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Verrucous malignant melanoma (MM) is a rare variant of melanoma that often presents diagnostic challenges. This case highlights the unique presentation of verrucous MM underlying a cutaneous horn. It is vital for dermatologists to be aware of this potentially benign-appearing variant to be able to diagnose and treat MM early on.

Introduction: Psoriasis, an immune-mediated disease that manifests cutaneously with possible arthritic complications, affects millions of people in the United States and worldwide. Depression and suicidal ideation and behavior (SIB) are two prevalent comorbidities associated with psoriasis, due to the chronic nature of the disease, lack of a cure, as well as social stigma, all of which are detrimental to quality of life. Among the options available for management of moderate-severe psoriasis, apremilast and brodalumab represent recent additions to the therapeutic armamentarium for managing psoriasis. It has been suggested that the aforementioned drugs can lead to depression and possibly increase the risk for SIB. Furthermore, a black box warning was issued for brodalumab. This review challenges opinions that the drugs are solely responsible for exacerbating depression and SIB, when in fact it could be psoriasis itself. Methods: An extensive search of available literature linking cytokines to suicidal behavior was performed. After filtering for relevance, 22 articles were reviewed in detail. Results: Brodalumab and apremilast, both molecularly and clinically, do not objectively increase the risk for depression and/or suicidal ideation and behavior. Conclusion: After careful review of the appropriate studies and relevant literature, patients with moderate-severe psoriasis, including those that experience depression resulting from their chronic condition, would likely benefit from early, rather than delayed initiation of effective medications like apremilast and brodalumab. The speed of response and high level of efficacy of brodalumab make it an ideal intervention for patients suffering depression caused by their psoriasis.

Dermatologists are often ill-equipped to promptly identify and manage patients with personality disorders. Patients with borderline personality disorder (BPD) and narcissistic personality disorder (NPD) frequently present to dermatology clinics, particularly those that provide esthetic services. Although dermatologists should ideally utilize specific management strategies when working with these patients, there is a lack of awareness and availability of resources on how to do so. Here, we review the psychiatry, plastic and reconstructive surgery, and dermatology literature to provide recommendations on tangible management strategies for dermatologists to avoid common mistakes that are made while managing patients with BPD and NPD. Additionally, we also discuss common dermatologic manifestations of BPD and NPD to improve providers' ability to identify patients with these conditions in their practices.

Introduction: Brodalumab is an interleukin-17 receptor blocker that is effective for the treatment of psoriasis. However, due to a Food and Drug Administration black box warning on depression and suicide, many providers are hesitant to use this agent despite its efficacy. Methods: We present the cases of 2 brothers seen at our clinic with treatment-resistant psoriasis who were both successfully treated with brodalumab, despite failing 6 other biologics. We also review the safety profile of brodalumab regarding the currently available evidence on the increased risk of suicidality or depression in patients treated with brodalumab. Results: Both patients achieved completely clear skin and maintained clearance on brodalumab. Discussion: Brodalumab appears to be an effective agent in severe treatment-resistant cases of psoriasis. In addition, a causal relationship between increased risk of suicidality or depression and brodalumab use has not been established.

Machine learning (ML) has the potential to improve the dermatologist’s practice from diagnosis to personalized treatment. Recent advancements in access to large datasets (e.g., electronic medical records, image databases, omics), faster computing, and cheaper data storage have encouraged the development of ML algorithms with human-like intelligence in dermatology. This article is an overview of the basics of ML, current applications of ML, and potential limitations and considerations for further development of ML. We have identified five current areas of applications for ML in dermatology: (1) disease classification using clinical images; (2) disease classification using dermatopathology images; (3) assessment of skin diseases using mobile applications and personal monitoring devices; (4) facilitating large-scale epidemiology research; and (5) precision medicine. The purpose of this review is to provide a guide for dermatologists to help demystify the fundamentals of ML and its wide range of applications in order to better evaluate its potential opportunities and challenges.

With the emergence of the novel coronavirus disease (COVID-19) viral pandemic, there is uncertainty whether biologic agents for psoriasis may place patients at a higher risk for infection or more severe disease course. This commentary offers patient counseling recommendations based on the current available evidence. While there are currently no specific data for psoriasis biologics and COVID-19, data are presented here from phase III clinical trials of psoriasis biologics on rates of upper respiratory infection, influenza, and serious infection. Overall these data reveal that on the whole, psoriasis biologics do not show major increases in infection risk compared to placebo during the course of these trials. However, as the COVID-19 virus is a novel pathogen that is associated with mortality in a subset of patients, a cautious approach is warranted. We discuss factors that may alter the benefit–risk ratio of biologic use during this time of COVID-19 outbreak. Ultimately, treatment decisions should be made on the basis of dialogue between patient and provider, considering each patient’s individualized situation. Once this pandemic has passed, it is only a matter of time before a new viral disease reignites the same issues discussed here.

