Comparative efficacy of biologics and oral agents in palmoplantar psoriasis and palmoplantar pustulosis: A systematic review and network meta-analysis of randomized clinical trials
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Palmoplantar pustulosis
In 18 ambulant patients with palmoplantar pustulosis low plasma zinc concentrations were observed. During treatment with an all-trans aromatic retinoid (RO-10-9359) the values increased while at the same time the skin condition improved in particular with regard to the pustule formation. The observed low plasma zinc values may in some way be related to pustulosis but not as causal factor.
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Palmoplantar pustulosis (PPP) is a rare skin disease characterized by episodes of neutrophilic pustules on the palms of the hands and soles of the feet. Current treatments for PPP have limited efficacy, and there is little real-world evidence characterizing the disease burden of PPP in patients.
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This study from the USA, Denmark and Germany looked at how often plaque psoriasis and palmoplantar pustulosis (PPP) occur together. Plaque psoriasis is the commonest form of psoriasis. PPP is a condition where pus‐filled spots are seen on the palms and soles, often on skin that is red and scaly like psoriasis. It is not known how PPP is related to psoriasis, if at all. From insurance records in the USA and Germany, and from the Danish National Patient Register, the researchers found approximately 4000 patients diagnosed with PPP. Many of their findings varied strikingly from country to country, as noted in the commentary for this study. For instance, the prevalence of PPP ranged from 0.005% in Denmark to 0.08% in Germany. The presence of plaque psoriasis in PPP patients varied from 14.2% in the Danish patients to 36.4% in Germany and 61.3% in the USA. As regards treatment, patients with PPP and plaque psoriasis together were more likely to have been prescribed strong steroid creams, ointments or gels, especially in the USA and Denmark. More patients with both conditions together were treated with acitretin, methotrexate and biologics in the USA and Denmark, and the differences for treatment with biologics ranged widely: 18.4% of USA patients compared with 8.5% in Denmark and 2.5% in Germany. In comparison with patients with PPP alone, patients who had PPP and plaque psoriasis together were more likely to have joint disease related to psoriasis, and this was roughly the same in all three countries.
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A 59-year-old female with palmoplantar pustulosis (PPP) of 20 years' duration was referred to our hospital.Although she had been treated with topical corticosteroid ointment, skin lesions had waxed and waned during this time period.She was a past smoker (three cigarettes a day for 1 year), but quit smoking soon after she was diagnosed as PPP.She occasionally had a sore throat when she was a child.Her mother also had PPP.The patient further developed arthralgia involving the left clavicle two years previously.Physical examination showed palmoplantar erythema with scales and a small number of pustules and vesiculopustules (Fig. 1).Skin atrophy due to long-term topical corticosteroid therapy was also observed.She did not have acne.Laboratory examination showed slight increases in inflammatory markers (C-reactive protein; 2.0 mg/dl, erythrocyte sedimentation rate; 34 mm/h); however, anti-thyroid, microsome, and nuclear antibodies were all within normal limits.Examination using technetium-99m bone scintigraphy revealed increased uptake in the left clavicle (Fig. 2).Otolaryngological examination revealed tonsillar hypertrophy.For joint pain, non-steroidal anti-inflammatory drugs (NSAIDs), methotrexate (6 mg/week) for 10 months, and cyclosporine (100-200 mg/day) for 8 months were administered, all of which resulted in little effect.The patient refused tonsillectomy, and guselkumab was initiated for severe joint pain.A few days after the first subcutaneous injection of guselkumab (100 mg), the patient's joint pain was dramatically improved, and NSAIDs were not needed.Her visual analogue scale score for joint pain was decreased to 0.
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Abstract Background Palmoplantar plaque psoriasis is a frequent clinical subtype of childhood psoriasis. This study evaluated the effectiveness of biologic therapies in children with palmoplantar plaque psoriasis using data from the two Biological treatments for Pediatric Psoriasis (BiPe) cohorts. Methods Data for all 170 patients included in the BiPe cohorts were analyzed. Data on the effectiveness (PGA, PASI between baseline and 3 months of treatment) of biologic therapies were then compared between children with palmoplantar plaque psoriasis ( n = 20) and those with generalized plaque psoriasis ( n = 136). Clinical and demographic data were also analyzed. Results Children in the palmoplantar group were more likely to be male ( p = .04), with an earlier age of psoriasis onset ( p < .001), and more frequent nail involvement ( p < .001). After 3 months of biologic treatment, mean PGA scores were higher in the palmoplantar group than in the generalized plaque psoriasis group ( p = .004). In the palmoplantar group, continuation rates were higher for adalimumab than for etanercept or ustekinumab ( p = .01). Primary inefficacy was a more frequent reason for stopping biologic therapies in the palmoplantar group ( p = .01), and disease remission was less frequent ( p = .05). Combined systemic and biologic therapies were more frequently used in palmoplantar plaque psoriasis ( p < .001). Conclusions This study demonstrated the treatment‐resistant nature of palmoplantar plaque psoriasis and indicated that adalimumab could be the most effective biologic treatment. Larger studies are needed to allow therapeutic algorithms for palmoplantar plaque psoriasis to be proposed in pediatric psoriasis management guidelines.
