Treatment with tumor necrosis factor-alpha (TNF-alpha) inhibitors increases the risk of tuberculosis (TB) due to reactivation of latent Mycobacterium tuberculosis infection (LTBI). Screening for LTBI is based mainly on t...Treatment with tumor necrosis factor-alpha (TNF-alpha) inhibitors increases the risk of tuberculosis (TB) due to reactivation of latent Mycobacterium tuberculosis infection (LTBI). Screening for LTBI is based mainly on the tuberculin skin test (TST), which has several limitations in any patient who is immunosuppressed due to drugs or autoimmune disease. T cell interferon-gamma release assays (IGRA) have been shown to be more specific than TST in immunocompetent patients and potentially represent a new approach for the management of patients taking TNF-alpha blockers. Even if there is no evidence-based literature of IGRA superiority versus TST in this specific clinical setting, some studies suggest blood assays may be helpful in clinical management of these patients, in addition to currently recommended clinical screening for risk factors for LTBI.
Psoriasis is a chronic, genetically determined and immunomediated inflammatory skin disease that affects 2%-3% of the Caucasian population. Psoriatic arthritis (PsA), which occurs in up to one-third of patients with psor...Psoriasis is a chronic, genetically determined and immunomediated inflammatory skin disease that affects 2%-3% of the Caucasian population. Psoriatic arthritis (PsA), which occurs in up to one-third of patients with psoriasis, has a heterogeneous pattern expressed by various manifestations, including mono-oligoarthritis, an erosive and destructive polyarthritis indistinguishable from rheumatoid arthritis (RA), and spondyloarthropathy with axial involvement or enthesitis. Early detection of inflamed joints or axial involvement in patients with PsA is important in order to reduce inflammation and prevent joint destruction, deformity, and functional disability. The treatment of moderate-severe PsA has tended to include the same disease modifying antirheumatic drugs used to treat RA, but there is much less evidence supporting their efficacy and essentially none demonstrating that they slow radiographic joint destruction in PsA. A number of clinical trials have shown that tumor necrosis factor antagonists are generally safe and efficacious in the treatment of PsA, and can inhibit the progression of radiographic damage.
Retinoids are the most widely used agents for systemic treatment of psoriasis; as structural and functional analogs of vitamin A, they are involved in the regulation of several biologic functions. Acitretin is the oral r...Retinoids are the most widely used agents for systemic treatment of psoriasis; as structural and functional analogs of vitamin A, they are involved in the regulation of several biologic functions. Acitretin is the oral retinoid currently used, alone or in combination with other treatments, for plaque type, erythrodermic, and pustular psoriasis. Due to its high teratogenic effect, therapeutic contraception is required for women taking the drug. Narrowband ultraviolet B (nbUVB, 311 +/- 2 nm) is effective for guttate and plaque-type psoriasis. At the molecular level, UV light acts (1) directly (type I reaction) inducing the formation of pyrimidine dimers that, in turn, cause a transient cellular growth arrest; and (2) indirectly (type II reaction) through the generation of reactive oxygen species that act on key molecules such as lipids (in particular lipid membranes), proteins, and nucleic acids. Several studies show that UV rays can cause a transient decrease in DNA, RNA, and protein synthesis. These events are accompanied by a temporary normalization of cell kinetics of psoriatic keratinocytes. Phototherapy is carried out 3 times a week alone or in combination with topical treatments and/or acitretin. Several studies have confirmed that oral retinoids together with nbUVB (ReUVB) reduce the recovery time and also the doses of both acitretin and nbUVB. The regimen is carried out treating the patient with acitretin alone (0.5 mg/kg bw) for 2 weeks, then the dose of acitretin is reduced to 0.3 mg/kg bw, and the nbUVB is added 3 times a week until complete resolution of disease. As retinoids exert an anticarcinogenic effect, the ReUVB regimen could lower skin cancer risk resulting from longterm UVB therapy.
Longterm use of tumor necrosis factor-alpha (TNF-alpha) blocking agents requires ongoing monitoring to confirm efficacy and to avoid drug toxicity. Epidemiologic studies may offer important complementary information abou...Longterm use of tumor necrosis factor-alpha (TNF-alpha) blocking agents requires ongoing monitoring to confirm efficacy and to avoid drug toxicity. Epidemiologic studies may offer important complementary information about risks and benefits of this class of drugs. The safety profile of biologic therapies includes a wide spectrum of adverse events, of which the most relevant are risk of infections, malignancy, and cardiovascular diseases. The lack of published recommendations on monitoring suggests that clinicians must evaluate the patient for the risk or presence of any adverse events by regular checkups, with careful assessments, for their early detection. The safety profile in regard to psoriatic arthritis is discussed.
