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Epidemiological data demonstrate strong associations between psoriasis and metabolic comorbidities, including obesity, hypertension, diabetes mellitus, dyslipidemia, and non-alcoholic fatty liver disease. The presence of metabolic comorbidities significantly influences the selection and effectiveness of pharmacological treatments. Some drugs should be prescribed with caution in patients with metabolic comorbidities because of an increased risk of adverse events, while others could have a reduced effectiveness. The aim of this narrative review is to highlight the challenges that healthcare professionals may face regarding the management of psoriasis in patients with metabolic comorbidities. In the first part of the article, the epidemiological association between psoriasis and metabolic comorbidities and their pathogenetic mechanisms is summarized. The second part describes the efficacy and safety profile of conventional and biologic drugs in patients with selected metabolic comorbidities including obesity, non-alcoholic fatty liver disease/hepatic steatosis, and diabetes. Finally, the role of pharmacological and non-pharmacological interventions, such as diet, alcohol abstinence, physical activity, and smoking avoidance is discussed. In conclusion, the choice of the best approach to manage patients with psoriasis with metabolic comorbidities should encompass both tailored pharmacological and individualized non-pharmacological interventions.
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Enfermedad del Hígado Graso no Alcohólico , Psoriasis , Humanos , Psoriasis/complicaciones , Psoriasis/tratamiento farmacológico , Psoriasis/terapia , Psoriasis/epidemiología , Enfermedad del Hígado Graso no Alcohólico/terapia , Enfermedad del Hígado Graso no Alcohólico/epidemiología , Enfermedad del Hígado Graso no Alcohólico/complicaciones , Enfermedad del Hígado Graso no Alcohólico/tratamiento farmacológico , Comorbilidad , Obesidad/complicaciones , Obesidad/epidemiología , Diabetes Mellitus/epidemiología , Diabetes Mellitus/tratamiento farmacológico , Diabetes Mellitus/terapia , Fármacos Dermatológicos/uso terapéutico , Productos Biológicos/uso terapéutico , Enfermedades Metabólicas/terapia , Enfermedades Metabólicas/epidemiología , Dislipidemias/epidemiología , Dislipidemias/tratamiento farmacológico , Dislipidemias/terapiaAsunto(s)
Biosimilares Farmacéuticos , Biosimilares Farmacéuticos/economía , Biosimilares Farmacéuticos/uso terapéutico , Europa (Continente) , Humanos , Factor de Necrosis Tumoral alfa/antagonistas & inhibidores , Infliximab/economía , Infliximab/uso terapéutico , Costos de los Medicamentos , Adalimumab/uso terapéutico , Adalimumab/economíaRESUMEN
INTRODUCTION: Psoriasis is a systemic immune-mediated disease primarily manifesting as skin redness and inflammation. Balneotherapy proved to be a successful non-pharmacological option to reduce the skin areas affected by the disease, but the specific mechanisms underlying this effect have not been elucidated yet. Here we test the hypothesis that the effect of thermal treatments on psoriatic lesions could be partially mediated by changes in the resident microbial population, i.e., the microbiome. METHODS: In this study, we enrolled patients with psoriasis and monitored changes in their skin and gut microbiome after a 12-bath balneotherapy course with a combination of 16S rRNA amplicon sequencing and metagenomics. Changes in the resident microbiome were then correlated with thermal therapy outcomes evaluated as changes in Psoriasis Area and Severity Index (PASI) and Body Surface Area index (BSA). RESULTS: The amplicon sequencing analysis of the skin microbiome showed that after thermal treatment the microbiome composition of affected areas improved to approach that typical of unaffected skin. We moreover identified some low-abundance bacterial biomarkers indicative of disease status and treatment efficacy, and we showed via metagenomic sequencing that thermal treatments and thermal water drinking affect the fecal microbiome to host more species associated with favorable metabolic health. CONCLUSIONS: Changes in lower-abundance microbial taxa presence and abundance could be the basis for the positive effect of thermal water treatment and drinking on the cutaneous and systemic symptomatology of psoriasis.
