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PubMed2004

Major histocompatibility complex class I chain-related gene A in Thai psoriasis patients: MICA association as a part of human leukocyte antigen-B-Cw haplotypes.

Psoriasis is a chronic inflammatory skin disorder. Although the aetiology and pathogenesis of psoriasis are unproven, it is hypothesised that the major histocompatibility complex (MHC) gene/haplotype contributes to the susceptibility of psoriasis in many populations. MHC class I chain-related gene A (MICA), located 46-kb centromeric of HLA-B, is expressed on keratinocytes and fibroblasts. MICA is in linkage disequilibrium with HLA-B and is involved in natural killer-cell functions. To investigate the relative contribution of the MICA gene in the pathogenesis of psoriasis, extracellular polymorphisms of MICA were studied by polymerase chain reaction-sequence specific primers in 128 Thai psoriasis patients (87 and 41 were Types I and II, respectively) from Srinagarind Hospital, Faculty of Medicine, Khon Kaen University. The control group included 255 healthy, unrelated Northeast Thais. We observed 11 MICA alleles (or groups of alleles) in the patients. A comparison of the psoriasis patients and the control group revealed that MICA*010 and MICA*017 were associated with Type I psoriasis whereas only MICA*010 was associated with Type II. The haplotype analysis revealed that MICA*008-HLA-B*13-Cw*0602 and MICA*010-HLA-B*4601-Cw*01 were significantly increased in both Types I and II, whereas MICA*002-HLA-B*38-Cw*07 (01-03) and MICA*017-HLA-B*57-Cw*0602 were elevated only in Type I. MICA*010 was in strong linkage with Cw*01. Analysis of independent association of MICA*010 in individuals lacking Cw*01 failed to maintain an association. Our results suggest that a significant increase of the MICA alleles in the patient group is a part of HLA-B-Cw haplotypes. It is conceivable that an unknown susceptibility gene, on certain HLA-B-Cw haplotypes, is responsible for the development of psoriasis.

Alleles↗
PubMed2004

K252a, a high-affinity nerve growth factor receptor blocker, improves psoriasis: an in vivo study using the severe combined immunodeficient mouse-human skin model.

The peripheral nervous system, in addition to its sensory and motor functions, can induce a local inflammatory response known as neurogenic inflammation. This phenomenon plays a critical role in several inflammatory diseases, e.g., asthma, atopy, rheumatoid arthritis, psoriasis, and ulcerative colitis. Neurogenic inflammation and the role of nerve growth factor (NGF) have been extensively studied in psoriasis. There are increased levels of NGF in the keratinocytes and upregulation of NGF receptor (NGF-R) in the cutaneous nerves of psoriatic plaques. NGF can influence all the salient pathologic events noticed in psoriasis such as proliferation of keratinocytes, angiogenesis, T cell activation, expression of adhesion molecules, proliferation of cutaneous nerves, and upregulation of neuropeptides. In this double-blinded, placebo-controlled study, we addressed the role of NGF/NGF-R in psoriasis in an in vivo system using the severe combined immunodeficient (SCID) mouse-human skin model of psoriasis. The transplanted psoriatic plaques on the SCID mice (n=12) were treated with K252a, a high-affinity NGF receptor blocker. Psoriasis significantly improved following 2 wk of therapy. The length of the rete pegs changed from 308.57+/-98.72 to 164.64+/-46.78 microm (p<0.01, Student's t test). A similar improvement of psoriasis was observed by directly inhibiting NGF with NGF-neutralizing antibody. NGF-neutralizing antibody in normal saline at 10 ng (n=4) and 20 ng (n=4) per kilogram of body weight doses were used. Both doses of NGF-neutralizing antibody reduced rete peg lengths significantly, e.g., from 298.5+/-42.69 to 150.52+/-32.93 microm (p<0.05, Student's t test). This study provides evidence for the role of NGF and its high-affinity receptor in the pathogenesis of psoriasis and insights to develop novel therapeutic modalities.

Animals↗
PubMed2004

Divergent beliefs about psoriasis are associated with increased psychological distress.

