Self-reported stress reactivity and psoriasis-related stress of Nordic psoriasis sufferers.

OBJECTIVES: The purpose of the study was to investigate the perceived influence of stress on psoriasis onset and disease severity in a large sample of psoriatics and to compare stress reactors and non-reactors with respect to psoriasis-related stress, disease severity, family history of psoriasis and sociodemographic factors. PATIENTS/METHODS: A total of 5795 members of the Nordic psoriasis associations and 702 patients recruited from Nordic dermatologists or university clinics were asked whether their first outbreak of psoriasis occurred during times of worry and stress. They were also asked to rate the degree to which their psoriasis was influenced by stress and to complete the Psoriasis Life Stress Index, the Psoriasis Disability Index and a number of additional questions concerning sociodemographic factors. RESULTS: Seventy-one per cent of the members and 66% of the patients reported that their psoriasis was exacerbated by stress, and 35% in both groups reported that the onset of their psoriasis occurred during a time of worry and stress. Stress reactors, scoring above the median on stress reactivity, reported greater disease severity, psoriasis-related stress and impairment of disease-related quality of life. They also reported more frequent use of tobacco, tranquillizers and antidepressants. More women than men were stress reactors, and stress reactors were more likely to have a family history of psoriasis. CONCLUSION: Our findings confirm and extend the results of previous studies and indicate that a subgroup of psoriatics may be more psychologically reactive to their disease and its influence on everyday life. Whether this group is also physiologically more reactive to psychosocial stress remains to be investigated.

Quality of life in 6497 Nordic patients with psoriasis.

BACKGROUND: Disease-specific psoriasis-related quality of life (QOL) measures have recently been developed and used in several hospital-based investigations. However, little is known about the impact of psoriasis on QOL in people with psoriasis who are not referred by dermatologists. OBJECTIVES: The purpose of the study was to investigate psoriasis-related QOL in a large sample of members of the psoriasis associations from the Nordic countries, and to compare the results with those from psoriasis patients recruited from Nordic dermatologists or Nordic University clinics. PATIENTS AND METHODS: A total of 5795 association members and 702 patients rated their psoriasis severity and completed the Psoriasis Disability Index and the Psoriasis Life Stress Index. RESULTS: Patients reported greater disease severity and greater impairment of QOL than members of associations, and Norwegian participants reported greater disease severity and greater impairment of QOL than participants from the remaining Nordic countries. Older and married participants reported less impairment of QOL than younger participants and those living alone. When controlling for the influence of these and other demographic and socio-economic factors, self-reported severity emerged as the most significant predictor of psoriasis-related QOL, explaining 32-26% of the variation in QOL scores, with the remaining factors only accounting for 4-5% of the variation. Although correlated with self-reported severity, Psoriasis Area and Severity Index scores were not a significant predictor of QOL in the patient sample. CONCLUSIONS: Though self-reported severity may be the most important predictor, further research is needed to determine factors explaining the remaining variance in psoriasis-related QOL.

Treatment of psoriasis in the Nordic countries: a questionnaire survey from 5739 members of the psoriasis associations data from the Nordic Quality of Life Study.

The data from a questionnaire-based study of 5,739 members of the psoriasis associations of Denmark, Finland, Iceland, Norway, Sweden and the Faeroe Islands showed that the two most commonly used active agents were topical steroids (89.7% total use and 49.4% present use) and calcipotriol (73.1% total use and 35.8% present use), with only small variations between the countries. Marked differences between the countries were, however, found within all other types of psoriasis therapy, including the so-called alternative treatments. Significant priorities varied between the different countries. The use of dithranol in Finland was almost twice the average. While 14.2% of Danish members had received grenz-rays within the last week only 0.1% of the Finns had been given the same treatment. Psoralen plus ultraviolet A (PUVA) was being used by 13.1% of the Finnish psoriatics compared with 3.8% of Danes, while PUVA was almost non-existent on the Faeroe Islands. The use of non-PUVA phototherapy was highest in Norway and Sweden. Almost 10% of the Danes were presently on methotrexate, which was used far more than etretinate/acitretin or cyclosporine. In contrast, Finnish patients more often received etretinate than other systemic agents, and in Iceland there was a higher present use of cyclosporine than of etretinate. The popularity of alternative therapies was highest in Iceland, where 26.6% had taken such medication during the last week. The results of the study suggest that different treatment patterns should be taken into consideration when discussing the prognosis of psoriasis in different countries.