Psoriasis is an immune-mediated disease primarily manifesting as skin redness and inflammation that affects 23% of the world's population. No cure is currently available for this condition, and patients are offered pharmacological and non-pharmacological options to alleviate the discomfort. Previous studies and clinical practice have shown that thermal water treatment can be a non-pharmacological option to reduce the areas affected by the disease. However, the specific mechanisms causing this reduction have not been clarified yet. Given that neither the chemical nor the physical composition of thermal water can explain this beneficial effect, recent studies have suggested that it might be due to the effect of thermal water on the microbial communities living on the skin (i.e., the skin microbiome). In this work carried out at Terme di Comano, Northern Italy, we describe the effect of thermal water treatment on the skin microbiome of patients with psoriasis and we highlight the potentially beneficial effect of thermal water drinking on the microbial communities living in the gut, namely the gut microbiome. Specifically, we show that after balneotherapy the areas affected by psoriasis have a higher diversity of microbes usually present on healthy skin, potentially explaining the reduction in disease severity after treatment, and we describe how the gut microbiome of patients who drank thermal water changes to host more species linked with favorable metabolic health. These findings highlight that thermal water treatment and drinking could reduce both the skin and systemic symptomatology of psoriasis by affecting the skin and gut microbiome.
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A 71-year-old woman presented with a persistent, intensely pruritic cutaneous eruption localized on the palmoplantar regions, lips and palate. The histological findings allowed to make the diagnosis of recurrent cutaneous eosinophilic vasculitis, a very rare cutaneous vasculitis characterized clinically by multiple erythematous or purpuric erythematous papules or plaques or angioedema with a relapsing course in the absence of systemic involvement and histologically by a necrotizing vasculitis of the dermal small vessels with a dominant eosinophilic infiltration. The patient was treated with oral methylprednisolone and pentoxifylline which led to a rapid resolution of the cutaneous lesions.
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Psoriatic arthritis (PsA) is a heterogeneous chronic inflammatory arthritis associated with psoriasis, which may manifest with different domains such as dactylitis, enthesitis, synovitis and spondylitis. The estimated prevalence of PsA in patients with psoriasis ranges widely between 6% and 42%. In most cases, PsA is preceded by skin involvement by an average time of 7-8 years. In the complex patho-mechanisms involved in the transition from psoriasis to PsA, the gut and skin have been proposed as the sites of immune activation triggering or contributing to the development of PsA. In such a transition, a subclinical phase has been identified, characterized by enthesopathy where soluble biomarkers and imaging findings but no clinical symptoms are detectable. Recent studies have provided some evidence that timely treated psoriasis may reduce the risk of developing PsA.
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INTRODUCTION: Given the increased infectious risk associated with biologics, particularly with TNFα inhibitors, concerns were raised over the safety of these agents in relation to SARS-CoV-2 infection. Furthermore, the impact of biologics on SARS-CoV-2 vaccination was questioned. AREAS COVERED: In this review, studies conducted on patients with moderate to severe plaque psoriasis treated with biologics during the COVID-19 pandemic have been analyzed, including 1) the safety of biologics in psoriatic patients in terms of increased risk and/or worse outcome of SARS-CoV-2 infection; and 2) whether biologic agents could affect the safety and response to SARS-CoV-2 vaccines in psoriatic patients. EXPERT OPINION: Current evidence indicates that the use of biologics in psoriatic patients does not seem to be associated with an increased COVID-19 infection risk or worse outcome, with TNFα inhibitors being even protective of severe COVID-19 relative to other treatments or no treatment at all. Furthermore, biologic treatment does not seem to have a significant impact on the response and safety of vaccines in patients with psoriasis treated with biologics. However, uncertainty remains given the limitations of current studies which are often of short duration, limited sample sizes and do not stratify on specific biologic classes.