The psychological adjustment of patients with psoriasis has been studied extensively. By comparison, no research has focused on their partners. We examined illness representations of psoriasis held by patients and their partners, and investigated whether divergent beliefs were associated with psychological distress. Fifty-eight patients with chronic plaque psoriasis and their partners completed a range of psychological assessments including beliefs about the condition, anxiety, depression, and worry. Patients also completed a self-assessment of psoriasis severity. Patients with psoriasis had significantly higher levels of anxiety, depression, and worry than their partners (t's > 2.53, p's < .05). Multiple regression analysis indicated that divergence in patients' and partners' beliefs about emotional impact of psoriasis and chronicity of timeline accounted for a statistically significant (21.3%) proportion of the variance in depression for partners. Differences in views on the consequences of having psoriasis and the cyclical nature of the condition were also significantly associated with increased levels of worry in partners. Dissimilarity in particular aspects of illness representations are associated with increased psychological distress in particular for the partners of patients with psoriasis. The results illustrate the importance of concordance between patients' and partners' models of illness in relation to adjustment, and highlight the need to consider and collaborate with both patients and their partners in managing this challenging condition.

Adaptation, Psychological↗
PubMed2005

Psoriasis phenotype at disease onset: clinical characterization of 400 adult cases.

Psoriasis is clinically a heterogeneous disease. Detailed evaluation of phenotype at disease onset is lacking. This study is a baseline characterization of 400 adult individuals with first time incidence of psoriasis on non-hairy skin, describing clinical phenotypes and putative environmental triggers at disease onset. In total, 74 patients with guttate and 326 patients with non-guttate phenotype, the majority with plaque psoriasis, were included. Guttate phenotype was associated with younger age and recent infection in 84%, where acute streptococcal pharyngitis was verified in 63%. The predominating factor associated with onset of plaque psoriasis was a recent life crisis (46%). A positive family history for psoriasis was approximately the same in both groups. Psoriasis arthropathy was diagnosed in 5% of guttate and 15% of non-guttate patients, with enthesopathy being the dominant symptom among guttate patients. This study confirms the strong link between onset of guttate psoriasis phenotype and streptococcal throat infection, whereas onset of plaque psoriasis was highly associated with a preceding distinct stressful life event. Longitudinal follow-up of the patients will provide robust information about disease development and response to treatment.

Adolescent↗
PubMed2006

Vascular endothelial growth factor gene polymorphisms increase the risk to develop psoriasis.

We investigated the relationship between eight polymorphisms in the gene encoding for vascular endothelial growth factor (VEGF) (-1540C > A, -1512Ins18, -1451C > T, -460T > C, -160C > T, -152G > A, -116G > A and +405G > C) and plaque-type psoriasis stratified for age at onset, gender and family history of dermatosis. For this purpose, 117 patients with chronic plaque-type psoriasis and 215 healthy subjects were enrolled. We found that being homozygous -1540AA, -1512InsIns, -1451TT, -460CC and -152AA conferred a significant risk in developing psoriasis compared with heterozygous (-1540CA, -1512 + Ins, -1451CT, -460CT and -152AG) and homozygous genotypes (-1540CC, -1512 + +-1451CC, -460TT and -152GG) grouped together [odds ratio (ORs) = 1.73, 1.73, 1.73, 1.77 and 1.87, respectively]. Conversely, having the -116AA or +405GG genotype did not significantly increase the risk of disease expression compared with other genotypes of the same loci. Interestingly, we found that -1540AA, -1512InsIns, -1451TT, -460CC and -152AA homozygous genotypes have a significant two-fold increased risk in developing psoriasis after the age of 40 years (late-onset psoriasis) (ORs = 2.19, 2.19, 2.19, 2.05 and 2.26; P = 0.02, 0.02, 0.02, 0.04 and 0.02, respectively) as compared with controls. On the contrary, we found no phenotype-genotype association of the same magnitude among the patients in whom psoriasis developed at or before the age of 40 years (early-onset psoriasis) compared with controls. Genotype distributions were not significantly different when cases and controls were stratified either by gender or family history of psoriasis. Finally, VEGF plasma concentration was not significantly different between patients and controls and was not correlated with the severity of the disease.

