This review was done by PubMed searches of English language publications, emphasising the past 5 years of published work. Key words included psoriasis cross-referenced with epidemiology, gene, or biologic*. Additional searches were done with the terms psoriasis cross-referenced with pimecrolimus, anti-IL-8, B7, CTLA4Ig, medi-507, anti-Tac antibody, IL-10, infliximab, etanercept, alefacept, and efalizumab. Recent breakthroughs reported in the Book of Abstracts of the Annual Meeting of the
SeminarPsoriasis
Section snippets
Epidemiology
Estimates of the prevalence of psoriasis vary from 0·5% to 4·6%, with rates varying between countries and races. Psoriasis tends to be more frequent at higher latitudes than lower latitudes and in more caucasians than in other races. These trends were confirmed in a postal survey to 50 000 households in the USA, in which 3% of 6·4 million Americans reported a diagnosis of psoriasis in 1994.1 Prevalence was almost equal in men and women, and more than twice as many whites than blacks or Asians
Diagnosis
Diagnosis of psoriasis relies almost entirely on characteristic clinical features and rarely requires histological confirmation. The presence of sharply demarcated, erythematous, scaling plaques on any part of the body should raise suspicion of psoriasis. In questionable cases, close examination of the scalp, and intergluteal cleft can show characteristic skin lesions even if the elbows and knees are clear. Pitted fingernails, subungual hyperkeratosis, or other nail changes could aid in
Clinical features
The clinical and histological features of psoriasis have been reviewed in detail.11, 12, 13 The most common form of psoriasis, plaque psoriasis, occurs in more than 80% of affected patients. This type of psoriasis is characterised by sharply demarcated, erythematous, scaling plaques that typically affect the elbows (figure 2), knees, scalp, and intergluteal cleft. Some individuals develop lesions on the palms and soles before other regions are affected, and occasionally patients will present
Genetics
The genetic basis of psoriasis has been investigated well in studies of families and twins. In an Australian study,14 concordance for psoriasis was 35% (12 of 34 pairs) in monozygotic twins and 12% (five of 43 pairs) for dizygotic twins. Results of an earlier Danish study15 showed a higher degree of concordance in monozygotic twins (18 of 32 pairs) than in dizygotic twins. Genetic factors contributed to clinical manifestations, including age of onset, type, and severity.
Most investigators
Pathogenesis
For many years psoriasis was thought to be a mainly epidermal disease. However, the discovery that immunosuppressive agents improve psoriasis has drastically changed our notions about the pathogenesis of this disease. Several lines of evidence point to a prominent role for T cells. Dermal infiltrates appear in early lesions before epidermal changes and consist of T cells and macrophages.20, 21 Reports that patients who received syngeneic bone marrow transplants from psoriatic donors developed
Treatment
Treatment of psoriasis ranges from topical therapies for mild disease to phototherapy or systemic therapy for more widespread disease (Panel). Despite their many shortcomings, topical drugs will remain the mainstay of psoriasis therapy for most patients. Topical tars were once used as an essential component of the Goeckerman regimen in which patients applied crude coal tar in the hospital for most of the day, removing the tar only before ultraviolet light treatments.26 Use of tars slowed when
Targeted treatments
Innovations in biotechnology have the potential to offer greater safety by building designer drugs that interfere with specific targets in the pathogenesis of psoriasis. Several drugs have been designed to treat this disorder by targeting specific cells, specific cytokines, or specific interactions between ligands and receptors. For example, denileukin diftitox, an interleukin 2-diphtheria toxin fusion protein mentioned above, targets activated T cells resulting in improvement of psoriasis.43
Other biological agents
Conflicting results have been obtained with some biological agents in development for psoriasis. Despite initial promise with an antibody against interleukin 8, further studies with this agent have proven disappointing. E-selectin, a vascular addressin thought to play a part in trafficking of T lymphocytes into lesional skin, was the target of a humanised monoclonal antibody. Results of a placebo-controlled trial98 showed decreased staining for E-selectin in lesional skin biopsies, but this
