Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with phototherapy.

Psoriasis is a chronic inflammatory disease involving multiple organ systems and affecting approximately 3.2% of the world’s population. In this section of the guidelines of care for psoriasis, we will focus the discussion on ultraviolet light-based therapies, which include narrowband and broadband UVB, UVA in conjunction with photosensitizing agents (PUVA), targeted UVB treatments like excimer laser, and several other modalities and variations of these core phototherapies, including newer applications of pulsed dye laser, intense pulse light, and light emitting electrodes. We will provide an in-depth, evidence-based discussion of efficacy and safety for each treatment modality and provide recommendations and guidance for the use of these therapies alone or in conjunction with other topical and/or systemic psoriasis treatments.

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Complete Skin Clearance and PASI response rates in clinical practice- Predictors, Health Related Quality of Life improvements and implications for treatment goals.

PASI90 is suggested to be the new standard endpoint RCTs of biologics for psoriasis, whereas treatment guidelines often still refer to PASI75.To analyse in a real-world setting: Firstly, what factors are associated with higher levels of treatment response to biologics. Secondly, the Health-Related Quality of Life gains associated with different response levels in clinical practice.Biologically-naïve patients with PASI, DLQI and EQ-5D outcomes before (maximum 6 months) and after (3-12 months) switch to biologics during registration in the Swedish Register for systemic treatment of psoriasis, PsoReg, were included (n=515). Patient characteristics associated with higher treatment response were analysed by regression analyses. Improvements in absolute PASI, DLQI and EQ-5D were assessed in different PASI percent response levels.High PASI percentage response was associated with higher PASI before switch and lower BMI. DLQI and EQ-5D improved within all responder groups (p<0·001). The magnitude of improvements in DLQI (p=0·02) differed between responder groups. The mean (SD) DLQI improvement for PASI75-<90, PASI90-<100 responders and patients achieving Complete Skin Clearance (PASI100) were 9·9 (7·4), 11·5 (7·0) and 8·0 (6·1), respectively.PASI percentage change is largely dependent on absolute PASI before switch. Patients in clinical practice lack "baseline" PASI values as they may switch directly from one treatment to another or stay successfully treated for a longer time period. Treatment goals such as PASI90 are thus not suitable for treatment guidelines or for follow-up in clinical practice. This article is protected by copyright. All rights reserved.

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Grading immunohistochemical markers p16INK4a and HPV E4 identifies productive and transforming lesions caused by low- and high-risk HPV within high-grade anal squamous intraepithelial lesions.

Current LAST guidelines recognise high- and low-grade anal squamous intraepithelial lesions (HSIL, LSIL) and recommend treatment of all HSIL, but not all HSIL progress to cancer. This study aims to distinguish transforming and productive HSIL by grading immunohistochemical (IHC) biomarkers p16 and E4 in lr- and hr-HPV- associated SIL as a potential basis for more selective treatment.Immunostaining for p16 and HPV E4 was performed and graded in 183 biopsies from 108 HIV+ MSM. Causative HPV genotype of the worst lesion was identified using SPF10-PCR-DEIA-LiPA25v1, with laser capture microdissection (LCM) for multiple infections. Worst lesions were scored for p16 (0-4) to identify activity of hrHPV E7 gene, and panHPV E4 (0-2) marking HPV production and life-cycle completion. There were 37 normal, 60 LSIL and 86 HSIL with 85% LSIL caused by lrHPV and 93% HSIL by hrHPV. No normal biopsy showed E4 but 43% of LSIL and 37% of HSIL were E4 positive. No differences in E4 positivity rates were found between lrHPV and hrHPV lesions. Most (90%) lesions caused by lrHPV showed very extensive patchy p16 staining. p16 grade in HSIL was variable with frequency of productive HPV infection dropping with increasing p16 grade.Combined p16/E4 IHC identifies productive and non-productive HSIL associated with hrHPV within the group of HSIL defined by the Lower Anogenital Squamous Terminology recommendations. This opens the possibility of investigating selective treatment of hrHPV-caused advanced transforming HSIL and a “wait and see” policy for productive HSIL.