5' Untranslated Regions↗
PubMed1988

A study of local immunity in psoriasis.

We have studied biopsies of lesional skin with monoclonal and polyclonal antibodies to determine the nature of the infiltrate in different forms of psoriasis. In guttate psoriasis the number of Langerhans cells (LC) was not increased and CD8+ cells predominated, however, most CD4+ cells were activated. In erythrodermal psoriasis some CDI+ cells were found in the dermis although CD8+ cells predominated and were activated. In palmo-plantar psoriasis LC were found in the epidermis and superficial dermis and CD4+ cells were more numerous than CD8+ cells, some in turn expressing HLA-DR. In flexural psoriasis the LC formed clusters in the epidermis, and activated CD4+ cells predominated. In psoriasis vulgaris CD4+ cells predominated over CD8+ although the latter were activated. Our observations tend to support Valdimarsson's hypothesis on the immune basis of psoriasis, but we believe that two cycles coexist in psoriasis--one inflammatory and the other immunological--and that interaction between these leads to epidermal hyperproliferation.

Adolescent↗
PubMed1994

Smoking, alcohol and life events related to psoriasis among women.

Possible risk factors for psoriasis were studied among women aged 18-50 years. The series consisted of 55 consecutive psoriatic patients and 108 unmatched controls with other skin diseases, from the university departments of dermatology in Helsinki, Oulu and Tampere. A questionnaire focused on two specified periods of time, 12 months before the onset of the skin disease and 12 months before the examination date. Before the onset of the skin disease, the recalled mean number of cigarettes smoked daily was 8.6 (1.2 SE) for psoriatics and 4.7 (0.7) for controls (P = 0.004). The respective alcohol intake figures (mean +/- SE) were 8.0 (2.2) and 4.7 (0.8) g/day (P = 0.17). In logistic regression analysis, psoriasis was associated significantly with smoking, but not with alcohol intake, marital status or social group. The odds ratio for psoriasis for those smoking 20 cigarettes daily compared with non-smokers was 3.3 (95% confidence limits 1.4-7.9). The odds ratio for psoriasis at an alcohol intake of 20 g/day compared with no intake was 1.8 (1.0-3.3). After the onset of the disease, psoriasis was associated significantly with alcohol intake, smoking, and the occurrence of negative life events. Among psoriatics, skin surface involvement was significantly associated with alcohol intake (P = 0.04), but not with smoking or negative life events. These results suggest that smoking is a risk factor for psoriasis in women, and that alcohol intake worsens their psoriasis. Smoking and negative life events were more common among psoriasis patients than among controls, perhaps as consequences of the disease.

Adolescent↗
PubMed2004

Rethinking the Psoriasis Area and Severity Index: the impact of area should be increased.

