今日の臨床サポート

乾癬

著者: 馬渕智生 東海大学医学部専門診療学系皮膚科学

監修: 戸倉新樹 掛川市・袋井市病院企業団立 中東遠総合医療センター 参与/浜松医科大学 名誉教授

著者校正/監修レビュー済:2022/06/08
参考ガイドライン:
  1. 生物学的製剤
  1. 日本皮膚科学会乾癬生物学的製剤検討委員会乾癬における生物学的製剤の使用ガイダンス(2019年版)
  1. Biologics Review Committee of the Japanese Dermatological Association for Psoriasis:Japanese guidance for use of biologics for psoriasis (the 2019 version).
  1. 光線療法
  1. 日本乾癬学会光線療法ガイドライン作成委員会乾癬の光線療法ガイドライン
  1. 乾癬性関節炎
  1. 日本皮膚学会乾癬性関節炎診療ガイドライン作成委員会厚生労働科学研究費補助金 難治性疾患等制作研究事業乾癬性関節炎研究班乾癬性関節炎診療ガイドライン2019
  1. 膿疱性乾癬(汎発型)
  1. 日本皮膚科学学会膿疱性乾癬(汎発型)診療ガイドライン作成委員会膿疱性乾癬(汎発型)診療ガイドライン2014年版
  1. Japanese Dermatological Association Guidelines Development Committee for the Guidelines for the Management and Treatment of Generalized Pustular Psoriasis:Japanese guidelines for the management and treatment of generalized pustular psoriasis: The new pathogenesis and treatment of GPP.
患者向け説明資料
薬価収載情報:2022年4月20日 ビンゼレックス 皮下注160mgオートインジェクター、皮下注160mgシリンジ(ビメキズマブ(遺伝子組換え) ヒト化抗ヒトIL-17A/IL-17Fモノクローナル抗体製剤)

概要・推奨   

  1. 広範な病変を有する症例では、治療を有用に行うためにも、外用療法から、内服療法、光線療法、あるいは生物学的製剤治療への変更も考慮に入れるべきであろう(推奨度2)
  1. 乾癬の外用療法において、各治療の特性を熟知した上で、症例ごとにその臨床効果を観察し、それに対応した治療方法を選択、実行して行くことが望ましい(推奨度2)
  1. ステロイド外用薬と活性型ビタミンD3外用薬における寛解までの期間、再燃までの期間を比較すると、前者では効果発現は速いが、再燃までの時間も短い。したがって、これらの外用療法ではその特性を説明し治療することが必要である(推奨度2)
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  1. ステロイド外用薬、活性型ビタミンD3外用薬、およびその合剤における臨床効果の比較では、合剤の速効性が認められた(推奨度2)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
馬渕智生 : 講演料(マルホ,日本イーライリリー,大鵬薬品),研究費・助成金など(協和キリン,鳥居薬品,大鵬薬品,マルホ,レオファーマ,サンファーマ)[2022年]
監修:戸倉新樹 : 講演料(マルホ,サノフィ,協和キリン),原稿料(医学書院)[2022年]

改訂のポイント:
  1. 定期レビューを行った。
  1. ホスホジエステラーゼ(PDE)-4阻害薬、生物学的製剤について改訂した。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 乾癬は、紅斑性局面を主徴とする慢性炎症性角化症である。
  1. 乾癬の原因はいまだ解明されてはいないものの、遺伝的要因を基盤に、何らかの環境因子により発症すると考えられている。
  1. ※第6染色体短腕のHLA遺伝子領域のうち、HLA-Cw6との強い関連が、世界中の施設から報告され、この相関は人種を超えて認められている。しかし、乾癬に関連する遺伝子として、世界各国から、その他、数種の候補遺伝子が報告されており、いまだ、その詳細は明確になってはいない。現在のところ、乾癬関連遺伝子は複数あると考えられ、その発症に関連する遺伝子(HLA-C遺伝子かその近傍に位置する)、その病態形成に関連する遺伝子(ゲノムワイド解析などにより複数報告されている)、その治療に関する遺伝子などが存在すると考えられている。
 
乾癬における遺伝解析

現時点までの乾癬の遺伝子解析結果から考えられる可能性をまとめた。

 
ゲノムワイド解析により報告されている乾癬候補遺伝子

乾癬の遺伝子解析は、その手法の進歩とともにゲノムワイド解析により、世界中で行われ、多くの候補遺伝子が報告されている。それによる結果からも、第6染色短碗に位置する(6P21.33)HLA-Cw6との強い関連が認められている。

出典

img1:  Current understanding of human genetics and genetic analysis of psoriasis.
 
