Anne-Marie Tobin

The 'psoriatic march': a concept of how severe psoriasis may drive cardiovascular comorbidity.

Abstract:  There is increasing awareness that psoriasis is more than ‘skin deep’. Several recent reviews focussed on biomarkers indicating the systemic dimension of psoriasis and the aspect of comorbidity psoriasis shares with other chronic inflammatory diseases, such as Crohn’s disease and rheumatoid arthritis. Of emerging significance is the relationship to cardiovascular disease, as this contributes substantially to the patients’ increased mortality. In this viewpoint, we examine currently available evidence favouring the concept of a causal link between psoriasis and cardiovascular disease: systemic inflammation may cause insulin resistance, which in turn triggers endothelial cell dysfunction, leading to atherosclerosis and finally myocardial infarction or stroke. While this ‘psoriatic march’ is not yet formally proven, it raises clinically and academically relevant questions, and gains support by recent observations of numerous investigators.

Cardiovascular Disease and Risk Factors in Patients with Psoriasis and Psoriatic Arthritis

Objective. Patients with psoriasis and psoriatic arthritis (PsA) have an increased incidence of cardiovascular disease (CVD) and cardiovascular risk factors such as smoking, hypertension, and metabolic syndrome compared to the normal population. Patients with psoriasis and PsA may also have increased risk from nonconventional risk factors such as raised levels of homocysteine and excessive alcohol consumption. We conducted a comprehensive review of the literature on CVD and all cardiovascular risk factors in patients with psoriasis and PsA. Methods. Data sources: All studies identified from a Medline (www.ncbi.nlm.nih.gov) search pertaining to CVD, individual risk factors in psoriasis, and PsA were included. Study selection: Studies included a healthy reference population, were published between 1975 and 2009, and were written in English. Results. Our search yielded 14 studies that documented rates of CVD in patients with psoriasis and PsA compared to controls. Substantial evidence points to elevated risk of CVD in patients with psoriasis and PsA. Conclusion. It remains difficult to conclude if risk factors are caused by psoriasis or share a common pathogenesis. Physicians treating patients with psoriasis and PsA must be aware of all potential cardiovascular risk factors in their patients.

TNFα Inhibitors in the Treatment of Psoriasis and Psoriatic Arthritis

Psoriasis is a chronic inflammatory skin disease that can lead to significant physical and psychologic distress for patients. Psoriatic arthritis (PsA), originally thought to be quite a mild disorder, is now recognized as a progressive and destructive arthritis. To date, therapies for both these conditions have been non-specific and unable to maintain long-lasting remission. In addition, many of the current therapies have significant adverse effects, limiting their usefulness. However, elucidation of the pathogenesis of psoriasis and PsA at a molecular level and the development of selective biologic agents have led to an enormous expansion of the armamentarium available to psoriasis patients.Two agents (infliximab and etanercept) selectively block the role of the cytokine tumor necrosis factor (TNF)-α and have proved effective in clinical trials in the treatment of both the skin and the joint manifestations of psoriasis. A third anti-TNFα agent (adalimumab Humira®) is licensed for the treatment of rheumatoid arthritis; however, no studies have been published to date on its use in PsA or psoriasis. It is known that TNFα is elevated in both the skin and synovium of psoriatic patients and the effectiveness of its blockade by these two agents in psoriasis and PsA confirms its role in their pathogenesis.Randomized, double-blind, placebo-controlled trials have been performed with both agents in the treatment of psoriasis and PsA; in the case of etanercept these have been to support US FDA approval for use in psoriatic arthropathy. These studies are supported by smaller cohorts in open-label studies and anecdotal reports in the literature. Anti-TNFα therapy has proved to have disease-reducing activity in PsA and psoriasis and appears to be well tolerated.These studies have generally featured small numbers of patients and, until a larger cohort of treated patients is available, vigilance must be exercised. A considerable body of post-marketing safety data exists on the use of infliximab in rheumatoid arthritis and Crohn disease and for etanercept in rheumatoid arthritis and PsA. Certain issues, particularly the risk of infection, have emerged as features of the use of these agents. It remains to be seen whether effects seen in other disease entities may be extrapolated to psoriatic patients.More long-term data and experience are needed to define the role of anti-TNFα agents in the management of psoriasis and PsA. In particular, more studies are required to elucidate the finer points of co-medication; in some studies both agents have been used with other medications but there have been no formal trials of various possible combinations.

The Use of Alternative Medicine in Pediatric Patients with Atopic Dermatitis

Abstract:  Alternative medicine has been defined as forms of therapy or examination that have no scientific basis and for which no effective or diagnostic reliability has been demonstrated by scientific methods. The use of complementary or alternative medicine is increasing and controlled clinical trials on the subject are few. We performed a questionnaire‐based study of 80 pediatric patients with atopic dermatitis. This questionnaire assessed the duration of treatment, the reason(s) for trying alternative therapy, the approximate cost and the success of the treatment, the duration of the childhood eczema, and whether the child had ever required hospital admission for eczema. Of the total, 34 (42.5%) patients had used alternative medicine. Herbal remedies and homeopathy were used most often. Most treatments were reported to show no benefit and in three instances deterioration was reported. This study has prompted us to enquire routinely regarding alternative medicine use. Alternative therapies are subject to minimal regulation and have been associated with serious side effects. We would recommend enquiries regarding alternative medicine use in all pediatric dermatology patients.

Hidradenitis suppurativa: the role of immune dysregulation

Hidradenitis suppurativa (HS) is a chronic relapsing inflammatory disease of follicular occlusion characterized by boils, sinus tracts, fistulae, and scarring. It has a significant underestimated morbidity. Antimicrobial, immunosuppressive, anti‐androgenic, and surgical approaches have been used with varying results. Knowledge of the pathogenesis of HS is fragmented, and treatment choices have hitherto been empiric without an exact understanding of the scientific basis for their use. Tumor necrosis factor‐α inhibitors have shown promise in the treatment of HS in recent years, and the concept of HS as an immunological condition has come to the fore. The focus of this review is to discuss the immunological abnormalities underpinning HS as elucidated to date.

Glucagon-like peptide-1 analogue therapy for psoriasis patients with obesity and type 2 diabetes: a prospective cohort study.

Background  Diabetes and obesity are more prevalent amongst psoriasis patients as is disturbance of the innate immune system. GLP‐1 analogue therapy considerably improves weight and glycaemic control in people with type 2 diabetes and its receptor is present on innate immune cells.

Natural killer cells in psoriasis.

Psoriasis is one of the most common immune-mediated disorders. There is evidence that it is mediated by Th1 and, more recently, Th17 cells. The cytokine pattern, particularly the dominance of TNF-α, implicates the innate immune system in psoriasis pathogenesis. Of the many components of the innate immune system known to be involved in psoriatic lesions, natural killer and natural killer T cells appear to have a unique role. We review the evidence supporting a role for natural killer cells in psoriasis.

Homocysteine status and cardiovascular risk factors in patients with psoriasis: a case-control study.

Background.  Psoriasis is a hyperproliferative, cutaneous disorder with the potential to lower levels of folate. This may result in raised levels of homocysteine, an independent risk factor for the development of cardiovascular disease.

Prevalence of psoriasis in patients with alcoholic liver disease.

Background.  Excessive alcohol use has been implicated as a risk factor in the development of psoriasis, particularly in men. Despite this, little is known of the incidence or prevalence of psoriasis in patients who misuse alcohol.

Successful treatment of recalcitrant acrodermatitis continua of Hallopeau with adalimumab and acitretin

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