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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriasis is a systemic&#44; chronic inflammatory disease of the skin that present multiple comorbidities&#44; such as psoriatic arthritis and cardiovascular disease&#44; which can even reduce life expectancy&#44; and is accompanied by a considerable physical&#44; mental&#44; and social burden&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> Today&#39;s therapeutic arsenal against moderate-to-severe psoriasis is extensive&#58; phototherapy&#44; conventional systemic drugs &#40;ciclosporin&#44; methotrexate&#44; acitretin&#44; fumarates&#41;&#44; next-generation synthetic molecules &#40;apremilast and&#44; soon&#44; deucravacitinib&#41;&#44; and biological therapies including some biosimilar agents &#40;adalimumab&#44; etanercept&#44; infliximab&#44; certolizumab&#44; ustekinumab&#44; secukinumab&#44; ixekizumab&#44; brodalumab&#44; tildrakizumab&#44; guselkumab&#44; and&#44; soon&#44; bimekizumab&#41;&#46; Not all patients respond equally to treatment&#44; however&#44; and access to the most efficacious treatments &#40;biological therapy&#41; tends to be restricted to a small number of patients with moderate-to-severe psoriasis&#46; Moreover&#44; the high economic cost of the new biological therapies has led nonclinical agents&#44; such as managers and payers&#44; to become major factors in the choice of these treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> A series of requirements have been established for prescribing biological therapy&#44; which&#44; for some patients&#44; involve a delay in receiving their first biological drug&#46; This can mean a lost opportunity to achieve more permanent responses and even prevent progression to more severe forms of the disease&#44; such as joint involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Precision medicine or stratified medicine aims to choose the treatment based on individual patient characteristics&#44; like a tailored suit&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> This strategy has been known for several years in oncology&#44; such as the use of BRAF inhibitors in patients with mutate BRAF melanoma&#44; which have demonstrated an increase in survival in advanced stages&#44; combined with a MEK inhibitor&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> but not so much in immune-mediated inflammatory diseases&#44; which are much more heterogeneous and require chronic &#40;sometimes for life&#41; and often expensive treatment&#46; Traditional medicine is based on the use of clinical patterns to diagnose a disease and on trial and error to select treatment&#46; In precision medicine&#44; depending on multiple multi-omic data combined with clinical data obtained and analyzed thanks to current technological advances&#44; patients are classified into different molecular phenotypes &#40;or endotypes&#41; for choosing targeted and personalized therapies&#44; which allow for long-term clearance of the disease in all patients in a cost-effective manner&#46; Precision medicine is based on the idea that subpopulations exist within a disease category and that they can be identified by means of biomarkers&#44; preferably before instating treatment or in the earliest stages<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Advances in knowledge of various aspects of psoriasis and the development of artificial intelligence mean that this individualization can begin to be applied in routine clinical practice&#46; For example&#44; in the field of genetics&#44; the presence of the human leukocyte antigen &#40;HLA&#41;-Cw6 allele has been linked to more extensive cutaneous involvement&#44; with early onset of the disease and with a lower risk of developing psoriatic arthritis<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a>&#59; it is also associated with a better response to methotrexate<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> and ustekinumab&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> and its absence is associated with a better response to adalimumab&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> With regard to secukinumab&#44; results are contradictory&#44; with some studies that find no link<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> and others that do observe an excellent response in patients with HLA-Cw6&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> Little information is available regarding the new IL23 inhibitors and we have found no link between effectiveness and the presence or absence of HLA-Cw6 &#40;personal observation&#41;&#46; The finding in forms of pustular psoriasis of mutations in the genes IL36RN&#44; AP1S3&#44; and CARD14 has made it possible to find new therapeutic targets against IL-1 and IL-36 that are in advanced stages of research&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> In relation to treatment&#44; levels of adalimumab and ustekinumab at an early stage may be used to predict and improve results in patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">14&#44;15</span></a> Patient phenotype may also be of utility for selecting treatment&#46; In the BIOBADADERM register&#44; women had a higher risk of adverse events but treatment survival was similar to that of men&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> In this Spanish register&#44; we also found that increased body mass index was associated with a higher rate of discontinuation of treatment due to lack of efficacy and higher risk of adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> Moreover&#44; the effect of the exposome &#40;environment<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>lifestyle&#41; on the course of the disease and the response to treatment is also interesting&#44; as these are factors that can potentially be modified&#46; A direct relationship exists between smoking and the prevalence and severity of psoriasis&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> and smoking is also associated with decreased efficacy of biologic therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> Alcohol consumption is also more frequent in patients with psoriasis&#44; and it may also trigger episodes of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Having biomarkers&#44; which will probably arise from a combination of demographic&#44; phenotypic&#44; genomic&#44; and biochemical data&#44; will help us to better understand the natural history of psoriasis&#44; the factors that can predict its appearance and episodes&#44; the development of comorbidities&#44; and the response to therapy of each individual&#46; Today&#44; we have the opportunity to use the data from registers&#44; and the use of digital health will make it possible to collect data remotely and&#47;or continuously&#44; which&#44; together with advances in artificial intelligence&#44; will allow us to develop algorithms to focus management of patients with psoriasis in an individualized manner&#44; as recommended by the World Health Organization in 2016 in its global report dedicated to this diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> It is important to choose the right drug for the right patient at the right time&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">Dr&#46; Rivera-D&#237;az has taken part as advisor&#47;author&#47;researcher in clinical trials promoted by companies that produce drugs for the treatment of psoriasis&#44; including Janssen Pharmaceuticals Inc&#44; Almirall SA&#44; Boehringer-Ingelheim&#44; Lilly&#44; AbbVie&#44; Novartis&#44; Celgene&#44; Biogen Amgen&#44; Leo-Pharma&#44; and UCB&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Dr&#46; Belinch&#243;n has taken part as advisor&#47;author&#47;researcher in clinical trials promoted by companies that produce drugs for the treatment of psoriasis&#44; including Janssen Pharmaceuticals Inc&#44; Almirall SA&#44; Lilly&#44; AbbVie&#44; Novartis&#44; Celgene&#44; Biogen Amgen&#44; Leo-Pharma&#44; Pfizer-Wyeth&#44; MSD&#44; and UCB&#46;</p></span></span>"
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Opinion Article
Precision Medicine in Psoriasis
Medicina de precisión en psoriasis
R. Rivera-Díaza,
Autor para correspondencia
rriveradiaz@hotmail.com

Corresponding author.
, I. Belinchónb
a Servicio de Dermatología, Hospital Universitario 12 de Octubre & Universidad Complutense, Madrid, Spain
b Servicio de Dermatología, Hospital Universitario General de Alicante & Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Psoriasis is a systemic&#44; chronic inflammatory disease of the skin that present multiple comorbidities&#44; such as psoriatic arthritis and cardiovascular disease&#44; which can even reduce life expectancy&#44; and is accompanied by a considerable physical&#44; mental&#44; and social burden&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">1</span></a> Today&#39;s therapeutic arsenal against moderate-to-severe psoriasis is extensive&#58; phototherapy&#44; conventional systemic drugs &#40;ciclosporin&#44; methotrexate&#44; acitretin&#44; fumarates&#41;&#44; next-generation synthetic molecules &#40;apremilast and&#44; soon&#44; deucravacitinib&#41;&#44; and biological therapies including some biosimilar agents &#40;adalimumab&#44; etanercept&#44; infliximab&#44; certolizumab&#44; ustekinumab&#44; secukinumab&#44; ixekizumab&#44; brodalumab&#44; tildrakizumab&#44; guselkumab&#44; and&#44; soon&#44; bimekizumab&#41;&#46; Not all patients respond equally to treatment&#44; however&#44; and access to the most efficacious treatments &#40;biological therapy&#41; tends to be restricted to a small number of patients with moderate-to-severe psoriasis&#46; Moreover&#44; the high economic cost of the new biological therapies has led nonclinical agents&#44; such as managers and payers&#44; to become major factors in the choice of these treatments&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">2</span></a> A series of requirements have been established for prescribing biological therapy&#44; which&#44; for some patients&#44; involve a delay in receiving their first biological drug&#46; This can mean a lost opportunity to achieve more permanent responses and even prevent progression to more severe forms of the disease&#44; such as joint involvement&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Precision medicine or stratified medicine aims to choose the treatment based on individual patient characteristics&#44; like a tailored suit&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">4</span></a> This strategy has been known for several years in oncology&#44; such as the use of BRAF inhibitors in patients with mutate BRAF melanoma&#44; which have demonstrated an increase in survival in advanced stages&#44; combined with a MEK inhibitor&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">5</span></a> but not so much in immune-mediated inflammatory diseases&#44; which are much more heterogeneous and require chronic &#40;sometimes for life&#41; and often expensive treatment&#46; Traditional medicine is based on the use of clinical patterns to diagnose a disease and on trial and error to select treatment&#46; In precision medicine&#44; depending on multiple multi-omic data combined with clinical data obtained