Psoriasis

PRAGUE — For psoriasis patients who can handle the smell and mess, coal tar remains an effective, inexpensive treatment option for stable disease, according to Dr. Uma Kumar.

Coal tar proved just as effective as topical tazarotene (Tazorac) in a small randomized study of patients with stable plaque psoriasis. All patients in both groups had either marked or moderate improvement after 12 weeks of treatment.

“Our results indicate that tazarotene 0.1% gel and coal tar 5% ointment appear to have comparable efficacy in stable plaque psoriasis,” Dr. Kumar of the All Indian Institute of Medical Sciences in New Delhi reported at the International Congress of Dermatology.

“Considering the overall cost to benefit ratio in a chronic disease like psoriasis, coal tar ointment is still an effective treatment modality for patients with stable plaque psoriasis, especially in developing countries where the treatment'health care costs are borne by patients themselves,” he said.

The findings came from a comparison of tazarotene gel and crude coal tar in 30 patients with stable plaque psoriasis. The patients had limited disease, defined as involvement of less than 20% of body surface area. Disease duration averaged about 9 years. Before the initiation of randomized treatment, patients completed a 4-week washout period for systemic therapy—2 weeks for topical therapy.

Each patient was treated simultaneously with both agents in an unblinded manner: tazarotene on the right side of the body and coal tar on the left. Treatment continued for 12 weeks, and patients were assessed at 2-week intervals. Response was determined by change in an erythema, scaling, and induration (ESI) score, which averaged about 28 at baseline.

The ESI scores did not differ significantly between treatments at any of the assessments. At 12 weeks, ESI scores averaged 7.1 with tazarotene treatment and 5.9 with coal tar. The mean ESI score for lesions treated with coal tar were lower at 6 and 10 weeks, in addition to the end of the study.

Dr. Kumar reported that 27 patients completed the study. Psoriasis lesions improved by at least 50% in all patients on both sides of the body. Investigators rated the improvement as marked in 41% of tazarotene-treated areas and 59% of areas treated with coal tar. The figures were reversed for moderate improvement.

“Coal tar is one of the commonest conventional treatment modalities for psoriasis,” Dr. Kumar said. “Various studies have proved its effectiveness time and again.

“Patient acceptability is the major problem with coal tar. The preparations are usually greasy and unpleasant smelling, and they can stain clothing,” he noted.

Dr. Kumar and his colleagues reported having no relevant conflicts of interest.

PRAGUE — For psoriasis patients who can handle the smell and mess, coal tar remains an effective, inexpensive treatment option for stable disease, according to Dr. Uma Kumar.

Coal tar proved just as effective as topical tazarotene (Tazorac) in a small randomized study of patients with stable plaque psoriasis. All patients in both groups had either marked or moderate improvement after 12 weeks of treatment.

“Our results indicate that tazarotene 0.1% gel and coal tar 5% ointment appear to have comparable efficacy in stable plaque psoriasis,” Dr. Kumar of the All Indian Institute of Medical Sciences in New Delhi reported at the International Congress of Dermatology.

“Considering the overall cost to benefit ratio in a chronic disease like psoriasis, coal tar ointment is still an effective treatment modality for patients with stable plaque psoriasis, especially in developing countries where the treatment'health care costs are borne by patients themselves,” he said.

The findings came from a comparison of tazarotene gel and crude coal tar in 30 patients with stable plaque psoriasis. The patients had limited disease, defined as involvement of less than 20% of body surface area. Disease duration averaged about 9 years. Before the initiation of randomized treatment, patients completed a 4-week washout period for systemic therapy—2 weeks for topical therapy.

Each patient was treated simultaneously with both agents in an unblinded manner: tazarotene on the right side of the body and coal tar on the left. Treatment continued for 12 weeks, and patients were assessed at 2-week intervals. Response was determined by change in an erythema, scaling, and induration (ESI) score, which averaged about 28 at baseline.

The ESI scores did not differ significantly between treatments at any of the assessments. At 12 weeks, ESI scores averaged 7.1 with tazarotene treatment and 5.9 with coal tar. The mean ESI score for lesions treated with coal tar were lower at 6 and 10 weeks, in addition to the end of the study.

Dr. Kumar reported that 27 patients completed the study. Psoriasis lesions improved by at least 50% in all patients on both sides of the body. Investigators rated the improvement as marked in 41% of tazarotene-treated areas and 59% of areas treated with coal tar. The figures were reversed for moderate improvement.

“Coal tar is one of the commonest conventional treatment modalities for psoriasis,” Dr. Kumar said. “Various studies have proved its effectiveness time and again.

“Patient acceptability is the major problem with coal tar. The preparations are usually greasy and unpleasant smelling, and they can stain clothing,” he noted.

Dr. Kumar and his colleagues reported having no relevant conflicts of interest.

PRAGUE — For psoriasis patients who can handle the smell and mess, coal tar remains an effective, inexpensive treatment option for stable disease, according to Dr. Uma Kumar.

Coal tar proved just as effective as topical tazarotene (Tazorac) in a small randomized study of patients with stable plaque psoriasis. All patients in both groups had either marked or moderate improvement after 12 weeks of treatment.

“Our results indicate that tazarotene 0.1% gel and coal tar 5% ointment appear to have comparable efficacy in stable plaque psoriasis,” Dr. Kumar of the All Indian Institute of Medical Sciences in New Delhi reported at the International Congress of Dermatology.

“Considering the overall cost to benefit ratio in a chronic disease like psoriasis, coal tar ointment is still an effective treatment modality for patients with stable plaque psoriasis, especially in developing countries where the treatment'health care costs are borne by patients themselves,” he said.

The findings came from a comparison of tazarotene gel and crude coal tar in 30 patients with stable plaque psoriasis. The patients had limited disease, defined as involvement of less than 20% of body surface area. Disease duration averaged about 9 years. Before the initiation of randomized treatment, patients completed a 4-week washout period for systemic therapy—2 weeks for topical therapy.

Each patient was treated simultaneously with both agents in an unblinded manner: tazarotene on the right side of the body and coal tar on the left. Treatment continued for 12 weeks, and patients were assessed at 2-week intervals. Response was determined by change in an erythema, scaling, and induration (ESI) score, which averaged about 28 at baseline.

The ESI scores did not differ significantly between treatments at any of the assessments. At 12 weeks, ESI scores averaged 7.1 with tazarotene treatment and 5.9 with coal tar. The mean ESI score for lesions treated with coal tar were lower at 6 and 10 weeks, in addition to the end of the study.

Dr. Kumar reported that 27 patients completed the study. Psoriasis lesions improved by at least 50% in all patients on both sides of the body. Investigators rated the improvement as marked in 41% of tazarotene-treated areas and 59% of areas treated with coal tar. The figures were reversed for moderate improvement.

“Coal tar is one of the commonest conventional treatment modalities for psoriasis,” Dr. Kumar said. “Various studies have proved its effectiveness time and again.

“Patient acceptability is the major problem with coal tar. The preparations are usually greasy and unpleasant smelling, and they can stain clothing,” he noted.

Dr. Kumar and his colleagues reported having no relevant conflicts of interest.

PRAGUE — The diabetes drug pioglitazone significantly improved psoriasis control when added to oral acitretin, data from a small clinical trial found.

The combination led to a 64% reduction in psoriasis severity, compared with 52% for acitretin alone, Dr. Sunil Dogra of the Postgraduate Institute of Medical Education and Research in Chandigarh, India, and colleagues reported at the International Congress of Dermatology.

“From our study results it is apparent that the addition of pioglitazone [Actos] to acitretin [Soriatane] therapy can enhance antipsoriatic efficacy,” he reported in a poster presentation. Initial worsening of disease severity occurred less often with the combination, but the difference did not achieve statistical significance.

“In comparison to other antipsoriatic drugs used in combination with acitretin, pioglitazone may offer a safer alternative, as it has been used in patients with diabetes mellitus for several years, and most placebo-controlled trials have shown the incidence of side effects due to pioglitazone to be approximately equal to that found with placebo,” he reported.

The rationale for using a thiazolidinedione drug to treat psoriasis came from evidence that activation of peroxisome-proliferator activated receptor-gamma (PPAR-gamma) may inhibit proliferation and promote cell differentiation, according to the investigators.

Experience with troglitazone showed reduced psoriasis disease activity and normalized histologic features of psoriatic skin, Dr. Dogra noted. And, studies of pioglitazone in psoriasis have shown response rates as high as 50%.

Given that acitretin and PPAR-gamma activators decrease proliferation, induce differentiation, and have anti-inflammatory activity, the investigators combined the drugs to try and achieve therapeutic synergy. They hypothesized that pioglitazone might counter acitretin-induced lipid abnormalities.

Dr. Dogra and colleagues randomized 41 patients with plaque psoriasis requiring systemic therapy. Patients received acitretin 25 mg/day plus either pioglitazone 15 mg/day or placebo.

Patients had follow-up visits at 2, 4, 8, and 12 weeks. The primary efficacy end point was the change in Psoriasis Area and Severity Index (PASI) from baseline to 12 weeks.

The baseline PASI score averaged 19.3 in the acitretin-placebo group and 17.5 in the acitretin-pioglitazone group. The mean PASI score had worsened at 2 weeks in 37% of the acitretin-pioglitazone group and 50% of the acitretin-placebo group.

At 12 weeks, the median PASI score in the pioglitazone group was 6.0, a reduction of 11.5 from baseline. That compared with a median score of 10.0 in the placebo group and a reduction of 9.7 from baseline. The difference translated into a statistically significant advantage in favor of acitretin-pioglitazone.

No unexpected adverse effects occurred in either treatment group, and no patients had any laboratory abnormalities during the study.

The investigators acknowledged the small size of the study, that they used the lowest available dose of pioglitazone, and that women of child-bearing potential were excluded from the study.

“PPAR-gamma agonists are known to possess an array of beneficial effects, including decreased blood pressure, increased HDL, and improved fibrinolysis,” the investigators said. “Moreover, the occurrence of diabetes, hypertension, and metabolic syndrome in patients with psoriasis is not uncommon. These conditions may co-exist more often than predicted from the prevalence of either disorder alone. Pioglitazone may be particularly useful in these subsets of patients.”

The results warrant additional studies of the combination, including evaluations of the safety and efficacy combining higher doses of pioglitazone with acitretin.

The investigators declared having no relevant conflicts of interest.

PRAGUE — The diabetes drug pioglitazone significantly improved psoriasis control when added to oral acitretin, data from a small clinical trial found.