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Latin American Clinical Practice Guidelines on the Systemic Treatment of Psoriasis SOLAPSO – Sociedad Latinoamericana de Psoriasis (Latin American Psoriasis Society).

This Clinical Practice Guideline on the systemic treatment of Psoriasis includes the recommendations elaborated by a panel of experts from the Latin American Psoriasis Society SOLAPSO, who assessed the quality of the available evidence using the GRADE system and the PICO process to guide the literature search. To answer each question, the experts discussed the results of randomized controlled trials, observational studies and metanalysis evaluating the interventions identified (non-biologics, biologics and phototherapy) in different populations of patients with moderate to severe plaque-psoriasis, which was summarized in Tables ad-hoc. The main end-points considered to assess efficacy were PASI 50, 75, 90 and 100, PGA 0-1 and significant improvement of health-related quality of life. Specific adverse events, either severe or leading to treatment interruption, were also evaluated. The 31 recommendations included in this CPG follow the structure proposed by GRADE: direction (for or against) and strength (strong or weak). The goal of this CPG is to improve the management of patients with psoriasis by recommending interventions of proved benefit and providing a reference standard for the treating physician. Adhering to the contents of this CPG does not guarantee therapeutic success. The final decision on the specific treatment is the responsibility of the physician based on the individual circumstances and considering the values, the preferences and the opinions of the patient or caregivers.

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Topical treatments in atopic dermatitis: unexpectedly low use of emollients; use of topical corticosteroid is higher in juvenile patients, higher in male vs females, and shows independent associations with asthma and depression.

Despite decades of use,the actual amounts of topical corticosteroids (TCS) and emollients used in moderate-to-severe atopic dermatitis (AD) under real-world conditions are unknown. Thus, it remains unclear if inadequate use is widespread.To quantify the use of TCS and emollients in moderate-to-severe AD.Double-blinded drug prescribing recorded prospectively at the point of drug dispensing within a catchment of approx. 450,000 over a 31-year period in a population-based cohort marked by failure of disease control in primary care (n = 844). For each patient, prescribing was recorded over 12-month to minimize fluctuations.The resulting dataset was near-complete, and essentially free of reporting- and recording bias. Atopic co-morbidities matched expected frequencies. Median use of TCS was statistically significantly higher in juvenile (age < 16) compared to adult patients (49·2 vs. 38·1 gram / month), in males vs. females (46·8 vs. 29·7), and in patients receiving concurrent asthma treatment (40·4 vs. 26·7). TCS use was strongly associated with anti-depressant treatment. Emollient use was unexpectedly low at median of 9·6 gram/day (range 1·4 - 30·1). Results replicated in an independent validation cohort. Conclusions Deficient use of emollients may be a factor contributing to AD severity. TCS use does not exceed current guidelines. Accurate quantification of topical treatments provides a widely accessible strategy to measure real-world impact of novel AD treatments. This article is protected by copyright. All rights reserved.

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Histopathologic upgrading of nonmelanoma skin cancer at the time of Mohs micrographic surgery: A prospective review.

Anecdotal experience and data from multiple retrospective studies have suggested that a significant percentage of nonmelanoma skin cancers (NMSCs) display an aggressive histologic subtype that is not diagnosed on initial biopsy.To prospectively determine the proportion of NMSCs upgraded at the time of Mohs micrographic surgery (MMS) and examine the surgical parameters of upgraded lesions.In this prospective, cross-sectional study, all patients undergoing MMS for NMSC at our institution over the course of 1 year were screened for inclusion. Frozen sections were reviewed independently by 2 fellowship-trained Mohs surgeons.In total, 265 of 2578 (10.3%) tumors displayed a more aggressive skin cancer histologic subtype on frozen-section analysis at the time of surgery than at the initial biopsy. Upgraded tumors required significantly more stages to reach tumor clearance, had a larger postoperative defect size, and more often required complicated repairs than nonupgraded tumors.Single center study, limited time period, and cross-sectional design.A significant portion of MMS cases were upgraded at the time of surgery to a more aggressive subtype than that seen at the initial biopsy. Upgraded cases were larger and more surgically challenging than nonupgraded ones. This finding has important implications for primary dermatologists’ referral practices and Mohs appropriate use criteria guidelines.

