Treatment Preferences in Young Adults with Moderate to Severe Psoriasis: A Qualitative Study from the Nordic Countries.

INTRODUCTION: The purpose of this study is to explore treatment preferences and identify patient characteristics in young bio-naive adults with moderate to severe psoriasis in the Nordic countries (Norway, Finland, Sweden, and Denmark). METHODS: Patients were 18-45 years old and bio-naive but referred for biologic treatment of moderate to severe psoriasis. Patients were included at eight Nordic dermatology clinics. Patients with significant comorbidity or psoriatic arthritis were excluded. The Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were assessed along with basic patient information. A semistructured interview guide was used in individual qualitative interviews, asking patients about their treatment preferences and reasons, disease journey, and disease management. The interviews were analyzed using thematic content analysis. Twenty-four patients sufficed to reach saturation in this qualitative study. RESULTS: The patient sample characteristics represented a qualitative variation in age, sex, symptoms, duration of disease, and country. We included a total of 12 male and 12 female patients. The mean age was 34 years (range 18-45 years), the mean age at diagnosis was 20 years (range 6-34 years), the mean ± standard deviation (SD) time since diagnosis was 13 ± 8 years, PASI was 9.5 ± 4.7, and DLQI was 15.2 ± 6.4. Interviews suggested that both the burden of disease as well as the burden of treatment influenced patient preferences regarding treatment attributes, hence getting alleviation from symptoms did not alone influence patient preferences. Time, effort, and inconvenience related to psoriasis treatments also influenced patient preferences. CONCLUSIONS: This first in-depth, qualitative study in young bio-naive adults with psoriasis suggests that patient preferences are focusing not only on symptom relief but also on alleviating the burden of psoriasis treatment. Understanding the reasons for patient preferences and the perspectives of young adults is needed to guide individual shared decision-making in psoriasis management.

Not much research has been done on understanding the disease burden and treatment needs of young adults suffering from psoriasis. This is an interview study with young adults from Nordic countries suffering from moderate to severe psoriasis with an active lifestyle. The adult patients were all referred for biologic treatment of psoriasis but had not yet started treatment when they were interviewed. The aim was to explore treatment preferences in this group.The study showed that treatment goals depended upon both alleviation of symptoms and obtaining a low treatment burden. The most influential symptoms were scaling, itching, and visible plaques. The most important treatment burden features were efficacy, durability, speed of response, safety, and convenience. Understanding the reasons behind these different treatment preferences is essential to help shared-decision psoriasis management that matches individual needs.

Uniting biobank resources reveals novel genetic pathways modulating susceptibility for atopic dermatitis.

BACKGROUND: Atopic dermatitis (AD) is a common chronic inflammatory skin disease with high heritability. Previous genome-wide association studies have identified several loci predisposing to AD. These findings explain approximately 30% of the variance in AD susceptibility, suggesting that further work is required to fully understand the genetic underpinnings. OBJECTIVE: We sought to gain additional understanding of the genetic contribution to AD risk by using biobank resources. METHODS: We completed a genome-wide meta-analysis of AD in 796,661 individuals (Ncases = 22,474) from the FinnGen study, the Estonian Biobank, and the UK Biobank. We further performed downstream in silico analyses to characterize the risk variants at the novel loci. RESULTS: We report 30 loci associating with AD (P < 5 × 10-8), 5 of which are novel. In 2 of the novel loci, we identified missense mutations with deleterious predictions in desmocollin 1 and serpin family B member 7, genes encoding proteins crucial to epidermal strength and integrity. CONCLUSIONS: These findings elucidate novel genetic pathways involved in AD pathophysiology. The likely involvement of desmocollin 1 and serpin family B member 7 in AD pathogenesis may offer opportunities for the development of novel treatment strategies for AD in the future.

Influence of Psoriasis on Household Chores and Time Spent on Skin Care at Home: A Questionnaire Study.

