2.1. Psoriasis in the atopic
Unlike some observations carried out in northern Germany, links between psoriasis and atopy have been observed in France. This link needs to be investigated in all psoriatics with major pruritus. In fact, scratching produces a permanent Köebner, and eliminating pruritus makes for a considerable improvement in the psoriasis. Note that methotrexate and cyclosporine are effective treatments for severe atopy.
Even treated, hypertension contraindicates cyclosporine, but the existence of hypertension also interacts with psoriasis through the use of antihypertensive drugs. Beta-blockers are capable of provoking psoriasis, aggravating psoriasis or provoking psoriasiform toxidermia. Angiotensin-converting enzyme inhibitors and calcium inhibitors are equally capable of aggravating psoriasis. Faced with late-onset psoriasis or aggravation of psoriasis for reasons not understood, it is therefore important to ponder any part these drugs might have. The time-lag between starting to take the antihypertensive and the worsening of the psoriasis may be of several months, or indeed several years.
Diabetes, essentially type II, seems to be more common in psoriatics than in the control population, probably because of the metabolic syndrome. The diabetes interacts with the psoriasis treatment by means of frequent hypertriglyceridaemia, which can make more difficult to use retinoids and cyclosporine, and by means of hepatic steatosis, responsible for more frequent hepatic cytolysis on retinoids or methotrexate. Fat diabetes is often associated, perhaps because of overweight, with a degree of skin fragility that favours the development of psoriasis. Psoriasis in the diabetic has a tendency to be pruriginous and inflammatory. An improvement in diabetes, essentially through diet and physical activity, is often associated with an improvement of psoriasis.
Increase of body weight coincides very often with a worsening of psoriasis, particularly in adults. Furthermore, it is difficult to treat psoriasis in obese people because of the fragility of normal skin, decreasing the tolerance to topical treatment. The psoriatic lesions are often quite inflammatory. The skin folds are frequently affected and systemic treatment less tolerated . This decreased tolerance to systemic treatment may be the consequence of different pharmacokinetics modifications, particularly for the hydrophobic drugs that will accumulate in the fatty third sector. It may also be the consequence of the hepatic steatosis that is often associated. It is also possible that the appearance of obesity is often associated with a toxic lifestyle, a degree of neglect for the self-image, a certain inability to manage one’s affairs or certain types of depression. Moreover, it is noted that a psoriatic who is able to take himself in hand and slim down seems equally able to control better his psoriasis.
[|I do believe this is a very significant problem in psoriasis, above that in the general population. Comorbidities, in addition to hepatic steatosis, should also include cardiovascular disease, including hypertension, increased risk of diabetes, as well as potential increase in joint morbidity.|auteur215]
It must be explained to the patient that no one can treat psoriasis in an alcoholic and that cutting out the source of the intoxication is a preliminary to any therapeutic initiative. Alcohol alters in fact the pharmacokinetics of most systemic drugs, reduces their efficacy and increases the risk of side effects. In addition, the inability to break away from dependency bodes very badly for the ability to take charge of and manage a chronic illness. Some patients who do not suffer from alcoholism observe a psoriasis flare from one to three days after drinking alcohol even in normal amount. In these cases, a total alcohol intake restriction can be quite helpful.
The alcoholic can make use of all topical treatments, UVB phototherapy and balneo-PUVA therapy.
Retinoids may be used in the absence of hypertriglyceridaemia and if liver enzymes are within the normal range. A close follow-up of liver enzymes every two weeks may be necessary. In the event of alcoholic hepatic cytolysis, and if the patient has displayed the will to take responsibility for himself, it is possible to contemplate retinoids but only once the liver levels have normalized again.
Methotrexate is contraindicated for as long as the intoxication persists. If it is prescribed after the intoxication stops, it is wise to perform a hepatic biopsy puncture (or fibrotest + fibroscan) at the end of the first six months of treatment.
There is no data on cyclosporine used in psoriasis with alcoholic liver involvement.
Alcoholism is not a contraindication of biologicals.
2.6. Chronic hepatitis
Chronic autoimmune hepatitis and chronic viral hepatitis B or C pose the same problems as alcoholic hepatitis. To these can be added the interactions between treatments for hepatitis and psoriasis. The most commonly encountered problem being that psoriasis is exacerbated by the interferon prescribed to treat hepatitis C. Hepatotoxic antipsoriatic drugs cannot be used. Retinoids, which are only very mildly hepatotoxic, may be used with the hepatologist’s agreement and subjected to bimonthly biomonitoring. Cyclosporine may be equally used, with the hepatologist’s agreement while monitoring viral load development, as it is an immunosuppressant.
Acute life threatening hepatitis has been observed under Remicade?, whereas Raptiva? may increase liver enzymes. The prescription of biologicals on patients suffering from chronic hepatitis must be discussed with the hepatologist.
2.7. Renal insufficiency
Hydration of the skin is always very important in those suffering from renal insufficiency and may improve psoriasis.
UVB phototherapy poses no problem.
PUVA therapy can only be administered if the dialysis sessions are held after the PUVA therapy.
Soriatane may be used starting with extremely small doses, 10 mg every other day, while monitoring the effects of epithelial weakening most vigorously.
Methotrexate is contraindicated.
Conversely, when the patient is dialysed, cyclosporine can be used without any problem, since the risk of renal toxicity is no longer a problem.
Biologicals are not contraindicated on the account of kidney insufficiency.
2.8. Psoriasis and HIV
Psoriasis and seborrheic dermatitis are much more common in subjects suffering from acquired immunodeficiency than in the normal population (photo 95). Moreover, the psoriasis associated with HIV is often serious, generalized, given to being arthropathic. In these patients, all topical treatments may be used, but they are often insufficient.