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Productos Biológicos , Vacunas contra la COVID-19 , COVID-19 , Psoriasis , Humanos , Factores Biológicos , Productos Biológicos/efectos adversos , COVID-19/epidemiología , Vacunas contra la COVID-19/efectos adversos , Pandemias , Psoriasis/epidemiología , SARS-CoV-2 , Factor de Necrosis Tumoral alfaRESUMEN
BACKGROUND: The EXCEED study evaluated the efficacy and safety of secukinumab versus adalimumab in psoriatic arthritis, but it did not include a pharmacoeconomic analysis. The objective of this study was to compare the cost per responder of secukinumab versus adalimumab in patients with psoriatic disease. METHODS: The cost per responder was calculated by multiplying the cost of treatment by the number needed to treat for each therapy. The 52-week primary endpoint was the American College of Rheumatology response rate (ACR) 20; secondary endpoints were ACR 50, Psoriasis Area and Severity Index (PASI) 90, and minimal disease activity (MDA). RESULTS: The cost per responder for ACR 20 was 19,846 versus 19,766 for secukinumab and adalimumab, respectively, whereas the costs per responder for ACR 50 and PASI 90 were 27,820 versus 27,384 and 22,102 versus 32,375 for secukinumab and adalimumab, respectively. The cost per MDA responder was 34,072 and 38,906 for secukinumab versus adalimumab. CONCLUSIONS: The costs per responder associated with the psoriatic arthritis end points were similar for adalimumab and secukinumab; conversely, the costs for psoriasis and composite end points were lower for secukinumab.
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BACKGROUND: Pharmacoeconomic studies comparing the cost of adalimumab biosimilars versus the originator and conventional drugs in psoriasis are lacking. RESEARCH DESIGN AND METHODS: To assess the cost per responder of adalimumab biosimilars versus the originator and methotrexate for psoriasis treatment. A cost per responder analysis comparing adalimumab biosimilars MSB11022 (Idacio®) and ABP 501 (Amgevita®), and methotrexate to the originator (Humira®) was performed. The incremental cost per responder was calculated by multiplying the cost of treatment based on the perspective of the National Healthcare System and number needed to treat for each therapy. RESULTS: Considering the PASI75 response rate at 16 weeks, the cost per responder for MSB11022 and ABP 501 compared to the originator was 500 versus 1,831 and 968 versus 1,949, respectively. For the same endpoint, the cost per responder for subcutaneous or oral methotrexate was 543 or 34 compared to 2,117 for adalimumab originator. At an indirect comparison among methotrexate, MSB11022 and ABP 501, the costs per PASI75 responder at week 16 were 2%, 26%, 27% and 50% of that of the originator, respectively. CONCLUSIONS: The use of biosimilars was confirmed as a valuable pharmacoeconomic strategy to lower healthcare cost in patients with psoriasis.
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Biosimilares Farmacéuticos , Psoriasis , Humanos , Adalimumab/uso terapéutico , Biosimilares Farmacéuticos/uso terapéutico , Metotrexato/uso terapéutico , Resultado del Tratamiento , Psoriasis/tratamiento farmacológicoAsunto(s)
Chancro , Eccema , Impétigo , Sífilis Cutánea , Sífilis , Genitales , Humanos , Impétigo/complicaciones , Sífilis/complicacionesRESUMEN
BACKGROUND: Plaque psoriasis has been associated with anxiety, depression, suicidal ideation and various personality traits. However, studies on hypochondriasis, i.e. the belief of serious illness despite having no or only mild symptoms, are currently scarce. OBJECTIVE: The aim of this study was to assess hypochondriasis and personality traits in psoriasis patients using the Minnesota Multiphasic Personality Inventory-2 (MMPI-2). METHODS: We conducted an observational study on patients with plaque psoriasis who underwent MMPI-2 testing. Demographic and clinical data, including comorbidities, alcohol consumption, and smoking, were collected. RESULTS: A total of 136 consecutive psoriatic patients were included. The mean age (±SD) was 53.7 (±13.5), mean PASI (Psoriasis Area Severity Index) was 12.4 (±9.9), and mean disease duration was 23.3 (±15.7) years. Pathologically elevated scores in the Hypochondriasis scale were observed in 27.9% of patients. Furthermore, in a few other MMPI-2 scales (Anxiety, Fears and Negative Treatment Indicators) ≥25% of patients obtained pathologically elevated scores. Conversely, the scales that had the highest proportion of low scorers were Ego Strength and Dominance. At regression analysis, higher psoriasis severity and female gender were associated with higher scores in the Hypochondriasis scale (p = 0.03 and 0.001). Finally, 72.8% reported any alcohol consumption and 8.1% heavy alcohol consumption. CONCLUSION: About one third of patients with psoriasis have high scores in the MMPI-2 hypochondriasis evaluation scale. Poor individual coping resources also appeared to be distinctive psychological features in a significant proportion of psoriatic patients.
