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Think methotrexate for juvenile localized scleroderma
COEUR D’ALENE, IDAHO – Long-term use of methotrexate has a lot going for it as first-line therapy for active juvenile localized scleroderma, according to Dr. Francesco Zulian, chief of pediatric rheumatology at the University of Padua (Italy).
"It’s a drug that’s very old, it’s not expensive, it’s used in many dermatologic and rheumatologic conditions – and it is very useful in patients with scleroderma," he observed in his Sidney Hurwitz Memorial Lecture at the annual meeting of the Society for Pediatric Dermatology.
The initial studies of methotrexate in scleroderma were conducted in adults. Dr. Zulian and colleagues are credited with performing the first randomized, double-blind, prospective clinical trial in pediatric patients, building upon other investigators’ favorable earlier nonrandomized results.
Based upon the randomized trial findings and the subsequent long-term follow-up study, his recommendation for patients with active juvenile localized scleroderma – whether of the linear, pansclerotic, or generalized morphea subtype – is 3 months of initial bridging therapy with a combination of methotrexate plus systemic corticosteroids, followed by at least 24 months of methotrexate without systemic steroids.
In the long-term follow-up study involving 65 patients, treatment was associated with a 74% clinical remission rate. This broke down as approximately a 54% complete remission rate maintained for at least 6 months without treatment, and a 20% clinical remission rate on treatment. Treatment for less than 24 months yielded lesser long-term benefit. Adverse effects were seen in nearly half of patients; however, they were typically mild, and no patients discontinued treatment as a result (J. Am. Acad. Dermatol. 2012;67:1151-6).
"This study shows there is a large group of patients who get better with a relatively mild treatment," Dr. Zulian noted.
The bridging therapy regimen employed in the landmark double-blind, placebo-controlled trial involved oral methotrexate at 15 mg/m2 or a maximum of 20 mg per week, along with prednisone at 1 mg/kg/day or a maximum of 50 mg daily for 3 months (Arthritis Rheum. 2011;63:1998-2006).
In his own clinical practice, Dr. Zulian said, he turns to mycophenolate mofetil (CellCept) in the minority of cases in which bridging therapy with methotrexate and prednisone proves inadequate.
In patients with circumscribed morphea as defined in the international Padua consensus conference guidelines, subsequently formalized by the American College of Rheumatology, the European League Against Rheumatism, and the Pediatric Rheumatism European Society (Arthritis Rheum. 2007;203-12), his recommended treatment is topical corticosteroids, calcipotriol, or phototherapy.
While scleroderma is a rare condition in children, it is nonetheless the third most frequent condition within pediatric rheumatology. For physicians with affected patients who are interested in collaborative research to advance the treatment and understanding of this disease, Dr. Zulian recommended contacting the Juvenile Scleroderma International Network (www.jusinet.org).
Dr. Zulian reported having no financial conflicts with regard to his presentation.
COEUR D’ALENE, IDAHO – Long-term use of methotrexate has a lot going for it as first-line therapy for active juvenile localized scleroderma, according to Dr. Francesco Zulian, chief of pediatric rheumatology at the University of Padua (Italy).
"It’s a drug that’s very old, it’s not expensive, it’s used in many dermatologic and rheumatologic conditions – and it is very useful in patients with scleroderma," he observed in his Sidney Hurwitz Memorial Lecture at the annual meeting of the Society for Pediatric Dermatology.
The initial studies of methotrexate in scleroderma were conducted in adults. Dr. Zulian and colleagues are credited with performing the first randomized, double-blind, prospective clinical trial in pediatric patients, building upon other investigators’ favorable earlier nonrandomized results.
Based upon the randomized trial findings and the subsequent long-term follow-up study, his recommendation for patients with active juvenile localized scleroderma – whether of the linear, pansclerotic, or generalized morphea subtype – is 3 months of initial bridging therapy with a combination of methotrexate plus systemic corticosteroids, followed by at least 24 months of methotrexate without systemic steroids.
In the long-term follow-up study involving 65 patients, treatment was associated with a 74% clinical remission rate. This broke down as approximately a 54% complete remission rate maintained for at least 6 months without treatment, and a 20% clinical remission rate on treatment. Treatment for less than 24 months yielded lesser long-term benefit. Adverse effects were seen in nearly half of patients; however, they were typically mild, and no patients discontinued treatment as a result (J. Am. Acad. Dermatol. 2012;67:1151-6).
"This study shows there is a large group of patients who get better with a relatively mild treatment," Dr. Zulian noted.
The bridging therapy regimen employed in the landmark double-blind, placebo-controlled trial involved oral methotrexate at 15 mg/m2 or a maximum of 20 mg per week, along with prednisone at 1 mg/kg/day or a maximum of 50 mg daily for 3 months (Arthritis Rheum. 2011;63:1998-2006).
In his own clinical practice, Dr. Zulian said, he turns to mycophenolate mofetil (CellCept) in the minority of cases in which bridging therapy with methotrexate and prednisone proves inadequate.
In patients with circumscribed morphea as defined in the international Padua consensus conference guidelines, subsequently formalized by the American College of Rheumatology, the European League Against Rheumatism, and the Pediatric Rheumatism European Society (Arthritis Rheum. 2007;203-12), his recommended treatment is topical corticosteroids, calcipotriol, or phototherapy.
While scleroderma is a rare condition in children, it is nonetheless the third most frequent condition within pediatric rheumatology. For physicians with affected patients who are interested in collaborative research to advance the treatment and understanding of this disease, Dr. Zulian recommended contacting the Juvenile Scleroderma International Network (www.jusinet.org).
Dr. Zulian reported having no financial conflicts with regard to his presentation.
COEUR D’ALENE, IDAHO – Long-term use of methotrexate has a lot going for it as first-line therapy for active juvenile localized scleroderma, according to Dr. Francesco Zulian, chief of pediatric rheumatology at the University of Padua (Italy).
"It’s a drug that’s very old, it’s not expensive, it’s used in many dermatologic and rheumatologic conditions – and it is very useful in patients with scleroderma," he observed in his Sidney Hurwitz Memorial Lecture at the annual meeting of the Society for Pediatric Dermatology.
The initial studies of methotrexate in scleroderma were conducted in adults. Dr. Zulian and colleagues are credited with performing the first randomized, double-blind, prospective clinical trial in pediatric patients, building upon other investigators’ favorable earlier nonrandomized results.
Based upon the randomized trial findings and the subsequent long-term follow-up study, his recommendation for patients with active juvenile localized scleroderma – whether of the linear, pansclerotic, or generalized morphea subtype – is 3 months of initial bridging therapy with a combination of methotrexate plus systemic corticosteroids, followed by at least 24 months of methotrexate without systemic steroids.
In the long-term follow-up study involving 65 patients, treatment was associated with a 74% clinical remission rate. This broke down as approximately a 54% complete remission rate maintained for at least 6 months without treatment, and a 20% clinical remission rate on treatment. Treatment for less than 24 months yielded lesser long-term benefit. Adverse effects were seen in nearly half of patients; however, they were typically mild, and no patients discontinued treatment as a result (J. Am. Acad. Dermatol. 2012;67:1151-6).
"This study shows there is a large group of patients who get better with a relatively mild treatment," Dr. Zulian noted.
The bridging therapy regimen employed in the landmark double-blind, placebo-controlled trial involved oral methotrexate at 15 mg/m2 or a maximum of 20 mg per week, along with prednisone at 1 mg/kg/day or a maximum of 50 mg daily for 3 months (Arthritis Rheum. 2011;63:1998-2006).
In his own clinical practice, Dr. Zulian said, he turns to mycophenolate mofetil (CellCept) in the minority of cases in which bridging therapy with methotrexate and prednisone proves inadequate.
In patients with circumscribed morphea as defined in the international Padua consensus conference guidelines, subsequently formalized by the American College of Rheumatology, the European League Against Rheumatism, and the Pediatric Rheumatism European Society (Arthritis Rheum. 2007;203-12), his recommended treatment is topical corticosteroids, calcipotriol, or phototherapy.
While scleroderma is a rare condition in children, it is nonetheless the third most frequent condition within pediatric rheumatology. For physicians with affected patients who are interested in collaborative research to advance the treatment and understanding of this disease, Dr. Zulian recommended contacting the Juvenile Scleroderma International Network (www.jusinet.org).
Dr. Zulian reported having no financial conflicts with regard to his presentation.
EXPERT ANALYSIS FROM THE SPD ANNUAL MEETING
Patching Psoriasis
Patch testing is one of the major diagnostic tools in the evaluation of allergic contact dermatitis. One limitation of patch testing is the use of steroids prior to testing. Because steroids may suppress a positive test reaction, the use of topical steroids on the test site or oral steroids should be discontinued for at least 2 weeks prior to testing. Therefore, it is interesting to consider the effect of biologics on the reliability of patch testing.
Kim et al (Dermatitis. 2014;25:182-190) evaluated the prevalence of positive patch tests in psoriasis patients receiving biologics and whether these results differed from those of psoriasis patients who were not receiving biologics. An institutional review board–approved retrospective chart review was performed for individuals with psoriasis who were patch tested from January 2002 to 2012 at Tufts Medical Center in Boston, Massachusetts. Patients were selected if they had a history of psoriasis, psoriatic arthritis, and patch testing as identified by International Classification of Diseases, Ninth Revision, codes 696.1, 696.0, and 95044, respectively, in their medical records. Patients were patch tested using a modified North American Contact Dermatitis Group standard and cosmetics series. Readings were performed at 48 hours and 72 to 96 hours. The North American Contact Dermatitis Group grading system was used to grade reactions.
The chart review included 15 psoriasis patients who were on biologics (cases) and 16 psoriasis patients who were not on biologics (control subjects). The biologics used were ustekinumab (n=7), etanercept (n=4), adalimumab (n=3), and infliximab (n=1). The authors determined that 80% (12/15) of cases had at least 1 positive reaction compared with 81% (13/16) of control subjects, 67% (10/15) of cases had 2+ positive reactions compared with 63% (10/16) of control subjects, and 27% (4/15) of cases had 3+ positive reactions compared with 38% (6/16) of control subjects. These differences were not statistically significant.
Given the limitation of the small number of patients evaluated, the authors concluded that biologics do not appear to influence the abilities of patients with psoriasis to mount a positive patch test.
What’s the issue?