BACKGROUND: The Psoriasis Area and Severity Index (PASI) is the most frequently used clinical severity scale in clinical trials. Drug approval often depends on a 75% improvement in the baseline PASI score, also known as a PASI 75 or Delta PASI 75. This benchmark may be an overly stringent way to determine the success of psoriasis treatments as Delta PASIs appear to under-represent true clinical improvement. This discrepancy may relate to the way numerical values are assigned to the degree of body surface area (BSA) involvement. OBJECTIVES: To assess whether altering the BSA component of the PASI formula so that it is weighted more heavily will result in a calculated change in psoriasis severity that more closely reflects patient assessment of improvement. Models developed included the Psoriasis Log-based Area and Severity Index (PLASI), which assigns values to the BSA score based on a linear scale using logarithms to define the intervals, and the Psoriasis Exact Area and Severity Index (PEASI), which uses the actual BSA as the multiplicative factor in the area score. METHODS: Data were abstracted retrospectively from two clinical trials involving psoriasis treatments that used the PASI. The same trained psoriasis graders were involved in both trials. In these trials, baseline and end-point PASI worksheets were completed that included the actual clinician-estimated BSA involvement (0-100%) for each of the four areas (head, upper extremities, trunk and lower extremities). In one of the trials, patients were asked to assess the percentage improvement in their psoriasis at the end of the treatment window. PASIs and Delta PASIs were recalculated based on the new models and all scoring systems were validated by analysing their relationship to patients' self-assessments. RESULTS: Clinical improvements under the new grading systems translated into greater percentage changes than calculated using the Delta PASI formula. Specifically, the Delta PASI 50 translated to a Delta PLASI 57.2 and Delta PEASI 61.1; Delta PASI 75 was equivalent to Delta PLASI 85.7 and Delta PEASI 91.7. Importantly, Delta PASI tended to be systematically lower than patients' self-assessment, while Delta PLASI and Delta PEASI better matched patients' self-assessments using a best-fit model. CONCLUSIONS: These results suggest that the Delta PASI underestimates percentage improvement when compared with measures of patient's self-assessment, while Delta PLASI and Delta PEASI correlate better. Prospective studies will have to be performed to confirm these relationships, but weighting BSA more heavily in the severity score may result in a more accurate reflection of clinical status.

Body Surface Area↗
PubMed2005

Gene expression profiles in psoriasis: analysis of impact of body site location and clinical severity.

BACKGROUND: Psoriasis is characterized by symmetry of plaques and modulation of multiple genes within those plaques. OBJECTIVES: We compared gene expression profiles of plaques of psoriasis at different anatomical sites for both symmetrical and asymmetrical disease to ascertain whether the same genes were expressed. METHODS: Gene expression profiles were analysed in biopsies from lesional and uninvolved skin from two groups of patients with either predominantly symmetrical or truncal plaques of psoriasis vulgaris, and from normal skin of healthy volunteers. Genomic analyses were performed using cDNA array and kinetically monitored reverse transcriptase-initiated polymerase chain reaction (kRT-PCR) approaches. A cluster of genes upregulated in involved psoriasis skin as compared with normal skin was identified using each of these two technologies. RESULTS: Clustering of patients based on their gene expression profile did not reveal any correlation with family history of psoriasis, age at onset or association of psoriasis with arthritis. There was no difference in gene expression profile between the type (symmetrical vs. truncal) or location (left vs. right side of body) of psoriatic plaques. Gene expression profiles of involved psoriatic skin analysed by kRT-PCR analysis did correlate with both global (Psoriasis Area and Severity Index) and local (erythema, desquamation and plaque elevation) clinical severity. CONCLUSIONS: These results indicate that it may be feasible to analyse the molecular effects of pharmacological agents on psoriatic skin in 'minizone' protocols, that the obtained data can be correlated with clinical severity and that plaques of psoriasis in the same individual express the same genes.

Adult↗
PubMed2005

Plaque psoriasis vs. atopic dermatitis and lichen planus: a comparison for lesional T-cell subsets, epidermal proliferation and differentiation.

