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This article discusses the use of tildrakizumab, an interleukin (IL) inhibitor, for the treatment of recalcitrant pityriasis rubra pilaris (PRP). PRP is a rare skin disorder with no approved biologic treatments in Australia. The article presents three cases of PRP that were successfully treated with tildrakizumab, resulting in significant improvements in symptoms and minimal adverse effects. Tildrakizumab is considered a promising therapeutic option for PRP, and further studies are needed to determine its optimal use. [Extracted from the article]

Background: Two phase 3 trials, POETYK PSO‐1 and PSO‐2, previously established the efficacy and overall safety of deucravacitinib, an oral, selective, allosteric tyrosine kinase 2 (TYK2) inhibitor, in plaque psoriasis. Objectives: To further assess the safety of deucravacitinib over 52 weeks in the pooled population from these two trials. Methods: Pooled safety data were evaluated from PSO‐1 and PSO‐2 in which patients with moderate‐to‐severe plaque psoriasis were randomized 1:2:1 to receive oral placebo, deucravacitinib or apremilast. Results: A total of 1683 patients were included in the pooled analysis. Adverse event (AE) incidence rates were similar in each treatment group, serious AEs were low and balanced across groups, and discontinuation rates were lower with deucravacitinib versus placebo or apremilast. No new safety signals emerged with longer deucravacitinib treatment. Exposure‐adjusted incidence rates of AEs of interest with placebo, deucravacitinib and apremilast, respectively, were as follows: serious infections (0.8/100 person‐years [PY], 1.7/100 PY, and 1.8/100 PY), major adverse cardiovascular events (1.2/100 PY, 0.3/100 PY, and 0.9/100 PY), venous thromboembolic events (0, 0.2/100 PY, and 0), malignancies (0, 1.0/100 PY and 0.9/100 PY), herpes zoster (0.4/100 PY, 0.8/100 PY, and 0), acne (0.4/100 PY, 2.9/100 PY, and 0) and folliculitis (0, 2.8/100 PY, and 0.9/100 PY). No clinically meaningful changes from baseline in mean levels, or shifts from baseline to CTCAE grade ≥3 abnormalities, were reported in laboratory parameters with deucravacitinib. Conclusions: Deucravacitinib was well‐tolerated with acceptable safety over 52 weeks in patients with psoriasis. [ABSTRACT FROM AUTHOR]

As with adults, paediatric patients may benefit from a number of advanced targeted therapies for inflammatory skin disease. This brief report aims to be an accessible reference tool with respect to regulatory approval and reimbursement of these treatments within Australia. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion Treatment goals have been established in Australia to facilitate the management of adults with moderate to severe psoriasis. The Australasian College of Dermatologists sought to determine if and how these adult treatment goals could be modified to accommodate the needs of paediatric and adolescent patients.A modified Delphi approach was used. Comprehensive literature review and guideline evaluation resulted in the development of statements and other questions to establish current clinical practices. Two rounds of anonymous voting were undertaken, with a collaborative meeting held in between to discuss areas of discordance. Overall, consensus was defined as achievement of ≥75% agreement in the range 7–9 on a 9‐point scale (1 strongly disagree; 9 strongly agree).Consensus was achieved on 23/29 statements in round 1 and 17/18 statements in round 2. There was a high level of concordance with treatment criteria in the adult setting. The limitations of applying assessment tools developed for use in adult patients to the paediatric setting were highlighted. Treatment targets in the paediatric setting should include objective metrics for disease severity and psychological impact on the patients and their family, and be based on validated, age‐appropriate tools.While the assessment, classification and management of moderate to severe psoriasis in paediatric patients aligns with metrics established for adults, it is vital that nuances in the transition from childhood to adolescence be taken into account. Future research should focus on psoriasis severity assessment scales specific to the paediatric setting. [ABSTRACT FROM AUTHOR]

This article discusses the use of dupilumab, a medication, for the treatment of chronic actinic dermatitis (CAD), a rare photosensitive disorder that primarily affects older men. The article presents two case studies of patients with CAD who were successfully treated with dupilumab, showing significant improvement in their symptoms. The article also reviews existing literature on the use of dupilumab for CAD and suggests the need for further studies to confirm its effectiveness. The document is a case series that includes information on patients with various medical conditions and the treatments they received, predominantly male patients treated with medications like hydroxychloroquine, methotrexate, and mycophenolate mofetil. The document also provides information on abbreviations used and conflicts of interest of the authors. Ethical approval was not required for this case series, and patient consent was obtained for the use of their information and images. [Extracted from the article]

Background: Over the last decade, the treatment landscape for moderate–severe psoriasis has rapidly evolved. The Australasian College of Dermatologists sought to review and update previously published treatment goals for moderate–severe psoriasis. Methods: A modified Delphi approach was used. Comprehensive literature review and guideline evaluation resulted in the development of statements and other questions to establish current clinical practices. Two rounds of anonymous voting were undertaken, with a collaborative meeting held in between to discuss areas of discordance. Overall, consensus was defined as achievement of ≥75% agreement in the range 7–9 on a 9‐point scale (1 strongly disagree; 9 strongly agree). Results: Consensus was achieved on 26/29 statements in round 1 and a further 20 statements in round 2. There was strong agreement to expanding the classification/definition of psoriasis severity by including a choice of metrics, incorporating quality of life measures, and widening the scope of high‐impact sites. Consensus was also reached on revised treatment response criteria, which were then incorporated into a new treatment algorithm. There was discordance with the current requirement to undertake a trial with established systemic agents before accessing targeted therapy. Conclusion: The ability of new targeted treatment options to change the narrative in psoriasis patient care can only be properly realised if challenges to timely and equitable access are addressed. The proposed framework for the assessment, classification and management of moderate–severe psoriasis aligns with international recommendations. Its adoption into Australian clinical practice is hoped to improve treatment outcomes and patients' satisfaction with their care. [ABSTRACT FROM AUTHOR]

