A concept for integrated care pathways for atopic dermatitis-A GA2 LEN ADCARE initiative.

INTRODUCTION: The integrated care pathways for atopic dermatitis (AD-ICPs) aim to bridge the gap between existing AD treatment evidence-based guidelines and expert opinion based on daily practice by offering a structured multidisciplinary plan for patient management of AD. ICPs have the potential to enhance guideline recommendations by combining interventions and aspects from different guidelines, integrating quality assurance, and describing co-ordination of care. Most importantly, patients can enter the ICPs at any level depending on AD severity, resources available in their country, and economic factors such as differences in insurance reimbursement systems. METHODS: The GA2 LEN ADCARE network and partners as well as all stakeholders, abbreviated as the AD-ICPs working group, were involved in the discussion and preparation of the AD ICPs during a series of subgroup workshops and meetings in years 2020 and 2021, after which the document was circulated within all GAL2 EN ADCARE centres. RESULTS: The AD-ICPs outline the diagnostic procedures, possible co-morbidities, different available treatment options including differential approaches for the pediatric population, and the role of the pharmacists and other stakeholders, as well as remaining unmet needs in the management of AD. CONCLUSION: The AD-ICPs provide a multidisciplinary plan for improved diagnosis, treatment, and patient feedback in AD management, as well as addressing critical unmet needs, including improved access to care, training specialists, implementation of educational programs, assessment on the impact of climate change, and fostering a personalised treatment approach. By focusing on these key areas, the initiative aims to pave the way for a brighter future in the management of AD.

An Online Community for Patient with Psoriasis with Built-in Self-Reported Questionnaires.

This study presents an online psoriasis community developed with dermatologists in a PHR. We describe the interaction of users with this platform and the relationship between the use of self-report questionnaires, their results and users' subsequent contact with the healthcare system. Out of 2175 users that interacted with the platform, 477 visited the forums. 60% of those who completed questionnaires presented at least one abnormal result that prompted a recommendation for an outpatient visit. Although our data suggest a trend, we failed to find a statistically significant association between questionnaire severity and visits scheduling. To our knowledge, this is the first study that analyses the relationship between patient self-reported disease severity and the subsequent contact with the healthcare system.

Treating the skin with biologics in patients with psoriasis decreases the incidence of psoriatic arthritis.

OBJECTIVES: To compare the incidence of psoriatic arthritis (PsA) in patients with psoriasis (PsO) according to different treatments for their skin: topics/no treatment, conventional disease-modifying antirheumatic drugs (DMARDs) (cDMARDs) or biological DMARDs (bDMARDs). METHODS: Patients with PsO without PsA followed at a university hospital were included in this retrospective cohort study. Patients were classified according to their treatment in topics (topics, phototherapy or no treatment), cDMARDs (methotrexate and cyclosporine) and bDMARDs (tumour necrosis factor inhibitors (TNFi), interleukin 17 inhibitors (IL-17i) and IL-12-23i ((interleukin (IL) 12/IL-23 inhibitor))) groups. Incident cases of PsA were attributed to one treatment if developed during the administration of that treatment. A Cox proportional hazards model was used to evaluate the adjusted risk of PsA development by treatment group. RESULTS: 1719 patients with PsO contributed a total of 14 721 patient/years (py). 1387 (81%) patients were in the topics, 229 (13%) in cDMARDs and 103 (6%) in the bDMARDs group. During follow-up, 239 patients (14%) developed PsA (231 under topics, six under cDMARDs and two under bDMARDs). Global incidence was 1.6 per 100 py. The risk of developing PsA in patients with PsO treated with bDMARDs was significantly lower (incidence rate ratio (IRR)=0.26; 95% CI 0.03 to 0.94; p=0.0111), compared with topics, but not compared with cDMARDs (IRR=0.35; 95% CI 0.035 to 1.96; p=0.1007). Adjusted Cox proportional hazards regression analysis showed that male sex, nail involvement and higher body max index were associated with increased risk of developing PsA, while biologics use was protective (HR: 0.19; 95% CI 0.05 to 0.81). CONCLUSION: Treatment with biologics in patients with PsO reduced the risk of PsA development.

[Analysis of a case series of adult patients with severe atopic dermatitis treated with dupilumab in Argentina]. / Análisis de una serie de casos de pacientes adultos con dermatitis atópica severa tratados con dupilumab en Argentina.