BACKGROUND: T-cell infiltration in plaque psoriasis has recently been an important subject of investigation. Interestingly, comparative analyses of the disease-specific composition of the lesional T-cell infiltrate in plaque psoriasis and other inflammatory dermatoses have only sparsely been performed. OBJECTIVES: To compare plaque psoriasis vs. atopic dermatitis and lichen ruber planus with respect to T-cell subsets, epidermal proliferation and keratinization. PATIENTS AND METHODS: Biopsies were taken from untreated lesional skin of patients, six with psoriasis, six with atopic dermatitis and six with lichen planus. T-cell subsets (CD4+, CD8+, CD45RO+, CD45RA+, CD2+, CD25+), an epidermal proliferation (Ki-67) and a keratinization marker (K10) were stained immunohistochemically and quantified using image analysis. RESULTS: The high number of CD8+ T cells (52 +/- 13 cells mm(-1)) found in the psoriatic epidermis was not found in the epidermis of atopic dermatitis (9 +/- 4), nor in the epidermis of lichen planus (34 +/- 10). The other T-cell subsets in the epidermis and dermis showed no statistically significant differences between psoriasis and atopic dermatitis. In contrast to the limited presence of CD4+, CD8+ and CD2+ in the psoriatic dermis (110 +/- 19, 27 +/- 9, 127 +/- 41, cells mm(-1), respectively), more impressive numbers of these cells were observed in the dermis of lichen planus (300 +/- 53, 144 +/- 38, 272 +/- 48, respectively). CD45RO+ memory effector T-cell counts were significantly higher in the epidermis of lichen planus (39 +/- 10) than in psoriasis (19 +/- 5). Psoriatic epidermis proved to have major keratinocyte hyperproliferation (247 +/- 26 cells mm(-1) lamina basalis), as compared with atopic dermatitis (134 +/- 15) and lichen planus (128 +/- 20). Furthermore, a marked decreased expression of keratin 10 was observed in psoriasis (41% of epidermal area) contrary to atopic dermatitis (70%). CONCLUSIONS: Psoriatic epidermis exhibits a pronounced CD8+ epidermotropism with accompanying epidermal hyperproliferation and abnormal keratinization, which changes are only minimally expressed in atopic dermatitis and lichen planus. In plaque psoriasis, substantially fewer activated CD4+ and CD8+ T cells in the dermis and less CD45RO+ T cells in the epidermis are present in comparison with lichen ruber planus.

Adult↗
PubMed2005

Diet and psoriasis: experimental data and clinical evidence.

Psoriasis is considered as a T-cell-mediated inflammatory skin disease which is characterized by hyperproliferation and poor differentiation of epidermal keratinocytes. While susceptibility to psoriasis is inherited, the disease is influenced by environmental factors such as infections and stress. Diet has been suggested to play a role in the aetiology and pathogenesis of psoriasis. Fasting periods, low-energy diets and vegetarian diets improved psoriasis symptoms in some studies, and diets rich in n-3 polyunsaturated fatty acids from fish oil also showed beneficial effects. All these diets modify the polyunsaturated fatty acid metabolism and influence the eicosanoid profile, so that inflammatory processes are suppressed. Some patients with psoriasis show an elevated sensitivity to gluten. In patients with IgA and/or IgG antigliadin antibodies the symptoms have been shown to improve on a gluten-free diet. The active form of vitamin D, 1,25-dihydroxyvitamin D(3), exhibits antiproliferative and immunoregulatory effects via the vitamin D receptor, and thus is successfully used in the topical treatment of psoriasis. In this review, dietary factors which play a role in psoriasis are assessed and their potential benefit is evaluated. Furthermore, the risk of drug-nutrient interactions in psoriasis therapy is discussed.

Antioxidants↗
PubMed2005

Response of the hypothalamic-pituitary-adrenal axis to psychological stress in patients with psoriasis.

BACKGROUND: Psoriasis may, in some patients, be triggered and/or exacerbated by stress. OBJECTIVES: As activation of the hypothalamic-pituitary-adrenal (HPA) axis is critical to a successful stress response we investigated this in patients with psoriasis. METHODS: Forty patients with chronic plaque psoriasis and 40 age-matched normal controls experienced three randomly presented acute psychological stressors (cognitive, emotional and social). Serial serum cortisol, pulse rate and blood pressure assessments were undertaken at baseline and following each of the stressors. Salivary cortisol samples were collected at 09.00 h on the day of testing. RESULTS: In control subjects there was a significant (r = 0.38; P < 0.05) correlation between pulse rate and serum cortisol level following the social performance stressor; this was not evident in the psoriasis group (r = 0.07; not significant). Patients who believed that their psoriasis was highly stress responsive had significantly lower salivary cortisol levels at baseline (P < 0.01) and lower serum cortisol levels following the social performance stressor (P = 0.016) than patients with nonstress-responsive disease who believed that stress had no impact. In contrast, there was no difference between the groups for change in pulse rate poststressor. CONCLUSIONS: This study shows that patients with psoriasis, and in particular those whose disease appears to be stress responsive, exhibit an altered HPA response to acute social stress. The implication is that such patients may perhaps be primed to flares of their psoriasis. Whether this is genetically predetermined and/or a consequence of the distress of living with psoriasis remains to be determined.

