Biological disease-modifying antirheumatic drugs may mitigate the risk of psoriatic arthritis in patients with chronic plaque psoriasis.

OBJECTIVE: To estimate the incidence of psoriatic arthritis (PsA) in patients with psoriasis who had received a continuous treatment with biological disease-modifying antirheumatic drugs (bDMARDs) compared with phototherapy. METHODS: A retrospective non-randomised study involving patients with moderate-to-severe plaque psoriasis, who were prescribed at least 5 years of bDMARDs or at least three narrow-band ultraviolet light B (nb-UVB) phototherapy courses, and did not have a diagnosis of PsA at enrolment. Development of PsA in each patient was assessed by a rheumatologist according to the Classification for Psoriatic Arthritis criteria. The annual and cumulative incidence rate of PsA was estimated by using an event per person-years analysis. Cox proportional hazards models were undertaken to assess the hazard risk (HR) of PsA after adjustment for confounders. RESULTS: A total of 464 psoriatic patients (bDMARDs, n=234 and nb-UVB, n=230) were followed between January 2012 and September 2020 (corresponding to 1584 and 1478 person year of follow-up for the two groups, respectively). The annual incidence rate of PsA was 1.20 cases (95% CI 0.77 to 1.89) versus 2.17 cases (95% CI 1.53 to 3.06) per 100 patients/year in the bDMARDs versus phototherapy group, respectively (HR 0.29, 0.12-0.70; p=0.006). The variables independently associated with higher risk of PsA were older age (adjusted HR 1.04, 1.02-1.07), nail psoriasis (adjusted HR 3.15, 1.63-6.06) and psoriasis duration >10 years (adjusted HR 2.02, 1.09-3.76); notably, bDMARDs treatment was associated with a lower risk of incident PsA (adjusted HR 0.27, 0.11-0.66). CONCLUSIONS: bDMARDs treatment may delay or reduce the risk of incident PsA in patients with moderate-to-severe chronic plaque psoriasis.

Management of patients with atopic dermatitis undergoing systemic therapy during COVID-19 pandemic in Italy: Data from the DA-COVID-19 registry.

BACKGROUND: Few and small studies have described the management of immunomodulant/immunosuppressive therapies or phototherapy in atopic dermatitis (AD) patients during coronavirus disease 2019 (COVID-19) pandemic. METHODS: A national registry, named DA-COVID-19 and involving 35 Italian dermatology units, was established in order to evaluate the impact of COVID-19 pandemic on the management of adult AD patients treated with systemic immunomodulant/immunosuppressive medications or phototherapy. Demographic and clinical data were obtained at different timepoints by teledermatology during COVID-19 pandemic, when regular visits were not allowed due to sanitary restrictions. Disease severity was assessed by both physician- and patient-reported assessment scores evaluating itch intensity, sleep disturbances, and AD severity. RESULTS: A total of 1831 patients were included, with 1580/1831 (86.3%) continuing therapy during pandemic. Most patients were treated with dupilumab (86.1%, 1576/1831) that was interrupted in only 9.9% (156/1576) of cases, while systemic immunosuppressive compounds were more frequently withdrawn. Treatment interruption was due to decision of the patient, general practitioner, or dermatologist in 39.9% (114/286), 5.6% (16/286), and 30.1% (86/286) of cases, respectively. Fear of increased susceptibility to SARS-CoV-2 infection (24.8%, 71/286) was one of the main causes of interruption. Sixteen patients (0.9%) resulted positive to SARS-CoV-2 infection; 3 of them (0.2%) were hospitalized but no cases of COVID-related death occurred. CONCLUSIONS: Most AD patients continued systemic treatments during COVID pandemic and lockdown period, without high impact on disease control, particularly dupilumab-treated patients.