 J Dermatol. 2012 Mar;39(3):231-41. doi: ・・・
 
中国人乾癬における体型とHLA-Cw6

中国人おいて、HLA-Cw6とWHRおよびBMIとの関係を検討した結果、HLA-Cw6を有すると、乾癬になる相対危険率は、HLA-Cw6を持たない場合の8.33倍であった。また、WHRを、0.8で分けると、HLA-Cw6wpを有し、WHRが0.8以上の場合は、HLA-Cw6を持たずに、WHRが0.8以下の場合と比べて、その発症の相対危険率は、17倍になった。さらに、HLA-Cw6を有し、BMIが35以上の場合は、HLA-Cw6を持たずに、BMIが25以下の場合に比べて、その発症の相対危険率は、35倍にもなった。
  1. WHR (Waist-hip ratio) = 胸囲 ÷ 臀囲
  1. BMI (Body mass index) = 体重 ÷ (身長)2

出典

img1:  Combined effects of HLA-Cw6, body mass index and waist-hip ratio on psoriasis vulgaris in Chinese Han population.
 
 J Dermatol Sci. 2008 Nov;52(2):123-9. do・・・
 
  1. 表皮細胞数の増加(基底細胞の分裂亢進、角化亢進)、真皮の慢性炎症(血管周囲性の炎症細胞浸潤、免疫動態の異常)を主体とする病態を呈する。
  1. 乾癬病理所見:図<図表>
  1. 乾癬病変における免疫学的動態:図<図表>
  1. 日本では、乾癬患者数は5~10万人以上と推定され、好発年齢は30~50歳代で、男女比は2:1である。
 
わが国の乾癬/日本乾癬学会登録患者数

日本乾癬学会では、全国約160の病院における新規乾癬患者を登録し、毎年集計している。
それによると、2014年度にはすでに約5万人の患者が登録されており、わが国では、6万人あるいはそれ以上の患者がいると考えられている。また男女比は、2:1で男に多い。
※男女比は、諸外国ではほぼ1:1で男女差はなく、なぜわが国だけが2:1かは不明である。

 
  1. 健康保険組合レセプト情報を利用した乾癬の実態調査では、わが国では約56万人の患者が保険診療を受けていると推定された。
 
健康保険組合レセプト情報を利用した乾癬の実態調査

日本医療データセンター(JMDC)における大手18健康保険組合のレセプトを解析。
  1. 2011年7月〜2012年6月(1年間)
  1. 対象総数 1,087,079 人
  1. 患者年齢を5歳ごとに区切り、対象の同年代層の対象から、その罹患率を算定
  1. 日本の総人口における同年齢層の実数をもとに、罹患率から、患者数を推定

 
乾癬治療の実態(レセプト情報)(2011年7月〜2012年6月、1年間)

 
  1. 皮膚病変は、全身のどこにでも出現するが、外的刺激を受けやすい部位(肘、膝など)、日光の被ばくの少ない部位(頭部、腰部、外陰部など)、および爪に好発する。
  1. 多くの場合、皮膚症状だけ(尋常性乾癬)であり、その約半数で瘙痒を認めるが、全身的症状はないものの、その経過は慢性、難治性である。その他、関節症性乾癬、膿疱性乾癬、乾癬性紅皮症、滴状乾癬がある。なお、膿疱性乾癬では、致死的転帰をとることもあり、厚生労働省の難病の1つに指定されている。
  1. 乾癬患者おける主な合併疾患の有病率:表<図表>
  1. 乾癬に対する治療の予後/背景因子の影響-東海大学医学部付属病院開院以来35年の解析:表<図表>
  1. 原因不明のため、根治療法はなく、種々の治療法があるが、個々の症例ごとに、多角的検討による治療法の選択が必要となる。
  1. 乾癬に対する外用療法の予後-東海大学医学部付属病院開院以来35年の解析:表<図表>
  1. わが国における乾癬治療の状況(各年度の新規登録患者の既治療):表<図表>
  1. 慢性の経過、外見的問題、長期治療によるコンプライアンスの低下、そして、家族や周囲の人々の疾患、治療に関する知識や理解の不足などにより、患者のQOLは低下し、その苦悩は想像を絶するものがある。
 
