Apremilast Use in Severe Psoriasis: Real-World Data from Central and Eastern Europe.

INTRODUCTION: The broad and sustained efficacy of apremilast for psoriasis has been demonstrated in randomized and real-world observational studies. Data from Central and Eastern Europe (CEE) are lacking. Moreover, apremilast use in this region is limited by country-specific reimbursement criteria. This is the first study to report data on the real-world use of apremilast in the region. METHODS: APPRECIATE (NCT02740218) was an observational, retrospective, cross-sectional study assessing psoriasis patients 6 (± 1) months after apremilast treatment initiation. The study aimed to describe the characteristics of patients with psoriasis receiving apremilast, estimate treatment outcomes, including Psoriasis Area Severity Index (PASI), Body Surface Area (BSA), and Dermatology Life Quality Index (DLQI), and assess dermatologists' and patients' perspectives on treatment using questionnaires including the Patient Benefit Index (PBI). Adverse event reports were taken from the medical records. RESULTS: Fifty patients (Croatia: 25; Czech Republic: 20; Slovenia: 5) were enrolled. In patients continuing apremilast at 6 (± 1) months, mean (± SD) PASI score was reduced from 16.2 ± 8.7 points at treatment initiation to 3.1 ± 5.2 at 6 (± 1) months; BSA from 11.9% ± 10.3% to 0.8% ± 0.9%; DLQI from 13.7 ± 7.4 points to 1.6 ± 3.2. PASI 75 was reached by 81% of patients. Physicians reported that the overall treatment success fulfilled their expectations in more than two thirds of patients (68%). At least three-quarters of patients reported apremilast had a quite or very high benefit on the needs they identified as being most important. Apremilast was well tolerated; no serious or fatal adverse events were identified. CONCLUSION: Apremilast was effective in reducing skin involvement and improving quality of life in CEE patients having severe disease. Treatment satisfaction among physicians and patients was very high. These data add to the growing body of evidence showing consistent effectiveness of apremilast across the continuum of psoriasis disease severity and manifestations. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT02740218.

Painful and Itchy Dermatoses Carry the Highest Psychological Burden for Dermatovenereological Patients.

BACKGROUND: Most dermatovenereological diseases are not life-threatening but nevertheless are highly prevalent disorders. Psychosocial aspects of skin diseases and physical symptoms strongly influence patient's quality of life (QoL) which results in the development of different coping mechanisms in patient's behaviour. Development of psychiatric comorbidity in patients with skin diseases is well known. On the other hand, little is known about psychological comorbidity associated with dermatovenereological diseases. Aims of this study were to investigate QoL and psychological burden among dermatovenereological patients. SUBJECTS AND METHODS: Two hundred and ninety patients suffering from different dermatological and venereological diseases participated in the study, divided into three study groups: itchy/painful dermatoses, non-itchy/non-painful dermatoses and venereological diseases. Participants completed standardized psychological questionnaires: Dermatology Specific Quality of Life (DSQL), Beck Depression Inventory (BDI) and State and Trait Anxiety Inventory (STAI). Intensity of the disease and localisation of the lesions were also assessed. RESULTS: Physical aspect of QoL was mostly influenced by itchy/painful dermatoses but psychological aspect and everyday activities and choices were mostly affected by patients with non-itchy/non-painful dermatoses and venereological diseases. 4.1% of participants had serious depressive symptoms, 11.5% had high and very high anxiety symptoms as state and 15.6% as trait. However, participants with severe skin conditions were more depressed, while participants with always and sometimes exposed lesions were more anxious. CONCLUSION: It is essential to recognise subgroups of dermatovenereological patients whose treatment approach should be interdisciplinary. Further studies are needed to detect psychosocial needs of patients with venereological diseases.

Study on the Impact of Psoriasis on Quality of Life: Psychological, Social and Financial Implications.

