Influence of Clinical and Psychosocial Factors on the Adherence to Topical Treatment in Psoriasis.

(1) Background: Psoriasis is a common chronic inflammatory skin disease with different manifestations, affecting the quality of life at social, emotional, and professional dimensions and requiring long-term treatment. This study aimed to investigate the effect of psychosocial and clinical factors on adherence to topical treatment in psoriasis. (2) Methods: Self-reported measures and weighing the medicines were used to assess adherence. Psychopathological symptoms were measured using the Brief Symptoms Inventory (BSI). Social and clinical factors were assessed by a sociodemographic and clinical questionnaire. Adherence to treatment with topical medication was assessed using a sample of 102 psoriasis patients. (3) Results: The explanatory models of adherence to topical treatment in psoriasis translated into positive associations between adherence and the education level (higher education) (p = 0.03; φ = 0.23), the single-family household (p = 0.01; φ = 0.44), active employment status (p = 0.05; φ = -0.19), familiar history of psoriasis (p = 0.04; φ = -0.21), and the presence of obsessive-compulsive symptoms (p = 0.01; d = 0.29). (4) Conclusions: In patients who present the characteristics identified that influence non-adherence, instructions should be reinforced to increase adherence. The experimental mortality (39.6%) reduced the sample size, representing a limitation of the study.

Clinical course and disease burden of patients with generalized pustular psoriasis in Portugal: a multicenter retrospective cohort study.

OBJECTIVES: Generalized pustular psoriasis (GPP) is a rare, life-threatening skin inflammatory disorder. This study aimed to describe the disease course, treatment strategies, and healthcare utilization among patients with GPP in Portugal. METHODS: This multicentric, observational, retrospective study included consecutive adult patients with GPP undergoing a dermatology evaluation in different reporting institutions by experienced dermatologists between 2002 and 2023. RESULTS: A total of 59 patients were assessed. Most of the cohort had a previous history of plaque psoriasis (71%) and 83% presented at least one comorbidity. At the initial encounter, 64% of the cohort needed hospitalization. Systemic involvement was common, including fever (37%), and elevated white blood cell count and erythrocyte sedimentation rate/C-reactive protein (49%). Nearly, 73% of patients initiated systemic drugs, and 70% had to discontinue the first treatment. During the study, 98% of patients experienced at least one flare. At the last visit, 3.4% of patients had died, and 71.2% exhibited signs of active disease despite undergoing treatment. CONCLUSIONS: Our study demonstrates that GPP is a chronic, debilitating condition associated with systemic involvement, frequent flares, and hospitalizations, despite receiving multiple systemic treatments. Improved disease awareness and new treatments are needed to improve patient care and decrease the burden of the disease.

Tildrakizumab for the treatment of moderate-to-severe psoriasis: a 52-week, real-world Portuguese multicentric study.

Background: Real-world evidence plays a pivotal role in validating the efficacy of biologic drugs beyond the controlled environment of randomized trials. This study aimed to evaluate the effectiveness of tildrakizumab in treating moderate-to-severe psoriasis within a real-world setting over a 52-week period in Portugal. Methods: This multicentric, prospective, observational study included adult patients with moderate-to-severe psoriasis. All participants received tildrakizumab 100 mg at weeks 0 and 4, followed by a maintenance dose every 12 weeks, and were monitored for 52 weeks. Primary endpoints were determined based on Psoriasis Area and Severity Index (PASI) assessments at baseline, 16 (±2) weeks, 28 (±2) weeks and 52 (±2) weeks. Results: A total of 54 patients were enrolled in the study (56% men, mean age of 50.3 ± 14.4 years). Half of the sample (n=27) had no prior experience with biologic treatments. About 74% of patients (n=40) presented at least one comorbidity during the study, with psoriatic arthritis being the most prevalent (29.6%). By week 52, there was a significant decrease in the mean PASI from 17.8±10.3 at baseline to 1.3±1.9 (p<0.001), indicating an overall improvement of 93%. By week 52, more than 85% of patients attained PASI ≤5, more than 80% reached PASI ≤3, and nearly 60% achieved PASI ≤1. Infections were observed in 9.3% of patients, and one patient required hospitalization (1.9%). The cumulative proportion of patients continuing treatment at 52 weeks was 88.9%. Conclusions: This study demonstrates that tildrakizumab is an effective and safe agent for the treatment of moderate-to-severe psoriasis in a diverse, real-world setting.