The purpose of this review is to provide an overview of the use of certolizumab pegol (Cimzia®, UCB S.A.) for psoriasis and psoriatic arthritis and summarize important findings. Three pivotal phase three clinical trials CIMPASI-1, CIMPASI-2, and CIMPACT have demonstrated efficacy and safety of certolizumab pegol (CZP) in patients with plaque psoriasis. In addition, another multicenter phase three clinical trial, RAPID-PsA, has shown long-term efficacy and safety data of CZP in psoriatic arthritis. When compared with other TNF-alpha blockers, CZP has demonstrated increased efficacy in psoriasis. In addition, CZP has also shown clinically significant and sustained improvement in psoriatic arthritis based on symptoms and radiographic evidence in patients with up to 4 years of follow-up. The safety profile of CZP is comparable to other anti-TNF agents. Finally, CZP’s unique structure as a PEGylated monoclonal antibody fragment prevents placental transfer and therefore may make it an ideal choice as a biologic medication for women of childbearing age.

Goeckerman therapy is a highly effective treatment regimen for moderate-to-severe psoriasis. It involves regular exposure to ultraviolet B radiation and the application of crude coal tar. To our knowledge, only three centers in the USA currently offer a formal Goeckerman therapy treatment program; thus, access to this therapy is geographically limited. In this article, a motivated patient discusses his experience with generalized plaque psoriasis. This patient, while living in a Goeckerman-inaccessible area, deferred treatment with biologics and outpatient phototherapy to develop a modified Goeckerman regimen for at-home use. This home regimen, which did not involve the use of prescription-strength medications, resulted in full clearance of his psoriasis. We also discuss the patient’s case from the perspective of a dermatology treatment team that has reviewed his experience.

Background: Traditionally, treatment with the excimer laser requires determining the minimal erythema dose on healthy skin or using plaque-based induration; however, these protocols often lead to underdosing of psoriatic plaques and reduced treatment efficacy. Objective: To prospectively evaluate the effect of the excimer laser on plaque psoriasis using an optimal therapeutic dose (OTD) protocol. Methods: Subjects with stable plaque psoriasis were tested with the Multi-Microdose (MMD) tip on the XTRAC excimer laser to determine a minimum blistering dose (MBD). Treatment was then initiated at 20% less than the MBD. A single psoriatic lesion was treated once weekly for up to 11 sessions. The change from baseline of the target lesion's modified psoriasis area severity index (mPASI), quality of life and safety were evaluated. Results: Thirteen subjects with a mean age of 48.9±14.9 years and Fitzpatrick skin types I-IV participated in the study. Target plaque mPASI significantly decreased at all time points relative to baseline with significant improvement by the second treatment. Patients reached mPASI-75 within 5±2 sessions. By the end of the study 92% of patients achieved mPASI-75. On average, patients maintained an mPASI score ≥50% for 60 days. Treatment was well tolerated with no erosions or hyperpigmentation. Erythema was the most common adverse event. Conclusion: The OTDTM protocol with the MMD® tip allows determining the optimal dose locally on the psoriatic plaque itself. Consequently, ineffectual dosing levels and treatments are minimized. The OTD protocol reduces treatment frequency from 2-3 times per week to once weekly. J Drugs Dermatol. 2020;19(4):349-354. doi:10.36849/JDD.2020.4891.

The purpose of this review article is to provide an overview of sleep and pulmonary comorbidities in patients with psoriasis and summarize important recent findings. Evidence continues to show that patients with psoriasis experience greater chronic sleep impairment when compared to healthy counterparts. In addition to other comorbidities seen in psoriasis patients, including cardiovascular disease, obesity, and diabetes, obstructive sleep apnea and chronic obstructive pulmonary disease have increased frequency in this population. Sleep and pulmonary comorbidities in psoriasis contribute to disease burden and impaired quality of life in psoriasis patients. The evaluation of sleep comorbidities is complicated by the overlap with other comorbidities such as depression and anxiety. Regardless, there is strong evidence to indicate an elevated prevalence of insomnia in psoriasis patients. A causal relationship between psoriasis and insomnia has yet to be determined. There is moderate evidence to suggest increased risk of developing OSA in psoriasis patients, even when accounting for increased BMI. Most studies on sleep impairment in psoriasis patients have used self-reported data, of which only a portion has been validated. As such, there is a need to better evaluate sleep dysfunction in psoriasis patients. Regarding pulmonary comorbidities, psoriasis patients are more likely to smoke compared to the general population, which complicates evaluation of risk of COPD, lung cancer, and pulmonary infections in this population.

