Effectiveness of guselkumab in patients with facial and/or genital psoriasis: Interim analysis results at Week 12 from the GULLIVER study.

BACKGROUND: Facial (FP) and genital psoriasis (GP) significantly affect patients' quality of life. Despite the advances in treatments, limited data on efficacy and safety are available on these difficult-to-treat areas. Guselkumab is an interleukin (IL)-23 inhibitor which has been proven effective in treating patients with moderate-to-severe plaque psoriasis. OBJECTIVES: The aim of this interim analysis was to report the efficacy and safety of guselkumab in the treatment of patients with FP and/or GP. MATERIALS AND METHODS: GULLIVER is a 52-week Italian observational study to evaluate the effectiveness and safety of guselkumab in a real-life setting in patients with FP and/or GP. Adult patients with facial and/or genital moderate-to-severe psoriasis (sPGA score ≥ 3) were included. The primary endpoint of this analysis was the percentage of patients achieving a facial or genital sPGA score of 0 (clear) or 1 (almost clear), at Week 12. The change in the score of the facial or genital sPGA components in patients with a score ≥3 for each sPGA component was assessed. PASI score in patients with a baseline PASI above or below 10 was evaluated. RESULTS: Overall, 351 patients were included in the study; 83.3% of FP and 76.5% of GP patients achieved the primary endpoint. Similar response rates were observed for the facial or genital sPGA components in patients with a baseline facial or genital sPGA score ≥3 in each component. Among patients with a baseline PASI score >10, mean PASI score improved from 19.0 (SD 8.3) to 2.2 (SD 4.8). Forty-four AEs were observed in 32 patients; two mild and transient AEs (fatigue and nausea) were considered treatment related. No SAEs were observed. CONCLUSIONS: Guselkumab, showing to be effective and safe in treating FP and GP, may be a valid therapeutic option for patients with psoriasis localized in these difficult-to-treat areas.

Association between autoimmune disease and cutaneous melanoma with regard to melanoma prognosis.

BACKGROUND: An association between autoimmune disease and malignant melanoma (MM) has often been reported in the literature as a positive prognostic factor for MM. Consequently, we evaluated the influence of different autoimmune diseases on the prognosis of MM. AIM: To evaluate the prognosis of patients with MM who also had an autoimmune disorder, whether tumour-associated, paraneoplastic or drug-induced. METHODS: Autoimmune diseases were classified and analysed as tumour-associated, paraneoplastic or drug-induced. Patients were enrolled according to their clinicopathological features and matched with control groups. Kaplan-Meier analysis was used to estimate disease-free survival (DFS) and overall survival (OS), and log-rank test was used to evaluate differences between the survival curves. RESULTS: In total, 49 patients with MM and tumour-associated autoimmune disease were included in our analysis. No case of paraneoplastic autoimmune disease was detected. The survival analyses showed a range of results, from a worsening of DFS and OS to a lack of any difference. In a second analysis, we separately analysed patients who developed autoimmune disorders after starting adjuvant therapy with interferon-α; we did not find significant differences between these patients and the untreated patients. CONCLUSIONS: Autoimmune disease, whether tumour-associated or drug-induced, was not associated with better prognosis in patients with MM. The results suggest that the reported relationship between autoimmunity and MM may be a result of individual variation in sensitivity to the autoimmune disease, the tumour or the treatments.

Immunohistochemical expression of VDR is associated with reduced integrity of tight junction complex in psoriatic skin.

BACKGROUND: Cell junctions are crucial for the formation and maintenance of the paracellular barrier and for cell polarity in simple epithelia and endothelia. Altered localization and formation of tissue junction proteins in the epidermis have been described in plaque-type psoriasis. Vitamin D receptor (VDR) is a nuclear hormone involved in anti-proliferative and pro-differentiation pathways in keratinocytes. However, still to date, vitamin D/VDR signalling involved in tissue barrier related to psoriasis remains largely unknown. OBJECTIVE: To study the expression of VDR and tight junctions (TJ) proteins (claudin 1, ZO-1 and occludin) in psoriatic skin, and to correlate the expression of VDR with that of the junctional proteins claudin- 1, occludin and ZO- 1. METHODS: A total of 20 psoriatic tissue samples were included in the analysis. Immunohistochemical studies for VDR, claudin-1, occludin and ZO-1 were performed. RESULTS: We observed a reduction of VDR, claudin-1 and ZO-1 expression in psoriatic skin if compared to normal skin, and the statistical analysis showed a significant correlation between a downgrading of VDR expression and that of claudin-1 (P < 0.005) and ZO-1(P < 0.005). CONCLUSIONS: Our results suggest a new role of VDR in the maintenance of the homeostasis skin barrier. Although the exiguity of our cohort, VDR status appears to be associated with the expression level and functions of TJ proteins, suggesting multiple and different cellular functions of the VDR.