INTRODUCTION: Previous studies have shown that psoriasis has a significant effect on patients' health-related quality of life. The impact of psoriasis on household chores and the need for assistance with such tasks are not well documented. The aim of this study was to estimate the impact of psoriasis on the ability to carry out household chores, the time spent on skin care at home and the assistance that patients with psoriasis require with these activities. METHODS: In a questionnaire study 262 patients with moderate-to-severe psoriasis, visiting a tertiary level dermatological clinic during a 1-year study period, listed household chores which they considered were particularly affected by psoriasis. This was done without a predefined list of chores. Questions on their ability to perform household chores as well as time spent on skin care at home were asked. The need for outside assistance with household chores and help received were also determined. RESULTS: More than half of the patients (57.8%) reported difficulties with household chores because of psoriasis. Psoriasis affected a wide range of everyday household activities, with physically demanding tasks and those involving contact with water mentioned most often. Most of the patients (84.6%) reported that they have increased the time spent on skin care because of psoriasis, on average by 87 min per week. A quarter of patients received assistance in household chores. Women received more assistance than men (p < 0.01). The need for additional assistance was reported by a fifth of patients, women more often than men (p < 0.05). CONCLUSION: When estimating the overall burden of psoriasis, considering only the economic and productivity consequences may underestimate the impact of the disease. The impact on everyday life events such as the ability to perform household chores should also be taken into account. FUNDING: This study was supported by unconditional grants from the research funds of the Hospital District of Southwest Finland. Hospital District of Southwest Finland's research permission K44/10/EVO13043.

How much of the productivity losses among psoriasis patients are due to psoriasis.

BACKGROUND: In previous studies, productivity losses have been measured specifically due to psoriasis or generally due to health problems in psoriasis patients. There is no information on the proportion of health related productivity losses that are due to psoriasis. The aim of this study was to estimate the proportion of productivity losses due to psoriasis and due to other medical problems among employed psoriasis patients. METHODS: Patients visiting a tertiary level dermatological clinic during a one-year period due to psoriasis or psoriasis arthritis, who were employed, were selected to the study. A questionnaire was used to assess productivity losses during the previous month. RESULTS: Psoriasis accounted for 38% of the total lost productivity costs. One fifth of patients had been on sick leave (absenteeism) due to psoriasis and a third of patients worked despite being sick with psoriasis (presenteeism). Men had higher costs of presenteeism, but the costs of absenteeism due to psoriasis were lower for men than for women. CONCLUSIONS: Productivity losses should be assessed disease specifically to avoid overestimations of the role of the disease on indirect costs. Our study shows that about a third of the lost productivity costs are due to psoriasis.

Treatment costs of psoriasis in a tertiary-level clinic.

BACKGROUND: The costs of psoriasis to a tertiary-level clinic vary considerably depending on the country of study and methods used. Hospitalisation and phototherapy have been significant cost components. This study was performed to estimate the distribution and relative magnitude of the costs of psoriasis to a tertiary-level clinic. METHODS: Based on 233 patients, outpatient and phototherapy visits and the days hospitalised were collected from the treatment provider's records. The visit costs represented true costs, used to charge the final payers. Patients were analysed according to their treatment modalities. RESULTS: On average, hospitalised patients (3.4%) had 31-fold higher total costs than non-hospitalised patients (p < 0.0001). The costs of hospitalisations formed 45% of all the treatment costs to the entire study population. Phototherapy accumulated 19% of the overall treatment costs. Patients receiving biological drugs or both phototherapy and traditional systemic therapy had the highest costs of treatment. CONCLUSIONS: The current study indicates that a small percentage of all psoriasis patients generate a large proportion of the overall costs to a tertiary-level hospital. Treatment modality has a significant effect on the costs to a tertiary-level hospital.

[UV radiation, tanning and DNA damage]. / UV-säteily, ruskettuminen ja DNA-vaurio.