Assessing patients' characteristics and treatment patterns among children with atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is the most common immune-mediated skin disease in childhood. Several treatment options for pediatric AD, both topical and systemic, are currently available. We carried out a single-center observational study with the aim of describing characteristics and treatment patterns in pediatric AD patients. METHODS: The study included 867 patients aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with a previous doctor-confirmed diagnosis of AD who underwent balneotherapy at the Comano Thermal Spring Water Center (Comano, Trentino, Italy) from April to October 2014. RESULTS: Among the patients included in the study, 41.2% had mild (SCORing Atopic Dermatitis, SCORAD 0-15), 43.6% moderate (SCORAD 16-40) and 15.2% severe AD (SCORAD > 40). A higher occurrence of reported food allergy was observed among children with more severe AD (p < 0.0001), while no association was found between AD severity and reported inhalant allergy or passive smoking (p = 0.15 and 0.92, respectively). Emollients (55.1%) and topical corticosteroids (TCS; 45.7%) were the main treatment options used in the previous month. The use of oral steroids and topical calcineurin inhibitors (TCI) was considerably less common (6.3 and 4.5%, respectively), while no patients were on systemic agents other than steroids. Among patients with severe AD, 9.8% had not used TCS, TCI or any systemic treatments. Moreover, 20.0% of the patients in the study population had followed elimination diets, although only 27.2% of them had a reported food allergy. CONCLUSIONS: A significant difference in the prevalence of reported food allergy emerged across the different AD severity categories. Furthermore, although further data are necessary to confirm our findings, undertreatment in children with AD appeared to be very common, at least among those attending the Comano Thermal Spring Water Center. Moreover, many patients followed elimination diets in the absence of reported food allergy.

Characteristics associated with clinical response to Comano thermal spring water balneotherapy in pediatric patients with atopic dermatitis.

BACKGROUND: Several studies have investigated the efficacy of balneotherapy in atopic dermatitis (AD), including a pediatric open randomized clinical trial conducted at the Comano thermal spring water center, which showed a significant reduction in AD severity and an improvement of the quality of life. However, so far many studies on balneotherapy in pediatric AD have included relatively small populations without identifying patients' characteristics associated with their response. The aim of the present study was to identify any features associated with the clinical response to the Comano thermal spring water balneotherapy in a large cohort of pediatric AD patients. METHODS: An observational study was conducted on 867 children aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with mild to severe AD who underwent balneotherapy at the Comano thermal spring water center (Comano, Trentino, Italy) from April to October 2014. Patients were stratified according to their disease severity, which was evaluated using five SCORing Atopic Dermatitis (SCORAD) categories before and immediately after a thermal spring water balneotherapy course. Potential characteristics associated with the patients' clinical response to Comano thermal spring water balneotherapy were investigated. RESULTS: A statistically significant improvement in AD severity was observed after Comano thermal spring water balneotherapy (p < 0.0001). A significantly higher percentage of patients achieving improvement in AD severity was reported among children ≤4 years old (p < 0.0001) with early-onset AD (p < 0.0001), severe AD (p < 0.0001) or coexistent reported food allergies (p < 0.01). The therapy was well tolerated, and no relevant adverse effects were reported during the treatment course. CONCLUSIONS: Comano thermal spring water balneotherapy is a safe complementary treatment for pediatric patients with AD, as it was able to reduce the disease severity, especially in children ≤4 years old, with early onset AD, severe AD or concomitant food allergies.

Effectiveness and Safety of Long-Term Dupilumab Treatment in Elderly Patients with Atopic Dermatitis: A Multicenter Real-Life Observational Study.

OBJECTIVE: The objective of this study was to assess the effectiveness and safety of dupilumab in treating elderly patients with atopic dermatitis from baseline to 52 weeks. METHODS: A retrospective observational real-life study was conducted in a group of elderly patients with severe atopic dermatitis treated with dupilumab for 52 weeks. Inclusion criteria were: age ≥ 65 years; diagnosis of atopic dermatitis made by an expert dermatologist; Eczema Area and Severity Index ≥ 24; and a contraindication, side effects, or failure to respond to cyclosporine. The primary outcome was the mean percentage reduction in the Eczema Area and Severity Index score from baseline to week 52. Secondary measures included the mean percentage reduction in the Pruritus and Sleep Numerical Rating Scales and the Dermatology Life Quality Index, and the types and rates of adverse events from baseline to week 52. RESULTS: One hundred and five patients were eligible for the study. Flexural dermatitis was the most frequent clinical phenotype (63.8%). The coexistence of more than one clinical phenotype was found in 70/105 (66.6%) patients. We observed a reduction in all disease severity scores from baseline to week 52 (p < 0.001). Adverse events were recorded in 30/105 (28.6%) patients, with conjunctivitis and injection-site reaction the most frequent. CONCLUSIONS: In this study, dupilumab is an effective and safe treatment for the long-term management of atopic dermatitis in patients aged over 65 years.

The pharmacological management of patients with comorbid psoriasis and obesity.

