Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this second of 5 sections of the guidelines of care for psoriasis, we give an overview of psoriatic arthritis including its cardinal clinical features, pathogenesis, prognosis, classification, assessment tools used to evaluate psoriatic arthritis, and the approach to treatment. Although patients with mild to moderate psoriatic arthritis may be treated with nonsteroidal anti-inflammatory drugs and/or intra-articular steroid injections, the use of disease-modifying antirheumatic drugs, particularly methotrexate, along with the biologic agents, are considered the standard of care in patients with more significant psoriatic arthritis. We will discuss the use of disease-modifying antirheumatic drugs and the biologic therapies in the treatment of patients with moderate to severe psoriatic arthritis.

https://www.jaad.org/article/S0190-9622(09)00012-7/pdf

Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 2. Psoriatic arthritis: Overview and guidelines of care for treatment with an emphasis on the biologics

Vitiligo is an acquired pigmentary disorder of unknown etiology that is clinically characterized by the development of white macules related to the selective loss of melanocytes. The prevalence of the disease is around 1% in the United States and in Europe, but ranges from less than 0.1% to greater than 8% worldwide. A recorded predominance of women may reflect their greater willingness to express concern about cosmetically relevant issues. Half of all patients develop the disease before 20 years of age. Onset at an advanced age occurs but is unusual, and should raise concerns about associated diseases, such as thyroid dysfunction, rheumatoid arthritis, diabetes mellitus, and alopecia areata. Generalized vitiligo is the most common clinical presentation and often involves the face and acral regions. The course of the disease is unpredictable and the response to treatment varies. Depigmentation may be the source of severe psychological distress, diminished quality of life, and increased risk of psychiatric morbidity. Part I of this two-part series describes the clinical presentation, histopathologic findings, and various hypotheses for the pathogenesis of vitiligo based on past and current research.

https://www.jaad.org/article/S0190-9622(11)00039-9/pdf

Vitiligo: A comprehensive overview: Part I. Introduction, epidemiology, quality of life, diagnosis, differential diagnosis, associations, histopathology, etiology, and work-up

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this fourth of 6 sections of the guidelines of care for psoriasis, we discuss the use of traditional systemic medications for the treatment of patients with psoriasis. Treatment should be tailored to meet individual patients' needs. We will discuss in detail the efficacy and safety, and offer recommendations for the use of the 3 most commonly used, and approved, traditional systemic agents: methotrexate, cyclosporine, and acitretin. We will also briefly discuss the available data for the use of azathioprine, fumaric acid esters, hydroxyurea, leflunomide, mycophenolate mofetil, sulfasalazine, tacrolimus, and 6-thioguanine in psoriasis.

https://piel-l.org/blog/wp-content/uploads/2010/05/Guidelines-of-care-for-the-management.pdf

Guidelines of care for the management of psoriasis and psoriatic arthritis: section 4. Guidelines of care for the management and treatment of psoriasis with traditional systemic agents.

There have been several articles and reports in recent months about comorbidities and risks that affect psoriasis patients in addition to their underlying disease. This piece reviews the current literature and begins to address what should be done with this new information by updating the clinician about what health screening tests, preventative exams, and referrals should be considered in this population.

National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening

Background: Chronic plaque-type psoriasis is a major dermatosis, but a significant question is still unanswered: What defines severity in chronic plaque-type psoriasis? While objective assessments like the Psoriasis Area and Severity Index (PASI) have frequently been used in clinical trials, quality of life (QOL) questionnaires are currently becoming more and more popular. Objective: This article summarizes the most important objective and subjective measurements of severity in psoriasis. For every dermatologist it is critically important to distinguish between severe psoriasis and psoriasis that severely affects QOL. Even if the PASI also has disadvantages, it is the most adequate instrument available to evaluate severity in plaque-type psoriasis. Result: We provide reasons why PASI >12 defines severe, PASI 7–12 moderate and PASI

/pdf/the-psoriasis-area-and-severity-index-is-the-adequate-3hd1cpn55s.pdf

The Psoriasis Area and Severity Index Is the Adequate Criterion to Define Severity in Chronic Plaque-Type Psoriasis