乾癬と他疾患との比較-SF-36 (short form health survey questionnaire)-

SF-36による各疾患に対する身体的、精神的負担を健康成人と比較して検討している。乾癬では、そのいずれも著しく低く、患者のQOLの低下を示唆している。

出典

img1:  Psoriasis causes as much disability as other major medical diseases.
 
 J Am Acad Dermatol. 1999 Sep;41(3 Pt 1):・・・
 
乾癬患者は治療に満足しているか?-国内の調査結果-

乾癬患者では、現在受けている治療に対して、満足が得られている患者は43.1%で、本当に満足している患者はわずかに10%しかいない。

出典

img1:  中川秀己、ほか:日皮会誌、115:1449-1459、2005
 
 
 
乾癬治療に対する要望-治療中の患者を対象にしたアンケート調査

患者の3/4は、「もっときれいになりたい」「治療効果を早く出したい」と思っている。

 
PASI改善度と患者の満足度-期待した治療効果があったか?

PASI 75(PASIが、治療前と比べて75%改善したことを表す)を達成した患者では、その9割以上が治療に満足している。

出典

img1:  Concordance of the Psoriasis Area and Severity Index (PASI) and patient-reported outcomes in psoriasis treatment.
 
 Eur J Dermatol. 2010 Jan-Feb;20(1):62-7.・・・
 
The Statement of the Tokai International Psoriasis Summit 2014(The TIPS 2014,Oct 31-Nov2.2015,TOKYO)

アジア諸国の乾癬研究者約100名が、乾癬についての連携を深めるために開催された。
  1. どんな疑問があり、それをどう解決しようとするのか?
  1. それによりどのような意味、意義があるのか?
  1. 医療行政の違いにより、医療の違い、考え方の違いは?
  1. 文化、歴史、国民性などの違いによる治療の違いは?
  1. これから何をすればよいのか?
上記について検討が行われ、共同宣言が採択された(会長 小澤 明/東海大学、事務総長 馬渕智生/東海大学、事務局長 Dr.Ping shen FAN/中国、Dr.Hae June SONG/韓国、Dr.Chang Lin TSAI/台湾)。
なお、2016年9月23~24日、ロッテホテルワールドで、第20回韓国乾癬学会の共催により、TIPS 2014の第2回として、Asian Summit for Psoriasis 2016(ASP 2016)が開催された(名誉会長 小澤 明;東海大学、会長 Jai Il YOUN;ソウル大学、事務総長 Hae Jun SONG;高麗大学、事務局長 馬渕智生;東海大学、Ping Shen FAN;中国第4軍医科大学、Chang Lin TSAI;台湾新光病院)。同会議において、2018年には、第3回会議として、中国が主催し、開催することになった(Jianzhong ZHANG;北京大学、Min ZHENG;広州医科大学)。The 20th Annual Meeting of Korean Society for Psoriasis and Asian Summit for Psoriasis(ASP)

出典

img1:  小澤明先生 ご提供
 
 
 
  1. 膿疱性乾癬(汎発型)は、指定難病であり、膿疱性乾癬(汎発型)の重症度分類基準(2010年)を用いて中等症以上を認める場合などでは申請をすると保険料の自己負担分の一部が公費負担として助成される。([2015年1月施行])
  1.  難病法に基づく医療費助成制度 
問診・診察のポイント  
皮疹の確認:
  1. 特徴的皮疹の確認:
  1. 数cm、ときには数10cmの大小さまざまな大きさで、円形楕円形、表面に銀白色の鱗屑を伴う、境界明瞭な紅斑性局面がみられる。

