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Summary: Background: Factors that might influence response to systemic treatment for moderate‐to‐severe psoriasis are varied, and generally, are poorly understood, aside from high bodyweight, suggesting that other unidentified factors may be relevant in determining response to treatment. The impact of alcohol misuse on treatment response has not been previously investigated. Objectives: To investigate whether alcohol misuse is associated with poor response to treatment for psoriasis. Methods: This was a prospective cohort study in which response to systemic therapies was assessed using the Psoriasis Area and Severity Index (PASI). The CAGE (Cut down, Annoyed, Guilty, Eye opener) questionnaire was used to screen for alcohol misuse. A multivariable factional polynomial linear regression model was used to examine factors associated with change in PASI between baseline and follow‐up. Results: The cohort comprised 266 patients (biologic cohort, n = 134; conventional systemic cohort, n = 132). For the entire cohort, the median (interquartile range) PASI improved from 13 (10·0–18·3) at baseline to 3 (1·0–7·5) during follow‐up. A higher CAGE score [regression coefficient: 1·40, 95% confidence interval (CI) 0·04–2·77]; obesity (1·84, 95% CI 0·48–3·20); and receiving a conventional systemic rather than a biologic therapy (4·39, 95% CI 2·84–5·95) were significantly associated with poor response to treatment; whereas a higher baseline PASI (–0·83, 95% CI –0·92 to –0·74) was associated with a better response to treatment. Conclusions: The poor response to therapy associated with alcohol misuse and obesity found in people with psoriasis calls for lifestyle behaviour change interventions and support as part of routine clinical care. Targeting interventions to prevent, detect and manage alcohol misuse among people with psoriasis is needed to minimize adverse health consequences and improve treatment response. Whatis already known about this topic?Factors that might influence response to systemic treatment for moderate‐to‐severe psoriasis are generally poorly understood, aside from high bodyweight, suggesting that other unidentified factors may be relevant in determining response to treatment.The potential influence of alcohol misuse on response to treatment for psoriasis has not been previously investigated. Whatdoes this study add?After adjusting for important factors that could influence response to treatment such as psychological distress and medication nonadherence, alcohol misuse was found to be significantly associated with poor response to treatment.Identification of potentially modifiable factors associated with poor treatment response emphasizes the need for lifestyle behaviour change support as part of routine clinical care.Effective interventions to detect and address high alcohol consumption should form part of routine care for people with psoriasis. Plain language summary available online [ABSTRACT FROM AUTHOR]

Summary: Background: There is a lack of any overview of changes over time and variation in the epidemiology of psoriasis with age and between genders. Objectives: To perform a systematic review of published population‐based studies on variations in psoriasis incidence and prevalence with age and between genders, and to explore trends in psoriasis epidemiology over time. Methods: Eleven electronic and regional databases were searched from their inception dates to October 2019. No language restrictions were applied. Studies were eligible if they reported on changes in psoriasis incidence and/or prevalence over time and/or by age group and gender. Results: In total 308 papers were critically appraised, from which 90 studies from 22 countries were included. Incidence data confirmed a clear bimodal age pattern in psoriasis onset, with the first and second peaks at around 30–39 and 60–69 years of age, respectively, and evidence suggesting that it presents slightly earlier in women than in men. Prevalence data showed an increasing trend with age until around 60 or 70 years, after which it decreases. Although there was lack of agreement on specific gender differences in psoriasis incidence and prevalence, a slight male predominance was reported in several studies. Studies worldwide suggested a stable or slightly decreasing trend in psoriasis incidence, while an increasing trend in psoriasis prevalence has been consistently reported. One particular challenge faced was the vastly different methodologies used in the included studies, which contributed to some of the heterogeneity of the results. Conclusions: Studies on changes over time in the occurrence of psoriasis have contributed to a greater appreciation of the increasing burden of the disease. However, further research is required to determine the reasons driving the increase in psoriasis prevalence over time. What is already known about this topic?Systematic reviews examining the global epidemiology of psoriasis have explored variations in the incidence and prevalence of psoriasis in children and adults, and in the overall population.The extent to which the occurrence of psoriasis varies over time, as well as by gender and with age, has not been systematically explored. What does this study add? Incidence data confirm a clear bimodal age pattern in psoriasis onset, with evidence suggesting it presents slightly earlier in women than in men.Psoriasis prevalence shows an increasing trend with age until 60 or 70 years, after which it decreases.There is lack of agreement on specific gender differences in psoriasis incidence and prevalence; however, several studies report a slight male predominance.The increasing trend in psoriasis prevalence, despite a stable or a slightly decreasing trend in its incidence, warrants further investigation. Plain language summary available online [ABSTRACT FROM AUTHOR]