The combination led to a 64% reduction in psoriasis severity, compared with 52% for acitretin alone, Dr. Sunil Dogra of the Postgraduate Institute of Medical Education and Research in Chandigarh, India, and colleagues reported at the International Congress of Dermatology.

“From our study results it is apparent that the addition of pioglitazone [Actos] to acitretin [Soriatane] therapy can enhance antipsoriatic efficacy,” he reported in a poster presentation. Initial worsening of disease severity occurred less often with the combination, but the difference did not achieve statistical significance.

“In comparison to other antipsoriatic drugs used in combination with acitretin, pioglitazone may offer a safer alternative, as it has been used in patients with diabetes mellitus for several years, and most placebo-controlled trials have shown the incidence of side effects due to pioglitazone to be approximately equal to that found with placebo,” he reported.

The rationale for using a thiazolidinedione drug to treat psoriasis came from evidence that activation of peroxisome-proliferator activated receptor-gamma (PPAR-gamma) may inhibit proliferation and promote cell differentiation, according to the investigators.

Experience with troglitazone showed reduced psoriasis disease activity and normalized histologic features of psoriatic skin, Dr. Dogra noted. And, studies of pioglitazone in psoriasis have shown response rates as high as 50%.

Given that acitretin and PPAR-gamma activators decrease proliferation, induce differentiation, and have anti-inflammatory activity, the investigators combined the drugs to try and achieve therapeutic synergy. They hypothesized that pioglitazone might counter acitretin-induced lipid abnormalities.

Dr. Dogra and colleagues randomized 41 patients with plaque psoriasis requiring systemic therapy. Patients received acitretin 25 mg/day plus either pioglitazone 15 mg/day or placebo.

Patients had follow-up visits at 2, 4, 8, and 12 weeks. The primary efficacy end point was the change in Psoriasis Area and Severity Index (PASI) from baseline to 12 weeks.

The baseline PASI score averaged 19.3 in the acitretin-placebo group and 17.5 in the acitretin-pioglitazone group. The mean PASI score had worsened at 2 weeks in 37% of the acitretin-pioglitazone group and 50% of the acitretin-placebo group.

At 12 weeks, the median PASI score in the pioglitazone group was 6.0, a reduction of 11.5 from baseline. That compared with a median score of 10.0 in the placebo group and a reduction of 9.7 from baseline. The difference translated into a statistically significant advantage in favor of acitretin-pioglitazone.

No unexpected adverse effects occurred in either treatment group, and no patients had any laboratory abnormalities during the study.

The investigators acknowledged the small size of the study, that they used the lowest available dose of pioglitazone, and that women of child-bearing potential were excluded from the study.

“PPAR-gamma agonists are known to possess an array of beneficial effects, including decreased blood pressure, increased HDL, and improved fibrinolysis,” the investigators said. “Moreover, the occurrence of diabetes, hypertension, and metabolic syndrome in patients with psoriasis is not uncommon. These conditions may co-exist more often than predicted from the prevalence of either disorder alone. Pioglitazone may be particularly useful in these subsets of patients.”

The results warrant additional studies of the combination, including evaluations of the safety and efficacy combining higher doses of pioglitazone with acitretin.

The investigators declared having no relevant conflicts of interest.

PRAGUE — The diabetes drug pioglitazone significantly improved psoriasis control when added to oral acitretin, data from a small clinical trial found.

The combination led to a 64% reduction in psoriasis severity, compared with 52% for acitretin alone, Dr. Sunil Dogra of the Postgraduate Institute of Medical Education and Research in Chandigarh, India, and colleagues reported at the International Congress of Dermatology.

“From our study results it is apparent that the addition of pioglitazone [Actos] to acitretin [Soriatane] therapy can enhance antipsoriatic efficacy,” he reported in a poster presentation. Initial worsening of disease severity occurred less often with the combination, but the difference did not achieve statistical significance.

“In comparison to other antipsoriatic drugs used in combination with acitretin, pioglitazone may offer a safer alternative, as it has been used in patients with diabetes mellitus for several years, and most placebo-controlled trials have shown the incidence of side effects due to pioglitazone to be approximately equal to that found with placebo,” he reported.

The rationale for using a thiazolidinedione drug to treat psoriasis came from evidence that activation of peroxisome-proliferator activated receptor-gamma (PPAR-gamma) may inhibit proliferation and promote cell differentiation, according to the investigators.

Experience with troglitazone showed reduced psoriasis disease activity and normalized histologic features of psoriatic skin, Dr. Dogra noted. And, studies of pioglitazone in psoriasis have shown response rates as high as 50%.

Given that acitretin and PPAR-gamma activators decrease proliferation, induce differentiation, and have anti-inflammatory activity, the investigators combined the drugs to try and achieve therapeutic synergy. They hypothesized that pioglitazone might counter acitretin-induced lipid abnormalities.

Dr. Dogra and colleagues randomized 41 patients with plaque psoriasis requiring systemic therapy. Patients received acitretin 25 mg/day plus either pioglitazone 15 mg/day or placebo.

Patients had follow-up visits at 2, 4, 8, and 12 weeks. The primary efficacy end point was the change in Psoriasis Area and Severity Index (PASI) from baseline to 12 weeks.

The baseline PASI score averaged 19.3 in the acitretin-placebo group and 17.5 in the acitretin-pioglitazone group. The mean PASI score had worsened at 2 weeks in 37% of the acitretin-pioglitazone group and 50% of the acitretin-placebo group.

At 12 weeks, the median PASI score in the pioglitazone group was 6.0, a reduction of 11.5 from baseline. That compared with a median score of 10.0 in the placebo group and a reduction of 9.7 from baseline. The difference translated into a statistically significant advantage in favor of acitretin-pioglitazone.

No unexpected adverse effects occurred in either treatment group, and no patients had any laboratory abnormalities during the study.

The investigators acknowledged the small size of the study, that they used the lowest available dose of pioglitazone, and that women of child-bearing potential were excluded from the study.

“PPAR-gamma agonists are known to possess an array of beneficial effects, including decreased blood pressure, increased HDL, and improved fibrinolysis,” the investigators said. “Moreover, the occurrence of diabetes, hypertension, and metabolic syndrome in patients with psoriasis is not uncommon. These conditions may co-exist more often than predicted from the prevalence of either disorder alone. Pioglitazone may be particularly useful in these subsets of patients.”

The results warrant additional studies of the combination, including evaluations of the safety and efficacy combining higher doses of pioglitazone with acitretin.

The investigators declared having no relevant conflicts of interest.

SEATTLE — Reductions in skin elasticity appear to be a possible biomarker for the progression of amyotrophic lateral sclerosis that deserves further study, according to study results.

The change in the potential biomarker was associated with changes in the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised and other clinical measures of disease progression, including forced vital capacity.

ALS patients are known to have reduced skin elasticity, in which the skin returns slowly to its original shape and dimensions after being stretched. However, this phenomenon has not been quantified and suffers from substantial intra- and interobserver variability.

Structural and biochemical abnormalities of the skin in ALS also have been identified, including reduced and loosely woven collagen bundles with accumulation of amorphous materials between the bundles, collagen fibrils with irregular diameter, noninflammatory vasculopathy, and deposits of beta-amyloid protein close to blood vessels. One study also found a significant negative correlation between the diameter of collagen fibrils and the duration of ALS (J. Neurol. Sci. 1993;119:74-8), Dr. Harvey Arbesman said at the annual meeting of the American Academy of Neurology.

The skin changes that appear in ALS patients could be analogous to changes that are occurring in the CNS because both the CNS and skin arise from the neural crest in development and many diseases affect both systems, suggested Dr. Arbesman, a dermatologist in Williamsville, N.Y.

"Our objective was to test the hypothesis that chronologic, quantitative measurements of skin elasticity could be a useful, noninvasive, biomechanical biomarker of disease progression in patients with ALS and aid in diagnosis," he said.

Dr. Arbesman and his colleagues measured skin elasticity with a cutometer on the arm and back at baseline in 40 ALS patients and 30 of their family members or caregivers, who served as controls. Most of the control participants were spouses. None of the patients had superoxide dismutase 1 (SOD1) mutations, which are known to cause about 20% of familial ALS cases.

Compared with the controls, skin elasticity in ALS patients was significantly reduced in measurements on the arm with 2-mm and 8-mm Cutometer probes.

The investigators controlled for age at baseline because skin elasticity declines with age. Cutometer measurements with 2-mm probes assessed the elastic properties of the epidermis and papillary dermis, whereas measurements with the 8-mm probe evaluated the elastic properties of the whole skin, he said.

"We took into account if the patient had developed, let's say, right-sided disease first and that was the presenting complaint, then we used the affected side. If it was bilateral involvement when it was presented, then by default we used the right side," Dr. Arbesman said.

Because the hydration status of the skin will affect its elasticity, the investigators instructed patients not to make any changes in their skin care habits on the day of each visit. The air temperature and humidity of the clinic were monitored at each visit to ensure that they were the same.

Skin elasticity on the back was significantly correlated with scores on the ALS Functional Rating Scale-Revised, as well as forced vital capacity, at 3 months. The group has collected 6-month follow-up data that are still being analyzed, he said.

The changes in the Cutometer readings between baseline and follow-up measurements were assessed on a plot of the area under the curve for the ratio between the two curves that are generated during the suction and relaxation phases of the elasticity measurement for each anatomic location. This tends to correct for any edema or changes in subcutaneous fat that might have occurred between measurements, he said.

"Further studies are needed to elucidate the relationship of this biomarker to specific biochemical changes relevant to the pathogenesis of ALS," Dr. Arbesman concluded.

The study was funded by ArbesIdeas Inc., the Muscular Dystrophy Association's Wings Over Wall Street, Prize4Life, and the University of Missouri-Columbia Dermatology Research Fund. Dr. Arbesman, the vice president of ArbesIdeas Inc., was awarded part of a $100,000 prize pool for winning Prize4Life's ALS Biomarker Discovery Prize.

SEATTLE — Reductions in skin elasticity appear to be a possible biomarker for the progression of amyotrophic lateral sclerosis that deserves further study, according to study results.

The change in the potential biomarker was associated with changes in the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised and other clinical measures of disease progression, including forced vital capacity.

ALS patients are known to have reduced skin elasticity, in which the skin returns slowly to its original shape and dimensions after being stretched. However, this phenomenon has not been quantified and suffers from substantial intra- and interobserver variability.

Structural and biochemical abnormalities of the skin in ALS also have been identified, including reduced and loosely woven collagen bundles with accumulation of amorphous materials between the bundles, collagen fibrils with irregular diameter, noninflammatory vasculopathy, and deposits of beta-amyloid protein close to blood vessels. One study also found a significant negative correlation between the diameter of collagen fibrils and the duration of ALS (J. Neurol. Sci. 1993;119:74-8), Dr. Harvey Arbesman said at the annual meeting of the American Academy of Neurology.