INTRODUCTION: Psoriasis is a chronic inflammatory skin disease that is increasingly being recognized as a complex disorder affecting multiple systems. Systemic inflammation is considered the pathogenic link between psoriasis and its comorbid conditions that include arthritis, metabolic disorders, depression, and cardiovascular diseases. The presence of comorbid conditions modifies both its clinical management and the therapeutic approach in psoriatic patients. AREAS COVERED: This review describes the clinical, epidemiological, and pathogenic link between psoriasis and obesity. Furthermore, data related to the effects of synthetic antipsoriatic drugs on obesity are collated. EXPERT OPINION: Obesity is one of the most common comorbid conditions that is relevant both for a patient's overall health and the clinical outcomes of antipsoriatic therapies. Indeed, some treatments of psoriasis might be impaired by adiposity. Moreover, obesity's association with dyslipidemia, hypertension, and increased liver enzymes could further be worsened by acitretin, cyclosporine and methotrexate, respectively. Therefore, the identification of therapeutic targets whose blockade could have positive effects on both psoriasis and mechanisms regulating body weight homeostasis may be of great relevance to the treatment of patients with psoriasis.

Back to the future: a new topical approach for mild-to-moderate psoriasis.

Psoriasis is a chronic-relapsing skin disorder which requires long-term treatments. Therapeutic options for psoriasis include topical treatments, phototherapy and systemic therapy. However, those treatments, and particularly the topical drug therapies, may present some limitations, including poor efficacy/tolerability ratio and lack of adherence. Recently, the supersaturated aerosol foam formulation of the fixed combination calcipotriene plus betamethasone dipropionate (Cal/BD) has gained major attention because it overcomes some of the limitations associated with other topical treatments. This fixed-combination has increased efficacy compared with its individual components. Moreover, the alcohol-free aerosol foam formulation allows a higher penetration of the active ingredients into the skin, resulting in enhanced bioavailability and, consequently, in better clinical outcomes than other products with the same components. Given the short duration of therapy course and the fast onset of action, a reduced amount of Cal/BD foam formulation would be required for the treatment of psoriasis patients, resulting also in cost saving. Therefore this novel formulation could represent an alternative to other topical agents and a first-line therapy in the treatment of mild and mild-to-moderate psoriasis.

Considerations for Systemic Treatment of Psoriasis in Obese Patients.

Psoriasis is an immune-mediated inflammatory skin disease frequently associated with metabolic disorders, including diabetes, dyslipidaemia and metabolic syndrome. Moreover, a growing number of studies confirm the association between psoriasis and obesity. It has been found that obesity, as measured by body mass index >30 kg/m2, can double the risk of incident psoriasis. A positive correlation between different measures of adiposity and the severity of psoriasis has also been reported. Epidemiologic studies have also provided robust evidence confirming the association between obesity and psoriatic arthritis. Genetic, metabolic and environmental factors are all likely to contribute to these associations. Adipose tissue is an active endocrine and paracrine organ that has a key role in lipid and glucose metabolism as well as inflammation. Fat tissue is traditionally distributed into two main compartments with different metabolic characteristics, i.e. the subcutaneous and visceral adipose tissue. Particular attention has been devoted to visceral adiposity because of its contribution to inflammation and atherosclerosis. The association between psoriasis and obesity should be properly considered when choosing a systemic treatment, because it could exert negative effects on metabolic parameters, including liver enzymes, serum lipids and renal function. Obesity may increase the risk of liver and renal toxicity from methotrexate and cyclosporine. Moreover, obesity can compromise the effectiveness of systemic treatments for psoriasis (conventional and biological therapies). Dermatologists are also expected to promote a healthy lifestyle and weight loss for obese patients because they could improve metabolic parameters and responsiveness to psoriasis therapies.

Keratosis lichenoides chronica: Case-based review of treatment options.

Keratosis lichenoides chronica (KLC) is a rare dermatological condition characterized by keratotic papules arranged in a parallel linear or reticular pattern and facial lesions resembling seborrheic dermatitis or rosacea. The clinical, histological and therapeutic information on 71 patients with KLC retrieved through a PubMed search plus one our new case were analyzed. KLC affects patients of all ages, with a modest male predominance. Pediatric cases represent about one quarter of patients. Diagnosis is usually delayed and histologically confirmed. All patients have thick, rough and scaly papules and plaques arranged in a linear or reticular pattern, on limbs (>80%) and trunk (about 60%). Face involvement is described in two-thirds of patients. Lesions are usually asymptomatic or mildly pruritic. Other manifestations, such as palmoplantar keratoderma, mucosal involvement, ocular manifestations, nail dystrophy, are reported in 20-30% of patients. Children present more frequently alopecia. No controlled trials are available. Results from small case series or single case reports show that the best treatment options are phototherapy and systemic retinoids, alone or in combination, with nearly half of patients reaching complete remission. Systemic corticosteroids as well as antibiotics and antimalarials are not effective.

