Journal of Psoriasis and Psoriatic Arthritis®

Psoriasis and psoriatic arthritis are chronic illnesses that are prevalent in women of childbearing age. The aim of this review is to bring to light data regarding the effect of pregnancy and the postpartum period on psoriasis and psoriatic arthritis and to discuss the major theories underlying these changes. To date, evidence indicates a tendency toward improvement of psoriasis and psoriatic arthritis during pregnancy and a flare in the postpartum period. This is likely a consequence of physiologic adaptations during pregnancy and the subsequent loss of these protective factors in the postpartum period. Most prominent among these adaptations are hormonally induced changes in helper T cell (Th1, Th2, and Th17) cytokines. However, alterations in proteins and cell surface molecules also have been implicated. The relatively high prevalence of psoriasis and psoriatic arthritis in women of childbearing age mandates that patients, dermatologists, and obstetricians alike be knowledgeable of the gestational and postpartum changes that occur in these diseases.

Psoriasis is characterized by excessive growth and aberrant differentiation of keratinocytes and by dysregulation of immune cells. Topical vitamin D analogs and corticosteroids are commonly used for the treatment of mild-to-moderate plaque psoriasis. The effects of corticosteroids are predominantly anti-inflammatory and immunosuppressive, while those of vitamin D analogs have long been considered antiproliferative. Recent evidence suggests an independent role of vitamin D analogs and corticosteroids in cytokine modulation, an important factor in treatment efficacy. In vitro and in vivo studies show that the combination of a vitamin D analog and a corticosteroid produces effects on T-cell subsets that are involved in psoriatic skin inflammation. Based on the respective mechanisms of action of vitamin D analogs and corticosteroids, there is a biologic rationale for the enhanced clinical effect observed with the combination therapy. This article reviews current understanding of the pathogenesis of psoriasis and recent evidence for immunomodulatory mechanisms of vitamin D analogs and corticosteroids.

Palmoplantar psoriasis is a variant form of psoriasis that characteristically affects the skin of the palms and soles. It is chronic and inflammatory in nature and presents with hyperkeratotic, pustular, or mixed morphologies. Painful fissuring and bleeding may occur, which produces significant physical, functional, and social disability. Palmoplantar psoriasis is a therapeutically challenging condition and notoriously difficult to treat with topical therapy alone. Furthermore, limited data exist on treatment given that patients are typically excluded from clinical trials, which often require at least 10% body surface area (BSA) involved as an inclusion criterion. This article reviews the topical and systemic agents including biologics that have been investigated in the treatment of palmoplantar psoriasis. Combination therapy, comprising topical, systemic, and/or light treatments, with a particular focus on improvement in function and pain reduction, appears to be the most effective approach in treating these patients.

We report two cases of patients who endorsed hoarding prescription medications for the treatment of their psoriasis, at times utilizing long-expired medications or starting a second course of a biologic without the guidance of a physician. These behaviors represent risk factors for possible adverse medication-related outcomes. Dermatologists should be aware that patients may be hoarding medications and counsel them accordingly.

The International Dermatology Outcome Measures (IDEOM) group was created with the goal of establishing improved, as well as patient-centered, outcome measures. The effort involves the worldwide participation of those involved in the treatment of psoriasis, including dermatologists, rheumatologists, pharmaceutical and device company medical officers, payors, regulatory officers, patient advocacy groups including the National Psoriasis Foundation, and patients themselves. This review will outline the work done to date, the methodology utilized, and future planned action, including a worldwide search for patient representatives to this endeavor.

There is a well-known association between psychosocial stress and psoriasis. However, the underlying mechanism of stress-induced exacerbation of psoriasis is not well understood. Until recently, the majority of evidence has pointed to alterations of the endocrine and peripheral nervous systems, while less is known about changes in the immune system despite psoriasis being a chronic inflammatory skin disease. In the past few years, there has been an increase in data concerning evidence for the immune system as a mediator between stress and psoriasis, which we now review. Possible immunological mechanisms explored include increased leukocyte trafficking to the skin, elevations in proinflammatory cytokines, and reductions in anti-inflammatory cytokines in response to psychosocial stress.