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Palmoplantar pustulosis (PPP) is a chronic pustular skin condition on the palms and soles. The disease is often seen in combination with plaque psoriasis, and whether PPP is a variant of psoriasis has been debated. The disease prevalence of PPP and co‐occurring psoriasis is not yet established and the patient group remains understudied. To estimate the prevalence of PPP and co‐occurring psoriasis in three population‐based cohorts and to provide information on patient demographics and characteristics. Administrative healthcare registries and insurance databases from the U.S.A., Denmark and Germany were used as data sources. Patients with PPP were defined by a single International Classification of Diseases 10th Revision code for PPP during a 1‐year period. Information regarding co‐occurring plaque psoriasis and other comorbidities was extracted. Furthermore, use of antipsoriatic medication was identified. In total 1435, 751 and 1832 patients with PPP were identified in the U.S., Danish and German populations, with estimated 1‐year prevalences of 0·009%, 0·005% and 0·08%, respectively. Plaque psoriasis was present in 14·2–61·3% of patients with PPP. Patients with co‐occurring psoriasis had an overall higher prevalence of psoriatic arthritis. Similarly, medication use was more prevalent in patients with PPP with co‐occurring psoriasis, and especially pronounced was the use of biologic therapies. This large observational study on patients with PPP provides detailed information regarding patient demographics, comorbidities and medication use. The 1‐year prevalence of PPP varied in the three studied populations, possibly due to differences in diagnostics and recording practices. Psoriasis frequently co‐occurred in patients with PPP. What's already known about this topic? Palmoplantar pustulosis (PPP) is a skin disease of the palms of the hands and soles of the feet and is known to be related to psoriasis. Whether PPP is a distinct disease or a variant of psoriasis is not yet established. The condition is understudied in terms of disease prevalence, disease predictors, patient characteristics and comorbidity. What does this study add? In this study using data from three large population‐based cohorts we found low prevalence rates (< 0·1%) of PPP. The prevalence of psoriasis was estimated at between 14·2% and 61·3% in patients with psoriasis. Patients with PPP with co‐occurring psoriasis have a higher prevalence of psoriatic arthritis and use of antipsoriatic drugs.
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Abstract Palmoplantar pustulosis is a chronic inflammatory disorder characterized by sterile pustules predominantly involving the palms and soles. Palmoplantar pustulosis has many similar aspects to psoriasis, either plaque and pustular type, namely familial occurrence between palmoplantar pustulosis and psoriasis, the appearance of the Köbner phenomenon, joint involvement, and nail involvement. Pustular psoriasis is classified into generalized and localized types, and there are a number of papers regarding palmoplantar pustulosis as an acral variant of localized pustular psoriasis. Many Japanese dermatologists consider palmoplantar pustulosis to be a distinct entity from pustular psoriasis, and the coexistence of palmoplantar pustulosis and psoriasis is rare. However, outside Japan, palmoplantar pustulosis is often considered to be palmoplantar psoriasis or palmoplantar pustular psoriasis, and extra‐palmoplantar lesions are also considered to be psoriasis. The purpose of the current review is to compare the similarities and differences between palmoplantar pustulosis and generalized/localized pustular psoriasis. Japanese patients with palmoplantar pustulosis have a close relationship with focal infection, and the associated bone–joint manifestation exclusively involves the anterior chest wall. Furthermore, pediatric occurrence of palmoplantar pustulosis is extremely rare, and difference of genetic background between palmoplantar pustulosis and psoriasis has also been reported. Treatment of focal infection often results in dramatic effects on both cutaneous lesions and joint pain of palmoplantar pustulosis. Those findings suggest that palmoplantar pustulosis should be separately considered from either palmoplantar psoriasis or palmoplantar pustular psoriasis. The clinicopathological features and therapeutic approach of both diseases are discussed.
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Pustular psoriasis
Generalized pustular psoriasis
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Abstract Background Generalized pustular psoriasis (GPP) and palmoplantar pustulosis (PPP) are chronic inflammatory skin conditions. Accumulating evidence shows that GPP and PPP have different characteristics to plaque psoriasis and are distinct clinical entities. Objectives To assess the epidemiology, comorbidities, mortality and healthcare use for patients in England with GPP and PPP versus those with plaque psoriasis. Methods We carried out a cohort study involving analyses of longitudinal electronic health record data in the Clinical Practice Research Datalink Aurum database and linked hospital and mortality data between 2008 and 2019. The primary study outcome was the incidence and prevalence rates of GPP, PPP and plaque psoriasis in England. Secondary outcomes included survival rates and healthcare resource use (HCRU) by disease type. Results We identified 373 patients with GPP, 1828 with PPP and 224 223 with plaque psoriasis. Mean (SD) age was 55.9 (18.6) years for patients with GPP, 51.5 (16.4) years for those with PPP and 48.5 (19.1) years for those with plaque psoriasis; 62.5% and 65.9% of patients with GPP and PPP, respectively, were women, vs. 49.4% of those with plaque psoriasis. About half of patients were overweight or obese at baseline (GPP 48.6%, PPP 56.0%, plaque psoriasis 45.9%). The incidence rates for GPP, PPP and plaque psoriasis were 0.25 [95% confidence interval (CI) 0.21–0.28], 2.01 (95% CI 1.92–2.11) and 103.2 (95% CI 102.5–103.9) per 100 000 person-years, respectively. From 2008 to 2019, the prevalence rates per 100 000 persons ranged from 1.61 to 3.0 for GPP, from 1.1 to 18.7 for PPP and from 1771.0 to 1903.8 for plaque psoriasis. Survival rates were lower for patients with GPP, particularly those who were > 55 years of age and those with a history of one or more comorbidities in each cohort. HCRU was lower in the cohort with plaque psoriasis and highest in the cohort with GPP, particularly among those who had more than one GPP flare. Conclusions Our results provide further evidence that, in England, GPP is a distinct disease with different epidemiology, lower survival and higher HCRU than plaque psoriasis.
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