Search strategy and selection criteria
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Acitretin in combination with UVB or PUVA
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Pimecrolimus identifies a common genomic anti-inflammatory profile, is clinically highly effective in psoriasis, and is well tolerated
J Invest Dermatol
A multicenter dose-escalation trial with denileukin diftitox (ONTAK, DAB (389)IL-2) in patients with severe psoriasis
J Am Acad Dermatol
Successful in vivo blockade of CD25 (high-affinity interleukin 2 receptor) on T cells by administration of humanized anti-Tac antibody to patients with psoriasis
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Immunomodulation by interleukin-10 therapy decreases the incidence of relapse and prolongs the relapse-free interval in psoriasis
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Treatment with anti-tumor necrosis factor alpha (TNF-alpha) monoclonal antibody dramatically decreases the clinical activity of psoriasis lesions
J Am Acad Dermatol
Efficacy and safety of infliximab monotherapy for plaque-type psoriasis: a randomised trial
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Infliximab for refractory ulcerative colitis
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Etanercept in the treatment of psoriatic arthritis and psoriasis: a randomised trial
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Drug-induced systemic lupus erythematosus associated with etanercept therapy
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Treatment of recalcitrant cicatricial pemphigoid with the tumor necrosis factor alpha antagonist etanercept
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Administration of DAB389IL-2 to patients with recalcitrant psoriasis: a double-blind, phase II multicenter trial
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Psoriasis and psoriatic arthritis. Dermatological and rheumatological co-operative clinical report
Acta Dermatol Venereol
Clinical observations on nail changes in psoriasis
Ann Acad Med Singapore
Psoriatic arthritis
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Psoriatic arthritis in psoriatic patients
Br J Rheumatol
Excess mortality related to alcohol and smoking among hospital-treated patients with psoriasis
Arch Dermatol
Mortality studies in psoriatic arthritis: results from a single outpatient center. II. Prognostic indicators for death
Arthritis Rheum
The epidemiology of psoriatic arthritis in Olmsted County, Minnesota, USA, 1982–1991
J Rheumatol
The risk of malignancy associated with psoriasis
Arch Dermatol
Psoriasis in monozygotic twins: variations in expression in individuals with identical genetic constitution
Acta Dermatol Venereol
Genetic aspects of psoriasis
Clin Exp Dermatol
Coding haplotype analysis supports HCR as the putative susceptibility gene for psoriasis at the MHC PSORS1 locus
Hum Mol Genet
Identification of subpopulation of mononuclear cells in psoriatic lesions
Acta Dermatol Venereol
Development of psoriasis after syngeneic bone marrow transplant from psoriatic donor: further evidence for adoptive auto-immunity
Br J Dermatol
Response of psoriasis to a lymphocyte-selective toxin (DAB389IL-2) suggests a primary immune, but not keratinocyte, pathogenic basis
Nat Med
The immunologic basis for the treatment of psoriasis with new biologic agents
J Am Acad Dermatol
Biologic therapy for psoriasis: the new therapeutic frontier
Arch Derm
Treatment of psoriasis
Northwest Med
Out-patient treatment of psoriasis: short contact and overnight dithranol therapy compared
Br J Dermatol
Short-contact treatment at home with Micanol
Acta Dermatol Venereol
Vitamin D analogs: mechanism of action and therapeutic applications
Curr Med Chem
Psoriasis remission time at the Dead Sea
J Am Acad Dermatol
Treatment of psoriasis with a new UVB-lamp
Acta Dermatol Venereol
Narrowband UV-B produces superior clinical and histopathological resolution of moderate-to-severe psoriasis in patients compared with broad-band UV-B
Arch Dermatol
Oral psoralen and ultraviolet-A light (PUVA) treatment of psoriasis and persistent risk of nonmelanoma skin cancer: PUVA Follow-up Study
J Natl Cancer Inst
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