H. Zachariae

Quality of Life and Prevalence of Arthritis Reported by 5,795 Members of the Nordic Psoriasis Associations Data from the Nordic Quality of Life Study

Quality of life measures are widely used in dermatology as well as in rheumatology, but there are no large studies taking arthritis into consideration when studying quality of life in psoriasis. The aim of this study was to investigate psoriasis-related quality of life in a large sample of members of the psoriasis associations from the Nordic countries including an arthritis-related evaluation. The prevalence of reported arthritis within the groups was also estimated. An Arthritis Disability Index suitable for parallel use together with Finlays Psoriasis Disability Index was constructed. A total of 5,795 members and 702 patients seen by Nordic dermatologists rated the severity of their disease and completed the Psoriasis Disability Index formula and a Psoriasis Life Stress Inventory, and if arthritis had been diagnosed, the Arthritis Disability Index formula. Approximately 30% of all psoriatic patients, irrespective of group, received a diagnosis of arthritis either by their dermatologist or a rheumatologist. Members previously hospitalized for their disease had a higher frequency of arthritis (41%) than those without a history of hospitalization (23%). The highest prevalence of arthritis was found in Norway (33.8%). Members with arthritis exhibited greater impairment of psoriasis-related quality of life, longer disease duration, and greater self-reported disease severity for psoriasis. Important predictors for impairment of arthritis-related quality of life were pain, number of affected joints, and restriction of joint mobility. These data show, that the prevalence of arthritis in psoriasis may be significantly higher than the previously accepted average of 7%. The results demonstrate that when studying quality of life in psoriasis, arthritis and arthralgia are important independent factors to be included in the evaluation.

Delayed wound healing and keloid formation following argon laser treatment or dermabrasion during isotretinoin treatment

We report the observation of delayed wound healing and keloid formation in three patients, following dermabrasion or Argon laser treatment administered while they were receiving isotretinoin for acne or rosacea.

HL-A in psoriasis vulgaris and in pustular psoriasis--population and family studies.

A collaborative study of HL‐A typing was done on 156 unrelated patients with psoriasis vulgaris and thirty‐one patients with pustular psoriasis. Highly significant increases of HL‐A13 and HL‐A17 were found in psoriasis vulgaris: about half of the patients carried either of these antigens as compared to about 12% of the controls. The effect of HL‐A13 and 17 is confined almost exclusively to psoriasis with onset before the age of 35 years. In contrast, none of these antigens was increased in pustular psoriasis, indicating that pustular and common psoriasis are different aetiological entities. Family studies in psoriasis vulgaris showed that psoriasis can develop in relatives lacking the HL‐A haplotype following psoriasis in the other family members. Hence, it seems most likely that HL‐A represents only part of the genetic basis of psoriasis vulgaris. This disease is probably of a polygenic threshold character, and HL‐A13 and 17 decreases the threshold making the expression of psoriasis more likely in individuals carrying these determinants in addition to other probably non‐HL‐A linked psoriasis determinants. This concept is supported by the observation of a higher incidence of a positive family history in HL‐A13 and/or 17 positive patients than in patients lacking these antigens. Studies of antistreptolysin O and antistreptococcal hyaluronidase titres and of triggering streptococcal infections yielded no clue as to the pathogenetic effect of HL‐A. The frequencies of HL‐A13 and 17 were not significantly increased in twenty‐one patients with psoriatic arthritis, but HL‐A27 may be increased in these patients. This study shows the importance of HL‐A in the subdivision of diseases and stresses the importance of family studies for clarifying the associations between HL‐A and disease.

Treatment of mycosis fungoides with recombinant interferon‐αza2 alone and in combination with etretinate

Eleven patients with mycosis fungoides (MF) were treated with recombinant alpha‐intcrfcron (rIFN‐α2a2) in combination with etretinate (seven patients) or alone. One patient, who also received etretinate, went into complete remission and remained without signs of MF after 18 months. Six patients experienced partial remission; one of these was treated with rIFN‐α2a alone and was clinically in complete remission, but had still a pteomorphic skin infiltrate. Two patients were non‐evaluable, and two stopped therapy due to progressive disease. Five patients discontinued therapy due to side‐effects although three had partial remission of their disease. Only four patients received 12 months therapy. The study shows that rIFN‐α2a in combination with etretinate or alone can induce remission of MF.

Methotrexate-induced liver cirrhosis: a follow-up

Studies on serial liver biopsies from 25 patients with methotrexate-induced liver cirrhosis, taken from 1 to 13 years after cirrhosis was established, confirm that this type is not of aggressive nature. When evaluated blind no progression was found in most of the later biopsies. Alcohol and previous use of hepatotoxic drugs such as the combination of arsenics and vitamin A seem to have been contributing factors to cirrhosis formation.