Introduction: Severe atopic dermatitis (AD) treatment is an unmet need, given the limited efficacy and safety of classical systemic treatments (CSTs). Dupilumab is a monoclonal antibody that blocks the signaling of the interleukins that mediate the inflammatory response involved in AD. Methods: the clinical response of a group of patients from Argentina with severe AD and insufficient response and/or toxicity to CSTs who were treated with dupilumab before commercial availability was analyzed. EASI, SCORAD, DLQI scales and analog visual scales of pruritus and sleep were evaluated, during a median follow-up of 189 days. In addition, the incidence of adverse events was analyzed. Results: 20 patients (13 male) were included; median age: 37.5 years; median AD evolution: 20 years; atopic comorbidity: 70%. 100% had received systemic corticosteroids (serious complications: 20%). Main reasons for discontinuation of CSTs were lack of efficacy and occurrence of adverse events. All scores were significantly and steadily reduced, with identifiable clinical response at the second month of treatment. At the end of the follow-up, only 3 patients required concomitant systemic immunosuppressive treatment. Dupilumab was well tolerated, with mild and controllable adverse events. Discussion: Dupilumab is the only biological agent with high efficacy demonstrated in clinical and observational studies. In this case series, its effectiveness was confirmed in difficult-to-treat patients with severe AD and inadequate response to CSTs. The safety profile was favorable and consistent.

Introducción: El tratamiento de la dermatitis atópica (DA) severa es una necesidad insatisfecha, dada la limitada eficacia y seguridad de los tratamientos sistémicos clásicos (TSC). Dupilumab es un anticuerpo monoclonal que bloquea la señalización de las interleuquinas mediadoras de la respuesta inflamatoria involucrada en la DA. Métodos: se analizó la respuesta clínica de un grupo de pacientes de Argentina con DA severa y respuesta insuficiente y/o toxicidad a los TSC que fueron tratados con dupilumab antes de su disponibilidad comercial. Se evaluaron las escalas EASI, SCORAD, DLQI y escalas visuales analógicas de prurito y sueño, durante una mediana de 189 días de seguimiento, así como la incidencia de eventos adversos. Resultados: Se incluyeron 20 pacientes (13 varones); mediana de edad: 37,5 años; mediana de evolución de la DA: 20 años; comorbilidad atópica: 70%. El 100% habían recibido corticoides sistémicos (complicaciones graves: 20%). Los principales motivos de suspensión de los TSC fueron falta de eficacia y aparición de eventos adversos. Los puntajes de todas las escalas se redujeron significativa y sostenidamente, con respuesta clínica evidente al segundo mes de tratamiento. Al final del seguimiento, solo 3 pacientes requerían tratamiento inmunosupresor sistémico concomitante. Dupilumab fue bien tolerado, con eventos adversos leves y controlables. Dsicusión: el dupilumab constituye el único agente biológico con elevada eficacia demostrada en estudios clínicos y observacionales. En esta casuística, se confirmó su efectividad en pacientes con DA severa de difícil tratamiento y respuesta inadecuada a los TSC. El perfil de seguridad resultó favorable y sostenido a mediano plazo.

Medical resource consumption of moderate/severe psoriasis in a private health organization of Buenos Aires, Argentina,

Abstract Background: Despite the economic burden of psoriasis for patients and societies, scant information exists regarding the impact and burden of the disease in Argentina. Objective: The objective of this study was to estimate medical resource consumption and direct health care costs for patients with moderate/severe psoriasis in Buenos Aires, Argentina from the perspective of the payer. Methods: Adults with moderate/severe psoriasis (severity was defined as receiving systemic treatment), during January 2010-January 2014, aged 18 years and older, members of the Italian Hospital Medical Care Program with at least 18 months of follow-up were included. All data on hospitalizations, drug prescription, outpatient episodes, consultations, and investigations/tests in the 12 months before inclusion in the study were considered for the estimation of medical resource consumption and direct health care costs. First-quarter 2018 costs were obtained from the IHMCP and converted into US dollars (using the January 2018 exchange rate). Results: A total of 791 patients were included. The mean age at diagnosis was 34 ± 12 years. Almost 65% of the patients had a dermatologist as their usual source of care, 43% had internists, and 14% had rheumatologists. The average yearly direct cost was US$ 5326 (95% CI: 4125-7896) per patient per year. Study limitation: The single center design and the retrospective nature are the main limitations. Conclusion: This is the first Argentine study that evaluated the costs of moderate/severe psoriasis by taking into consideration the direct medical costs of the disease.

Medical resource consumption of moderate/severe psoriasis in a private health organization of Buenos Aires, Argentina.