Psoriatic arthritis (PsA) is a seronegative spondyloarthropathy (SpA) occurring in up to 30% of patients with psoriasis. It has a wide variation of annual incidence (median 6.4, range 0.1-3.1 per 10(5) people), based on...Psoriatic arthritis (PsA) is a seronegative spondyloarthropathy (SpA) occurring in up to 30% of patients with psoriasis. It has a wide variation of annual incidence (median 6.4, range 0.1-3.1 per 10(5) people), based on analysis of 13 incidence and prevalence reviews published between 1987 and December 2006. Conventional treatments with antiinflammatory and disease modifying or antirheumatic drugs are not efficacious in all patients, in particular those with axial disease. This review examines new pharmacological developments in the treatment of PsA with a focus on biologic therapies.
Psoriasis is a common chronic inflammatory skin disease that may lead to disability and significant effects on patients' quality of life. A challenge in psoriasis management is to use an effective therapy early in the di...Psoriasis is a common chronic inflammatory skin disease that may lead to disability and significant effects on patients' quality of life. A challenge in psoriasis management is to use an effective therapy early in the disease course in order to achieve a safe and well tolerated maintenance of remission with an improvement of both skin and joint manifestations. Recent advances in knowledge of the pathogenesis of psoriasis helped develop targeted treatment options that may be effective and well tolerated over long periods of administration, thus improving the patient's quality of life. These novel "biologic" agents specifically target tumor necrosis factor-alpha (infliximab, etanercept, and adalimumab) or T cells (efalizumab).
Drug ingestion may result in exacerbation of preexisting psoriasis, induction of psoriatic lesions on clinically uninvolved skin in patients with psoriasis, or precipitation of the disease. In view of their relationship...Drug ingestion may result in exacerbation of preexisting psoriasis, induction of psoriatic lesions on clinically uninvolved skin in patients with psoriasis, or precipitation of the disease. In view of their relationship to psoriasis, therapeutic agents may be classified as follows: (1) drugs with strong evidence for a causal relationship to psoriasis including lithium, beta blockers, and synthetic antimalarial drugs; (2) drugs with considerable number of studies but insufficient data to support induction or aggravation of the disease; (3) drugs occasionally reported to be associated with aggravation or induction. While focusing on the most common causative agents for drug induced/aggravated psoriasis, we discuss the controversies about the relationship between drugs and psoriasis and report our own experience at the Section of Dermatology, University of Genoa.
The aim of this focus is to establish the role of methotrexate (MTX) in the treatment of psoriatic disease (PD). Despite the lack of hard evidence, MTX can be regarded as the nonbiological drug of choice for the treatmen...The aim of this focus is to establish the role of methotrexate (MTX) in the treatment of psoriatic disease (PD). Despite the lack of hard evidence, MTX can be regarded as the nonbiological drug of choice for the treatment of peripheral psoriatic arthritis, although its effect on psoriatic dactylitis, enthesitis, and spondylitis needs to be further studied by means of well conducted clinical trials. MTX is effective in improving the skin involvement of PD, and can be used in moderate to severe psoriasis before starting a biological agent. Although rheumatologists consider it relatively safe in PD, dermatologists are very concerned about its toxicity and so, until more definite data are available, precautions should be taken to prevent MTX-induced liver fibrosis and cirrhosis.
Cyclosporin A (CsA) has been proved to be effective in the treatment of severe cutaneous psoriasis and psoriatic arthritis (PsA). In psoriasis, CsA therapy can be used as: (1) intermittent short-course therapy; (2) conti...Cyclosporin A (CsA) has been proved to be effective in the treatment of severe cutaneous psoriasis and psoriatic arthritis (PsA). In psoriasis, CsA therapy can be used as: (1) intermittent short-course therapy; (2) continuous long-term therapy; (3) crisis intervention; and (4) a combination of sequential and rotational therapy. Several open prospective studies have shown the short-term efficacy of CsA in PsA. While there were no randomized controlled trials (RCT) comparing CsA to placebo, 3 published controlled trials compared CsA to other disease modifying antirheumatic drugs (DMARD). These studies support the efficacy of CsA in patients with PsA and peripheral arthritis. However, no conclusions can be drawn on the efficacy of CsA for dactylitis and axial disease. Long-term studies have shown the persistent efficacy and safety of CsA in PsA. The beneficial effects of CsA in angiogenesis-related diseases such as PsA and cutaneous psoriasis may also be mediated by its ability to block the angiogenic effects induced by vascular endothelial growth factor.
