Vaccination recommendations for adults receiving biologics and oral therapies for psoriasis and psoriatic arthritis: Delphi consensus from the medical board of the National Psoriasis Foundation.

BACKGROUND: For psoriatic patients who need to receive nonlive or live vaccines, evidence-based recommendations are needed regarding whether to pause or continue systemic therapies for psoriasis and/or psoriatic arthritis. OBJECTIVE: To evaluate literature regarding vaccine efficacy and safety and to generate consensus-based recommendations for adults receiving systemic therapies for psoriasis and/or psoriatic arthritis receiving nonlive or live vaccines. METHODS: Using a modified Delphi process, 22 consensus statements were developed by the National Psoriasis Foundation Medical Board and COVID-19 Task Force, and infectious disease experts. RESULTS: Key recommendations include continuing most oral and biologic therapies without modification for patients receiving nonlive vaccines; consider interruption of methotrexate for nonlive vaccines. For patients receiving live vaccines, discontinue most oral and biologic medications before and after administration of live vaccine. Specific recommendations include discontinuing most biologic therapies, except for abatacept, for 2-3 half-lives before live vaccine administration and deferring next dose 2-4 weeks after live vaccination. LIMITATIONS: Studies regarding infection rates after vaccination are lacking. CONCLUSION: Interruption of antipsoriatic oral and biologic therapies is generally not necessary for patients receiving nonlive vaccines. Temporary interruption of oral and biologic therapies before and after administration of live vaccines is recommended in most cases.

Therapeutic application of machine learning in psoriasis: A Prisma systematic review.

Dermatology, being a predominantly visual-based diagnostic field, has found itself to be at the epitome of artificial intelligence (AI)-based advances. Machine learning (ML), a subset of AI, goes a step further by recognizing patterns from data and teaches machines to automatically learn tasks. Although artificial intelligence in dermatology is mostly developed in melanoma and skin cancer diagnosis, advances in AI and ML have gone far ahead and found its application in ulcer assessment, psoriasis, atopic dermatitis, onychomycosis, etc. This article is focused on the application of ML in the therapeutic aspect of psoriasis.

Psoriasis: Embarking a dynamic shift in the skin microbiota.

Recent interest has arisen regarding the role of microbiome and its composition in the pathogenesis of psoriasis. Numerous studies have shown that there are alterations in skin flora arrangement between normal individuals and psoriatic patients. Psoriasis exacerbation could be interconnected with epidermal or mucosal colonization with streptococci, Malassezia, Staphylococcus aureus, or Candida albicans. The role of cutaneous and gut microbiome in psoriasis pathogenesis has recently been studied in both human and animal models. In this review, we try to evaluate various pathogenic mechanisms linking the microbiota and psoriasis. The literature research included peer-reviewed articles which included clinical trials, original reports, and scientific reviews. MEDLINE and PubMed databases were searched from January 1990 to March 2021, including the reference lists of articles meeting our criteria.

Antihistamines in Psoriasis.

Psoriasis is polygenic, interleukin (IL)-17 and IL-23 driven chronic relapsing inflammatory multisystem disease caused by a complex interplay of endogenous and environmental factors. The most common and distressing symptom in psoriasis is itch, adding significantly to the burden of disease. Although histamine has historically not been considered a key itch mediator in psoriasis, there is some evidence from the literature that antihistamines may be effective to reduce itch in psoriasis. This review focuses on the role of antihistamines in the management of itch in psoriasis. The literature search included peer-reviewed articles published in English language (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) until January 2021 and by reference lists of respective articles. J Drugs Dermatol. 2021;20(8):844-847. doi:10.36849/JDD.5966.

Interleukin 23p19 inhibitors in chronic plaque psoriasis with focus on mirikizumab: A narrative review.

Psoriasis, a T-cell mediated chronic dermatosis, has a complex etiopathogenesis. There has been extensive research into the aberrant immune response, which leads to the formation of clinical lesions, and the need for developing better and safer drugs has been unrelenting. The past two decades of research has opened up new areas of the immune pathway that can be targeted in order to control the disease. Therefore, we have seen the emergence of biologics which either target T-cell receptors or inhibit Tumor Necrosis Factor-alpha (TNF-α) or inhibit interleukins (IL) like IL-12, IL-17, IL-17 receptor, and more recently IL-23. Drugs specifically targeting the p19 subunit of IL-23 have shown promising results in the management of chronic plaque psoriasis. This has given way to the development of a new class of biologics, that is, the IL-23p19 inhibitors that have a better safety profile as compared to its predecessors. In this review, we shall scrutinize the role of IL-23 and Th17 cell signaling in the evolution of the psoriatic lesions and summarize the clinical experience with IL-23p19 inhibitors especially mirikizumab in the treatment of chronic plaque psoriasis.