BACKGROUND: Despite the economic burden of psoriasis for patients and societies, scant information exists regarding the impact and burden of the disease in Argentina. OBJECTIVE: The objective of this study was to estimate medical resource consumption and direct health care costs for patients with moderate/severe psoriasis in Buenos Aires, Argentina from the perspective of the payer. METHODS: Adults with moderate/severe psoriasis (severity was defined as receiving systemic treatment), during January 2010-January 2014, aged 18 years and older, members of the Italian Hospital Medical Care Program with at least 18 months of follow-up were included. All data on hospitalizations, drug prescription, outpatient episodes, consultations, and investigations/tests in the 12 months before inclusion in the study were considered for the estimation of medical resource consumption and direct health care costs. First-quarter 2018 costs were obtained from the IHMCP and converted into US dollars (using the January 2018 exchange rate). RESULTS: A total of 791 patients were included. The mean age at diagnosis was 34±12 years. Almost 65% of the patients had a dermatologist as their usual source of care, 43% had internists, and 14% had rheumatologists. The average yearly direct cost was US$ 5326 (95% CI: 4125-7896) per patient per year. STUDY LIMITATION: The single center design and the retrospective nature are the main limitations. CONCLUSION: This is the first Argentine study that evaluated the costs of moderate/severe psoriasis by taking into consideration the direct medical costs of the disease.

Ultrasound entheseal abnormalities at the distal interphalangeal joints and clinical nail involvement in patients with psoriasis and psoriatic arthritis, supporting the nail-enthesitis theory.

OBJECTIVE: It has been shown that nail involvement in psoriasis is associated with systemic enthesopathy. Our objective was to evaluate the association of nail involvement and enthesopathy at distal interphalangeal joint (DIP) level in psoriasis (PsO) and psoriatic arthritis (PsA) patients. METHODS: Consecutive patients (54 PsO and 56 PsA) seen at the outpatients clinic in this cross-sectional study were included. All patients underwent both clinical and ultrasound (US) assessment on the same day. RESULTS: US revealed enthesopathy in at least 1 DIP joint in 9 patients with PsO (17%, 95% CI: 8-29%) and in 18 patients with PsA (32%, 95% CI: 20-46%). US extensor tendon enthesopathy was detected in a higher proportion of fingers with clinical nail involvement compared with fingers without clinical nail involvement, both in PsO and PsA patients (61.2% vs 16.8%, p < 0.0001 and 60.1% vs 22%, p < 0.0001, respectively). Among patients with PsO, 20% (95% CI: 7-41%) and 14% (95% CI: 4-32%) of those with and without clinical nail involvement showed enthesopathy on US examination, respectively (p = 0.54). Among PsA patients, the prevalence of enthesopathy was 30% (95% CI: 15-49%) for patients with clinical nail involvement and 35% (95% CI: 17-56%) for those without nail involvement (p = 0.71). CONCLUSION: Nail disease was associated with DIP US enthesopathy. There was a significant increased prevalence of extensor tendon enthesopathy in fingers with involved nails both in PsO and PsA, although no association was found between nail involvement and extensor tendon enthesopathy at patients' level. These features might support the nail-entheseal pathogenesis theory at DIP level.

Mortalidad en pacientes con psoriasis. Análisis de una cohorte retrospectiva / Mortality in patients with psoriasis. A retrospective cohort study

Fundamentos y objetivos: Las modificaciones inmunológicas e inflamatorias observadas en la psoriasis podrían favorecer el desarrollo de la aterosclerosis, aumentando consecuentemente la mortalidad. Los objetivos fueron: 1) determinar la mortalidad de una población con psoriasis en comparación con un grupo control, y 2) conocer la prevalencia de los factores de riesgo cardiovascular. Pacientes y método: Se analizó una cohorte retrospectiva a partir de una base de datos secundaria (historia clínica electrónica). Se incluyeron todos los pacientes con diagnóstico de psoriasis a 1-01-2010, comparándolos con un grupo control del mismo sistema de salud, seleccionados de forma aleatoria (relación 1:1). Se excluyeron los sujetos con antecedentes cardiovasculares. Se realizó un análisis de sobrevida, determinando como episodio la muerte por cualquier causa. El seguimiento se extendió hasta el 30-6-2015. Resultados: Se analizaron 1.481 pacientes con psoriasis y 1.500 controles. La prevalencia de los factores de riesgo cardiovascular fue más elevada en el grupo con psoriasis. El tiempo promedio de seguimiento fue de 4,6±1,7 años. La mortalidad fue mayor en los psoriásicos en comparación con los controles (15,1 frente a 9,6 episodios cada 1.000 personas-año, p < 0,005). La psoriasis se asoció significativamente con una mayor mortalidad en comparación con el grupo control en el análisis univariado (HR 1,58, IC 95% 1,16-2,15, p = 0,004) y luego de ajustar por los factores de riesgo cardiovascular (HR 1,48, IC 95% 1,08-2,3, p = 0,014). Conclusión: En esta población, los pacientes con psoriasis mostraron una mayor prevalencia de factores de riesgo cardiovascular en el momento del diagnóstico y una mayor mortalidad en el seguimiento (AU)