Summary: Background: Psoriasis is associated with risk factors for serious infections, but the independent relationship between psoriasis and serious infection is as yet unclear. Objectives: To determine whether people with psoriasis have a higher risk of hospitalization due to any infection, respiratory infections, soft‐tissue and skin infections, or a higher risk of death due to infection. Methods: We conducted a cohort study of people (≥ 18 years) with psoriasis using the UK Clinical Practice Research Datalink (CPRD GOLD) linked to Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality records between 1 April 2003 and 31 December 2016, and matched with up to six comparators on age, sex and general practice. Hospitalization was ascertained from HES records; death was ascertained from ONS mortality records. Stratified Cox proportional hazard models were estimated, with stepwise adjustment in different models for potential confounders or mediators between psoriasis and serious infection. Results: There were 69 315 people with psoriasis and 338 620 comparators who were followed up for a median (interquartile range) of 4·9 (5·9) and 5·1 (6·3) years, respectively. People with psoriasis had a higher incidence rate of serious infection [20·5 per 1000 person‐years, 95% confidence interval (CI) 20·0–21·0, n = 7631] compared with those without psoriasis (16·1 per 1000 person‐years, 95% CI 15·9–16·3, n = 30 761). The fully adjusted hazard ratio for the association between psoriasis and serious infection was 1·36 (95% CI 1·31–1·40), with similar results across the other outcomes. Conclusions: Psoriasis is associated with a small increase in the risk of serious infection. Further research is needed to understand how psoriasis predisposes to a higher risk of infection. What is already known about this topic? Several studies have shown that people with psoriasis have a higher risk of hospitalization due to infection, but these studies are limited by residual confounding for lifestyle factors or underestimation of the true incidence of hospital admissions from primary care electronic health records. What does this study add? Using a large primary care database linked with secondary care Hospital Episode Statistics, we found that, after adjusting for potential confounders and mediators, the hazard ratio for the association between psoriasis and the development of serious infection was 1·36 (95% confidence interval 1·31–1·40).In summary, we show that having psoriasis is independently associated with a small but increased risk of serious infection. Linked Comment:Naldi. Br J Dermatol 2021; 184:6. Plain language summary available online [ABSTRACT FROM AUTHOR]

Background The British Association of Dermatologists Biologic Interventions Register ( BADBIR) is a prospective, observational cohort designed to assess the long-term safety of biologic and conventional systemic therapies used for adults with moderate-to-severe psoriasis in the U.K. and Republic of Ireland. Objectives To describe the demographics, disease severity and comorbidities of patients with psoriasis on enrolment into BADBIR, and to highlight differences in those commencing biologics compared with those on conventional systemic therapies. Methods Baseline data were collected from 151 dermatology departments in the U.K. and Republic of Ireland. Descriptive analysis was conducted. Results As of August 2014, 8399 patients were registered with BADBIR; 5065 (60%) received biologics, of whom 52·8% received adalimumab, 24·6% etanercept, 18·7% ustekinumab and 3·9% infliximab. In the comparator cohort 44·1% received methotrexate, 23·1% ciclosporin, 18·0% acitretin and 7·6% fumaric acid esters. Overall 4897 (58%) were male. Patients on biologics had a higher mean ± SD age and disease duration than patients on conventional systemic therapies (46·3 ± 12·7 vs. 44·3 ± 14·3 years and 23·0 ± 12·6 vs. 19·0 ± 13·4 years, respectively; both P < 0·001). Mean body mass index, Psoriasis Area and Severity Index and Dermatology Life Quality Index scores for patients on biologics were higher than for those on conventional systemic therapies (31·0 ± 7·2 vs. 30·1 ± 7·3 kg m−2; 16·4 ± 8·3 vs. 15·5 ± 7·9 and 17·4 ± 7·5 vs. 15·0 ± 7·1, respectively; all P < 0·001). In total 71% of all patients had comorbidities and 47% had more than one comorbidity. The most frequent comorbidities were obesity (42·1%), hypertension (25·7%), depression (22·1%) and psoriatic arthritis (17·1%). Conclusions BADBIR is an invaluable resource to study the safety and effectiveness of both biologic and conventional systemic therapies. Understanding differences in baseline characteristics between cohorts is crucial in undertaking future pharmacovigilance studies. [ABSTRACT FROM AUTHOR]

Thirty-two panel members agreed that at least four of the eight supportive diagnostic criteria must be present together with the essential criterion to make a diagnosis of CPP. Dear Editor, Despite psoriasis being a common disease, surprisingly little guidance exists on clinical diagnostic criteria.1 The variable presentation of psoriasis and its differential diagnoses make diagnosis challenging,2 particularly for nondermatologists. The consensus exercise included a recommendation for the clinical diagnosis of CPP across diverse ethnic groups. [Extracted from the article]

Psoriasis is associated with considerable physical and psychological morbidity. Optimal use of psoriasis treatments can limit the physical manifestations of psoriasis and help improve quality of life, but nonadherence is common. Smoking, obesity and excessive alcohol consumption are prevalent in this population. A systematic review of adherence to medication and recommendations for lifestyle change in psoriasis was undertaken, with a critical appraisal of the quality of the selected studies. Electronic searches from inception to March 2012 (PubMed, Web of Science and Embase) were conducted. Twenty-nine studies were included; however, none examined adherence to advice about lifestyle change. Studies using a dichotomous classification of adherence tended to report suboptimal adherence, with 21·6-66·6% of patients classed as adherent. No consistent pattern of results emerged for sociodemographical, disease and lifestyle factors as determinants of adherence. However, some treatment factors were associated with adherence. While mixed findings were reported for quality of life as a determinant of adherence, psychological factors (psychological distress and patient satisfaction with care and therapy) were associated with adherence. Only tentative conclusions can be made for determinants of adherence because the methodological quality of many of the included studies limits conclusions. There is a need for improved quality of research and reporting in this area, and this review provides a platform from which future research within this area should progress, along with suggested research recommendations. [ABSTRACT FROM AUTHOR]