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Mammalian target of rapamycin (mTOR) inhibitors and skin cancer risk in nonrenal solid organ transplant recipients: systematic review and meta-analysis.

Solid organ transplant recipients have an increased risk of malignancy compared with the general population. Mammalian target of rapamycin (mTOR) inhibitors have been used as immunosuppressants in transplant recipients. There remains a lack of evidence of this treatment in nonrenal solid organ transplantation. We aimed to perform a systematic review and meta-analysis to assess the effects of mTOR inhibitors on secondary nonmelanoma skin cancer (NMSC) malignancies in nonrenal transplant recipients.A systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eligible studies for the present systematic review and meta-analysis included those in which patient cohorts underwent heart, liver, lung, and pancreas (i.e. nonrenal solid organ) transplantation, with treatment group being those treated with an mTOR inhibitor such as sirolimus or everolimus, and control group being placebo, or alternative non-mTOR inhibitor treatment such as calcineurin inhibitors or as per standard treatment protocol.From the six included studies, we found no significant difference in the odds of either primary or secondary NMSC (OR 0.73, 95% CI 0.41-1.29, P = 0.28). Pooled analysis of patients with secondary NMSC demonstrated a trend toward significant benefit with mTOR inhibitor treatment (OR 0.61, 95% CI 0.37-1.02, P = 0.06) but no protective effect for primary NMSC (OR 0.53, 95% CI 0.03-9.96, P = 0.67).Our results suggest that in nonrenal transplant recipients, mTOR inhibitors may have a protective effect against secondary NMSC but not primary NMSC posttransplantation. Extrapolating the findings of reduced NMSC in renal transplant populations to nonrenal transplant cases should be cautioned.

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Eczema apps conformance with clinical guidelines: A systematic assessment of functions, tools and content.

Eczema is a prevalent complex skin condition requiring active disease monitoring and personalized education. No studies have assessed the quality of apps aiming to support eczema self-management.To evaluate quality and comprehensiveness of English, Chinese and Spanish self-management eczema smartphone apps for patients and/or their caregivers.A systematic assessment of eczema apps from July to November 2018. The assessment criteria were based on conformance with international eczema guidelines. Following domains were assessed: consistency and comprehensiveness of eczema specific educational information; quality and comprehensiveness of eczema specific tracking functions; compliance with health information best practice principles.98 apps were assessed. 82 (84%) provided educational information, 38 (39%) tracking functions, and 13 (13%) both. 34% (28/82) of apps provided misleading information, particularly in aspects of treatment and disease progression of eczema. Only 15% (12/82) provided international guidelines supported information on pharmacological therapies and 16% (13/82) on non-pharmacological therapies. Among 38 apps with a tracking function, 82% (31/38) measured specific symptoms, disease severity or current skin condition and 89% (34/38) helped users to record medication usage including application of topicals. 34% (13/38) recorded environmental or dietary allergens. None of the included apps complied with all criteria for educational information, tracking functions or health information principles.The eczema apps have not yet reached their potential. The large variance in quality of eczema apps highlights the need for quality assurance mechanisms for health apps and guidance for clinicians which would enable them to make personalized recommendations to patients and caregivers. This article is protected by copyright. All rights reserved.

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Measuring Psoriatic Arthritis Symptoms, A Core Domain in Psoriasis Clinical Trials.

The International Dermatology Outcome Measures (IDEOM) established a set of core domains to be measured in all psoriasis trials. This set indicates that symptoms of psoriatic arthritis (PsA) should be measured in all psoriasis studies.To identify the approach to PsA screening, and the most appropriate outcome measure for capturing PsA symptoms.Following the COSMIN-COMET and OMERACT guidelines, we conducted a consensus-building study including patients, physicians, industry partners and patient association representatives. The process consisted of: (1) literature review and quality appraisal of measures for PsA symptoms, (2) pre-Delphi exercise, (3) Delphi survey, and (4) consensus meeting.Among the 297 expert participants in the Delphi survey, 87.5% agreed that all patients in a psoriasis trial should be screened for PsA with a validated screening tool. Regarding the measurement of PsA symptoms, the preferred instrument was the Psoriatic Arthritis Impact of Disease-9 (PsAID9), with the Routine Assessment Patient Index Data-3 (RAPID3) representing an acceptable alternative.Only IDEOM members participated in the consensus meeting.The overwhelming majority of expert stakeholders agreed that all psoriasis trial subjects should be screened for PsA with subsequent measurement of PsA symptoms with use of the PsAID9 (with the RAPID3 as an acceptable alternative measure).