Metastatic hidradenocarcinoma: a report of two rare cases.

BACKGROUND: Hidradenocarcinoma is a rare malignant sweat gland tumour, characterized by a slow but aggressive course, with high rates of local recurrence and metastasis. Due to its rarity, histological criteria and therapeutic guidelines are poorly defined, posing a major challenge for clinicians and pathologists. OBJECTIVES: To present two new cases of metastatic hidradenocarcinoma as well as a review of the literature. MATERIALS & METHODS: We describe two case studies and a review of the literature based on a search using the MEDLINE (PubMed) electronic database. RESULTS: The first patient was a 61-year-old woman with a perimamillary hidradenocarcinoma that arose from the malignant transformation of a benign childhood lesion and developed regional lymph node metastases after wide excision and adjuvant radiotherapy. The second patient was a 63-year-old man who developed cutaneous and renal metastases several years after the complete excision of a lumbar hidradenocarcinoma. As far as we can ascertain, kidney metastasis from hidradenocarcinoma has not previously been described. CONCLUSION: Most authors recommend wide excision as the treatment of choice for hidradenocarcinoma, however, optimal adjuvant therapy remains to be determined. Our cases add to the limited knowledge available, but high-quality studies to find new effective treatments are needed.

Oral isotretinoin in the treatment of juvenile acne and psychiatric adverse effects - a systematic review.

PURPOSE: Acne vulgaris is a very prevalent dermatological condition, especially among adolescents and young adults up to 25 years old, classifying it as juvenile acne. One of the most effective treatments for severe acne is isotretinoin, a derivative of retinoic acid. Despite its high efficacy, this drug has been linked to several side effects including psychiatric adverse alterations, such as anxiety, depression and even suicide. With this systematic review we aim to determine if it is possible to establish a causal relation between oral isotretinoin in the treatment of juvenile acne and the appearance of psychiatric adverse effects. MATERIALS AND METHODS: We searched two distinct databases, PubMed and Web of Science, and considered the work published between January 2000 and November 2021. RESULTS: Out of the 599 identified articles, we included 19 studies in this systematic review. Globally, the results we found do not support an association between the use of isotretinoin for acne treatment and mental side effects and the safety of this drug appears to be assured. However, the individual characteristics of each adolescent and their environment should be considered; the personal and family history of mental disorders are pointed out as red flags we should look out for when treating these patients. CONCLUSION: Despite this being a highly debated topic, especially among the dermatology community, more studies with larger populations and randomised controlled trials are necessary to increase the strength of the evidence presented.

Efficacy of topical vitamin C in melasma and photoaging: A systematic review.

BACKGROUND: Vitamin C is a micronutrient present in high concentrations in normal skin and a highly prescribed cosmeceutical, well known for protecting against ultraviolet-induced pigmentation and regulating collagen production. However, there is a lack of studies evaluating the efficacy of topical vitamin C in photoaging and melasma, with this systematic review being the first to assess the existing evidence. AIM: This systematic review aims to assess whether topical vitamin C could be effective in reversing photoaging signs and treating melasma. METHODS: Prospective, randomized controlled trials assessing protocols with topically applied vitamin C in patients with melasma or photodamage were searched in Medline, CENTRAL, and Scopus databases until the 12th of May 2022. Risk of bias was conducted in accordance with Cochrane Collaboration's tool for assessing the risk of bias in randomized trials, using RevMan 5.0. RESULTS: Seven publications were included, with 139 volunteers in total. Studies that evaluated the topography of skin indicated that the treated skin appeared smoother and less wrinkled, which was supported by biopsies data. On objective assessments of pigmentation, there was a significant lightening of the skin treated. Hydration improved equally in the vitamin C and placebo-treated sites. CONCLUSIONS: This study revealed that vitamin C is effective in treating uneven, wrinkled skin and has depigmenting properties, but long-term use may be needed to achieve noticeable changes. Q-switched Nd:YAG laser-associated protocols appear beneficial in enhancing vitamin C effects. Topical vitamin C may be a suitable alternative for melasma and photoaging, but more studies are needed to confirm these results and assess the ideal vitamin C concentration.