The skin changes that appear in ALS patients could be analogous to changes that are occurring in the CNS because both the CNS and skin arise from the neural crest in development and many diseases affect both systems, suggested Dr. Arbesman, a dermatologist in Williamsville, N.Y.

"Our objective was to test the hypothesis that chronologic, quantitative measurements of skin elasticity could be a useful, noninvasive, biomechanical biomarker of disease progression in patients with ALS and aid in diagnosis," he said.

Dr. Arbesman and his colleagues measured skin elasticity with a cutometer on the arm and back at baseline in 40 ALS patients and 30 of their family members or caregivers, who served as controls. Most of the control participants were spouses. None of the patients had superoxide dismutase 1 (SOD1) mutations, which are known to cause about 20% of familial ALS cases.

Compared with the controls, skin elasticity in ALS patients was significantly reduced in measurements on the arm with 2-mm and 8-mm Cutometer probes.

The investigators controlled for age at baseline because skin elasticity declines with age. Cutometer measurements with 2-mm probes assessed the elastic properties of the epidermis and papillary dermis, whereas measurements with the 8-mm probe evaluated the elastic properties of the whole skin, he said.

"We took into account if the patient had developed, let's say, right-sided disease first and that was the presenting complaint, then we used the affected side. If it was bilateral involvement when it was presented, then by default we used the right side," Dr. Arbesman said.

Because the hydration status of the skin will affect its elasticity, the investigators instructed patients not to make any changes in their skin care habits on the day of each visit. The air temperature and humidity of the clinic were monitored at each visit to ensure that they were the same.

Skin elasticity on the back was significantly correlated with scores on the ALS Functional Rating Scale-Revised, as well as forced vital capacity, at 3 months. The group has collected 6-month follow-up data that are still being analyzed, he said.

The changes in the Cutometer readings between baseline and follow-up measurements were assessed on a plot of the area under the curve for the ratio between the two curves that are generated during the suction and relaxation phases of the elasticity measurement for each anatomic location. This tends to correct for any edema or changes in subcutaneous fat that might have occurred between measurements, he said.

"Further studies are needed to elucidate the relationship of this biomarker to specific biochemical changes relevant to the pathogenesis of ALS," Dr. Arbesman concluded.

The study was funded by ArbesIdeas Inc., the Muscular Dystrophy Association's Wings Over Wall Street, Prize4Life, and the University of Missouri-Columbia Dermatology Research Fund. Dr. Arbesman, the vice president of ArbesIdeas Inc., was awarded part of a $100,000 prize pool for winning Prize4Life's ALS Biomarker Discovery Prize.

SEATTLE — Reductions in skin elasticity appear to be a possible biomarker for the progression of amyotrophic lateral sclerosis that deserves further study, according to study results.

The change in the potential biomarker was associated with changes in the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised and other clinical measures of disease progression, including forced vital capacity.

ALS patients are known to have reduced skin elasticity, in which the skin returns slowly to its original shape and dimensions after being stretched. However, this phenomenon has not been quantified and suffers from substantial intra- and interobserver variability.

Structural and biochemical abnormalities of the skin in ALS also have been identified, including reduced and loosely woven collagen bundles with accumulation of amorphous materials between the bundles, collagen fibrils with irregular diameter, noninflammatory vasculopathy, and deposits of beta-amyloid protein close to blood vessels. One study also found a significant negative correlation between the diameter of collagen fibrils and the duration of ALS (J. Neurol. Sci. 1993;119:74-8), Dr. Harvey Arbesman said at the annual meeting of the American Academy of Neurology.

The skin changes that appear in ALS patients could be analogous to changes that are occurring in the CNS because both the CNS and skin arise from the neural crest in development and many diseases affect both systems, suggested Dr. Arbesman, a dermatologist in Williamsville, N.Y.

"Our objective was to test the hypothesis that chronologic, quantitative measurements of skin elasticity could be a useful, noninvasive, biomechanical biomarker of disease progression in patients with ALS and aid in diagnosis," he said.

Dr. Arbesman and his colleagues measured skin elasticity with a cutometer on the arm and back at baseline in 40 ALS patients and 30 of their family members or caregivers, who served as controls. Most of the control participants were spouses. None of the patients had superoxide dismutase 1 (SOD1) mutations, which are known to cause about 20% of familial ALS cases.

Compared with the controls, skin elasticity in ALS patients was significantly reduced in measurements on the arm with 2-mm and 8-mm Cutometer probes.

The investigators controlled for age at baseline because skin elasticity declines with age. Cutometer measurements with 2-mm probes assessed the elastic properties of the epidermis and papillary dermis, whereas measurements with the 8-mm probe evaluated the elastic properties of the whole skin, he said.

"We took into account if the patient had developed, let's say, right-sided disease first and that was the presenting complaint, then we used the affected side. If it was bilateral involvement when it was presented, then by default we used the right side," Dr. Arbesman said.

Because the hydration status of the skin will affect its elasticity, the investigators instructed patients not to make any changes in their skin care habits on the day of each visit. The air temperature and humidity of the clinic were monitored at each visit to ensure that they were the same.

Skin elasticity on the back was significantly correlated with scores on the ALS Functional Rating Scale-Revised, as well as forced vital capacity, at 3 months. The group has collected 6-month follow-up data that are still being analyzed, he said.

The changes in the Cutometer readings between baseline and follow-up measurements were assessed on a plot of the area under the curve for the ratio between the two curves that are generated during the suction and relaxation phases of the elasticity measurement for each anatomic location. This tends to correct for any edema or changes in subcutaneous fat that might have occurred between measurements, he said.

"Further studies are needed to elucidate the relationship of this biomarker to specific biochemical changes relevant to the pathogenesis of ALS," Dr. Arbesman concluded.

The study was funded by ArbesIdeas Inc., the Muscular Dystrophy Association's Wings Over Wall Street, Prize4Life, and the University of Missouri-Columbia Dermatology Research Fund. Dr. Arbesman, the vice president of ArbesIdeas Inc., was awarded part of a $100,000 prize pool for winning Prize4Life's ALS Biomarker Discovery Prize.

CHICAGO — Few physicians would be fooled nowadays by gadolinium-induced nephrogenic systemic fibrosis, but there are other diseases that can masquerade as scleroderma.

The precise diagnosis of sclerodermalike illnesses is important because even though many of them are called scleroderma, they are different from systemic sclerosis in their treatments and outcomes, Dr. Virginia Steen said at a symposium sponsored by the American College of Rheumatology. The diagnosis is most often based on the distribution and clinical characteristics of skin findings, as biopsies don't always differentiate types of scleroderma. She recommended watching for the following conditions:

▸ Lipodermatosclerosis is one condition that physicians often fail to think of as a scleroderma mimic. Also known as hypodermatitis sclerodermaformis, it refers to localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg. In the acute stage, the leg is inflamed and warm, the skin is very tight, and cellulitis may be present. The ankle and toes are not involved.

In its chronic stage, there is induration, contraction of the skin and subcutaneous tissues, and irregular depressions that can look almost identical to lower-leg scleroderma, she said. The leg eventually resembles an inverted champagne bottle, in which the upper half remains edematous and has a much greater circumference than does the lower sclerotic portion.

Lipodermatosclerosis is a sign of severe end-stage venous insufficiency, and should be differentiated from scleroderma, cellulitis, superficial thrombophlebitis, and erythema nodosum. The diagnosis is made from clinical observation, but direct immunofluorescence of early and late lesions has been used to show dermal pericapillary fibrin deposits.

If left untreated, lipodermatosclerosis can progress to ulceration, atrophy blanche, or shortening of the Achilles tendon. Treatment involves weight loss, controlling the underlying disease, and emphasis on support stockings that may need to be specially made, said Dr. Steen, professor of medicine and director of the rheumatology fellowship program at Georgetown University in Washington. Topical steroids are useful if the skin is inflamed, and antibiotics are recommended for cellulitis.

▸ Scleredema tends to target the upper body without affecting the lower extremities. The skin on the neck and face thicken and harden; severely affected patients are unable to wrinkle their foreheads or open their mouths. In most patients, the shawl sign is present, with skin involvement over the chest and arms, she said.

Pathological features include swollen collagen with clear spaces and accumulation of hyaluronic acid and glycosaminoglycans. Although scleredema is commonly associated with diabetes, it can also occur after a viral illness. The treatment emphasis is on better diabetes control, but spontaneous resolution of symptoms is possible after infection.

▸ Eosinophilic fasciitis is a rare disorder characterized by symmetrical and painful inflammation and swelling of the extremities, leading to induration and the characteristic peau d'orange configuration. The palms may be involved, but typically the fingers and toes are spared. Contractures demonstrating the groove sign commonly evolve as a result of induration.

Eosinophilic fasciitis is slightly more common in middle-aged men, but can occur in women and children. It was initially distinguished from systemic sclerosis by the absence of Raynaud's phenomenon, autoantibodies, and visceral involvement, and it responds to corticosteroids.

Histologically, there are marked eosinophilia and inflammatory infiltrates in the fascia. The extent of the histologic changes depends on the stage of the disease, and thus is not a consistent component of the disease. Aside from marked peripheral eosinophilia, other laboratory features to watch for include an increased erythrocyte sedimentation rate, increased gamma globulin, and an increased aldolase, with a normal creatinine phosphokinase.

Physical therapy is a key component of treatment, because this and most scleroderma mimics discussed here can cause joint contractures. In eosinophilic fasciitis, low- to moderate-dose prednisone—and, if needed, methotrexate—can be given. There is also some evidence to suggest that rituximab, mycophenolate mofetil, or tumor necrosis factor inhibitors may be useful, Dr. Steen said.

▸ Diabetic cheiroarthropathy is a syndrome of limited joint mobility in the hands. It is characterized by thickened, tight, waxy hands with sclerosis of the palmar tendon sheaths that noticeably restricts mobility in the proximal interphalangeal joints and metacarpophalangeal joints. Therapeutic options are focused on improved diabetic control and exercise to improve mobility, said Dr. Steen, who disclosed having no relevant conflicts of interest.

The sclerotic plaque on this patient's lower leg is lipodermatosclerosis. COURTESY DR. KENNETH E. GREER

CHICAGO — Few physicians would be fooled nowadays by gadolinium-induced nephrogenic systemic fibrosis, but there are other diseases that can masquerade as scleroderma.

