD relative reduction (RR) of the clinical scores (SASSAD, 43·7 ± 31·4% vs. 39·4 ± 24·1%, P = 0·5; pruritus score, 16 ± 61·8% vs. 25·2 ± 30·5%, P = 0·5, respectively). There was no significant difference in the mean ± SD RR of the Skindex‐29 after UVA1 and NB‐UVB phototherapy (12·7 ± 18·8% vs. 16·5 ± 17·6%, P = 0·1). Changes in the total IgE and ECP levels following UVA1 and NB‐UVB did not differ significantly (P = 0·3 and P = 0·9, respectively). Conclusions A 6‐week course of NB‐UVB and UVA1 phototherapy of AE resulted in significant clinical improvement. With regard to efficacy and tolerability, both phototherapeutic modalities may be considered comparably good.     

An assessment of adalimumab efficacy in three Phase III clinical trials using the European Consensus Programme criteria for psoriasis treatment goals

Background The European Consensus Programme (ECP) established pan‐European consensus definitions of psoriasis disease severity and treatment goals among 19 psoriasis experts from European nations. Objectives To use the ECP treatment goals to retrospectively assess adalimumab efficacy in patients who participated in Phase III clinical trials and met ECP criteria for moderate to severe psoriasis. Methods Three trials were analysed: CHAMPION (n = 108), REVEAL (n = 814) and BELIEVE (n = 364). Moderate to severe psoriasis was defined as Dermatology Life Quality Index (DLQI) score > 10, with either > 10% body surface area involvement or Psoriasis Area and Severity Index (PASI) score > 10. Treatment goals were achieved with either treatment success (≥ 75% PASI score reduction) or intermediate response (PASI response ≥ 50% and < 75%) with DLQI ≤ 5. Results The percentages of patients who achieved treatment goals at week 16 in CHAMPION, REVEAL and BELIEVE were, respectively, (i) treatment success, 79·3%, 72·1% and 68·2%; (ii) intermediate response, 1·7%, 5·0% and 5·0%; or (iii) either goal, 81·0%, 77·1% and 73·2%. DLQI ≤ 5 at week 16 was achieved by 70·7%, 70·1% and 67·4% of patients, respectively. Differences between the percentages of adalimumab‐ vs. placebo‐treated patients achieving treatment success were statistically significant (P < 0·001) from week 4 and week 8 of REVEAL and CHAMPION, respectively. Conclusions Treatment success was achieved by > 93% of patients who attained treatment goals. At week 16 > 70% of patients achieved ECP treatment goals and met ECP criteria for continued treatment without modification. These results support the utility of ECP treatment goals for the assessment of therapeutic efficacy in moderate to severe psoriasis.     

Psoriasis and smoking: a systematic review and meta‐analysis

Psoriasis is an inflammatory skin disease associated with increased cardiovascular comorbidity. Smoking is associated with an increased risk of cardiovascular disease, and prior studies have suggested that patients with psoriasis are more likely to be active smokers. Smoking may also be a risk factor in the development of psoriasis. We conducted a systematic review and meta‐analysis to assess the prevalence of smoking among patients with psoriasis, and we reviewed the contribution of smoking to the incidence of psoriasis. A total of 25 prevalence and three incidence studies were identified. The meta‐analysis of prevalence studies included a total of 146 934 patients with psoriasis and 529 111 patients without psoriasis. Random effects meta‐analysis found an association between psoriasis and current smoking [pooled odds ratio (OR) 1·78, 95% confidence interval (CI) 1·52–2·06], as well as between psoriasis and former smoking (pooled OR 1·62, 95% CI 1·33–1·99). Meta‐regression analysis did not reveal any sources of study heterogeneity, but a funnel plot suggested possible publication bias. A subset of studies also examined the association between moderate‐to‐severe psoriasis and smoking, with a pooled OR of 1·72 (95% CI 1·33–2·22) for prevalent smoking. The three incidence studies found an association between smoking and incidence of psoriasis, with a possible dose‐effect of smoking intensity and duration on psoriasis incidence. These findings suggest that smoking is an independent risk factor for the development of psoriasis, and that patients with established psoriasis continue to smoke more than patients without psoriasis.     

Randomized controlled trial comparing the effectiveness of 308-nm excimer laser alone or in combination with topical hydrocortisone 17-butyrate cream in the treatment of vitiligo of the face and neck