This study is small, but the findings do give an indication that the biologic agents utilized for psoriasis do not suppress patch test reactions. These data are not typically what we collect in this population, but it is nice to know. What has been your experience in patch testing patients on biologic therapy?
Patch testing is one of the major diagnostic tools in the evaluation of allergic contact dermatitis. One limitation of patch testing is the use of steroids prior to testing. Because steroids may suppress a positive test reaction, the use of topical steroids on the test site or oral steroids should be discontinued for at least 2 weeks prior to testing. Therefore, it is interesting to consider the effect of biologics on the reliability of patch testing.
Kim et al (Dermatitis. 2014;25:182-190) evaluated the prevalence of positive patch tests in psoriasis patients receiving biologics and whether these results differed from those of psoriasis patients who were not receiving biologics. An institutional review board–approved retrospective chart review was performed for individuals with psoriasis who were patch tested from January 2002 to 2012 at Tufts Medical Center in Boston, Massachusetts. Patients were selected if they had a history of psoriasis, psoriatic arthritis, and patch testing as identified by International Classification of Diseases, Ninth Revision, codes 696.1, 696.0, and 95044, respectively, in their medical records. Patients were patch tested using a modified North American Contact Dermatitis Group standard and cosmetics series. Readings were performed at 48 hours and 72 to 96 hours. The North American Contact Dermatitis Group grading system was used to grade reactions.
The chart review included 15 psoriasis patients who were on biologics (cases) and 16 psoriasis patients who were not on biologics (control subjects). The biologics used were ustekinumab (n=7), etanercept (n=4), adalimumab (n=3), and infliximab (n=1). The authors determined that 80% (12/15) of cases had at least 1 positive reaction compared with 81% (13/16) of control subjects, 67% (10/15) of cases had 2+ positive reactions compared with 63% (10/16) of control subjects, and 27% (4/15) of cases had 3+ positive reactions compared with 38% (6/16) of control subjects. These differences were not statistically significant.
Given the limitation of the small number of patients evaluated, the authors concluded that biologics do not appear to influence the abilities of patients with psoriasis to mount a positive patch test.
What’s the issue?
This study is small, but the findings do give an indication that the biologic agents utilized for psoriasis do not suppress patch test reactions. These data are not typically what we collect in this population, but it is nice to know. What has been your experience in patch testing patients on biologic therapy?
Patch testing is one of the major diagnostic tools in the evaluation of allergic contact dermatitis. One limitation of patch testing is the use of steroids prior to testing. Because steroids may suppress a positive test reaction, the use of topical steroids on the test site or oral steroids should be discontinued for at least 2 weeks prior to testing. Therefore, it is interesting to consider the effect of biologics on the reliability of patch testing.
Kim et al (Dermatitis. 2014;25:182-190) evaluated the prevalence of positive patch tests in psoriasis patients receiving biologics and whether these results differed from those of psoriasis patients who were not receiving biologics. An institutional review board–approved retrospective chart review was performed for individuals with psoriasis who were patch tested from January 2002 to 2012 at Tufts Medical Center in Boston, Massachusetts. Patients were selected if they had a history of psoriasis, psoriatic arthritis, and patch testing as identified by International Classification of Diseases, Ninth Revision, codes 696.1, 696.0, and 95044, respectively, in their medical records. Patients were patch tested using a modified North American Contact Dermatitis Group standard and cosmetics series. Readings were performed at 48 hours and 72 to 96 hours. The North American Contact Dermatitis Group grading system was used to grade reactions.
The chart review included 15 psoriasis patients who were on biologics (cases) and 16 psoriasis patients who were not on biologics (control subjects). The biologics used were ustekinumab (n=7), etanercept (n=4), adalimumab (n=3), and infliximab (n=1). The authors determined that 80% (12/15) of cases had at least 1 positive reaction compared with 81% (13/16) of control subjects, 67% (10/15) of cases had 2+ positive reactions compared with 63% (10/16) of control subjects, and 27% (4/15) of cases had 3+ positive reactions compared with 38% (6/16) of control subjects. These differences were not statistically significant.
Given the limitation of the small number of patients evaluated, the authors concluded that biologics do not appear to influence the abilities of patients with psoriasis to mount a positive patch test.
What’s the issue?
This study is small, but the findings do give an indication that the biologic agents utilized for psoriasis do not suppress patch test reactions. These data are not typically what we collect in this population, but it is nice to know. What has been your experience in patch testing patients on biologic therapy?
Infliximab may carry a higher infection rate in psoriasis patients
CHICAGO – Patients with psoriasis treated with infliximab had the highest incidence of serious infections in a retrospective analysis of commercial claims data.
After 5 years of follow-up among 22,753 patients, there were 554.7 hospitalized infectious events (HIEs) per 10,000 patient-years of exposure to infliximab (Remicade).
Among the other treatment groups, the incidence of HIEs varied within a comparatively narrow range of 261.2 for phototherapy to 341.4 per 10,000 patient-years of exposure to nonbiologic therapies, Dr. Alexa B. Kimball reported at the American Academy of Dermatology summer meeting.
The biologics etanercept (Enbrel), ustekinumab (Stelara), and adalimumab (Humira) fell somewhere in between with HIE incidence rates of 261.5, 287.1, and 321.9 per 10,000 patient years, respectively.
"It is reassuring that some of the rates we reported for patients on biologics were similar to that found in the phototherapy-treated population, which is not expected to have a reduced immune response to infection," Dr. Kimball of Massachusetts General Hospital, Boston, said in an interview. "Still, in any given patient, individual risk and benefits are important to assess when starting or continuing therapy."
In one other study evaluating the safety of anti–tumor necrosis factor agents, rates of serious infections and lymphoma were higher among patients with psoriasis and psoriatic arthritis treated with infliximab and adalimumab, compared with etanercept (Immunopharmacol. Immunotoxicol. 2012;34:548-60).
In the current analysis, hospitalizations for an infectious event were also higher in patients on concomitant corticosteroid therapy at baseline, Dr. Kimball reported.
Five-year HIE incidence rates were higher in patients with systemic corticosteroid exposure versus those without, regardless of treatment group: nonbiologics (649.2 vs. 251.6); etanercept (676.9 vs. 198.1); adalimumab (424.5 vs. 260.9); infliximab (990.2 vs. 443.3); ustekinumab (542.4 vs. 201.2); and phototherapy (320.3 vs. 235.3).
"This finding reinforces that combination therapy, especially with systemic steroids, may confer additional risk," Dr. Kimball said. "Patients on infliximab were also more likely to have psoriatic arthritis and may have a different underlying level of disease severity and risk, which we could not ascertain from these data."
The retrospective analysis was based on data obtained from the MarketScan Commercial Claims and Encounters and Medicare Supplemental and COB databases for patients with a diagnosis of psoriasis on or before Dec. 31, 2006, and at least one prescription claim for one of the above-mentioned therapies. Patients could belong to more than one treatment group.
A new HIE was defined as at least one overnight hospitalization with an ICD-9 infection code. Patients hospitalized in the previous 3 months for the same ICD-9 code were not eligible.
In all, there were 5,857 patients with any exposure to nonbiologics, 6,856 to etanercept, 3,314 to adalimumab, 1,044 to infliximab, 526 to ustekinumab, and 5,156 to phototherapy.
Unique exposures to these agents totaled 2,700; 3,433; 719; 301; 0; and 3,482, respectively, according to the poster.
Amgen sponsored the study. Dr. Kimball is a consultant for Amgen and several other pharmaceutical companies.
CHICAGO – Patients with psoriasis treated with infliximab had the highest incidence of serious infections in a retrospective analysis of commercial claims data.
After 5 years of follow-up among 22,753 patients, there were 554.7 hospitalized infectious events (HIEs) per 10,000 patient-years of exposure to infliximab (Remicade).
Among the other treatment groups, the incidence of HIEs varied within a comparatively narrow range of 261.2 for phototherapy to 341.4 per 10,000 patient-years of exposure to nonbiologic therapies, Dr. Alexa B. Kimball reported at the American Academy of Dermatology summer meeting.
The biologics etanercept (Enbrel), ustekinumab (Stelara), and adalimumab (Humira) fell somewhere in between with HIE incidence rates of 261.5, 287.1, and 321.9 per 10,000 patient years, respectively.
"It is reassuring that some of the rates we reported for patients on biologics were similar to that found in the phototherapy-treated population, which is not expected to have a reduced immune response to infection," Dr. Kimball of Massachusetts General Hospital, Boston, said in an interview. "Still, in any given patient, individual risk and benefits are important to assess when starting or continuing therapy."
In one other study evaluating the safety of anti–tumor necrosis factor agents, rates of serious infections and lymphoma were higher among patients with psoriasis and psoriatic arthritis treated with infliximab and adalimumab, compared with etanercept (Immunopharmacol. Immunotoxicol. 2012;34:548-60).
In the current analysis, hospitalizations for an infectious event were also higher in patients on concomitant corticosteroid therapy at baseline, Dr. Kimball reported.
Five-year HIE incidence rates were higher in patients with systemic corticosteroid exposure versus those without, regardless of treatment group: nonbiologics (649.2 vs. 251.6); etanercept (676.9 vs. 198.1); adalimumab (424.5 vs. 260.9); infliximab (990.2 vs. 443.3); ustekinumab (542.4 vs. 201.2); and phototherapy (320.3 vs. 235.3).
"This finding reinforces that combination therapy, especially with systemic steroids, may confer additional risk," Dr. Kimball said. "Patients on infliximab were also more likely to have psoriatic arthritis and may have a different underlying level of disease severity and risk, which we could not ascertain from these data."
The retrospective analysis was based on data obtained from the MarketScan Commercial Claims and Encounters and Medicare Supplemental and COB databases for patients with a diagnosis of psoriasis on or before Dec. 31, 2006, and at least one prescription claim for one of the above-mentioned therapies. Patients could belong to more than one treatment group.
A new HIE was defined as at least one overnight hospitalization with an ICD-9 infection code. Patients hospitalized in the previous 3 months for the same ICD-9 code were not eligible.
In all, there were 5,857 patients with any exposure to nonbiologics, 6,856 to etanercept, 3,314 to adalimumab, 1,044 to infliximab, 526 to ustekinumab, and 5,156 to phototherapy.
Unique exposures to these agents totaled 2,700; 3,433; 719; 301; 0; and 3,482, respectively, according to the poster.
Amgen sponsored the study. Dr. Kimball is a consultant for Amgen and several other pharmaceutical companies.
