Recomendaciones del Colegio Mexicano de Reumatología para el manejo de la artritis psoriásica / Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis

La artritis psoriásica (APs) es una enfermedad inflamatoria sistémica crónica que afecta a la piel, las estructuras musculoesqueléticas y otros órganos y sistemas, comprometiendo la funcionalidad, la calidad de vida y reduciendo la expectativa de vida de los pacientes. Es una enfermedad compleja que requiere atención y manejo especializado y oportuno. Las alternativas para el tratamiento de las manifestaciones de la APs se han incrementado y, adicionalmente, el efecto de los distintos agentes sobre manifestaciones específicas ha sido aclarado en estudios recientes, por lo tanto, es conveniente incorporar la evidencia disponible para construir una estrategia en el tratamiento de estos pacientes. El Colegio Mexicano de Reumatología seleccionó una comisión para evaluar estas distintas alternativas y generar recomendaciones. Métodos: El grupo de estudio incluyó a 16 reumatólogos y tres dermatólogos certificados, que fueron seleccionados de diferentes instituciones de salud y regiones del país. Se conformó un comité ejecutivo que coordinó las reuniones y un comité de expertos que seleccionó los criterios de búsqueda en la literatura, elaboró las preguntas de investigación, calificó la calidad de la evidencia y generó las recomendaciones en los distintos dominios de la enfermedad con base en la metodología GRADE. Resultados: Se generaron 24 recomendaciones actualizadas para el tratamiento de pacientes con APs. Las recomendaciones establecen el papel de los medicamentos disponibles actualmente en nuestro país. Se enfatiza la importancia del control adecuado de la enfermedad, individualizando el perfil de involucramiento de cada paciente en cada uno de los seis dominios potencialmente afectados por la enfermedad. Además, se establece la secuencia en la elección de los tratamientos disponibles para cada dominio, basada en su eficacia, perfil de seguridad y accesibilidad.(AU)

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. Methods: The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. Results: 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. Conclusions: With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.(AU)

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis.

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. METHODS: The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. RESULTS: 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. CONCLUSIONS: With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Recommendations of the Mexican College of Rheumatology for the management of psoriatic arthritis. / Recomendaciones del Colegio Mexicano de Reumatología para el manejo de la artritis psoriásica.

Psoriatic arthritis is a chronic systemic inflammatory disease that affects the skin, musculoskeletal structures and other organs and systems compromising functionality, quality of life and reducing the life expectancy of patients. It is a complex disease that requires specialist and timely care and management. The alternatives for treating the manifestations of psoriatic arthritis have increased and the effect of the different agents on specific manifestations has been clarified in recent studies. Therefore, we should incorporate the available evidence to build a strategy for the treatment of these patients. The Mexican College of Rheumatology selected a committee to evaluate these different alternatives and make recommendations. METHODS: The study group included 16 rheumatologists and 3 certified dermatologists, selected from different health institutions and regions of the country. An executive committee was formed to coordinate the meetings and a committee of experts selected the literature search criteria, prepared the research questions, rated the quality of the evidence, and produced the recommendations in the different disease domains based on the GRADE methodology. RESULTS: 24 updated recommendations were generated for the treatment of patients with psoriatic arthritis. The recommendations establish the role of the drugs currently available in our country. The importance of adequate disease control is emphasized, individualizing the level of involvement of each patient in each of the six domains potentially affected by the disease. In addition, the sequence in the choice of treatments available for each domain is established, based on their efficacy, safety profile and accessibility. CONCLUSIONS: With this consensus document, it will be possible to improve the care of patients with psoriatic arthritis. The recommendations were generated based on the best available information and in consideration of the Mexican health system.

Psoriatic arthritis in patients with psoriasis: A clinical-epidemiological study at a dermatology center in western Mexico.

BACKGROUND/OBJECTIVE: Psoriatic arthritis (PsA) is a chronic inflammatory illness. Approximately, 15% of psoriasis patients have undiagnosed PsA. In Mexico, we found no related studies. Our objective was to investigate the clinical-epidemiological characteristics of PsA in psoriasis patients in western Mexico. METHODS: A cross-sectional study including Mexican patients with clinical and histopathological diagnosis of psoriasis. Physical examination, rheumatoid factor analysis and radiographies of axial and peripheral skeleton were performed. The prevalence of PsA using the CASPAR criteria, age, sex; clinical variants of PsA, psoriasis type and the Psoriasis Area and Severity Index (PASI), were assessed. Descriptive and inferential statistics were used. RESULTS: Of 90 patients with psoriasis, 48 met the criteria for PsA, with a prevalence of 53%, and average age of 50 ± 15 years. Predominating were, the female sex in 29 (60%), the axial variant of PsA in 24 (50%), and psoriasis plaques in 40 (83%). The average PASI was 12 ± 11. All cases were rheumatoid factor negative. These variables were not significantly different when comparing subjects with and without PsA, except for the female sex (60% vs. 7%; P < 0.001). CONCLUSIONS: Patients with psoriasis should intentionally be evaluated jointly Dermatologists and Rheumatologists searching joint involvement given the high prevalence of PsA previously undiagnosed.