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文献 

Christie L Carroll, Steven R Feldman, Fabian T Camacho, Janeen C Manuel, Rajesh Balkrishnan
Adherence to topical therapy decreases during the course of an 8-week psoriasis clinical trial: commonly used methods of measuring adherence to topical therapy overestimate actual use.
J Am Acad Dermatol. 2004 Aug;51(2):212-6. doi: 10.1016/j.jaad.2004.01.052.
Abstract/Text INTRODUCTION: Medication nonadherence is common throughout medicine, and research into this area is increasing; however, knowledge about topical medication adherence is limited.
METHODS: A total of 30 patients were enrolled in a clinical trial for psoriasis and followed up for 8 weeks using 3 methods of adherence monitoring: electronic monitoring caps; medication logs; and medication usage by weight.
RESULTS: Adherence rates calculated from the medication logs and medication weights were consistently higher than those of the electronic monitors (P <.05). Electronically measured adherence rates declined from 84.6% to 51% during the 8-week study (P <.0001). Female sex and increasing age by 1 year predicted improved adherence of 5% and 0.8%, respectively (P <.0001). The number of treatment gaps increased from the first half to the last half of the study, and weekend days were overrepresented in treatment gaps.
CONCLUSION: Medication logs and weights do not ensure medication adherence to topical therapy. Electronic monitoring allows a more precise method of adherence measurement.

PMID 15280839
J Koo, M Lebwohl
Duration of remission of psoriasis therapies.
J Am Acad Dermatol. 1999 Jul;41(1):51-9.
Abstract/Text The armamentarium of therapies for psoriasis continues to expand with drugs such as tazarotene, calcipotriene, and acitretin approved in recent years. New forms of old treatments such as cyclosporine and anthralin have also been introduced. Frequently, inadequate attention is devoted to duration of remission. The purpose of this article is to examine the duration of remission reported with many therapies currently used for psoriasis. Studies examining duration of remission are included. Among our conclusions were the following: the definitions of remission/relapse used in various studies differ, duration of remission is influenced by the natural history of each patient's disease, among topical monotherapies anthralin and tazarotene appear to induce longer remissions than calcipotriene and corticosteroids, among systemic agents longer remissions occur with etretinate than cyclosporine or methotrexate but compared with the remission rate of phototherapeutic modalities, especially Goeckerman and PUVA therapy, the remission rates are much less.

PMID 10411411
S Singh, D C Reddy, S S Pandey
Topical therapy for psoriasis with the use of augmented betamethasone and calcipotriene on alternate weeks.
J Am Acad Dermatol. 2000 Jul;43(1 Pt 1):61-5. doi: 10.1067/mjd.2000.105167.
Abstract/Text BACKGROUND: Topical corticosteroids, commonly used for psoriasis, show diminished response on continuous use.
OBJECTIVE: We tested efficacy of topical corticosteroid and calcipotriene used on alternate weeks versus daily corticosteroid in patients with psoriasis.
METHODS: In a randomized, observer-blind design, the experimental group of 25 patients with stable plaque psoriasis received augmented betamethasone dipropionate 0.05% cream once daily in the first and third weeks and calcipotriene 0.005% ointment twice daily in the second and fourth weeks. The control group of 27 patients received augmented betamethasone once daily for 4 weeks.
RESULTS: The experimental regimen was more effective than the control regimen as evidenced by (1) more patients with at least a 90% reduction in Psoriasis Area and Severity Index (PASI) score (difference 49.5%, 95% confidence interval [CI], 26.1%-72.9%, P <. 001), (2) lower PASI after 2 weeks (P < or =.04), and (3) greater percentage reduction in PASI after 2 and 4 weeks (difference 23.1% [CI, 11.1%-35.1%] and 46.4% [28.9%-63.8%], respectively; P <.001). The study had power of 93.7%. No patient had skin irritation.
CONCLUSION: Use of augmented betamethasone and calcipotriene on alternate weeks is more effective than daily corticosteroid and represents a novel strategy for treating psoriasis.