Excessive exposure to UV radiation is the most significant known risk factor for skin cancer. Solarium devices produce UVA radiation that is 5 to 10 times stronger than that produced by the sun. All wavelengths of UV radiation cause DNA damage to skin cells and cause tanning. Tanning protects skin cells from further damage. The DNA damages caused by UVA and UVB radiation, however, differ from each other. The protective capacity of tanning caused by UVA radiation seems to be lower than that caused by UVB radiation.

Perceived impact of psoriasis on leisure-time activities.

BACKGROUND: Psoriasis has an influence on various aspects of patients' everyday life. When estimating the total burden of the disease, the influence on leisure-time should also be taken into account. OBJECTIVES: To evaluate the perceived impact of psoriasis on leisure-time activities. MATERIAL AND METHODS: The questionnaire study was based on 262 patients with psoriasis. The patients were asked to list their leisure-time activities, any activities they had reduced or given up completely because of psoriasis, the time spent on current leisure-time activities and the time they would have spent in a hypothetical situation if they did not have psoriasis. Using a visual analogue scale (VAS) of 0-100, the patients assessed how well they could currently perform their leisure-time activities and how well in a hypothetical situation without psoriasis. The difference between the VAS scores depicted the level of disadvantage caused by psoriasis. RESULTS: More than half the patients (51.9%) had reduced or completely given up at least one leisure-time activity. The disadvantage score (VAS) of psoriasis was 16.9. Younger age was associated with higher disadvantage (r = 0.154, p<0.05). Sports activities were completely given up by 30.2% and reduced by 23.7%. Social activities and those which could be expected to cause embarrassment were given up by 29.0% and reduced by 21.4% of the patients. CONCLUSION: A majority of patients with psoriasis reduce or give up leisure-time activities because of their condition, so the influence of psoriasis on leisure-time is considerable.

The costs of psoriasis medications.

INTRODUCTION: Psoriasis is a chronic disease, which contributes to the economic burden on health care. The distribution of psoriasis medication costs and the quality of life in these patients has been estimated to be around 20% of total costs. OBJECTIVES: To estimate the economic distribution of medications and the impact of multiple treatment options on a patient's quality of life. MATERIALS AND METHODS: The study was based on 236 Finnish psoriasis patients. The Finnish Social Insurance Institution had databases for all psoriasis related medications purchased. Each purchase, during the 1-year study period (1 October 2009-30 September 2010), was recorded and analyzed. The dermatological quality-of-life index was collected from the medical records. RESULTS: Total medication costs were 1,083 per year per patient. Topical treatments were the most often purchased medication and they comprised 18% of the total medication costs. Ten percent of the patients needed 3 or more medication changes during the 1-year study period. Biologics were used only by 5% of patients, but they produced 67% of total medication costs. Patients needing various treatments had higher medication costs and a poorer quality of life. CONCLUSION: A small number of patients generated a great sum of medication costs partly due to the need to change medications. These patients had the worst quality-of-life index scores. Biologics formed a major cost component.

Black currant seed oil supplementation of mothers enhances IFN-γ and suppresses IL-4 production in breast milk.

BACKGROUND: The first year of infancy is crucial for the development of atopic immune response. Inadequate early Th1 and Treg responses and increased production of Th2 cytokines are associated with atopy. Breast milk contains several immunomodulatory cytokines and other factors that might influence the maturation of the infant's immune system. We assessed the cytokines in breast milk of mother of newborn infants and their associations with black currant seed oil (BCSO) supplementation during pregnancy, mother's atopic status and the development of infant's atopic dermatitis. METHODS: Mothers and infants from an intervention study by black currant seed oil (n = 31) or olive oil as placebo (n = 30) were included in the study. Breast milk samples were collected during the first 3 months of breastfeeding. Breast milk levels of IL-4, IL-5, IL-10, IL-12, IFN-γ and TNF were measured by Luminex technology. RESULTS: BCSO intervention group had decreased level of IL-4 (p = 0.044) and elevated level of IFN-γ (p = 0.014) in breast milk as compared to olive oil group. No significant differences were observed in IL-5, IL-10, IL-12 and TNF levels between the BCSO and olive oil groups. Mothers who had atopic dermatitis had significantly decreased levels of IL-10 (p = 0.044) in breast milk. Breast milk of the mothers of the children who developed atopic dermatitis had lower levels of IFN-γ (p = 0.039) as compared to the breast milk of the mothers of the children without dermatitis. CONCLUSION: Dietary intervention with BCSO had immunomodulatory effects on breast milk cytokine production towards Th2 to Th1 immunodeviation.

