Efalizumab in the treatment of psoriasis: when comorbidity is an issue

Psoriasis is a common dermatosis affecting the skin, mucosal surfaces, and cutaneous adnexa, and joints and bones can be involved at some degree in the clinical features of the disease, configuring psoriatic arthritis. Moderate to severe psoriasis has a high impact on quality of life and requires an integrated and long-term treatment schedule. However, management of psoriasis in patients affected by other systemic diseases can be challenging because of the possible side effects or contraindications of various treatments in accordance with patients' medical history. In recent times, the therapeutical approaches have changed a lot, thanks to biologicals. The current authors present some cases of psoriatic patients with comorbidities successfully treated with efalizumab, an anti-T lymphocyte biological.     

Epidemiology and comorbidity of psoriasis in children

Background Psoriasis is a common disease affecting all age groups. In contrast to adult psoriasis, only few studies on the epidemiology of childhood psoriasis have been published. Objectives Assessment of prevalence and comorbidities of juvenile psoriasis in Germany based on health insurance data. Methods Data were collected from a database of about 1·3 million nonselected individuals from a German statutory health insurance organization which covers all geographical regions. Individuals with psoriasis were identified by ICD‐10 codes applied to all outpatient and inpatient visits. The present analysis consists of all patients who were enlisted throughout the year 2005. The diagnosis of psoriasis was registered whenever there was at least one documented patient contact using code L40.* and subcodes. Comorbidities were also evaluated by ICD‐10 diagnoses. Results In total, 33 981 patients with the diagnosis of psoriasis were identified. The prevalence in 2005 was 2·5%. The total rate of psoriasis in children younger than 18 years was 0·71%. The prevalence rates increased in an approximately linear manner from 0·12% at the age of 1 year to 1·2% at the age of 18 years. The overall rate of comorbidity in subjects with psoriasis aged under 20 years was twice as high as in subjects without psoriasis. Juvenile psoriasis was associated with increased rates of hyperlipidaemia, obesity, hypertension, diabetes mellitus, rheumatoid arthritis and Crohn disease. Conclusions Psoriasis is a common disease in children. Like in adults, it is associated with significant comorbidity. Increased attention should be paid to the early detection and treatment of patients affected.     

Neuropsychiatric comorbidity among adolescents with psoriasis

Psoriasis is a common skin disease, typically presenting as a red scaly rash. In mild cases it can be treated with creams, while in patients with so called “moderate to severe psoriasis”, where it is extensive or cannot be controlled with creams only, a systemic treatment, such as pills and phototherapy, is necessary. Psoriasis affects about 2% of adults. It commonly develops in adulthood, but can also be seen in children and adolescents. As might be expected, psoriasis may be physically and emotionally disabling. Growing data suggests that psoriasis patients are at risk of suffering from multiple medical conditions, including mental health disorders (e.g depression) and neurological disorders (e.g migraine). This study, from Israel, aimed to find out whether psoriasis carries a risk of suffering from mental health and neurological disorders, focusing on adolescents, an age group which was previously less studied for these conditions. Data were retrieved from records of recruits evaluated for military service. The study included 1746 and 1366 adolescents (aged 16 to 18) with mild and moderate to severe psoriasis, respectively, and compared them to 884653 healthy adolescents. Differences in the prevalence of the following medical conditions were found between adolescents with moderate to severe psoriasis and healthy adolescents: Overall chronic headaches (8.1% vs. 3.4%), intermediate frequency migraine (4.8% vs. 1.6%), low frequency migraine and non‐migraine headaches (3.4% vs. 1.8%), anxiety (2.1% vs. 0.7%) and social adjustment disabilities (7.5% vs. 4.2%). Interestingly, mild psoriasis was not shown to carry a risk for these conditions. The authors conclude that adolescents with psoriasis, especially those with a moderate to severe disease, are at risk of neurological and mental health disorders. The authors call for physicians’ awareness of these conditions, alongside the need for psychological counselling.     

Clinical practice guideline for an integrated approach to comorbidity in patients with psoriasis

Background The relationship between psoriasis and associated diseases has drawn particular interest in recent years. To provide appropriate management of psoriasis from an early stage, it is necessary to include prompt diagnosis of concomitant disease and to prevent and treat any comorbidity found. Such an integrated approach also serves to ensure that the drugs used to treat associated diseases do not interfere with the management of psoriasis, and vice versa. Objective To provide the dermatologist a guide focuses specifically on the diagnosis and management of the diseases most often found in patients with psoriasis. Methods The selection of the diseases, and corresponding supporting research, to be included was based on a systematic review of the literature. The recommendations on diagnostic criteria are based on the main clinical practice guidelines for each of the diseases discussed as well as on the recommendations of a clinical expert advisory group. The information regarding the repercussions of psoriasis treatments on associated comorbid diseases was obtained from the summary of product characteristics of each drug. In turn, the statements concerning the impact of the associated diseases, and their treatment, on psoriasis are based on the review of the literature. Results This guide is a precise, easy‐to‐use tool for systematizing the diagnosis of comorbidity in patients with psoriasis and facilitate decision making regarding referral and treatment of patients diagnosed with an associated disease. Conclusion The application of this guide not only will benefit psoriasis patients’ health and quality of life but it will also optimize available resources.     

