Decision-making factors for the long-term topical treatment of mild-to-moderate plaque psoriasis: TEPPSO, a case-vignette study on clinical practice.

OBJECTIVES: Topical maintenance therapy strategy with regard to patients with mild-to-moderate plaque psoriasis (PP) continues to be heterogeneous and insufficiently investigated in real-life clinical practice. The objective of this study was to describe the initiation of long-term maintenance treatment and to identify clinical parameters influencing the therapeutic decision. METHODS: TEPPSO was a French and Belgian multicentre cross-sectional study based on completion of questionnaires and assessment of credible clinical scenarios of mild-to-moderate PP by physicians using the validated case-vignette method. RESULTS: Maintenance therapy was recommended by dermatologists (Ds) and by general practitioners (GPs) in 79.1% and 76.8% of cases, respectively. GPs recommended the use of a fixed-dose combination of corticosteroid and vitamin D analogues in only 14.8% of cases, whereas this therapy was recommended by French and Belgian Ds in 54.8% and 39.8% of cases, respectively. In a multivariate analysis, significant determinants of the therapeutic decision were skin lesions impacting quality of life (OR 1.9 [95% CI: 1.1; 3.2] P=0.01) for Ds, and patient corticophobia (OR 1.7 [95% CI: 1.1; 2.7] P=0.03) or the presence of skin pruritus (OR 1.8 [95% CI: 1.2; 1.8] P=0.004) for GPs, respectively. CONCLUSIONS: Maintenance treatment with topical agents in patients with mild-to-moderate PP was considered in more than two thirds of cases. Heterogeneity in the choice of topical agents was evidenced particularly between Ds and GPs. Our study is the first to identify significant clinical determinants affecting the therapeutic decision. Updated and validated clinical practice guidelines are needed to ensure uniform therapeutic choices.

A Belgian consensus on the definition of a treat-to-target outcome set in psoriasis management.

OBJECTIVE: Treat-to-target (T2T) is an algorithm to reach a predefined outcome. Here, we define a T2T outcome for moderate-to-severe psoriasis vulgaris. METHODS: Briefly, the study included a literature review, discussions with key opinion leaders, recruitment of additional dermatologists with experience in managing moderate-to-severe psoriasis, 3 eDelphi survey rounds and a patient focus group. Relevant topics were selected during discussions prior to the survey for the statements. Surveys were based on the eDelphi methodology for consensus-building using a series of statements. Consensus was defined as at least 80% of participants agreeing. A psoriasis patient focus group provided feedback on topic selection and outcome. RESULTS: A total of 5 discussions were held, and 3 eDelphi rounds were conducted with an average of 19 participants per round. The T2T outcome was set assuming shared decision between patient and dermatologist, awareness and referral for comorbidities by the dermatologist and appropriate treatment adherence by the patient. We defined 'ideal' and 'acceptable' targets; the latter referring to conditions restricting certain drugs. The T2T outcome was multidimensional, including ≥ ΔPASI90/75 or PGA ≤ 1, itch VAS score ≤ 1, absence of disturbing lesions, DLQI ≤ 1/3, incapacity daily functioning VAS score ≤ 1, safety ≤ mild side-effects and full/mild tolerability of treatment for the ideal and acceptable target, respectively. Finally, time to achieve the T2T outcome was set at 12 weeks after initiation for all treatments. At all times, safety should not exceed the presence of mild side-effects. CONCLUSION: With this novel T2T composite outcome for psoriasis, clinicians and patients can make shared decisions on the treatment goals they envisage, as a guidance for future treatment steps - leading to a tight control management of the disease.

Psoriasis: state of the art 2013.

Psoriasis affects about 2 to 3% of the caucasian population. It is a chronic inflammatory disease affecting predominantly the skin with the involvement of autoimmune mediated mechanisms. Typical pathogenic features include an increased renewal of epidermal keratinocytes, the enlargement of the germinating compartment, papillomatosis, altered epidermal differentiation, angiogenesis, lymphangiogenesis and inflammatory infiltration. Several types of psoriasis are distinguished and may be present simultaneously in some patients. Up to 20 candidate genes have been evidenced in psoriasis. Genetic variability explains different types of the disease and influences response to therapeutics. Furthermore, psoriasis is triggered or aggravated by infections, traumatisms, medications, stress, tobacco, alcohol and endocrine factors. Severe psoriasis is frequently associated with co-morbidities as obesity, diabetes, metabolic syndrome and cardiovascular diseases. For this reason, the similar pathogenic mechanisms of psoriasis and other IMID's (Immune Mediated Inflammatory Diseases) and the use of systemic treatments shared with other specialties, an updated vision of psoriasis for the internist is mandatory.

Psoriasis: state of the art 2013.

The treatment of psoriasis is mainly based on anti-inflammatory and/or anti-hyperproliferative agents. The topical steroids appeared in the fifties and were the first therapeutic breakthrough for psoriasis, followed by methotrexate and phototherapy in the sixties, photochemotherapy (PUVA) in the seventies and acitretin and cyclosporine in the eighties. The targeted biologic therapies represent a whole new era of therapeutic possibilities with a highly beneficial safety record. The choice of treatment depends on a large series of factors, including the type and extend of the psoriasis, the patient's preferences, co-medications, comorbidities and drug tolerance. This overview presents the currently available topical and systemic agents for treating psoriasis, including topical corticosteroids, vitamin D derivatives, UV-light based therapies, methotrexate, cyclosporine, acitretin, and the biologic agents such as the TNF antagonists etanercept, adalimumab and infliximab, as well as the anti-p40 IL12/23 agent ustekinumab. Newer, very promising, agents aiming the Th17 pathway are under development for psoriasis.