Influence of psoriasis on work.

BACKGROUND: Previous research indicates that psoriasis has an impact on early retirement, sick leave days and reduced work performance. OBJECTIVES: To evaluate the disadvantages at work caused by psoriasis. MATERIAL AND METHODS: The sample was based on patients visiting the dermatology outpatient clinic in Turku University Hospital. 262 returned a mailed questionnaire. The subjects were asked how many hours they were on a sick leave (absenteeism) and working while sick (presenteeism) due to psoriasis and other health reasons. RESULTS: Of the retired, 17.0% felt they were retired due to psoriasis. Those in the active work force reported on average 4.5 hours absenteeism and 8.3 hours of presenteeism due to psoriasis during the last 4 weeks. Psoriasis caused 27.0% of the total absenteeism and 39.0% of presenteeism. More than a quarter (28.9%) had been forced to modify their work due to psoriasis, most frequently to make the work less irritating for the skin. CONCLUSION: Psoriasis has a negative effect on patients' work in many ways, causing early retirement from work, sick leave days, change of occupation and work modifications.

[How is hyposensitization executed?]. / Miten siedätyshoito toteutetaan?

Hyposensitization alleviates the symptoms of allergic rhinitis, eye symptoms and asthma by attenuating the underlying allergic inflammation. In the treatment of hymenoptera allergy, hyposensitization may be life-saving. The need for anti-allergic medication decreases markedly with successful hyposensitization. The decision about the initiation of hyposensitization is made by a doctor specialized in allergies together with the patient. Before the treatment decision, the IgE-mediated nature of the allergic symptoms is confirmed by skin-prick or blood tests. With the development of new sublingual hyposensitizations the availability of hyposensitization will improve and its application become more common.

Cutaneous lupus erythematosus after treatment with paclitaxel and bevacizumab for metastatic breast cancer: a case report.

INTRODUCTION: The monoclonal anti-vascular endothelial growth factor antibody bevacizumab is increasingly used in the treatment of several malignant tumors. The usual side effects of this drug are hypertension and proteinuria. Paclitaxel is widely used in the treatment of breast cancer and head and neck carcinomas. Neither of these two drugs typically causes skin disorders. Paclitaxel-related cutaneous lupus erythematosus has been described before, but in earlier cases patients had a history of autoimmune disease. CASE PRESENTATION: We report a case of a 65-year-old Caucasian woman who presented with cutaneous lupus erythematosus after receiving paclitaxel-bevacizumab combination treatment as first-line therapy for metastatic breast cancer. Her cutaneous symptoms and increased serum anti-SSA and anti-SSB antibodies disappeared shortly after the discontinuation of therapy. CONCLUSION: We conclude that cutaneous lupus erythematosus can also be seen in patients without earlier anamnesis of autoimmune disorders and that, furthermore, bevacizumab might cause atypical cutaneous side effects.

[Treatment of skin psoriasis]. / Ihopsoriaasin hoito.

Partly similar inflammatory mediators are functioning in the disease process of psoriasis and its associated diseases. An overall improvement in patient's health status is likely to result in a better control of the comorbidities as well. Arthropathic psoriasis should be suspected, if arthritis and psoriasis occur simultaneously. Dermatitis can be only rarely rendered symptomless. Skin psoriasis with mild symptoms requires no treatment, provided that it doesn't disturb the patient. Most patients will manage moderately with topical therapy. Internal treatment of skin psoriasis will be initiated and monitored by a specialized dermatologist.