Aseptic Pustulosis of the Folds Successfully Treated with Methotrexate.

An otherwise healthy 47-year-old woman presented with confluent pustular lesions on the scalp for 5 months and asymptomatic pustular lesions on the trunk and extremities for 2 weeks. She did not have systemic clinical manifestations and was treated with oral antifungals and antibiotics (amoxicillin, and clavulanic acid and flucloxacillin), with no effect. The lesions were unrelated to her menstrual cycle, and she had no history of dermatosis, including acne, psoriasis, or folliculitis. (SKINmed. 2022;20:466-468).

Systematic review - alopecia areata and tofacitinib in paediatric patients.

INTRODUCTION: Alopecia Areata is a nonscarring hair loss disorder and is the most common hair loss cause in children. It is a chronic autoimmune disorder with a severe psychological impact in patients' lives. JAK inhibitors, in particular Tofacitinib, have been having promising results on Alopecia Areata Treatment. In this study we aimed to do a Systematic Review on the role of Tofacitinib (either orally or topically), considering efficacy and safety, in treating children with Alopecia Areata. MATERIALS AND METHODS: PubMed, Cochrane and Web of Science databases were searched (up to 1st of September of 2021) looking for Tofacitinib (all text/all fields) and MeSH/Keyword term Alopecia Areata. RESULTS AND CONCLUSIONS: We included 14 studies and 64 cases in the Systematic Review. From these, 12 were considering systemic administration (47 patients) and two were considering topical administration (17 patients). Responsiveness was as high as 81.3%. The responsiveness was similar among different genders (78.6% in males and 80.0% in females) and either whether administration was topic (70.6% responsiveness) or systemic (85.1% responsiveness). Adverse effects were rare and, when present, were mild. Studies shows promising results in what considers the efficacy and safety of Tofacitinib in the treatment of Alopecia Areata. As the available evidence to date is of low quality, further randomised studies are required to confirm these findings.

Influence of psoriasis lesions' location and severity on psychosocial disability and psychopathology. Observational study and psychometric validation of the SAPASI Portuguese version.

OBJECTIVES: The psychosocial impact of psoriasis is well documented. However, the contributing role of clinical disease characteristics is not satisfactorily explored. This study aimed to validate the Self-administered Psoriasis Area and Severity Index (SAPASI) to a Portuguese population (SAPASI-PT) and to perform its cross-validation, assessing how the results will generalize to an independent data set, with the Psoriasis Area and Severity Index (PASI), in order to assess the influence of psoriasis' severity on psychosocial disability and psychopathology. METHODS: A cross-sectional study with 228 patients with psoriasis was carried out. Data was collected through a sociodemographic and clinical questionnaire, SAPASI-PT, the Psoriasis Disability Index (PDI) and the Brief Symptoms Inventory (BSI). The cultural and linguistic adaptation of SAPASI to a Portuguese version and the cross validation with PASI was carried out. Multiple associations between psychosocial disability, psychopathology and severity, discomfort and location of lesions were investigated through logistic regression models. RESULTS: A good adjustment model for SAPASI-PT is found. Also, associations between psychosocial disability, psychopathology and the psoriasis severity and discomfort are found. The existence of lesions is positively associated with the severity of the disease. Patients with lesions in hands or genitals are those reporting a greater discomfort. The presence of lesions in hands is positively associated with PDI, i.e., with leisure and with treatment, marginally. Additionally, patients scoring higher in the personal dimension are found to have a significantly greater percentage of lesions in the genitals. CONCLUSIONS: The psoriasis severity and location of lesions are important determinants of patients´ quality of life. Lesions on face, hands and genitals are associated with a higher impact on psychosocial wellbeing of patients. Psychological counselling should be considered within psoriasis treatment context in patients with the described disease manifestations.

