Journal of Clinical and Aesthetic Dermatology

Psoriasis and Cutaneous Supplement 2016

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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S 1 6 S U P P L E M E N T T O T H E J O U R N A L O F C L I N I C A L A N D A E S T H E T I C D E R M AT O L O G Y [ S E P T E M B E R 2 0 1 6 • V O L U M E 9 • N U M B E R 9 ] anti-psoriatic cytokines, IL-4 and IL-10. These designer cells prevented the onset of psoriatic flares, stopped acute episodes of psoriasis, and improved psoriatic skin lesions in mice. 105 Protein therapeutics may one day be able to provide personalized gene-based and/or cell- based treatments for psoriasis and other disorders. Reviews. In a rapidly changing, dynamic field like psoriasis research, clinical reviews help digest and organize information from the vast amount of research. A number of relevant reviews for psoriasis appeared in 2015 (Table 7 106–109 ). Psoriatic Arthritis Update Psoriatic arthritis (PsA), which occurs among approximately 30 percent of patients with skin psoriasis, has a substantial impact on affected patients. There has been tremendous recent progress in delineating the immunopathophysiological basis of PsA. In a recent study, gene expression in PsA synovial samples was compared to that from synovial samples from other inflammatory arthritides as well as affected skin samples with active psoriasis using principal component analysis. Interestingly, gene expression in PsA synovia was more closely related to gene expression in psoriatic skin lesions than to gene expression in synovia in patients with other forms of arthritis, including osteoarthritis (OA), RA, and systemic lupus erythematosus (SLE). In that same paper, microarray results quantifying mRNA expression of biologically significant genes by real-time polymerase chain reaction, normalizing expression values to the housekeeping gene hARP, found greater elevation of mRNA for IL-17A and IL-17F in psoriatic lesional skin compared to inflamed psoriatic synovium, while TNF expression was similar for skin and synovium. 110 These intriguing results seem to align with results from recent clinical trials using various targeted therapies, and may help inform future studies. Because PsA is a progressive disorder that can result in severe joint damage early in the disease course, and because the vast majority of patients develop skin involvement prior to joint involvement, early detection of articular manifestations among psoriasis patients would be valuable. A variety of screening questionnaires to detect PsA have been developed (e.g., PASE, EARP, PEST, TOPAS, etc). In a cross-sectional study of adult primary care patients with psoriasis, patients completed the four questionnaires and then were evaluated by a trained research nurse. 111 The clinical assessments included a PASI score, LEI/MASES, and 66/68-joint count and evaluation for the presence of nail psoriasis. Patients who reported a painful enthesis on LEI/MASES then underwent an ultrasound examination of the entheses. A PsA case fulfilled the CASPAR criteria. Sensitivity and specificity for PEST and EARP cutoff ≥3 and PASE cutoff ≥44 and ≥47 were obtained. A total of 473 psoriasis patients (mean age 55.7±13.9 years, 50.9% men) were examined. Median PASI score was 2.3 (IQR 1–4) and 15 percent exhibited nail abnormalities consistent with psoriasis. In the study, 3.6 percent of patients could be diagnosed with PsA (as confirmed by a rheumatologist) and 36 new cases of enthesitis were found, confirmed by ultrasound examination. For enthesitis, EARP had a sensitivity and specificity of 87 and 33 percent, respectively; PEST was 68 and 71 percent, respectively; and PASE was 66 and 55 percent for cutoff ≥44 and 59 and 64 percent for cutoff ≥47. Of note, a number of patients refused further evaluation for their musculoskeletal symptoms. This may partly explain both the relatively low sensitivity and specificity that has been seen for all of these questionnaires, especially in studies subsequent to their initial development. The PEST screening tool for primary care involves showing psoriasis patients a simplified drawing of a person with various joints called out (shoulder, hip, wrist, ankle, knee, and so on) and asking them to indicate by tic marks if any of those body areas had ever been swollen, stiff, or painful. 112,113 They would then be asked five questions and scores of three or more positive answers warranted referral to a rheumatologist. The questions included the following: Have you ever had a swollen or painful joint (as indicated in the drawing)? Have you ever been told by a doctor that you had arthritis? Do your fingernails or toenails have pits or holes in them? Do you have heel pain? Have you ever experienced a finger or toe that swelled up completely and was painful for no apparent reason? Because not all psoriasis patients with musculoskeletal signs and symptoms desire further evaluation and/or treatment for their PsA, Dr. Arthur Kavanaugh suggests perhaps a single question could be used instead of the questionnaires noted: "Do you have pain or any other symptoms in or around your joints that you want to do something about?" Patients answering affirmatively may wish to discuss tenderness, swelling, pain with motion, loss of function, loss of range, or other symptoms that may relate to PsA, and try to achieve improved outcomes. All rheumatologists would be happy to see such patients in consultation. There has been notable development in newer therapies for PsA. However, questions also remain concerning the efficacy of older agents, for example methotrexate. While it is frequently used in PsA, there have been relatively few studies of methotrexate in PsA. In a subanalysis of the TICOPA (treat-to-target study in early, drug-naïve PsA patients), 188 patients were randomized to receive oral methotrexate monotherapy for 12 weeks versus standard care, which was left to physician discretion but was often methotrexate. 114 At 12 weeks, 22.4 percent of patients had minimal disease activity (MDA) and patients treated with methotrexate had less dactylitis (63% decrease) and less enthesitis (26% drop). There was a trend for more PsA patients receiving methotrexate doses of greater than 15mg/wk to

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