Medical comorbidity associated with psoriasis in adults: a population-based study

Background Most publications to date on comorbidities associated with psoriasis have focused on cardiovascular and metabolic diseases. Few comprehensive investigations of medical comorbidities in a cohort of patients with psoriasis appear in the literature. Objectives To examine the prevalence of comorbidities in adult patients with psoriasis, including a comparison of comorbid prevalence vs. that in controls without psoriasis, in a nationally representative dataset in Taiwan. Methods There were 1685 adult patients with psoriasis in the study group and 5055 randomly selected subjects in the comparison group. We used conditional logistic regression analyses to examine the risk of 29 comorbidities for these two groups after adjusting for monthly income, geographical region of residence and the level of urbanization of each patient’s community of residence. Results After adjusting for several potential confounders, patients with psoriasis had higher odds of comorbid congestive heart failure [odds ratio (OR) 1·63], ischaemic heart disease (OR 1·51), renal failure (OR 1·45), uncomplicated diabetes (OR 1·37), liver diseases (OR 1·34), hepatitis B or C (OR 1·34), complicated diabetes (OR 1·32), hyperlipidaemia (OR 1·28), hypertension (OR 1·24) and peptic ulcer (OR 1·22) than did patients without psoriasis. However, patients with mild psoriasis had higher odds of comorbidity only with uncomplicated diabetes (OR 1·55), asthma (OR 1·30), liver diseases (OR 1·30) and peptic ulcer (OR 1·26) than patients without psoriasis. Conclusions We conclude that psoriasis is associated with a variety of medical comorbidities including cardiovascular diseases, metabolic diseases, renal failure, liver diseases, viral hepatitis B or C, asthma and peptic ulcers.     

银屑病与代谢综合征发病机制的研究进展

银屑病和代谢综合征是两种临床常见病,可合并出现.银屑病是慢性复发性炎症性多因素皮肤病,发病与遗传、免疫,感染、吸烟以及精神紧张等因素有关.代谢综合征以中心性肥胖为核心,合并高血糖、高血压和脂代谢紊乱等多种代谢异常集结的病理状态.银屑病与代谢综合征发病机制密切相关,且存在共同的细胞因子表达.对代谢综合征的研究可以为银屑病的治疗提供新的靶位.     

Exogenous Cushing syndrome from an unexpected source of systemic steroids

A 12‐year‐old Hispanic boy with chronic atopic dermatitis and cushingoid features presented to our institution. He was being treated with an unknown quantity of oral prednisolone 15 mg/5 mL, equivalent to 70 mg/m²/d of oral prednisone, purchased over the counter in El Salvador. Systemic corticosteroids are not recommended for chronic therapy of atopic dermatitis because of their significant adverse effects. Foreign‐sourced pharmaceuticals account for almost half of the drugs consumed in the United States, which means that, to protect our patients, medical providers must inquire about and report unsafe medications deemed legal outside the United States to the Food and Drug Administration.     

The 'psoriatic march': a concept of how severe psoriasis may drive cardiovascular comorbidity

There is increasing awareness that psoriasis is more than 'skin deep'. Several recent reviews focussed on biomarkers indicating the systemic dimension of psoriasis and the aspect of comorbidity psoriasis shares with other chronic inflammatory diseases, such as Crohn's disease and rheumatoid arthritis. Of emerging significance is the relationship to cardiovascular disease, as this contributes substantially to the patients' increased mortality. In this viewpoint, we examine currently available evidence favouring the concept of a causal link between psoriasis and cardiovascular disease: systemic inflammation may cause insulin resistance, which in turn triggers endothelial cell dysfunction, leading to atherosclerosis and finally myocardial infarction or stroke. While this 'psoriatic march' is not yet formally proven, it raises clinically and academically relevant questions, and gains support by recent observations of numerous investigators.     