Concept of Remission in Chronic Plaque Psoriasis.

Psoriasis is a lifelong chronic inflammatory disease affecting 2-3% of the worldwide population. Current understanding of the pathogenesis of psoriasis assigns central importance to an interaction between acquired and innate immunity. The disease is characterized by a series of linked cellular changes in the skin, including hyperplasia of epidermal keratinocytes, angiogenesis, and infiltration of T lymphocytes, neutrophils, and other types of leukocytes in the affected skin. Plaque psoriasis is the most common clinical form and is characterized by red and scaly plaques generally localized at extensor sites such as elbows and knees. Major determinants of psoriasis severity include the extent of skin involvement; localization in highly affected areas such as scalp, palms, and soles; pruritus; presence of comorbidities including psoriatic arthritis; and impairment on quality of life. About one-third of patients have moderate to severe psoriasis defined as PASI (Psoriasis Area and Severity Index) and/or Dermatology Life Quality Index>10, and/or affected body surface area>10%. The optimal treatment goal is to safely achieve complete or almost complete skin clearance. Treatments available are various and they are chosen according to disease features, comorbidities, and patient characteristics and priorities. Topical treatments including corticosteroids and Vitamin D analogs are reserved for mild disease. Phototherapy, cyclosporine, methotrexate, acitretin, or biologics such as tumor necrosis factor-α antagonists and ustekinumab are reserved for the moderate to severe forms.

Differential management of mild-to-severe psoriasis with biologic drugs: An Italian Delphi consensus expert panel.

BACKGROUND: In the management of moderate-to-severe psoriasis, increasingly complex clinical scenarios necessitate practical tools for appropriate biologic therapy selection in individual patients. An Italian Delphi consensus panel provided guidance on biologic use in selected clinical scenarios. METHODS: Ten experts defined statements under consideration, which were distributed as an online survey to a dermatologist panel. Plenary discussions of contentious statements were held to achieve consensus. RESULTS: The survey was sent to 30 clinicians. After plenary discussions, consensus was reached on all 20 statements on the following topics: special populations; infections; comorbidities; immunogenicity; extra-cutaneous involvement; pregnancy; and adherence. Three statements required further discussion in order to gain consensus: use of subcutaneous biologics in mild liver impairment (final 94% agreement), use of any biologic in discoid lupus erythematosus (final 100% disagreement), and use of etanercept in patients with history of hypersensitivity reactions to drugs and/or food (final 75% disagreement). CONCLUSIONS: This Delphi expert consensus on the use of biologics in psoriasis provides practical recommendations for dermatologists to use when choosing an appropriate biologic in challenging but common clinical scenarios. More data are required to clarify clinical differences of biologic drugs used to treat psoriasis.

The cost effectiveness of biologic therapy for the treatment of chronic plaque psoriasis in real practice settings in Italy.

BACKGROUND AND OBJECTIVES: Biologic therapies are considered to be cost effective by leading Health Technology Assessment (HTA) agencies and, therefore, eligible for reimbursement by public health services. However, biologic therapies entail sizable incremental costs and, besides, have a considerable financial impact that in Italy amounts to 13.7 % of the national health service's pharmaceutical expenditure. In the reimbursability decision process, an important role is played by both the drug efficacy data observed in pre-licensing RCTs and the economic modelling assumptions, as they give evidence on cost effectiveness. The administration of therapies in real practice settings is likely to produce a significant deviation from the results predicted by the models, theoretically outweighing the assumption on which the decision process is founded. This is a matter of concern for public health services and, consequently, an interesting topic to investigate. METHODS: To overcome the lack of knowledge concerning the actual cost effectiveness of biologic therapies for the treatment of plaque psoriasis in the clinical practice setting in Italy, an observational study was conducted in 12 specialist centres on patients switching to biologic therapy within a 6-month enrolment window. RESULTS: The study confirms in clinical practice the efficacy of the switch to biologic therapies, analysed using a number of clinical [Psoriasis Area and Severity Index (PASI), pain visual analogue scale (VAS) and itching VAS] and quality-of-life parameters. A general health-related quality of life (HR-QOL) improvement, with a 0.23 quality-adjusted life-year (QALY) mean gain per patient, has been reported in the 6-month observation period. The direct medical costs to treat plaque psoriasis with biologic therapies amount to 15,073.7 per year (prior to their enrolment, the same patients cost 2,166.2 on an annual basis). After the switch to biologic agents, the cost per QALY during the first year of treatment amounts to 28,656.3. CONCLUSION: At least in the short-term, the clinical practice of the specialised Italian centres taking part in the study confirms that switching patients to a biologic drug produces an incremental cost-effectiveness ratio comparable with the values predicted by the HTA bodies.