Adolescent↗
PubMed2005

Corneodesmosin (CDSN) gene association with psoriasis vulgaris in Caucasian but not in Japanese populations.

PSORS1 on chromosome 6p21.3, which contains the MHC, is a major susceptibility locus for psoriasis vulgaris. This region is characterized by strong linkage disequilibrium and contains the corneodesmosin (CSDN) gene, an attractive candidate for psoriasis susceptibility based on its putative biological function in keratinocyte adhesion, and HLA-Cw6, an established marker for psoriasis susceptibility. We compared two genetically independent populations in order to define the major psoriasis susceptibility gene, a British Caucasian population comprising parent-offspring trios analysed by the transmission disequilibrium test (TDT) and a Japanese case-control population. All individuals were investigated for CDSN polymorphism (+619, +1236, +1240 and +1243) and HLA-C association. Our data confirms strong association with HLA-Cw6 and CDSN allele 5 (+619T, +1240G, +1243C) in the Caucasian cohort (TDT, P = 5.4 x 10(-6)) and in addition defines this region further by identifying a high-risk CDSN haplotype (allele 5 and +1236T, P = 8.5 x 10(-8)). In contrast no association was observed in the Japanese cohort for any HLA-C or CDSN alleles. This data supports a role for the CDSN gene in Caucasian populations with psoriasis. However the lack of association with HLA-Cw6 and CDSN alleles in Japanese psoriasis patients may be because Japanese patients exhibit a form of psoriasis similar to late onset or Type II psoriasis vulgaris in contrast to early onset or Type I disease characterizing our Caucasian population.

Adolescent↗
PubMed1996

Clearance of recalcitrant psoriasis after tonsillectomy.

Infection is a well-recognized triggering factor for both guttate and chronic plaque psoriasis. We investigated prospectively 13 patients with recalcitrant psoriasis exacerbated by recurrent tonsillitis, who underwent tonsillectomy between 1990 and 1993. There were 12 female patients and one male, with a mean age of 17 yr (range 6-28). Six patients had guttate psoriasis resistant to standard treatments and seven patients had chronic plaque psoriasis exacerbated by tonsillitis that was severe enough to warrant at least one admission to hospital. Patients were followed by chart review and postal questionnaire. Psoriasis was cleared completely after tonsillectomy in five out of the six patients (83%) with guttate psoriasis and was improved in one patient. Two out of seven patients with plaque psoriasis (29%) were cleared, two (29%) were improved and three (42%) were unchanged. We conclude that tonsillectomy may be a successful treatment modality in selected patients with recalcitrant guttate or chronic plaque psoriasis.

Adolescent↗
PubMed1993

Psychosocial consequences of rejection and stigma feelings in psoriasis patients.

BACKGROUND: Many studies as well as clinical experience indicate that patients often feel stigmatized by their psoriasis and may experience rejection due to their skin disease. METHODS: In this study of connections between feelings about having psoriasis, rejection by others, and the impact on work experience, alcohol use, and psychiatric help-seeking, 100 adults with moderate to severe psoriasis responded to a specially designed questionnaire. Multiple regression analysis is used to determine whether, and how, rejection experience and stigma feelings are associated with the three psychosocial outcomes after controlling for psoriasis severity. RESULTS: Nineteen percent of the subjects experienced 50 episodes of gross rejection as a result of their psoriasis, most often from a gym, pool, hairdresser, or job. Rejection experience leads to feeling stigmatized, which is then associated with help seeking and, to some degree, with interference with work. Rejection can lead to feeling stigmatized and to increased alcohol consumption, but the data show that patients may drink without conscious awareness of their feelings. CONCLUSIONS: When patients experience psoriasis-related rejection, they may feel stigmatized and suffer further adverse effects on their emotional and occupational life. It is urgent that ways of helping people deal with the impact of psoriasis, its stigmatizing potential, and the consequences of psoriasis-induced rejection be emphasized.

