A Delphi Consensus Approach to Challenging Case Scenarios in Moderate-to-Severe Psoriasis: Part 1.

INTRODUCTION: Traditional clinical trials in psoriasis exclude a significant proportion of patients with complex disease and comorbidities. A consensus panel of 14 experts in the field of psoriasis was formed to conduct a Delphi method exercise to identify difficult-to-treat psoriasis clinical scenarios and to rank treatment approaches. METHODS: The exercise consisted of both survey questionnaires and a live meeting to review and discuss current data (as of 2009, when the exercise was conducted) and arrive at a consensus for optimal treatment options. Seventy difficult treatment scenarios were identified, and the top 24 were selected for discussion at the live meeting. RESULTS: Six of the 24 discussed case scenarios are presented in this article (another five are presented in Part 2): (1) psoriasis with human papilloma virus-induced cervical or anogenital dysplasia; (2) concomitant psoriasis and systemic lupus erythematosus; (3) severe psoriatic nail disease causing functional or emotional impairment; (4) psoriasis therapies that potentially reduce cardiovascular morbidity and mortality; (5) older patients (≥65 years of age) with psoriasis; and (6) severe scalp psoriasis that is unresponsive to topical therapy. CONCLUSION: The Delphi exercise resulted in guidelines for practicing physicians to utilize when confronted with challenging patients with psoriasis.

A Delphi Consensus Approach to Challenging Case Scenarios in Moderate-to-Severe Psoriasis: Part 2.

INTRODUCTION: Clinicians may be confronted with difficult-to-treat psoriasis cases for which there are scant data to rely upon for guidance. To assist in managing such patients, who are typically excluded from clinical trials, a consensus panel of 14 experts in the field of psoriasis was formed to conduct a Delphi method exercise. METHODS: The exercise consisted of both survey questionnaires and a live meeting to review and discuss current data (as of 2009, when the exercise was conducted) and arrive at a consensus for optimal treatment options. Seventy difficult treatment scenarios were identified, and the top 24 were selected for discussion at the live meeting. RESULTS: Five of the 24 discussed case scenarios are presented in this article: (1) moderate-to-severe psoriasis that has failed to respond to all currently approved therapies for psoriasis; (2) palmoplantar psoriasis that is unresponsive to topical therapy and phototherapy; (3) erythrodermic psoriasis; (4) pustular psoriasis; and (5) the preferred therapeutic choice to combine with low-dose methotrexate. A previous article (part 1) presented six other scenarios. CONCLUSION: The Delphi exercise resulted in guidelines for practicing physicians to utilize when confronted with patients with challenging cases of psoriasis.

SAPHO syndrome associated with hidradenitis suppurativa successfully treated with infliximab and methotrexate.

SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) is a rare chronic inflammatory musculoskeletal disorder of unknown etiology observed in children and young adults, which involves both osteo-articular inflammation and skin abnormalities. We review the case of a 22-year-old male, who presented with a 5-year history of hidradenitis suppurativa (HS), acne vulgaris, joint stiffness, and pain. Previous ineffective treatments included isotretinoin and oral antibiotics. Marked improvement of all cutaneous features was noticed after the first dose of infliximab and methotrexate; continued treatment resulted in the complete remission of the arthritis and enthesopathy. This case report demonstrates the efficacy and safety of infliximab and methotrexate in refractory SAPHO syndrome.

T-cell agents in the treatment of rheumatoid arthritis.

T cells play a prominent role in the pathogenesis of rheumatoid arthritis. Abatacept is the first FDA approved agent for rheumatoid arthritis that blocks the activation of T cells by interrupting the interaction between the CD28 ligand on the T cell and the CD80/86 ligand on the antigen presenting cell. Inhibition of T cell activation has pleotropic effects that lowers the downstream production of multiple cytokines. In clinical trials, abatacept is effective in treating the signs and symptoms of rheumatoid arthritis as well as in inhibiting structural damage. It has a favorable safety profile and can be used in patients who may have comorbidities that preclude the use of anti-TNF agents. While no direct head to head trials exist, a study in which both abatacept and infiximab were compared to an identical control population, suggested that the efficacy of the two drugs was similar but that there were fewer adverse effects with abatacept than with infiximab. Abatacept is an important addition to the therapeutic repertoire available to treat rheumatoid arthritis. Available data support its use as a first line agent to treat patients who have had and inadequate response to methotrexate.