Phototherapy and PUVA therapy may be used without any risk of aggravating the disease.
Retinoids are the treatment of choice.
Prescribing methotrexate for these immunodepressed patients is possible but only on second line, and an immunosuppressive drug like cyclosporine is contraindicated.
The use of biological treatments in these patients with high risk of infection is quite questionable.
- 2019/08/12 Focus on...Latin American Clinical Practice Guidelines on the Systemic Treatment of Psoriasis
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News from the web office
- 2017/06/05PIN becomes SPIN - Skin Inflammation & Psoriasis International Network
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- 2018/07/16SPIN Symposium at the Spring continental meeting - Tehran, 25-27 April 2018
- 2018/02/222nd National Meeting of the Egyptian Society for Psoriasis
- 2018/02/211st Psoriasis Symposium - Sarajevo 2017
- 2017/06/2815th São Paulo Meeting of Psoriasis and Vitiligo
News from medical groups
- 2018/04/183rd Turkish National Psoriasis Symposium
- 2017/06/21Brazilian Center for Psoriasis Studies joins SPIN!
- 2017/06/21Costa Rica Psoriasis Group - Meet them!
- 2017/02/02Works of the 1st Senegalese Psoriasis Day published!
- 2016/07/29Swiss S1 Guidelines for Systemic treatment of psoriasis vulgaris
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- 2017/02/08France Psoriasis - 2016 World Psoriasis Day
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- 2015/08/04Epidermia Greece: a new partner association of PIN
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- 2015/04/09AEPSO Argentina launches digital map to find people with psoriasis in the country
Recent publications on Psoriasis and Atopic Dermatitis
JAK-inhibitors in dermatology: current evidence and future applications.
J Dermatolog Treat. 2019 Nov , 30, (7):648-658.
The Janus kinase (JAK) and signal transducer and activator of transcription (STAT) pathway is a ubiquitous intracellular signaling network. Selective JAK-inhibitors have anti-inflammatory properties and have been approved in many countries for the treatment of rheumatoid arthritis (tofacitinib, baricitinib) and myelofibrosis or polycythemia vera (ruxolitinib). The aim of the publication was to summarize and critically analyze the efficacy and safety of JAK-inhibitors in skin diseases, such (...)see on pubmed
Patient preferences for attributes of topical anti-psoriatic medicines.
J Dermatolog Treat. 2019 Nov , 30, (7):659-663.
Patient preferences should be considered when prescribing topical treatments to drive up adherence and improve clinical outcomes. The aim of this work was to identify the most important attributes of topical medicines for psoriasis treatment in the patients' view, and explore the sociodemographic and clinical determinants of these preferences. A questionnaire for the evaluation of the relevancy given to specific attributes of topical medicines used for psoriasis treatment was developed (...)see on pubmed
Salidroside inhibits MAPK, NF-κB, and STAT3 pathways in psoriasis-associated oxidative stress via SIRT1 activation.
Redox Rep.. 2019 Dec , 24, (1):70-74.
To unveil the role of SIRT1 in limiting oxidative stress in psoriasis and to further discuss the therapeutic prospects of salidroside in psoriasis. Literature from 2002 to 2019 was searched with "psoriasis", "oxidative stress", "SIRT1", "salidroside" as the key words. Then, Oxidative stress in psoriasis and the role of SIRT1 were summarized and the potential role of salidroside in the disease was speculated. Oxidative stress might contribute to the pathogenesis of psoriasis. High levels (...)see on pubmed
A case of infective endocarditis associated with atopic dermatitis perioperatively treated with dupilumab.
J Dermatolog Treat. 2019 Nov , 30, (7):674-676.
Several case reports and reviews support a relationship between atopic dermatitis (AD) and infective endocarditis (IE). Here, we present a case of severe AD suspected of causing IE. A 21-year-old man with severe AD was admitted to our hospital due to unidentified fever, syncope, and headache. He was diagnosed with IE with cerebral embolism and mitral regurgitation. Before elective cardiac surgery, he was subcutaneously administered dupilumab for 2 months to control AD. Dupilumab improved (...)see on pubmed
Effect of cinnamamides on atopic dermatitis through regulation of IL-4 in CD4 cells.
J Enzyme Inhib Med Chem. 2019 Dec , 34, (1):613-619.
This study aimed to evaluate the effects of cinnamamides on atopic dermatitis (AD) and the mechanisms underlying these effects. To this end, the actions of two cinnamamides, (E)-3-(4-hydroxyphenyl)-N-phenylethyl acrylamide (NCT) and N-trans-coumaroyltyramine (NCPA), were determined on AD by orally administering them to mice. Oral administration of the cinnamamides ameliorated the increase in epidermal and dermal thickness as well as mast cell infiltration. Cinnamamides suppressed serum (...)see on pubmed
Sublingual immunotherapy of atopic dermatitis in mite-sensitized patients: a multi-centre, randomized, double-blind, placebo-controlled study.
Artif Cells Nanomed Biotechnol. 2019 Dec , 47, (1):3540-3547.
Allergen-specific immunotherapy is widely used for allergic rhinitis and asthma treatment worldwide. This study explored the efficacy and safety of sublingual immunotherapy (SLIT) with the extracts of ( Drops) on house dust mites (HDM)-induced atopic dermatitis (AD). 239 patients with HDM-induced AD were recruited and exposure to a multi-centre, randomized, double-blind, and placebo-controlled clinical trials for 36 weeks, which were randomly divided into placebo and sublingual Drops (...)see on pubmed