PMID 10863225
R Kaufmann, A J Bibby, R Bissonnette, F Cambazard, A C Chu, J Decroix, W S Douglas, D Lowson, J M Mascaro, G M Murphy, B Stymne
A new calcipotriol/betamethasone dipropionate formulation (Daivobet) is an effective once-daily treatment for psoriasis vulgaris.
Dermatology. 2002;205(4):389-93. doi: 66440.
Abstract/Text BACKGROUND: Topical corticosteroids and calcipotriol have been used separately for many years to treat psoriasis. A new combination ointment has been formulated, which contains both calcipotriol and the corticosteroid betamethasone dipropionate.
OBJECTIVE: To compare the combination ointment with betamethasone dipropionate ointment, calcipotriol ointment and ointment vehicle in patients with psoriasis vulgaris.
METHODS: 1,603 patients were randomised to one of the 4 double-blind treatments used once daily for 4 weeks.
RESULTS: The mean percentage change in the PASI at the end of treatment was -71.3 (combination), -57.2 (betamethasone), -46.1 (calcipotriol) and -22.7 (vehicle). The mean difference of combination minus betamethasone was -14.2 (95% CI: -17.6 to -10.8, p < 0.001), of combination minus calcipotriol -25.3 (95% CI: -28.7 to -21.9, p < 0.001) and of combination minus vehicle -48.3 (95% CI: -53.2 to -43.4, p < 0.001). 6.0% of patients (combination) reported local adverse reactions compared to 4.9% (betamethasone), 11.4% (calcipotriol) and 13.6% (vehicle).
CONCLUSION: Calcipotriol/betamethasone dipropionate combination ointment used once daily is well tolerated and more effective than either active constituent used alone.

Copyright 2002 S. Karger AG, Basel
PMID 12444337
Mamitaro Ohtsuki, Hidemi Nakagawa, Junichi Sugai, Akira Ozawa, Muneo Ohkido, Juichiro Nakayama, Jiro Hanada, Yosuke Morimoto, Kowichi Jimbow, Takashi Horikoshi, Hiroto Kitahara, Kunihiko Tamaki, Kazunori Urabe, Yoshiaki Hori
Long-term continuous versus intermittent cyclosporin: therapy for psoriasis.
J Dermatol. 2003 Apr;30(4):290-8.
Abstract/Text A multicenter randomized controlled study was conducted to assess the long-term efficacy and safety of cyclosporin A therapy for psoriasis using either a continuous or an intermittent regimen. Initially, both regimens consisted of 3-5 mg/kg/day administration of CyA. Once remission was obtained, CyA dose was maintained between 0.5 and 3 mg/kg/day under the continuous regimen, while under the intermittent regimen, CyA dose was tapered off and, when necessary, topical corticosteroids were used until relapse occurred. Thirty-one patients were followed for at least 48 months (mean follow-up period: 55.9+/-4.6 months): 15 received continuous therapy, and 16 received intermittent therapy. With both regimens, the PASI (Psoriasis Area and Severity Index) score was maintained at 5-12 points throughout the follow-up period. The score was decreased by more than 70% from baseline with both regimens: the responses between them were not significantly different. However, overall control of psoriasis, as assessed from the averaged PASI score, was better in the patients receiving continuous therapy. Although the overall frequency of adverse reactions was similar for the two regimens, cancer occurred in two patients on continuous therapy (gastric cancer and hepatocellular carcinoma in one patient each). We could not, however, definitely attribute the cancers in the two patients to continuous therapy itself. There was a significantly higher incidence of renal impairment in elderly patients receiving either regimen when compared with younger patients. In conclusion, CyA administered to psoriasis patients under both regimens exhibited long-term efficacy and tolerability. Despite a lower overall efficacy, it seems proper to conclude that intermittent therapy is more useful than continuous therapy due to the occurrence of malignancies with continuous therapy. Further investigation is required to determine whether intermittent therapy is really safer than continuous therapy, and, if so, how it should be designed to minimize long-term adverse reactions and achieve overall control comparable to that of continuous CyA therapy.