Nevoid acanthosis nigricans: Report of four cases localized to the umbilicus.

Nevoid acanthosis nigricans is a rare, benign form of acanthosis nigricans. Of the 24 cases documented in the literature, only two are exclusively localized to the umbilicus. We present four cases of nevoid acanthosis nigricans localized to the umbilicus; in patients less than 25 years of age, with no known co-morbidities, three of whom were females. Two of the cases received, with good response, treatment based on topical calcipotriol, a medication not previously reported to be used for this indication. Contrary to other types of acanthosis nigricans, the nevoid acanthosis nigricans is not associated with any syndrome, endocrinopathy, obesity, medication, or neoplasia and it can be confused with other pathologies such as epidermal nevus or dermatosis neglecta.

Consenso mexicano en el manejo clínico de la hidradenitis supurativa / Mexican consensus on the clinical management of hidradenitis suppurativa

Resumen ANTECEDENTES: La hidradenitis supurativa es una enfermedad inflamatoria, crónica y recurrente con gran repercusión en la calidad de vida de los pacientes, específicamente en los aspectos psicológicos y sexuales, así como también en la productividad laboral. OBJETIVO: Generar un documento de consenso sobre el manejo clínico de los pacientes con hidradenitis supurativa en México que sirva para homologar el diagnóstico y tratamiento de estos pacientes. MÉTODO: Se convocó a un grupo multidisciplinario (dermatólogos, ginecólogos, cirujanos, infectólogos, proctólogos) para analizar la evidencia en el tratamiento integral de la hidradenitis supurativa (calidad de vida, clinimetría, diagnóstico y tratamiento), localizada mediante una revisión sistemática de la bibliografía. El grupo discutió sobre los temas y se generaron las recomendaciones por acuerdo unánime de los participantes. RESULTADOS: Con frecuencia los pacientes con hidradenitis supurativa pueden tardar mucho tiempo en obtener el diagnóstico y manejo correctos, principalmente debido a la falta de evidencia sobre la enfermedad, así como a la falta de criterios para referir al paciente con un especialista. Se emitieron 22 recomendaciones para el tratamiento de pacientes con hidradenitis supurativa, que comprenden el diagnóstico, estadificación y clinimetría, así como el manejo clínico en el primer, segundo y tercer nivel de atención. CONCLUSIONES: Se emitieron las recomendaciones con base en la mejor evidencia disponible, así como la experiencia del grupo multidisciplinario de expertos en el tratamiento de hidradenitis supurativa.

Abstract BACKGROUND: Hidradenitis suppurativa is an inflammatory, chronic and recurrent disease with a high impact on patients quality of life, specifically in psychological and sexual aspects, as well as in labor productivity. OBJECTIVE: To generate a consensus document on the clinical management of patients with hidradenitis suppurativa in Mexico, that serves to standardize the diagnosis and treatment of these patients. METHOD: A multidisciplinary group was convened (dermatologists, gynecologists, surgeons, infectologists, proctologists) to analyze the evidence on the integral treatment of hidradenitis suppurativa (quality of life, clinimetry, diagnosis and treatment), located through a systematic review of the literature. The group discussed the issues and the recommendations were generated by unanimous agreement of the participants. RESULTS: Frequently, patients with hidradenitis suppurativa can take a long time to obtain the correct diagnosis and management, mainly due to the lack of evidence about the disease, as well as the lack of criteria to refer the patient to a specialist. Twenty-two recommendations were issued for the treatment of patients with hidradenitis suppurativa, which include diagnosis, staging and clinimetry, as well as clinical management in the first, second and third levels of care. CONCLUSIONS: The recommendations were issued based on the best available evidence, as well as the experience of the multidisciplinary group of experts in the treatment of hidradenitis suppurativa.

[Mexican consensus on the diagnosis and treatment of atopic dermatitis in adolescents and adults]. / Consenso mexicano para el diagnóstico y tratamiento de la dermatitis atópica en adolescentes y adultos.