The excimer laser has emerged as an efficacious treatment modality for many dermatologic diseases. The excimer laser is an alternative to standard narrowband ultraviolet B (NBUVB) phototherapy treatment in patients with limited disease. In comparison to standard NBUVB, the excimer laser requires fewer treatment sessions, has reduced treatment duration, requires a lower cumulative UVB dose, and limits UVB exposure to lesional skin. This review addresses the mechanism, safety, application, and efficacy of the excimer laser for the treatment of these conditions.

Psoriasis patients with comorbid depression represent a common therapeutic challenge for dermatologists. Depressed patients often require the practicing dermatologist to go outside of their comfort zone, and the FDA’s labeling of medications such as brodalumab have further complicated an already difficult-to-treat patient population. A multi-disciplinary work-group consisting of a board-certified psychiatrist, a licensed clinical psychologist, and multiple dermatologists was convened to formulate practical recommendations for the evaluation and treatment of this at-risk population. How to broach the subject of depression and when to refer patients for formal evaluation were discussed. The expert panel also produced a consensus statement regarding the use of brodalumab in patients with both psoriasis and depression.

Dupilumab is a biologic agent approved by the US Food and Drug Administration for the treatment of atopic dermatitis (AD). Here, we report 2 patients with AD who were treated with dupilumab and subsequently developed facial flushing after consuming alcohol. A possible mechanism of action for this side effect is discussed along with a potential role of dupilumab.

Case Scenerio: A 26-year-old patient presents to the dermatology clinic with severe nodulocystic scarring acne. The patient identifies as a transgender male and notes that he has been receiving hormone replacement therapy for the past 4 years with weekly intramuscular testosterone injections.

Acrodermatitis continua of Hallopeau (ACH) is a rare, sterile pustular eruption of one or more digits. The condition presents with tender pustules and underlying erythema on the tip of a digit, more frequently arising on a finger than a toe. As far as classification, ACH is considered a localized form of pustular psoriasis. The eruption typically occurs after local trauma or infection, but such a history is not always present and various other etiologies have been described including infectious, neural, inflammatory, and genetic causes. The natural progression of ACH is chronic and progressive, often resulting in irreversible complications such as onychodystrophy that can result in anonychia, as well as osteitis that can result in osteolysis of the distal phalanges. Because of the rarity of ACH, there have been no randomized controlled studies to evaluate therapies, resulting in an absence of standardized treatment guidelines. In clinical practice, a wide variety of treatments have been attempted, with outcomes ranging from recalcitrance to complete resolution. In recent years, the introduction of biologics has provided a new class of therapy that has revolutionized the treatment of ACH. Specifically, rapid and sustained responses have been reported with the use of anti-tumor necrosis factor agents like infliximab, adalimumab, and etanercept; IL-17 inhibitors like secukinumab; IL-12/23 inhibitors like ustekinumab; and IL-1 inhibitors like anakinra. Nevertheless, there remains a considerable need for more research into treatment for the benefit of individual patients with ACH as well as for the clinical knowledge gained by such efforts. The purpose of this review is to provide a comprehensive overview of the key features of ACH as well as a discussion of clinical management strategies for this unique and debilitating condition.

Generalized pustular psoriasis (GPP) is a rare and potentially life-threatening variant of psoriasis that is characterized by recurrent, acute onset, widely distributed pustular eruptions on inflamed, erythematous skin. It is important to recognize acute GPP as a subtype of psoriasis associated with high morbidity and mortality so therapy can be initiated without delay. Since GPP was first described in 1910 by Leopold von Zumbusch, it has been inconsistently defined, stratified, and diagnosed in the literature. Multiple definitions and diagnostic criteria have been proposed over the years. Recently, formal consensus guidelines on GPP have been published by international groups. This article reviews the current evidence and understanding in the diagnosis and screening of GPP.