CHICAGO – Patients with psoriasis treated with infliximab had the highest incidence of serious infections in a retrospective analysis of commercial claims data.
After 5 years of follow-up among 22,753 patients, there were 554.7 hospitalized infectious events (HIEs) per 10,000 patient-years of exposure to infliximab (Remicade).
Among the other treatment groups, the incidence of HIEs varied within a comparatively narrow range of 261.2 for phototherapy to 341.4 per 10,000 patient-years of exposure to nonbiologic therapies, Dr. Alexa B. Kimball reported at the American Academy of Dermatology summer meeting.
The biologics etanercept (Enbrel), ustekinumab (Stelara), and adalimumab (Humira) fell somewhere in between with HIE incidence rates of 261.5, 287.1, and 321.9 per 10,000 patient years, respectively.
"It is reassuring that some of the rates we reported for patients on biologics were similar to that found in the phototherapy-treated population, which is not expected to have a reduced immune response to infection," Dr. Kimball of Massachusetts General Hospital, Boston, said in an interview. "Still, in any given patient, individual risk and benefits are important to assess when starting or continuing therapy."
In one other study evaluating the safety of anti–tumor necrosis factor agents, rates of serious infections and lymphoma were higher among patients with psoriasis and psoriatic arthritis treated with infliximab and adalimumab, compared with etanercept (Immunopharmacol. Immunotoxicol. 2012;34:548-60).
In the current analysis, hospitalizations for an infectious event were also higher in patients on concomitant corticosteroid therapy at baseline, Dr. Kimball reported.
Five-year HIE incidence rates were higher in patients with systemic corticosteroid exposure versus those without, regardless of treatment group: nonbiologics (649.2 vs. 251.6); etanercept (676.9 vs. 198.1); adalimumab (424.5 vs. 260.9); infliximab (990.2 vs. 443.3); ustekinumab (542.4 vs. 201.2); and phototherapy (320.3 vs. 235.3).
"This finding reinforces that combination therapy, especially with systemic steroids, may confer additional risk," Dr. Kimball said. "Patients on infliximab were also more likely to have psoriatic arthritis and may have a different underlying level of disease severity and risk, which we could not ascertain from these data."
The retrospective analysis was based on data obtained from the MarketScan Commercial Claims and Encounters and Medicare Supplemental and COB databases for patients with a diagnosis of psoriasis on or before Dec. 31, 2006, and at least one prescription claim for one of the above-mentioned therapies. Patients could belong to more than one treatment group.
A new HIE was defined as at least one overnight hospitalization with an ICD-9 infection code. Patients hospitalized in the previous 3 months for the same ICD-9 code were not eligible.
In all, there were 5,857 patients with any exposure to nonbiologics, 6,856 to etanercept, 3,314 to adalimumab, 1,044 to infliximab, 526 to ustekinumab, and 5,156 to phototherapy.
Unique exposures to these agents totaled 2,700; 3,433; 719; 301; 0; and 3,482, respectively, according to the poster.
Amgen sponsored the study. Dr. Kimball is a consultant for Amgen and several other pharmaceutical companies.
AT THE AAD SUMMER ACADEMY 2014
Key clinical point: The risk of being hospitalized for an infectious event was higher with exposure to infliximab.
Major finding: The incidence of hospitalized infectious events was 554.7 per 10,000 patient-years of exposure to infliximab, compared with 261.2-341.4 events per 10,000 patient-years of exposure to other therapies.
Data source: Retrospective database analysis of 22,753 patients with psoriasis.
Disclosures: Amgen sponsored the study. Dr. Kimball is a consultant for Amgen and several other pharmaceutical companies.
VIDEO: Stress and inflammatory skin diseases – Does the science prove a link?
CHICAGO – The data are still being developed, but evidence of a direct link between stress and inflammatory skin conditions continues to mount.
The research is especially compelling for psoriasis; experimental data suggest that stress triggers the nerves to release elevated levels of neuropeptides and neurotransmitters, which in turn affect the nervous system.
Dr. Richard Granstein, chairman of the dermatology department at Weill Cornell Medical College in New York, gave an exclusive interview to Frontline Medical News in which he described studies of how calming the nerves clearly interrupts psoriatic and other inflammatory skin conditions. Dr. Granstein discussed the implications of this new, and still controversial, line of research, and what this means for clinicians: Should they prescribe stress management programs to their patients with these skin conditions?
Dr. Granstein disclosed he has financial relationships with Velius and Clinique.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
CHICAGO – The data are still being developed, but evidence of a direct link between stress and inflammatory skin conditions continues to mount.
The research is especially compelling for psoriasis; experimental data suggest that stress triggers the nerves to release elevated levels of neuropeptides and neurotransmitters, which in turn affect the nervous system.
Dr. Richard Granstein, chairman of the dermatology department at Weill Cornell Medical College in New York, gave an exclusive interview to Frontline Medical News in which he described studies of how calming the nerves clearly interrupts psoriatic and other inflammatory skin conditions. Dr. Granstein discussed the implications of this new, and still controversial, line of research, and what this means for clinicians: Should they prescribe stress management programs to their patients with these skin conditions?
Dr. Granstein disclosed he has financial relationships with Velius and Clinique.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
CHICAGO – The data are still being developed, but evidence of a direct link between stress and inflammatory skin conditions continues to mount.
The research is especially compelling for psoriasis; experimental data suggest that stress triggers the nerves to release elevated levels of neuropeptides and neurotransmitters, which in turn affect the nervous system.
Dr. Richard Granstein, chairman of the dermatology department at Weill Cornell Medical College in New York, gave an exclusive interview to Frontline Medical News in which he described studies of how calming the nerves clearly interrupts psoriatic and other inflammatory skin conditions. Dr. Granstein discussed the implications of this new, and still controversial, line of research, and what this means for clinicians: Should they prescribe stress management programs to their patients with these skin conditions?
Dr. Granstein disclosed he has financial relationships with Velius and Clinique.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @whitneymcknight
EXPERT ANALYSIS FROM THE AAD SUMMER ACADEMY 2014
Psoriasiform lesions in Kawasaki disease may spell trouble
COEUR D’ALENE, IDAHO – The psoriasiform eruptions that occur in a subgroup of patients with Kawasaki disease during the acute or subacute phase may be a red flag for more severe coronary artery involvement, according to a retrospective, case-control study.
Another striking feature of these psoriasiform lesions is that they go into remission. No recurrences were seen in the study population during up to 13 years of follow-up, in marked contrast to classic psoriasis, a chronic disease, Dr. Wynnis L. Tom observed at the annual meeting of the Society for Pediatric Dermatology.
She presented what she believes to be the first study to formally compare the psoriasiform lesions arising in a minority of Kawasaki disease (KD) patients with the lesions of classic psoriasis. The study population consisted of 11 KD patients with psoriasiform eruptions whose median age was 1.9 years, 22 matched controls with KD and no psoriasiform lesions, and another 22 matched controls with psoriasis but not KD.
Kawasaki disease patients who developed psoriasiform eruptions had significantly more dilated coronary arteries than did those who did not, as reflected in their median maximal echocardiographic z-score of 2.7, compared with 1.8 in controls. A z-score greater than 2.5 is deemed to indicate clinically significant coronary artery dilation, noted Dr. Tom, a pediatric dermatologist at Rady Children’s Hospital and the University of California, San Diego.
The psoriasiform eruptions resolved within 13 months in all 11 affected KD patients, with no recurrences. In contrast, only 5 of 22 controls with classic psoriasis experienced remission during follow-up of up to 6 years.
The cutaneous distribution of the psoriasiform lesions in patients with KD was also distinctive. The eruptions were significantly less common in the head, neck, and diaper area than is the case in classic psoriasis. In addition, patients with KD and psoriasiform eruptions were significantly less likely to be overweight or obese than were controls with classic psoriasis.
Skin biopsies read by a blinded dermatopathologist showed that the psoriasiform lesions that arose during KD demonstrated suprabasilar staining of keratin 16 and increased expression of Ki-67 antigen. They differed from classic psoriasis lesions in that they displayed more crusting, serum, and an increased prevalence of bacteria at the epidermis.
There was no significant difference between KD patients with and without psoriasiform eruptions in terms of maximum levels of C-reactive protein, erythrocyte sedimentation rate, and other inflammatory markers. However, patients with psoriasiform lesions required significantly more time for their gamma-glutamyl transferase level and platelet count to return to normal.
One possible explanation for the distinct phenotype of these psoriasiform eruptions is that KD brings forth the skin lesions in patients who are predisposed to psoriasis, but without causing typical chronic psoriasis because the underlying KD is self-limited. But further study with larger numbers of patients is required for clarification, according to Dr. Tom.
Her work is supported by a career development award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. She reported having no financial conflicts regarding this study.
COEUR D’ALENE, IDAHO – The psoriasiform eruptions that occur in a subgroup of patients with Kawasaki disease during the acute or subacute phase may be a red flag for more severe coronary artery involvement, according to a retrospective, case-control study.
Another striking feature of these psoriasiform lesions is that they go into remission. No recurrences were seen in the study population during up to 13 years of follow-up, in marked contrast to classic psoriasis, a chronic disease, Dr. Wynnis L. Tom observed at the annual meeting of the Society for Pediatric Dermatology.
She presented what she believes to be the first study to formally compare the psoriasiform lesions arising in a minority of Kawasaki disease (KD) patients with the lesions of classic psoriasis. The study population consisted of 11 KD patients with psoriasiform eruptions whose median age was 1.9 years, 22 matched controls with KD and no psoriasiform lesions, and another 22 matched controls with psoriasis but not KD.
Kawasaki disease patients who developed psoriasiform eruptions had significantly more dilated coronary arteries than did those who did not, as reflected in their median maximal echocardiographic z-score of 2.7, compared with 1.8 in controls. A z-score greater than 2.5 is deemed to indicate clinically significant coronary artery dilation, noted Dr. Tom, a pediatric dermatologist at Rady Children’s Hospital and the University of California, San Diego.
The psoriasiform eruptions resolved within 13 months in all 11 affected KD patients, with no recurrences. In contrast, only 5 of 22 controls with classic psoriasis experienced remission during follow-up of up to 6 years.
The cutaneous distribution of the psoriasiform lesions in patients with KD was also distinctive. The eruptions were significantly less common in the head, neck, and diaper area than is the case in classic psoriasis. In addition, patients with KD and psoriasiform eruptions were significantly less likely to be overweight or obese than were controls with classic psoriasis.