A major obstacle toward creating human‐scale artificial tissue models is supplying encapsulated cells with oxygen and other nutrients throughout the construct. In particular, creating channels in hydrogels that match the resolution and density of the smallest blood capillaries (≤10 µm) remains highly challenging. Here, a novel method is demonstrated where polycaprolactone fibers printed using melt‐electrowriting are encapsulated in cell‐laden hydrogels and then physically removed to produce hollow, perfusable channels. This technique produces a range of channel diameters (10–41 µm) with circular cross‐sections and in hydrogels representing various crosslinking mechanisms. The channels can be formed as interconnected grids, hierarchically branched patterns, or stacked in layers with ≈200 µm channel spacing, thus matching average capillary density in the human body. Alternatively, selective removal of fibers from a melt electrowriting grid can generate perfusable channels within a reinforcing fiber network. This method can be performed in the presence of cells, with human fibroblasts exhibiting encapsulated in gelatin methacryloyl showing no detectable cytotoxic effects. This technique is a promising approach for creating perfusable channels with very small diameters within cell‐laden hydrogel matrices, with potential applications including in vitro tissue models and hydrogel microfluidics. [ABSTRACT FROM AUTHOR]

Background/Objectives: Dupilumab‐associated ocular surface disease (DAOSD) is of particular relevance in patients with atopic dermatitis (AD). Guidance on DAOSD assessment and management in the Australian setting is needed to reduce its impact and minimise disruption to treatment. Methods: A systematic review of the literature was undertaken to identify data pertaining to the incidence, pathophysiology, risk factors and management of DAOSD. A critical review of this literature was used to inform a decision framework for dupilumab‐prescribers and develop a graded severity scoring tool to guide appropriate management options. Results: DAOSD typically emerges within 4 months of commencing dupilumab and the occurrence of new events diminishes over time. The reported incidence varies widely depending on the nature and source of the data: 8.6–22.1% (clinical trials programme), 0.5–70% (real‐world data; differences in study size, duration of follow‐up, ophthalmologist intervention, use of prophylaxis). Occurrence increases with AD severity and in patients with prior history of ocular disease; pathophysiology is still to be fully characterised. Management options have evolved over time and include lubricants/artificial tears, corticosteroids, calcineurin inhibitors, antihistamines, anti‐inflammatory agents and antimicrobial agents. Current therapies aim to resolve symptoms or reduce severity to levels sufficiently tolerable to enable continuation of dupilumab therapy. Conclusions: Recommendations for DAOSD assessment and management include identification of high‐risk patients, vigilance for red flags (keratoconus, herpetic and bacterial keratitis), regular assessment of symptom severity (before and during dupilumab therapy), conservative management of mild DAOSD by the prescribing physician and ophthalmologist referral for collaborative care of moderate–severe DAOSD and high‐risk patients. [ABSTRACT FROM AUTHOR]

Background: Drug survival measures the rate and duration of adherence to a given therapeutic agent and evaluates its long‐term effectiveness, safety, and real‐world utility. The SUSTAIN study sought to establish the drug survival and effectiveness of secukinumab for patients with severe chronic plaque psoriasis (CPP) in the Australian clinical setting. Methods: Data of all patients (aged ≥18 years) from Australasian Psoriasis Registry (APR) treated with secukinumab were analysed. The primary objective was to describe the drug survival of secukinumab at 9 months. Key secondary objectives included drug survival of secukinumab at 3, 6, 15, and 21 months, stratified by biologic‐naïve vs biologic‐experienced patients; proportion of patients achieving Psoriasis Area and Severity Index (PASI) 75/90/100 responses; and changes in health‐related quality of life over time utilising the Dermatology Life Quality Index (DLQI). Results: Of 294 patients included in this analysis, 110 (37.4%) were biologic‐naïve and 184 (62.6%) biologic‐experienced. Kaplan–Meїer drug survival rates in biologic‐naïve vs biologic‐experienced patients were 0.92 vs. 0.86 (9 months) and 0.82 vs. 0.68 (21 months), respectively. The proportion of patients with PASI 75/90/100 responses for biologic‐naïve vs. biologic‐experienced was 100/87.7/38.4 vs 98.5/61.5/27.2 (9 months) and 100/81.0/41.7 vs. 98.4/62.0/24.2 (21 months), respectively. The mean (standard deviation [SD]) DLQI in biologic‐naïve vs. experienced patients was 2.2 (4.1) vs. 3.1 (5.2) (9 months) and 1.4 (2.5) vs. 3.1 (5.3) (21 months). No new safety signals were observed. Conclusions: Secukinumab demonstrated high drug survival and sustained effectiveness in Australian real‐world setting, in biologic‐naïve and biologic‐experienced patients with severe CPP. [ABSTRACT FROM AUTHOR]

Background: Psoriasis imposes a disease burden that can have a profound negative impact on patients' quality of life (QoL). HOPE was the first non‐interventional study conducted in patients with severe chronic plaque psoriasis in Australia that evaluated health‐related QoL in response to treatment with secukinumab. Methods: HOPE was a prospective, open‐label, single‐arm, multicentre, non‐interventional, exploratory study in patients with severe chronic plaque psoriasis in Australia. The study investigated the change in QoL, using the Dermatology Life Quality Index (DLQI), Assessment Quality of Life‐8 Dimension questionnaire (AQoL‐8D) and Psoriasis Area and Severity Index (PASI), and safety profile in response to treatment with secukinumab 300 mg SC weekly for 4 weeks followed by monthly maintenance for 58 weeks. Results: At Week 14, the mean percentage reduction in total DLQI score from baseline was −82.4% (n = 65), which indicates a substantial improvement in QoL. This level of improvement was sustained up to Week ≥58, with a mean percentage change of −87.4%. The mean percentage change from baseline for AQoL‐8D weighted total score decreased from Week 14 (41.1%) to Week 58 (35.2%), indicating an improvement in patients' QoL. A high proportion of patients achieved PASI 75/90/100 responses at Week 14 (97.0%/71.2%/34.8%), with rates sustained up to Week ≥58 (100%/87.9%/43.1%). The safety profile of secukinumab was favourable, with no cumulative or unexpected safety concerns. Conclusion: Secukinumab treatment demonstrated a striking improvement in patients' QoL in the HOPE study, the first real‐world study in patients with severe chronic plaque psoriasis in the Australian clinical setting. [ABSTRACT FROM AUTHOR]