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Hipocondriasis , Psoriasis , Ansiedad/epidemiología , Femenino , Humanos , Hipocondriasis/complicaciones , Hipocondriasis/diagnóstico , Hipocondriasis/psicología , MMPI , Personalidad , Psoriasis/complicacionesRESUMEN
Pseudo-Pelger-Huët anomaly is a condition in which almost all the granulocytes are hyposegmented and/or hypogranulated. It is typically recognized in peripheral blood smears and represents a marker of several disorders, such as myeloproliferative diseases and myelodysplasia. The occurrence of the pseudo-Pelger-Huët anomaly in the cutaneous infiltrate of pyoderma gangrenosum is very rare. We describe the case of a 70-year-old man with idiopathic myelofibrosis who developed pyoderma gangrenosum. Histological examination showed an infiltrate consisting of granulocytic elements with features of dysmaturity and segmentation anomalies (hypo- and hypersegmented forms), suggestive of pseudo-Pelger-Huët anomaly. Methylprednisolone treatment resulted in progressive improvement of pyoderma gangrenosum.
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Síndromes Mielodisplásicos , Anomalía de Pelger-Huët , Mielofibrosis Primaria , Piodermia Gangrenosa , Masculino , Humanos , Anciano , Anomalía de Pelger-Huët/complicaciones , Anomalía de Pelger-Huët/patología , Mielofibrosis Primaria/complicaciones , Mielofibrosis Primaria/patología , Piodermia Gangrenosa/patología , Granulocitos/patología , Síndromes Mielodisplásicos/complicacionesRESUMEN
Psychological stress has long been recognized as a trigger for plaque psoriasis, and preliminary evidence suggests that psoriasis could be associated with alterations in the hypothalamic-pituitary-adrenal (HPA) axis, resulting in impaired cortisol response to stress. This study aimed to investigate psychological stress, anxiety, depression and salivary cortisol in psoriatic patients. A cross sectional study involving 126 adult patients with plaque psoriasis and 116 adult healthy controls was conducted. Demographic, clinical data, Perceived Stress Scale (PSS) and Hospital Anxiety and Depression Scale (HADS) were collected. Cases and controls were asked whether they felt stressed in the last month, whilst psoriatic patients were also interrogated whether they found that psoriasis could have been worsened by stress. Moreover, 54 randomly selected subjects (27 psoriasis patients and 27 controls) underwent salivary cortisol testing at 8 am. PSS, HADS depression and anxiety subscales were significantly higher in psoriatic patients than in controls (17.2 ± 0.6 vs. 15.1 ± 0.8 p = 0.0289), (9.5 ± 0.3 vs. 6.2 ± 0.3 p < 0.001) and (8.2 ± 0.4 vs. 4.2 ± 0.3 p < 0.001), respectively. A higher rate of psoriatic patients reported feeling stress over the last month (45% vs. 19%, p < 0.001), and stress was considered a potential trigger for psoriasis flare-ups in 69% of cases. Psoriasis was strongly associated with higher PSS and HADS scores independently of sex, body mass index, diabetes, hypertension, dyslipidemia, and occupational status. Salivary cortisol was significantly lower in psoriatic patients compared to controls (9.6 ± 0.5 vs. 14.0 ± 1.1 nmol/L, p < 0.001). In conclusion, psoriasis was associated with higher psychological stress, anxiety and depressive symptoms, and with impaired cortisol response to stress.
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BACKGROUND: Atopic dermatitis (AD) is the most common immune-mediated skin disease in childhood. Several treatment options for pediatric AD, both topical and systemic, are currently available. We carried out a single-center observational study with the aim of describing characteristics and treatment patterns in pediatric AD patients. METHODS: The study included 867 patients aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with a previous doctor-confirmed diagnosis of AD who underwent balneotherapy at the Comano Thermal Spring Water Center (Comano, Trentino, Italy) from April to October 2014. RESULTS: Among the patients included in the study, 41.2% had mild (SCORing Atopic Dermatitis, SCORAD 0-15), 43.6% moderate (SCORAD 16-40) and 15.2% severe AD (SCORAD > 40). A higher occurrence of reported food allergy was observed among children with more severe AD (p < 0.0001), while no association was found between AD severity and reported inhalant allergy or passive smoking (p = 0.15 and 0.92, respectively). Emollients (55.1%) and topical corticosteroids (TCS; 45.7%) were the main treatment options used in the previous month. The use of oral steroids and topical calcineurin inhibitors (TCI) was considerably less common (6.3 and 4.5%, respectively), while no patients were on systemic agents other than steroids. Among patients with severe AD, 9.8% had not used TCS, TCI or any systemic treatments. Moreover, 20.0% of the patients in the study population had followed elimination diets, although only 27.2% of them had a reported food allergy. CONCLUSIONS: A significant difference in the prevalence of reported food allergy emerged across the different AD severity categories. Furthermore, although further data are necessary to confirm our findings, undertreatment in children with AD appeared to be very common, at least among those attending the Comano Thermal Spring Water Center. Moreover, many patients followed elimination diets in the absence of reported food allergy.
