Chelsea Ma

The association between psoriasis and dyslipidaemia: a systematic review

Psoriasis may be associated with dyslipidaemia, a known risk factor for cardiovascular disease. This systematic review aims to synthesize evidence for the association between psoriasis and dyslipidaemia. Through a systematic search using MEDLINE, Embase and the Cochrane Central Register, from 1 January 1980 to 1 January 2012, we identified 25 observational studies that met the inclusion criteria. These 25 studies included over 2·4 million participants, among whom 265 512 were patients with psoriasis. Twenty studies (80%) reported that psoriasis was significantly associated with dyslipidaemia, with odds ratios (ORs) for dyslipidaemia ranging from 1·04 to 5·55 in 238 385 patients with psoriasis, from a population of 2 340 605 participants. Specifically, four studies defining dyslipidaemia as triglyceride levels ≥ 150 mg dL−1 reported significantly increased ORs of 1·20–4·98 for hypertriglyceridaemia in psoriasis. Three studies found that patients with psoriasis presented with significantly increased ORs (1·36–1·77) for high‐density lipoprotein cholesterol levels < 40 mg dL−1, and two studies found hyperlipoproteinaemia to be significantly elevated in patients with psoriasis (ORs 1·55 and 2·09). One cohort study found a significantly higher incidence of hyperlipidaemia among patients with psoriasis (hazard ratio 1·17; 95% confidence interval 1·11–1·23). Among studies that assessed the severity of psoriasis, in 2662 patients with mild psoriasis and 810 patients with severe psoriasis, higher odds of dyslipidaemia were seen in patients with severe psoriasis. Five of the 25 studies (20%) in our review did not show any significant relationship between psoriasis and dyslipidaemia. This systematic review found that psoriasis was significantly associated with greater odds and incidence of dyslipidaemia. Greater psoriasis severity appeared to be associated with higher prevalence of dyslipidaemia.

Severe adverse events from the treatment of advanced melanoma: a systematic review of severe side effects associated with ipilimumab, vemurafenib, interferon alfa-2b, dacarbazine and interleukin-2

Background: Current immunomodulatory agents for stage III and IV melanoma exert different mechanisms of action that manifest in distinct adverse events. Objective: This systematic review aims to synthesize safety data from clinical trials on ipilimumab, vemurafenib, interferon (IFN) alfa-2b, dacarbazine and interleukin (IL)-2 to elucidate the severe adverse events associated with each melanoma therapy. Methods: Through a systematic search using MEDLINE, EMBASE and the Cochrane Central Register between January 1, 2010 and June 1, 2012, we identified 32 clinical trials with 5802 subjects that met the inclusion criteria. Results:Ipilimumab was associated with immune-mediated diarrhea and colitis, with an incidence rate of 0.0017 cases per 100 person-years. Patients receiving vemurafenib developed keratoacanthomas and cutaneous squamous cell carcinoma at an incidence rate of 0.0025 cases per 100 person-years. Treatment with IFN alfa-2b precipitated depression at an incidence rate of 0.0002 cases per 100 person-years. Dacarbazine was associated with respiratory toxicity and dyspnea, with incidence rates of 0.0001 and 0.00008 cases per 100 person-years, respectively. IL-2 treatment induced vascular leak syndrome (VLS), with symptoms of hypotension and oliguria, was observed at incidence rates of 0.17 and 0.15 cases per 100 person-years, respectively. Findings may serve as a foundation for future research in this area and guide clinical recommendations.

Psoriasis and dyslipidemia: a population-based study analyzing the National Health and Nutrition Examination Survey (NHANES)

Psoriasis has been linked to an increased incidence of coronary artery disease, stroke, myocardial infarctions and cardiovascular deaths. Dyslipidemia, a well‐established risk factor for cardiovascular disease, involves inflammatory pathways that are also implicated in psoriasis. An understanding of the relationship between psoriasis and dyslipidemia may have a substantial clinical impact.

Diagnostic Criteria of Ulcerative Pyoderma Gangrenosum: A Delphi Consensus of International Experts

Importance Pyoderma gangrenosum is a rare inflammatory skin condition that is difficult to diagnose. Currently, it is a “diagnosis of exclusion,” a definition not compatible with clinical decision making or inclusion for clinical trials. Objective To propose and validate diagnostic criteria for ulcerative pyoderma gangrenosum. Evidence Review Diagnostic criteria were created following a Delphi consensus exercise using the RAND/UCLA Appropriateness Method. The criteria were validated against peer-reviewed established cases of pyoderma gangrenosum and mimickers using k-fold cross-validation with methods of multiple imputation. Findings Delphi exercise yielded 1 major criterion—biopsy of ulcer edge demonstrating neutrophilic infiltrate—and 8 minor criteria: (1) exclusion of infection; (2) pathergy; (3) history of inflammatory bowel disease or inflammatory arthritis; (4) history of papule, pustule, or vesicle ulcerating within 4 days of appearing; (5) peripheral erythema, undermining border, and tenderness at ulceration site; (6) multiple ulcerations, at least 1 on an anterior lower leg; (7) cribriform or “wrinkled paper” scar(s) at healed ulcer sites; and (8) decreased ulcer size within 1 month of initiating immunosuppressive medication(s). Receiver operating characteristic analysis revealed that 4 of 8 minor criteria maximized discrimination, yielding sensitivity and specificity of 86% and 90%, respectively. Conclusions and Relevance This Delphi exercise produced 1 major criterion and 8 minor criteria for the diagnosis of ulcerative pyoderma gangrenosum. The criteria may serve as a guideline for clinicians, allowing for fewer misdiagnoses and improved patient selection for clinical trials.