Evaluation of blood redox-balance, nitric oxide content and CCR6 rs3093024 in the genetic susceptibility during psoriasis.

The aim of our study was to evaluate whether this polymorphism of CCR6 gene and oxidative stress are associated with psoriasis risk in Caucasian population. The association of the CCR6 polymorphism in the genetic susceptibility of psoriasis was performed at the Department of Dermatology and Venereology, Policlinico Umberto I of Rome (Italy). 516 participants were enrolled including 127 patients affected with psoriasis and 389 healthy controls. Cases and controls were genotyped, using a commercially available assay (Life Technologies, Carlsbad, California, USA) for CCR6 rs3093024 polymorphism. To verify the relations between genotypes and psoriasis risk we evaluated genotype frequencies for each individual DNA polymorphism in both case and control series. There were no differences in the genotype frequencies of the polymorphism between psoriasis cases and healthy controls. When patients with arthropathic psoriasis were excluded from the analysis, logistic regression showed that allele A was likely to reduce the risk of developing psoriasis in a dominant model. Logistic regression showed that male patients harboring the heterozygous genotype GA presented a reduced risk of developing psoriasis, compared with the reference GG genotype. None of the clinical features as age at onset, gender, family history of psoriasis, type of psoriasis, severity, BMI, smoking history or alcohol consumption, were associated with the genotype frequencies of the tested CCR6 polymorphism. In blood samples of patients with psoriasis intensive EPR signals of lipoperoxide (LOO.) free radicals were detected. Activity of blood SOD was significantly decreased in psoriatic patients compared to healthy controls. Activity of catalase was significantly increased in psoriatic patients, reflecting a high concentration of peroxide radicals. In blood samples of psoriatic patients decrease of free spin-trapped NO content were detected, that may be explained by biological transformation of NO into other reactive nitrogen species (proxy nitrite or nitrosylated hemoglobin). Thus, the alterations of redox-balance and NO degradation leads to development of skin perfusion impairments, disorder of proliferation and transcription of cell cycle, initiation of T-cell mediated immune responses, formation of chemokine receptor 6 (CCR6) related with intensification of cellular infiltration in the psoriatic plaques. Furthermore, correction of redox-balance is responsible for inhibiting CCR6 formation resulted in suppressed cellular infiltration with concomitant decrease in oxidative stress. The data reviewed suggest the necessity of evaluation of other blood redox-balance and nitric oxide in psoriasis should with additional investigations to targeting CCR6 rs3093024 in the genetic susceptibility of psoriasis.

Melanoma and IFN alpha: potential adjuvant therapy.

Interferon alpha (IFNalpha) is the most used adjuvant treatment in clinical practice for melanoma (MEL) high-medium risk patients; however, the use of IFNalpha has yielded conflicting data on Overall Survival (OS) and disease free survival (DFS) rates. Starting from these considerations, we carried out an analysis on our MEL patients who received adjuvant IFNalpha therapy, in order to identify possible predictors for their outcome. A total of 140 patients were included in our analysis. Patients with Breslow thickness ≤2.00 mm presented a significantly longer mean DFS than patients with Breslow ≥2.01 mm (p = 0.01). Using non- parametric Spearman’s Coefficient test we found association between DFS and Breslow thickness (p < 0.001) and between DFS and ulceration (p = 0.03). Performing Multiple Regression test, Breslow thickness (p < 0.001) remained the only statistically significant predictor. From the OS analysis we found that patients with lower Breslow values ≤ 2.00 mm (p < 0.0001), and absence of ulceration (p <0.004) showed a significantly better long-term survival. From the current analysis we found that the use of low dose IFNalpha is justified only for cutaneous melanoma ≤ 4.01 mm that was not ulcerated; patients with Breslow ≥ 4.01 mm, in our opinion, should not carry out adjuvant treatment with low dose IFNalpha, because its side effects could be higher than the its benefits.

Costs of therapy with biologics in the treatment of moderate to severe plaque psoriasis in the context of the Italian health-care system.