As the phase III COVID‐19 vaccine trials excluded patients on immunosuppressive treatments, or patients with significant autoimmunity, the Australasian Medical Dermatology Group make the following preliminary recommendations around COVID‐19 vaccination in dermatology patients on immunomodulatory and/or biologic agents. Vaccination against COVID‐19 is strongly encouraged for all patients on immunomodulatory drugs and/or biologic agents.There are currently insufficient data to recommend one COVID‐19 vaccine or vaccine type (mRNA, recombinant, inactivated virus) over another.No specific additional risk in patients on immunomodulatory or biologic therapies has so far been identified.Data on vaccine efficacy in patients on immunomodulatory or biologic therapies are missing, so standard vaccination protocols are recommended until otherwise advised. [ABSTRACT FROM AUTHOR]

Background: Psoriasis is a chronic inflammatory disease affecting ~2–3% of the Australasian population. Therapeutic options include topical agents, phototherapy, systemic immunomodulators and biologic agents. Biologics present an acceptable short‐ and medium‐term safety profile, derived mainly from randomised controlled trials (RCTs) and, however, may not represent real‐world rates of adverse events (AEs). Methods: A retrospective, observational study of patients enrolled in The Australasian Psoriasis Registry from April 2008 to October 2018 was conducted. Data were collected from 104 sites in Australia and New Zealand. Patient characteristics, treatments and AE data were collected. AEs were classified by MedDRA System events. Results: 2094 patients were included (3765 patient‐treatments), comprising; 1110 phototherapy, 1280 systemic and 1375 biologic therapy patient‐treatments. Treatment arms were not mutually exclusive. The mean ± SD from date of diagnosis of psoriasis to commencement of biologic therapy was 8.9 ± 12.3 years. Methotrexate had the longest exposure time (3740.3 patient‐years), and ustekinumab had the longest median (95% CI) time on treatment, 4.3 years (2.2, 6.6). AE differences on biologic treatment were present between patients who would have been eligible or ineligible for RCTs. Approximately 29% of registry patients would have been excluded from clinical trials enrolment. Patients ineligible for RCTs had increased adjusted hazard ratios (95% CI) of: infections and infestations (2.3, 1.7–3.1; P < 0.001), cardiac (8.2, 3.5–25.6; P < 0.001), gastrointestinal (3.5, 1.52–8.0; P < 0.001), hepatobiliary (5.6 1.7–19.1; P < 0.001), psychiatric (4.7, 1.5–14.1; P = 0.006) and eye disorders (4.8 1.5–15.6; P = 0.008), compared to those eligible for RCTs. Incidence rates in the trial eligible patients were similar to those reported from RCT rates. Conclusions: This study establishes treatment modalities in use for severe psoriasis and the clinical rates of AEs associated with biologic therapy. [ABSTRACT FROM AUTHOR]

Chronic hand/foot eczemas are common, but treatment is often challenging, with widespread dissatisfaction over current available options. Detailed history is important, particularly with regard to potential exposure to irritants and allergens. Patch testing should be regarded as a standard investigation. Individual treatment outcomes and targets, including systemic therapy, should be discussed early with patients, restoring function being the primary goal, with clearing the skin a secondary outcome. Each new treatment, where appropriate, should be considered additive or overlapping to any previous therapy. Management extends beyond mere pharmacological or physical treatment, and requires an encompassing approach including removal or avoidance of causative factors, behavioural changes and social support. To date, there is little evidence to guide sequences or combinations of therapies. Moderately symptomatic patients (e.g. DLQI ≥ 10) should be started on a potent/super‐potent topical corticosteroid applied once or twice per day for 4 weeks, with tapering to twice weekly application. If response is inadequate, consider phototherapy, and then a 12‐week trial of a retinoid (alitretinoin or acitretin). Second line systemic treatments include methotrexate, ciclosporin and azathioprine. For patients presenting with severe symptomatic disease (DLQI ≥ 15), consider predniso(lo)ne 0.5–1.0 mg/kg/day (or ciclosporin 3 – 5 mg/kg/day) for 4–6 weeks with tapering, and then treating as for moderate disease as above. In non‐responders, botulinum toxin and/or iontophoresis, if associated with hyperhidrosis, may sometimes help. Some patients only respond to long‐term systemic corticosteroids. The data on sequencing of newer agents, such as dupilumab or JAK inhibitors, are immature. [ABSTRACT FROM AUTHOR]

Biological disease‐modifying agents have increasingly become available for the effective treatment of both cutaneous and non‐cutaneous inflammatory conditions. We report a case of a woman treated successfully for psoriasis and psoriatic arthritis with the IL‐17 inhibitor secukinumab whilst simultaneously being treated for severe asthma and nasal polyps, initially with the IL‐5 inhibitor benralizumab, followed by dupilumab, a monoclonal antibody that targets the IL‐4 receptor alpha subunit which blocks signalling from both IL‐4 and IL‐13. [ABSTRACT FROM AUTHOR]

Patients on immunomodulators, including biologic agents and new small molecular inhibitors, for cutaneous disease, represent a potentially vulnerable population during the COVID‐19 pandemic. There is currently insufficient evidence to determine whether patients on systemic immunomodulators are at increased risk of developing COVID‐19 disease or more likely to have severe disease. As such, clinicians need to assess the benefit‐to‐risk ratio on a case‐by‐case basis. In patients with suspected or confirmed COVID‐19 disease, all immunomodulators used for skin diseases should be immediately withheld, with the possible exception of systemic corticosteroid therapy, which needs to be weaned. In patients who develop symptoms or signs of an upper respiratory tract infection, but COVID‐19 is not yet confirmed, consider dose reduction or temporarily cessation for 1–2 weeks. In otherwise well patients, immunomodulators and biologics should be continued. In all patients, and their immediate close contacts, the importance of preventative measures to minimise human‐to‐human transmission cannot be overemphasised. [ABSTRACT FROM AUTHOR]

Psoriasis is a chronic inflammatory disease that is commonly encountered in primary care and is associated with significant morbidity that extends beyond the skin manifestations. Psoriasis is associated with an elevated risk of psoriatic arthritis, cardiovascular disease, obesity, insulin resistance, mental health disorders, certain types of malignancy, inflammatory bowel disease and other immune-related disorders, and hepatic and renal disease. Enhanced recognition of these comorbidities may lead to earlier diagnosis and potentially better overall health outcomes. Psoriatic nail involvement, severe skin disease and obesity are associated with a greater risk of psoriatic arthritis. Individuals with psoriasis should be routinely screened for psoriatic arthritis to allow for early intervention to improve long term prognosis. Life expectancy is reduced in people with psoriasis due to a variety of causes, with cardiovascular disease and malignancy being the most common aetiologies. Psoriasis affects several factors that contribute to worsened quality of life and increased risk of depression and anxiety. Effective therapies are now available that have been shown to concurrently improve skin disease, quality of life and psychiatric symptoms. As the concordance between psychosocial impact and objective disease severity does not always correlate, it is essential to tailor management strategies specifically to the needs of each individual. Cigarette smoking and excess alcohol consumption are among the most important modifiable risk factors that increase the likelihood of psoriasis development and severity of skin disease. This provides a compelling rationale for smoking cessation and limiting alcohol intake in people with psoriasis beyond their traditional harmful health consequences. [ABSTRACT FROM AUTHOR]