Oesophageal pressure-cross-sectional area distributions and secondary peristalsis in relation to subclassification of systemic sclerosis.

The aim of the present study was to correlate the severity of oesophageal motor dysfunction with the severity of cutaneous disease in systemic sclerosis (SS). Patients were divided into three groups based on the degree of skin involvement: type I, acrosclerosis distal to the wrist; type II, scleroderma extending above the wrist in proximal direction; type III, diffuse cutaneous systemic sclerosis. Impedance planimetry employing distensions with pressures up to 5 kPa with the concomitant measurement of oesophageal cross-sectional area (CSA) was used in combination with standard oesophageal manometry. Measurements were made at 7 and 15 cm above the lower oesophageal sphincter (LOS). Thirty patients (16 type I, six type II and eight type III patients) and 23 normal controls were included. LOS pressure was lower in SS patients than in normal patients, with the lowest values in type III. The CSAs were higher in SS patients than in controls at both sites (P < 0.001). The CSAs at the distal site were highest in type III, as compared to type I and II (P < 0.03). The CSA at the highest induced pressure (5.0 kPa) was 613 +/- 45, 719 +/- 79, and 808 +/- 115 mm2 in types I, II and III, respectively. No differences in CSA were found at the proximal site between the three types of SS. The distensibility did not differ between SS and normal patients at the distal site. The distensibility was lowest in SS patients (P < 0.001) at the proximal distension site. The distensibility did not vary with the type of SS at either site. Significant differences in contraction frequency of the secondary peristalsis as function of wall tension were demonstrated between the SS patients and controls at the distal site (P < 0.05). No differences were found at the proximal site. The contraction frequency and amplitude at the distal and proximal sites did not differ among the three types. In conclusion for most parameters studied, SS patients differed from normal patients. Among SS types, the most pronounced changes were found in type III.

The value of amino-terminal propeptide of type III procollagen in routine screening for methotrexate-induced liver fibrosis: a 10-year follow-up.

BACKGROUND: Methotrexate (MTX) -induced liver damage is an important complication in patients treated with this drug for skin disease. Reliable non-invasive monitoring tests would have considerable importance. OBJECTIVES: This retrospective study was designed in order to evaluate if serial normal serum levels of amino-terminal propeptide of type III procollagen (PIIINP) might indicate that no significant fibrosis is taking place in the liver, and thereby reduce the need for repeated liver biopsies in psoriatic patients treated with MTX. METHODS: The clinical records of 70 patients with psoriasis, who in the years 1989/90 were on MTX and had both a liver biopsy without fibrosis and a normal PIIINP, were examined and followed until the patient stopped taking the drug. The follow-up time was from 1 to 11 years. RESULTS: A total of 189 liver biopsies and 329 analyses of PIIINP were recorded. Twenty-one patients had only one and no further biopsies, but their data included at least two to three PIIINP samples obtained within a year around the time of the biopsy, and at least two were taken either prior to or at the time of the biopsy. The remaining patients had from two to seven liver biopsies each and a total of 267 analyses of PIIINP. In the study period only four patients developed fibrosis of the liver as shown by liver biopsies, and all four of these patients developed elevated serum PIIINP levels. In addition two further patients, one of them with psoriatic arthritis, had elevated PIIINP, but normal liver biopsy. Thus no liver fibrosis was missed in the 63 patients with consistently normal PIIINP levels. CONCLUSIONS: Present data support the view that, as long as PIIINP is consistently normal in serial investigations, there is minimal risk of development of substantial liver fibrosis.

Oesophageal manometry and video-radiology in patients with systemic sclerosis: a retrospective study of its clinical value.