PMID 12707465
Tamar Nijsten, Caspar W N Looman, Robert S Stern
Clinical severity of psoriasis in last 20 years of PUVA study.
Arch Dermatol. 2007 Sep;143(9):1113-21. doi: 10.1001/archderm.143.9.1113.
Abstract/Text OBJECTIVE: To assess the severity of psoriasis over time.
DESIGN: We analyzed the results of structured dermatologic examinations administered over a 20-year period beginning 10 years after study enrollment.
SETTING: The PUVA [psoralen-UV-A] Follow-up Study, which is a prospective cohort study.
PATIENTS: The analyses were restricted to 815 patients (83.2% of those eligible) who underwent at least 2 of 4 possible examinations between 1985 and 2005.
MAIN OUTCOME MEASURE: A 4-point physician global assessment (PGA).
RESULTS: The distribution of the PGA levels in the study group did not change significantly over time, except that in 2005 more patients had no psoriasis compared with patients who underwent examinations in the previous study years (9.6% vs < 5.1%, P < .03). The PGA level changed more than 1 level between examinations in only 14% of patients. Multistate Markov models estimated that patients had a likelihood of about 80% to remain at the same PGA level 1 year later. After 10 years, this likelihood varied between 19% and 53%, depending on the PGA level. Except for patients who were clear of disease at baseline, on average patients had about 1 year without psoriasis over 20 years. On average, individuals with moderate to severe disease remained at these levels for 11 or more years. Conclusion Three decades after a large and diverse group of patients sought a cure for their psoriasis, consistent control of their psoriasis often had not been achieved.

PMID 17875871
Emiko Akasaka, Tomotaka Mabuchi, Yasuaki Manabe, Eiichiro Yahagi, Azusa Yamada-Hiruma, Hanako Yamaoka, Tomoko Kojima, Masayuki Kato, Norihiro Ikoma, Akira Ozawa, Yasuo Haruki
Long-term efficacy of psoriasis vulgaris treatments: analysis of treatment with topical corticosteroid and/or vitamin D3 analog, oral cyclosporin, etretinate and phototherapy over a 35-year period, 1975-2010.
J Dermatol. 2013 Apr;40(4):238-43. doi: 10.1111/1346-8138.12069. Epub 2013 Jan 21.
Abstract/Text Various therapies have been tried for psoriasis. In Japan, biologics began to be used for psoriasis treatment in January 2010. Their clinical efficacy is well known, but biologics cannot be used in all psoriasis patients for reasons such as side-effects and cost. It is necessary to evaluate the effect of long-term psoriasis treatment, but there have been no reports evaluating long-term treatment. Therefore, the outcomes of patients who had been treated at the Tokai University Hospital for more than 5 years, before biological agents were released, were examined. Three categories, classified by initial severity, changes in severity by method of treatment and background characteristics, were investigated. In conclusion, cases of long-term treatment with a combination of topical corticosteroid and topical vitamin D3 analog or oral cyclosporin were found to be effective therapies. Patients with a history of diabetes mellitus or cardiovascular disease of psoriasis were likely to be treatment resistant.

© 2013 Japanese Dermatological Association.
PMID 23330814
Lindsay C Strowd, Brad A Yentzer, Alan B Fleischer, Steven R Feldman
Increasing use of more potent treatments for psoriasis.
J Am Acad Dermatol. 2009 Mar;60(3):478-81. doi: 10.1016/j.jaad.2008.10.055. Epub 2008 Dec 5.
Abstract/Text BACKGROUND: Psoriasis therapy has evolved during the past 25 years as newer and more effective medications become available. Furthermore, various combination regimens and approaches have been advocated.
OBJECTIVE: We sought to describe patterns of psoriasis treatment from 1986 to 2005.
METHODS: Visits to dermatologists for treatment of psoriasis were identified using National Ambulatory Medical Care Survey data, a representative survey of visits to physician offices in the United States. We focused on medications listed at these visits during the 1986-to-2005 interval to determine how treatment for psoriasis has changed.
RESULTS: There were an estimated 23.9 million visits for psoriasis during the 20-year study period. As a category, the most common medications used for psoriasis were topical steroids. Dermatologists are prescribing more potent topical steroids compared with nondermatologists. The use of these potent drugs has increased from 1986 to 2005. There has been growing use of systemic treatments, with biologic therapies introduced in the 2001-to-2005 time period.
LIMITATIONS: National Ambulatory Medical Care Survey data represent national trends in psoriasis treatment and cannot be used to evaluate smaller subpopulations of patients with psoriasis. These data are used to speculate why certain trends in treatment are seen.
CONCLUSION: The primary treatment for psoriasis in the late 1980s and early 1990s was mid-potency corticosteroids. Since then, the primary therapies for psoriasis have evolved to include class I ultrapotent topical corticosteroids, vitamin-D analogs, and systemic medications such as methotrexate and biologic agents. These changes in psoriasis management are consistent with patient desire for better disease control.

