The Surface by PSOLVE+, Issue #15, June 2022
Issue #15, June 2022

Issue 15 of The Surface highlights four new publications of interest to Canadian dermatologists. The first featured article is a shared clinical pathway to screen and identify non-alcoholic fatty liver disease in psoriasis patients, followed by a study of fractional laser-assisted treatment of nail psoriasis. We also highlight a case report of methotrexate-associated lymphoproliferative disease and a review of the role of S aureus colonization in IgE-mediated disease. View all issues of The Surface at psolve.org/the-surface.
 

Screening PsO patients for non-alcoholic fatty liver disease

As psoriasis (PsO) is strongly associated with non-alcoholic fatty liver disease (NAFLD), Torbator and colleagues designed a pilot study to create a shared clinical pathway between dermatology and gastroenterology to screen PsO patients for NAFLD. It is it is hypothesized that chronic proinflammatory, pro-atherogenic, and pro-oxidative state of PsO results in cumulative free fatty acid accumulation, chronic hepatic inflammation and fibrogenesis. Methotrexate can also exacerbate hepatotoxicity.

The pilot study included 57 psoriasis patients with a median age of 56 years, of whom 30 (52.6%) had evidence of hepatic steatosis on ultrasound. There were more males in the PsO-NAFLD group (56.7%) compared to the no-NAFLD group (37%). Thirteen patients underwent transient elastography, of whom six were found to have a liver stiffness measurement of > 7 kPa, indicating moderate-to-severe fibrosis. Three patients had evidence of cirrhosis. The authors have established a shared care pathway to direct PsO patients to screening for NAFLD. PsO patients with evidence of metabolic syndrome (T2D, obesity, insulin resistance, dyslipidemia, dysglycemia) and no excess alcohol use are screened using liver ultrasound. Based on those results, patient are either sent for transient elastography / FibroScan or have liver function tests performed. Patients with FibroScan > 7 kPa are referred to hepatology.

Read more: [Sosido link] Torbator K, Poo S, Al-Rubaye T, et al. Whether Screening for Non-alcoholic Fatty Liver Disease in Patients With Psoriasis Is Necessary: A Pilot Quality Improvement Project. Cureus. 2022;14(5):e24714. Published 2022 May 3. doi:10.7759/cureus.24714 

 

Fractional CO2 laser-assisted delivery of topical corticosteroid for nail psoriasis

Treatment of nail PsO is challenging as most topical medications cannot penetrate the nail plate. Nassar and colleagues evaluated two different strategies to deliver triamcinolone acetonide to psoriatic nails. A total of 36 patients were enrolled in the randomized study. In the first group, patients received intralesional injection of triamcinolone acetonide. The second group received fractional CO2 laser therapy to create holes in the nail plate followed by topical application of triamcinolone acetonide. Both treatments were repeated at two-week intervals for a total of six sessions.

Although there were some numerical imbalances in this small study population at baseline, differences in age, duration of disease, and family history of PsO were not significant. There were between-group differences in presence of skin PsO and prior treatments. Two patients withdrew from the intralesional injection arm due to treatment-associated pain. Both treatment strategies resulted in similar improvements in clinical and dermatoscopic scores. The laser treatment was associated with lower pain and higher patient satisfaction.

Read more: [Sosido link] Nassar A, Atef H, Eldeeb F, Alakad R. Comparison of fractional laser-assisted drug delivery and intralesional injection of triamcinolone acetonide in nail psoriasis [published online ahead of print, 2022 May 12]. J Dtsch Dermatol Ges. 2022;10.1111/ddg.14731. doi:10.1111/ddg.14731

 

Case report of methotrexate-associated Hodgkin’s Lymphoma

Afonso and colleagues report a rare case of methotrexate treatment-associated lymphoproliferative disorder in a PsO patient. A 56-year-old male with a four decade history of moderate-to-severe plaque PsO had been treated for over 10 years with 15mg per week of methotrexate. He presented with fatigue and unintentional weight loss. He had palpable nodes and spleen, and underwent CT and PET/CT imaging which revealed lymphadenopathy and splenomegaly. Biopsies did not reveal clonal lymphoid infiltration. Methotrexate treatment was stopped due to high clinical suspicion for methotrexateassociated lymphoproliferative disease.

At four months after stopping methotrexate, PET/CT imaging showed improvement and partial regression of disease. However, imaging at nine and 15 months demonstrated disease progression. Biopsy now revealed methotrexate-associated classical Hodgkin lymphoma. The patient was treated with ABVD/AVD (adriamycin, bleomycin, vinblastine, and dacarbazine) and achieved a complete response. The case illustrates the need for high clinical suspicion of lymphoproliferative disorders in the presence of vague constitutional symptoms in a patient on methotrexate and the need for repeat imaging even with apparent spontaneous remission.

Read more: [Sosido link] Afonso C, Roque A, Almeida C, et al. Methotrexate-Associated Lymphoproliferative Disorder in a Patient with Psoriasis: A Case Report and Review of the Literature. Case Rep Hematol. 2022;2022:7178065. Published 2022 Apr 30. doi:10.1155/2022/7178065

 

The role of S. aureus and IgE-mediated diseases

Calabrese and colleagues have published a new narrative review exploring the interplay between Staphylococcus aureus colonization and IgE-mediated diseases. They note that up to one quarter of the population is persistently colonized by S. aureus, and that there is an association between colonization and chronic rhinosinusitis with nasal polyps (CRSwNP), allergic rhinitis, bronchial asthma, and chronic spontaneous urticaria (CSU). The review describes how infection with S. aureus can activate Type 2 inflammatory pathways and that S. aureus enterotoxins drive increased production of IgE.

The article reviews the data in each clinical state separately: asthma, CRSwNP, and CSU / atopic dermatitis. It also describes studies with omalizumab in these disease areas. The authors consider S. aureus enterotoxins to be perennial allergens and drivers of severe asthma, CRSwNP, and CSU. They recommend patients be screened for IgE directed at these endotoxins. In a study of severe asthmatics classified as non-atopic, half of patients were sensitized to at least one aeroallergen, and the two most common sensitizations were toward staphylococcal enterotoxins A and B. This suggests the percentage of allergic asthmatics may be underestimated.

Read more: [Sosido link] Calabrese C, Seccia V, Pelaia C, et al. S. aureus and IgE-mediated diseases: pilot or copilot? A narrative review. Expert Rev Clin Immunol. 2022;18(6):639-647. doi:10.1080/1744666X.2022.2074402


 

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