Compiled by our Editorial Team of Louise Todd, Tom Chown, Jacob Baker, Penny Staton, Georgina Mason, Allen Wellings, Abhi Chakravorty and Adam Jeffery.
The second day of the 27th European Academy of Dermatology and Venereology (EADV) meeting continued the scientific conversation, with sessions focussing on the diagnosis and pathogenesis of psoriasis, clinical manifestations of the condition, a review of current treatment options as well as insights into the surgical management of hidradenitis suppurativa (HS). Here are some of the day’s highlights from these captivating sessions.
Professor Michel Gilliet, University Hospital, Lausanne, Switzerland provided a fascinating overview of paradoxical psoriasis, sharing a case of a psoriasis patient (PASI 19) who had a good response to anti-TNF treatment (PASI 2). The patient went on to develop psoriasis on the palms of the hands, soles of the feet and the scalp, a phenomenon known as paradoxical psoriasis. This occurs in approximately 5% of patients treated with anti-TNF therapy.
Paradoxical psoriasis is independent of the underlying disease, and a consequence of anti-TNF treatment. Professor Gilliet went on to explain that classical psoriasis begins with an IFN-α-driven acute phase which promotes the TNF/IL-23/IL-17 mediated chronic phase of the disease.
Paradoxical psoriasis differs from classical psoriasis as it is associated with increased levels of IFN-α2 and IFN-β1 compared to classical psoriasis. This is driven by anti-TNF treatment, with loss of TNF signalling resulting in increased IFN-α but also reduced plasmacytoid dendritic cell (pDC) differentiation. This leads to an increase in pDC and a prolonged IFN-α signalling response. Furthermore, due to the lack of IL-23 and IL-17 signalling, there is no T-cell involvement or CD8+ infiltration of the epidermis seen in paradoxical psoriasis. Professor Gilliet suggested, therefore, that this is not a form of psoriasis and its naming should be amended to reflect this.
Professor Gilliet went on to explain that pDC cells can be targeted with immunosuppressants, phototherapy or topical steroids, and studies are ongoing.
This session provided a comprehensive review of current treatment options for the management of psoriasis, expertly reviewed by Professor Rolland Gyulai, of the University of Pécs, Hungary.
Professor Gyulai began with an overview of the development of psoriasis treatments and explained the role of these in improving patient outcomes to PASI 100.
The audience agreed that, whilst biological therapies have shown promising results in the treatment of psoriasis, classical oral therapies are still very much a mainstay of treatment, due to cost effectiveness, and the long-standing wealth of clinical evidence supporting their use.
Professor Gyulai provided a valuable overview of currently available treatment options, including methotrexate, which is commonly used in the treatment of severe psoriasis in Hungary, and as an active comparator in many clinical trials. This has recently been shown to have improved efficacy with intensified dosing schedules, with a PASI 75 response of 41% at Week 16 and with adherence levels of approximately 50% (Warren et al. Lancet. 2017; 389:528–537). However, Professor Gyulai reminded the audience that methotrexate has a well-known safety profile, and liver fibrosis should be assessed before and after treatment, as hepatotoxicity can increase with comorbid conditions including diabetes and obesity.
In his review of acitretin, the audience were reminded of the teratogenic side effects of treatment, and the need for timely and well-monitored up-dosing to improve treatment efficacy balanced against the management of side effects. The benefits of ciclosporin as an induction therapy were also discussed.
Professor Gyulai concluded his presentation by remarking that the use of classical therapies alongside biologics may lead to improved outcomes in psoriasis patients, due to their differences in pharmacological targets. Pharmacokinetic data suggests that methotrexate may affect both the clearance and immunogenicity of biological treatments; whilst data supporting combination therapies looks promising, further psoriasis-specific data are required.
The presentations around the management of psoriasis were nicely complemented with an overview of the surgical treatment of patients with hidradenitis suppurativa (HS) by Dr Klemens Rappersberger, of the Rudolfstiftung Hospital, Vienna, Austria.
Dr Rappersburger began his presentation by recapping the use of the Hurley scale, as the most commonly used system for the staging of HS. This categorises HS according to spread and severity of disease, and Dr Rappersburger reminded the audience that whilst surgery is not suitable for patients with generalised disease, it is an effective treatment option for certain patients with localised HS such as those with Hurley grade III. This is defined as multiple interconnected tracts and abscesses throughout an entire area, and the goal of treatment for patients with this level of HS should be healing their condition.
He went on to present results from a retrospective analysis of HS patients treated at the Rudolfstiftung Hospital. The use of wide excision surgery in 74 patients with localised HS resulted in significant improvements in Dermatology Life Quality Index [DLQI] scores (improvement of 22.6 points following surgery; p<0.01). Patients were hospitalised for a mean of 10 days, with approximately 80% experiencing complete healing in treated areas, without signs of relapse. Overall, 70.3% of patients were highly satisfied with their cosmetic results. (Posch et al. J Am Acad Dermatol. 2017;77(1):123-12).
Dr Rappersburger advised that surgery should be considered as standard treatment for this patient group, concluding that wide excision surgery may cure up to 80% of patients with Hurley grade III HS.
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