Diet and nutrition in psoriasis: analysis of the National Health and Nutrition Examination Survey (NHANES) in the United States.

There is limited research examining the association between psoriasis, dietary intake and nutritional status in the general U.S. population.

Amelanotic blue nevus

CLINICAL PRESENTATION A 38-year-old woman presented to clinic with a solitary 6.53 4-mm sharply demarcated ivory-white papule on her left temple of unknown duration (Fig 1). The lesion had a smooth surface without scale or ulceration. Small perifollicular dells were also noted. The patient reported no symptoms but believed the lesion recently turned white. She had no other similarly appearing lesions.

Meta-analysis of RNA sequencing datasets reveals an association between TRAJ23, psoriasis, and IL-17A.

Numerous studies of relatively few patients have linked T cell receptor (TCR) genes to psoriasis but have yielded dramatically conflicting results. To resolve these discrepancies, we have chosen to mine RNA-Seq datasets for patterns of TCR gene segment usage in psoriasis. A meta-analysis of 3 existing and 1 unpublished datasets revealed a statistically significant link between the relative expression of TRAJ23 and psoriasis and the psoriasis-associated cytokine IL-17A. TRGV5, a TCR-γ segment, was also associated with psoriasis but correlated instead with IL-36A, other IL-36 family members, and IL-17C (not IL-17A). In contrast, TRAJ39 was strongly associated with healthy skin. T cell diversity measurements and analysis of CDR3 sequences were also conducted, revealing no psoriasis-associated public CDR3 sequences. Finally, in comparison with the expression of TCR-αβ genes, the expression of TCR-γδ genes was relatively low but mildly elevated in psoriatic skin. These results have implications for the development of targeted therapies for psoriasis and other autoimmune diseases. Also, the techniques employed in this study have applications in other fields, such as cancer immunology and infectious disease.

Effectiveness of Online vs In-Person Care for Adults With Psoriasis: A Randomized Clinical Trial

IMPORTANCE Innovative, online models of specialty-care delivery are critical to improving patient access and outcomes. OBJECTIVE To determine whether an online, collaborative connected-health model results in equivalent clinical improvements in psoriasis compared with in-person care. DESIGN, SETTING, AND PARTICIPANTS The Patient-Centered Outcomes Research Institute Psoriasis Teledermatology Trial is a 12-month, pragmatic, randomized clinical equivalency trial to evaluate the effect of an online model for psoriasis compared with in-person care. Participant recruitment and study visits took place at multicenter ambulatory clinics from February 2, 2015, to August 18, 2017. Participants were adults with psoriasis in Northern California, Southern California, and Colorado. The eligibility criteria were an age of 18 years or older, having physician-diagnosed psoriasis, access to the internet and a digital camera or mobile phone with a camera, and having a primary care physician. Analyses were on an intention-to-treat basis. INTERVENTIONS Participants were randomized 1:1 to receive online or in-person care (148 randomized to online care and 148 randomized to in-person care). The online model enabled patients and primary care physicians to access dermatologists online asynchronously. The dermatologists provided assessments, recommendations, education, and prescriptions online. The in-person group sought care in person. The frequency of online or in-person visits was determined by medical necessity. All participants were exposed to their respective interventions for 12 months. MAIN OUTCOMES AND MEASURES The prespecified primary outcome was the difference in improvement in the self-administered Psoriasis Area and Severity Index (PASI) score between the online and in-person groups. Prespecified secondary outcomes included body surface area (BSA) affected by psoriasis and the patient global assessment score. RESULTS Of the 296 randomized participants, 147 were women, 149 were men, 187 were white, and the mean (SD) age was 49 (14) years. The adjusted difference between the online and in-person groups in the mean change in the self-administered PASI score during the 12-month study period was –0.27 (95% CI, –0.85 to 0.31). The difference in the mean change in BSA affected by psoriasis between the 2 groups was –0.05% (95% CI, –1.58% to 1.48%). Between-group differences in the PASI score and BSA were within prespecified equivalence margins, which demonstrated equivalence between the 2 interventions. The difference in the mean change in the patient global assessment score between the 2 groups was –0.11 (95% CI, –0.32 to 0.10), which exceeded the equivalence margin, with the online group displaying greater improvement. CONCLUSIONS AND RELEVANCE The online, collaborative connected-health model was as effective as in-person management in improving clinical outcomes among patients with psoriasis. Innovative telehealth delivery models that emphasize collaboration, quality, and efficiency can be transformative to improving patient-centered outcomes in chronic diseases. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02358135

Exuberant scale crust of the scalp

An otherwise healthy 19-year-old African-American man presented with a 6-month history of unremitting scabbed lesions on the scalp. Physical examination found hyperkeratotic plaques with matted, powdery, white crust along the scalp (Fig 1, A and B). He did not respond to antibiotic therapy with cephalexin and doxycycline or topical antifungal therapy with ketoconazole 2% shampoo. A punch biopsy was obtained. On histopathology, suprabasilar acantholysis was seen (Fig 2). Additional studies were subsequently done, including a direct immunofluorescence (DIF), which indicated epidermal IgG and C3 deposition with sparse junctional C3 deposition. Periodic acideSchiff was suggestive of superficial colonization.