Prurigo nodularis: an update on etiopathogenesis and therapy.

Prurigo nodularis (PN) is a chronic, highly pruritic condition characterized by the presence of hyperkeratotic, excoriated, pruritic papules and nodules, with a tendency to symmetrical distribution. No reliable data exist about incidence and prevalence of PN in the general population, but it seems to be more frequent and more intense in females. PN may be associated with many dermatological and non-dermatological comorbidities, including psychiatric disease. Recent findings suggest a neuropathic origin of PN, with alterations in the dermal and epidermal small diameter nerve fibers. PN may have a tremendous impact on the quality of life, and few effective treatment options are available. Few randomized controlled trials (RCT) on the therapy of PN are available, demonstrating the efficacy of phototherapy alone or with psoralen, and of topical calcipotriol and topical steroids in occlusive medications. Thalidomide may be effective, but no RCT are available and its use is impractical due to the unfavorable safety profile. Gabapentin, pregabalin and the neurokinin receptor 1 antagonist, aprepitant, seem also to be effective in the therapy of PN, but RCTs are still lacking.

Balneotherapy for atopic dermatitis in children at Comano spa in Trentino, Italy.

BACKGROUND: No controlled studies have investigated whether balneotherapy is effective in atopic dermatitis (AD). OBJECTIVES: To investigate the efficacy and safety of balneotherapy performed at Comano spa (Trentino, Italy) compared to topical corticosteroids (TCS) in the treatment of AD. METHODS: This was an open, randomized, clinical trial including 104 children (aged 1-14 years) with mild to moderate AD who were assigned either to balneotherapy (n = 54) or TCS (n = 50) once daily for 2 weeks. AD severity and quality of life were measured using the SCORAD, investigator global assessment (IGA), patients' self global assessment (PSGA), children's dermatology life quality index (CDLQI) and family dermatitis impact questionnaire (FDIQ). Subjective measures were re-evaluated 4 months after the end of therapy. RESULTS: Balneotherapy and TCS resulted in a significant reduction of all parameters at week 2. TCS were more effective than balneotherapy regarding SCORAD (46% ± 7.71 vs 26% ± 9.4, mean ± SD; p < 0.03). In contrast, IGA, PSGA, CDLQI and FDIQ improvement was similar. At month 4, the number and duration of relapses were less in patients treated with balneotherapy compared to those treated with TCS (p <0.0001). CONCLUSIONS: Balneotherapy at Comano spa appears to be beneficial in children with mild to moderate AD.

Chronic pruritus in the absence of specific skin disease: an update on pathophysiology, diagnosis, and therapy.

Chronic pruritus is a major and distressing symptom of many cutaneous and systemic diseases and can significantly impair the patient's quality of life. Pruritus perception is the final result of a complex network involving dedicated nerve pathways and brain areas, and an increasing number of peripheral and central mediators are thought to be involved. Itch is associated with most cutaneous disorders and, in these circumstances, its management overlaps with that of the skin disease. Itch can also occur without associated skin diseases or primary skin lesions, but only with nonspecific lesions secondary to rubbing or scratching. Chronic itch with no or minimal skin changes can be secondary to important diseases, such as neurologic disorders, chronic renal failure, cholestasis, systemic infections, malignancies, and endocrine disorders, and may also result from exposure to some drugs. The search for the cause of pruritus usually requires a meticulous step-by-step assessment involving careful history taking as well as clinical examination and laboratory investigations. Few evidence-based treatments for pruritus are available. Topical therapy, oral histamine H(1) receptor antagonists, and phototherapy with UV radiation can target pruritus elicitation in the skin, whereas antiepileptic drugs, opioid receptor antagonists, and antidepressants can block signal processing in the CNS.

Plasmacytoid dendritic cell leukemia: a rapidly evolving disease presenting with skin lesions sensitive to radiotherapy plus hyperthermia.