The precise diagnosis of sclerodermalike illnesses is important because even though many of them are called scleroderma, they are different from systemic sclerosis in their treatments and outcomes, Dr. Virginia Steen said at a symposium sponsored by the American College of Rheumatology. The diagnosis is most often based on the distribution and clinical characteristics of skin findings, as biopsies don't always differentiate types of scleroderma. She recommended watching for the following conditions:

▸ Lipodermatosclerosis is one condition that physicians often fail to think of as a scleroderma mimic. Also known as hypodermatitis sclerodermaformis, it refers to localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg. In the acute stage, the leg is inflamed and warm, the skin is very tight, and cellulitis may be present. The ankle and toes are not involved.

In its chronic stage, there is induration, contraction of the skin and subcutaneous tissues, and irregular depressions that can look almost identical to lower-leg scleroderma, she said. The leg eventually resembles an inverted champagne bottle, in which the upper half remains edematous and has a much greater circumference than does the lower sclerotic portion.

Lipodermatosclerosis is a sign of severe end-stage venous insufficiency, and should be differentiated from scleroderma, cellulitis, superficial thrombophlebitis, and erythema nodosum. The diagnosis is made from clinical observation, but direct immunofluorescence of early and late lesions has been used to show dermal pericapillary fibrin deposits.

If left untreated, lipodermatosclerosis can progress to ulceration, atrophy blanche, or shortening of the Achilles tendon. Treatment involves weight loss, controlling the underlying disease, and emphasis on support stockings that may need to be specially made, said Dr. Steen, professor of medicine and director of the rheumatology fellowship program at Georgetown University in Washington. Topical steroids are useful if the skin is inflamed, and antibiotics are recommended for cellulitis.

▸ Scleredema tends to target the upper body without affecting the lower extremities. The skin on the neck and face thicken and harden; severely affected patients are unable to wrinkle their foreheads or open their mouths. In most patients, the shawl sign is present, with skin involvement over the chest and arms, she said.

Pathological features include swollen collagen with clear spaces and accumulation of hyaluronic acid and glycosaminoglycans. Although scleredema is commonly associated with diabetes, it can also occur after a viral illness. The treatment emphasis is on better diabetes control, but spontaneous resolution of symptoms is possible after infection.

▸ Eosinophilic fasciitis is a rare disorder characterized by symmetrical and painful inflammation and swelling of the extremities, leading to induration and the characteristic peau d'orange configuration. The palms may be involved, but typically the fingers and toes are spared. Contractures demonstrating the groove sign commonly evolve as a result of induration.

Eosinophilic fasciitis is slightly more common in middle-aged men, but can occur in women and children. It was initially distinguished from systemic sclerosis by the absence of Raynaud's phenomenon, autoantibodies, and visceral involvement, and it responds to corticosteroids.

Histologically, there are marked eosinophilia and inflammatory infiltrates in the fascia. The extent of the histologic changes depends on the stage of the disease, and thus is not a consistent component of the disease. Aside from marked peripheral eosinophilia, other laboratory features to watch for include an increased erythrocyte sedimentation rate, increased gamma globulin, and an increased aldolase, with a normal creatinine phosphokinase.

Physical therapy is a key component of treatment, because this and most scleroderma mimics discussed here can cause joint contractures. In eosinophilic fasciitis, low- to moderate-dose prednisone—and, if needed, methotrexate—can be given. There is also some evidence to suggest that rituximab, mycophenolate mofetil, or tumor necrosis factor inhibitors may be useful, Dr. Steen said.

▸ Diabetic cheiroarthropathy is a syndrome of limited joint mobility in the hands. It is characterized by thickened, tight, waxy hands with sclerosis of the palmar tendon sheaths that noticeably restricts mobility in the proximal interphalangeal joints and metacarpophalangeal joints. Therapeutic options are focused on improved diabetic control and exercise to improve mobility, said Dr. Steen, who disclosed having no relevant conflicts of interest.

The sclerotic plaque on this patient's lower leg is lipodermatosclerosis. COURTESY DR. KENNETH E. GREER

CHICAGO — Few physicians would be fooled nowadays by gadolinium-induced nephrogenic systemic fibrosis, but there are other diseases that can masquerade as scleroderma.

The precise diagnosis of sclerodermalike illnesses is important because even though many of them are called scleroderma, they are different from systemic sclerosis in their treatments and outcomes, Dr. Virginia Steen said at a symposium sponsored by the American College of Rheumatology. The diagnosis is most often based on the distribution and clinical characteristics of skin findings, as biopsies don't always differentiate types of scleroderma. She recommended watching for the following conditions:

▸ Lipodermatosclerosis is one condition that physicians often fail to think of as a scleroderma mimic. Also known as hypodermatitis sclerodermaformis, it refers to localized chronic inflammation and fibrosis of the skin and subcutaneous tissues of the lower leg. In the acute stage, the leg is inflamed and warm, the skin is very tight, and cellulitis may be present. The ankle and toes are not involved.

In its chronic stage, there is induration, contraction of the skin and subcutaneous tissues, and irregular depressions that can look almost identical to lower-leg scleroderma, she said. The leg eventually resembles an inverted champagne bottle, in which the upper half remains edematous and has a much greater circumference than does the lower sclerotic portion.

Lipodermatosclerosis is a sign of severe end-stage venous insufficiency, and should be differentiated from scleroderma, cellulitis, superficial thrombophlebitis, and erythema nodosum. The diagnosis is made from clinical observation, but direct immunofluorescence of early and late lesions has been used to show dermal pericapillary fibrin deposits.

If left untreated, lipodermatosclerosis can progress to ulceration, atrophy blanche, or shortening of the Achilles tendon. Treatment involves weight loss, controlling the underlying disease, and emphasis on support stockings that may need to be specially made, said Dr. Steen, professor of medicine and director of the rheumatology fellowship program at Georgetown University in Washington. Topical steroids are useful if the skin is inflamed, and antibiotics are recommended for cellulitis.

▸ Scleredema tends to target the upper body without affecting the lower extremities. The skin on the neck and face thicken and harden; severely affected patients are unable to wrinkle their foreheads or open their mouths. In most patients, the shawl sign is present, with skin involvement over the chest and arms, she said.

Pathological features include swollen collagen with clear spaces and accumulation of hyaluronic acid and glycosaminoglycans. Although scleredema is commonly associated with diabetes, it can also occur after a viral illness. The treatment emphasis is on better diabetes control, but spontaneous resolution of symptoms is possible after infection.

▸ Eosinophilic fasciitis is a rare disorder characterized by symmetrical and painful inflammation and swelling of the extremities, leading to induration and the characteristic peau d'orange configuration. The palms may be involved, but typically the fingers and toes are spared. Contractures demonstrating the groove sign commonly evolve as a result of induration.

Eosinophilic fasciitis is slightly more common in middle-aged men, but can occur in women and children. It was initially distinguished from systemic sclerosis by the absence of Raynaud's phenomenon, autoantibodies, and visceral involvement, and it responds to corticosteroids.

Histologically, there are marked eosinophilia and inflammatory infiltrates in the fascia. The extent of the histologic changes depends on the stage of the disease, and thus is not a consistent component of the disease. Aside from marked peripheral eosinophilia, other laboratory features to watch for include an increased erythrocyte sedimentation rate, increased gamma globulin, and an increased aldolase, with a normal creatinine phosphokinase.

Physical therapy is a key component of treatment, because this and most scleroderma mimics discussed here can cause joint contractures. In eosinophilic fasciitis, low- to moderate-dose prednisone—and, if needed, methotrexate—can be given. There is also some evidence to suggest that rituximab, mycophenolate mofetil, or tumor necrosis factor inhibitors may be useful, Dr. Steen said.

▸ Diabetic cheiroarthropathy is a syndrome of limited joint mobility in the hands. It is characterized by thickened, tight, waxy hands with sclerosis of the palmar tendon sheaths that noticeably restricts mobility in the proximal interphalangeal joints and metacarpophalangeal joints. Therapeutic options are focused on improved diabetic control and exercise to improve mobility, said Dr. Steen, who disclosed having no relevant conflicts of interest.

The sclerotic plaque on this patient's lower leg is lipodermatosclerosis. COURTESY DR. KENNETH E. GREER

CHICAGO — Several pioneering treatment approaches have emerged to modify the vascular and fibrotic disease in scleroderma, Dr. Frederick Wigley said at a symposium sponsored by the American College of Rheumatology.

Dr. Wigley, director of the scleroderma center at Johns Hopkins University in Baltimore, discussed several of these novel therapies that are being studied and/or are in use, including the following six:

▸ Bosentan. This endothelial inhibitor is approved in the United States and Europe to manage the symptoms of pulmonary artery hypertension (PAH). Two trials in scleroderma show that bosentan (Tracleer) reduces digital ulcers but has no benefit on Raynaud's attacks, Dr. Wigley said.

▸ Tyrosine kinase inhibition with imatinib mesylate. Industry-sponsored trials are underway evaluating imatinib (Gleevec) in systemic sclerosis and PAH, and dasatinib (Sprycel) in scleroderma pulmonary fibrosis.

▸ Immunoablation with and without stem cell transplantation. This should be looked at as "an experiment in progress," Dr. Wigley said.

In a pilot study of 34 patients with poor prognosis for systemic sclerosis, major improvements in skin and overall function were reported in 17 of 27 evaluable patients who survived 1 year after high-dose immunosuppressive treatment and autologous hematopoietic cell transplantation (Blood 2007;110:1388-96).

These results came at a cost, however, with relapse occurring in 10 survivors and 23% of the 34 patients dying as a result of the procedure.

▸ Statins. These drugs have shown some benefit in early trials, possibly because they display pleiotropic effects on endothelial function that could potentially delay vascular injury.

Levels of circulating endothelial precursor cells, reduced in scleroderma, were increased up to eightfold after 12 weeks of therapy with atorvastatin (Lipitor) 10 mg/day in 14 patients with systemic sclerosis in an open-label pilot study (Arthritis Rheum. 2006;54:1946-51).

Endothelial markers improved and fewer new digital ulcers occurred with atorvastatin 40 mg/day for 16 weeks vs. placebo in 86 patients with scleroderma (J. Rheumatol. 2008;35:1801-8).

▸ ACE inhibitors. These agents have been shown to improve 12-month survival in patients with systemic scleroderma-induced renal disease, which is often associated with corticosteroids. ACE inhibitors can be used with angiotensin II receptor blockers (ARBs), calcium channel blockers, and prostaglandins when full doses of an ACE inhibitor do not control a crisis.

The true benefits and risks of combining an ACE inhibitor with other agents in scleroderma have not been fully studied, he said.