Background Vitiligo is a pigmentary disorder which may have disfiguring consequences. Its treatment remains a challenge. Objectives We designed a parallel‐group randomized controlled trial to compare the effectiveness of 308‐nm excimer laser alone or in combination with topical hydrocortisone 17‐butyrate cream in patients with vitiligo unresponsive to previous treatment with topical steroids or narrow‐band ultraviolet (UV) B phototherapy. Methods Consecutive patients aged 18–75 years with nonsegmental vitiligo localized on the face and/or neck lacking response to previous conventional treatment were eligible. In total, 84 patients (44 women and 40 men, mean age 44 years) were randomized to 308‐nm excimer laser phototherapy twice weekly alone or in combination with topical hydrocortisone 17‐butyrate cream twice daily for three periods of 3 weeks followed by a 1‐week steroid‐free interval. The primary outcome was a reduction of at least 75% of the overall lesional areas as judged by automatic image analysis on reflected UV photographs, conducted blind to treatment assignment, at 12 weeks compared with baseline. Secondary outcomes were clearance, and improvements on Physician’s Global Assessment (PGA) and Skindex‐29 scores. Results A total of 76 (90%) patients completed the study. In an intention‐to‐treat analysis, seven [16·6%; 95% confidence interval (CI) 5·3–27·8%] patients in the excimer monotherapy arm and 18 (42·8%; 95% CI 27·8–57·8%) in the combination arm showed ≥ 75% reduction of vitiligo lesions at 12 weeks (χ² test 6·89, P = 0·0087). Clearance was observed in two (4·7%; 95% CI 1·6–11·2%) and nine (21·4%; 95% CI 9·0–33·8%) patients, respectively (Fisher’s exact test P = 0·04). A significant difference also emerged for PGA scores, while no difference was documented for Skindex‐29. Conclusions Recalcitrant vitiligo of the face and neck may benefit from the combination of excimer laser phototherapy with topical hydrocortisone 17‐butyrate cream.     

Measuring disease activity and damage in discoid lupus erythematosus

Background Discoid lupus erythematosus (DLE) is a disfiguring inflammatory skin disease. There is no specific tool for measuring disease severity. Objectives To determine the features needed in a score measuring activity and damage in DLE and to investigate the score’s reliability and its correlation with the physician’s global assessment of disease severity and the patient‐reported Dermatology Quality of Life Index (DLQI). Methods The content of the score was determined following a peer review, pilot work in patients and a preliminary inter‐rater reliability study. The Score of Activity and Damage in DLE (SADDLE) measures severity of activity (erythema, scale, induration) and damage (scarring/atrophy and dyspigmentation) attributable to DLE. Summed scores range between 0 and 195. Inter‐ and intrarater reliability of the score was tested using six assessors and nine patients with DLE. Intraclass correlation coefficients (ICCs) > 0·7 were considered evidence of good inter‐ and intrarater agreement. Results The mean ± SD SADDLE score of nine patients in the inter‐rater reliability study was 47 ± 22 (range 14–102). There was good inter‐rater agreement for the total score [ICC 0·82; 95% confidence interval (CI) 0·61–0·95] and for the activity and damage scales, the individual physical signs and the total scores at individual body sites. The total score demonstrated excellent intrarater reliability (ICC 0·98; 95% CI 0·86–1·00). Although there was poor inter‐rater agreement for global assessments (ICC 0·28; 95% CI 0·06–0·66), a good correlation was demonstrated between total scores and global assessments (r = 0·7). A weaker positive correlation was observed between disease activity scores and DLQI (r = 0·4). Conclusions The SADDLE measures activity and damage in patients with DLE. It demonstrates good inter‐ and excellent intrarater agreement, over and above that for global assessment. It correlates well with global assessment scores. Further studies are required to investigate SADDLE’s responsiveness to change with therapy.     

Narrowband ultraviolet B treatment improves vitamin D balance and alters antimicrobial peptide expression in skin lesions of psoriasis and atopic dermatitis

Background Narrowband ultraviolet B (NB‐UVB) is a routine treatment for psoriasis and atopic dermatitis (AD) but its effect on vitamin D balance is not well studied. Objectives To examine whether NB‐UVB treatment in winter improves vitamin D balance in psoriasis and AD, and to study the effects of NB‐UVB on antimicrobial peptide and cytokine expression in the skin. Methods Eighteen adult patients with psoriasis, 18 with AD and 15 healthy subjects received a total of 15 NB‐UVB exposures on the whole body, given three times a week. Serum calcidiol (25‐hydroxyvitamin D) was measured by radioimmunoassay. Antimicrobial peptide and cytokine expression in skin lesions was examined by real‐time quantitative polymerase chain reaction. Results At onset 16 (89%) patients with psoriasis, 17 (94%) patients with AD and eight (53%) healthy subjects had vitamin D insufficiency (calcidiol < 50 nmol L^?1). NB‐UVB treatment significantly increased (P < 0·001) serum calcidiol. The increase was 59·9 nmol L^?1 (95% confidence interval, CI 53·5–66·9) in psoriasis, 68·2 nmol L^?1 (95% CI 55·4–80·1) in AD and 90·7 nmol L^?1 (95% CI 63·8–123·4) in healthy subjects. Psoriasis Area and Severity Index and SCORAD improved significantly (P < 0·001) but no correlation to the increase of serum calcidiol was found. Cathelicidin and human β‐defensin 2 (HBD2) expression was high in skin lesions of psoriasis. After six NB‐UVB treatments cathelicidin increased further while HBD2 expression decreased. A similar trend was observed in AD lesions. NB‐UVB caused a marked but nonsignificant decrease of interleukin (IL)‐1β and IL‐17 in psoriasis lesions. Conclusions The present study shows that in addition to a significant improvement of psoriasis and AD, NB‐UVB treatment effectively corrects vitamin D insufficiency. It also increases cathelicidin and decreases HBD2 levels in healing skin lesions of psoriasis and AD. This effect might be mediated by improved vitamin D balance and the local cytokine network.