Prior to the availability of biologic agents such as anti-tumor necrosis factor (TNF), traditional treatment schemes for psoriatic arthritis were not extensively evaluated. While it appears that the newer forms of treatm...Prior to the availability of biologic agents such as anti-tumor necrosis factor (TNF), traditional treatment schemes for psoriatic arthritis were not extensively evaluated. While it appears that the newer forms of treatment are more effective, conventional agents still need to be scrutinized with similar methodology and will still have a role in those patients with less progressive disease, in combination with biologic agents, and in patients where biologics are not tolerated or have failed.
Psoriasis is an inflammatory skin disease with a chronic relapsing course. In about 20%-30% of psoriatic patients, disease severity requires systemic treatment, which carries a huge economic and management burden for the...Psoriasis is an inflammatory skin disease with a chronic relapsing course. In about 20%-30% of psoriatic patients, disease severity requires systemic treatment, which carries a huge economic and management burden for the healthcare system. The decision to employ systemic treatment, reserved for severe or extensive forms, needs to be weighed carefully and is influenced by factors from the host. Each form of treatment, i.e., photochemotherapy, cyclosporin A, methotrexate, acitretin - considered the traditional psoriatic treatments - should be evaluated for each specific clinical condition.
The use of magnetic resonance imaging (MRI) has modified the imaging strategies of inflammatory arthritides. In psoriatic arthritis (PsA), MRI study of the nail unit identifies nail involvement that appears as the initia...The use of magnetic resonance imaging (MRI) has modified the imaging strategies of inflammatory arthritides. In psoriatic arthritis (PsA), MRI study of the nail unit identifies nail involvement that appears as the initial lesion for induction of distal phalanx damage and consequently of distal interphalangeal joint arthritis. All psoriatic patients, also in the absence of a clinically evident onychopathy, show characteristic MRI changes of the nail. This evidence could have practical diagnostic value because MRI study of the nail could document diagnosis in patients with undifferentiated spondyloarthropathies who have barely evident psoriasis. We discuss the advantages and problems related to the use of low- and high-field MRI in the study of the nail unit of patients with PsA.
Although magnetic resonance imaging (MRI) studies of psoriatic arthritis (PsA) are fewer than those of rheumatoid arthritis (RA), interest in this field is growing. The type and site of the lesions, rather than the mere...Although magnetic resonance imaging (MRI) studies of psoriatic arthritis (PsA) are fewer than those of rheumatoid arthritis (RA), interest in this field is growing. The type and site of the lesions, rather than the mere severity of synovitis, can help differentiate PsA from other arthritides. Extracapsular enhancement and enthesitis are features emphasized as typical of PsA, but their relevance for the diagnosis is more quantitative than qualitative. Erosions in PsA are probably less frequent and progressive than in RA. Bone edema is unlikely to predict the appearance of erosions in patients with PsA. The Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) system has been adapted to peripheral PsA, but standardization is still in progress. Dactylitis is a relatively specific feature of PsA. Its pathogenic mechanisms have been investigated with MRI. MRI evaluation of PsA may facilitate diagnosis, evaluation of treatment effects, and understanding of associated mechanisms.
Over the last decade, ultrasound has been increasingly used in rheumatology for assessing soft tissue involvement in patients with chronic arthritis. In spite of the high number of studies supporting the role and the val...Over the last decade, ultrasound has been increasingly used in rheumatology for assessing soft tissue involvement in patients with chronic arthritis. In spite of the high number of studies supporting the role and the validity of ultrasound in the assessment of patients with rheumatoid arthritis, the potential of ultrasound imaging in patients with psoriatic arthritis still waits to be adequately investigated. Our report illustrates the most relevant sonographic findings obtainable with the latest generation ultrasound equipment in patients with psoriatic arthritis.
J Rheumatol Suppl
· 2009 Aug · PMID 19661536
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Full text
The term psoriatic disease encompasses the array of disorders (arthritis, inflammatory bowel disease, uveitis, obesity, metabolic syndrome, type II diabetes, and cardiovascular disease) that are associated with psoriasis...The term psoriatic disease encompasses the array of disorders (arthritis, inflammatory bowel disease, uveitis, obesity, metabolic syndrome, type II diabetes, and cardiovascular disease) that are associated with psoriasis. Psoriatic arthritis (PsA) is present in about 25% of patients with psoriasis; in most cases, the psoriasis precedes joint disease by about 10 years. Previous studies revealed that osteoclast precursors (OCP) are elevated in PsA and that the frequency of these circulating cells correlates with bone destruction. More recently OCP were found to be increased also in early rheumatoid arthritis and in 25% of psoriasis patients without arthritis. Bone marrow edema, observed on magnetic resonance imaging, in PsA represents infiltration of underlying marrow with inflammatory cells based on studies in transgenic tumor necrosis factor (TNF) arthritis murine models. Studies in the TNF transgenic mouse model also revealed that changes in lymph node volume precede joint flare. These translational studies point to potential biomarkers of arthritis in psoriasis patients and generate alternative hypotheses to explain the events that lead to arthritic flare.