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Association Between Alopecia Areata, Anxiety, and Depression: A Systematic Review and Meta-analysis.

To date, there is no comprehensive meta-analysis analyzing the association between alopecia areata, anxiety, and depression.We sought to analyze the existing literature to examine the association between alopecia areata, anxiety, and depression.We extracted literature from four databases including Medline, Embase, PsychINFO, and Web of Science. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines in order to finalize a list of relevant articles to be included in our systematic review and meta-analysis. There were no restrictions placed on publication year or age of participants.A total of 8 studies that included 6,010 patients with AA and 20,961 control patients were included in the quantitative analysis. These included 4 cross-sectional studies and 4 case-control studies. Analysis of these studies demonstrated a positive association with anxiety (pooled OR, 2.50; 95% CI, 1.54-4.06) and depression (pooled OR, 2.71; 95% CI, 1.52-4.82).Publication bias may be a limitation of the study.This study suggests that patients with AA are at higher risk of both anxiety and depression. Healthcare professionals must be cognizant of this higher risk and consider routine assessment of these conditions and referral to appropriate providers when indicated.

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Hidradenitis suppurativa and metabolic syndrome – systematic review and adjusted meta-analysis.

Hidradenitis suppurativa (HS) is a debilitating and distressing chronic systemic inflammatory skin disease. There have been several prior observational studies which reported a possibility link between HS and metabolic syndrome, however the current evidence is not definitive. It is unclear in HS whether this possible relationship is independent or driven by underlying risk factors and comorbidities.To determine whether HS is independently associated with metabolic syndrome via adjusted meta-analysis of case-control studies.A systematic review and meta-analysis was performed according to PRISMA guidelines. Electronic searches were performed using six electronic databases (Ovid Medline, PubMed, CCTR, CDSR, ACP Journal Club, and DARE) from their inception until September 2018. Data were extracted and analyzed according to predefined clinical endpoints.We identified six case-control studies included for meta-analysis. Based on unadjusted analysis, we found a significant association between adult cases of HS and metabolic syndrome (OR 1.95, 95% CI 1.31-2.89, P = 0.001). Adjusted meta-analysis, after adjustment for age, sex, other cardiovascular risk factors, and comorbidities, found a significant association (OR 2.19, 95% CI 1.70-2.81, I2  = 32%, P < 0.00001).Studies reviewed were observational by design which are susceptible to bias, and there was lack of randomization. The quality of the current systematic review is also limited by the quality of available evidence which was predominantly observational in nature.This pooled analysis of existing case-control studies supports an association between HS and metabolic syndrome. Clinicians treating patients with HS should be aware of this potential association.

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Management of Pediatric Plaque Psoriasis using Biologics.

Psoriasis is a chronic inflammatory disease with clinical manifestations of the skin that affect both adults and children. In adults, biologics have revolutionized the treatment of moderate to severe plaque psoriasis where clear or almost clear is a tangible goal. Recently, research on biologics has been extended to children. The introduction of these new therapeutic options has outpaced the limited guidelines in this population.To provide a review of current data on biologics, with a proposal for a clinically relevant treatment algorithm on the management of moderate to severe plaque psoriasis in the pediatric population.A Canadian panel with expertise in psoriasis, pediatric dermatology and/or experience with consensus recommendation processes was selected to review the current landscape of pediatric psoriasis and clinical data on biologics plus identify special considerations for baseline work-up and monitoring. Recommendations were reviewed and edited by each expert in an iterative process.A treatment algorithm for moderate to severe plaque psoriasis in pediatric patients is presented, incorporating approved biologics. Guidance on baseline screening and ongoing monitoring is also provided. Ultimately, treatment choice depends on the patient and his/her caregiver, with consideration of comorbidities, impact on quality of life, and relevant safety aspects.

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