ONTARGET (Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial), which did not include scleroderma patients, showed that the use of combined ARBs and ACE inhibitors was associated with worse renal outcomes in high-risk patients, Dr. Wigley added.

▸ Prostaglandins. When administered intravenously, prostaglandins are an option for reducing digital ulcers, Raynaud's attacks, and PAH associated with scleroderma. Two trials are underway to evaluate oral formulations of iloprost and treprostinil in vascular scleroderma and Raynaud's, he said.

Dr. Wigley disclosed receiving research grants from MediQuest Therapeutics Inc., Novartis Pharmaceuticals Corp., and United Therapeutics Corp., and honoraria from MediQuest.

CHICAGO — Several pioneering treatment approaches have emerged to modify the vascular and fibrotic disease in scleroderma, Dr. Frederick Wigley said at a symposium sponsored by the American College of Rheumatology.

Dr. Wigley, director of the scleroderma center at Johns Hopkins University in Baltimore, discussed several of these novel therapies that are being studied and/or are in use, including the following six:

▸ Bosentan. This endothelial inhibitor is approved in the United States and Europe to manage the symptoms of pulmonary artery hypertension (PAH). Two trials in scleroderma show that bosentan (Tracleer) reduces digital ulcers but has no benefit on Raynaud's attacks, Dr. Wigley said.

▸ Tyrosine kinase inhibition with imatinib mesylate. Industry-sponsored trials are underway evaluating imatinib (Gleevec) in systemic sclerosis and PAH, and dasatinib (Sprycel) in scleroderma pulmonary fibrosis.

▸ Immunoablation with and without stem cell transplantation. This should be looked at as "an experiment in progress," Dr. Wigley said.

In a pilot study of 34 patients with poor prognosis for systemic sclerosis, major improvements in skin and overall function were reported in 17 of 27 evaluable patients who survived 1 year after high-dose immunosuppressive treatment and autologous hematopoietic cell transplantation (Blood 2007;110:1388-96).

These results came at a cost, however, with relapse occurring in 10 survivors and 23% of the 34 patients dying as a result of the procedure.

▸ Statins. These drugs have shown some benefit in early trials, possibly because they display pleiotropic effects on endothelial function that could potentially delay vascular injury.

Levels of circulating endothelial precursor cells, reduced in scleroderma, were increased up to eightfold after 12 weeks of therapy with atorvastatin (Lipitor) 10 mg/day in 14 patients with systemic sclerosis in an open-label pilot study (Arthritis Rheum. 2006;54:1946-51).

Endothelial markers improved and fewer new digital ulcers occurred with atorvastatin 40 mg/day for 16 weeks vs. placebo in 86 patients with scleroderma (J. Rheumatol. 2008;35:1801-8).

▸ ACE inhibitors. These agents have been shown to improve 12-month survival in patients with systemic scleroderma-induced renal disease, which is often associated with corticosteroids. ACE inhibitors can be used with angiotensin II receptor blockers (ARBs), calcium channel blockers, and prostaglandins when full doses of an ACE inhibitor do not control a crisis.

The true benefits and risks of combining an ACE inhibitor with other agents in scleroderma have not been fully studied, he said.

ONTARGET (Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial), which did not include scleroderma patients, showed that the use of combined ARBs and ACE inhibitors was associated with worse renal outcomes in high-risk patients, Dr. Wigley added.

▸ Prostaglandins. When administered intravenously, prostaglandins are an option for reducing digital ulcers, Raynaud's attacks, and PAH associated with scleroderma. Two trials are underway to evaluate oral formulations of iloprost and treprostinil in vascular scleroderma and Raynaud's, he said.

Dr. Wigley disclosed receiving research grants from MediQuest Therapeutics Inc., Novartis Pharmaceuticals Corp., and United Therapeutics Corp., and honoraria from MediQuest.

CHICAGO — Several pioneering treatment approaches have emerged to modify the vascular and fibrotic disease in scleroderma, Dr. Frederick Wigley said at a symposium sponsored by the American College of Rheumatology.

Dr. Wigley, director of the scleroderma center at Johns Hopkins University in Baltimore, discussed several of these novel therapies that are being studied and/or are in use, including the following six:

▸ Bosentan. This endothelial inhibitor is approved in the United States and Europe to manage the symptoms of pulmonary artery hypertension (PAH). Two trials in scleroderma show that bosentan (Tracleer) reduces digital ulcers but has no benefit on Raynaud's attacks, Dr. Wigley said.

▸ Tyrosine kinase inhibition with imatinib mesylate. Industry-sponsored trials are underway evaluating imatinib (Gleevec) in systemic sclerosis and PAH, and dasatinib (Sprycel) in scleroderma pulmonary fibrosis.

▸ Immunoablation with and without stem cell transplantation. This should be looked at as "an experiment in progress," Dr. Wigley said.

In a pilot study of 34 patients with poor prognosis for systemic sclerosis, major improvements in skin and overall function were reported in 17 of 27 evaluable patients who survived 1 year after high-dose immunosuppressive treatment and autologous hematopoietic cell transplantation (Blood 2007;110:1388-96).

These results came at a cost, however, with relapse occurring in 10 survivors and 23% of the 34 patients dying as a result of the procedure.

▸ Statins. These drugs have shown some benefit in early trials, possibly because they display pleiotropic effects on endothelial function that could potentially delay vascular injury.

Levels of circulating endothelial precursor cells, reduced in scleroderma, were increased up to eightfold after 12 weeks of therapy with atorvastatin (Lipitor) 10 mg/day in 14 patients with systemic sclerosis in an open-label pilot study (Arthritis Rheum. 2006;54:1946-51).

Endothelial markers improved and fewer new digital ulcers occurred with atorvastatin 40 mg/day for 16 weeks vs. placebo in 86 patients with scleroderma (J. Rheumatol. 2008;35:1801-8).

▸ ACE inhibitors. These agents have been shown to improve 12-month survival in patients with systemic scleroderma-induced renal disease, which is often associated with corticosteroids. ACE inhibitors can be used with angiotensin II receptor blockers (ARBs), calcium channel blockers, and prostaglandins when full doses of an ACE inhibitor do not control a crisis.

The true benefits and risks of combining an ACE inhibitor with other agents in scleroderma have not been fully studied, he said.

ONTARGET (Ongoing Telmisartan Alone and in Combination With Ramipril Global End Point Trial), which did not include scleroderma patients, showed that the use of combined ARBs and ACE inhibitors was associated with worse renal outcomes in high-risk patients, Dr. Wigley added.

▸ Prostaglandins. When administered intravenously, prostaglandins are an option for reducing digital ulcers, Raynaud's attacks, and PAH associated with scleroderma. Two trials are underway to evaluate oral formulations of iloprost and treprostinil in vascular scleroderma and Raynaud's, he said.

Dr. Wigley disclosed receiving research grants from MediQuest Therapeutics Inc., Novartis Pharmaceuticals Corp., and United Therapeutics Corp., and honoraria from MediQuest.

People with psoriasis are at higher risk than others for a full range of atherosclerotic diseases, not just cardiovascular but also cerebrovascular and peripheral vascular diseases, according to a new report.

The magnitude of risk appears to be similar to that of other well-established cardiovascular risk factors such as dyslipidemia, smoking, hypertension, and diabetes, said Dr. Srjdan Prodanovich of the departments of dermatology and cutaneous surgery at the University of Miami and associates. In recent years, psoriasis has been linked to myocardial infarction. Dr. Prodanovich and colleagues investigated whether the inflammatory skin disease could be associated with other manifestations of atherosclerosis as well.

They assessed the prevalences of ischemic heart disease, cerebral vascular disease, and peripheral arterial disease in 3,236 patients with psoriasis and 2,500 nonpsoriatic control patients treated at the Miami VA Medical Center between 1985 and 2006.

After controlling for subject age, sex, and history of hypertension, diabetes, dyslipidemia, and smoking status, the researchers found that patients with psoriasis were approximately twice as likely as controls to have any of these types of vascular disease.

This finding “has tremendous and far-reaching clinical implications, as all of these vascular conditions represent a major financial cost to the health care system as well as a major cause of disability and death,” they noted (Arch. Dermatol. 2009; 145:700-3).

Psoriasis was also found to be an independent risk factor for death. Mortality was nearly 20% among patients with psoriasis, compared with 10% among patients in the control group.

Because this was an observational study, it could not be determined whether psoriasis and its attendant inflammation caused the atherosclerosis. Also unknown is whether aggressive treatment of either cardiovascular risk factors or psoriasis will improve patients' total atherosclerotic burden.

For the present, “we recommend that health care providers who are caring for patients with psoriasis be vigilant with respect to traditional [cardiovascular] risk factor screening.

“Many of these patients are cared for solely by dermatologists. It would be prudent for dermatologists to be familiar with suggested screening for cardiovascular risk factors and recommendations for aspirin use. If not, it is imperative that they work in collaboration with a primary care provider or another internal medicine specialist,” Dr. Prodanovich and associates said.

“Clinicians caring for patients with this skin disorder should use a lower threshold when considering testing for peripheral arterial disease, carotid disease, or coronary artery disease in those with typical or atypical symptoms,” they added.

The investigators reported no financial conflicts of interest.

People with psoriasis are at higher risk than others for a full range of atherosclerotic diseases, not just cardiovascular but also cerebrovascular and peripheral vascular diseases, according to a new report.

The magnitude of risk appears to be similar to that of other well-established cardiovascular risk factors such as dyslipidemia, smoking, hypertension, and diabetes, said Dr. Srjdan Prodanovich of the departments of dermatology and cutaneous surgery at the University of Miami and associates. In recent years, psoriasis has been linked to myocardial infarction. Dr. Prodanovich and colleagues investigated whether the inflammatory skin disease could be associated with other manifestations of atherosclerosis as well.

They assessed the prevalences of ischemic heart disease, cerebral vascular disease, and peripheral arterial disease in 3,236 patients with psoriasis and 2,500 nonpsoriatic control patients treated at the Miami VA Medical Center between 1985 and 2006.

After controlling for subject age, sex, and history of hypertension, diabetes, dyslipidemia, and smoking status, the researchers found that patients with psoriasis were approximately twice as likely as controls to have any of these types of vascular disease.

This finding “has tremendous and far-reaching clinical implications, as all of these vascular conditions represent a major financial cost to the health care system as well as a major cause of disability and death,” they noted (Arch. Dermatol. 2009; 145:700-3).

Psoriasis was also found to be an independent risk factor for death. Mortality was nearly 20% among patients with psoriasis, compared with 10% among patients in the control group.