A multidisciplinary approach in psoriatic disease: the different models of dermatology-rheumatology collaborations in Portugal.

Psoriatic disease (Psoriasis and Psoriatic Arthritis, PsD) is a condition that affects the skin, the musculoskeletal system, and beyond, impairing patients' quality of life. A multidisciplinary approach of combined dermatology-rheumatology clinics is recommended and valuable to respond to PsD diagnosis, management, and treatment challenges. In Portugal, five Hospitals have implemented a multidisciplinary clinic for PsD assessment. This report aims to describe how these multidisciplinary clinics were developed, their characteristics, and the main obstacles to their implementation. Although the different hospitals adopted distinct functional models, a consensus respecting the minimal core set assessment for PsD in Multidisciplinary Dermatology/Rheumatology Clinics should comprise all disease manifestations and, if possible, quality of life. The main objective of these clinics is to achieve remission/minimal disease activity. Limitations to these multidisciplinary approaches are discussed, namely financial, time management, and human resources obstacles that can be a handicap in their implementation, despite the benefits of PsD integrated care.

Does the Vehicle Matter? Real-World Evidence on Adherence to Topical Treatment in Psoriasis.

The influence of the vehicle in topical treatment adherence remains to be elucidated. The aim of this study is to analyze the influence of the pharmaceutical dosage form on adherence to topical treatment in psoriasis patients, taking into consideration the mechanical features. The adherence was evaluated in a sample of 102 psoriasis patients, followed for approximately 45 days. Adherence was calculated with a new combined methodology using a log and medication weights. The effect of the group formulation was evaluated using logistic regression models. A complex effect of the vehicle on adherence was found, mediated by the affected area. The adherence was significantly higher for patients applying gels and creams than for those using ointments, whenever the body area affected was extensive. The opposite was found when the affected area was small. Mechanical properties can partially explain the findings since gels and creams may be easier to apply. Patient beliefs and preferences regarding vehicles and their sensory attributes might also explain the results. It is noteworthy that adherence was strikingly low, with more than 75% non-adherent patients. This real-world evidence provides an insight for pharmaceutical industries and guidance for treatment prescription by physicians aiming to address the public health emergency of treatment non-adherence.

[Cutaneous Toxicity of Immune Checkpoint Inhibitors: A Narrative Review]. / Toxicidade Cutânea dos Inibidores de Checkpoint Imunológico: Uma Revisão Narrativa.

INTRODUCTION: Immune checkpoint inhibitors revolutionized anti-neoplastic treatment. Recently, the European Medicines Agency and the United States Food and Drug Administration approved inhibitors of various immune checkpoints, namely the cytotoxic T-lymphocyte-associated protein 4, programmed cell death protein 1 and its ligand. Despite the added benefits in the treatment of several neoplasms, immune checkpoint blockade may also be associated with multiple immune-related adverse events. MATERIAL AND METHODS: A literature review in PubMed database on the cutaneous toxicity of immune checkpoint inhibitors was performed until April 30, 2019. RESULTS AND DISCUSSION: A total of 380 articles were initially screened, of which 75 are the basis of this bibliographic review. The immune checkpoint inhibitors monoclonal antibodies produce their beneficial effects by activating the patient's immune system. This activation also results in adverse events that can affect any organ, whereas cutaneous toxicity is the most frequent and precocious. The adverse events of the programmed cell death protein 1 and its ligand and of the cytotoxic T-lymphocyte-associated protein 4 are similar (class effect), despite the apparent higher skin toxicity of inhibitors of the cytotoxic T-lymphocyte-associated protein 4 (or its use in combination with inhibitors of programmed cell death protein 1 and its ligand). The most common cutaneous toxicities are maculopapular exanthema and pruritus, but other more specific adverse effects (e.g. lichenoid or psoriasiform reaction, vitiligo, sarcoidosis, among others) or located in the oral mucosa and/or adnexa are underreported. CONCLUSION: Given the high rate of cutaneous toxicity associated with new immune checkpoint inhibitors and their impact on quality of life, their early recognition and appropriate approach are crucial in the treatment of cancer patients. Observation by a dermatologist should be provided in patients with certain toxicities.