BACKGROUND: Psoriasis is a chronic and stigmatising disease with significant and hard to meet clinical needs in patient management. Psoriasis is a relatively common disease, affecting up to 2% of the population. The impact of psoriasis on quality of life is significant given its chronicity and visibility. Psychological stress is a well-established systemic triggering factor in psoriasis. It has been associated with initial presentation of the disease as well as exacerbations of pre-existing psoriasis. The purpose of this study is to assess the psychological, social and financial implications of psoriasis. SUBJECTS AND METHODS: 51 patients participated in this study. After dermatological examination and determination of Psoriasis Area and Severity Index score, patients were referred to a psychological consult. Assessment was done through questionnaires concerning quality of life, depression, anxiety, illness perception, financial domain and personal data. RESULTS: Results of our study indicate that psoriasis has a strong impact on patients' life. It influences working habits, poses a significant financial burden, but most of all, significantly impairs their quality of life and psychological status. CONCLUSION: Psoriasis poses a substantial threat to several dimensions in patient's quality of life. Patients feel that the current treatment, although often effective, does not provide a satisfactory long-term solution. Thus, long-term psychologic support for patients with psoriasis is desirable.

Baclofen-Induced Dyshidrosiform Bullous Pemphigoid in a Paraplegic Patient Complicated by Methicillin-Resistant Staphylococcus aureus (MRSA) and Urinary Infection.

Bullous pemphigoid (BP) is an autoimmune disorder which is usually chronic, with blistering that predominantly affects the skin and occasionally the mucosa, and which includes several different types. One of them is a very rare dyshidrosiform type which is localized on the hands and feet with small or large blisters on the palmoplantar surfaces. BP resulting from a drug reaction is a relatively rare occurrence, and so far more than 50 different medications have been identified as triggers. The aim of this article was to present the case of a paraplegic patient who developed this rare dyshidrosiform type of BP while he was being neurologically treated with baclofen. In spite of therapy with systemic and topical corticosteroids and other measures, successful treatment was achieved only after eliminating baclofen from the patient's regimen. His general state of health was seriously endangered due to nasal and skin methicillin-resistant Staphylococcus aureus (MRSA), urinary infection, and oral mycosis (soor), and he was at high risk of sepsis and a fatal outcome. Through our efforts, however, we managed to achieve an excellent outcome. According to our knowledge, this was the first case of baclofen-induced dyshidrosiform BP.

Delusion of parasitosis: case report and current concept of management.

Delusions of parasitosis (DP) is a primary psychiatric disorder, a type of monosymptomatic hypochondriac psychosis in which patients believe that 'bugs' or 'parasites' have infested their skin or that they have even spread into their visceral organs. Patients with DP usually approach different medical specialists, mostly dermatologists and primary care physicians because of symptoms presenting as crawling under their skin. Therefore, the exact prevalence of DP is unknown. It is believed that it is a rare disorder but different studies indicate that the prevalence is greater than presented. The etiology of this disorder is still unclear. Patients with DP come to a physician with a stereotypic history. Usually the patient has previously addressed many other different specialists and symptoms are usually present for several months to years. The main cutaneous symptom is crawling, biting and pruritus due to 'burrowing of parasites, insects or bugs' under the skin. Patients with DP are rare but can be very challenging for making the correct diagnosis and for the treatment as well. It is essential to distinguish primary from secondary disorder since the approach to these patients is different. Dermatologists who have good knowledge in diagnosis, both dermatologic and psychodermatologic, and who dare prescribe antipsychotics after consulting liaison-psychiatrist, can have good results in treating patients with DP. When treating patients with DP, multidisciplinary approach by collaboration between a dermatologist and a psychiatrist is necessary to provide complete and meaningful treatment for these patients.

The mechanisms of action of phototherapy in the treatment of the most common dermatoses.