Adult↗
PubMed1996

Psoriasis and pregnancy: hormone and immune system interaction.

BACKGROUND: Various hormonal states are known to be associated with the waxing and waning of psoriasis. Patients with psoriasis commonly experience changes in their cutaneous disease during pregnancy or post partum. OBJECTIVE: We evaluated 100 women with psoriasis by questionnaire and interview. The women had been seen at the Baylor Psoriasis Center, Dallas, and had experienced a pregnancy while having psoriasis. The answers were sorted and tabulated. In addition, we reviewed the literature to ascertain possible causes of clinical changes in psoriasis during pregnancy. RESULTS: Ninety questionnaires were completed. Sixty-nine women (76.7%) described a change in their psoriasis during pregnancy with 57 (63.3%) noting improvement. Seventy-nine patients (87.7%) had a postpartum flare, most within 4 months of delivery. CONCLUSIONS: The majority of women with psoriasis, who become pregnant, experience a change, usually an improvement, in their cutaneous disease. Pregnancy is associated with hormonal changes in estrogens and progesterone resulting in a state of altered immune surveillance.

Adolescent↗
PubMed2006

Psoriasis treatment in the United States at the end of the 20th century.

BACKGROUND: Psoriasis presents many management complexities. A cornerstone of therapy has been topical corticosteroids, although over the past 10 years there have been many additions to the medication armamentarium. Furthermore, various combination regimens and approaches have been advocated. OBJECTIVE: We sought to characterize various patterns of psoriasis health care delivery and the changes associated with these patterns from 1990 to 2001. METHODS: Visits for psoriasis were identified using National Ambulatory Medical Care survey data, a representative survey of visits to physician offices in the United States. We determined basic demographic characteristics, specialty of the physician provider and medications listed at these visits over the 1990-2001 interval. RESULTS: There were more than 13.5 million visits for psoriasis during the 12-year study period. Dermatologists were responsible for the majority of the visits over the study interval (82%) although there was an overall decline in the proportion of psoriasis visits to dermatologists. As a category, the most common medications used for psoriasis were topical steroids. Topical calcipotriene was the single-most listed medication. There was no observed use of non-corticosteroid topical agents at visits to non-dermatologists. Non-dermatologists were as likely as dermatologists to list a systemic medication at a visit as well as use a systemic as monotherapy. DISCUSSION: In conclusion, the primary topical therapies for psoriasis remain clobetasol and calcipotriene. The decreasing role of dermatologists in the treatment of psoriasis is probably a complex issue, but may relate in part to the difficulty of obtaining access to dermatology care.

Administration, Topical↗
PubMed2006

Concomitant psoriasis and bullous pemphigoid: coincidence or pathogenic relationship?

Psoriasis vulgaris and bullous pemphigoid represent two clinically well-characterized, chronic, inflammatory skin diseases. The concomitant occurrence of these two entities in a patient is rare, and the pathogenic implications of this phenomenon are unknown. We describe a 55-year-old woman with a 25-year history of plaque-type psoriasis who presented with disseminated tense bullae. Skin biopsies showed the typical histologic and immunohistochemical traits of bullous pemphigoid, and she had circulating immunoglobulin G (IgG) antibodies against the basement membrane zone, specifically the BP180 antigen. The bullous eruption was successfully treated with oral methylprednisolone and dapsone. Bullous pemphigoid is the autoimmune blistering disease that has most often been associated with psoriasis. Forty cases have been described in the literature. Classical psoriasis and psoriasis associated with bullous pemphigoid are identical. The pathogenic relationship between psoriasis and bullous pemphigoid is unclear. It has been postulated that the autoimmune process responsible for bullous pemphigoid lesions may be induced by ultraviolet light therapy, topical corticosteroids, and/or the inflammatory processes that occur in psoriasis. Immunomodulatory therapy may positively influence shared as well as distinct inflammatory mechanisms in patients who have psoriasis and bullous pemphigoid.

Autoantigens↗