Acitretin in psoriasis: an evolving scenario

Acitretin, an active metabolite of etretinate, is the most widely used systemic retinoid in the treatment of psoriasis. There are several unique characteristics of this drug, which set it apart from other options in the therapeutic armamentarium of psoriasis. It is highly efficacious as monotherapy in some specific clinical subtypes of psoriasis. It has dose‐sparing effects when used as combination therapy with conventional systemic drugs as well as the biologics. It is a good option for long‐term maintenance therapy. Side effects are common but usually mild and can be managed by its proper dosing and monitoring. With appropriate patient selection, gradual dose escalation, and patient counseling, we can deliver good results in psoriasis with this useful drug. This review gives a comprehensive recount of acitretin use in the present era of biologics in psoriasis.     

Development of photosensitivity and an SLE-like syndrome in a patient with psoriasis

An unusual case of photosensitive psoriasis and systemic lupus erythematosus-related syndrome was characterized by erythroderma, chronic urticaria, angioneurotic edema, intermittent low-grade fever, and polyarthralgias. Investigation revealed no measurable total hemolytic complement and markedly diminished levels of C4, C2, and C3. Microscopic examination of three skin biopsy sections of sun-exposed skin showed psoriasis. Skin biopsy sections of sun-exposed psoriatic plaques and of non-sun-exposed, uninvolved skin (which were stained with fluorescein-tagged anti-IgG, anti-IgM, anti-IgA, and anti-C3) showed granular deposits of IgM and C3 at the dermal-epidermal junction in the sun-exposed plaques, and IgM alone in a granular pattern at the dermal-epidermal junction in uninvolved skin. Antibodies to single-stranded but not double-stranded DNA were detected in the patient's serum. In addition, serum immune complex-like material was detected by sucrose density-gradient ultracentrifugation, standard anticomplementary assays, and radioimmunoassays using both C1q and monoclonal rheumatoid factor.     

银屑病的流行病学研究进展

银屑病的患病率欧洲较高约为0.75％ ～ 2.9％,亚洲较低为＜1％;中国银屑病患病率＜0.5％,大陆部分地区的最新数据为0.47％;银屑病的发病率、患病率均有逐年升高的趋势.银屑病最常见的并发症包括高血压、糖尿病、脂代谢异常、代谢综合征、心脏病,年轻患者及病情严重者更易产生并发症、死亡率较高,但并发代谢综合征的风险则与病情严重性无关.与普通高血压患者相比,银屑病高血压者更容易患难治性高血压,男性患者并发代谢综合征的风险明显高于女性患者,女性患者并发糖尿病的风险则明显高于男性患者.     

银屑病免疫学的研究进展

银屑病是一种基因、环境、精神心理等多种体内外因素导致的慢性炎症性皮肤病,各种免疫细胞特别是各型CD4+辅助性T细胞及其分泌的细胞因子形成复杂的调控网络,调节银屑病的发病及转归,如IL-23/Th17轴、IL-4/Th2轴等信号通路.抗原提呈细胞、自然杀伤细胞等介导的固有免疫和T细胞介导的获得性免疫是维持免疫稳态的基础,综合银屑病相关的免疫细胞、获得性免疫细胞及其信号传导的最新研究成果,进一步阐述银屑病的免疫学发病机制.     

Evidence for an immunodeficiency syndrome related to beta-haemolytic streptococci in patients with psoriasis

Infection with beta-haemolytic streptococci is accepted as one of the triggering factors leading to exacerbation of psoriasis. In a long-term study lasting nine years (1982–1991) we investigated whether there is any evidence of dysfunction of humoral and cellular immune factors, and what part is played by microbial infection in this connection, with specific reference to streptococcal antigens. 110 patients with chronic psoriasis, either clinically inactive (stage 1) or active with eruptions (stage 2) and 70 healthy controls underwent the following immunologic investigations: streptococcal antibody titres, serum immunoglobulins IgM, IgA, IgG, total serum IgE, complement factors C3, C4, B and T cells, and subpopulations. The findings demonstrate that phases of inactivity are associated with a mechanism described as "Immunologic Regulation"-activated antibacterial titres and unremarkable findings for humoral and cellular parameters. Eruptions of psoriasis are with phases of humoral and cellular deficiency; antibacterial titres are significantly elevated, serum IgM or IgA or IgG show deficient levels, C3 is activated, C4 is decreased, as are serum IgE and T4:T8 ratio. Shift in T-cell subpopulations may depend on serum IgE concentration.
The question for consideration is whether antigen-eliminating inflammatory lesions present in immunodeficiency phases trigger the formation of circulating immune complexes. It seems probable that the pathogenicity of these immune complexes is controlled by serum factors and that they are involved in the initiation of keratinocyte hyperproliferation.