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Dermatitis Atópica/complicaciones , Dermatitis Atópica/terapia , Administración Cutánea , Administración Oral , Adolescente , Balneología , Inhibidores de la Calcineurina/uso terapéutico , Niño , Preescolar , Emolientes/uso terapéutico , Femenino , Hipersensibilidad a los Alimentos/complicaciones , Glucocorticoides/uso terapéutico , Humanos , Italia , Masculino , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Several studies have investigated the efficacy of balneotherapy in atopic dermatitis (AD), including a pediatric open randomized clinical trial conducted at the Comano thermal spring water center, which showed a significant reduction in AD severity and an improvement of the quality of life. However, so far many studies on balneotherapy in pediatric AD have included relatively small populations without identifying patients' characteristics associated with their response. The aim of the present study was to identify any features associated with the clinical response to the Comano thermal spring water balneotherapy in a large cohort of pediatric AD patients. METHODS: An observational study was conducted on 867 children aged ≤16 years (females 50.5%, mean patient's age 5.9 years, standard deviation ±3.6 years) with mild to severe AD who underwent balneotherapy at the Comano thermal spring water center (Comano, Trentino, Italy) from April to October 2014. Patients were stratified according to their disease severity, which was evaluated using five SCORing Atopic Dermatitis (SCORAD) categories before and immediately after a thermal spring water balneotherapy course. Potential characteristics associated with the patients' clinical response to Comano thermal spring water balneotherapy were investigated. RESULTS: A statistically significant improvement in AD severity was observed after Comano thermal spring water balneotherapy (p < 0.0001). A significantly higher percentage of patients achieving improvement in AD severity was reported among children ≤4 years old (p < 0.0001) with early-onset AD (p < 0.0001), severe AD (p < 0.0001) or coexistent reported food allergies (p < 0.01). The therapy was well tolerated, and no relevant adverse effects were reported during the treatment course. CONCLUSIONS: Comano thermal spring water balneotherapy is a safe complementary treatment for pediatric patients with AD, as it was able to reduce the disease severity, especially in children ≤4 years old, with early onset AD, severe AD or concomitant food allergies.
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Balneología , Dermatitis Atópica/terapia , Niño , Preescolar , Dermatitis Atópica/complicaciones , Femenino , Hipersensibilidad a los Alimentos/complicaciones , Humanos , Italia , Masculino , Índice de Severidad de la EnfermedadRESUMEN
BACKGROUND: Red blood cell distribution width (RDW) is frequently increased in inflammatory disorders, and the magnitude of its elevation correlates with disease severity. This study was hence aimed to explore RDW values in patients with psoriasis. METHODS: The study population consisted of 366 adult patients with mild to severe plaque psoriasis and 366 age- and sex-matched blood donor controls. For each psoriatic patient, demographic, clinical, and laboratory data were regularly collected. RESULTS: RDW and MCV were significantly higher in psoriatic patients compared to controls (13.95 vs. 13.40% and 90.4 vs. 89 fL; both p<0.01). In order to assess whether RDW elevations were related to psoriasis severity, we divided our psoriatic patient population into two groups based on a PASI cut-off of 10. No significant differences were observed between the two groups (i.e., PASI>10 and 10) in terms of RDW (p=0.36). Adopting different PASI cut-offs (i.e. 3, 5, 7, 12) did not result in statistically significant differences (p=0.93, 0.48, 0.22, 0.42, respectively). In linear regression analysis, no significant correlation was found between RDW and PASI or CRP, nor with age, gender, or the psoriasis comorbidities listed in Table I. Furthermore, no significant difference in RDW values was noted between psoriatic patients with and without PsA (p=0.27). CONCLUSIONS: The results of this study confirm that RDW is elevated in psoriatic patients, though the magnitude of its increase did not appear to be associated with disease severity.