Skin biopsies read by a blinded dermatopathologist showed that the psoriasiform lesions that arose during KD demonstrated suprabasilar staining of keratin 16 and increased expression of Ki-67 antigen. They differed from classic psoriasis lesions in that they displayed more crusting, serum, and an increased prevalence of bacteria at the epidermis.
There was no significant difference between KD patients with and without psoriasiform eruptions in terms of maximum levels of C-reactive protein, erythrocyte sedimentation rate, and other inflammatory markers. However, patients with psoriasiform lesions required significantly more time for their gamma-glutamyl transferase level and platelet count to return to normal.
One possible explanation for the distinct phenotype of these psoriasiform eruptions is that KD brings forth the skin lesions in patients who are predisposed to psoriasis, but without causing typical chronic psoriasis because the underlying KD is self-limited. But further study with larger numbers of patients is required for clarification, according to Dr. Tom.
Her work is supported by a career development award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. She reported having no financial conflicts regarding this study.
COEUR D’ALENE, IDAHO – The psoriasiform eruptions that occur in a subgroup of patients with Kawasaki disease during the acute or subacute phase may be a red flag for more severe coronary artery involvement, according to a retrospective, case-control study.
Another striking feature of these psoriasiform lesions is that they go into remission. No recurrences were seen in the study population during up to 13 years of follow-up, in marked contrast to classic psoriasis, a chronic disease, Dr. Wynnis L. Tom observed at the annual meeting of the Society for Pediatric Dermatology.
She presented what she believes to be the first study to formally compare the psoriasiform lesions arising in a minority of Kawasaki disease (KD) patients with the lesions of classic psoriasis. The study population consisted of 11 KD patients with psoriasiform eruptions whose median age was 1.9 years, 22 matched controls with KD and no psoriasiform lesions, and another 22 matched controls with psoriasis but not KD.
Kawasaki disease patients who developed psoriasiform eruptions had significantly more dilated coronary arteries than did those who did not, as reflected in their median maximal echocardiographic z-score of 2.7, compared with 1.8 in controls. A z-score greater than 2.5 is deemed to indicate clinically significant coronary artery dilation, noted Dr. Tom, a pediatric dermatologist at Rady Children’s Hospital and the University of California, San Diego.
The psoriasiform eruptions resolved within 13 months in all 11 affected KD patients, with no recurrences. In contrast, only 5 of 22 controls with classic psoriasis experienced remission during follow-up of up to 6 years.
The cutaneous distribution of the psoriasiform lesions in patients with KD was also distinctive. The eruptions were significantly less common in the head, neck, and diaper area than is the case in classic psoriasis. In addition, patients with KD and psoriasiform eruptions were significantly less likely to be overweight or obese than were controls with classic psoriasis.
Skin biopsies read by a blinded dermatopathologist showed that the psoriasiform lesions that arose during KD demonstrated suprabasilar staining of keratin 16 and increased expression of Ki-67 antigen. They differed from classic psoriasis lesions in that they displayed more crusting, serum, and an increased prevalence of bacteria at the epidermis.
There was no significant difference between KD patients with and without psoriasiform eruptions in terms of maximum levels of C-reactive protein, erythrocyte sedimentation rate, and other inflammatory markers. However, patients with psoriasiform lesions required significantly more time for their gamma-glutamyl transferase level and platelet count to return to normal.
One possible explanation for the distinct phenotype of these psoriasiform eruptions is that KD brings forth the skin lesions in patients who are predisposed to psoriasis, but without causing typical chronic psoriasis because the underlying KD is self-limited. But further study with larger numbers of patients is required for clarification, according to Dr. Tom.
Her work is supported by a career development award from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. She reported having no financial conflicts regarding this study.
AT THE SPD ANNUAL MEETING
Key clinical point: Further study will need to determine
if treatment, time to diagnosis, or other factors influence the
association between psoriasis-like skin lesions during the acute or subacute phase of Kawasaki disease and greater coronary artery dilatation.
Major finding: The median maximal echocardiographic z-score in Kawasaki disease patients who developed psoriasiform eruptions was 2.7, compared with 1.8 in those who did not.
Data source: A retrospective, case-control study involving 11 children with psoriasiform eruptions during Kawasaki disease, 22 matched controls with Kawasaki disease but not the psoriasis-like skin lesions, and another 22 matched controls with typical psoriasis but not Kawasaki disease.
Disclosures: The study presenter reported having no financial conflicts.
Link between autoimmune therapy, preterm birth is largely due to confounding
BELLEVUE, WASH. – Women with autoimmune diseases who take corticosteroids and disease-modifying antirheumatic drugs later in pregnancy have an increased risk of preterm birth, but this association is largely explained by confounding with sociodemographic and clinical factors and disease severity, a study showed.
Researchers prospectively studied 678 pregnant women from the MotherToBaby database who had rheumatoid arthritis, psoriasis or psoriatic arthritis, ankylosing spondylitis, or Crohn’s disease. They focused on steroid use and disease-modifying antirheumatic drug (DMARD) use in the 16 weeks before delivery.
The results presented at the annual meeting of the Teratology Society showed that the incidence of preterm birth (birth before 37 weeks of gestation) was 19.2% among women using only steroids, 11.9% among those using only DMARDs, and 25.0% among those using both, compared with 11.2% among women who used neither throughout pregnancy.
In unadjusted analyses, women taking both steroids and DMARDs had significantly higher odds of preterm birth relative to peers who took neither (relative risk, 2.23), reported lead author Kristin Palmsten, Sc.D., of the University of California, San Diego.
But this risk was attenuated and no longer significant after adjustment for sociodemographic and clinical factors, such as age, race/ethnicity, parity, prior preterm birth, twin pregnancy, prepregnancy hypertension, depression, and use of nonsteroidal anti-inflammatory drugs.
It was attenuated further still after additional adjustment for the severity of autoimmune disease earlier in pregnancy, as assessed with the Health Assessment Questionnaire Disability Index (HAQ-DI) in analyses that excluded patients with Crohn’s disease (because they were not asked about disease severity).
The use of steroids alone and the use of DMARDs alone were not associated with a significantly elevated risk of preterm birth in either unadjusted or adjusted analyses.
The findings showed that confounders at least partially explain the heightened risk of preterm birth associated with autoimmune therapy, according to Dr. Palmsten.
A major study strength was exposure ascertainment, as the women were directly asked about their medication use several times during pregnancy, she noted. A limitation was the potential lack of generalizability, as the women studied were predominantly white and had higher socioeconomic status and lower disease severity.
In ongoing analyses, the investigators are looking at the proportions of preterm births that were spontaneous and medically indicated, and at the specific gestational age of the preterm births.
"I’d like to confirm the results in a different population; I’d like to look at this association in the Medicaid population, which is a low-income population," Dr. Palmsten added. "And I think preterm birth subtypes should be considered in further investigation. I’d also like to explore the timing of exposure and dose as well."
Session attendee Dr. Jan M. Friedman of the University of British Columbia in Vancouver noted the wide confidence intervals seen in analyses. "Obviously, that’s partially a function of the fact that the groups are fairly small. Is this an ongoing study? Will you have more data, more patients to look at in a year or something?" he asked.
"It is ongoing," Dr. Palmsten replied. "I don’t think that we’ll have 500 women exposed even after a year. But I do hope to address that with the Medicaid data because that would have a very large population."
Dr. Palmsten disclosed no relevant conflicts of interest. The MotherToBaby Pregnancy Study is sponsored by AbbVie, Amgen, Sanofi-Aventis, Apotex, Barr, Par Pharmaceutical, Sandoz, Teva, Bristol-Myers Squibb, Roche/Genentech, UCB Pharma, Pfizer, and Janssen.
BELLEVUE, WASH. – Women with autoimmune diseases who take corticosteroids and disease-modifying antirheumatic drugs later in pregnancy have an increased risk of preterm birth, but this association is largely explained by confounding with sociodemographic and clinical factors and disease severity, a study showed.
Researchers prospectively studied 678 pregnant women from the MotherToBaby database who had rheumatoid arthritis, psoriasis or psoriatic arthritis, ankylosing spondylitis, or Crohn’s disease. They focused on steroid use and disease-modifying antirheumatic drug (DMARD) use in the 16 weeks before delivery.
The results presented at the annual meeting of the Teratology Society showed that the incidence of preterm birth (birth before 37 weeks of gestation) was 19.2% among women using only steroids, 11.9% among those using only DMARDs, and 25.0% among those using both, compared with 11.2% among women who used neither throughout pregnancy.
In unadjusted analyses, women taking both steroids and DMARDs had significantly higher odds of preterm birth relative to peers who took neither (relative risk, 2.23), reported lead author Kristin Palmsten, Sc.D., of the University of California, San Diego.
But this risk was attenuated and no longer significant after adjustment for sociodemographic and clinical factors, such as age, race/ethnicity, parity, prior preterm birth, twin pregnancy, prepregnancy hypertension, depression, and use of nonsteroidal anti-inflammatory drugs.
It was attenuated further still after additional adjustment for the severity of autoimmune disease earlier in pregnancy, as assessed with the Health Assessment Questionnaire Disability Index (HAQ-DI) in analyses that excluded patients with Crohn’s disease (because they were not asked about disease severity).
The use of steroids alone and the use of DMARDs alone were not associated with a significantly elevated risk of preterm birth in either unadjusted or adjusted analyses.
The findings showed that confounders at least partially explain the heightened risk of preterm birth associated with autoimmune therapy, according to Dr. Palmsten.
A major study strength was exposure ascertainment, as the women were directly asked about their medication use several times during pregnancy, she noted. A limitation was the potential lack of generalizability, as the women studied were predominantly white and had higher socioeconomic status and lower disease severity.
In ongoing analyses, the investigators are looking at the proportions of preterm births that were spontaneous and medically indicated, and at the specific gestational age of the preterm births.
"I’d like to confirm the results in a different population; I’d like to look at this association in the Medicaid population, which is a low-income population," Dr. Palmsten added. "And I think preterm birth subtypes should be considered in further investigation. I’d also like to explore the timing of exposure and dose as well."
Session attendee Dr. Jan M. Friedman of the University of British Columbia in Vancouver noted the wide confidence intervals seen in analyses. "Obviously, that’s partially a function of the fact that the groups are fairly small. Is this an ongoing study? Will you have more data, more patients to look at in a year or something?" he asked.