Because this was an observational study, it could not be determined whether psoriasis and its attendant inflammation caused the atherosclerosis. Also unknown is whether aggressive treatment of either cardiovascular risk factors or psoriasis will improve patients' total atherosclerotic burden.

For the present, “we recommend that health care providers who are caring for patients with psoriasis be vigilant with respect to traditional [cardiovascular] risk factor screening.

“Many of these patients are cared for solely by dermatologists. It would be prudent for dermatologists to be familiar with suggested screening for cardiovascular risk factors and recommendations for aspirin use. If not, it is imperative that they work in collaboration with a primary care provider or another internal medicine specialist,” Dr. Prodanovich and associates said.

“Clinicians caring for patients with this skin disorder should use a lower threshold when considering testing for peripheral arterial disease, carotid disease, or coronary artery disease in those with typical or atypical symptoms,” they added.

The investigators reported no financial conflicts of interest.

People with psoriasis are at higher risk than others for a full range of atherosclerotic diseases, not just cardiovascular but also cerebrovascular and peripheral vascular diseases, according to a new report.

The magnitude of risk appears to be similar to that of other well-established cardiovascular risk factors such as dyslipidemia, smoking, hypertension, and diabetes, said Dr. Srjdan Prodanovich of the departments of dermatology and cutaneous surgery at the University of Miami and associates. In recent years, psoriasis has been linked to myocardial infarction. Dr. Prodanovich and colleagues investigated whether the inflammatory skin disease could be associated with other manifestations of atherosclerosis as well.

They assessed the prevalences of ischemic heart disease, cerebral vascular disease, and peripheral arterial disease in 3,236 patients with psoriasis and 2,500 nonpsoriatic control patients treated at the Miami VA Medical Center between 1985 and 2006.

After controlling for subject age, sex, and history of hypertension, diabetes, dyslipidemia, and smoking status, the researchers found that patients with psoriasis were approximately twice as likely as controls to have any of these types of vascular disease.

This finding “has tremendous and far-reaching clinical implications, as all of these vascular conditions represent a major financial cost to the health care system as well as a major cause of disability and death,” they noted (Arch. Dermatol. 2009; 145:700-3).

Psoriasis was also found to be an independent risk factor for death. Mortality was nearly 20% among patients with psoriasis, compared with 10% among patients in the control group.

Because this was an observational study, it could not be determined whether psoriasis and its attendant inflammation caused the atherosclerosis. Also unknown is whether aggressive treatment of either cardiovascular risk factors or psoriasis will improve patients' total atherosclerotic burden.

For the present, “we recommend that health care providers who are caring for patients with psoriasis be vigilant with respect to traditional [cardiovascular] risk factor screening.

“Many of these patients are cared for solely by dermatologists. It would be prudent for dermatologists to be familiar with suggested screening for cardiovascular risk factors and recommendations for aspirin use. If not, it is imperative that they work in collaboration with a primary care provider or another internal medicine specialist,” Dr. Prodanovich and associates said.

“Clinicians caring for patients with this skin disorder should use a lower threshold when considering testing for peripheral arterial disease, carotid disease, or coronary artery disease in those with typical or atypical symptoms,” they added.

The investigators reported no financial conflicts of interest.

MONTREAL — Women who drank alcohol, especially those consuming at least five beers per week, were at increased risk of developing psoriasis, based on an analysis of the Nurses' Health Study.

Compared to abstainers, women who drank alcohol (defined as consumption of at least 30 grams, or roughly two drinks, per week) had a significantly increased risk of developing psoriasis, with a relative risk (RR) of 1.6, said Dr. Patrick Dominguez, who presented his findings at the annual meeting of the Society for Investigative Dermatology

When type of alcohol was examined, however, only regular beer consumption of more than 5 drinks per week was a significant predictor (RR 1.8) for the development of psoriasis. “For any amount of light beer, wine, or liquor consumed, the relative risks were not significant.”

At study entry in 1989, women in the Nurses' Health Study were asked about their level of alcohol consumption in grams per week. According to the Centers for Disease Control and Prevention, a standard drink contains 13.7 grams of alcohol and is defined as 12 ounces of regular beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.

Over a 14-year period, biennial questionnaires were used to monitor both the amount as well as the type of alcohol consumed (regular beer, light beer, wine, or liquor), said Dr. Dominguez, who is a research fellow in the department of dermatology at Brigham and Women's Hospital in Boston.

In 2005, participants were asked if they had psoriasis. A total of 2,169 reported a diagnosis of psoriasis; 1,162 were prevalent cases and the remaining 1,007 were incident cases, said Dr. Dominguez, who declared no conflicts of interest. After excluding incident cases for which there was incomplete information on alcohol consumption, 955 participants with new onset psoriasis were included for analysis.

The abstainers and women who drank alcohol did not differ significantly in age. Abstainers had slightly higher body mass indices. Drinkers were more physically active, and a higher percentage of drinkers also reported current or past smoking.

One possible explanation for the study's findings is that gluten, a non-alcoholic ingredient found in beer, might trigger the onset of psoriasis, Dr. Dominguez speculated.

“There are multiple case series in which patients with gluten sensitivity, or celiac disease, and psoriasis go on a gluten-free diet, and their psoriasis clears up,” he said in an interview. “Beer is the only alcoholic drink that contains gluten. Light beer has some gluten but much less.”

Gluten, which is found in beer but not other forms of alcohol, may be a trigger. Courtesy Len Rizzi/National Cancer Institute

MONTREAL — Women who drank alcohol, especially those consuming at least five beers per week, were at increased risk of developing psoriasis, based on an analysis of the Nurses' Health Study.

Compared to abstainers, women who drank alcohol (defined as consumption of at least 30 grams, or roughly two drinks, per week) had a significantly increased risk of developing psoriasis, with a relative risk (RR) of 1.6, said Dr. Patrick Dominguez, who presented his findings at the annual meeting of the Society for Investigative Dermatology

When type of alcohol was examined, however, only regular beer consumption of more than 5 drinks per week was a significant predictor (RR 1.8) for the development of psoriasis. “For any amount of light beer, wine, or liquor consumed, the relative risks were not significant.”

At study entry in 1989, women in the Nurses' Health Study were asked about their level of alcohol consumption in grams per week. According to the Centers for Disease Control and Prevention, a standard drink contains 13.7 grams of alcohol and is defined as 12 ounces of regular beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.

Over a 14-year period, biennial questionnaires were used to monitor both the amount as well as the type of alcohol consumed (regular beer, light beer, wine, or liquor), said Dr. Dominguez, who is a research fellow in the department of dermatology at Brigham and Women's Hospital in Boston.

In 2005, participants were asked if they had psoriasis. A total of 2,169 reported a diagnosis of psoriasis; 1,162 were prevalent cases and the remaining 1,007 were incident cases, said Dr. Dominguez, who declared no conflicts of interest. After excluding incident cases for which there was incomplete information on alcohol consumption, 955 participants with new onset psoriasis were included for analysis.

The abstainers and women who drank alcohol did not differ significantly in age. Abstainers had slightly higher body mass indices. Drinkers were more physically active, and a higher percentage of drinkers also reported current or past smoking.

One possible explanation for the study's findings is that gluten, a non-alcoholic ingredient found in beer, might trigger the onset of psoriasis, Dr. Dominguez speculated.

“There are multiple case series in which patients with gluten sensitivity, or celiac disease, and psoriasis go on a gluten-free diet, and their psoriasis clears up,” he said in an interview. “Beer is the only alcoholic drink that contains gluten. Light beer has some gluten but much less.”

Gluten, which is found in beer but not other forms of alcohol, may be a trigger. Courtesy Len Rizzi/National Cancer Institute

MONTREAL — Women who drank alcohol, especially those consuming at least five beers per week, were at increased risk of developing psoriasis, based on an analysis of the Nurses' Health Study.

Compared to abstainers, women who drank alcohol (defined as consumption of at least 30 grams, or roughly two drinks, per week) had a significantly increased risk of developing psoriasis, with a relative risk (RR) of 1.6, said Dr. Patrick Dominguez, who presented his findings at the annual meeting of the Society for Investigative Dermatology

When type of alcohol was examined, however, only regular beer consumption of more than 5 drinks per week was a significant predictor (RR 1.8) for the development of psoriasis. “For any amount of light beer, wine, or liquor consumed, the relative risks were not significant.”

At study entry in 1989, women in the Nurses' Health Study were asked about their level of alcohol consumption in grams per week. According to the Centers for Disease Control and Prevention, a standard drink contains 13.7 grams of alcohol and is defined as 12 ounces of regular beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof distilled spirits.

Over a 14-year period, biennial questionnaires were used to monitor both the amount as well as the type of alcohol consumed (regular beer, light beer, wine, or liquor), said Dr. Dominguez, who is a research fellow in the department of dermatology at Brigham and Women's Hospital in Boston.

In 2005, participants were asked if they had psoriasis. A total of 2,169 reported a diagnosis of psoriasis; 1,162 were prevalent cases and the remaining 1,007 were incident cases, said Dr. Dominguez, who declared no conflicts of interest. After excluding incident cases for which there was incomplete information on alcohol consumption, 955 participants with new onset psoriasis were included for analysis.

The abstainers and women who drank alcohol did not differ significantly in age. Abstainers had slightly higher body mass indices. Drinkers were more physically active, and a higher percentage of drinkers also reported current or past smoking.

One possible explanation for the study's findings is that gluten, a non-alcoholic ingredient found in beer, might trigger the onset of psoriasis, Dr. Dominguez speculated.

“There are multiple case series in which patients with gluten sensitivity, or celiac disease, and psoriasis go on a gluten-free diet, and their psoriasis clears up,” he said in an interview. “Beer is the only alcoholic drink that contains gluten. Light beer has some gluten but much less.”

Gluten, which is found in beer but not other forms of alcohol, may be a trigger. Courtesy Len Rizzi/National Cancer Institute

MONTREAL — Mortality rates are significantly increased in patients with severe psoriasis compared with the general population, according to two new studies.

But studies have conflicting results regarding the cause of death, researchers reported at the annual meeting of the Society for Investigative Dermatology. A study by Dr. Rahat Azfar showed an age-dependent, significantly increased risk of cardiovascular death with severe psoriasis, compared with patients without psoriasis.

“Severe psoriasis may be an independent risk factor for cardiovascular mortality,” noted Dr. Azfar of the University of Pennsylvania, Philadelphia, whose study showed a 50% increase in cardiovascular death.

Her findings are in direct contrast to another study presented in the same session and conflict with a growing body of evidence. Dr. Robert Stern presented results from the 30-year PUVA Follow-Up Study, which showed no increase in cardiovascular death risk in severe psoriasis patients, all of whom had undergone PUVA.