The Pott's puffy tumor: an unusual complication of frontal sinusitis, methods for its detection.

This is a case report of a Pott's puffy tumor, characterized by a subperiosteal abscess associated with frontal bone osteomyelitis, as a consequence of a frontal sinusitis, in a 15-year-old boy. Pott's puffy tumor is a rare condition usually seen as a complication of frontal sinusitis and more commonly described in children. Given that, superficial temporal artery pseudoaneurysms might be interpreted as a cyst or lipoma, it is imperative that physicians be aware of their presentation.

[Home plants and allergies]. / Les allergies aux plantes d'intérieur.

Allergic manifestations due to outdoor plants are relatively well known, contrary to those related to home plants. This review presents the various allergens linked to home plants that may be responsible for several allergic manifestations affecting the skin, the lungs, the eyes, and the rhinopharynx. The ficus and its family members constitute the principal sources of the incriminated allergens.

Altered expression of angiogenesis and lymphangiogenesis markers in the uninvolved skin of plaque-type psoriasis.

BACKGROUND: Vascular alterations are significant events in the pathomechanism of psoriasis. A disorder in the mechanisms regulating skin angiogenesis and lymphangiogenesis could participate in the pathogenesis of the disease. OBJECTIVES: To quantify differences in the expression of angiogenesis and lymphangiogenesis growth factors, receptors, coreceptors as well as their antagonists in the uninvolved skin of patients with psoriasis compared with the skin of nonpsoriatic volunteers. METHODS: Skin biopsies were collected from the involved skin of 13 patients with untreated plaque-type psoriasis, from their nonlesional skin at distance from the lesions and from the skin of 16 healthy volunteers. The mRNA steady-state level of keratins 10, 14 and 16, glyceraldehyde-3-phosphate dehydrogenase (GAPDH), vimentin, collagen I and IV, proliferating cell nuclear antigen, the various splice variants of vascular endothelial growth factor, VEGF-A, VEGF-C and VEGF-D, their receptors VEGFR1, VEGFR2 and VEGFR3, neuropilin (NRP)-1 and its soluble forms, NRP-2, semaphorin 3A and prox-1, was measured by reverse transcription-polymerase chain reaction. Immunohistochemistry was performed for Ki-67, von Willebrand factor and D2-40. Blood and lymphatic vessel density, area and distance from epidermis were estimated by morphological analysis coupled to an original computer-assisted method of quantification. RESULTS: Skin from healthy volunteers and nonlesional skin from patients with psoriasis displayed similar histological, morphometric and proliferative features. However, a significant overexpression of VEGFR3, the VEGF-A isoform VEGF121, soluble 12 NRP-1 and GAPDH was observed in the nonlesional psoriatic skin as compared with that of normal volunteers. CONCLUSIONS: These data point to significant differences in the blood and lymphatic vascular transcriptome between the clinically normal-appearing skin of patients with psoriasis and the skin of volunteers without psoriasis.

Cosmetic surgery for congenital nail deformities.

Only a few nail dystrophies may be improved by surgery: malalignment of the big toenail, racquet thumbs, trapezoidal nails, and vertical implantation of the nail on the fifth toe. Knowledge of the surgical management of these deformities may allow a nice cosmetic outcome if performed by skilled surgeons.

Scalp psoriasis: a review of current topical treatment options.

The scalp is the most common site of disease involvement at the onset and throughout the course of psoriasis. For many patients, psoriasis of the scalp is the most difficult aspect of their disease; yet, despite a wide range of therapy options and an extensive literature base, scalp psoriasis remains difficult to treat, highlighting a long-standing unmet need for the effective treatment of scalp psoriasis. A review of past and current medical literature reveals that a number of interesting therapeutic approaches have been used in the treatment of scalp psoriasis. The diverse and sometimes extreme therapeutic approaches, the marginal benefit of many topical agents, the paucity of controlled studies evaluating the efficacy of topical agents in the treatment of scalp psoriasis and the high level of patient dissatisfaction with currently available treatments for psoriasis all support the need for new, effective and well-tolerated treatment options for scalp psoriasis.

[Corticosteroids and their vehicle in the treatment of scalp psoriasis]. / Types de dermocorticoïdes et excipients à conseiller dans le traitement du psoriasis du cuir chevelu.

This paper is concerned with the adequate use of topical corticosteroids for the treatment of scalp psoriasis. Very potent corticosteroids are indicated in all forms of psoriasis. The vehicle itself plays a significant role in any topical treatment. The choice of the vehicle depends on its biodisponibility and cosmetic aspect. Ideally, an easy-to-use vehicle will be preferred since it improves compliance to therapy. Foams, lotions, gels, and shampoos are better accepted than creams, pomades, ointments, and other substances with high residue content.

[Anogenital condylomata in the children. Practice guidelines for a medical expertise]. / Les condylomes ano-génitaux chez l'enfant. Conduite pratique à tenir en expertise médicale.

Belgium has been confronted to cases of paedophilia for years. It seems adequate to suggest some guidelines in cases of a child or a teenager diagnosed with ano-genital warts during a consultation. They are not always the consequence of sexual abuse. Three contaminations are possible: ante natal and peri natal (in utero or during delivery), by direct contact (auto or hetero inoculation), through sexual contact. This trusted practitioners to handle this unusual situation from the child protection, to multidisciplinary management and judicial prosecution against suspect. When using some different way to know what kind of HPV type; it's possible to give some information about transmission and it's possible to do confrontations with the results of the lesions' suspect. It is also interesting to identify very highs oncogenic potential HPV for the survey's patient. Finally the most important is to know that the most recurrences result into reactivations from infra-clinically infections and are not new contaminations. It is important do not drop a new suspicion through hypothetic contaminator.