The aim of this retrospective study was to evaluate the initial video-radiology and manometry in 40 consecutive patients with systemic sclerosis (n=21) or suspected systemic sclerosis (n = 19) in relation to oesophageal symptoms; and, furthermore, to evaluate the consequence of radiographic or manometric findings in the oesophagus on diagnosis and treatment. Evaluating oesophageal abnormalities in relation to diagnosis and treatment has, to our knowledge, not been reported before. Video-radiology together with manometry demonstrated oesophageal dysfunction in 80% of patients. Thirteen patients (33%) were asymptomatic in spite of identified motility abnormalities. Following the radiographic and manometric investigation, 9 patients (23%) had a change of diagnosis and, in 20 patients (50%), systemic treatment was instituted or intensified. The study confirms that both manometry and video-radiology are important for the identification of oesophageal motility abnormalities in patients with systemic sclerosis. Oesophageal symptom profiles alone do not predict abnormal findings.

Renal toxicity of long-term cyclosporin.

An analysis of the literature on renal toxicity of long-term cyclosporin A (CsA) in auto-immune diseases reveals that besides functional renal toxicity also de novo morphological kidney damage can be induced already after 12 months with low dose (< or = 5 mg CsA/kg/day). In the early stage the findings are light changes. However, after two years treatment they are light to moderate. In a blinded study on 30 patients with psoriasis, including 18 with psoriatic arthritis, the severity of findings increased with length of therapy, and after four years all but one had arteriolar hyalinosis, with interstitial fibrosis pronounced in five and moderate in six of eleven patients, and at the same time glomerular sclerosis had become significant. The data presented indicate the necessity of an evaluation of the risk-benefit ratio for each patient. Accepted guide-lines should be strictly followed, and after two years treatment a rotation to other therapies, or a careful following by glomerular filtration rate (GFR) together with sequential renal biopsies should be considered.

[Renal biopsy in connection with long-term treatment of psoriasis with cyclosporine]. / Nyrebiopsi i forbindelse med langtidsbehandling af psoriasis med ciclosporin.

Renal biopsies were performed in 30 psoriatics during long-term low-dose cyclosporin (CSA) therapy (range 2.5-6 mg/kg/day) of from six months to eight years. The study included pretreatment biopsies in 25 of the patients. After two years all biopsies shared features consistent with CSA nephropathy despite completely normal pretreatment morphology in 18 of the 25 patients. The severity of the findings, which consisted of arteriolar hyalinosis, focal interstitial fibrosis and sclerotic glomeruli, increased with length of therapy. Mild renal lesions were seen during the first two years. After four years all but one had arteriolar hyalinosis, with interstitial fibrosis pronounced in five and moderate in six of 11 patients. At the same time glomerular sclerosis had become significant. A decrease in glomerular filtration rate (GFR) correlated with the severity of the fibrosis. GFR studied in 14 patients six months to seven years after discontinuation of CSA was still significantly decreased in relation to baseline prior to therapy. The data from our study together with experiences from cardiac-transplanted patients indicate that patients with psoriasis, after two years therapy with CSA, should be rotated to other treatments or be followed carefully by GFR and sequential renal biopsies.

Soluble intercellular adhesion molecule-1 (sICAM-1) and soluble interleukin-2 receptors (sIL-2R) in scleroderma skin.

In order to investigate whether soluble intercellular adhesion molecule-1 (sICAM-1) and soluble interleukin-2 receptors (sIL-2R) were present in scleroderma skin, and to compare their levels to concentrations measured in plasma and clinical parameters, we examined suction blister fluid and plasma from 13 patients with systemic sclerosis and 11 healthy volunteers. Suction blisters and biopsies were from the transition zone between normal skin and scleroderma, and uninvolved abdominal skin. The levels of sICAM-1 and sIL-2R were significantly increased in both plasma and suction blister fluid from systemic sclerosis patients compared with healthy volunteers. ICAM-1 was localized to vessels and perivascular mononuclear infiltrates by immunohistochemical methods. IL-2R was expressed by CD3-positive cells. The elevated levels of sICAM-1 and sIL-2R in suction blister fluid point towards activation of endothelial cells and T cells in both the transition zone and uninvolved skin of systemic sclerosis patients.

Conversion of psoriasis patients from the conventional formulation of cyclosporin A to a new microemulsion formulation: a randomized, open, multicentre assessment of safety and tolerability.