“In patients with extremely severe psoriasis, there is an increased risk of death from noncardiovascular, but not cardiovascular causes,” said Dr. Stern, professor of dermatology at Harvard Medical School and vice chair of dermatology at Beth Israel Deaconess Medical Center in Boston.

“Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done,” commented Dr. Azfar, who declared no conflicts of interest.

Her study, which she presented at the meeting, was funded by the National Institutes of Health and a grant from Centocor. It examined more than 3,000 patients with severe psoriasis, matched to more than 14,000 controls from the United Kingdom's General Practice Research Database.

Compared with controls, patients with severe psoriasis had a significantly increased risk of all-cause mortality (odds ratio 1.78), she said. After the researchers controlled for traditional cardiovascular risk factors, psoriasis patients had a clinically significant increased risk of cardiovascular death (hazard ratio [HR] 1.55). This risk was modified by age, with patients aged 40 and younger being at greater risk (HR 2.65) than patients aged between 41 and 60 (HR 1.90). This translated to an excess risk of 5.78 cardiovascular deaths per 10,000 person-years at age 40, and 58.9 per 10,000 person-years at age 60, she said.

Dr. Stern, who declared no conflicts of interest, agreed that cardiovascular risk factors are important, but his data suggest they are no more important than other risk factors.

The data show “that liver disease and nonmelanoma skin cancer accounted for more than half the approximately 70 excess deaths we observed,” he said. His prospective study followed 1,376 patients from the PUVA Follow-Up for 28 years, from 1976 to 2004. The patients had participated in a therapeutic PUVA study in 1975–1976 in 16 tertiary care academic centers across the United States.

Comparing the observed and expected mortality rates among patients and controls, the researchers found an increased all-cause mortality rate (HR 1.51) among only those patients with the most severe psoriasis. When cause of death was examined in this group, noncardiovascular reasons explained the increased risk (HR 1.74), and there was a nonsignificant increase in the rate of cardiovascular deaths, compared with controls (HR 1.29), Dr. Stern said.

“Dr. Stern's study results need to be interpreted with extreme caution due to the inherent bias in his study design,” warned Dr. Joel Gelfand, also of the University of Pennsylvania, and principal investigator on Dr. Azfar's study.

Dr. Stern's study design compares apples to oranges, commented Dr. Gelfand. “Patients who participate in psoriasis clinical trials at tertiary care medical centers may be healthier, better educated, and have better access to medical care than the general U.S. population,” he noted. “Our study … was population based.”

'Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done.' DR. AZFAR

MONTREAL — Mortality rates are significantly increased in patients with severe psoriasis compared with the general population, according to two new studies.

But studies have conflicting results regarding the cause of death, researchers reported at the annual meeting of the Society for Investigative Dermatology. A study by Dr. Rahat Azfar showed an age-dependent, significantly increased risk of cardiovascular death with severe psoriasis, compared with patients without psoriasis.

“Severe psoriasis may be an independent risk factor for cardiovascular mortality,” noted Dr. Azfar of the University of Pennsylvania, Philadelphia, whose study showed a 50% increase in cardiovascular death.

Her findings are in direct contrast to another study presented in the same session and conflict with a growing body of evidence. Dr. Robert Stern presented results from the 30-year PUVA Follow-Up Study, which showed no increase in cardiovascular death risk in severe psoriasis patients, all of whom had undergone PUVA.

“In patients with extremely severe psoriasis, there is an increased risk of death from noncardiovascular, but not cardiovascular causes,” said Dr. Stern, professor of dermatology at Harvard Medical School and vice chair of dermatology at Beth Israel Deaconess Medical Center in Boston.

“Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done,” commented Dr. Azfar, who declared no conflicts of interest.

Her study, which she presented at the meeting, was funded by the National Institutes of Health and a grant from Centocor. It examined more than 3,000 patients with severe psoriasis, matched to more than 14,000 controls from the United Kingdom's General Practice Research Database.

Compared with controls, patients with severe psoriasis had a significantly increased risk of all-cause mortality (odds ratio 1.78), she said. After the researchers controlled for traditional cardiovascular risk factors, psoriasis patients had a clinically significant increased risk of cardiovascular death (hazard ratio [HR] 1.55). This risk was modified by age, with patients aged 40 and younger being at greater risk (HR 2.65) than patients aged between 41 and 60 (HR 1.90). This translated to an excess risk of 5.78 cardiovascular deaths per 10,000 person-years at age 40, and 58.9 per 10,000 person-years at age 60, she said.

Dr. Stern, who declared no conflicts of interest, agreed that cardiovascular risk factors are important, but his data suggest they are no more important than other risk factors.

The data show “that liver disease and nonmelanoma skin cancer accounted for more than half the approximately 70 excess deaths we observed,” he said. His prospective study followed 1,376 patients from the PUVA Follow-Up for 28 years, from 1976 to 2004. The patients had participated in a therapeutic PUVA study in 1975–1976 in 16 tertiary care academic centers across the United States.

Comparing the observed and expected mortality rates among patients and controls, the researchers found an increased all-cause mortality rate (HR 1.51) among only those patients with the most severe psoriasis. When cause of death was examined in this group, noncardiovascular reasons explained the increased risk (HR 1.74), and there was a nonsignificant increase in the rate of cardiovascular deaths, compared with controls (HR 1.29), Dr. Stern said.

“Dr. Stern's study results need to be interpreted with extreme caution due to the inherent bias in his study design,” warned Dr. Joel Gelfand, also of the University of Pennsylvania, and principal investigator on Dr. Azfar's study.

Dr. Stern's study design compares apples to oranges, commented Dr. Gelfand. “Patients who participate in psoriasis clinical trials at tertiary care medical centers may be healthier, better educated, and have better access to medical care than the general U.S. population,” he noted. “Our study … was population based.”

'Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done.' DR. AZFAR

MONTREAL — Mortality rates are significantly increased in patients with severe psoriasis compared with the general population, according to two new studies.

But studies have conflicting results regarding the cause of death, researchers reported at the annual meeting of the Society for Investigative Dermatology. A study by Dr. Rahat Azfar showed an age-dependent, significantly increased risk of cardiovascular death with severe psoriasis, compared with patients without psoriasis.

“Severe psoriasis may be an independent risk factor for cardiovascular mortality,” noted Dr. Azfar of the University of Pennsylvania, Philadelphia, whose study showed a 50% increase in cardiovascular death.

Her findings are in direct contrast to another study presented in the same session and conflict with a growing body of evidence. Dr. Robert Stern presented results from the 30-year PUVA Follow-Up Study, which showed no increase in cardiovascular death risk in severe psoriasis patients, all of whom had undergone PUVA.

“In patients with extremely severe psoriasis, there is an increased risk of death from noncardiovascular, but not cardiovascular causes,” said Dr. Stern, professor of dermatology at Harvard Medical School and vice chair of dermatology at Beth Israel Deaconess Medical Center in Boston.

“Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done,” commented Dr. Azfar, who declared no conflicts of interest.

Her study, which she presented at the meeting, was funded by the National Institutes of Health and a grant from Centocor. It examined more than 3,000 patients with severe psoriasis, matched to more than 14,000 controls from the United Kingdom's General Practice Research Database.

Compared with controls, patients with severe psoriasis had a significantly increased risk of all-cause mortality (odds ratio 1.78), she said. After the researchers controlled for traditional cardiovascular risk factors, psoriasis patients had a clinically significant increased risk of cardiovascular death (hazard ratio [HR] 1.55). This risk was modified by age, with patients aged 40 and younger being at greater risk (HR 2.65) than patients aged between 41 and 60 (HR 1.90). This translated to an excess risk of 5.78 cardiovascular deaths per 10,000 person-years at age 40, and 58.9 per 10,000 person-years at age 60, she said.

Dr. Stern, who declared no conflicts of interest, agreed that cardiovascular risk factors are important, but his data suggest they are no more important than other risk factors.

The data show “that liver disease and nonmelanoma skin cancer accounted for more than half the approximately 70 excess deaths we observed,” he said. His prospective study followed 1,376 patients from the PUVA Follow-Up for 28 years, from 1976 to 2004. The patients had participated in a therapeutic PUVA study in 1975–1976 in 16 tertiary care academic centers across the United States.

Comparing the observed and expected mortality rates among patients and controls, the researchers found an increased all-cause mortality rate (HR 1.51) among only those patients with the most severe psoriasis. When cause of death was examined in this group, noncardiovascular reasons explained the increased risk (HR 1.74), and there was a nonsignificant increase in the rate of cardiovascular deaths, compared with controls (HR 1.29), Dr. Stern said.

“Dr. Stern's study results need to be interpreted with extreme caution due to the inherent bias in his study design,” warned Dr. Joel Gelfand, also of the University of Pennsylvania, and principal investigator on Dr. Azfar's study.

Dr. Stern's study design compares apples to oranges, commented Dr. Gelfand. “Patients who participate in psoriasis clinical trials at tertiary care medical centers may be healthier, better educated, and have better access to medical care than the general U.S. population,” he noted. “Our study … was population based.”

'Previous studies of cardiovascular mortality have not controlled for traditional CV risk factors, as our work has done.' DR. AZFAR

SAN FRANCISCO — A study of 156 patients with systemic sclerosis in two European cities found that vitamin D deficiency was common, present in 28%.

Deficient levels of serum 25-hydroxyvitamin D (25[OH]D)—less than 10 ng/mL—were seen in 29 (32%) of 90 patients in Paris and 15 (23%) of 66 in southern Italy, Dr. Alessandra Vacca and her associates reported in a poster presentation at the annual meeting of the American College of Rheumatology. In addition, 84% of all patients had insufficient vitamin D levels (less than 30 ng/mL), seen in 75 (82%) of the Parisians and 57 (86%) of the Italians.

Overall, patients had a mean age of 57 years, and 97% were female. The mean vitamin D value in the two cohorts was 19 ng/mL, said Dr. Vacca of the University of Cagliari.

The rates of vitamin D deficiency did not differ significantly between cities and so were independent of the different UV radiation levels in the northern and southern cities. Rates of vitamin D deficiency also were independent of usual levels of vitamin D supplementation (800 IU/day), taken by 30% of Parisian patients and 45% of Italian patients.

Because conventional doses of vitamin D supplementation did not prevent vitamin D deficiency, higher-dose supplementation may be needed in patients with systemic sclerosis, especially those with inflammatory activity, she said.

