Evidence-based recommendations to assess psoriasis severity: systematic literature review and expert opinion of a panel of dermatologists.

BACKGROUND: Severity of psoriasis appears to be multidimensional and its assessment in everyday clinical practice requires a complex holistic approach. OBJECTIVES: To develop evidence-based recommendations to assess severity of plaque-type psoriasis in adult patients in everyday clinical practice. METHODS: A scientific committee (10 members identified on the basis of their expertise in psoriasis) using Delphi methodology selected eight questions in three domains: severity, health-related quality of life (HR-QoL) and comorbidities. Three systematic literature reviews (one per domain) of all studies published between January 1980 and June 2009 were performed based on Pub-Med, Cochrane and Embase database. Selected articles were systematically reviewed and evidence appraised according to the Oxford Levels of Evidence. On June 2009, a group of 44 French dermatologists both hospital and office based participated in a meeting including three separate rounds of discussions, plenary sessions, and modified Delphi technique votes. Recommendations for clinical practice based on systematic review and clinical experience were formulated by the group. Subsequently, agreements among the participants regarding these recommendations as well as potential impact on clinical practice were evaluated. RESULTS: A total of 10 642 references were identified, of which 154 articles were analysed. Ten key recommendations on the assessment of psoriasis severity were formulated: three recommendations relating to severity assessment, three recommendations relating to HR-QoL (including the use of the Dermatology Life Quality Index [DLQI] in clinical practice) and four recommendations relating to comorbidities (including systematic screening for peripheral or axial inflammatory joint damage, regardless of psoriasis severity). CONCLUSIONS: Ten recommendations to assess the severity of plaque-type psoriasis in adult patients in daily practice were developed. The recommendations are based on systematic appraisal of available evidence. They were developed and supported by a panel of dermatologists, which enhances their validity and practical relevance.

What are the best outcome measures for assessing plaque psoriasis severity? A systematic review of the literature.

BACKGROUND: A wide variety of scoring systems have been proposed to assess severity of psoriasis. Given its importance as a health issue both for patients and health care systems, it is critically important to evaluate the validity and reliability of existing outcome measures. OBJECTIVE: The objective of this systematic review was to assess the extent of validation including the validity, reliability, sensitivity to change and ease of use of available outcome measures for psoriasis. MATERIALS AND METHODS: We conducted a systematic review of all clinical studies (prospective and retrospective) investigating the severity of psoriasis patients and published between January 1980 and June 2009. The following methodological validation and quality criteria were recorded systematically: construct validity, content validity and internal consistency, intra-observer variation and inter-observer variation, sensitivity to change and acceptability/ease of use assessed as time required to perform measurement. RESULTS: Based on methodological validation and quality criteria, six clinical severity scores were selected and analysed (PASI, BSA, PGA, LS-PGA, SPI and SAPASI scores). We did not find substantial evidence of construct validity for any of the psoriasis clinical severity scores. Content validity was studied by considering the PASI score as gold standard. The relative content validity was good for the LS-PGA, PGA, and SPI scores, which correlated strongly with the PASI score. The SAPASI and PASI scores showed moderate correlation. Internal consistency was good for the PASI and LS-PGA scores. The PASI, BSA, PGA and LS-PGA scores displayed limited intra-observer variation. The inter-observer variation was low for LS-PGA (ICC < 0.5) and SAPASI, moderate for PASI, SPI and PGA and high for BSA (ICC > 0.8). The PASI score and the SAPASI displayed moderate sensitivity to change. DISCUSSION: Based on this systematic review, it appears that none of the severity scores used for psoriasis meets all of the validation criteria required for an ideal score. However, we can conclude that the PASI score is the most extensively studied psoriasis clinical severity score and the most thoroughly validated according to methodological validation criteria. Despite certain limitations, use of the PASI score can be recommended for scientific evaluation of the clinical severity of psoriasis.

Cardiovascular risk factors in patients with plaque psoriasis: a systematic review of epidemiological studies.