With the rapid development of new, targeted therapies for the treatment of moderate/severe atopic dermatitis, it is opportune to review the available conventional systemic agents. We assess the published evidence for systemic therapies for atopic dermatitis and amalgamate this with real‐world experience. Discussions are centred on when systemic therapy should be considered, which drug(s), what dose, how to sequence or combine these therapies, how long they should be continued for and what is considered success. [ABSTRACT FROM AUTHOR]

Background/Objectives: Atopic dermatitis (AD) has significant negative impact on health‐related quality of life, mood, sleep, work productivity and everyday activities. Research into the use of new drugs in the management of AD continues to develop, and international updates and recommendations have been published. However, questions remain in the Australian setting. This consensus aims to provide evidence‐based insights and practical advice on the management of adult AD in Australia. Methods: A panel (five dermatologists and one clinical immunologist) met to review the literature, critically examine clinical questions of relevance to Australian healthcare practitioners and develop a series of recommendation statements. A consensus panel, comprising the initial panel plus nine additional members, used a 2‐round Delphi voting process to determine a set of final guidance statements. Consensus: ≥75% agreement in the range 7–9. Results: Round 1 voting comprised 66 guidance statements. Of these, consensus was reached on 26, which were retained, and five were removed. The remainder (35) were modified and one new guidance statement was added for inclusion in round 2 voting. After round 2, consensus was reached on 35, which were retained, and one was removed (considered redundant). The 61 guidance statements upon which consensus was reached were then used to support a series of core consensus recommendations and a management flow chart. Conclusions: Expert consensus recommendations providing practical guidance of clinical relevance to specialists and primary care physicians in Australia have been developed. Dissemination of this guidance and evaluation of its impact on patient outcomes remain to be undertaken. [ABSTRACT FROM AUTHOR]

The aim of this article is to provide education to clinicians about certain barriers restricting the use of advanced targeted treatments in Australian health care. For illustrative purposes, the article focuses on dermatological conditions, but the content is relevant to all specialties that treat inflammatory and chronic diseases. Barriers to care discussed result in a lower than necessary standard of care for patients in Australia despite important advancements in medicine. [ABSTRACT FROM AUTHOR]

Objectives: To conduct initial assessment of the early arthritis for psoriatic patients (EARP) questionnaire for Australian, Korean and Chinese populations using translated and linguistically validated versions. To measure the proportion of patients with psoriatic arthritis (PsA) among patients with psoriasis who attended dermatology clinics. Methods: Questionnaires were translated and culturally validated into Australian English, Korean and Chinese. A multicenter, observational, descriptive estimate of the proportion of patients with PsA among patients with psoriasis attending dermatology clinics in Australia, Korea and China was conducted. Initial assessments included evaluations of floor and ceiling effects, internal consistency (using Cronbach's alpha), test‐retest reliability (using intraclass coefficient), and correlations between EARP score and rheumatology findings. If the initial EARP score was ≥3, patients were assessed by a rheumatologist for PsA within 3 months of their retest questionnaire. Results: Two hundred and fifty patients participated. Translated EARP questionnaires showed satisfactory internal consistency and test‐retest reliability. A potential floor effect was observed for the Chinese and Korean versions. Cronbach's alpha was 0.885 (Australian), 0.776 (Korean) and 0.789 (Chinese), indicating acceptable internal consistency. Intraclass correlation coefficients were 0.89 (Australian), 0.86 (Korean) and 0.87 (Chinese), indicating acceptable test‐retest reliability. EARP summary scores had weak to moderate linear correlation with the relevant PsA assessments. Overall, 32 (12.8%) patients were diagnosed with PsA based on Classification for Psoriatic Arthritis (CASPAR) score. Conclusion: The Australian, Korean, and Chinese versions of the EARP questionnaire are suitable for the early detection of PsA symptoms in patients with psoriasis by dermatologists working in specialist dermatology clinics. Trial registration: NCT02470481. [ABSTRACT FROM AUTHOR]

Solar urticaria (SU) is a rare form of urticaria with a pathogenesis that is poorly understood. It affects all skin types, can be difficult to diagnose, and is challenging to manage effectively. We conducted a retrospective review of patients with SU in our institution. A total of 83 patients (56 females) were identified as having SU. The mean age was 32 years (7–74) at first development of symptoms/signs of SU. Pruritus was the most common symptom reported (79%). Of the 60 patients who underwent monochromator testing at least once, 35 had SU confirmed with most reacting to visible light and UVA, or to UVA alone. Antihistamines and sun avoidance remain the mainstay treatment for SU but other treatments, including omalizumab, are of potential interest in treating patients with recalcitrant SU. The characterisation of this large case series of patients may help dermatologists recognise and manage this rare disorder appropriately. [ABSTRACT FROM AUTHOR]

The Australasian Psoriasis Collaboration has developed a clinical practice narrative with respect to the relationship between psoriasis, its treatment and infection. The cutaneous microbiome of patients with psoriasis is different to those without psoriasis, although the significance of this is unclear. Whilst a wide range of microorganisms has been associated with psoriasis (including β‐haemolytic streptococci, Staphylococcus aureus, Porphyromonas gingivalis, Candida albicans, Chlamydia psittaci, human immunodeficiency virus and hepatitis C virus), there is limited evidence that antimicrobial therapy is of direct benefit in preventing flares of psoriasis. Psoriasis is independently associated with an increased risk of serious infection, but the absolute risk is low. The risk of serious infections is further increased with immune‐modulatory treatments. The decision whether to, and when to, stop or resume immune‐modulatory treatment after a serious infection has occurred depends on risk assessment for that patient, taking into account the infection being treated, the risk of recurrent infection, any interventions that can modify the risk and the need for psoriasis control. Live vaccines (e.g. MMR, varicella, zoster and yellow fever) are generally contraindicated in patients with psoriasis on immune‐modulatory agents, but this depends on the degree of immune suppression and individual risk factors. Wound healing in psoriasis is normal. Treatment with infliximab, adalimumab, etanercept, methotrexate and ciclosporin can safely be continued through low‐risk surgical procedures. For moderate‐ and high‐risk surgeries, a case‐by‐case approach should be taken based on the patient's individual risk factors and comorbidities. [ABSTRACT FROM AUTHOR]