Introduction Sleep is essential for overall health and well-being, yet more than one-third of adults report inadequate sleep. The prevalence is higher among people with psoriasis, with up to 85.4% of the psoriatic population reporting sleep disruption. Poor sleep among psoriasis patients is particularly concerning because psoriasis is independently associated with many of the same comorbidities as sleep dysfunction, including cardiovascular disease, obesity, and depression. Given the high prevalence and serious consequences of disordered sleep in psoriasis, it is vital to understand the nature of sleep disturbance in this population. This study was designed to help meet this need by using survey data from Citizen Pscientist, an online patient portal developed by the National Psoriasis Foundation. Methods Our analysis included 3118 participants who identified as having a diagnosis by a physician of psoriasis alone or psoriasis with psoriatic arthritis. Demographic information, psoriasis severity and duration, sleep apnea status, smoking and alcohol consumption, itch timing, and sleep characteristics were included. Two separate multivariate logistic regression models in STATA were used to determine whether the presence of psoriatic arthritis, age, gender, body mass index, comorbid sleep apnea, psoriasis severity, timing of worst itch, smoking status, or high-risk alcohol consumption were associated with sleep difficulty or low sleep quantity, defined by the American Academy of Sleep Medicine as less than 7 h of sleep per night on average. Results Results from the multivariate logistic regressions found that sleep difficulty was associated with psoriatic arthritis (OR 2.15, 95% CI [1.79–2.58]), female gender (2.03 [1.67–2.46]), obese body mass index (BMI ≥ 30) (1.25 [1.00–1.56]), sleep apnea (1.41 [1.07–1.86]), psoriasis severity of moderate (1.59 [1.30–1.94]) or severe (2.40 [1.87–3.08]), and smoking (1.60 [1.26–2.02]). Low sleep quantity was associated with obese BMI (1.62 [1.29–2.03]), sleep apnea (1.30 [1.01–1.68]), psoriasis severity of moderate (1.41 [1.16–1.72]) or severe (1.40 [1.11–1.76]), and smoking (1.62 [1.31–2.00]). Sleep difficulty and low sleep quantity were not associated with age, alcohol consumption, or timing of worst itch. Conclusion These results are potentially meaningful in several aspects. We identify an important distinction between sleep difficulty and sleep quantity in psoriatic disease, whereby having psoriatic arthritis and being female are each associated with sleep difficulty despite no association with low sleep quantity. Furthermore, there is conflicting evidence from prior studies as to whether psoriasis severity is associated with sleep difficulty, but this well-powered, large study revealed a strong, graded relationship between psoriasis severity and both sleep difficulty and low sleep quantity. Overall, our results show that both sleep difficulty and low sleep quantity were associated with multiple factors in this analysis of a large psoriatic cohort. These findings suggest that dermatologists may gather clinically useful information by screening psoriatic patients for trouble sleeping and low sleep quantity to identify potential comorbidities and to more effectively guide disease management.

Vitiligo is a chronic autoimmune condition involving selective dysfunction and destruction of melanocytes in the skin, hair, or both. The typical presentation is well-demarcated depigmented skin patches. Given vitiligo is the most common cause of depigmentation worldwide and early disease responds best to treatment, prompt diagnosis and proactive management of vitiligo are critical. While a wide variety of treatments has demonstrated variable effectiveness in treating vitiligo, phototherapy remains standard of care because of its proven efficacy and favorable side effect profile. However, many patients with vitiligo are unable to access affordable, consistent, or convenient phototherapy. To address these issues, home-based phototherapy has emerged as a patient-centered alternative. The purpose of this review is to discuss management of vitiligo with a specific focus on access to home-based phototherapy (HBPT) for patients with this condition. Key challenges to HBPT include misperceptions around safety and efficacy, inadequate physician education and training, insurance and financial barriers, and appropriate patient selection. Solutions to these challenges are presented, such as approaches to improve physician education and increasing the evidence surrounding the effectiveness and safety of this treatment for vitiligo. In addition, various practical considerations are discussed to guide dermatologists on how to approach HBPT as a treatment option for patients with vitiligo.

Dupilumab is a fully human monoclonal IgG4 antibody directed against the alpha subunit of the IL-4 receptor and prevents the signaling of IL-4 and IL-13, two type 2 cytokines known to be important drivers of atopic diseases. In March of 2017, the United States Food and Drug Administration (FDA) approved dupilumab for the treatment of moderate-to-severe atopic dermatitis in adults that is uncontrolled with topical medications, becoming the first biologic agent approved to treat this chronic skin condition. In October of 2018, Dupilumab received approval by the FDA as an add-on maintenance therapy in patients with moderate-to-severe asthma aged 12years or older with an eosinophilic phenotype or with oral corticosteroid-dependent asthma. This review summarizes the characteristics of dupilumab and the clinical research that has been published to date, including treatment efficacy and adverse events.