AIM: Biologics were introduced as innovative and effective therapies for the treatment of moderate-to severe psoriasis. However, in the Italian context there are no comparative cost-effectiveness analyses of all biologics currently approved for psoriasis by the European Medicines Agency (EMA). This study estimates whether the cost of ustekinumab (meant as cost of drug therapies and monitoring) is lower, similar to or higher than that of anti-TNF-α. METHODS: The incremental cost-effectiveness ratio (ICER) and the cost-effectiveness ratio (CER) in terms of cost for patients achieving 75% improvement in PASI (PASI 75) were calculated. The analysis, both during the first 52 weeks, including induction and in maintenance period is based on efficacy data taken from single studies. The costs, based on official source, are calculated in the perspective of National Health Service (SSN). RESULTS: Ustekinumab has the lowest cost for responder, resulting always cost-effective and, in some case, cost saving in the baseline scenario at 52 weeks and in maintenance period. CONCLUSION: Ustekinumab seems to be the most favorable biologic in term of cost per PASI 75 responder for the treatment of psoriasis and it is cost-effective in all scenarios analyzed. Further cost-effectiveness evaluations based on data of use of long-term treatment with biologics in clinical practice, are necessary to support this results.

The role of nitric oxide in the pathogenesis and severity of psoriasis.

The aim of our study was to investigate the possible role of nitrogen reactive species in pathogenesis of psoriasis. A total of 187 individuals were included in this study, out of these 84 were patients suffering from psoriasis and 103 were healthy subjects, served as a control. Patients with psoriasis were graded according to the Psoriasis Area Severity Index (PASI), presenting at the time of blood collection. After obtaining prior consent, about 2 ml of random blood was collected for estimation blood free nitric oxide (NO) content by Electron Paramagnetic Resonance (EPR) Spectroscopic method. For detection of NO in blood the spin-trap (diethilditiocarbamate (DETC) (Sigma) was used. In blood samples of patients with psoriasis nitrosilated hemoglobin (HbNO) complexes and alterations of free spin-trapped NO EPR signal intensity and were detected. Free NO content in blood decreased with the increasing severity of the psoriasis. It may be concluded that under oxidative stress conditions during psoriasis the decrease level of free nitric oxide in the patient's blood may contribute to a violation of the vasomotor activity of subcutaneous capillaries, impairment of skin blood supply, development of hypoxia, exacerbation of oxidative stress, alteration of immune balance, spreading of skin infection and exacerbation of the severity of psoriasis. Use of NO-containing creams will contribute to a partial recovery of disturbed functions and remission of the disease.

Alterations of redox-status during psoriasis.

The skin is constantly exposed to oxidative stress induced by reactive oxygen species (ROS) that are generated both from endogenous neutrophils and external pro-oxidant stimuli. The present study was planned to investigate the possible involvement of free radical oxidation in psoriatic patients. Study was carried out in the Department of Dermatology and Venereology in Tbilisi State Medical University. A total of 60 individuals were included in this study, out of these 40 were patients suffering from psoriasis and 20 were healthy subjects (a control). Psoriasis patients were further graded according to the Psoriasis Area Severity Index (PASI); in patients' blood redox-status superoxide (O2-) and lipoperoxide (LOO.) free radicals, free Mn2+-ions and (ceruloplasmin/Fe3+-transferrin) system antioxidant activity were estimated by Electron Paramagnetic Resonance (EPR) method and activity of catalase (CAT) and superoxide dismutase (SOD) were determined by spectrophotometry. In the blood of patients with psoriasis, the EPR signal intensities of oxidized form ceruloplasmin (Cp) increased and ferrum-transport protein, Fe3+-transferrin (Fe3+-Tr) decreased in comparison to the same parameters of healthy persons. Activity of blood catalase increased and activity of blood SOD decreased with increasing severity of psoriasis. EPR signals of low-molecular Mn2+-containing complexes and lipoperoxide (LOO.) free radicals were detected. The obtained data indicate the alteration of blood redox-balance during psoriasis; the intensity of impairment of redox balance correlates with severity of psoriasis.

Antibacterial activity of methyl aminolevulinate photodynamic therapy in the treatment of a cutaneous ulcer.

We describe a 79-year-old female with a chronic venous ulceration infected by Staphylococcus aureus and Enterococcus faecalis and not responsive to conventional treatments. The patient was treated with Methyl-Aminolaevulinate Photodynamic Therapy (MAL-PDT). After four weeks the cutaneous swabs become negative and we observed a significant clinical improvement. Therefore we suppose that MALPDT could represent a valid therapeutic option in the treatment of infected chronic ulcers.

A case of infliximab-induced psoriasis.