PMID 19058875
Yongtang Jin, Fengyu Zhang, Sen Yang, Yunming Kong, Fengli Xiao, Yong Hou, Xing Fan, Xuejun Zhang
Combined effects of HLA-Cw6, body mass index and waist-hip ratio on psoriasis vulgaris in Chinese Han population.
J Dermatol Sci. 2008 Nov;52(2):123-9. doi: 10.1016/j.jdermsci.2008.04.016. Epub 2008 Jun 27.
Abstract/Text BACKGROUND: Psoriasis is a chronic inflammatory skin disease associated with an HLA-Cw6 allele. Higher waist-hip ratio (WHR) and body mass index (BMI) may increase the risk of psoriasis vulgaris, but, to our knowledge, no evidence of the combined effects of HLA-Cw6 and BMI, WHR are available.
OBJECTIVES: To evaluate the combined effect of HLA-Cw6, BMI and WHR on psoriasis vaulgaris.
METHODS: The data of 466 patients and 177 controls were investigated and analyzed by a hospital-based case-control study and non-condition logistic regress model.
RESULTS: There was a graded positive association of WHR and BMI with psoriasis vulgaris. Compared with a WHR of 0.80 or less than 0.80, the odds ratio (OR) was 2.36 (p < 0.01) for WHR 0.80-0.85, and 2.74 (p < 0.01) for WHR greater than 0.85. Compared with subjects with a BMI of 20 or less than 20, the multivariate OR of psoriasis were 1.20 (p > 0.05) for a BMI of 20-25, 1.84 (p < 0.05) for a BMI of more than 25 corresponding overweight (p for trend, <0.01). We found not only the risk of psoriasis for the individual with HLA-Cw6+ was 8.33 times greater than that for individual with HLA-Cw6(-) but also the risk increased approximately 35 times in individuals with HLA-Cw6+ and a overweight as compared with one with HLA-Cw6(-) and a non-overweight, and 17-fold when the individuals with HLA-Cw6+ and a WHR of more than 0.80 were compared with individuals with HLA-Cw6(-) and a WHR of 0.80 or less than 0.80, displaying the combined effect of HLA-Cw6, BMI and WHR (all p < 001).
CONCLUSION: This study suggested that HLA-Cw6, overweight and higher waist-hip ratio are material risk factors of psoriasis vulgaris, specially the combined effects of HLA-Cw6 and BMI, WHR on psoriasis vulgaris in Chinese population.

PMID 18585007
K Kragballe, J Austad, L Barnes, A Bibby, M de la Brassinne, F Cambazard, C Fleming, H Heikkilä, Z Williams, J Peyri Rey, A Svensson, J Toole, G Wozel
Efficacy results of a 52-week, randomised, double-blind, safety study of a calcipotriol/betamethasone dipropionate two-compound product (Daivobet/Dovobet/Taclonex) in the treatment of psoriasis vulgaris.
Dermatology. 2006;213(4):319-26. doi: 10.1159/000096069.
Abstract/Text BACKGROUND: The calcipotriol/betamethasone dipropionate two-compound product is safe and effective in the short-term treatment of psoriasis.
OBJECTIVE: The primary objective was to investigate the safety of two treatment regimens involving use of the two-compound product over 52 weeks. The efficacy results are presented here.
METHODS: Six hundred and thirty-four patients were randomised double-blind to treatment (once daily, when required) with either: 52 weeks of two-compound product (two-compound group), 52 weeks of alternating 4-week periods of two-compound product and calcipotriol (alternating group), or 4 weeks of two-compound product followed by 48 weeks of calcipotriol (calcipotriol group).
RESULTS: There was a trend towards a difference between treatments from the overall treatment effect for the percentage of satisfactory responses for each patient during the study (p = 0.071). This appeared to be due to the comparison of the two-compound and calcipotriol groups (p = 0.025).
CONCLUSION: There was a trend towards the efficacy of the two-compound product used for up to 52 weeks being better than that of 4 weeks of the two-compound product followed by 48 weeks of calcipotriol.

