Consensus guidelines for the management of plaque psoriasis.

The Canadian Guidelines for the Management of Plaque Psoriasis were reviewed by the entire National Psoriasis Foundation Medical Board and updated to include newly approved agents such as ustekinumab and to reflect practice patterns in the United States, where the excimer laser is approved for psoriasis treatment. Management of psoriasis in special populations is discussed. In the updated guidelines, we include sections on children, pregnant patients or pregnant partners of patients, nursing mothers, the elderly, patients with hepatitis B or C virus infections, human immunodeficiency virus-infected patients, and patients with malignant neoplasms, as well as sections on tumor necrosis factor blockers, elective surgery, and vaccinations.

From the Medical Board of the National Psoriasis Foundation: monitoring and vaccinations in patients treated with biologics for psoriasis.

BACKGROUND: Biologics are widely used in the treatment of psoriasis and psoriatic arthritis. OBJECTIVE: Our aim was to arrive at a consensus on the kind of monitoring and the vaccinations that should be performed before and during biologic therapy. METHODS: Medical literature and data presented at meetings were reviewed and a consensus conference was held by members of the Medical Board of the National Psoriasis Foundation. RESULTS: Consensus was established on monitoring and vaccination practices that included discussion and recognition of variations in those practices. History, physical examination, chemistry screen with liver function tests, complete blood cell count, and platelet count and tuberculosis testing are widely obtained at baseline and with variable frequencies thereafter. Patients treated with efalizumab have platelet counts checked more often; liver function tests are repeated more frequently in patients treated with infliximab; patients taking tumor necrosis factor blockers undergo tuberculosis testing more often; and patients treated with alefacept have CD4 counts checked approximately every 2 weeks. Avoidance of live vaccines during biologic therapy and administration of essential vaccines before biologic therapy were discussed, although vaccination is performed only to a variable degree. There was no consistency in the measurement of antinuclear antibodies among the experts. LIMITATIONS: There are few evidence-based studies on monitoring practices for patients with psoriasis taking biologic therapies. CONCLUSIONS: In patients taking biologic therapies for psoriasis, monitoring of blood chemistries, blood counts, CD4 counts, antinuclear antibodies, tuberculin skin tests, history, and physical examination may be warranted depending on the particular therapy and the particular patient. Vaccination practices are also addressed.

Effective treatment of scalp psoriasis using the excimer (308 nm) laser.

BACKGROUND: Psoriasis of the scalp can be a major therapeutic challenge as response to topical medication is often inadequate. The excimer laser has potential for providing local phototherapy as its high irradiance makes treatment at this site a practical option. OBJECTIVES: To analyze retrospectively results of treating scalp psoriasis with the excimer (308 nm) laser. METHODS: Thirty-five patients were treated and all had failed intensive topical therapy. Manual separation of hair was used to provide access to the treatment site. Starting doses ranged from 300 mJ/cm(2) (type I) to 1000 mJ/cm(2) (type IV) with treatment twice weekly. RESULTS: All patients improved. Seventeen/35 (49%) of patients cleared>95% (mean: 21 treatments; range: 6-52) and 16/35 (45%) cleared 50-95%. Phototoxicity in the form of erythema and blistering occurred in all patients, particularly around the ears and nape of neck. CONCLUSION: The excimer laser is a successful approach to treatment of psoriasis of the scalp being a simple treatment that can be performed in a short period of time and which has a high rate of effectiveness.

Photoaging: mechanisms and repair.

UNLABELLED: Aging is a complex, multifactorial process resulting in several functional and esthetic changes in the skin. These changes result from intrinsic as well as extrinsic processes, such as ultraviolet radiation. Recent advances in skin biology have increased our understanding of skin homeostasis and the aging process, as well as the mechanisms by which ultraviolet radiation contributes to photoaging and cutaneous disease. These advances in skin biology have led to the development of a diversity of treatments aimed at preventing aging and rejuvenating the skin. The focus of this review is the mechanism of photoaging and the pathophysiology underlying the treatments specifically designed for its prevention and treatment. LEARNING OBJECTIVES: At the conclusion of this learning activity, participants should be familiar with the mechanism of photoaging, the treatments for photoaging, and the data that supports the use of these treatments.