"It is ongoing," Dr. Palmsten replied. "I don’t think that we’ll have 500 women exposed even after a year. But I do hope to address that with the Medicaid data because that would have a very large population."
Dr. Palmsten disclosed no relevant conflicts of interest. The MotherToBaby Pregnancy Study is sponsored by AbbVie, Amgen, Sanofi-Aventis, Apotex, Barr, Par Pharmaceutical, Sandoz, Teva, Bristol-Myers Squibb, Roche/Genentech, UCB Pharma, Pfizer, and Janssen.
BELLEVUE, WASH. – Women with autoimmune diseases who take corticosteroids and disease-modifying antirheumatic drugs later in pregnancy have an increased risk of preterm birth, but this association is largely explained by confounding with sociodemographic and clinical factors and disease severity, a study showed.
Researchers prospectively studied 678 pregnant women from the MotherToBaby database who had rheumatoid arthritis, psoriasis or psoriatic arthritis, ankylosing spondylitis, or Crohn’s disease. They focused on steroid use and disease-modifying antirheumatic drug (DMARD) use in the 16 weeks before delivery.
The results presented at the annual meeting of the Teratology Society showed that the incidence of preterm birth (birth before 37 weeks of gestation) was 19.2% among women using only steroids, 11.9% among those using only DMARDs, and 25.0% among those using both, compared with 11.2% among women who used neither throughout pregnancy.
In unadjusted analyses, women taking both steroids and DMARDs had significantly higher odds of preterm birth relative to peers who took neither (relative risk, 2.23), reported lead author Kristin Palmsten, Sc.D., of the University of California, San Diego.
But this risk was attenuated and no longer significant after adjustment for sociodemographic and clinical factors, such as age, race/ethnicity, parity, prior preterm birth, twin pregnancy, prepregnancy hypertension, depression, and use of nonsteroidal anti-inflammatory drugs.
It was attenuated further still after additional adjustment for the severity of autoimmune disease earlier in pregnancy, as assessed with the Health Assessment Questionnaire Disability Index (HAQ-DI) in analyses that excluded patients with Crohn’s disease (because they were not asked about disease severity).
The use of steroids alone and the use of DMARDs alone were not associated with a significantly elevated risk of preterm birth in either unadjusted or adjusted analyses.
The findings showed that confounders at least partially explain the heightened risk of preterm birth associated with autoimmune therapy, according to Dr. Palmsten.
A major study strength was exposure ascertainment, as the women were directly asked about their medication use several times during pregnancy, she noted. A limitation was the potential lack of generalizability, as the women studied were predominantly white and had higher socioeconomic status and lower disease severity.
In ongoing analyses, the investigators are looking at the proportions of preterm births that were spontaneous and medically indicated, and at the specific gestational age of the preterm births.
"I’d like to confirm the results in a different population; I’d like to look at this association in the Medicaid population, which is a low-income population," Dr. Palmsten added. "And I think preterm birth subtypes should be considered in further investigation. I’d also like to explore the timing of exposure and dose as well."
Session attendee Dr. Jan M. Friedman of the University of British Columbia in Vancouver noted the wide confidence intervals seen in analyses. "Obviously, that’s partially a function of the fact that the groups are fairly small. Is this an ongoing study? Will you have more data, more patients to look at in a year or something?" he asked.
"It is ongoing," Dr. Palmsten replied. "I don’t think that we’ll have 500 women exposed even after a year. But I do hope to address that with the Medicaid data because that would have a very large population."
Dr. Palmsten disclosed no relevant conflicts of interest. The MotherToBaby Pregnancy Study is sponsored by AbbVie, Amgen, Sanofi-Aventis, Apotex, Barr, Par Pharmaceutical, Sandoz, Teva, Bristol-Myers Squibb, Roche/Genentech, UCB Pharma, Pfizer, and Janssen.
AT TERATOLOGY SOCIETY 2014
Key clinical point: Confounders at least partially explain the heightened risk of preterm birth associated with autoimmune therapy.
Major finding: Women taking both steroids and DMARDs had 2.23 times the risk of a preterm birth relative to peers taking neither, but the association was no longer significant after adjustment for confounders.
Data source: A prospective cohort study of 678 pregnant women with autoimmune diseases
Disclosures: Dr. Palmsten disclosed no relevant conflicts of interest. The MotherToBaby Pregnancy Study is sponsored by AbbVie, Amgen, Sanofi-Aventis, Apotex, Barr, Par Pharmaceutical, Sandoz, Teva, Bristol-Myers Squibb, Roche/Genentech, UCB Pharma, Pfizer, and Janssen.
Recent Findings About Psoriatic Arthritis
Nail Involvement May Be a Predictor of Concomitant Psoriatic Arthritis in Psoriasis Patients
Early detection and treatment of psoriatic arthritis (PsA) could contribute to the prevention of disease progression. Langenbruch et al (Br J Dermatol. July 17, 2014. doi:10.1111/bjd.13272) conducted a retrospective analysis of data from 3 independent national cross-sectional studies on health care in psoriasis and PsA, including psoriasis history, clinical findings, PsA, nail involvement, health care, and patient-reported outcomes. The researchers reported that the strongest predictors for concomitant PsA were nail involvement and inpatient hospital treatment, while scalp involvement was not a significant predictor.
Practice Point: Nail disease may be the most predictive clinical indicator of PsA in psoriasis patients.
>>Read more at British Journal of Dermatology
Consider Cardiovascular Risk Factors in Patients With Psoriatic Arthritis
There is an increased prevalence of cardiovascular risk factors and/or morbidity in patients with psoriasis or psoriatic arthritis (PsA). Khraishi et al (Clin Rheumatol. July 18, 2014. doi:10.1007/s10067-014-2743-7) evaluated the cardiovascular profile of 196 patients with PsA, either early PsA or established PsA. Hypercholesterolemia was most prevalent in patients, followed by obesity, hypertension, diabetes mellitus, anxiety/depression, and coronary heart disease. The results were similar for patients with early PsA and established PsA, except for anxiety/depression and obesity, which were more prevalent in patients with established PsA.
Practice Point: Cardiovascular risk should be taken into consideration even in patients with early PsA.
>>Read more at Clinical Rheumatology
Psoriatic Arthritis Screening Tools Help Dermatologists
Dermatologists may have difficulty accurately detecting psoriatic arthritis (PsA) in psoriasis patients. Mease et al (J Am Acad Dermatol. June 25, 2014. doi:10.1016/j.jaad.2014.05.010) evaluated 3 PsA screening questionnaires based on rheumatologist assessment in patients with psoriasis. Of 949 patients with psoriasis evaluated by rheumatologists, 30% received a clinical diagnosis of PsA.
Practice Point: The questionnaires may help dermatologists identify patients without PsA and patients with possible PsA who may benefit from rheumatologist assessment.
>>Read more at Journal of the American Academy of Dermatology
Dermatologists Play Important Role in the Diagnosis and Management of Psoriatic Arthritis
Dermatologists play a key role in identifying psoriasis patients at risk for psoriatic arthritis (PsA) and working with rheumatologists to diagnose PsA. Richard et al (J Eur Acad Dermatol Venereol. 2014;28[suppl 5]:3-12) provided practical recommendations on the risk factors for PsA, PsA prevalence, screening tools, and initial PsA treatment options. Relevant articles in the literature were reviewed to provide these recommendations for dermatologists to utilize.
Practice Point: Dermatologists and rheumatologists must collaborate to better identify and manage PsA patients.
>>Read more at Journal of the European Academy of Dermatology and Venereology
Nail Involvement May Be a Predictor of Concomitant Psoriatic Arthritis in Psoriasis Patients
Early detection and treatment of psoriatic arthritis (PsA) could contribute to the prevention of disease progression. Langenbruch et al (Br J Dermatol. July 17, 2014. doi:10.1111/bjd.13272) conducted a retrospective analysis of data from 3 independent national cross-sectional studies on health care in psoriasis and PsA, including psoriasis history, clinical findings, PsA, nail involvement, health care, and patient-reported outcomes. The researchers reported that the strongest predictors for concomitant PsA were nail involvement and inpatient hospital treatment, while scalp involvement was not a significant predictor.
Practice Point: Nail disease may be the most predictive clinical indicator of PsA in psoriasis patients.
>>Read more at British Journal of Dermatology
Consider Cardiovascular Risk Factors in Patients With Psoriatic Arthritis
There is an increased prevalence of cardiovascular risk factors and/or morbidity in patients with psoriasis or psoriatic arthritis (PsA). Khraishi et al (Clin Rheumatol. July 18, 2014. doi:10.1007/s10067-014-2743-7) evaluated the cardiovascular profile of 196 patients with PsA, either early PsA or established PsA. Hypercholesterolemia was most prevalent in patients, followed by obesity, hypertension, diabetes mellitus, anxiety/depression, and coronary heart disease. The results were similar for patients with early PsA and established PsA, except for anxiety/depression and obesity, which were more prevalent in patients with established PsA.
Practice Point: Cardiovascular risk should be taken into consideration even in patients with early PsA.
>>Read more at Clinical Rheumatology
Psoriatic Arthritis Screening Tools Help Dermatologists
Dermatologists may have difficulty accurately detecting psoriatic arthritis (PsA) in psoriasis patients. Mease et al (J Am Acad Dermatol. June 25, 2014. doi:10.1016/j.jaad.2014.05.010) evaluated 3 PsA screening questionnaires based on rheumatologist assessment in patients with psoriasis. Of 949 patients with psoriasis evaluated by rheumatologists, 30% received a clinical diagnosis of PsA.
Practice Point: The questionnaires may help dermatologists identify patients without PsA and patients with possible PsA who may benefit from rheumatologist assessment.
>>Read more at Journal of the American Academy of Dermatology
Dermatologists Play Important Role in the Diagnosis and Management of Psoriatic Arthritis
Dermatologists play a key role in identifying psoriasis patients at risk for psoriatic arthritis (PsA) and working with rheumatologists to diagnose PsA. Richard et al (J Eur Acad Dermatol Venereol. 2014;28[suppl 5]:3-12) provided practical recommendations on the risk factors for PsA, PsA prevalence, screening tools, and initial PsA treatment options. Relevant articles in the literature were reviewed to provide these recommendations for dermatologists to utilize.
Practice Point: Dermatologists and rheumatologists must collaborate to better identify and manage PsA patients.
