INFLAMMATORY SKIN DISEASES
INFLAMMATORY SKIN DISEASES
For this Theme Issue of Acta Dermato-Venereologica we have selected 23 articles and letters under a common heading: “Inflammatory Skin Diseases”. Eleven of these deal with various aspects of psoriasis, from treatment decision-making and clinical assessment via long-term effects of treatment on the occurrence of cerebrovascular disease and new observations related to treatment with biologics, to experimental investigative studies.
“There is a wide range of treatment options currently available for psoriasis treatment: … Nonetheless, studies have reported treatment dissatisfaction, non-adherence and a sense of frustration among patients… In other patient groups, increased satisfaction with treatment has been demonstrated when patients’ preferences are incorporated into treatment decision-making.”
With these premises Umar and co-workers (pp. 341–346) carried out a critical review and a summary of studies aimed at examining psoriasis patients’ preferences, and how this knowledge is applied in clinical management. They conclude that patients with psoriasis do indeed have preferences of significance for making choices among treatment options, and that these preferences can be revealed using methods from other areas of healthcare research. They also conclude, however, that patient’s preferences have so far been largely ignored in treatment decision-making and, in their own words: “We can only hypothesize, based on the evidence for other patient groups, that effective use of patient preferences in psoriasis treatment decision-making would likely improve both patients’ satisfaction with treatment and objective clinical outcomes.”
Nishizawa and co-workers (pp. 360–361) had the opportunity to observe effects on erythrodermic psoriasis in a patient treated for spread rectal cancer with biologicals directed towards vascular-endothelial growth factor (VEGF; bevacizumab) and epidermal growth factor receptor (EGFR; panitumumab). Interestingly, whereas no effect on skin symptoms was seen with bevacizumab, the patient’s skin disease showed dramatic improvement after administration of panitumumab. These findings may provide further insight into psoriasis pathophysiology and support previous findings that EGFR antagonists may offer new treatment modalities. The authors suggest that VEGF may not be an ideal therapeutic target for psoriasis. Besides the fact that only one patient is presented, questions may be asked as to whether the lack of effect would be true for VEGF antagonists in general, or only for the specific antibody used in the present case. As shown by Inzinger and co-workers (pp. 357–358) antibodies directed to the same target (anti-IL-12/23 agents) may lead to different therapeutic responses, an observation that is also valid for the various biologicals directed towards tumour necrosis factor-alpha (TNF-α).
Under the heading “Other Inflammatory Dermatoses” we have included articles and letters presenting clinical, therapeutic and mechanistic aspects.
In the mini-review “Beyond Zoster: Sensory and Immune Changes in Zoster-affected Dermatomes” Ruocco and co-workers (pp. 378–382) present current knowledge on herpes zoster, focusing not only on post-herpetic neuralgia, but also on the so-called “Wolf post-herpetic isotopic response” (PHIR), i.e. the localization of a wide variety of immune skin diseases and malignant tumours to an area of skin previously affected by an outbreak of herpes zoster. The virus causes nerve damage, which can result in long-standing pain, itch and other sensory disturbances, but also to dysfunctions in the neuro-immune system resulting in lowered thresholds for a number of diseases and tumours. This is further illustrated by the case presented by Mehra and co-workers (pp. 383–384), in which graft-versus-host disease was manifested as an isotopic response after herpes zoster.
Schnitzler syndrome (urticarial vasculitis with monoclonal gammopathy) and the autosomal dominant cryopyrin-associated periodic syndrome (CAPS) are both rare autoinflammatory diseases with several features in common. They are both associated with urticaria-like skin rash in combination with various systemic manifestations, such as fever, malaise and arthralgia, and both conditions respond favourably to the interleukin-1 (IL-1) antagonist anakinra. In CAPS there are mutations in the gene encoding cryoporin. Cryoporin is involved in mechanisms leading to conversion of the inactive precursor of IL-1b to its biologically active form. Aoyama and co-workers (pp. 395–398) present a case of CAPS with a mutation in the cryoporin gene and review the clinical characteristics of 19 other cases of CAPS. Volz and co-workers (pp. 393–394) present a case of Schnitzler syndrome in which the presence of active IL-1b in the dermis could be demonstrated with a specific antibody. Thus, CAPS and Schnitzler syndrome may also share a pathophysiological mechanism at the molecular level.
The ever-widening spectrum of inflammatory skin diseases in which treatment with anti-TNF-α biologicals may be indicated is illustrated by reports of beneficial effects in lichen ruber planus (pp. 385–386), lupus erythematosus profundus (pp. 401–403), type II pityriasis rubra pilaris (pp. 399–400), and cutaneous Crohn’s disease (pp. 406–407).
Even if the beneficial effects of high-dose intravenous immunoglobulins (IVIG) in immune disorders occur by mechanisms other than the specific antibody-biologicals, this treatment modality may also be regarded as “biological”. Bidier et al. (pp. 408–409) report cases with scleromyxoedema responding favourably to IVIG, but with different outcomes as regards long-term remission.
In preparing this issue the following colleagues have provided invaluable help: Anders Vahlquist, Earl Carstens, Lars Iversen, Gregor Jemec, Mona Ståhle and Carl-Fredrik Wahlgren.
We wish you a pleasant reading!
Umeå, May 25, 2012