Pustular psoriasis: A distinct aetiopathogenic and clinical entity.

Pustular psoriasis is a distinct subset of psoriasis that presents with involvement of the skin in the form of sterile pustules along with systemic manifestations. Though it has been conventionally grouped under the umbrella of psoriasis, recent research has shed light on its pathogenetic mechanisms associated with the IL-36 pathway, which is distinct from conventional psoriasis. Pustular psoriasis in itself is a heterogeneous entity consisting of various subtypes, including generalised, localised, acute, and chronic forms. There is confusion regarding its current classification as entities like deficiency of IL-36 antagonist (DITRA) which are closely related to pustular psoriasis both in their pathogenetic mechanism and its clinical manifestations, are not included under pustular psoriasis. Entities like palmoplantar pustulosis, which presents with similar clinical features but is pathogenetically distinct from other forms of pustular psoriasis, are included under this condition. Management of pustular psoriasis depends upon its severity; while some of the localised variants can be managed with topical therapy alone, the generalised variants like Von Zumbusch disease and impetigo herpetiformis may need intensive care unit admission and tailor-made treatment protocols. The advent of newer biologics and better insight into the pathogenesis of pustular psoriasis has opened the way for newer therapies, including tumour necrosis factor-alpha inhibitors, interleukin-1 inhibitors, interleukin-17 inhibitors, and granulocyte monocyte apheresis. It continues to be an enigma whether pustular psoriasis is actually a variant of psoriasis or an entirely different disease entity, though we feel that it is an entirely different disease process.

Review of the reasons for and effectiveness of switching biologics for psoriasis treatment in Korea.

Background Switching of biologics in patients has become common in clinical practice. Objectives This study investigated the reasons for and effectiveness of switching biologic agents during the treatment of psoriasis. Methods We retrospectively reviewed patients with psoriasis who were treated with biologics at Pusan National University Hospital and Chosun University Hospital from March 2012 to June 2020. We assessed their demographics and treatment characteristics (reasons for switching biologics and efficacy of the first- and second biologic agents). Results Of the 162 psoriatic patients treated with biologic agents for more than 52 weeks, 35 required a switch to another biologic agent. The reasons for switching biologic agents were inefficacy (n = 30), adverse events (n = 2) and others (n = 3). The mean psoriasis area and severity index (PASI) score was 12.1 at the start of the second biologic and 3.4 at 14-16 weeks later. Patients were more likely to switch to another biologic agent when they exhibited a high initial psoriasis area and severity index score and concomitant psoriatic arthritis. Limitations As a retrospective study, there were some limitations such as lack of a placebo control group and the time point of 14-16 weeks being somewhat early to judge the effect of the biologics. Conclusions The most common reason for switching biologic agents in Korea was treatment inefficacy, especially secondary failure. Despite the inefficacy of previous biologic agents, switching to a different agent may be an efficacious approach.

Pattern of use of biologics in psoriasis among Indian dermatologists - A cross sectional survey.

Background and Aims Biologics are a relatively new class of highly effective drugs in the management of psoriasis. They act on specific immune processes, achieve rapid and sustained clearance and do not cause target organ damage unlike conventional systemic therapy. It appears that their use in our country is not as widespread as in developed nations despite these benefits ; their prohibitive cost may be a major factor for the limited usage. This survey aimed to find out the extent of use and factors hindering usage of biologics for the management of psoriasis by Indian dermatologists. Methods It was a cross-sectional questionnaire based study. The questionnaire was designed after a focussed group discussion, followed by validation. The survey was sent in the form of a link to Indian dermatologists. The responses were recorded in excel-sheet and the data was analyzed by SPSS ver 25. Results Of the 310 participants who took part, 287 completed the survey. Two hundred (70%) were users of biologics, while 87 (30%) had never used them. Cost was the major factor which prevented biologic use. Majority of the respondents used biologics in less than 2 cases per month. Secukinumab was the most common biologic used followed by etanercept. The factors which determined choice of biologics were convenience, cost, previous experience, co-morbid conditions and recommendations by an expert. Limitations A small sample size was the limitation of the study. Dermatologists who do not use biologics may be under-represented in the study. Conclusions Biologics are not used optimally by Indian dermatologists for management of psoriasis. The cost, fear of adverse effects, lack of awareness and inadequate felt need are major factors which prevent their regular use.