>>Read more at Journal of the European Academy of Dermatology and Venereology
Nail Involvement May Be a Predictor of Concomitant Psoriatic Arthritis in Psoriasis Patients
Early detection and treatment of psoriatic arthritis (PsA) could contribute to the prevention of disease progression. Langenbruch et al (Br J Dermatol. July 17, 2014. doi:10.1111/bjd.13272) conducted a retrospective analysis of data from 3 independent national cross-sectional studies on health care in psoriasis and PsA, including psoriasis history, clinical findings, PsA, nail involvement, health care, and patient-reported outcomes. The researchers reported that the strongest predictors for concomitant PsA were nail involvement and inpatient hospital treatment, while scalp involvement was not a significant predictor.
Practice Point: Nail disease may be the most predictive clinical indicator of PsA in psoriasis patients.
>>Read more at British Journal of Dermatology
Consider Cardiovascular Risk Factors in Patients With Psoriatic Arthritis
There is an increased prevalence of cardiovascular risk factors and/or morbidity in patients with psoriasis or psoriatic arthritis (PsA). Khraishi et al (Clin Rheumatol. July 18, 2014. doi:10.1007/s10067-014-2743-7) evaluated the cardiovascular profile of 196 patients with PsA, either early PsA or established PsA. Hypercholesterolemia was most prevalent in patients, followed by obesity, hypertension, diabetes mellitus, anxiety/depression, and coronary heart disease. The results were similar for patients with early PsA and established PsA, except for anxiety/depression and obesity, which were more prevalent in patients with established PsA.
Practice Point: Cardiovascular risk should be taken into consideration even in patients with early PsA.
>>Read more at Clinical Rheumatology
Psoriatic Arthritis Screening Tools Help Dermatologists
Dermatologists may have difficulty accurately detecting psoriatic arthritis (PsA) in psoriasis patients. Mease et al (J Am Acad Dermatol. June 25, 2014. doi:10.1016/j.jaad.2014.05.010) evaluated 3 PsA screening questionnaires based on rheumatologist assessment in patients with psoriasis. Of 949 patients with psoriasis evaluated by rheumatologists, 30% received a clinical diagnosis of PsA.
Practice Point: The questionnaires may help dermatologists identify patients without PsA and patients with possible PsA who may benefit from rheumatologist assessment.
>>Read more at Journal of the American Academy of Dermatology
Dermatologists Play Important Role in the Diagnosis and Management of Psoriatic Arthritis
Dermatologists play a key role in identifying psoriasis patients at risk for psoriatic arthritis (PsA) and working with rheumatologists to diagnose PsA. Richard et al (J Eur Acad Dermatol Venereol. 2014;28[suppl 5]:3-12) provided practical recommendations on the risk factors for PsA, PsA prevalence, screening tools, and initial PsA treatment options. Relevant articles in the literature were reviewed to provide these recommendations for dermatologists to utilize.
Practice Point: Dermatologists and rheumatologists must collaborate to better identify and manage PsA patients.
>>Read more at Journal of the European Academy of Dermatology and Venereology
Multicenter cooperative psoriatic arthritis study group formed
NEW YORK – A research consortium in psoriatic arthritis has been recently organized by a group of researchers at academic centers hoping to accelerate data collection by pooling resources.
Formed about 1 year ago, the research group, called PPACMAN (Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network) is currently open to those centers in which dermatologists and rheumatologists are already collaborating in the management of psoriatic arthritis (PsA).
"One of the advantages of this group is that we hope to pursue research goals with minimal costs and need for funding," explained Dr. Jose U. Scher, director of the arthritis clinic and codirector of the psoriatic arthritis center at NYU Langone Medical Center, New York. In addition to NYU, the collaborating centers include the Cleveland Clinic; the National Institutes of Health; the University of Pennsylvania, Philadelphia; the University of Utah, Salt Lake City; the University of Toronto, Harvard University’s Brigham and Women’s Hospital, Boston; North Shore-Long Island Jewish Health System, Manhasset, N.Y.; Oregon Health & Science University, Portland; the University of Rochester, N.Y.; and the National Psoriasis Foundation, Portland.
In outlining progress so far at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Spondyloarthritis Research & Treatment Network, Dr. Scher reported on three initiatives underway.
Of these, the most ambitious may be a multicenter longitudinal cohort being created by collating electronic medical records of PsA patients from the participating centers. As it grows over time, this database has the potential to serve as a rich resource of information on PsA characteristics, treatment approaches, and outcomes.
"This is an example of how we can leverage data in PsA through collaboration with resources already devoted to clinical care," Dr. Scher reported. By collating the data from electronic medical records in compatible formats, the cohort data to some degree will collect themselves.
In addition, PPACMAN centers are participating in an effort to evaluate tools used by dermatologists to screen for PsA. According to Dr. Scher, this initiative is the first step in an effort to work toward identifying the screening approaches that are most effective.
"It is still unclear which tools are being used and their relative value for early detection of PsA in a practical sense," said Dr. Scher, referring to such screening instruments as the Psoriasis Arthritis Screening Evaluation. The goal is to document how instruments are being used currently and then to define strategies that best accelerate the time to diagnosis.
A third project being developed by the PPACMAN collaborative group involves the study of biomarkers. Biomarkers have enormous potential for predicting the course of PsA and guiding therapy, but the complex interaction of genetic, environmental, and immunologic factors complicates the effort to isolate their independent predictive value. In attempting to control for variables, studies conducted with a relatively large number of patients have a practical advantage.
"The principle of PPACMAN, integrated by highly driven and talented researchers, is that we can achieve more by working together," Dr. Scher explained. Indeed, he said that other centers with an interest in PsA are welcome to join as long as they have a program in which dermatologists and rheumatologists collaborate.
"This is a relatively new initiative, but we are excited about its potential," Dr. Scher said.
Dr. Scher reported no relevant financial relationships.
NEW YORK – A research consortium in psoriatic arthritis has been recently organized by a group of researchers at academic centers hoping to accelerate data collection by pooling resources.
Formed about 1 year ago, the research group, called PPACMAN (Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network) is currently open to those centers in which dermatologists and rheumatologists are already collaborating in the management of psoriatic arthritis (PsA).
"One of the advantages of this group is that we hope to pursue research goals with minimal costs and need for funding," explained Dr. Jose U. Scher, director of the arthritis clinic and codirector of the psoriatic arthritis center at NYU Langone Medical Center, New York. In addition to NYU, the collaborating centers include the Cleveland Clinic; the National Institutes of Health; the University of Pennsylvania, Philadelphia; the University of Utah, Salt Lake City; the University of Toronto, Harvard University’s Brigham and Women’s Hospital, Boston; North Shore-Long Island Jewish Health System, Manhasset, N.Y.; Oregon Health & Science University, Portland; the University of Rochester, N.Y.; and the National Psoriasis Foundation, Portland.
In outlining progress so far at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Spondyloarthritis Research & Treatment Network, Dr. Scher reported on three initiatives underway.
Of these, the most ambitious may be a multicenter longitudinal cohort being created by collating electronic medical records of PsA patients from the participating centers. As it grows over time, this database has the potential to serve as a rich resource of information on PsA characteristics, treatment approaches, and outcomes.
"This is an example of how we can leverage data in PsA through collaboration with resources already devoted to clinical care," Dr. Scher reported. By collating the data from electronic medical records in compatible formats, the cohort data to some degree will collect themselves.
In addition, PPACMAN centers are participating in an effort to evaluate tools used by dermatologists to screen for PsA. According to Dr. Scher, this initiative is the first step in an effort to work toward identifying the screening approaches that are most effective.
"It is still unclear which tools are being used and their relative value for early detection of PsA in a practical sense," said Dr. Scher, referring to such screening instruments as the Psoriasis Arthritis Screening Evaluation. The goal is to document how instruments are being used currently and then to define strategies that best accelerate the time to diagnosis.
A third project being developed by the PPACMAN collaborative group involves the study of biomarkers. Biomarkers have enormous potential for predicting the course of PsA and guiding therapy, but the complex interaction of genetic, environmental, and immunologic factors complicates the effort to isolate their independent predictive value. In attempting to control for variables, studies conducted with a relatively large number of patients have a practical advantage.
"The principle of PPACMAN, integrated by highly driven and talented researchers, is that we can achieve more by working together," Dr. Scher explained. Indeed, he said that other centers with an interest in PsA are welcome to join as long as they have a program in which dermatologists and rheumatologists collaborate.
"This is a relatively new initiative, but we are excited about its potential," Dr. Scher said.
Dr. Scher reported no relevant financial relationships.
NEW YORK – A research consortium in psoriatic arthritis has been recently organized by a group of researchers at academic centers hoping to accelerate data collection by pooling resources.
Formed about 1 year ago, the research group, called PPACMAN (Psoriasis and Psoriatic Arthritis Clinics Multicenter Advancement Network) is currently open to those centers in which dermatologists and rheumatologists are already collaborating in the management of psoriatic arthritis (PsA).
"One of the advantages of this group is that we hope to pursue research goals with minimal costs and need for funding," explained Dr. Jose U. Scher, director of the arthritis clinic and codirector of the psoriatic arthritis center at NYU Langone Medical Center, New York. In addition to NYU, the collaborating centers include the Cleveland Clinic; the National Institutes of Health; the University of Pennsylvania, Philadelphia; the University of Utah, Salt Lake City; the University of Toronto, Harvard University’s Brigham and Women’s Hospital, Boston; North Shore-Long Island Jewish Health System, Manhasset, N.Y.; Oregon Health & Science University, Portland; the University of Rochester, N.Y.; and the National Psoriasis Foundation, Portland.
In outlining progress so far at the joint meetings of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis and the Spondyloarthritis Research & Treatment Network, Dr. Scher reported on three initiatives underway.
Of these, the most ambitious may be a multicenter longitudinal cohort being created by collating electronic medical records of PsA patients from the participating centers. As it grows over time, this database has the potential to serve as a rich resource of information on PsA characteristics, treatment approaches, and outcomes.
"This is an example of how we can leverage data in PsA through collaboration with resources already devoted to clinical care," Dr. Scher reported. By collating the data from electronic medical records in compatible formats, the cohort data to some degree will collect themselves.
In addition, PPACMAN centers are participating in an effort to evaluate tools used by dermatologists to screen for PsA. According to Dr. Scher, this initiative is the first step in an effort to work toward identifying the screening approaches that are most effective.