Anti-tumor necrosis factor (anti-TNF-alpha) are a group of new drugs able to inhibit the action of this cytokine. Although systemic side effects have been well described, cutaneous adverse reactions have not yet been clearly elucidated. The authors report a case of a 29-year-old man affected by Crohn disease and ankylosing spondylitis who developed psoriatic lesions after IV infusion of infliximab 5 mg/Kg. The patient underwent cyclosporine treatment after interruption of biological therapy, and had complete resolution of cutaneous lesions. The reason for this phenomenon is not clear, Obviously more studies are necessary to define more clearly this paradoxical reaction. In addition, dermatologists must be informed about this potential cutaneous adverse event.

[Pyoderma gangrenosum: case series]. / Pioderma gangrenoso: presentazione di alcuni casi clinici.

Pyoderma Gangrenosum (PG) is a rare ulcerative cutaneous condition with distinctive characteristics, and the aetiology is not clear yet. PG is commonly associated with inflammatory bowel disease (Ulcerative Colitis and Crohn's disease). The features of PG are not specific histopathologically and for this reason diagnosis is based on clinical feature. There is no single successful treatment for PG. In fact certain type of lesions respond more readily to some therapies than others. Local treatments (advanced wound care, local corticosteroids, local immunomodulator agents) may be sufficient for some clinical features, while others may be required systemic therapy (corticosteroids, immunosuppressive therapy, intravenous immune globulins, TNF-alpha blocking agents). We present four cases of PG associated with inflammatory bowel diseases treated with different therapeutic approaches.

PEL, Kaposi's sarcoma HHV8+ and idiopathic T-lymphocitopenia CD4+.

We described a case report of a 36-year-old woman with a 10-year-history of idiopathic CD4+ T-lymphocitopenia and Kaposi's sarcoma HHV8+ who developed recurrent pleural effusion. Laboratory and instrumental tests with morphologic, immunophenotypic and molecular analysis of pleural sediment suggest us the diagnosis of primary effusion lymphoma (PEL). The term primary effusion lymphoma defines an extranodal non-Hodgkin's lymphoma HHV8-related, usually classified as a B-cell lymphoma, that grows in liquid-phase within body cavities. The case reported by the Authors appears to be of great interest for its epidemiological and clinical features.

Alterations of microsatellites in neurofibromas of von Recklinghausen's disease.

von Recklinghausen's disease, or type I neurofibromatosis, a common familial tumor syndrome, is characterized by the occurrence of multiple benign neoplasms of nerve sheath cells. The disease is caused by germ-line mutations of the NF1 gene, which encodes a member of the GTPase-activating superfamily of Ras regulatory proteins. We analyzed 5 dinucleotide repeat loci in DNAs from neurofibromas and matched normal skin from 16 NF1 patients. Eight cases (50%) manifested microsatellite alterations. Expansions or compressions of dinucleotide repeats were observed at one locus in four cases and at two loci in one case. Banding patterns compatible with the loss of a microsatellite allele were observed in four cases, including one that also presented microsatellite instability. The surprisingly high frequency of microsatellite alterations suggests that the NF1 gene or another gene(s) contributing to the pathogenesis of neurofibromas might be directly or indirectly implicated in the control of genomic integrity.

Peripheral blood regulatory T cell measurements correlate with serum vitamin D level in patients with psoriasis.

OBJECTIVE: Vitamin D is the precursor of a hormone (1,25-dihydroxyvitamin D3), which has many biological effects in the skin. The immune modulator properties of vitamin D are mediated in part through effects on regulatory T cells (T-reg). Currently, in psoriasis, the relationship between vitamin D and T-reg has not well elucidated. We assess whether vitamin D status is correlated with circulating T-reg in patients affected by psoriasis and if there is a correlation with the severity of the disease evaluated with Psoriasis Area Severity Index (PASI) score. PATIENTS AND METHODS: For each patient we have analyzed, PASI-score, serum levels vitamin D and regulatory T cell percentages. Spearmen's coefficient was used between serum vitamin D levels and the predictors. Subsequently, the independent predictive factors were assessed by Multiple Regression. RESULTS: A total of 26 patients were included in our analysis. Using no parametric Spearman's Coefficient test between serum levels of vitamin D and the single variables, we found an association with T-reg population (p < 0.001) and with PASI-score (p = 0.04). CONCLUSIONS: While vitamin D treatment induces a cytokine profile known to favor the differentiation of T cells with suppressive activity, at the same time, several studies showed how vitamin D can prime for tolerogenic dendritic cells able to favor the differentiation of Treg from T naïve cells. Low levels of vitamin-D may decrease the number of circulatory T-reg, disrupting the immunological homeostasis in psoriatic patients and encouraging the inflammatory activity.