Introdução: Os inibidores de checkpoint imunológico revolucionaram o tratamento anti-neoplásico. Nos últimos anos, a European Medicines Agency e a United States Food and Drug Administration aprovaram inibidores de vários checkpoint imunológicos, nomeadamente do antigénio 4 associado aos linfócitos T citotóxicos e da proteína 1 de morte celular programada ou o seu ligante. Apesar dos benefícios que acrescentam no tratamento de várias neoplasias, o bloqueio dos checkpoint imunológicos também se pode associar a múltiplos efeitos adversos imunorrelacionados. Material e Métodos: Foi efetuada uma pesquisa da literatura da base de dados PubMed sobre a toxicidade cutânea dos inibidores de checkpoint imunológico até 30 de abril de 2019. Resultados e Discussão: Foram triados 380 artigos em primeira análise, dos quais 75 constituem a base desta revisão bibliográfica. Os anticorpos monoclonais inibidores de checkpoint imunológico produzem os seus efeitos benéficos através da ativação do sistema imunológico. Desta ativação resultam também efeitos adversos que podem afetar qualquer órgão, sendo a toxicidade cutânea a mais frequente e precoce. Os efeitos adversos imunorrelacionados dos inibidores da proteína 1 de morte celular programada ou o seu ligante e inibidores do antigénio 4 associado aos linfócitos T citotóxicos são similares (efeito de classe), apesar da aparente maior toxicidade cutânea dos inibidores do antigénio 4 associado aos linfócitos T citotóxicos (ou do seu uso em combinação com os inibidores da proteína 1 de morte celular programada ou o seu ligante). Os efeitos adversos cutâneos mais comuns são o exantema maculopapular e o prurido, mas estão descritos outros mais característicos (reação liquenóide ou psoriasiforme, vitiligo e sarcoidose, entre outros) ou localizados às faneras e/ou mucosa oral, que estão aparentemente subestimados. Conclusão: Dada a elevada frequência da toxicidade cutânea associada aos novos inibidores de checkpoint imunológico e respetivo impacto na qualidade de vida, o seu reconhecimento precoce e a abordagem adequada são cruciais no tratamento do doente oncológico. A observação pelo dermatologista deve ser providenciada em doentes com determinadas toxicidades.

Asymptomatic reactivation of hepatitis B virus after prolonged treatment with etanercept.

Etanercept is an anti-tumor necrosis factor ɑ (anti-TNFɑ) drug used for treating immunomediated inflammatory diseases. It is least associated with hepatitis B virus (HBV) reactivation. We present a 71-year-old man with psoriasis refractory to phototherapy and acitretin, which led to etanercept monotherapy. Before anti-TNFɑ treatment, past contact with HBV was elicited; antibodies to HBc and HBs were positive whereas HBsAg was negative. Seven years after treatment initiation, while the patient was completely asymptomatic, a transaminase elevation was found and a reactivation of HBV was documented, with a high viral load of the virus. He started entecavir therapy and, after a 14-month follow-up, the viral load is still detectable at a low level, as well as HBsAg. We emphasize the late and asymptomatic reactivation of HBV associated with soluble anti-TNFɑ monotherapy. This case reinforces the importance of current recommendations for periodic monitoring of viral load and HBV markers in all patients that have had prior contact with HBV (positive anti-HBc), with or without indication for treatment of HBV (HBsAg and HBV-DNA negative).

Hidradenitis suppurativa in a prepubertal girl.

Hidradenitis suppurativa (HS) is a chronic and recurrent inflammatory disease characterized by the presence of painful and deep inflammatory lesions usually located in intertriginous areas. It rarely occurs in children, especially in prepubertal age. Treatment for HS in this age group is challenging considering the scant data available and the risk of adverse effects in younger patients. We report the case of a 10-year-old girl with Hurley III HS, refractory to multiple topical and systemic therapies. After introducing adalimumab, there was significant improvement of the skin lesions and therefore in the child's quality of life.

Awareness, knowledge, and practice patterns of general practitioner residents and specialists toward hidradenitis suppurativa: a survey study.