"It is still unclear which tools are being used and their relative value for early detection of PsA in a practical sense," said Dr. Scher, referring to such screening instruments as the Psoriasis Arthritis Screening Evaluation. The goal is to document how instruments are being used currently and then to define strategies that best accelerate the time to diagnosis.
A third project being developed by the PPACMAN collaborative group involves the study of biomarkers. Biomarkers have enormous potential for predicting the course of PsA and guiding therapy, but the complex interaction of genetic, environmental, and immunologic factors complicates the effort to isolate their independent predictive value. In attempting to control for variables, studies conducted with a relatively large number of patients have a practical advantage.
"The principle of PPACMAN, integrated by highly driven and talented researchers, is that we can achieve more by working together," Dr. Scher explained. Indeed, he said that other centers with an interest in PsA are welcome to join as long as they have a program in which dermatologists and rheumatologists collaborate.
"This is a relatively new initiative, but we are excited about its potential," Dr. Scher said.
Dr. Scher reported no relevant financial relationships.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
Conventional DMARDs may be excluded from psoriatic arthritis enthesitis guidelines
NEW YORK – Conventional disease-modifying antirheumatic drugs will not be included among acceptable treatments for enthesitis related to psoriatic arthritis, according to a draft of guidelines being prepared for publication.
"The only controlled trial with a DMARD [disease-modifying antirheumatic drug] for enthesitis was conducted with sulfasalazine, and it was negative," said Dr. Evan L. Siegel, who is in group practice in rheumatology in Rockville, Md. Dr. Siegel led a group of experts preparing psoriatic arthritis enthesitis treatment recommendations to be issued by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).
In a preliminary report on the planned treatment recommendations, which were delivered at the joint meetings of GRAPPA and the Spondyloarthritis Research & Treatment Network (SPARTAN), Dr. Siegel reported that the new recommendations will recognize only two gradations of enthesitis: mild or moderate/severe.
"It is difficult to differentiate moderate from severe because these have not been treated as distinct entities in the clinical trials," Dr. Siegel said. Patients experience severity in regard to intensity of pain and limitation of function, either or both of which may represent severe enthesitis in any given individual patient, according to Dr. Siegel, who also noted that the number of sites of activity is also generally unhelpful.
"Significant activity at a single site may be sufficient to produce a major functional deficit in one individual, whereas the activity at multiple sites may not produce much symptomatology or functional loss in another," Dr. Siegel said.
Enthesitis, an inflammation at the site where tendons or ligaments attach to bone, has been reported in up to 70% of patients with psoriatic arthritis. In some patients, it is the dominant symptom. However, the number of treatment trials in which control of enthesitis is the primary outcome continues to be limited, according to Dr. Siegel. He acknowledged that many of the proposed treatment recommendations owed more to expert opinion than to data.
This is true of the proposed first-line recommendation, he said, which is the use of nonsteroidal anti-inflammatory drugs and physical therapy. For NSAIDs, the wording of the recommendation will emphasize the need to monitor side effects.
The expert opinion of the GRAPPA consensus group was nearly unanimous that NSAIDs and physical therapy are effective and should be tried initially in both mild and moderate/severe disease, even though Dr. Siegel said that the supportive data from controlled trials are limited.
For those with moderate/severe enthesitis not sufficiently controlled on NSAIDs, alternatives include tumor necrosis factor inhibitors, ustekinumab, and apremilast. Some supportive data are available for each of these options, even though the consensus group concluded that there is not enough comparative evidence "to recommend one over another," he said.
Rather, the consensus group is recommending that the choice of therapies beyond NSAIDs and physical therapy be individualized in relationship to comorbidities, personal preference, and other considerations.
Special wording is being developed in regard to the use of corticosteroid injections. This wording was partly inspired by a meta-analysis that associated corticosteroid injections with an adverse effect on the integrity of tendons. Although there were many criticisms of this report, there was sufficient concern among the consensus group to urge that this treatment be used with caution.
"We think that these injections should only be provided by experienced physicians," Dr. Siegel reported. The wording in the preliminary draft is that adjunctive corticosteroid injections "may be considered on an individual basis."
When published, the enthesitis guidelines will include grading for the quality of the evidence behind each recommendation as well as the relative strength of the recommendation conferred by the expert panel.
Dr. Siegel reported financial relationships with Amgen and AbbVie.
NEW YORK – Conventional disease-modifying antirheumatic drugs will not be included among acceptable treatments for enthesitis related to psoriatic arthritis, according to a draft of guidelines being prepared for publication.
"The only controlled trial with a DMARD [disease-modifying antirheumatic drug] for enthesitis was conducted with sulfasalazine, and it was negative," said Dr. Evan L. Siegel, who is in group practice in rheumatology in Rockville, Md. Dr. Siegel led a group of experts preparing psoriatic arthritis enthesitis treatment recommendations to be issued by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).
In a preliminary report on the planned treatment recommendations, which were delivered at the joint meetings of GRAPPA and the Spondyloarthritis Research & Treatment Network (SPARTAN), Dr. Siegel reported that the new recommendations will recognize only two gradations of enthesitis: mild or moderate/severe.
"It is difficult to differentiate moderate from severe because these have not been treated as distinct entities in the clinical trials," Dr. Siegel said. Patients experience severity in regard to intensity of pain and limitation of function, either or both of which may represent severe enthesitis in any given individual patient, according to Dr. Siegel, who also noted that the number of sites of activity is also generally unhelpful.
"Significant activity at a single site may be sufficient to produce a major functional deficit in one individual, whereas the activity at multiple sites may not produce much symptomatology or functional loss in another," Dr. Siegel said.
Enthesitis, an inflammation at the site where tendons or ligaments attach to bone, has been reported in up to 70% of patients with psoriatic arthritis. In some patients, it is the dominant symptom. However, the number of treatment trials in which control of enthesitis is the primary outcome continues to be limited, according to Dr. Siegel. He acknowledged that many of the proposed treatment recommendations owed more to expert opinion than to data.
This is true of the proposed first-line recommendation, he said, which is the use of nonsteroidal anti-inflammatory drugs and physical therapy. For NSAIDs, the wording of the recommendation will emphasize the need to monitor side effects.
The expert opinion of the GRAPPA consensus group was nearly unanimous that NSAIDs and physical therapy are effective and should be tried initially in both mild and moderate/severe disease, even though Dr. Siegel said that the supportive data from controlled trials are limited.
For those with moderate/severe enthesitis not sufficiently controlled on NSAIDs, alternatives include tumor necrosis factor inhibitors, ustekinumab, and apremilast. Some supportive data are available for each of these options, even though the consensus group concluded that there is not enough comparative evidence "to recommend one over another," he said.
Rather, the consensus group is recommending that the choice of therapies beyond NSAIDs and physical therapy be individualized in relationship to comorbidities, personal preference, and other considerations.
Special wording is being developed in regard to the use of corticosteroid injections. This wording was partly inspired by a meta-analysis that associated corticosteroid injections with an adverse effect on the integrity of tendons. Although there were many criticisms of this report, there was sufficient concern among the consensus group to urge that this treatment be used with caution.
"We think that these injections should only be provided by experienced physicians," Dr. Siegel reported. The wording in the preliminary draft is that adjunctive corticosteroid injections "may be considered on an individual basis."
When published, the enthesitis guidelines will include grading for the quality of the evidence behind each recommendation as well as the relative strength of the recommendation conferred by the expert panel.
Dr. Siegel reported financial relationships with Amgen and AbbVie.
NEW YORK – Conventional disease-modifying antirheumatic drugs will not be included among acceptable treatments for enthesitis related to psoriatic arthritis, according to a draft of guidelines being prepared for publication.
"The only controlled trial with a DMARD [disease-modifying antirheumatic drug] for enthesitis was conducted with sulfasalazine, and it was negative," said Dr. Evan L. Siegel, who is in group practice in rheumatology in Rockville, Md. Dr. Siegel led a group of experts preparing psoriatic arthritis enthesitis treatment recommendations to be issued by the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).
In a preliminary report on the planned treatment recommendations, which were delivered at the joint meetings of GRAPPA and the Spondyloarthritis Research & Treatment Network (SPARTAN), Dr. Siegel reported that the new recommendations will recognize only two gradations of enthesitis: mild or moderate/severe.
"It is difficult to differentiate moderate from severe because these have not been treated as distinct entities in the clinical trials," Dr. Siegel said. Patients experience severity in regard to intensity of pain and limitation of function, either or both of which may represent severe enthesitis in any given individual patient, according to Dr. Siegel, who also noted that the number of sites of activity is also generally unhelpful.
"Significant activity at a single site may be sufficient to produce a major functional deficit in one individual, whereas the activity at multiple sites may not produce much symptomatology or functional loss in another," Dr. Siegel said.
Enthesitis, an inflammation at the site where tendons or ligaments attach to bone, has been reported in up to 70% of patients with psoriatic arthritis. In some patients, it is the dominant symptom. However, the number of treatment trials in which control of enthesitis is the primary outcome continues to be limited, according to Dr. Siegel. He acknowledged that many of the proposed treatment recommendations owed more to expert opinion than to data.
This is true of the proposed first-line recommendation, he said, which is the use of nonsteroidal anti-inflammatory drugs and physical therapy. For NSAIDs, the wording of the recommendation will emphasize the need to monitor side effects.
The expert opinion of the GRAPPA consensus group was nearly unanimous that NSAIDs and physical therapy are effective and should be tried initially in both mild and moderate/severe disease, even though Dr. Siegel said that the supportive data from controlled trials are limited.
For those with moderate/severe enthesitis not sufficiently controlled on NSAIDs, alternatives include tumor necrosis factor inhibitors, ustekinumab, and apremilast. Some supportive data are available for each of these options, even though the consensus group concluded that there is not enough comparative evidence "to recommend one over another," he said.
Rather, the consensus group is recommending that the choice of therapies beyond NSAIDs and physical therapy be individualized in relationship to comorbidities, personal preference, and other considerations.
Special wording is being developed in regard to the use of corticosteroid injections. This wording was partly inspired by a meta-analysis that associated corticosteroid injections with an adverse effect on the integrity of tendons. Although there were many criticisms of this report, there was sufficient concern among the consensus group to urge that this treatment be used with caution.
"We think that these injections should only be provided by experienced physicians," Dr. Siegel reported. The wording in the preliminary draft is that adjunctive corticosteroid injections "may be considered on an individual basis."
