Marlies Wakkee

Psoriasis May Not be an Independent Risk Factor for Acute Ischemic Heart Disease Hospitalizations: Results of a Large Population-Based Dutch Cohort

Although psoriasis has been associated with components of the metabolic syndrome, its association with myocardial infarction is less clear. A cohort study was conducted using hospital and pharmacy records of 2.5 million Dutch residents between 1997 and 2008. The risk of ischemic heart disease (IHD) hospitalizations was compared between psoriasis patients and a matched reference cohort. Additional adjustments were made for healthcare consumption and use of cardiovascular drugs. A total of 15,820 psoriasis patients and 27,577 reference subjects were included, showing an incidence rate of 611 and 559 IHD per 100,000 person-years, respectively (P=0.066). The age- and gender-adjusted risk of IHD was comparable between both cohorts (hazard ratio (HR)=1.10, 95% confidence interval 0.99-1.23). Before cohort entry, psoriasis patients used more antihypertensive, antidiabetic, and lipid-lowering drugs and were more often hospitalized. Adjusting for these confounders decreased the HR for IHD, but it remained comparable between both populations. There was no different risk of IHD between the subgroup of patients who only used topicals versus those who received systemic therapies or inpatient care for their psoriasis. This study, therefore, suggests that psoriasis is not a clinically relevant risk factor for IHD hospitalizations on the population level.

The Prevalence and Odds of Depressive Symptoms and Clinical Depression in Psoriasis Patients: A Systematic Review and Meta-Analysis

The reported prevalence of depression in psoriasis varies substantially. This study aims to determine the prevalence and odds of depressive symptoms and clinical depression in psoriasis. A systematic literature search was conducted. Mean questionnaire values and proportions for depressive symptoms and clinical depression were pooled according to different assessment methods. In controlled studies, standardized mean differences (SMDs) and odds ratio (OR) compared depression in psoriasis patients with controls using the random-effect model. The majority of the 98 eligible studies were conducted in tertiary centers without a control group. The prevalence of depressive symptoms was 28% using questionnaires and the prevalence of clinical depression was 12% using International Classification of Diseases codes, 19% using Diagnostic and Statistical Manual of Mental Disorders IV, and 9% for antidepressant use. Psoriasis patients had significantly more depressive symptoms (SMD 1.16; 95% confidence interval (CI) 0.67-1.66), and population-based studies showed that they were at least one and a half times more likely to experience depression (OR 1.57; 95% CI 1.40-1.76) and used more antidepressants than did controls (OR 4.24, 95% CI 1.53-11.76). More than 10% of psoriasis patients suffer from clinical depression, and twice as many have depressive symptoms. The high prevalence of these symptoms is likely to be affected by the tertiary study populations and differential misclassification using questionnaires, where psoriasis-related symptoms may be detected as depressive symptoms.

Psoriasis May Not Be an Independent Predictor for the Use of Cardiovascular and Anti-diabetic Drugs: A 5-year Prevalence Study

Most studies investigating the association between psoriasis and cardiovascular disease have shown a significant relationship. This comparison study investigated the association between psoriasis and prevalent use of cardiovascular drugs. Drug exposure data for 1998 to 2006 were extracted from the Dutch PHARMO-Record Linkage System database. Psoriasis patients were selected using an algorithm of hospitalization and drug dispensing records specific for psoriasis and matched with controls for gender, age and time-period. From the records of 2.5 million Dutch residents, 9,804 (0.4%) psoriasis patients and 15,288 (0.6%) controls were selected. Psoriasis patients used significantly more anti-hypertensives, anti-coagulant and anti-platelet agents, digoxin, nitrates, lipid-lowering and anti-diabetic drugs than the reference population during a 5-year period observation. In a multiple linear regression model adjusting for the number of unique drugs used, psoriasis was no longer significantly associated with any of these drug classes. Psoriasis patients used more cardiovascular-related drugs, but surveillance bias appears to affect this association considerably.

Epidemiology of basal cell carcinoma: scholarly review

Basal cell carcinoma (BCC) is the most common cancer in white‐skinned individuals with increasing incidence rates worldwide. Patients with BCC place a large burden on healthcare systems, because of the high incidence and the increased risk of synchronous and metachronous BCCs and other ultraviolet radiation (UVR) related skin cancers (i.e. field cancerization). As a result, the disability‐adjusted life years and healthcare costs have risen significantly in recent decades. BCC is a complex disease, in which the interplay between UVR, phenotype (UVR‐sensitive) and genotype (somatic mutations and germline mutations/polymorphisms) fulfils a key role in the aetiopathogenesis. Prevention programmes with continual refinements and improvements could be of major importance in tackling the growing skin cancer problem. To provide the most appropriate BCC care, physicians should engage in shared decision‐making and choose their treatments wisely.

Comorbidities in Dermatology

Recently, comorbidities have been rediscovered in dermatology. Although numerous associations between skin diseases and other conditions have been reported, only a few are well documented. The association of comorbidities and dermatoses is complex and multifactorial. Life-style factors, impaired health-related quality of life, depression, therapeutic interventions, and several biases may confound the relationship between skin diseases and comorbidities. This article discusses observational studies that assess comorbidities in psoriasis, atopic dermatitis, vitiligo, and nonmelanoma skin cancer, and the likelihood of the observed associations and their clinical consequences.