Background and objectives: The immune and inflammatory pathways involved in psoriasis could favor the development of atherosclerosis, consequently increasing mortality. The objectives of this study were: 1) to assess the mortality of a population with psoriasis compared to a control group, and 2) to assess the prevalence of cardiovascular risk factors. Patients and method: A retrospective cohort was analyzed from a secondary database (electronic medical record). All patients with a diagnosis of psoriasis at 1-01-2010 were included in the study and compared to a control group of the same health system, selected randomly (1:1). Subjects with a history of cardiovascular disease were excluded from the study. A survival analysis was performed considering death from any cause as an event. Follow-up was extended until 30-06-2015. Results: We included 1,481 subjects with psoriasis and 1,500 controls. Prevalence of cardiovascular risk factors was higher in the group with psoriasis. The average follow-up time was 4.6±1.7 years. Mortality was higher in psoriasis patients compared to controls (15.1 vs. 9.6 events per 1,000 person-year, P < .005). Psoriasis was seen to be significantly associated with increased mortality rates compared to the control group in the univariate analysis (HR 1.58, 95% CI 1.16-2.15, P = .004) and after adjusting for cardiovascular risk factors (HR 1.48, 95% CI 1.08-2.3, P = .014). Conclusion: In this population, patients with psoriasis showed a higher prevalence for the onset of cardiovascular risk factors as well as higher mortality rates during follow-up (AU)

Mortality in patients with psoriasis. A retrospective cohort study. / Mortalidad en pacientes con psoriasis. Análisis de una cohorte retrospectiva.

BACKGROUND AND OBJECTIVES: The immune and inflammatory pathways involved in psoriasis could favor the development of atherosclerosis, consequently increasing mortality. The objectives of this study were: 1) to assess the mortality of a population with psoriasis compared to a control group, and 2) to assess the prevalence of cardiovascular risk factors. PATIENTS AND METHOD: A retrospective cohort was analyzed from a secondary database (electronic medical record). All patients with a diagnosis of psoriasis at 1-01-2010 were included in the study and compared to a control group of the same health system, selected randomly (1:1). Subjects with a history of cardiovascular disease were excluded from the study. A survival analysis was performed considering death from any cause as an event. Follow-up was extended until 30-06-2015. RESULTS: We included 1,481 subjects with psoriasis and 1,500 controls. Prevalence of cardiovascular risk factors was higher in the group with psoriasis. The average follow-up time was 4.6±1.7 years. Mortality was higher in psoriasis patients compared to controls (15.1 vs. 9.6 events per 1,000 person-year, P<.005). Psoriasis was seen to be significantly associated with increased mortality rates compared to the control group in the univariate analysis (HR 1.58, 95% CI 1.16-2.15, P=.004) and after adjusting for cardiovascular risk factors (HR 1.48, 95% CI 1.08-2.3, P=.014). CONCLUSION: In this population, patients with psoriasis showed a higher prevalence for the onset of cardiovascular risk factors as well as higher mortality rates during follow-up.

Penfigoide ampollar por fármacos: entidad subdiagnosticada? / Drug-Induced Bullous Pemphigoid: an Underdiagnosaed Entity?

El penfigoide ampollar (PA) es una enfermedad infrecuente, de curso crónico y benigno, que aparece en personas de edad avanzada y se caracteriza por la presencia de ampollas subepidérmicas.En términos generales, el diagnóstico de las enfermedades ampollares se basa en las manifestaciones clínicas, los hallazgos histopatológicos y la inmunofluorescencia directa. Si bien la ausencia de alguno de estos métodos puede dificultar el mismo, una adecuada correlación clínico-patológica permite, en la mayoría de los casos, arribar al diagnóstico y realizar el tratamiento apropiado. El PA puede ser causado por fármacos y produce cuadros clínicos similares al PA idiopático. A continuación se presentan dos casos con diagnóstico de penfigoide ampollar por fármacos.

Bullous Pemphigoid is a chronic, infrequent benign disease of the elderly, characterized by the presenceof subepidermal bullae. Diagnosis is based on clinical, histopathological and direct immunofluorescencefindings. Though the absence of any of them hampers the diagnosis, a correct clinico-pathologic correlation is necessary to make the appropriate treatment. Drug induced-BullousPemphigoid presents with identical clinical features as those of the Idiopathic Bullous Pemphigoid.We present two patients with drug-induced Bullous Pemphigoid.