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BACKGROUND: Epidermal growth factor receptor (EGFR) inhibitors are routinely used in advanced non-small-cell lung cancer (NSCLC) harboring EGFR mutations. However, their use is associated with gastrointestinal and cutaneous toxicities, including acneiform eruptions, pruritus, xerosis, nail and hair changes. Aside from reducing patients' quality of life, such cutaneous reactions have a considerable impact on the oncologic treatment given that dose reduction or even drug discontinuation may be necessary, especially for the severe forms. OBJECTIVES: To assess the incidence, impact on treatment and management of EGFR inhibitor-related cutaneous reactions in patients with NSCLC. METHODS: We conducted a prospective observational study on 87 consecutive patients with advanced NSCLC treated with EGFR-tyrosine kinase inhibitors from January to December 2019. Patients who developed mucocutaneous reactions were evaluated and treated by both oncologists and dermatologists, and underwent dermatologic follow-up until resolution of the cutaneous reaction. Demographic and clinical data were collected for each patient, and the severity of the cutaneous reaction was graded using the Common Terminology Criteria for Adverse Events. RESULTS: Seventy-one patients (81.6%) developed cutaneous reactions. The number of cutaneous reactions per patient was 1 in 37%, 2 in 41% and 3 or more in 22%. The most common cutaneous reactions included acneiform eruptions (56.3%), xerosis ± asteatotic eczema (48.3%), nail changes (39.1%), mucositis (29.9%), pruritus (24.1%) and hair changes (12.6%). Afatinib was associated with a higher rate of nail changes and mucositis (p < 0.01 and p < 0.005, respectively) compared to other agents, while no patient-related predictive factors were identified. Dose reduction was performed in 18% of patients. Multidisciplinary management involving dermatologists allowed to resume the drug in all patients who had discontinued it due to the cutaneous reactions. CONCLUSIONS: A multidisciplinary approach to EGFR inhibitor-related cutaneous reactions is advantageous and can reduce the need to discontinue oncologic treatment.
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Carcinoma de Pulmón de Células no Pequeñas/tratamiento farmacológico , Erupciones por Medicamentos/epidemiología , Receptores ErbB/efectos adversos , Receptores ErbB/antagonistas & inhibidores , Neoplasias Pulmonares/tratamiento farmacológico , Inhibidores de Proteínas Quinasas/efectos adversos , Acrilamidas/efectos adversos , Anciano , Compuestos de Anilina/efectos adversos , Erupciones por Medicamentos/diagnóstico , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Quinazolinas/efectos adversosAsunto(s)
Arthrodermataceae/patogenicidad , Tiña del Cuero Cabelludo/microbiología , Antifúngicos/uso terapéutico , Preescolar , Griseofulvina/uso terapéutico , Humanos , Cetoconazol/uso terapéutico , Masculino , Cuero Cabelludo/patología , Tiña del Cuero Cabelludo/tratamiento farmacológico , Resultado del TratamientoRESUMEN
INTRODUCTION: Biologics have revolutionized the therapy of moderate-to-severe plaque psoriasis. Despite their greater efficacy over conventional systemic therapies their high cost has represented a burden for health-care systems, which limited their use. The availability of biosimilars at low cost is changing the place in therapy of biologics for psoriasis. AREAS COVERED: The role of TNF- α inhibitors in the management of plaque psoriasis, their efficacy and safety profile are presented. Phase 3 clinical trials and real-life data from the use of TNF- α inhibitor biosimilars in the treatment of plaque psoriasis are also reviewed in detail. Furthermore, arguments in favor of the use of TNF- α inhibitor biosimilars as a first-line therapy in moderate-to-severe plaque psoriasis are discussed. EXPERT OPINION: An increasing amount of data show that biosimilars represent a safe and effective alternative to the originator biologics. In the face of ever-increasing health-care costs, switching to biosimilars and starting naïve patients on the best-value biologic can reduce expenditure for patients and payers while maintaining a high-quality care. Moreover, as the cost of biosimilars is approaching the cost of conventional systemic treatments, TNF-α inhibitors biosimilars may represent a first-line systemic treatment for psoriasis patients because they are effective and safe.