Dermatology practice in the times of the COVID-19 pandemic.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is implicated in the ongoing pandemic across the globe since December 2019. It was first notified by China from Wuhan on 31 December 2020 and transmission to healthcare workers was first reported on 20 January 2020. Human-to-human transmission is mainly by droplet infection. At present no effective vaccine is available. Our speciality needs to collectively address the urgent issue of risk of transmission in dermatology practice. A case series of Coronavirus Disease 2019 (COVID-19) from Wuhan described that 41.3% of their patients may have acquired the infection from the hospital. Of all the infected health care workers, 77.5% worked in general wards and departments. These data highlight the significant risk of nosocomial transmission of COVID-19 and also the higher risk in general wards and departments compared to the emergency room or intensive care unit. Dermatology patients are generally seen in clinics and in outpatient departments in hospitals. Patients wait together in the waiting area, intermingle and then are seen by the physician in their chamber. This can cause transmission of the pathogen among patients and from patient to physician. Social distancing, hand hygiene and the use of personal protective equipment are important for preventing the spread of infection and dermatology practices also have to incorporate these aspects. Telemedicine is becoming an important tool for the management of dermatology patients in these times. At-risk patients in dermatology also need to be given priority care. Protocols for the use of immunosuppressants and biologics in dermatology during the pandemic are being developed.

Biologics in Leprosy: A Systematic Review and Case Report.

Tumor necrosis factor (TNF)-α inhibitors increase susceptibility to tuberculosis, but the effect of biologics on susceptibility to leprosy has not been described. Moreover, biologics may play a role in treating erythema nodosum leprosum (ENL). The objectives of this systematic review were to determine whether the development of clinical leprosy is increased in patients being treated with biologics and to assess the use of biologics in treating leprosy reactions. A systematic literature review was completed of patients with leprosy who received treatment with biologics either before or after a diagnosis of leprosy was confirmed. All studies and case reports were included for qualitative evaluation. The search yielded 10 cases (including one duplicate publication) of leprosy diagnosed after initiation of TNF-α inhibitors and four case reports of refractory ENL successfully treated with infliximab or etanercept. An unpublished case of persistent ENL responsive to infliximab is also presented. These data demonstrate that the use of TNF-α inhibitors may be a risk factor for developing leprosy or reactivating subclinical infections. Leprosy can present with skin lesions and arthritis, so leprosy should be considered in patients presenting with these signs before starting treatment with these agents. Leprosy should be considered in patients who develop worsening eruptions and neurologic symptoms during treatment with TNF-α inhibitors. Finally, TNF-α inhibitors appear effective in some cases of refractory ENL.

[Some case reports which suggest correlation between biologics and leprosy, Mini-symposium on problems on leprosy].

Biologics are relatively new drugs developed through modern monoclonal antibody techniques and became more familiar to some disease treatments such as Rheumatoid arthritis, psoriasis, ankylosing spondylitis, ulcerative colitis, malignant lymphoma, SLE and lupus nephritis. Some case reports shows development of leprosy during/after biolo- gics treatment and success treatment of ENL with biologics. Collection of reports was done through web search by using document retrieval engine such as Pub-med and ProQuest. 7 cases of development of leprosy with biologics and 2 cases of ENL treatment with biologics and they were reported in the mini-symposium of Annual academic meeting of Japan Leprosy association. The widespread use of biologics reminds us of development of some infectious diseases as a side-effect and leprosy might be one of them. Because number of the reports was still very limited, we cannot go to further discussion at this moment. Accu- mulation of reported cases will lead the detailed information about correlation between biologics and leprosy, either on effectiveness or on adverse ones.

Platelet-rich plasma in dermatology: boon or a bane?

There has been a recent spurt in application of platelet-rich plasma (PRP) in dermatology and aesthetic medicine. However, the details regarding use of PRP in various dermatological indications ranging from hair restoration to chronic ulcers are dispersed in literature, herein we have tried to focus all under one heading. Overall, PRP seems to be a promising therapeutic modality but the level of evidence as of now, from the available published data is low. This review will also stimulate readers to carry out well designed, larger population based trials, so as to validate its use in dermatology practice.

[Psoriasis]. / Psoriasis.

Psoriasis is a skin disease typically presenting with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. The name derives from pisigmaomicronrhoalpha (mange or scabies), and in ancient times the disease was confused with leprosy resulting in expulsion from society. Hence, both itching and social stigmatization are major problems affecting patients with psoriasis. Today, psoriasis is recognized as a genetically determined, autoimmune, T cell mediated systemic disease manifesting on the skin, nails and joints and associated with a number of co-morbidities. Accordingly, therapeutic strategies are antiinflammatory, antiproliferative and keratolytic. The extent and severity of disease (PASI), impairment of life quality (DLQI), and affected anatomic regions (inverse, palmoplantar, nails) as well as co-morbidities (arthritis, metabolic syndrome, cardiovascular disease, depression) determine the therapy. In 80 % of cases psoriasis is mild or moderate and sufficiently treated with topical corticosteroids, vitamin D-analogues, and phototherapy. 20 % of patients suffer from severe psoriasis, necessitating systemic drugs such as acitretin, methotrexate, ciclosporin A or the newer biologic agents. Especially in severe psoriasis, psychological strain, co-morbidities, and medico-economic aspects must be taken into account.