UV-induced tolerance to a contact allergen is impaired in polymorphic light eruption.

Polymorphic light eruption (PLE) is a common skin disorder provoked by exposure to UVR. Its clinical symptoms resemble those of a contact allergic reaction. PLE is generally considered a T-cell-mediated autoimmune reaction toward a yet unidentified antigen formed in UVR-exposed skin. Predisposition to such an immune reaction may result from aberrant epitope formation, increased immune reactivity to a universal epitope, or diminished propensity to UVR-induced immunosuppression or to the induction of tolerance. In a study comprising a total of 24 PLE patients and 24 healthy sex- and age-matched controls, we found that both groups demonstrated similar immunosuppression of contact sensitization to diphenylcyclopropenone by earlier exposure to solar-simulating UVR. However, only 1 out of 13 PLE patients (8%) versus 6 out of 11 controls (55%) that had been immunosuppressed by UVR exhibited a state of immunotolerance toward the same allergen after 10-24 months (P=0.023). We conclude that the impaired propensity to UVR-induced allergen-specific immunotolerance may promote recurrent PLE.

Neurological symptoms and natural course of xeroderma pigmentosum.

We have prospectively followed 16 Finnish xeroderma pigmentosum (XP) patients for up to 23 years. Seven patients were assigned by complementation analysis to the group XP-A, two patients to the XP-C group and one patient to the XP-G group. Six of the seven XP-A patients had the identical mutation (Arg228Ter) and the seventh patient had a different mutation (G283A). Further patients were assigned to complementation groups on the basis of their consanguinity to an XP patient with a known complementation group. The first sign of the disease in all the cases was severe sunburn with minimal sun exposure in early infancy. However, at the time the diagnosis was made in only two cases. The XP-A patients developed neurological and cognitive dysfunction in childhood. The neurological disease advanced in an orderly fashion through its successive stages, finally affecting the whole nervous system and leading to death before the age of 40 years. Dermatological and ocular damage of the XP-A patients tended to be limited. The two XP-C patients were neurologically and cognitively intact despite mild brain atrophy as seen by neuroimaging. The XP-G patients had sensorineural hearing loss, laryngeal dystonia and peripheral neuropathy. The XP-C patients had severe skin and ocular malignancies that first presented at pre-school age. They also showed immunosuppression in cell-mediated immunity. Neurological disease appears to be associated with the complementation group and the failure of fibroblasts to recover RNA synthesis following UV irradiation, but not necessarily to the severity of the dermatological symptoms, the hypersensitivity of fibroblasts to UVB killing or the susceptibility of keratinocytes to UVB-induced apoptosis.

Demonstration of UV-dimers in human skin DNA in situ 3 weeks after exposure.

Data on DNA repair rates of specific types of DNA lesions are very limited in humans in situ. Rate of repair of UV-induced DNA damage was followed in the skin of 17 volunteers up to 3 weeks of UV exposure, using a (32)P-postlabelling technique for the determination of specific photoproducts. The subjects of skin phototypes I and IV were exposed to 40 mJ/cm(2) of solar simulating radiation on buttock skin, and biopsies were taken at 0 h, 48 h and 3 weeks of exposure for the analysis of two cyclobutane pyrimidine dimers, TT=C and TT=T, and two 6-4 photoproducts, TT-C and TT-T, as trinucleotides. Repair rates were heterogeneous for different photoproducts. T=T dimers were repaired slower than C=T dimers, and 2.3-9.0% of the initial T=T damage remained unrepaired after 3 weeks, and was detectable in 16/17 subjects. The identity of the identified photoproducts was confirmed by a photochemical reversion assay. Damage level correlated with skin types, type I being more sensitive than type IV in an age-matched comparison. This is the first time the persistence of defined human DNA damage is demonstrated up to 3 weeks. Long-lasting DNA damage increases the likelihood of mutations.