BACKGROUND: The diagnostic approaches and therapeutic strategies of atopic dermatitis (AD) are generally inconsistent among physicians and health institutions. OBJECTIVE: To develop a consensus statement among experts to reduce the variations in practice regarding the diagnosis and treatment of patients ≥ 12 years with AD to improve their care. METHODS: Systematic literature search in PubMed and GREAT. With methodological support and using the Delphi method, a formal consensus was developed among 16 experts in Dermatology and Allergology, based on the current evidence and its applicability in the Mexican context. Apart from intense electronic communication, several issues of disagreement were discussed in two face-to-face meetings. RESULTS: The clinical experts reached consensus on 46 statements related to the definition, classification, diagnostic strategies and treatment of AD. For the diagnosis we suggest the Williams criteria and for severity scoring the SCORAD (by the doctor) and POEM (by the patient). In addition to general care and treatment education (workshops), we suggest four steps for treatment, depending on severity: 1. Topical treatment with anti-inflammatory agents (and systemic: antihistamines/antileukotrienes -low level evidence-) 2. Phototherapy, 3. Cyclosporin A and 4. Dupilumab, with the possibility of managing this biological earlier on if a fast effect is needed. In extrinsic AD we suggest evaluating the addition of allergen immunotherapy or an elimination diet, if there is an IgE-mediated respiratory or food allergy, respectively. CONCLUSION: The panel of experts reached consensus on relevant aspects of AD with a focus on the transcultural adaptation of recent evidence.

Antecedentes: Los abordajes diagnósticos y las estrategias terapéuticas de la dermatitis atópica generalmente son inconsistentes entre los médicos y entre las instituciones de salud. Objetivo: Consensar las opiniones de expertos para reducir las variaciones en la práctica respecto al diagnóstico y tratamiento de pacientes ≥ 12 años con dermatitis atópica para mejorar su cuidado. Métodos: Búsqueda sistemática de la literatura en PubMed y GREAT. Con apoyo metodológico y utilizando el método Delphi se desarrolló un consenso formal entre 16 expertos en dermatología y alergología, basándose en la evidencia actual y su aplicabilidad en el contexto mexicano. A parte de una comunicación electrónica intensa, se discutieron los puntos en desacuerdo en dos reuniones presenciales. Resultados: Los expertos clínicos alcanzaron consenso en 46 declaraciones relacionadas con la definición, clasificación, estrategias de diagnóstico y tratamiento de la dermatitis atópica. Para el diagnóstico sugerimos se usan los criterios de Williams y el SCORAD (por parte del médico) y POEM (por parte del paciente) para definir la gravedad. Aunado a cuidados generales y educación terapéutica, sugerimos cuatro pasos para tratamiento, según gravedad: 1. Manejo tópico con antiinflamatorio (y sistémico: antihistamínico/antileucotrieno ­evidencia reducida­) 2. Fototerapia, 3. Ciclosporina A y 4. Dupilumab, con la posibilidad de manejarlo antes si se necesita efecto rápido. En la dermatitis atópica extrínseca sugerimos agregar inmunoterapia con alérgenos o una dieta de eliminación si existe una alergia IgE-mediada, inhalatoria o alimentaria, respectivamente. Conclusión: El panel de expertos realizó consenso en aspectos relevantes de la dermatitis atópica con enfoque en la adaptación transcultural de evidencia reciente.

Ácido úrico sérico como marcador de gravedad clínica y comorbilidad en psoriasis en placas.