The article focuses on the impact of psoriasis has on cancer risk factors. It states psoriasis patients have an increased relative risk of solid organ malignancies which reflects the co-risk factors of alcohol consumption, obesity, and smoking. It mentions while the relative risk of developing lymphoma and other hematological malignancies is higher, absolute risk is very low. It considers the impact of systemic immune modulatory agents on cancer risks compared to common risks from lifestyles.

Dear editor, Ciclosporin is approved for short-term use to treat moderate-to-severe chronic plaque psoriasis.1-4 Ciclosporin used at 5 mg/kg/d has been assessed as the optimal dose to achieve disease control, 58-71% of patients achieving Psoriasis Area and Severity Index (PASI) 75.1-4 Higher doses (more than 5 mg/kg/d) may improve efficacy but are associated with increased toxicity.1,4 Known potential adverse effects of ciclosporin include hypertension, nephrotoxicity, neurotoxicity, electrolyte disturbances, hyperlipidaemia, diabetes, opportunistic infection and non-melanoma skin cancers among others.1,3 Adverse effects are also related to treatment duration, resulting in recommendations to avoid prolonged use.5,6 Ciclosporin is typically used for short courses (12-16 weeks) to treat severe flares of disease or as bridging therapy to a maintenance therapy.7 All patients in the Australasian Psoriasis Registry (APR) with moderate-to-severe psoriasis who had been treated with ciclosporin until July 2019 were included. In combination with the mean dose for all patients on ciclosporin, it would appear that the availability of biologics may be driving more conservative dosing and duration of treatment with ciclosporin, given the potential for toxicity. Almost all patients in this cohort went on to have treatment with a biologic agent. [Extracted from the article]

We update the results of a case series of 22 patients with chronic plaque psoriasis from the product familiarisation programme that took place in 2007 prior to the listing of infliximab on the Pharmaceutical Benefits Scheme in December 2007.1 Infliximab is a chimeric monoclonal antibody against tumour necrosis factor (TNF)- administered by intravenous infusion. All patients enrolled in the product familiarisation programme met the eligibility criteria as previously described.1 Infliximab was administered by intravenous infusion at 5 mg/kg at weeks 0, 2 and 6 for induction and 8 weekly thereafter for maintenance. From the original 22 patients enrolled in the product familiarisation programme, as previously reported,1 four patients developed a serious adverse event, and four were lost to follow-up (Table 1). Infliximab induction therapy for patients with severe plaque-type psoriasis: a randomized, double-blind, placebo-controlled trial. [Extracted from the article]

Though there are countless reports of I de novo i and paradoxical worsening of palmoplantar pustular psoriasis (PPPP) and palmoplantar pustulosis (PPP) with TNF inhibitors,[1] these side effects are not well-recognised with ustekinumab. A 54-year-old male smoker with palmoplantar psoriasis consisting of erythema, scale and hyperkeratosis in the absence of pustules noticed a flare after the initial dose of ustekinumab. The pathophysiology of palmoplantar psoriasis, PPPP and PPP is thought to be different to chronic plaque-type psoriasis with different cytokines such as IL-36 and IL-17 playing a role. [Extracted from the article]

Abstract: The Australasian Psoriasis Collaboration has reviewed the evidence for managing moderate to severe psoriasis in those who are pregnant or are breast‐feeding, or planning a family. The severity of the psoriasis, associated comorbidities and specific anti‐psoriasis treatment, along with other exposures, can have a deleterious effect on pregnancy outcomes. Psoriasis itself increases the risk of preterm and low birthweight babies, along with spontaneous and induced abortions, but no specific birth defects have been otherwise demonstrated. The baseline risk for a live born baby to have a major birth defect is 3%, and significant neuro‐developmental problem is 5%. In Australia, pregnant women with psoriasis are more likely to be overweight or obese, depressed, or smoke in their first trimester, and are also less likely to take prenatal vitamins or supplements. Preconception counselling to improve maternal, pregnancy and baby health is therefore strongly encouraged. The topical and systemic therapies commonly used in psoriasis are each discussed separately, with regards to pregnancy exposure, breast‐feeding and effects on male fertility and mutagenicity. The systemic therapies included are acitretin, adalimumab, apremilast, certolizumab, ciclosporin, etanercept, infliximab, ixekizumab, methotrexate, NBUVB, prednisone, PUVA, secukinumab and ustekinumab. The topical therapies include dithranol (anthralin), calcipotriol, coal tar, corticosteroids (weak, potent and super‐potent), moisturisers, salicylic acid, tacrolimus, and tazarotene. As a general recommendation, effective drugs that have been widely used for years are preferable to newer alternatives with less foetal safety data. It is equally important to evaluate the risks of not treating, as severe untreated disease may negatively impact both mother and the foetus. [ABSTRACT FROM AUTHOR]

The Australasian Psoriasis Collaboration reviewed methotrexate ( MTX) in the management of psoriasis in the Australian and New Zealand setting. The following comments are based on expert opinion and a literature review. Low-dose MTX (< 0.4 mg/kg per week) has a slow onset of action and has moderate to good efficacy, together with an acceptable safety profile. The mechanism of action is anti-inflammatory, rather than immunosuppressive. For pretreatment, consider testing full blood count ( FBC), liver and renal function, non-fasting lipids, hepatitis serology, HbA1c and glucose. Body mass index and abdominal circumference should also be measured. Optional investigations in at-risk groups include an HIV test, a Quanti FERON- TB Gold test and a chest X-ray. In patients without complications, repeat the FBC at 2-4 weeks, then every 3-6 months and the liver/renal function test at 3 months and then every 6 months. There is little evidence that a MTX test dose is of value. Low-dose MTX rarely causes clinically significant hepatotoxicity in psoriasis. Most treatment-emergent liver toxicity is related to underlying metabolic syndrome and non-alcoholic fatty liver disease or non-alcoholic steatohepatitis. Alcohol itself is not contraindicated, but should be limited to < 20 gm/day. [Correction added on 6 January 2017, after first online publication: '20 mg/day' has been corrected to '20 gm/day'.] Although MTX is a potential teratogen post-conception, there is little evidence for this pre-conception. MTX does not affect the quality of sperm. There is no evidence that MTX reduces healing, so there is no specific need to stop MTX peri-surgery. MTX may be used in combination with cyclosporine, acitretin, prednisone and anti-tumour necrosis factor biologics. [ABSTRACT FROM AUTHOR]

