Louis Dubertret

European S3‐Guidelines on the systemic treatment of psoriasis vulgaris

Of the 131 studies on monotherapy or combination therapy assessed, 56 studies on the different forms of phototherapy fulfilled the criteria for inclusion in the guidelines. Approximately three-quarters of all patients treated with phototherapy attained at least a PASI 75 response after 4 to 6 weeks, and clearance was frequently achieved (levels of evidence 2 and 3). Phototherapy represents a safe and very effective treatment option for moderate to severe forms of psoriasis vulgaris. The onset of clinical effects occurs within 2 weeks. Of the unwanted side effects, UV erythema from overexposure is by far the most common and is observed frequently. With repeated or long-term use, the consequences of high, cumulative UV doses (such as premature aging of the skin) must be taken into consideration. In addition, carcinogenic risk is associated with oral PUVA and is probable for local PUVA and UVB. The practicability of the therapy is limited by spatial, financial, human, and time constraints on the part of the physician, as well as by the amount of time required by the patient. From the perspective of the cost-bearing institution, phototherapy has a good cost-benefit ratio. However, the potentially significant costs for, and time required of, the patient must be considered.

European patient perspectives on the impact of psoriasis: the EUROPSO patient membership survey

Background  EUROPSO (European Federation of Psoriasis Patient Associations) undertook a Europe‐wide survey examining quality of life and patients’ perspectives on treatment and their disease.

Review of the potential photo-cocarcinogenicity of topical calcineurin inhibitors: Position statement of the European Dermatology Forum

ABSTRACT  Topical Calcineurin Inhibitors (TCIs) used for the treatment of atopic eczema modify the immune regulatory function of the skin and may have the potential to enhance immunosuppressive ultraviolet (UV) effects. Current recommendations on UV protection in eczema patients treated with PCIs are inconsistent and have given rise to uncertainty and anxiety in patients. Therefore, the European Dermatology Forum (EDF) developed a position statement which reviews critically the available data with regard to the problem, especially analysing and commenting the limitations of rodent models for the human situation. There is no conclusive evidence from rodent trials to indicate that long‐term application of TCIs is photococarcinogenic. There is a need for further studies to investigate the validity of mouse models as well as long‐term cohort studies in patients using TCIs. Available data suggest that long‐term application of TCIs is safe, that there is no evidence of increased skin cancer risk and that it is ethical to treat patients with TCIs when indicated.

High frequency of cholestasis in generalized pustular psoriasis: Evidence for neutrophilic involvement of the biliary tract

Generalized pustular psoriasis is a rare form of psoriasis that is sometimes associated with extracutaneous manifestations. Evidence for biliary involvement has been suggested in isolated cases. We investigated the prevalence and nature of liver abnormalities occurring in this disease. Twenty‐two patients consecutively admitted for generalized pustular psoriasis who underwent liver biological tests at the time of the attack and during the following weeks were included. Twenty patients (90%) had at least one abnormal biological liver parameter. Eleven patients (50%) had pronounced abnormalities: jaundice (4/22), gammaglutamyl transferase higher than 5 times the normal value (10/22), alkaline phosphatase higher than twice the normal value (7/22), and/or aminotransferases higher than 3 times the normal value (7/22). These abnormalities returned to normal range at the time of remission of pustular psoriasis, suggesting that severe liver abnormalities could be associated with severe cutaneous disease. Neutrophilic cholangitis was observed on liver biopsy. Persistent magnetic resonance cholangiopancreatography features similar to those observed in sclerosing cholangitis were found in 3 of the 4 patients studied. No causal factor other than pustular psoriasis could be identified. In conclusion, our results demonstrate the high frequency of liver abnormalities in patients with generalized pustular psoriasis. Biliary involvement related to neutrophilic cholangitis should be added to the spectrum of extracutaneous manifestations of this disease, and physicians should be aware of such a complication. (HEPATOLOGY 2004;40:452–458.)

Recommendations for the use of etanercept in psoriasis: a European dermatology expert group consensus

Background  Psoriasis is a chronic, inflammatory skin disorder that has a significant impact on quality of life and, particularly in moderate to severe cases, adversely affects the patients overall health and well‐being. Biological treatments, such as etanercept, are being widely adopted across Europe for treatment of moderate to severe psoriasis due to favourable safety and efficacy profiles. The increase in usage, combined with a growing body of clinical evidence, has identified a need to clarify the best use of etanercept within its current treatment label.

Onset of psoriatic arthritis in patients treated with efalizumab for moderate to severe psoriasis.

OBJECTIVE To investigate the nature of polyarthritis in patients with moderate to severe psoriasis undergoing treatment with efalizumab, a humanized anti-CD11a monoclonal antibody. METHODS In a multicenter study, we retrospectively analyzed patients who developed arthritis during treatment with efalizumab. The relationship between joint manifestations and psoriatic disease was addressed by using different classification criteria for psoriatic arthritis (PsA). The course of arthritis and its response to treatment were also investigated. RESULTS Sixteen patients developed de novo inflammatory rheumatic disease, with a mean delay of 15 weeks following the start of treatment, and with exclusive asymmetric peripheral monarthritis or oligoarthritis (8 patients), inflammatory spinal disease (1 patient), or both (7 patients), associated in some cases with enthesitis and dactylitis. All patients fulfilled at least 2 different sets of classification criteria for PsA. In most of them, an improvement in skin lesions was observed at the onset of PsA, as measured using the Psoriasis Area and Severity Index (mean score 24.88 before efalizumab versus 18.78 at the time of arthritis). Efalizumab treatment was stopped in 11 patients and was followed by the elimination of rheumatologic symptoms in 1 patient, while 8 patients required treatment with nonsteroidal antiinflammatory drugs with or without methotrexate, with 2 later being switched to tumor necrosis factor alpha inhibitors. Reintroduction of efalizumab (2 patients) was followed by a relapse of PsA. CONCLUSION This study questions the role of efalizumab in the induction of PsA. It also emphasizes the discrepancy between the courses of psoriatic skin and joint manifestations under treatment. Prospective case-control studies are needed to accurately investigate the impact of efalizumab on PsA.

Alice, Eloi, Magali and Robert: the lives of four patients with psoriasis and the therapeutic approaches of eight European experts

*Department of Dermatology, Hôpital Saint-Louis, Paris, France Department of Dermatology, University of Rome Tor Vergata, Rome, Italy Department of Dermatology, Schleswig Holstein University Clinic, Kiel, Germany §Department of Dermatology, Hospital Universitario de la Princesa, Madrid, Spain –Novartis Institutes for BioMedical Research, Basel, Switzerland **Dermatological Sciences Research Group, University of Manchester, Manchester, UK Department of Dermatology, Århus University Hospital, Århus, Denmark Department of Medicine, Karolinska Institute, Stockholm, Sweden §§Department of Dermatology, Vienna General Hospital, Vienna, Austria

An unusual bipolar primary herpes simplex virus 1 infection.

We describe an atypical primary HSV 1 genital infection with bilateral palmar involvement. Two routes of dissemination of HSV are discussed, self-inoculation and blood dissemination. This case highlights the role of HSV 1 in extragenital pustules in the context of sexually transmitted diseases.