Implementing best practice in psoriasis: a Nordic expert group consensus.

In the absence of Nordic-wide guidelines on the best practice management of psoriasis, this paper aims to provide Nordic recommendations for treatment goals, evaluation of quality of life impact and assessment/management of co-morbidities. This Delphi approach consisted of telephone interviews, local Nordic face-to-face meetings, and a Nordic-wide meeting, in which questions on treatment goals, quality of life impact and assessment/management of co-morbidities were posed to 17 dermatologists with psoriasis-treatment experience to gain consensus (≥ 90% agreement). The dermatologists agreed on the individualisation of treatment goals using Psoriasis Area and Severity Index and Dermatology Life Quality Index, which should be measured at the same frequency. Training of healthcare professionals on the use of these tools and psychological assessments were considered important, along with the referral of psoriasis patients with cardio-metabolic risk factors to their general practitioner. In order to achieve the best practice management of psoriasis, Nordic dermatologists should be trained and adhere to these recommendations in conjunction with available treatment guidelines.

[A man with erythrodermia, muscle weakness and weight loss]. / En mann med erytrodermi, muskelsvakhet og vekttap.

A man in his late fifties was treated with acitretin for psoriasis. The treatment was discontinued when liver enzymes started to increase. He subsequently developed erythrodermia, weakness of proximal muscle groups, heliotrope rash, Gottron's papules and elevation of creatine kinase to more than 9000 U/L. However, histological examination of a muscle biopsy displayed neuropathic atrophy and only a few scattered necrotic fibers. Alpha 1 foetoprotein was substantially elevated (1600 kU/L) and computed tomography showed two hepatic tumors, lytic lesions in the spine and in the ninth rib. Although no chronic liver disease could be documented, the patient was found to have a hepatocellular carcinoma which presented as dermatomyositis and erythrodermia.

The combination of etanercept and methotrexate increases the effectiveness of treatment in active psoriasis despite inadequate effect of methotrexate therapy.

Many patients with moderate-to-severe plaque psoriasis do not respond adequately to methotrexate monotherapy. This pilot study, with a small patient population, was performed to evaluate the effectiveness and safety of etanercept and methotrexate combination in patients with plaque psoriasis and inadequate response to methotrexate. Outpatients with plaque psoriasis (Psoriasis Area and Severity Index > or = 8 and/or body surface area > 10%), despite methotrexate treatment (> or = 3 months; > or = 7.5 mg/week) were randomized to either etanercept with metho nottrexate tapered and discontinued (n = 28) or etanercept with continuous methotrexate (n = 31). Significantly more patients had a Physicians' Global Assessment of "clear"/"almost clear" in the combination group compared with etanercept/methotrexate taper (66.7 vs. 37.0%, respectively; p = 0.025). Adverse events were similar for both groups, with no cases of tuberculosis, malignancies or opportunistic infections reported. Addition of etanercept to methotrexate achieved significant improvement in psoriasis after 24 weeks.