Brodalumab, a first-in-class interleukin-17 (IL-17) receptor blocker, carries a black box warning for suicidal ideation and behavior, yet it is also one of the most powerful biologic agents in our armamentarium. We wish to highlight three patients with moderate-to-severe psoriasis and comorbid depression who were successfully treated with brodalumab. The patients were chosen by an expert panel comprising dermatologists, psychiatrists, and psychologists. Psoriasis disease severity was measured using the Psoriasis Area and Severity Index (PASI) score. All three patients experienced PASI 100 after treatment with brodalumab (N=3). Importantly, depressive symptoms improved or resolved in two out of three patients. One patient, who had a history of psychiatric hospitalizations, required in-patient psychiatric treatment during treatment. The use of brodalumab in patients with psoriasis can provide rapid-onset improvement in both skin and depressive symptoms.

Erythrodermic psoriasis is a relatively rare, more dangerous inflammatory variant of psoriasis associated with high morbidity and mortality. It can be exceptionally challenging to manage, defeating even the most experienced dermatologist's arsenal of treatment strategies. Goeckerman therapy, a regimen of ultraviolet B phototherapy and crude coal tar, has demonstrable efficacy in severe and recalcitrant plaque-type psoriasis. However, its utility in erythrodermic psoriasis has not been explored within the dermatology literature. Herein, we present a patient with a long-standing history of erythrodermic psoriasis refractory to eleven treatment modalities including four biologic agents, who had his erythroderma 'turned around' following Goeckerman therapy. 'Turned around' is used to describe dramatically reducing a patient's cutaneous inflammation so that previously recalcitrant disease can now respond to maintenance therapy. The importance of a one to three week 'cool down' period of topical corticosteroid therapy prior to phototherapy or crude coal tar use is highlighted in this case as well. Although Goeckerman therapy is no longer regularly used, it remains one of the most efficacious treatments available for intractable psoriasis, attracting patients from all over the country desperate for symptom relief. This case suggests it may be useful in 'turning around' extremely difficult-to-treat erythrodermic psoriasis as well.

Background: The management of psoriatic disease in HIV-positive patients is challenging. Psoriasis in HIV-positive patients is often severe, progressive, and resistant to first- and second-line therapies, including topical treatments, phototherapy, highly active antiretroviral therapy (HAART), and oral retinoids. Other systemic agents used to treat psoriasis, such as methotrexate and cyclosporine, are immunosuppressants and thus many dermatologists may not feel comfortable prescribing them to HIV-positive patients who are already immunocompromised. Biologic agents, which target specific aspects of overactive immune pathways in psoriasis, have revolutionized the management of moderate-to-severe psoriasis. However, data are limited regarding their safety and efficacy in HIV-positive patients. Objective: Report 4 cases of HIV-positive patients managed on biologic therapy and summarize the cases of psoriasis in HIV-positive patients managed on biologic therapy that have been published in dermatologic literature to date. Methods: We searched PubMed and Embase databases using the terms HIV and psoriasis or HIV and psoriatic arthritis combined with one of the 11 biologics currently approved for treating psoriasis. Results: We identified 48 cases of anti-psoriasis biologic therapy (including adalimumab, infliximab, etanercept, ustekinumab, and guselkumab) in HIV-positive patients and added 4. While data are limited, the evidence available suggests biologic agents are safe and efficacious in moderate-to-severe psoriasis and may even have a favorable effect on CD4 and HIV viral counts when used with concomitant HAART. Conclusion: Further research would be helpful to establish practical guidelines for the use of anti-psoriasis biologic therapy in the HIV population, including that of newer agents.

Treatment options for psoriasis are numerous and span a wide array of modalities. For mild-to-moderate disease, topical therapy may be adequate for complete control; however, moderate-to-severe disease often requires systemic agents or phototherapy. Laser therapy is also a helpful tool in the armamentarium against psoriasis. For localized disease that is not adequately controlled with topicals or for lesions in difficult-to-treat areas, laser therapy may be an ideal treatment option. Lasers enable the delivery of therapeutic radiation to lesional skin only, thus sparing non-lesional skin from any possible adverse events. Over the past few decades, various lasing devices have been demonstrated to be safe and effective treatment options for psoriasis. The most commonly used devices include the 308-nm excimer laser and the 585 or 595-nm pulsed dye laser. Despite recent advances in targeted biologic therapy, lasers continue to play an important role in the management of psoriatic disease.