This 5-year retrospective analysis is of 22 patients who participated in the product familiarisation program ( PFP) at St Vincent's Hospital Melbourne, prior to the listing of infliximab on the Pharmaceutical Benefit Scheme. Criteria for inclusion were being an adult with chronic plaque psoriasis, having a psoriasis area and severity index ( PASI) score of at least 15 with an inadequate response or intolerance to three of the following: phototherapy, acitretin, cyclosporin and methotrexate. Participants were infused with infliximab 5 mg/kg on the standard induction (weeks 0, 2 and 6) and maintenance (8-weekly) protocols. At each visit PASI and dermatology life quality index ( DLQI) scores were recorded. Success was determined as the proportion of patients achieving at least a 75% improvement in the PASI score from baseline ( PASI 75). At 60 months after commencement of therapy, 31% of patients remained on infliximab. Those who did retained PASI 75 with a DLQI of 0 or 1. Of those who ceased infliximab, nine did so due to loss of efficacy, three for personal reasons, two for serious adverse events and one was lost to follow up. Adverse events included non-melanoma skin cancers, infections and abnormal liver enzymes. Infliximab in the Australian context has proven to be a highly effective treatment of chronic plaque psoriasis, and patients who remained on the drug derived a high level of satisfaction, assessed both subjectively ( DLQI) and objectively ( PASI 75). The variable response indicates that psoriasis is a heterogeneous disease and investigation into potential patient selection for treatment in the future is warranted. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 62-year-old woman who had been commenced on ixekizumab prior for chronic plaque psoriasis presented in the spring. It mentions that skin biopsies revealed mild to moderate spongiosis with hyperkeratosis, focal parakeratosis and focal interface change with occasional necrotic keratinocytes. It also mentions that patient was managed with topical betamethasone dipropionate ointment daily and strict photoprotection including long-sleeved clothing.

Australia has the highest prevalence of actinic keratoses ( AK) worldwide. Because of the risk of transformation of AK to invasive squamous cell carcinomas, consensus guidelines recommend that AK are removed using appropriate therapies to prevent progression to invasive disease. Daylight photodynamic therapy ( PDT) is emerging as an efficacious treatment for AK, particularly for patients who require treatment of large areas of chronic actinic damage that can be exposed easily to daylight. Daylight PDT with methyl aminolevulinate ( MAL) cream is a simple treatment for AK, almost painless, well tolerated and convenient, requiring minimal time in the clinic. Randomised controlled studies from northern Europe and Australia support the use of daylight PDT as an effective therapy for grade I and II AK on the face and scalp. There is sufficient daylight to conduct daylight PDT in Australia at any time of the year and during most weather conditions. Hence, daylight PDT with MAL can be included as an effective and well-tolerated new treatment option for the treatment of AK in Australia. These consensus recommendations provide guidelines for Australian clinicians on the use of daylight PDT in the treatment of diagnosed AK. [ABSTRACT FROM AUTHOR]

Background/Objectives Solar (actinic) keratosis ( AK) is an emergent concern worldwide and is associated with an increased risk of development of non-melanoma skin cancer, especially squamous cell carcinoma. Daylight-mediated photodynamic therapy ( DL-PDT) using methyl aminolaevulinate cream has proved to be an effective, nearly painless, and more convenient alternative to conventional PDT for the treatment of AK. In a phase III, randomised, controlled trial performed in Australia, the mean irradiance (light intensity) received by patients during DL-PDT treatment, assessed via a spectroradiometer, was 305 W/m2 (min. 40 to max. 585 W/m2) with similar efficacy irrespective of intensity or dose. The objective of the present meteorological study was to assess the suitability of natural daylight to perform DL-PDT for the treatment of face and scalp AK during different periods of the year and different geographical locations and latitudes across Australia. Methods To determine daylight irradiance during a complete year in eight different geographical locations throughout Australia, we used meteorological software ( Meteonorm, Meteotest, Bern, Switzerland), and available solar radiation and weather data from 1986-2005. Results The average daily irradiance remained within the levels (40-585 W/m2) measured during the clinical DL-PDT study in Australia, throughout the year and in all geographical locations investigated (yearly average from Darwin 548 W/m2 to Hobart 366 W/m2). Conclusions DL-PDT for the treatment of face and scalp AK in Australia can be performed effectively throughout the entire year as long as weather conditions permit daylight exposure and allow participants to remain under direct light for 2 h. [ABSTRACT FROM AUTHOR]

SUMMARY Solar urticaria is an uncommon disorder characterized by pruritus, erythema and whealing commencing within minutes of exposure to ultraviolet (UV) and visible light, and generally resolves in a few hours. We describe a 28-year-old woman who developed pruritus and erythema 5 min after sun exposure while on tetracycline for treatment of perioral dermatitis. Phototesting elicited urticarial reactions in the UVA, UVB and visible spectra. Repeat phototesting after cessation of tetracycline was negative. This report documents the first case of solar urticaria induced by tetracycline. [ABSTRACT FROM AUTHOR]

Background Topical therapy is important in the treatment of actinic keratosis, but guidance for improving adherence/persistence during topical therapy is still lacking. Objectives To utilize expert consensus to generate a list of recommendations to improve real-world efficacy when prescribing topical therapy for actinic keratosis. Methods An expert panel of eight dermatologists was convened to generate recommendations based on facilitated discussion and consensus generation using a modified Delphi session. The recommendations were ratified with the expert panel. Results Facilitated discussion generated 31 issues within five themes, which were prioritized using expert voting. Consensus was achieved on the importance of short and simple treatment regimens for maximizing patient compliance, physician awareness of the progression of actinic keratosis to squamous cell carcinoma, provision of appropriate patient information, and the use of effective communication strategies to educate physicians about actinic keratosis. Based on these key findings, eight recommendations were generated. Conclusions The recommendations will assist physicians when prescribing topical actinic keratosis therapy. Further research should focus on the types of patient outcomes that are influenced by the characteristics of topical field therapy. [ABSTRACT FROM AUTHOR]