Plasmacytoid dendritic cell leukemia (pDCL) is a rapidly evolving disease, which frequently presents with skin lesions, particularly nodules and plaques with a typical reddish-brown or brown color. Treatment of pDCL is based on multiagent chemotherapy followed by allogeneic hematopoietic stem cell transplant, but skin lesions may be refractory to therapy. Here, we report on a 61-year-old patient affected by pDCL who first presented with multiple cutaneous nodules and plaques on the trunk. Lesions showed an excellent response to radiotherapy plus hyperthermia. Although this treatment did not avoid the systemic evolution of disease, it resolved skin lesions and prevented their relapse, thus representing a therapeutic option to be used in combination with chemotherapy regimens. The case presentation is followed by a general discussion with an emphasis on the diagnosis and treatment of this rare malignancy.

Treatment of psoriasis with efalizumab in patients with hepatitis C viral infection: report of five cases.

BACKGROUND: Concomitant hepatitis C virus infection (HCV) needs caution when selecting systemic treatments in psoriasis patients as some agents confer a risk of liver toxicity and/or are immunosuppressant. Phototherapy may provide a therapeutic choice but it is not always a practical option. Limited evidence supports the use of cyclosporine or TNF-alpha blockers. No data are available concerning the safety of efalizumab in patients with HCV infection. OBJECTIVE: To describe the clinical characteristics and evolution of 5 adult patients with severe chronic plaque psoriasis and concomitant HCV infection who were treated with efalizumab. METHOD: A retrospective clinical case report. RESULTS: Five adult patients with severe chronic plaque psoriasis and concomitant HCV infection were treated successfully using efalizumab with no increased viral replication and progression of liver disease for a follow-up of 8-20 months. CONCLUSION: Although further confirmation is needed, this report provides preliminary evidence to support also a cautious use of efalizumab in patients with HCV infection.

Balneotherapy for chronic plaque psoriasis at Comano spa in Trentino, Italy.

Thermal therapy is used worldwide in the treatment of psoriasis but few controlled studies have evaluated its efficacy and safety. We studied the efficacy and safety of balneotherapy compared to photobalneotherapy performed at Comano spa in Trentino, Italy, in chronic plaque psoriasis in a prospective, nonrandomized, open study. Three hundred adult patients with mild to severe chronic plaque psoriasis were assigned to either balneotherapy or photobalneotherapy with daily narrow-band ultraviolet B for a mean period of 1 or 2 weeks, reflecting the times that most patients can dedicate to thermal therapy. Patients were evaluated at baseline and end of treatment for psoriasis area and severity index (PASI) and body surface area; self-administered PASI (SAPASI) and Skindex-29 were evaluated at the same times, and also at 4 months by a mailed questionnaire. One-week balneotherapy or photobalneotherapy resulted in a significant reduction in PASI score (11.54% +/- 2.76 and 12.76% +/- 3.79, respectively; mean +/- standard deviation; p < 0.001). Two-week therapy induced a greater response with photobalneotherapy than with balneotherapy alone, with PASI reduction of 19.8% +/- 24.5 and 13.5% +/- 23.1 (p < 0.005), respectively. These results were confirmed by SAPASI and Skindex-29 evaluation. The therapy was well tolerated. Skin improvement was mostly lost after 4 months. Short-term balneotherapy and photobalneotherapy could thus be offered to patients willing to temporarily discontinue pharmacologic therapy or as adjuvant therapy.

Biologic therapies in psoriasis: a new therapeutic approach.

Chronic plaque psoriasis is an immune-mediated, inflammatory skin disease with a heavy burden on quality of life of patients. The disease has a chronic relapsing course and may be life long. Comorbid disorders include psoriatic arthritis, obesity, dyslipidemia, hypertension and an increased rate of cardiovascular disease. Conventional systemic treatments include methotrexate, cyclosporine and acitretin, which are associated with end organ toxicity that precludes long term therapy. Biological drugs are designed to selectively interfere with the immune mechanisms that induce psoriasis. Efalizumab is effective for skin psoriasis but not psoriatic arthritis. Anti-TNF-alpha agents (etanercept, infliximab and adalimumab) are active on both psoriasis and psoriatic arthritis. Infliximab is the most effective and rapid agent, but its safety profile may be less favourable. Moreover, efficacy can reduce over time. Etanercept is moderately active but has a better safety profile, and can be discontinued and re-used without loss of efficacy. The long term safety of all these agents has not been established.