Copyright (c) 2006 S. Karger AG, Basel.
PMID 17135738
D Thaçi, J-P Ortonne, S Chimenti, P-D Ghislain, P Arenberger, K Kragballe, J-H Saurat, A Khemis, P Sprøgel, H-U Esslinger, K Unnebrink, H Kupper
A phase IIIb, multicentre, randomized, double-blind, vehicle-controlled study of the efficacy and safety of adalimumab with and without calcipotriol/betamethasone topical treatment in patients with moderate to severe psoriasis: the BELIEVE study.
Br J Dermatol. 2010 Aug;163(2):402-11. doi: 10.1111/j.1365-2133.2010.09791.x. Epub 2010 Apr 2.
Abstract/Text BACKGROUND: Data are lacking on the use of topical therapies in combination with tumour necrosis factor blockers for the treatment of psoriasis.
OBJECTIVES: To assess the efficacy and safety of adalimumab (ADA) with topical calcipotriol/betamethasone (C/B) in patients with psoriasis resembling those treated in routine clinical practice.
METHODS: A 16-week, randomized, vehicle-controlled trial was conducted in patients with moderate to severe psoriasis and previous failure, intolerance or contraindications to two or more systemic treatments. All patients received ADA (80 mg, week 0; 40 mg every other week, weeks 1-15) in addition to either topical C/B or drug-free vehicle applied once daily for 4 weeks, and as needed thereafter. The primary endpoint was 75% improvement from baseline in Psoriasis Area and Severity Index (PASI 75) at week 16.
RESULTS: A total of 730 patients received either ADA + C/B (n = 366) or ADA + vehicle (n = 364). PASI 75 response was initially higher with the combination therapy [14.8% for ADA + C/B vs. 5.8% for ADA + vehicle at week 2 (P < 0.001); and 40.7% vs. 32.4%, respectively, at week 4 (P = 0.021)]. After week 4, the trend was towards a higher response with ADA monotherapy, with no statistical difference in the PASI 75 response at week 16 (64.8% for ADA + C/B vs. 70.9% for ADA monotherapy, P = 0.086). Safety findings were consistent with previous ADA trials.
CONCLUSIONS: ADA + C/B resulted in more rapid and higher efficacy within the first 4 weeks; thereafter, the trend was towards a higher response with ADA monotherapy. There was no statistical difference in the PASI 75 response at week 16. Both treatment regimens were well tolerated.

PMID 20377585
Emily Edson-Heredia, Kimberly L Sterling, Carlos I Alatorre, Gebra Cuyun Carter, Rosirene Paczkowski, Victoria Zarotsky, Tomoko Maeda-Chubachi
Heterogeneity of response to biologic treatment: perspective for psoriasis.
J Invest Dermatol. 2014 Jan;134(1):18-23. doi: 10.1038/jid.2013.326. Epub 2013 Aug 6.
Abstract/Text Psoriasis treatment responses are affected by patient characteristics. However, the literature does not contain reviews of factors that affect the response to biologic therapies. We therefore performed a comprehensive literature search to identify papers describing demographic, lifestyle, and clinical factors associated with response to biologic drug therapy in psoriatic patients. We found that age, gender, ethnicity, alcohol consumption, smoking, geographic location, age at diagnosis, duration and severity of psoriasis, and baseline C-reactive protein levels did not consistently affect response to biologic psoriasis therapy. However, increased body mass index (BMI) appears to adversely affect responses. It might therefore be valuable to include BMI as a stratification variable in future studies of psoriasis therapies and to consider a patient's weight or BMI when selecting a systemic psoriasis treatment.

PMID 23921949

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