Issue #6, August 2021
Welcome back to The Surface, a monthly feature of the PSOLVE+ community where we summarize recent publications with high clinical relevance for Canadian dermatologists. View archived issues of The Surface at psolve.org/the-surface.
Predictors of methotrexate discontinuation in plaque psoriasis
A retrospective study of psoriasis patients at five referral centres in Turkey evaluated drug survival for methotrexate monotherapy, defined as the length of time from initiation until discontinuation of the drug. There were 649 patient charts included in the analysis, and the data set included patients with and without psoriatic arthritis (PsA). Two-thirds of participants had not received any prior conventional systemic therapy, and all were biologic-naïve.
The mean PASI score was 12.9, and 62.6% of patients had a score of ≥10. Patients were evenly split between oral and subcutaneous methotrexate, and the average weekly dose was 15.3 mg. Nearly 65% of patients discontinued methotrexate. The reasons cited were side effects (32.2%), patient choice (12.5%), primary inefficacy (9.2%), secondary inefficacy (6.9%), and other (3.4%). Gastrointestinal events were the most common adverse events leading to discontinuation, followed by liver events, infections, and hematologic abnormalities. The overall drug survival rate was 54.7%, 17.4%, and 8% after 1, 3, and 5 years, respectively, and the median drug survival was 15 months.
Read more: [Sosido Link] Ozkok Akbulut T, Topaloglu Demir F, Oguz Topal I, et al. Drug survival and predictor factors for discontinuation of methotrexate in psoriasis: a real-life multicenter study [published online ahead of print, 2021 May 20]. Int J Dermatol. 2021;10.1111/ijd.15628. doi:10.1111/ijd.15628
Systematic review of predictive biomarkers for treatment response in psoriasis and psoriatic arthritis
Magee and colleagues conducted a systemic review of the literature in order to identify predictive biomarkers for treatment response in both psoriasis and PsA. Particularly for the arthritic manifestations, response rates with both conventional and biologic therapies have significant room to improve. The review included cohort, case-control, and randomized clinical studies, and 44 articles fit the inclusion criteria. There was one study for each of tofacitinib and methotrexate, with the balance of studies evaluating response to biologic agents. One limitation of the study is the small number of patients included in the biomarker studies.
In psoriasis, several studies revealed conflicting results for the HLA-C*06 allele, while interleukin-12 serum levels and polymorphisms in the IL-12B gene showed promise as biomarkers for treatment response. For PsA, most studies found that higher baseline levels of C-reactive protein were associated with a better treatment response. The outcomes measured in the PsA studies were not consistent, making comparisons more difficult than in psoriasis. Further validation of these potential biomarkers is needed.
Read more: [Sosido Link] Magee C, Jethwa H, FitzGerald OM, Jadon DR. Biomarkers predictive of treatment response in psoriasis and psoriatic arthritis: a systematic review. Ther Adv Musculoskelet Dis. 2021;13:1759720X211014010. Published 2021 May 8. doi:10.1177/1759720X211014010
Normalization of bone microarchitecture following anti-TNF treatment for PsA
Soldati and colleagues report bone microarchitecture changes in a single PsA patient and seven matched controls before and after adalimumab treatment using ultra-high field MRI (UHF MRI). The patient had psoriasis on his elbows and knees, as well as axial and peripheral PsA. At baseline, the patient was treatment-naïve and had experienced arthritis in his knee for the past six months.
At baseline, the MRI-based microarchitecture measurements indicated the patient showed statistically different measurements from controls in 24 out of 32 measurements. After one year of treatment the microarchitectural parameters for the PsA patient were reduced and approaching or within the control range (9 of 32 measurements still statistically different from controls). Additionally, the patient’s BMI increased from 14.5 to 18.9 kg/m2.
Read more: [Sosido Link] Soldati E, Escoffier L, Gabriel S, et al. Assessment of in vivo bone microarchitecture changes in an anti-TNFα treated psoriatic arthritic patient. PLoS One. 2021;16(5):e0251788. Published 2021 May 19. doi:10.1371/journal.pone.0251788
Characterizing Degos disease by systematic review
Degos disease is a rare multisystem vasculopathic condition with benign and malignant variants and no standardized treatment. Kim and colleagues conducted a systemic review of the literature to better characterize the condition. The review found a total of 357 patient cases in the literature, with twothirds having malignant disease (malignant atrophic papulosis, MAP) and one-third benign disease (BAP). Mean age of onset was 34 years of age. The most common cutaneous features were atrophic porcelainlike central scarring (70.3%) and erythema (59.1%), while the most common systemic manifestations were digestive (71.4%) and nervous (43.9%). Cutaneous lesions were most often asymptomatic. Antiplatelet monotherapy was the most common treatment for BAP, while surgery was the most common treatment for MAP. Death occurred in 56.6% of MAP cases. Further studies should be conducted to confirm the findings; however the rarity of the condition limits the possible sample size of any study.
Read more: [Sosido Link] Kim PJ, Lytvyn Y, Kashetsky N, Bagit A, Mufti A, Yeung J. Clinical manifestations and treatment outcomes in degos disease: a systematic review [published online ahead of print, 2021 Apr 29]. J Eur Acad Dermatol Venereol. 2021;10.1111/jdv.17311. doi:10.1111/jdv.17311
Case report of cutaneous Emmonsia infection in a renal transplant recipient
Kuzyk and colleagues describe a case report of the fungal infection Emmonsia in a 52-year-old Canadian renal transplant recipient. Cases of Emmonsia are more commonly found in South Africa in those with impaired cell-mediated immunity. The normal presentation includes respiratory symptoms and a widespread rash. The Canadian case described in the report presented with a single ulcerated facial nodule and no respiratory symptoms. Differential diagnoses included a deep fungal or mycobacterial infection, basal cell carcinoma, squamous cell carcinoma, and cutaneous metastasis.
While waiting for cultures, the patient developed pleuritic chest pain. Cultures from the skin and lung indicated Emmonsia and the diagnosis was confirmed by Alberta Public Health. The patient was treated with amphotericin B 300 mg intravenously and discontinuation of his immunosuppressive medications. The patient’s course became complicated by aspiration pneumonia, adrenal insufficiency, an ileus, and pancreatitis, and he passed away a few weeks later.
Read more: [Sosido Link] Kuzyk AC, Burbidge T, Mydlarski PR. Cutaneous Emmonsia infection in a renal transplant recipient. JAAD Case Rep. 2021;11:44-46. Published 2021 Mar 20. doi:10.1016/ j.jdcr.2021.03.019
Case report of atypical melanocytic nevi with segmental distribution
Mainville and colleagues published a case of atypical melanocytic nevi with a segmental distribution and seborrheic keratoses (SK)-like clinical and histopathologic features. Previous reports have not featured the SK appearance. The patient was a 40-year-old female who presented with over 50 flat, verrucous, tanned clustered papules and 10-15 typical nevi on her trunk and limbs. Punch skin biopsies showed atypical nevi with SK changes. BRAFV600E mutation was not found. The patient has remained healthy with observational follow up. The authors note that clinicians should be aware of this rare presentation and recognize that segmental SK-like lesions may be associated with underlying melanocytic proliferation.
Read more: [Sosido Link] Mainville L, Vallée S, Labonté S, Perron É, Veillette H. Atypical melanocytic nevi with segmental distribution resembling seborrheic keratoses. JAAD Case Rep. 2021;11:78-80. Published 2021 Mar 26. doi:10.1016/j.jdcr.2021.03.002
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