INTRODUCTION: Many epidemiological studies have associated psoriasis with an increased risk of coronary artery disease, resulting from a higher prevalence of cardiovascular risk factors in psoriasis patients compared with unmatched controls. However, the results of epidemiological studies vary depending upon the populations studied. The aim of this systemic review was to evaluate the risk of diabetes, hypertension, dyslipidaemia and obesity in adults with plaque psoriasis. In addition, we assessed the relationship between the risk of cardiovascular risk factors and psoriasis severity. METHODS: A systematic search was performed on Pubmed, Cochrane and Embase databases, using the key-words 'psoriasis', 'diabetes', 'hypertension', 'high blood pressure', 'dyslipidaemia', 'metabolic syndrome' and 'obesity', during the period from 1980 to June 2009. RESULTS: The initial literature search identified 353 articles. The final selection included 18 cross-sectional case-control studies. An increased risk of metabolic syndrome was observed in psoriatic patients (OR = 1.3-5.92), and a trend for a higher risk of obesity (OR = 1.18-5.49), especially in patients with severe psoriasis. For hypertension, hypertriglyceridaemia, and diabetes, the association was not significant in all studies. DISCUSSION: There was important heterogeneity in study design preventing from pooling results. Most often lifestyle factors such as smoking, alcohol consumption, physical activities were not taken into account. CONCLUSION: There is an increased risk of obesity and metabolic syndrome in psoriasis. For hypertension, diabetes and dyslipidaemia no consistency was found across studies. Prospective epidemiological studies with thorough recording of cardiovascular risk factors are required in psoriasis patients.

What are the best outcome measures for assessing quality of life in plaque type psoriasis? A systematic review of the literature.

BACKGROUND: The assessment of health-related quality of life (QOL) is important in psoriasis. Despite this, among the wide variety of QOL questionnaires used in psoriasis, there is no consensus as to which is the best. OBJECTIVE: The objective of this systematic review was to identify which of these measurements have acceptable evaluation criteria for both monitoring disease and research purposes. We looked at validity, reliability, sensitivity to change (responsiveness) and acceptability, which are common criteria for any score and specific criteria for QOL questionnaire. MATERIALS AND METHODS: We performed a systematic review of all clinical studies investigating the QOL of psoriasis patients, published between January 1988 and June 2009. RESULTS: Twenty-one QOL questionnaires were identified. Eight of these satisfied most of the validation criteria; they were multidimensional and had been used in clinical research: short form 36 (SF 36), Dermatology Life Quality Index (DLQI), Skindex 29, Skindex 17, Dermatology Quality of life Scale (DQOLS), Psoriasis Disability Index (PDI) Impact of Psoriasis Questionnaire (IPSO) and Psoriasis Index of Quality of Life (PSORIQOL). Construct validity, content validity and internal consistency were adequately assessed and good performance was achieved for all questionnaires. Reproducibility (undetermined for Skindex 17) and acceptability were good for all questionnaires. Sensitivity to change was determined good for the SF36, DLQI, Skindex 29 and PDI. Item bias, unidimensional structure and cross-cultural equivalence were poor for all but the Skindex 17 and SF36 questionnaires. CONCLUSION: On the basis of this systematic review, we can conclude that the DLQI is easy to use in clinical practice because of its brevity and simplicity. SF36 is widely used in clinical trials. Skindex 29 and Skindex 17, although rarely used, are interesting because of their cross-cultural validation.

Assessment of risk of psoriatic arthritis in patients with plaque psoriasis: a systematic review of the literature.

OBJECTIVE: The aim of this study was to determine the prevalence of psoriatic arthritis (PsA) in the patients with plaque psoriasis and to give recommendation for the diagnosis of PsA for dermatologists. METHODS: A systematic search was performed in Pubmed, Cochrane and Embase databases. The key-words used from the Medical Searching Heading (MeSH) were: 'Psoriasis', 'Arthritis, Psoriatic', 'Uveitis' and 'Dactylitis'. We selected cross-sectional epidemiological studies written in English or French between January 1980 and October 2009. RESULTS: The initial literature search identified 2171 references. Based on abstract reading and exclusion of studies not written in English or French, and without control group, the final selection included 20 epidemiological studies. With the eight studies using rheumatologically validated criteria, the prevalence of PsA among psoriasis patient spanned a wide range from 7% to 26%. CONCLUSION: Psoriasis arthritis may affect up to 24% of psoriasis patients. Dermatologist should be aware of main clinical sign of PsA to promote earlier recognition and treatment of PsA.

[Immunohistochemical characterization of a median raphe cyst of the penis]. / Caractérisations immunohistochimiques d'un kyste du raphé médian de la verge.

Cysts and canals found on the ventral surface of the penis have been ascribed to minor dysembryoplasia of the male genitalia. These lesions occur almost exclusively on the ventral surface of the penis along the median raphe and can extend from the urethral meatus to the anus. They are lined by stratified urothelium or squamous epithelium and they do not communicate with the urethra. Most cases are noted in early adulthood, they are usually asymptomatic but may become infected. Surgical removal is the adapted treatment. In this report we describe a case in which the urothelial origin of the cyst was documented by immunohistochemistry for cytokeratin 13.