When published, the enthesitis guidelines will include grading for the quality of the evidence behind each recommendation as well as the relative strength of the recommendation conferred by the expert panel.
Dr. Siegel reported financial relationships with Amgen and AbbVie.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
New guidelines proposed for nail involvement in psoriatic arthritis
NEW YORK – A consensus group has developed evidence-based treatment recommendations for patients with psoriatic arthritis and nail involvement and raised the possibility of issuing them independent of recommendations for the skin, according to a report on the deliberations.
"The suggestion has been made to separate out skin from nail because the assessment is quite different to the point where you can potentially have patients with severe nail disease but limited skin disease," reported Dr. April W. Armstrong, director of the psoriasis program at the University of Colorado, Denver.
The proposal was made in the course of presenting the preliminary evidence-based recommendations on managing psoriatic arthritis (PsA) nail involvement to the full membership of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. GRAPPA is in the process of preparing a new set of PsA treatment recommendations.
The decision to address nails separately from skin was not a unanimous recommendation within the committee, and no conclusion was reached, but Dr. Armstrong brought the issue forward "to be clear about our ambiguity" regarding this specific aspect of how to best outline treatment options useful to clinicians.
Other recommendations, based on evidence, are more assured of making the final version, because they are evidence based. When presented at GRAPPA, which convened its most recent annual meeting jointly with the Spondyloarthritis Research & Treatment Network, each recommendation was graded for the quality of the evidence and strength of the consensus.
For example, the committee found little controlled evidence to support a significant benefit from topical therapies, including those commonly used, such as steroids and vitamin D analogs. Although the consensus committee concluded that the risk of adverse events is low and the costs are low to moderate, the efficacy is only modest. The strength for recommending topical therapies overall was characterized as "weak."
For procedural therapies, such as pulsed-dye laser or intralesional injections, no placebo-controlled trials could be identified by the committee, and the expert opinion of its members was that the efficacy is relatively low in general even if benefit is achieved in some individuals. The cost was characterized as low to moderate. The committee concluded that only a "weak" recommendation should be conferred to these types of interventions for nail involvement.
The proposed recommendation for oral therapies, such a methotrexate, cyclosporine, leflunomide, and acitretin, was considered "stronger than that for topical therapies" when nail involvement is moderate, but the committee also found supportive evidence of benefit to be of "low quality." Again, although recognizing that some PsA patients may benefit, the recommendation for oral therapies overall for nail involvement was characterized as weak.
For biologics, including both tumor necrosis factor (TNF) inhibitors and the interleukin 12/23 inhibitor ustekinumab, the consensus committee reported that there are good quality data showing efficacy in nails, including some studies showing superiority of TNF inhibitors to methotrexate and cyclosporine. For patients with moderate to severe nail involvement warranting the potential risks of these therapies, the preliminary recommendation for these agents was "strong" even if the costs of these therapies were characterized as "high to crazy."
One unresolved issue, however, is which strategy to recommend for placing nail involvement into "mild," "moderate," or "severe" categories. Objective scores, such as Nail Psoriasis Severity Index (NAPSI), were considered by the consensus committee to be helpful but insufficient.
"Perhaps in addition to objective scoring of nail disease, we should also take into account [the impact] on quality of life as well as function," Dr. Armstrong said.
The final GRAPPA treatment recommendations for nail involvement, as well as other aspects of PsA management, will be made after a discussion of the consensus group proposals over the next several months, followed by voting among the GRAPPA membership. As GRAPPA is an international organization, it is intended that final recommendations will be broadly applicable.
Dr. Armstrong reported financial relationships with AbbVie, Amgen, Janssen Biotech, Merck, Novartis, and Pfizer.
NEW YORK – A consensus group has developed evidence-based treatment recommendations for patients with psoriatic arthritis and nail involvement and raised the possibility of issuing them independent of recommendations for the skin, according to a report on the deliberations.
"The suggestion has been made to separate out skin from nail because the assessment is quite different to the point where you can potentially have patients with severe nail disease but limited skin disease," reported Dr. April W. Armstrong, director of the psoriasis program at the University of Colorado, Denver.
The proposal was made in the course of presenting the preliminary evidence-based recommendations on managing psoriatic arthritis (PsA) nail involvement to the full membership of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. GRAPPA is in the process of preparing a new set of PsA treatment recommendations.
The decision to address nails separately from skin was not a unanimous recommendation within the committee, and no conclusion was reached, but Dr. Armstrong brought the issue forward "to be clear about our ambiguity" regarding this specific aspect of how to best outline treatment options useful to clinicians.
Other recommendations, based on evidence, are more assured of making the final version, because they are evidence based. When presented at GRAPPA, which convened its most recent annual meeting jointly with the Spondyloarthritis Research & Treatment Network, each recommendation was graded for the quality of the evidence and strength of the consensus.
For example, the committee found little controlled evidence to support a significant benefit from topical therapies, including those commonly used, such as steroids and vitamin D analogs. Although the consensus committee concluded that the risk of adverse events is low and the costs are low to moderate, the efficacy is only modest. The strength for recommending topical therapies overall was characterized as "weak."
For procedural therapies, such as pulsed-dye laser or intralesional injections, no placebo-controlled trials could be identified by the committee, and the expert opinion of its members was that the efficacy is relatively low in general even if benefit is achieved in some individuals. The cost was characterized as low to moderate. The committee concluded that only a "weak" recommendation should be conferred to these types of interventions for nail involvement.
The proposed recommendation for oral therapies, such a methotrexate, cyclosporine, leflunomide, and acitretin, was considered "stronger than that for topical therapies" when nail involvement is moderate, but the committee also found supportive evidence of benefit to be of "low quality." Again, although recognizing that some PsA patients may benefit, the recommendation for oral therapies overall for nail involvement was characterized as weak.
For biologics, including both tumor necrosis factor (TNF) inhibitors and the interleukin 12/23 inhibitor ustekinumab, the consensus committee reported that there are good quality data showing efficacy in nails, including some studies showing superiority of TNF inhibitors to methotrexate and cyclosporine. For patients with moderate to severe nail involvement warranting the potential risks of these therapies, the preliminary recommendation for these agents was "strong" even if the costs of these therapies were characterized as "high to crazy."
One unresolved issue, however, is which strategy to recommend for placing nail involvement into "mild," "moderate," or "severe" categories. Objective scores, such as Nail Psoriasis Severity Index (NAPSI), were considered by the consensus committee to be helpful but insufficient.
"Perhaps in addition to objective scoring of nail disease, we should also take into account [the impact] on quality of life as well as function," Dr. Armstrong said.
The final GRAPPA treatment recommendations for nail involvement, as well as other aspects of PsA management, will be made after a discussion of the consensus group proposals over the next several months, followed by voting among the GRAPPA membership. As GRAPPA is an international organization, it is intended that final recommendations will be broadly applicable.
Dr. Armstrong reported financial relationships with AbbVie, Amgen, Janssen Biotech, Merck, Novartis, and Pfizer.
NEW YORK – A consensus group has developed evidence-based treatment recommendations for patients with psoriatic arthritis and nail involvement and raised the possibility of issuing them independent of recommendations for the skin, according to a report on the deliberations.
"The suggestion has been made to separate out skin from nail because the assessment is quite different to the point where you can potentially have patients with severe nail disease but limited skin disease," reported Dr. April W. Armstrong, director of the psoriasis program at the University of Colorado, Denver.
The proposal was made in the course of presenting the preliminary evidence-based recommendations on managing psoriatic arthritis (PsA) nail involvement to the full membership of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. GRAPPA is in the process of preparing a new set of PsA treatment recommendations.
The decision to address nails separately from skin was not a unanimous recommendation within the committee, and no conclusion was reached, but Dr. Armstrong brought the issue forward "to be clear about our ambiguity" regarding this specific aspect of how to best outline treatment options useful to clinicians.
Other recommendations, based on evidence, are more assured of making the final version, because they are evidence based. When presented at GRAPPA, which convened its most recent annual meeting jointly with the Spondyloarthritis Research & Treatment Network, each recommendation was graded for the quality of the evidence and strength of the consensus.
For example, the committee found little controlled evidence to support a significant benefit from topical therapies, including those commonly used, such as steroids and vitamin D analogs. Although the consensus committee concluded that the risk of adverse events is low and the costs are low to moderate, the efficacy is only modest. The strength for recommending topical therapies overall was characterized as "weak."
For procedural therapies, such as pulsed-dye laser or intralesional injections, no placebo-controlled trials could be identified by the committee, and the expert opinion of its members was that the efficacy is relatively low in general even if benefit is achieved in some individuals. The cost was characterized as low to moderate. The committee concluded that only a "weak" recommendation should be conferred to these types of interventions for nail involvement.
The proposed recommendation for oral therapies, such a methotrexate, cyclosporine, leflunomide, and acitretin, was considered "stronger than that for topical therapies" when nail involvement is moderate, but the committee also found supportive evidence of benefit to be of "low quality." Again, although recognizing that some PsA patients may benefit, the recommendation for oral therapies overall for nail involvement was characterized as weak.
For biologics, including both tumor necrosis factor (TNF) inhibitors and the interleukin 12/23 inhibitor ustekinumab, the consensus committee reported that there are good quality data showing efficacy in nails, including some studies showing superiority of TNF inhibitors to methotrexate and cyclosporine. For patients with moderate to severe nail involvement warranting the potential risks of these therapies, the preliminary recommendation for these agents was "strong" even if the costs of these therapies were characterized as "high to crazy."
One unresolved issue, however, is which strategy to recommend for placing nail involvement into "mild," "moderate," or "severe" categories. Objective scores, such as Nail Psoriasis Severity Index (NAPSI), were considered by the consensus committee to be helpful but insufficient.
"Perhaps in addition to objective scoring of nail disease, we should also take into account [the impact] on quality of life as well as function," Dr. Armstrong said.
The final GRAPPA treatment recommendations for nail involvement, as well as other aspects of PsA management, will be made after a discussion of the consensus group proposals over the next several months, followed by voting among the GRAPPA membership. As GRAPPA is an international organization, it is intended that final recommendations will be broadly applicable.
Dr. Armstrong reported financial relationships with AbbVie, Amgen, Janssen Biotech, Merck, Novartis, and Pfizer.
AT THE 2014 GRAPPA AND SPARTAN ANNUAL MEETINGS