Basal cell carcinomas ( BCCs) account for around 80% of non-melanoma skin cancer. Australia has the highest incidence of BCC globally and the rates continue to increase in both Australia and New Zealand. BCC causes significant morbidity, placing an enormous burden on the healthcare system. Treatment of patients with advanced BCC can be particularly challenging. A panel of UK experts recently defined advanced disease as BCC that in which current treatment modalities are considered potentially contraindicated by clinical or patient-driven factors. Research has found that mutations in the hedgehog signalling pathway underpin the pathogenesis of the vast majority of sporadic BCC, as well as Gorlin syndrome. The first-in-class oral small molecule hedgehog pathway inhibitor - vismodegib-is now approved in a number of countries for use in locally-advanced and metastatic BCC and has resulted in improved outcomes in the majority of patients treated. With a number of similar agents in the pipeline, research is now focusing on identifying mechanisms that may contribute to resistance to this agent in some lesions. [ABSTRACT FROM AUTHOR]

The article presents research on the effect of anti-tumour necrosis factor (TNF) alpha therapies on bodyweight and body mass index (BMI) in patients with psoriasis. Topics include the results of a retrospective study of psoriasis patients from the Skin and Cancer Foundation and St. Vincent's Hospital in Melbourne, Victoria; the use of anti-TNF alpha agents such as adalimumab, etanercept, and infliximab; and the use of non-anti-TNF alpha agents such as efalizumab and ustekinumab.

The article discusses the research investigating goals for the treatment for the skin disorder psoriasis. It states that in addition to psoriasis area severity index (PASI) assessment, a quality of life assessment was relevant in distinguishing psoriasis severity and treatment outcome. It mentions that the identification of treatment goals will lead clinicians in treatment decision-making, improve the availability and proper use of therapies and increase patient satisfaction with their care.

Background/Objectives Internationally, the understanding of psoriasis has advanced in recent years to the point now where it is no longer considered a benign or cosmetic skin condition but a systemic, immune-mediated disease associated with significant comorbidities and considerable detriment to quality of life. The aim of this study was to gain a better understanding of the physical, psychosocial and medical burden of psoriasis on Australian adults and the impact on health status. Methods Two large-scale multi-centre cross-sectional studies of Australian adults with psoriasis were conducted during 2010 and 2011, with the participation of a national patient representative group ( Psoriasis Australia). The studies were based on detailed questionnaires that were self-completed by individuals with psoriasis. Results A total of 362 and 330 completed surveys were received in 2010 and 2011, respectively. A significant physical, psychosocial and medical burden was reported by the respondents. It was noteworthy that patients reported actively concealing their disease from the general public (83%), work colleagues (65%), friends (58%), employers (49%), family (40%), close friends (39%) and spouse/partner (20%). The mean five-dimension European quality of life ( EQ- 5D) score for the 2011 cohort was 0.73, representing a significant impact on their HRQoL. The presence of comorbidities, found in three-quarters of the cohort, was associated with an even greater detriment to their HRQoL (mean score 0.64). Conclusions Psoriasis imposes a significant psychosocial burden on the lives of patients, including a profound impact upon their personal and professional relationships, social interactions and quality of life, to a degree comparable to other serious chronic conditions. This study highlights the importance of collaboration between primary and specialist health-care providers in developing patient management strategies that address the spectrum of physical and psychological manifestations associated with psoriasis. [ABSTRACT FROM AUTHOR]

ABSTRACT A 38-year-old woman developed clinical, biochemical, radiological and histopathological evidence of cutaneous and pulmonary sarcoidosis 5 months after commencing adalimumab for chronic plaque psoriasis. Signs and symptoms resolved within 3 months of cessation of adalimumab. [ABSTRACT FROM AUTHOR]

We present a retrospective audit on efficacy and impact of 35 units of botulinum toxin type A per axilla on quality of life in female patients with axillary hyperhidrosis. This audit shows that 35 units of botulinum toxin type A is a reasonable starting dose and could significantly improve patients' quality of life and reduce the cost of treatment. [ABSTRACT FROM AUTHOR]

A series of four cases of severe recalcitrant hidradenitis suppurativa treated with infliximab is presented. All patients had failed to respond to prior medical and surgical management. Baseline Quantiferon-TB Gold and chest radiograph were carried out before commencement of treatment. No patients had associated Crohn's disease. All patients received induction infusions of infliximab 5 mg/kg at weeks 0, 2 and 6, followed by eight weekly maintenance infusions. The total number of infusions varied between 4 and 6. Skin photography with Sartorius scoring was used to evaluate response to treatment. All patients experienced marked improvement in their disease activity, with a mean 48% improvement in Sartorius score after one infusion (week 2, P < 0.01), and 70% improvement after three infusions (week 14, P < 0.01). Time to relapse following cessation of therapy ranged from 6 weeks to 4 months. Further studies examining the efficacy of infliximab and its effect on the course of the disease, particularly relating to long-term management, are required. [ABSTRACT FROM AUTHOR]

Background Psoriasis is a chronic skin disease that can impact heavily on a patient’s well-being. Efalizumab, a unique, targeted, biological therapy, has demonstrated efficacy in treating moderate-to-severe, chronic plaque psoriasis with ≤36 months of continuous therapy. The objective of this Extended Access Program (EAP) was to evaluate further the benefit of efalizumab as long-term therapy in a real-world clinical setting. Methods After an initial conditioning dose of efalizumab (0.7 mg/kg subcutaneously), a weekly dose of efalizumab (1.0 mg/kg) was administered for ≤21 months. Patients with reduced Psoriasis Area and Severity Index (PASI) scores (≥50%, or a score ≤8) at month 3 entered the long-term maintenance treatment period. Results In total, 101 patients (>18 years) with severe plaque psoriasis enrolled on the EAP, of these 93 (92.1%) met all the inclusion criteria. After 3 months of treatment, 84/101 (83.2%) patients had evaluable data and entered the maintenance period. After 3 months, 57/84 (67.9%) patients had achieved PASI-50. Using an intent-to-treat analysis, after 21 months of treatment, PASI-75 and PASI-50 were achieved by 43/101 (42.6%) and 69/101 (68.3%) of patients, respectively. Efalizumab was generally well tolerated during the 21 months of continuous therapy. Conclusion Efalizumab, 1.0 mg/kg/week, is effective and well tolerated in a ‘real world’ clinical setting, providing enduring reduction of psoriasis symptoms for up to 21 months. [ABSTRACT FROM AUTHOR]