In about 20% of patients with psoriatic arthritis (PsA) the rheumatological manifestations precede the onset of the cutaneous lesions. If there is a family history of psoriasis these patients are diagnosed as having psor...In about 20% of patients with psoriatic arthritis (PsA) the rheumatological manifestations precede the onset of the cutaneous lesions. If there is a family history of psoriasis these patients are diagnosed as having psoriatic arthritis sine psoriasis. In the past, they were also classified among patients with undifferentiated spondyloarthritis. The clinical spectrum of PsA sine psoriasis is wide and identified by dactylitis and/or distal interphalangeal arthritis, HLA-Cw6, and a family history of psoriasis. The ClASiffication of Psoriatic ARthritis (CASPAR) criteria of PsA include PsA sine psoriasis.
Early detection of psoriatic arthritis (PsA) can effectively help in reducing the risk of joint damage and disability. Accordingly, the authors offer diagnostic insights in order to improve the approach to the patient's...Early detection of psoriatic arthritis (PsA) can effectively help in reducing the risk of joint damage and disability. Accordingly, the authors offer diagnostic insights in order to improve the approach to the patient's medical history, clinical examination, and the imaging modalities. Early PsA is a condition with a consistent risk of clinical progression. Marked entheseal involvement is a distinctive clinical aspect that helps discriminate early PsA from other conditions observed at their onset, in particular rheumatoid arthritis.
Psoriasis is a common chronic skin disorder estimated to affect about 2% of the Western population. The disease creates a significant stigma for patients and is a major economic burden. Psoriasis has a large spectrum of...Psoriasis is a common chronic skin disorder estimated to affect about 2% of the Western population. The disease creates a significant stigma for patients and is a major economic burden. Psoriasis has a large spectrum of clinical features and evolution. Clinical features of chronic psoriasis are generally sufficient to make the diagnosis. Diagnostic doubts, however, may arise in several clinical variants and atypical cases or when the psoriatic lesions are localized in particular sites.
Thirty-five years after the hallmark "Moll and Wright" publication, the rheumatology community continues to debate both classification criteria and subgroup analysis of this fascinating yet heterogeneous disease, psoriat...Thirty-five years after the hallmark "Moll and Wright" publication, the rheumatology community continues to debate both classification criteria and subgroup analysis of this fascinating yet heterogeneous disease, psoriatic arthritis (PsA). Although Moll and Wright noted the predominant subgroup to be oligoarticular, using tighter definitions for each of the subgroups, historical archives suggest that a majority of their patients had polyarticular disease. One subgroup, arthritis mutilans, remains to be defined clinically, but data from the CASPAR study have been useful as a starting point. Both dactylitis and enthesitis are hallmark features of PsA, and new data on these manifestations are appearing. Dactylitis appears to be a severity marker not only within the affected digit but for the disease as a whole. Enthesitis remains an elusive clinical feature: recent data confirmed the poor association between clinical and ultrasonographic enthesitis in PsA. Finally, spinal disease in PsA is qualitatively and quantitatively different from classical ankylosing spondylitis, and a new scoring system combines elements of the BASRI and mSASSS to give a new modified index.
Psoriasis is a disease mediated by Th1 and Th17 cytokines that has different phenotypes (plaque, guttate, pustular, and erythrodermic type). Aside from the well known psoriatic arthritis, associated disorders may occur m...Psoriasis is a disease mediated by Th1 and Th17 cytokines that has different phenotypes (plaque, guttate, pustular, and erythrodermic type). Aside from the well known psoriatic arthritis, associated disorders may occur more frequently than expected, including Crohn's disease, anxiety/depression, and metabolic syndrome. This is based on a constellation of different factors, including abdominal obesity, atherogenic dyslipidemia, hypertension, and glucose intolerance, and is a strong predictor of type 2 diabetes, cardiovascular disease, and stroke. People with moderate to severe psoriasis have more risk for cardiac disease, presumably due to the inflammatory nature of psoriasis, causing inflammatory changes in coronary arteries. The strong association between psoriasis and obesity potentially makes psoriasis an important healthcare issue. Since cardiovascular risk factors are higher in psoriatic patients, dermatologists treating moderate to severe psoriasis should screen for their presence, thus approaching psoriasis as a potential multisystem disorder.