Recognition, diagnosis, and treatment of primary focal hyperhidrosis

Objectives: To evaluate the safety and efficacy of botulinum toxin type A in the treatment of bilateral primary axillary hyperhidrosis. Design: Multicentre, randomised, parallel group, placebo controlled trial. Setting: 17 dermatology and neurology clinics in Belgium, Germany, Switzerland, and the United Kingdom. Participants: Patients aged 18-75 years with bilateral primary axillary hyperhidrosis sufficient to interfere with daily living. 465 were screened, 320 randomised, and 307 completed the study. Interventions: Patients received either botulinum toxin type A (Botox) 50 U per axilla or placebo by 10-15 intradermal injections evenly distributed within the hyperhidrotic area of each axilla, defined by Minor9s iodine starch test. Main outcome measures: Percentage of responders (patients with ≥50% reduction from baseline of spontaneous axillary sweat production) at four weeks, patients9 global assessment of treatment satisfaction score, and adverse events. Results: At four weeks, 94% (227) of the botulinum toxin type A group had responded compared with 36% (28) of the placebo group. By week 16, response rates were 82% (198) and 21% (16), respectively. The results for all other measures of efficacy were significantly better in the botulinum toxin group than the placebo group. Significantly higher patient satisfaction was reported in the botulinum toxin type A group than the placebo group (3.3 v 0.8, P 0.05). Conclusion: Botulinum toxin type A is a safe and effective treatment for primary axillary hyperhidrosis and produces high levels of patient satisfaction. What is already known on this topic Primary hyperhidrosis is a chronic disorder that can affect any part of the body, especially the axillas, palms, feet, and face Current treatments are often ineffective, short acting, or poorly tolerated What this study adds Botulinum toxin type A was significantly better than placebo on all measures of sweating Patient satisfaction was high and few adverse events were reported Effects of treatment remained apparent at 16 weeks

https://www.bmj.com/content/bmj/323/7313/596.full.pdf

Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial

A direct clinical comparison has been made of the efficacy of oral 8-methoxypsoralen with bath-water delivery of 8-methoxypsoralen during psoralen ultraviolet A (PUVA) phototherapy for a group of forty patients with stable plaque-type psoriasis vulgaris. The 8-methoxypsoralen concentration was 3.7 mg/liter in the bath water. The efficacy of these treatments was assessed by their ability to improve or clear the psoriasis. The skin of eight of the twenty patients with oral psoralen cleared, and another eight showed good improvement. Of the twenty patients who received 8-methoxypsoralen in bath water, eight patients had clearing of the skin, whereas nine patients had good improvement during the initial 8-week treatment period. Administration of 8-methoxypsoralen in bath water required much lower ultraviolet A irradiance to achieve maximum improvement. There were no systemic side effects in the patients treated by bath-water delivery; however, some patients did develop phototoxic erythema. Minimal phototoxic doses were also studied in patients and in volunteers using both routes of psoralen delivery. The minimal phototoxic dose threshold after psoralen bath delivery gradually declined over five treatments from 5.3 ± 0.6 joules/cm 2 to 2.8 ± 0.3 joules/cm 2 , suggesting an accumulation of psoralen in the skin with this method of drug delivery. Bath-water delivery of 8-methoxypsoralen was therefore found to be as effective as oral administration of 8-methoxypsoralen and yet required smaller amounts of ultraviolet A radiation and yielded fewer side effects. It would thus seem to be confirmed as a useful alternative means of 8-methoxypsoralen administration in PUVA therapy.

https://www.jaad.org/article/S0190-9622(86)70089-3/pdf

PUVA therapy for psoriasis: comparison of oral and bath-water delivery of 8-methoxypsoralen.

Background The long-term effects of botulinum toxin type A (BoNTA) on the global impairment associated with severe primary axillary hyperhidrosis have not been comprehensively assessed relative to placebo. Objective To assess the efficacy and safety of 2 dosages of BoNTA compared with placebo in subjects with primary axillary hyperhidrosis. Methods Subjects (N = 322) were randomized to the use of BoNTA (75 U or 50 U/axilla) or placebo in this 52-week, multicenter, double-blind study. Results BoNTA treatment significantly reduced daily activity limitations at 4 weeks after injection. A 2-point improvement on the 4-point Hyperhidrosis Disease Severity Scale (HDSS) was reported in 75% of subjects in the 75-U and 50-U BoNTA groups and in 25% of the placebo group ( P Limitations The effect of total surface area involvement on treatment efficacy was not evaluated. Conclusion BoNTA treatment effectively reduces the symptoms of primary axillary hyperhidrosis and is well tolerated.

Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety.

Nicholas J. Lowe

Papers

Recognition, diagnosis, and treatment of primary focal hyperhidrosis

Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial

PUVA therapy for psoriasis: comparison of oral and bath-water delivery of 8-methoxypsoralen.

Botulinum toxin type A in the treatment of primary axillary hyperhidrosis: a 52-week multicenter double-blind, randomized, placebo-controlled study of efficacy and safety.

Ultraviolet Radiation-Induced Connective Tissue Changes in the Skin of Hairless Mice