Psocare: Italy shows the way in postmarketing studies

will perform coordinated postmarketing surveillance studies to monitor the effectiveness and safety of system-ic agents, including biologics, in the treatment of psoria-sis. Accordingly, international data can be pooled to reach sufficient power and new drugs can be easily monitored in the future. Established registries try to link to Psonet and new ones are under construction to use the Psocare framework to collect a standardized ‘core set’ of vari-ables. The countries that participate include Italy, France, Israel, Portugal, Spain, Sweden, the Netherlands and the UK. Moreover, the establishment of a multidisciplinary and international group of investigators sharing resourc-es and activities may increase the quality of (pharma-co)epidemiological studies and stimulate the develop-ment of independent pragmatic randomized controlled trials (RCT) that are needed by patients and physicians [4, 5] .I n our opinion, Psocare and Psonet may revolutionize postmarketing and pharmacoepidemiological studies in and outside dermatology. The manufacturers of the pso-riasis drugs should have studied several aims of the these frameworks, but a recent Food and Drug Administration survey showed that only 34% of 2,701 postmarketing commitments were honoured [5, 6] . No such data are available for the European Medicines Agency. Since there is a lack of information about drug behaviour outside the restricted clinical trial population, commercially less in-teresting (hard) outcomes and long-term safety of drugs,

Knowledge, attitudes and use of the guidelines for the treatment of moderate to severe plaque psoriasis among Dutch dermatologists

Background  In 2003, the Dutch psoriasis guidelines were among the first evidence‐based medicine guidelines in dermatology. Although pivotal, the implementation of dermatological guidelines has not been assessed.

Increased Antidepressant Drug Exposure in Psoriasis Patients: A Longitudinal Population-based Cohort Study

Psoriasis has a major impact on health-related quality of life. The present cohort study investigated the use of antidepressant drugs in psoriasis patients and a reference cohort, using pharmacy and hospitalization data from 1998 to 2008 for more than 2.5 million Dutch residents. Multivariate Cox regression was used to compare the risk of first antidepressant use, and Poisson regression to compare the number of episodes of antidepressant use. A total of 25,691 psoriasis cases and 128,573 reference subjects were followed for more than 9 years. The incidence of first antidepressant use was 21 and 9 per 1,000 person years, respectively, and the adjusted hazard ratio (HR) was 1.55 (95% confidence interval (CI) 1.50-1.61). Within the psoriasis cohort, the HR of receiving an antidepressant was significantly higher after the first antipsoriatic treatment (HR 1.07, 95% CI 1.02-1.12). Psoriasis patients have a two-fold increase in antidepressant use, the period after antipsoriatic treatment being characterized by a further increase in antidepressant drug dispenses.

Increased prevalence of advanced liver fibrosis in patients with psoriasis: A cross-sectional analysis from the rotterdam study

Prevalence of non-alcoholic fatty liver disease is increased in patients with psoriasis. However, it is not known how liver fibrosis correlates with psoriasis. This study investigated the association between psoriasis and liver fibrosis compared with participants without psoriasis within the population-based Rotterdam Study. All participants were screened for liver fibrosis using transient elastography. Liver stiffness > 9.5 kPa suggested advanced liver fibrosis. Psoriasis was identified using a validated algorithm. A total of 1,535 participants were included (mean age ± standard deviation 70.5 ± 7.9 years; 50.8% female; median body mass index 26.4 kg/m2 (interquartile range 24.2-28.9)) of whom 74 (4.7%) had psoriasis. Prevalence of advanced liver fibrosis was 8.1% in psoriasis patients compared with 3.6% in the reference group (p = 0.05). The risk of advanced liver fibrosis in psoriasis patients remained comparable after adjustment for demographics, lifestyle characteristics and laboratory findings (odds ratio 2.57 (95% confidence interval 1.00-6.63). This study suggests that elderly people with psoriasis are twice as likely to have advanced liver fibrosis irrespective of common risk factors.

Evaluation of the reimbursement criteria for biological therapies for psoriasis in the Netherlands

testosterone levels returned to normal ranges. Hypertrichosis is an uncommon and distressing reaction to drugs. Its mechanisms are poorly understood, but hair growth usually reverts back to normal after discontinuation of the drug. The disorder starts on the upper limbs or the face and spreads to the back and lower limbs, but spares the elbows, knees and gluteal area, as in our patient. Efalizumab has not been associated with hypertrichosis but the increased levels of free testosterone in our patient might have been caused by an androgen-dependent mechanism induced by the drug. A reversible increase in the circulating lymphocyte count was also observed and it is a matter of further investigation to determine whether or not this is associated with efalizumab’s systemic (or extensive?) adverse reactions. Efalizumab-induced hypertrichosis represents a new adverse reaction. It is not necessary to terminate efalizumab therapy and hypertrichosis may be treated with various methods of hair removal. Physicians should be aware of this and inform their patients accordingly.