INTRODUCCIÓN: La hiperuricemia es común en pacientes con psoriasis. Se ha sugerido que la elevación de ácido úrico en psoriasis está fuertemente asociada con morbilidad cardiovascular. OBJETIVO: Determinar la relación entre niveles de ácido úrico, gravedad clínica medida por Psoriasis Area Severity Index (PASI), Body Surface Area (BSA) y static Physician's Global Assessment (sPGA) en pacientes con psoriasis en placas y comorbilidades ungueales y artritis psoriásica. MÉTODO: Determinación de ácido úrico sérico en 45 pacientes con psoriasis en placas y 45 controles pareados por sexo, edad e índice de masa corporal; medición de índices de gravedad clínica en pacientes y presencia de manifestaciones ungueales y articulares. RESULTADOS: Los pacientes con psoriasis presentaron niveles más elevados de ácido úrico (7.03 ± 1.47 versus 5.32 ± 1.17, p < 0.01) y mayor prevalencia de hiperuricemia asintomática (68 versus 17.8 %, p < 0.01) que los controles. Existió correlación proporcional significativa entre gravedad determinada por PASI y ácido úrico (r2 = 0.70) y entre manifestaciones articulares e hiperuricemia en pacientes con psoriasis en placas (p < 0.01; RM = 2.85, IC 95 % = 1.52-5.33). CONCLUSIONES: Los niveles séricos de ácido úrico tuvieron correlación proporcional con PASI y se asociaron con manifestaciones articulares en pacientes con psoriasis en placas. INTRODUCTION: Hyperuricemia is common in patients with psoriasis. Uric acid elevation in psoriasis has been suggested to be strongly associated with cardiovascular morbidity. OBJECTIVE: To determine the relationship between uric acid levels and clinical severity as measured by the Psoriasis Area Severity Index (PASI), body surface area (BSA) and static Physician's Global Assessment (sPGA) in patients with plaque psoriasis and nail comorbidities and psoriatic arthritis. METHOD: Determination of serum uric acid in 45 patients with plaque psoriasis and 45 controls matched by gender, age and body mass index; measurement of patient clinical severity indices and presence of nail and joint manifestations. RESULTS: Patients with psoriasis had higher levels of uric acid (7.03 ± 1.47 versus 5.32 ± 1.17, p < 0.01), and higher prevalence of asymptomatic hyperuricemia than controls (68% versus 17.8%, p < 0.01). There was significant proportional correlation between PASI-determined severity and uric acid (r2 = 0.70), and between joint manifestations and hyperuricemia in patients with plaque psoriasis (p < 0.01; OR = 2.85, 95% CI = 1.52-5.33). CONCLUSIONS: Serum uric acid levels had a proportional correlation with PASI and were associated with joint manifestations in patients with plaque psoriasis.

Macrophage migration inhibitory factor (MIF) promoter polymorphisms (-794 CATT5-8 and -173 G>C): association with MIF and TNFα in psoriatic arthritis.

Psoriatic arthritis (PsA) is an autoimmune disease with a complex interaction of gene and with a dysregulation of pro-inflammatory cytokine such as Macrophage migration Inhibitory Factor (MIF) and Tumor Necrosis Factor-alpha (TNFα). Two polymorphisms identified in the promoter region of the MIF gene have been described: the STR-794 CATT5-8 (rs5844572) and the SNP-173 G>C (rs755622), which are associated with increased MIF levels in circulation and with autoimmune diseases in several populations. In this case-control study we investigated whether commonly occurring functional MIF polymorphisms are associated with PsA susceptibility and clinical variables as well as with MIF and TNFα serum levels in a Mexican-Mestizo population. Genotyping of the -794 CATT5-8 and -173 G>C MIF polymorphisms was performed by PCR and PCR-RFLP respectively in 50 PsA patients and 100 healthy subjects (HS). MIF and TNFα serum levels were determined by ELISA. A significant increase of MIF (PsA: 7.8 vs. HS: 5.25 ng/mL; p < 0.001) and TNFα (PsA: 24.6 vs. HS: 9.9 pg/mL; p < 0.001) levels was found in PsA patients, a significant correlation was observed between MIF and TNFα (r = 0.41; p < 0.01). The 5,6 repeats genotype of the -794 CATT5-8 MIF was associated with protection to PsA (OR = 0.29; CI 0.77-0.98; p = 0.03), and the G/C genotype (OR = 7.5; CI 2.92-21.64; p < 0.001) and the -173*C allele (OR = 2.45; CI 1.43-4.20; p < 0.001) of the -173 G>C MIF were associated with susceptibility to PsA. In conclusion the -173*C allele is associated with susceptibility to PsA in Mexican-Mestizo population, whereas the correlation between MIF and TNFα soluble levels provided evidence that both cytokines are closely related in the pathophysiology of the PsA.

Metástasis cutánea de adenocarcinoma renal: reporte de un caso / Metastasis cutaneous of adenocarcinoma of kidney: report of a case

Se presenta el caso de un paciente masculino de 68 años, con una neoformación en cuero cabelludo, que histológicamente fue diagnosticada como metástasis de adenocarcinoma de células claras del riñón. Paciente con antecedentes de nefrectomía de hace 4 años, sin estudio histopatológico. No se encontró alteración en el resto de la economía. Se manejó con radioterapia. Las lesiones metastásicas de un adenocarcinoma renal afectan diferentes órganos, observándose solamente el 3 por ciento de ellas en piel, la localización más frecuente es la piel cabelluda y la cara. Clínicamente las lesiones deben diferenciarse de aquellas ampliamente vascularizadas. Su diagnóstico y manejo debe realizarse integramente y ser multidisciplinario