Objective: To examine the relative cost effectiveness of topical calcipotriol and short-contact dithranol in the treatment of mild to moderate plaque psoriasis.Design and Setting: This was a modelling study from the perspective of the UK National Health Service as payer.Methods: The interventions were compared using 2 decision-analytic models: one using a short term horizon (12 weeks) and the other using a longer term horizon (up to 1 year). Clinical success of treatment and relapse rates were obtained from the results of randomised controlled trials.Main Outcome Measures and Results: The outcome measure used was the degree of improvement in psoriasis as judged by the patient. In the short term comparison, calcipotriol was the most effective treatment (60.8% success), but it was also the most expensive (96.03 Pounds; 2000 values). The incremental cost per success was 577.50 Pounds using a 12-week course of calcipotriol compared with short-contact dithranol. Over the long term horizon, first-line treatment with calcipotriol still had the highest expected cost per successful treatment (164.91 Pounds), but the incremental cost using this strategy was 38.66 Pounds compared with short-contact dithranol. In terms of cost per successful day's treatment (i.e. the cost for a day in which the patient reported a marked improvement or cleared lesions), the cost of each additional successful day's treatment was 19.93 Pounds when using calcipotriol as first-line treatment rather than short-contact dithranol.Conclusion: The combination of differences in drug acquisition costs and relapse rates can lead to large differences in the comparative cost effectiveness of topical treatments for plaque psoriasis. From the perspective of the prescriber, the results of this analysis suggest that selecting short-contact dithranol as first-line treatment was the most cost-effective strategy. [ABSTRACT FROM AUTHOR]

In recent years, the use of alternative therapies has become widespread. In particular, there has been a resurgence in the public's demand for herbal remedies, despite a lack of high-quality evidence to support the use of many of them. Given the increasing pressures to control healthcare spending in most countries, it is not surprising that attention is being focused on the cost effectiveness of herbal remedies. We address the question of whether there is sufficient information to enable the assessment of the cost effectiveness of herbal remedies. In so doing, we discuss the current state of play with several of the more high-profile alternative herbal remedies [Chinese medicinal herbs for atopic eczema, evening primrose oil, ginkgo biloba, hypericum (St John's wort)] and some which have made the transition from being alternative to being orthodox remedies. We use historical context to discuss, on the one hand, the increasing commodification of herbal remedies and on the other, the trend towards greater regulatory control and licensing of alternative herbal remedies. We argue that unless great care is exercised, these changes are not necessarily in the best interests of patients. In order to identify cost-effective care, we need reliable information about the costs as well as the efficacy and safety of the treatments being assessed. For most alternative therapies, such data are not available. We believe that studies to gather such data are long overdue. Whilst we argue strongly in favour of control of some herbal remedies, we urge caution with the trend towards licensing of all herbal remedies. We argue that the licensing of those herbal remedies with equivocal benefits and few risks, as evidenced by a long history of safe use, increases barriers to entry and increases societal healthcare costs. [ABSTRACT FROM AUTHOR]

Summary: This study was carried out by a group of investigators from dermatology departments in Manchester and Hamburg. It used information from the German Psoriasis Registry and also the British Association of Dermatologists Biologic Interventions Register, or BADBIR, which collects information on the use and outcomes of new biologic drugs used for psoriasis. The team developed and then assessed a model for predicting which patients with psoriasis were most likely to develop severe infection within one year of starting systemically administered treatment (i.e. treatment that works on the whole body, rather than being applied just to the skin). The treatments assessed ranged from older methods where the drug is taken by mouth, such as methotrexate or ciclosporin, to the newer injected biologic therapies, such as etanercept or ustekinumab. Potential risk factors to be investigated, such as age, gender, disease severity and initial therapy, amongst others, were agreed by the assessment group. These serious infections were those where patients had prolonged admissions to hospital, were treated with intravenous antibiotics or where they died, within one year of starting these therapies. 1.7 % of both BADBIR and German patients developed a severe infection. Risk factors for a higher likelihood of serious infections included female gender, other underlying illnesses such as chronic lung disease, higher alcohol intake, and treatment with the biologic, infliximab. Interestingly age did not, by itself, pose a higher risk of infection. This work will prove very useful in helping dermatologists to decide which patients to treat, and with what drug, and to advise patients of lifestyle choices such as drinking alcohol. Linked Article: Yiu et al. Br J Dermatol 2019; 180:894–901 [ABSTRACT FROM AUTHOR]

Linked Article: Yiu et al. Br J Dermatol 2019; 180:894–901 [ABSTRACT FROM AUTHOR]