Background Data suggest that photodynamic therapy using topical methyl aminolevulinate (MAL PDT) may be a noninvasive alternative to excisional surgery for nodular basal cell carcinoma (BCC). In the studies described here, we investigated the histologic response, tolerability, and cosmetic outcome with MAL PDT for primary nodular BCC (≤ 5 mm in depth). Methods Two multicenter, randomized, double-blind studies with similar design and procedures were conducted. After surface debridement and minor tumor debulking, MAL cream 160 mg/g (66 patients with 75 lesions) or placebo cream (65 patients with 75 lesions) was applied for 3 h, followed by illumination with broad-spectrum red light (75 J/cm2, 570–670 nm). This was repeated 7 days later. Lesions with a partial response (≥ 50% reduction in greatest diameter) at 3 months were re-treated (21%). Treatment sites were excised at 3 months (clinical nonresponders) or 6 months (clinical responders) after the last treatment. Results Histologically verified lesion complete response rates were higher with MAL PDT than with placebo [73% (55/75) vs. 27% (20/75)]. Treatment was most effective for facial lesions (89% complete response). Cosmetic outcome was good or excellent in 98% of evaluable, completely responding lesions treated with MAL PDT. Conclusion Although longer follow-up studies are required, these promising data indicate the potential of topical MAL PDT as a noninvasive treatment alternative for nodular BCC. [ABSTRACT FROM AUTHOR]

A 48-year-old woman presented with pruritic, scaly, annular plaques over her upper back and chest that were clinically, serologically and histologically characteristic of subacute cutaneous lupus erythematosus (SCLE). She failed to respond to conventional treatment, which included high-dose hydroxychloroquine, methotrexate, prednisolone, chloroquine, acitretin, thalidomide, dapsone and azathioprine. Subsequently treated with intravenous rituximab 375 mg/m2 weekly for 4 weeks, she remained on adjuvant oral hydrochloroquine 600 mg daily and topical clobetasol propionate 0.05% ointment as required. Clearing of annular plaques was noted 8 weeks after the initial course of rituximab. By 12 weeks there were no new lesions and only post-inflammatory hyperpigmentation remained. Both hyper- and hypopigmentation, which is more common, are consistent with SCLE lesion regression. Skin lesions recurred 11 months later; however, no further lesions occurred after re-introduction of rituximab therapy. The treatment was well tolerated. A maintenance regimen of rituximab, 375 mg/m2 every 8 weeks for 2 years, was commenced 3 months after completing the second course of treatment, with ongoing disease remission. Rituximab appears to have activity in refractory SCLE and clinical trials are required to further assess this potential therapy. [ABSTRACT FROM AUTHOR]

A 40-year-old woman presented with a prolonged history of recurrent crops of erythematous papules and nodules on her abdomen, arms and legs. Histological examination of a cutaneous biopsy revealed Type A lymphomatoid papulosis. Over a 3-year period, some of the patient's lesions had proven to be resistant to treatment with topical and intralesional corticosteroids and systemic agents including methotrexate, tetracycline and nicotinamide. These resistant lesions were treated with two sessions of methyl aminolevulinate photodynamic therapy given 1 week apart. Review 11 months post-photodynamic therapy demonstrated complete clinical clearance at the treatment site. While photodynamic therapy is considered a standard non-surgical treatment option for non-melanoma skin cancers and has been described in a number of non-oncological indications, this is the first report of its use in lymphomatoid papulosis. [ABSTRACT FROM AUTHOR]

Actinic Prurigo (AP), an uncommon idiopathic photodermatosis, presents a distinct clinical picture and can be severely debilitating. The clinical features, investigation and treatment of AP are reviewed. We report the experience of an Australian photobiology unit with this condition. [ABSTRACT FROM AUTHOR]

Differences in mode of action between biologic agents could explain why one agent is more efficacious than another in the treatment of recalcitrant and erythrodermic flares of chronic plaque psoriasis. Here, we present our experience using a case series of three patients with chronic plaque psoriasis who showed consistent and similar responses to three different biologic agents. All three patients who were refractory to efalizumab developed erythrodermic flares 2–12 weeks after a direct switch to etanercept. Switching from efalizumab to etanercept could provoke paradoxical flaring of psoriasis, which might be prevented by transitioning to systemic agents. The erythrodermic flares in all three patients responded dramatically to infliximab with marked and maintained improvements in Psoriasis Area and Severity Index scores. [ABSTRACT FROM AUTHOR]

Solar keratosis is a common problem encountered by dermatologists, particularly in Australia. Solar keratosis is most commonly found on sun-exposed areas such as the scalp, face and forearms. UV radiation is thought to be the major aetiological factor, with age, immunosuppression and human papillomavirus being important contributing factors. Solar keratosis usually presents as a discrete, variably erythematous and irregular lesion with a scaly surface. Although the exact rate of malignant transformation to squamous cell carcinoma is unknown, the majority of squamous cell carcinomas appear to arise from within solar keratosis. For this reason, solar keratosis is commonly treated and, consequently, an increasing number of therapeutic options is now available. Traditional therapies, such as liquid nitrogen cryotherapy, are still popular, but newer choices, such as photodynamic therapy and imiquimod cream, are now providing further options with similar efficacy and superior adverse effect profiles, albeit at a higher cost. [ABSTRACT FROM AUTHOR]

Advice regarding COVID-19 and use of immunomodulators, in patients with severe dermatological diseases Dear Editors, Coronavirus disease 2019 (COVID-19) is the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), as named by the International Committee on Taxonomy of Viruses (ICTV). In a patient with confirmed COVID-19 disease Any patient with an inflammatory skin disorder being actively managed with an immunomodulator, who is diagnosed with COVID-19, should stop the immunomodulator (s) immediately, with the possible exception of systemic corticosteroids (see below). [Extracted from the article]