and analyzed thanks to current technological advances&#44; patients are classified into different molecular phenotypes &#40;or endotypes&#41; for choosing targeted and personalized therapies&#44; which allow for long-term clearance of the disease in all patients in a cost-effective manner&#46; Precision medicine is based on the idea that subpopulations exist within a disease category and that they can be identified by means of biomarkers&#44; preferably before instating treatment or in the earliest stages<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Advances in knowledge of various aspects of psoriasis and the development of artificial intelligence mean that this individualization can begin to be applied in routine clinical practice&#46; For example&#44; in the field of genetics&#44; the presence of the human leukocyte antigen &#40;HLA&#41;-Cw6 allele has been linked to more extensive cutaneous involvement&#44; with early onset of the disease and with a lower risk of developing psoriatic arthritis<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">7</span></a>&#59; it is also associated with a better response to methotrexate<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">8</span></a> and ustekinumab&#44;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">9</span></a> and its absence is associated with a better response to adalimumab&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">10</span></a> With regard to secukinumab&#44; results are contradictory&#44; with some studies that find no link<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">11</span></a> and others that do observe an excellent response in patients with HLA-Cw6&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">12</span></a> Little information is available regarding the new IL23 inhibitors and we have found no link between effectiveness and the presence or absence of HLA-Cw6 &#40;personal observation&#41;&#46; The finding in forms of pustular psoriasis of mutations in the genes IL36RN&#44; AP1S3&#44; and CARD14 has made it possible to find new therapeutic targets against IL-1 and IL-36 that are in advanced stages of research&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">13</span></a> In relation to treatment&#44; levels of adalimumab and ustekinumab at an early stage may be used to predict and improve results in patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">14&#44;15</span></a> Patient phenotype may also be of utility for selecting treatment&#46; In the BIOBADADERM register&#44; women had a higher risk of adverse events but treatment survival was similar to that of men&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">16</span></a> In this Spanish register&#44; we also found that increased body mass index was associated with a higher rate of discontinuation of treatment due to lack of efficacy and higher risk of adverse events&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">17</span></a> Moreover&#44; the effect of the exposome &#40;environment<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>lifestyle&#41; on the course of the disease and the response to treatment is also interesting&#44; as these are factors that can potentially be modified&#46; A direct relationship exists between smoking and the prevalence and severity of psoriasis&#44;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">18</span></a> and smoking is also associated with decreased efficacy of biologic therapies&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">19</span></a> Alcohol consumption is also more frequent in patients with psoriasis&#44; and it may also trigger episodes of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">20</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Having biomarkers&#44; which will probably arise from a combination of demographic&#44; phenotypic&#44; genomic&#44; and biochemical data&#44; will help us to better understand the natural history of psoriasis&#44; the factors that can predict its appearance and episodes&#44; the development of comorbidities&#44; and the response to therapy of each individual&#46; Today&#44; we have the opportunity to use the data from registers&#44; and the use of digital health will make it possible to collect data remotely and&#47;or continuously&#44; which&#44; together with advances in artificial intelligence&#44; will allow us to develop algorithms to focus management of patients with psoriasis in an individualized manner&#44; as recommended by the World Health Organization in 2016 in its global report dedicated to this diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">21</span></a> It is important to choose the right drug for the right patient at the right time&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0025" class="elsevierStylePara elsevierViewall">Dr&#46; Rivera-D&#237;az has taken part as advisor&#47;author&#47;researcher in clinical trials promoted by companies that produce drugs for the treatment of psoriasis&#44; including Janssen Pharmaceuticals Inc&#44; Almirall SA&#44; Boehringer-Ingelheim&#44; Lilly&#44; AbbVie&#44; Novartis&#44; Celgene&#44; Biogen Amgen&#44; Leo-Pharma&#44; and UCB&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Dr&#46; Belinch&#243;n has taken part as advisor&#47;author&#47;researcher in clinical trials promoted by companies that produce drugs for the treatment of psoriasis&#44; including Janssen Pharmaceuticals Inc&#44; Almirall SA&#44; Lilly&#44; AbbVie&#44; Novartis&#44; Celgene&#44; Biogen Amgen&#44; Leo-Pharma&#44; Pfizer-Wyeth&#44; MSD&#44; and UCB&#46;</p></span></span>"
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