Pityriasis Lichenoides Chronica in a Patient With Ankylosing Spondylitis Treated With Etanercept.

BACKGROUND: Pityriasis lichenoides chronica, a papulosquamous disorder often considered a subtype of pityriasis lichenoides. It is considered a clonal T-cell disorder, which may be associated with cutaneous T-cell lymphoma that may develops in response to foreign antigens. CASE PRESENTATION: We present a 38-year-old male patient with ankylosing spondylitis who was on treatment with etanercept. After 8 weeks of treatment, the patient presented with scaly erythematous papules, on the back and arms. He was diagnosed clinically with pityriasis lichenoides chronica. CONCLUSION: Pityriasis lichenoides chronica should be included among the broad clinical spectrum of chronic inflammatory skin diseases which may occur during treatment with TNF-alpha antagonists. J Drugs Dermatol. 2020;19(5): doi:10.36849/JDD.2020.2191.

Pityriasis Lichenoides Chronica in a Patient With Ankylosing Spondylitis Treated With Etanercept.

Pityriasis lichenoides is a scarce cutaneous disorder with unknown etiology. It contains a range of clinical manifestations including acute papular lesions that quickly grow into pseudo vesicles and central necrosis to small, scaling, benign-appearing papules.1,2.

Clinical and Molecular Effects of Interleukin-17 Pathway Blockade in Psoriasis

The interleukin-17 (IL-17) pathway plays a crucial role in the development of psoriasis. Briefly, naive T cells differentiate into helper T (Th17) cells through interaction with activated dendritic cells in the presence of IL-23, Th17 cells produce IL-17 cytokines, and keratinocytes stimulated by IL-17 ligands lead to aberrant differentiation and proliferation that promote production of proinflammatory chemokines and further recruitment of inflammatory cells, setting up a positive feedback loop. Currently, 3 US Food and Drug Administration­approved agents to treat psoriasis affect the IL-17 pathway: brodalumab, secukinumab, and ixekizumab. Brodalumab is a fully human IL-17 receptor A antagonist that blocks signaling of multiple downstream inflammatory cytokines involved in psoriasis. Secukinumab and ixekizumab selectively bind to and neutralize only IL-17A. Pharmacologic effects in patients with psoriasis include decreased keratinocyte hyperproliferation, reduced epidermal thickening, decreased inflammatory markers, and resolution of histologic and genomic features of psoriasis. In clinical trials, therapeutic doses of brodalumab, secukinumab, and ixekizumab have demonstrated skin clearance efficacy by psoriasis area and severity index and static physician's global assessment scores at 12 weeks. The immunomodulation of these agents is associated with a favorable safety profile. Overall, the clinical improvement and normalization of genetic hallmarks of psoriasis provide a strong case for the unique role of IL-17 receptor blocking as a therapeutic mechanism of action to treat psoriasis. Understanding the unique mechanisms by which treatments interact with the IL-17 pathway to inhibit downstream proinflammatory signal cascade can help physicians make informed treatment decisions when selecting the appropriate medication for patients. J Drugs Dermatol. 2020;19(2)138-143. doi:10.36849/JDD.2020.4645

Necrobiosis Lipoidica Mimicking Cutaneous Sarcoidosis Finally Treated With an Intralesional Injection of Corticosteroid: A Case Report

BACKGROUND: Necrobiosis lipoidica (NL) and sarcoidosis are granulomatous disorders with an unknown pathogenesis. They may coexist in the same patient, which suggests a possible overlap between these diseases among shared granulomatous inflammatory pathways. Case Presentation: This study presents the case of a non-diabetic 52-year-old woman who presented with red-yellowish border plaques on the face and upper extremities previously diagnosed as sarcoidosis. After 13 years of inappropriate treatment, histopathological findings consistent with the clinical and para-clinical examination suggested the diagnosis of NL. After treatment with an intralesional injection of steroids, significant improvement was observed, and no recurrent lesions were found. CONCLUSION: Necrobiosis lipoidica may mimic cutaneous sarcoidosis. Prompt recognition and treatment of NL can be helpful for managing the disease. J Drugs Dermatol. 2020;19(1):92-94. doi:10.36849/JDD.2020.4675

Treatment of Medicare Patients with Moderate-to-Severe Psoriasis who Cannot Afford Biologics or Apremilast.