Methotrexate-lnduced Liver Cirrhosis

Background : Methotrexate (MTX) may induce liver damage, which in some psoriatics will lead to fibrosis or cirrhosis. Studies performed 10 years ago on 25 patients with MTX-induced l

HL-A antigens in pustular psoriasis.

HL-A typing was performed on 97 patients with pustular psoriasis. HLA-B27 was found increased for the combined three subgroups: localized psoriasis of palms and soles, acrodermatitis continua and generalized pustular psoriasis, who were associated with a high incidence of arthritis. These subgroups have this in common with Reiters disease indicating a link between the entities. In persistent palmo-plantar pustulosis an increased incidence of HLA-Bw35 was found. HLA-B13, HLA-B17 and HLA-Bw37 which are found markedly increased in psoriasis vulgaris were in acrodermatitis continua, generalized pustular psoriasis and persistent palmo-plantar pustulosis either absent or not increased as compared with the control population. 7 of 30 patients with localized psoriasis of palms and soles had one of these antigens. Our findings confirm that psoriasis vulgaris and pustular psoriasis as such, seem to be different aetiological entities. Some patients with localized psoriasis of palms and soles may be true psoriatics which besides their psoriasis have a tendency to develop a pustular reaction in their palms and soles similar to persistent palmo-plantar pustulosis.

Methotrexate side-effects

Methotrexate is by far the most widely used cytotoxic drug in psoriasis. Treatment requires normal kidney, liver and bone‐marrow function, and pregnancy and alcohol abuse are absolute contraindications. Serious toxic reactions are recognized, but can be avoided if the drug is used correctly. The most important side‐effects are haematopoietic and hepatotoxic. It is well established that long‐term methotrexate can induce liver damage which, in a number of patients, may lead to fibrosis or cirrhosis. Recent studies have, however, documented that the methotrexate‐induced liver cirrhosis is not aggressive. Interaction can occur with a number of drugs; serious problems in particular may arise with concomitant use of sulphonamides and salicylates. The recommended guidelines for methotrexate use in psoriasis should be followed and patients given clear instructions.

Renal Toxicity of Long-term Ciclosporin: EDITORIAL REVIEW

An analysis of the literature on renal toxicity of long-term cyclosporin A (CsA) in auto-immune diseases reveals that besides functional renal toxicity also de novo morphological kidney damage can be induced already after 12 months with low dose (≤ 5 mg CsA/kg/day). In the early stage the findings are light changes. However, after two years treatment they are light to moderate. In a blinded study on 30 patients with psoriasis, including 18 with psoriatic arthritis, the severity of findings increased with length of therapy, and after four years all but one had arteriolar hyalinosis, with interstitial fibrosis pronounced in five and moderate in six of eleven patients, and at the same time glomerular sclerosis had become significant. The data presented indicate the necessity of an evaluation of the risk-benefit ratio for each patient. Accepted guide-lines should be strictly followed, and after two years treatment a rotation to other therapies, or a careful following by glomerular filtration rate (GFR) together with sequential renal biopsies should be considered.An analysis of the literature on renal toxicity of long-term cyclosporin A (CsA) in auto-immune diseases reveals that besides functional renal toxicity also de novo morphological kidney damage can be induced already after 12 months with low dose (< or = 5 mg CsA/kg/day). In the early stage the findings are light changes. However, after two years treatment they are light to moderate. In a blinded study on 30 patients with psoriasis, including 18 with psoriatic arthritis, the severity of findings increased with length of therapy, and after four years all but one had arteriolar hyalinosis, with interstitial fibrosis pronounced in five and moderate in six of eleven patients, and at the same time glomerular sclerosis had become significant. The data presented indicate the necessity of an evaluation of the risk-benefit ratio for each patient. Accepted guide-lines should be strictly followed, and after two years treatment a rotation to other therapies, or a careful following by glomerular filtration rate (GFR) together with sequential renal biopsies should be considered.

The red man syndrome: Exfoliative dermatitis of unknown etiology: A description and follow-up of 38 patients

Thirty-eight patients with erythroderma of unknown etiology were diagnosed over a 15-year period, and represented 19% of all patients admitted to our department for erythroderma. The male:female ratio was 6.6:1, and the median disease duration was 2 years (range 1 to 23 years). Keratoderma of palms and/or soles was seen in 79%. Laboratory findings were normal, except for an increased IgE level in 69% of the patients studied. Lymph node histology showed dermatopathic lymphadenopathy. Bone marrow investigation results were normal in 48%, or showed eosinophilia (32%) or hyperplasia (20%). Initial skin biopsies showed nonspecific histology in most patients, but later biopsies revealed pleomorphic infiltration. During the observation period four patients progressed to mycosis fungoides and another nine patients were suspected of having mycosis. None developed Sézarys syndrome. Only one third of the patients went into complete remission; half of them died during the observation period. Patients with erythroderma of unknown etiology are predominantly men and seem to belong to a certain subgroup--herein called the red man syndrome.