INTRODUCTION: Hidradenitis suppurativa (HS) is an unrecognized chronic inflammatory and debilitating disease with severe consequences for patients' quality of life. METHODS: A survey was performed among general practitioner (GP) residents and consultants in order to determine awareness, knowledge, and attitudes about HS. RESULTS: Among 372 respondents, 74% were GP residents in the first 2 years, 22% GP residents in the 3rd and 4th year, and 4% consultants. For a patient with boils and/or recurrent abscesses in folds, 90% considered a diagnosis of HS with no significant difference according to years of experience. These patients were referred to dermatology by 273 residents (80%) and eight consultants (53%), and this difference is statistically significant (p < 0.05). Regarding acute treatment, 84% prescribed topical antibiotics and 76% oral antibiotics. Respecting therapeutic approach, we observed that treatment with non-steroidal anti-inflammatory drugs is higher among older residents (51%) compared to younger ones (36%, p < 0.02) and the prescription of oral clindamycin is higher among consultants (31%) compared to residents (12%, p < 0.04). CONCLUSIONS: Our survey demonstrates that knowledge of HS is lacking among primary care physicians. Communication channels between GPs and dermatologists are often hampered, and so we recommend incorporating medical education into GP residency programs on how to treat mild HS, when to refer, and how to approach HS.

Clinical management of Anti-TNF-alpha-induced psoriasis or psoriasiform lesions in inflammatory bowel disease patients: a systematic review.

Tumor necrosis factor alpha inhibitors (anti-TNF-α) completely revolutionized the treatment of inflammatory bowel disease (IBD). However, anti-TNF-α-induced cutaneous side effects have been increasingly reported in the literature. Particularly, psoriasis and the recently recognized psoriasiform lesions are of particular concern, as anti-TNF-α agents are also used in the treatment of psoriasis, seemingly reflecting an immunological paradox. The clinical management of these cutaneous lesions is particularly challenging, owing to the potential need of anti-TNF-α discontinuation and scarcity of other therapeutic options. Therefore, optimization of current topical and systemic therapies and incorporation of new therapeutic agents is of great interest. Our aim is to review data in the literature regarding the clinical management of these cutaneous lesions and provide a therapeutic algorithm, supported by our experience as a tertiary referral center for IBD. Although in older reports no distinction was made, anti-TNF-α-induced psoriasiform lesions are not only more prevalent but also bear notable differences from classical psoriasis, possibly reflecting a different nosological entity. Onset of lesions has been related to periods of IBD remission, as supported by low levels of fecal calprotectin. Psoriasiform lesions can be adequately managed either by topical (glucocorticoids, calcineurin inhibitors, and antibiotics) or systemic (phototherapy, acitretin, glucocorticoids, and antibiotics) therapies and/or switch to other anti-TNF-α agents. Data referring to patients who were able to continue on the same IBD therapy ranged from 30.7 to 100%, reinforcing the importance of an adequate control of these lesions. The recently approved ustekinumab offers another step in the management of anti-TNF-α-intolerant patients.

Psoriasis and comorbidities: general practitioners' awareness.

INTRODUCTION: Systemic inflammatory diseases such as psoriasis, systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA) are associated with an increased prevalence of cardiovascular diseases (CVD) and other comorbidities. The primary aim of this study was to assess the screening practices of general practitioners (GPs) with regard to the most frequent comorbidities in patients with psoriasis. METHODS: We adapted, with permission, a questionnaire that was used by Parsi et al. in 2012, which was then distributed to GP residents and consultants. RESULTS: Overall, 372 questionnaires were collected. Significantly more physicians screen for CV risk factors in patients with RA and SLE than in patients with psoriasis. There was no statistically significant difference between GP residents in the initial and final phase of residency, or between GP residents and consultants regarding awareness of increased prevalence of CVD in psoriasis or comorbidity screening practices in psoriasis patients. CONCLUSIONS: Most GP residents and consultants that participated in this study are not aware of an increased CV risk in patients with psoriasis and assign greater importance regarding this risk to other inflammatory diseases such as RA and SLE.