Elderly patients are a group with a high frequency of psoriasis. Their disease burden has negative impacts on their quality of life. While there is a clear need to treat these patients, there are challenges in doing so. This work seeks to define the challenges that exist in treating elderly Medicare patients, as well as to provide treatment suggestions for providers to follow if they encounter one or more of these challenges. Providers face the following challenges when creating treatment plants for elderly patients with psoriasis: difficulty in obtaining drug coverage through Medicare, increased medical comorbidities, and polypharmacy. Providers aim for regimens that are affordable, safe, and efficacious, but it is not always clear how to achieve this combination, especially in elderly Medicare patients. This work is relevant in that it aims to explain the logistical roadblocks posed by Medicare coverage and provide solutions for commonly encountered issues in the treatment of a disabling and common disease in a high-risk population. Specifically, alternative treatment options to biologics and small-molecule inhibitors are discussed and include topical therapies, phototherapy, methotrexate, acitretin, and cyclosporine and for psoriatic arthritis include corticosteroids and leflunomide. The specific risks and benefits of these therapies in the elderly population are provided, allowing providers to make patient-specific decisions about optimal regimens.

Correction: The Impact of Diet on Psoriasis.

Due to a submission error, the article "The Impact of Diet on Psoriasis" (Cutis. 2019;104[suppl 2]:7-10) stated the incorrect academic degree for one of the authors. The byline should read: Albert G. Wu, MS; Jeffrey M. Weinberg, MD. The article has been corrected online at www.mdedge.com/dermatology.

The impact of diet on psoriasis.

Because psoriasis is a chronic and inflammatory disease, many patients seek alternative therapies and lifestyle modifications to supplement their treatments and help relieve symptoms. Both the disease and the modifications are multifactorial, making it difficult to quantify the effectiveness of a single change. A review of the available literature reveals that most diets have mixed impacts on psoriasis, though some individual foods have seen more prominence in studies. Foods and supplements with systemic anti-inflammatory effects seem to have a higher chance of improving psoriasis symptoms. Overall, additional large-population studies with a higher statistical power are needed to review these studies. We suggest web-based national cohort surveys as a possible method to quickly gather a large amount of data for future studies.

Systemic therapies in psoriasis: an update on newly approved and pipeline biologics and oral treatments.

Although there are numerous biologics and several oral treatments for psoriasis, a number of promising systemic therapies are on the horizon. Knowledge of these medications might help guide our treatment approach to the patient with psoriasis. This article provides an update on the most recent (as of 2019) approved therapies and medications in the pipeline for moderate to severe plaque psoriasis, with a focus on systemic agents in phase 3 clinical trials.

Successful Treatment of Refractory Plaque-Type Psoriasis and Psoriatic Arthritis With Guselkumab and Adalimumab Combination Therapy: A Case Report

Copy: A number of biologics have been approved for use in plaque-type psoriasis. They act by either blocking the action of a specific type of cell or protein in the immune system. Case presentation: Herein, we report a case of a 46-year-old woman with a 12-year history of severe plaque psoriasis and psoriatic arthritis who was treated successfully with guselkumab and adalimumab after failure of prior topical corticosteroids, cyclosporine and narrow-band ultraviolet B (NBUVB) phototherapy. Conclusion: There is limited data supporting the combination of biological agents in the management of psoriasis and psoriatic arthritis. This is the first case report of plaque psoriasis with arthritis, successfully treated with guselkumab and adalimumab combination therapy, without concurrent use of other systemic agents during the treatment. However, further studies need to be carried out to evaluate the efficacy and safety of this biologic combination therapy. J Drugs Dermatol. 2019;18(4):394-396.

Update on the pathophysiology of psoriasis.

Psoriasis is a genetically programmed pathologic interaction among skin cells, immunocytes, and numerous biologic signaling molecules that is triggered by environmental stimuli. The immune response is a cellular one; type 1 (TH1) and type 17 (TH17) T cells are activated by IL-12 and IL-23 secreted by antigen-presenting cells (APCs) in the skin. Through various cytokines, such as tumor necrosis factor (TNF) α, these cells cause a chronic inflammatory state and alter epidermal hyperproliferation, differentiation, apoptosis, and neoangiogenesis that produce the cutaneous findings seen in this disease. The newer biologic therapies target the immunologic signaling pathways and cytokines identified in the pathogenesis of psoriasis and provide notable clinical improvement. Further study in the pathogenesis of psoriasis can help identify targets for future therapies.