The effect of clinical UVA/B exposures on urinary urocanic acid isomer levels in individuals with caucasian type (II/III) skin types.

Terrestrial ultraviolet radiation (UVR) exposure, consisting of ultraviolet A (320-40 nm) and B (290-320 nm), results in the photoisomerizion of epidermal trans-urocanic acid (trans-UCA) to cis-urocanic acid (cis-UCA), a potential suppressor of local and systemic immune responses. This study examines urinary UCA isomers as biomarkers of UVA/B exposure. It presents results measuring both cis- and trans-UCA in human urine samples collected from a group of study subjects (skin types II/III) that underwent controlled UVA/B exposures similar to those administered in commercial suntanning parlors. The UCA isomers were purified from urine using C18 solid-phase extraction columns followed by high-performance liquid chromatography (HPLC) with UV absorbance (268 nm) detection. The UCA biomarker was expressed as the ratio of cis-UCA to trans-UCA (UCA ratio), or as cis-UCA concentration corrected for urine volume using creatinine (cis-UCA-Cr). The UCA ratio increased over baseline in the urine of individuals exposed to UVA/B. A single exposure to approximately 70 percent minimal erythema dose (MED) of UVR (95 % UVA/5 % UVB to approximately 90 % of skin area) produced a 4.75-fold increase in the UCA ratio (p< 0.001) relative to baseline. Repeated daily UV exposures of similar doses produced a minimal increase in UCA ratio above that of the single UV exposure. These findings indicate that UCA cis-trans ratio holds promise as a biomarker for recent solar UV exposure.

Chronic stress accelerates ultraviolet-induced cutaneous carcinogenesis.

BACKGROUND: Physical and emotional stressors have been found to mediate a wide variety of biological changes including the facilitation of tumor progression; however most of these paradigms utilized artificial sources of neoplasms and stress. METHODS: Skh mice were exposed to carcinogenic doses of ultraviolet light (UV). The stressed group was subjected to the close proximity of fox urine as a source of stress from the presence of the odor of their natural predator, while the control group remained stress free. RESULTS: A significant acceleration in the development of cutaneous neoplasms was observed in mice that had been exposed to the stressor. The first tumor appeared in the group after 8 weeks, whereas nonstressed mice began to develop these by week 21. CONCLUSION: These results suggest that stress plays a role in potentiating cutaneous carcinogenesis.

Clinical and epidemiologic characterization of photosensitivity in HIV-positive individuals.

BACKGROUND: An increased prevalence and severity of cutaneous photosensitivity has been recognized in association with human immunodeficiency virus (HIV) infection. However, this disorder remains poorly characterized in terms of its epidemiology, predisposing factors, clinical, and environmental associations. METHODS: To define the risk factors associated with the presence of photosensitivity among HIV-positive individuals, a cross-sectional study of 631 primary patient visits to an urban HIV Dermatology clinic between January 1997 and August 2001, inclusive, was conducted. A multivariate model was fit to estimate adjusted odds ratios for risk factors associated with photosensitivity diagnosis. Subsequently, a case-series of the patients with photosensitivity was reported. RESULTS: The overall prevalence of photosensitivity was 5.4%, while African-Americans (AA) exhibited a prevalence of 7.3%. In the multivariate model, using highly active anti-retroviral therapy (HAART) (OR=2.82, 95% CI: 1.13, 7.03) and being AA (OR=6.68, 95% CI: 1.56, 28.65) significantly increased the odds of photosensitivity. Patients with photosensitivity were more likely to present during periods of higher ultraviolet (UV) index (P=0.08). Two distinct clinical morphologies were noted: lichenoid and non-lichenoid, eczematous. Sub-morphologies in the non-lichenoid group were suggestive of differences in immunologic profile and estimated UV exposure. CONCLUSION: Photosensitivity associated with HIV infection is an increasingly recognized dermatologic condition with a heterogeneous clinical presentation. AA ethnicity and HAART were independent indicators for the diagnosis of photosensitivity, whereas CD4+ and UV exposure had non-significant associations. The subtleties in these and other clinical variables may directly aid in the recognition and diagnosis of this poorly characterized disorder.