OBJECTIVE: To assess the safety, tolerability and efficacy of a new cyclosporin A (CyA) microemulsion formulation, Sandimmun Neoral (Neoral), in patients with severe psoriasis that was stable on CyA administered as Sandimmun (SIM). METHODS: In this 24-week, open, randomized, prospective, multicentre trial, 28 patients continued on the same dosage of SIM, while 30 converted to Neoral at 2.5 mg/kg/day or a dosage equivalent to their pre-conversion SIM dosage. During the study, dosages could be adjusted to maintain efficacy, because of adverse events or after disease stabilization. The maximum permitted dosage for either formulation was 5.0 mg/kg/day. Primary efficacy criteria were change in Psoriasis Area and Severity Index (PASI) from baseline and time to relapse. RESULTS: The dosage was increased to maintain efficacy in 22 patients (Neoral 13; SIM 9) and 20 dose reductions for safety were required (Neoral 14, SIM 6). In both groups, PASI scores remained stable throughout and relapses were primarily a result of dosage reduction after disease stabilization. No significant difference was found between groups in the proportion of patients remaining relapse-free. Adverse events were recorded in 20 patients receiving Neoral and 14 receiving SIM. Most drug-related events were of mild or moderate severity and reflected the known CyA side-effect profile. Dose titration guidelines ensured that mean blood pressure and serum creatinine concentrations remained stable in both groups. CONCLUSIONS: If the guidelines for CyA use are followed and the Neoral dosage does not exceed 5 mg/kg/day, conversion of stable patients with severe psoriasis from SIM to Neoral should present no clinically relevant safety or tolerability problems and efficacy of treatment is maintained.

Evaluation of the free-running ruby laser for hair removal. A retrospective study.

The free-running ruby laser has recently been introduced for removal of unwanted hair growth. It is assumed that the mode of action of ruby laser depilation is that of selective photothermolysis of the melanin-rich structures. The present data reflects our results of ruby treatment of 133 patients attending a dermatological laser clinic for hair removal. When success of the laser treatment was defined as greater than 50% hair removal, 59.0% of patients reported successful results after 90 or more days after last treatment. With success defined as greater than 25% hair removal at 90 days, successful treatment was obtained in 75.0%. Also, the patients evaluated the overall result of their treatments. The percentage of patients who were either "very satisfied" or "satisfied" after 90 days was 64.2%. Only a few side-effects were observed. In general, pain was no clinical problem. No significant scarring was observed. A temporary hypopigmentation was experienced by approximately 10%, but only one patient still had hypopigmentation 90 days after treatment. Due to variability of hair density as well as anagen and telogen phase durations in different anatomical locations, firm conclusions regarding the long-term effect still cannot be drawn.

Skin symptoms in patients with atopic dermatitis using enzyme-containing detergents. A placebo-controlled study.

Detergent enzymes may cause skin irritation and occasionally hypersensitivity reactions. The potential hazards of these enzymes have led some physicians to advise atopic dermatitis patients against the use of enzyme-enriched detergents. A three-phased randomised, double-blind, cross-over experiment was designed to question this recommendation. Each period was of 1 month's duration. In the first phase patients continued using their normal washing detergent. In phase II patients used trial detergent with or without added enzymes, and during phase III patients were given the opposite trial detergent. A total of 25 patients completed the study. The primary efficacy parameters were inter-period changes in corticosteroid usage and changes in SCORAD. Secondary efficacy parameters were altered subjective symptoms scored during the final 2 weeks of each interval. Analyses of all data revealed no statistical differences in any of the primary or secondary parameters comparing treatment and placebo periods. Our data therefore seem to exclude that atopic dermatitis may exacerbate during 1 month's exposure to enzyme-enriched detergents. Since no significant irritant capacity was detected in atopic dermatitis patients, it is unlikely that consumers with "normal skin" will experience any skin discomfort when enzyme-enriched detergents are used.

[Doxycycline induced photoonycholysis]. / Doxycyclinudløst fotoonykolyse.

A case of phototoxic onycholysis secondary to treatment with doxycycline is presented. Tetracyclines are known to provoke photosensitivity reactions in some individuals exposed to sunlight. The typical photo-toxic manifestation is erythema, but cases with onycholysis have also been reported in the past. With travel to regions with sunny climates it will be important to be aware of the risk of developing onycholysis following the use of tetracyclines and to avoid the most potential phototoxic derivates, especially doxycycline.