Low vitamin D levels were associated with pulmonary fibrosis (P = .04), systolic pulmonary arterial hypertension (P = .004), and inflammatory activity indicated by acute phase reactants—erythrocyte sedimentation rate (P = .004) and C-reactive protein values (P = .01). There was a significant negative correlation between low vitamin D levels and European disease activity scores (P = −0.04). A mild negative association was seen between vitamin D deficiency and anticentromere antibodies.

Low vitamin D levels may be linked to multiple risk factors, Dr. Vacca suggested, including scarce sun exposure due to disability, insufficient intake and malabsorption of vitamin D due to gastroenteric involvement, or use of drugs that can alter metabolism of vitamin D. There was no association between vitamin D deficiency and other markers of impaired malabsorption such as hemoglobin, ferritin, or albuminemia. No associations were found between vitamin D deficiency and acro-osteolysis, calcinosis, or Medsger's disease severity score.

The investigators reported no conflicts of interest related to this study.

SAN FRANCISCO — A study of 156 patients with systemic sclerosis in two European cities found that vitamin D deficiency was common, present in 28%.

Deficient levels of serum 25-hydroxyvitamin D (25[OH]D)—less than 10 ng/mL—were seen in 29 (32%) of 90 patients in Paris and 15 (23%) of 66 in southern Italy, Dr. Alessandra Vacca and her associates reported in a poster presentation at the annual meeting of the American College of Rheumatology. In addition, 84% of all patients had insufficient vitamin D levels (less than 30 ng/mL), seen in 75 (82%) of the Parisians and 57 (86%) of the Italians.

Overall, patients had a mean age of 57 years, and 97% were female. The mean vitamin D value in the two cohorts was 19 ng/mL, said Dr. Vacca of the University of Cagliari.

The rates of vitamin D deficiency did not differ significantly between cities and so were independent of the different UV radiation levels in the northern and southern cities. Rates of vitamin D deficiency also were independent of usual levels of vitamin D supplementation (800 IU/day), taken by 30% of Parisian patients and 45% of Italian patients.

Because conventional doses of vitamin D supplementation did not prevent vitamin D deficiency, higher-dose supplementation may be needed in patients with systemic sclerosis, especially those with inflammatory activity, she said.

Low vitamin D levels were associated with pulmonary fibrosis (P = .04), systolic pulmonary arterial hypertension (P = .004), and inflammatory activity indicated by acute phase reactants—erythrocyte sedimentation rate (P = .004) and C-reactive protein values (P = .01). There was a significant negative correlation between low vitamin D levels and European disease activity scores (P = −0.04). A mild negative association was seen between vitamin D deficiency and anticentromere antibodies.

Low vitamin D levels may be linked to multiple risk factors, Dr. Vacca suggested, including scarce sun exposure due to disability, insufficient intake and malabsorption of vitamin D due to gastroenteric involvement, or use of drugs that can alter metabolism of vitamin D. There was no association between vitamin D deficiency and other markers of impaired malabsorption such as hemoglobin, ferritin, or albuminemia. No associations were found between vitamin D deficiency and acro-osteolysis, calcinosis, or Medsger's disease severity score.

The investigators reported no conflicts of interest related to this study.

SAN FRANCISCO — A study of 156 patients with systemic sclerosis in two European cities found that vitamin D deficiency was common, present in 28%.

Deficient levels of serum 25-hydroxyvitamin D (25[OH]D)—less than 10 ng/mL—were seen in 29 (32%) of 90 patients in Paris and 15 (23%) of 66 in southern Italy, Dr. Alessandra Vacca and her associates reported in a poster presentation at the annual meeting of the American College of Rheumatology. In addition, 84% of all patients had insufficient vitamin D levels (less than 30 ng/mL), seen in 75 (82%) of the Parisians and 57 (86%) of the Italians.

Overall, patients had a mean age of 57 years, and 97% were female. The mean vitamin D value in the two cohorts was 19 ng/mL, said Dr. Vacca of the University of Cagliari.

The rates of vitamin D deficiency did not differ significantly between cities and so were independent of the different UV radiation levels in the northern and southern cities. Rates of vitamin D deficiency also were independent of usual levels of vitamin D supplementation (800 IU/day), taken by 30% of Parisian patients and 45% of Italian patients.

Because conventional doses of vitamin D supplementation did not prevent vitamin D deficiency, higher-dose supplementation may be needed in patients with systemic sclerosis, especially those with inflammatory activity, she said.

Low vitamin D levels were associated with pulmonary fibrosis (P = .04), systolic pulmonary arterial hypertension (P = .004), and inflammatory activity indicated by acute phase reactants—erythrocyte sedimentation rate (P = .004) and C-reactive protein values (P = .01). There was a significant negative correlation between low vitamin D levels and European disease activity scores (P = −0.04). A mild negative association was seen between vitamin D deficiency and anticentromere antibodies.

Low vitamin D levels may be linked to multiple risk factors, Dr. Vacca suggested, including scarce sun exposure due to disability, insufficient intake and malabsorption of vitamin D due to gastroenteric involvement, or use of drugs that can alter metabolism of vitamin D. There was no association between vitamin D deficiency and other markers of impaired malabsorption such as hemoglobin, ferritin, or albuminemia. No associations were found between vitamin D deficiency and acro-osteolysis, calcinosis, or Medsger's disease severity score.

The investigators reported no conflicts of interest related to this study.

SAN FRANCISCO — Chronic wounds due to scleroderma responded well to a combination of mesenchymal stem cells and bilayer bioengineered skin, in a study of 12 patients followed for up to 6 months.

Four wounds completely healed, and the others decreased in size enough that patients' quality of life was improved, Dr. Vincent Falanga said in a press briefing at the annual meeting of the American Academy of Dermatology.

He and his associates harvested the patients' own stem cells from a small amount of bone marrow taken from the hip. And they applied the stem cells to the wound with an innovative fibrin spray system that had not been used before in humans.

Using a pressurized double-barrel syringe, they placed the cells in fibrinogen in one barrel and in a thrombin solution in the other. This produced a fine spray, spreading the cells evenly over the wound and simultaneously combining the fibrinogen and thrombin to form fibrin, which glued the cells to the exposed wound tissue, said Dr. Falanga of Boston University and Roger Williams Medical Center, Providence, R.I.

In prior studies, Dr. Falanga determined that the spray alone would not be enough to encourage the stem cells to differentiate into skin cells. To teach the stem cells to become skin cells, he covered the spray with living bioengineered skin substitute, specifically a product from Organogenesis Inc. called Apligraf that contains two layers of living cells, one of fibroblasts and one of keratinocytes.

Dr. Falanga gave each patient three treatments, the maximum permitted by the Food and Drug Administration. He said that he thinks the patients would do even better with additional treatments and hopes to receive approval for this as his studies continue.

Dr. Falanga said he found it necessary to use quite a large number of stem cells, 1.5 million to 2 million/cm

He continued, “I think that this is a lesson that's going to be learned when we go into other areas of medicine. Whether it's skin, brain, spinal cord, we have to have some methods whereby we impart upon the stem cells a didactic component, a direction we want them to go to.”

Dr. Falanga disclosed that he is a former consultant to the company Organogenesis.

SAN FRANCISCO — Chronic wounds due to scleroderma responded well to a combination of mesenchymal stem cells and bilayer bioengineered skin, in a study of 12 patients followed for up to 6 months.

Four wounds completely healed, and the others decreased in size enough that patients' quality of life was improved, Dr. Vincent Falanga said in a press briefing at the annual meeting of the American Academy of Dermatology.

He and his associates harvested the patients' own stem cells from a small amount of bone marrow taken from the hip. And they applied the stem cells to the wound with an innovative fibrin spray system that had not been used before in humans.

Using a pressurized double-barrel syringe, they placed the cells in fibrinogen in one barrel and in a thrombin solution in the other. This produced a fine spray, spreading the cells evenly over the wound and simultaneously combining the fibrinogen and thrombin to form fibrin, which glued the cells to the exposed wound tissue, said Dr. Falanga of Boston University and Roger Williams Medical Center, Providence, R.I.

In prior studies, Dr. Falanga determined that the spray alone would not be enough to encourage the stem cells to differentiate into skin cells. To teach the stem cells to become skin cells, he covered the spray with living bioengineered skin substitute, specifically a product from Organogenesis Inc. called Apligraf that contains two layers of living cells, one of fibroblasts and one of keratinocytes.

Dr. Falanga gave each patient three treatments, the maximum permitted by the Food and Drug Administration. He said that he thinks the patients would do even better with additional treatments and hopes to receive approval for this as his studies continue.

Dr. Falanga said he found it necessary to use quite a large number of stem cells, 1.5 million to 2 million/cm

He continued, “I think that this is a lesson that's going to be learned when we go into other areas of medicine. Whether it's skin, brain, spinal cord, we have to have some methods whereby we impart upon the stem cells a didactic component, a direction we want them to go to.”

Dr. Falanga disclosed that he is a former consultant to the company Organogenesis.

SAN FRANCISCO — Chronic wounds due to scleroderma responded well to a combination of mesenchymal stem cells and bilayer bioengineered skin, in a study of 12 patients followed for up to 6 months.

Four wounds completely healed, and the others decreased in size enough that patients' quality of life was improved, Dr. Vincent Falanga said in a press briefing at the annual meeting of the American Academy of Dermatology.

He and his associates harvested the patients' own stem cells from a small amount of bone marrow taken from the hip. And they applied the stem cells to the wound with an innovative fibrin spray system that had not been used before in humans.

Using a pressurized double-barrel syringe, they placed the cells in fibrinogen in one barrel and in a thrombin solution in the other. This produced a fine spray, spreading the cells evenly over the wound and simultaneously combining the fibrinogen and thrombin to form fibrin, which glued the cells to the exposed wound tissue, said Dr. Falanga of Boston University and Roger Williams Medical Center, Providence, R.I.

In prior studies, Dr. Falanga determined that the spray alone would not be enough to encourage the stem cells to differentiate into skin cells. To teach the stem cells to become skin cells, he covered the spray with living bioengineered skin substitute, specifically a product from Organogenesis Inc. called Apligraf that contains two layers of living cells, one of fibroblasts and one of keratinocytes.

Dr. Falanga gave each patient three treatments, the maximum permitted by the Food and Drug Administration. He said that he thinks the patients would do even better with additional treatments and hopes to receive approval for this as his studies continue.

Dr. Falanga said he found it necessary to use quite a large number of stem cells, 1.5 million to 2 million/cm

He continued, “I think that this is a lesson that's going to be learned when we go into other areas of medicine. Whether it's skin, brain, spinal cord, we have to have some methods whereby we impart upon the stem cells a didactic component, a direction we want them to go to.”

Dr. Falanga disclosed that he is a former consultant to the company Organogenesis.