Photoprotection by clothing.

Wearing of clothing, hats, and sunglasses to protect from exposure to sunlight should be part of a package of protection. Clothing specifically designed to avoid exposure is now available and recently standards have been published in several countries to measure the degree of protection. The ultraviolet protection factor (UPF) is likely to be as ubiquitous in clothing aisles as the sun protection factor (SPF) is now in the sunscreen aisle of your local department store.

Standardized protocols for photocarcinogenesis safety testing.

Solar ultraviolet radiation (UVR) is recognized as a major cause of non-melanoma skin cancer in man. Skin cancer occurs most frequently in the most heavily exposed areas and correlates with degree of outdoor exposure. The incidence of skin cancer is also increased by contact with photosensitizing drugs and chemicals such as psoralens, coal tars and petroleum stocks. Other substances which do not act as photosensitizers, such as immunosuppressants taken by organ transplant recipients, also increase the risk of skin cancer. The U.S. Food and Drug Administration requests, on a case-by-case basis, that risk of enhanced photocarcinogenesis is assessed for many classes of drugs. Health Canada's Therapeutic Products Programme has issued a Notice of Intent to regulate pharmaceutical products which may enhance carcinogenicity of the skin induced by ultraviolet radiation. Other national regulatory agencies review such data when they exist, but their own requirements emphasize batteries of short-term in vitro and in vivo tests. While they may support drug development strategies, short-term tests have yet to be validated as predictors of the ability of drugs or chemicals to enhance photocarcinogenesis. Published protocols now describe study designs and procedures capable of determining whether test agents enhance the rate of formation of UVR-induced skin tumors.

Efficacy of the 308-nm excimer laser for treatment of psoriasis: results of a multicenter study.

OBJECTIVE: Our purpose was to demonstrate the efficacy of the 308-nm excimer laser for treatment of psoriasis. METHODS: This study was a multicenter open trial from 5 dermatology practices (one university-based and 4 private practices). Up to 30 patients per center with stable mild to moderate plaque-type psoriasis constituted the study population. Patients received 308-nm ultraviolet B doses to affected areas. The initial dose was based on multiples of a predetermined minimal erythema dose. Subsequent doses were based on the response to treatment. Treatments were scheduled twice weekly for a total of 10 treatments. The main outcome measure was 75% clearing of the target plaque. Time to clearing was analyzed by Kaplan-Meier methods, accounting for truncated observations. RESULTS: One hundred twenty-four patients were enrolled in the study, and 80 completed the entire protocol. The most common reason for exiting from the study was noncompliance. Of the patients who met the protocol requirements of 10 treatments or clearing, 72% (66/92) achieved at least 75% clearing in an average of 6.2 treatments. Eighty-four percent of patients (95% confidence interval [CI], 79%-87%) reached improvement of 75% or better after 10 or fewer treatments. Fifty percent of patients (95% CI, 35%-61%) reached improvement of 90% or better after 10 or fewer treatments. Common side effects included erythema, blisters, hyperpigmentation, and erosions, but they were well tolerated. CONCLUSIONS: Monochromatic 308-nm excimer laser treatment appears to be effective and safe for psoriasis. It requires fewer patient visits than conventional phototherapy, and, unlike those treatments, the laser targets only the affected areas of the skin, sparing the surrounding uninvolved skin.