Phototherapy denotes the use of ultraviolet (UV) light in the management of several dermatoses. Most phototherapy regimens utilize ultraviolet radiation of different wavelenghts. Currently, irradiations with broadband UVB (290-320 nm), narrowband UVB (311-313 nm), 308 nm excimer laser, UVA 1 (340-400 nm), UVA with psoralen (PUVA), and extracorporeal photochemotherapy (photopheresis) are being used. The interplay of the various photobiologic pathways is far from being completely understood. Disordes that may benefit from such approach are numerous, with psoriasis, atopic dermatitis, cutaneous T-cell lymphomas, morphea, and vitiligo as main indications. The immunomodulatory effects of UVB radiation primarily affect the epidermis and superficial dermis, while UVA radiation affects mid and deep dermal components, especially blood vessels. UVB radiation is absorbed by endogenous chromophores, such as nuclear DNA, which initiates a cascade of events. Absorption of UV light by nucleotides causes the formation of DNA photoproducts and suppresses DNA synthesis. In addition UV light stimulates synthesis of prostaglandins and cytokines that play important roles in immune suppression. It may reduce the number of Langerhans cells, cutaneous T lymphocytes and mast cells in the dermis. UV radiation can also affect extranuclear molecular targets located in the cytoplasm and cell membrane. Immune suppression, alteration in cytokine expression, and cell cycle arrest may all contribute to the suppression of disease activity. PUVA is a form of chemophototherapy which uses UVA light to activate chemicals known as psoralens, hence psoralen ultraviolet A. The conjunction of psoralens with epidermal DNA inhibits DNA replication and causes cell cycle arrest. Psoralen photosensitization also causes an alteration in the expression of cytokines and cytokine receptors. Psoralens interact with RNA, proteins and other cellular components and indirectly modify proteins and lipids via singlet oxygen-mediated reactions or by generating of free radicals. Infiltrating lymphocytes are strongly suppressed by PUVA, with variable effects on different T-cell subsets. Psoralens and UV radiation also stimulate melanogenesis. Extracorporeal photopheresis is technique used in treatment of erythrodermic cutaneous lymphomas. It is very potent in induction of lymphocyte apoptosis. Despite the introduction of numerous effective systemic medications and biologic agents in dermatology, phototherapy remains a reliable, and often preferred option for several dermatoses.

Dysplastic nevus--risk factor or disguise for melanoma.

Dysplastic nevus is an acquired or hereditary nevus that clinically seems atypical and pathohistologically dysplastic. The term of dysplastic nevus has changed through history and even until now the dermatologists and pathologists have not found the same conclusion for name and definition of dysplastic nevus. Epidemiology of dysplastic nevus is different depending on geographic lattitude, being three times higher in Australia than in Great Britain. Genetic factors play a role in etiology of dysplastic nevus but are still not well defined. UV radiation is indisputable main etiological factor in developing dysplastic nevus. Many studies confirm that children who have been using sun protection creams with SPF have less dysplastic nevi than those who did not. Nevus with geographic shape and muddy borders, dominately macular, red to brown colored and has 5 mm or more in diameter is clinically dysplastic nevus. ABCDE rules count for dysplastic nevus as well as for melanoma but prefferable diagnostic criteria for dysplastic nevus would be "ugly duckling sign". Pathohistologic analysis is the key in confirming the diagnosis of dysplastic nevus. Great experience and knowledge in dermatopathology field is essential for pathologists to make a distinction between dysplastic nevus and melanoma in situ. Likewise great experience in dermatooncology field is essential in differentiating dysplastic nevus from other nevi. Surgical excision is the only therapy that should be done for dysplastic nevus. Regular follow up is highly recommended for patients with dysplastic nevus and syndroma naevi dysplastic. Education about sun protection measures and self-examination techniques is essential for all patients with dysplastic nevi and their family.

Knowledge and attitudes towards sun protection in Croatia.

Skin cancer is the most common form of cancer; the World Health Organization estimates that more than 2 million cases of skin cancer are being diagnosed each year worldwide. Excessive sun exposure and ultraviolet (UV) radiation are the major avoidable risk factors for skin cancer, including melanoma. Sun protection can be achieved through behavioral modification, social changes and environmental changes: regular use of sunscreen, wearing hats and protective clothes, staying in the shade, creating shade by planting trees or constructing canopies, practicing work and sport activities during the time of the day when the sun is not the strongest and many others. The aim of this paper was to investigate the knowledge and attitudes about sun protection and sun behavior patterns in Croatia, as well as the perception of melanoma among general population. Our results indicate relatively good sun behavior patterns among our participants and their mostly correct perception of melanoma.

Association of psoriasis and alcoholism: psychodermatological issue.

Psoriasis is a chronic, hereditary disease generally characterized by eruption of erythematous, silvery-scaled plaques, predominantly on the elbows, knees, scalp and trunk, affecting between 1-2% of the population worldwide. Psoriasis is a multifactorial disease of unknown etiology. It has been shown that in some patients alcohol abuse has been associated with psoriasis. Chronic alcohol abuse results in the impairment of health-related, social and occupational functioning. Therefore the association of psoriasis and alcoholism represents one of the major psychodermatological issues where a multidisciplinary approach (including dermatologist, psychiatrist, psychologist and others) is crucial for optimal outcome.