Is the prognosis and course of acral melanoma related to site-specific clinicopathological features?

OBJECTIVE: Acral melanoma is an uncommon type of melanoma in Caucasian patients. However, acral melanoma is the most common type of melanoma in African and Asian patients. Comparison analyses between hand-acral melanoma and foot-acral melanoma have been rarely reported in the literature. Acral melanoma is an uncommon melanocytic tumor characterized by an intrinsic aggressiveness, with specific histological and clinicopathological features. Acral melanoma involves the palms, soles and sub-ungueal sites. PATIENTS AND METHODS: A total of 244 patients with acral melanoma were included in our analysis. The current study was performed in three different medical centers: Sapienza University of Rome, San Gallicano Institute of Rome and University of Magna Graecia (Italy). The Kaplan-Meier product was used to estimate survival curves for disease-free survival and overall survival. The log-rank test was used to evaluate differences between the survival curves. Assuming that the effects of the predictor variables are constant over time, the independent predictive factors were assessed by Spearman's test and subsequently data were analyzed performing Cox proportional-hazard regression. RESULTS: In both univariate and multivariate analyses Breslow thickness (p < 0.0001) and ulceration (p = 0.003) remained the main predictors. General BRAF mutation was detected in 13.8% of cases. We found that median Breslow value and the percentage of recurrences were similar in hand-acral melanoma and foot-acral melanoma, as well as there were no differences in both short and long-term. CONCLUSIONS: The absence of differences in survival between hand-acral melanoma and foot-acral melanoma shows that the aggressiveness of the disease is related to distinct mutational rate, as well as to anatomical site-specific features, rather than to the visibility of the primary lesion.

Psoriasis of the dorsal surface of the tongue.

Psoriasis is primarily an inherited inflammatory skin disease, it is characterized by erythemato-squamous lesions that usually involve elbows, knees and the scalp. Oral manifestations are rare in psoriasis, infact, oral psoriasis involves 2% of psoriatic patients and usually it is observed with the onset of cutaneous lesions and progresses with them. Differential diagnosis should be done for Reiter's syndrome, leukoplakia and geographic tongue. The authors describe a case of tongue psoriasis without cutaneous lesions.

Improvement of survival in patients with melanoma and non-melanoma skin cancers compared to patients without double cutaneous malignancies.

OBJECTIVE: The worldwide incidence of cutaneous malignant melanoma (MM) has been rising steadily over the past 30 years. At the same time non-melanoma skin cancers (NMSC) are the most prevalent type of cancer in United States and Europe. Up to date, no paper has explored the influence on the general survival in patients with MM and NMSC. We decided to perform a study with the aim to evaluate the different survival in patients with MM-NMSC compared to control patients (MM-CTRL). PATIENTS AND METHODS: To evaluate prognosis in both groups, we analyzed disease-free survival (DFS) and overall survival (OS).Kaplan-Meier product was performed for the survival analysis. Median DFS was 73 months in group and 72 months in MM-CTRL patients (p = 0.4); while, median OS was 74.2 months in MM-NMSC patients and 63.1 in MM-CTRL (p < 0.001). Also at Odds-Ratio (OR), the statistical significance was maintained (p < 0.007) with a better prognostic value for MM-NMSC. RESULTS: Among group patients, the ones with a basal cell carcinoma showed a batter behavior, than the ones with squamous cell carcinoma (p = 0.01). CONCLUSIONS: Patients with MM-NMSC showed a better survival than MM-CTRL patients (p < 0.001). The causes of this improved survival are still unknown; probably the endogenous immune response can play a pivotal role in this class of patients. However, further studies are necessary to better understand this phenomenon, not yet explored in literature.

Integrin b4 expression in peripheral-nerve tumors.

The alpha 6 beta 4 integrin complex is expressed in epithelial, endothelial and nerve cells. We analyzed the immunohistochemical expression of the beta 4 subunit in normal peripheral nerves, in neurofibromas associated with type 1 neurofibromatosis and in sporadic neurofibrosarcomas. In normal peripheral nerves (4 samples), the beta 4 integrin was diffusely expressed at the level of the perinevrium and at the interface between axons and Schwann cells. In neurofibromas (6 cases), beta 4 was undetectable or markedly decreased relative to normal peripheral nerves. Neurofibrosarcomas (3 cases) were immunohistochemically negative for beta 4 expression. These observations suggest that a down-regulation of the alpha 6 beta 4 integrin is associated with the neoplastic progression of peripheral nerve tumors.