Background: Sleep dysfunction and sleep disorders are important comorbidities of psoriasis. Not only do these sleep comorbidities contribute to reduced quality of life, but they may also lead to worsening psoriasis and increased susceptibility to cardiometabolic diseases. While psoriasis and sleep dysfunction are thought to be linked by itch, depression, and immune system dysregulation, the relationship between psoriasis and sleep dysfunction is not yet fully understood. Objective: We sought to compare previous studies characterizing the gut microbiome in psoriasis and sleep dysfunction and examine the potential relevance of shared findings on cardiometabolic and overall health. Methods: We performed literature searches of PubMed and Embase databases to find studies evaluating the gut microbiome in psoriasis, sleep dysfunction, and cardiometabolic diseases. Results: Studies characterizing the gut microbiome in psoriasis and sleep dysfunction reveal shared findings, specifically an increased Firmicutes to Bacteroidetes ratio and reduced abundance of short-chain fatty acid–producing bacteria. These dysbiotic features have also been shown to promote systemic inflammation and cardiometabolic disease. Conclusion: In favoring an increased Firmicutes to Bacteroidetes ratio and reduced abundance of short-chain fatty acid–producing bacteria, sleep dysfunction could be contributing to worsening psoriasis and cardiometabolic comorbidities through intestinal dysbiosis. Future studies are needed to determine whether gut- and sleep-targeting interventions could be therapeutic in patients with psoriasis having poor sleep.

Doxepin, a tricyclic antidepressant, is the most efficacious antipruritic available to dermatologists; however its use is often suboptimal because of significant interindividual variability in doxepin plasma levels and clinical response between patients taking the same dose. As result, the Food and Drug Administration approves a maximum dose of 300 mg of doxepin per day and a 10 mg per cc liquid doxepin concentrate. These allow patients to significantly increase or decrease their dose, due to either a lack of clinical efficacy or side effects at typical dermatologic doses (often 10-25 mg per day). This review initially discusses the unique advantages of doxepin in dermatology. Then, it explores internal and external reasons why doxepin plasma levels and clinical response vary so significantly between patients, including genetic polymorphisms, drug interactions, comorbidities, sex, and ethnicity. Blood level monitoring is introduced, a tool dermatologists can use to optimize doxepin dosing in patients responding subtherapeutically to typical dermatologic doses. Without blood level monitoring, patients initially unresponsive to treatment could be labeled treatment failures when in fact they may be cases of inadequate dosing. Blood level monitoring allows for safe dose adjustments in these individuals to maximize patients' chances of achieving therapeutic success with this agent.

Background: Diagnosis of psoriatic arthritis (PsA) can be challenging, resulting in delays that contribute to irreversible joint damage, reduced quality of life, and increased mortality. Objective: Use genetic markers to develop and evaluate a PsA genetic risk score (GRS) for its ability to discriminate between psoriasis (PsO) only and PsO with PsA among a psoriatic cohort with full genome-wide genotype data. Methods: Genome-wide single-nucleotide polymorphism genotyping was performed on 724 psoriatic patients. A set of 11 candidate risk genes previously shown to be preferentially associated with PsO or PsA were selected. To evaluate the cumulative effects of these risk loci, a PsA GRS was developed using an unweighted risk allele count (cGRS) and a weighted (wGRS) approach. Additional analyses included only human leukocyte antigen (HLA) risk alleles. Results: The discriminative power attributable to each GRS was evaluated by calculating the areas under the receiver operator characteristic curve (AUROC). The AUROC for the wGRS is 56.2% versus 54.1% for the cGRS, and the AUROC for the HLA-only wGRS model was 56.9% versus 55.7% for the HLA-only cGRS. Conclusion: The AUROC of 56.9% for HLA-only wGRS indicates that this approach has the greatest power in discriminating PsA from PsO among these models. Given that an AUROC of 56.9% is quite modest, this study suggests that using a small number of well-validated genetic loci provides limited predictive power for PsA, and that future approaches may benefit from using a larger number of genetic loci.

Plaque psoriasis is a chronic inflammatory skin condition that affects an estimated 0.91% to 8.5% of the global population.1 The prevalence of psoriasis varies based on ethnoracial and geographic distribution. In the United States, psoriasis affects approximately 3.6% of Caucasians (non-Hispanic white), 1.9% of African Americans (non-Hispanic black), and 1.6% of Hispanic-identifying adults.2 Population-based studies in East and Southeast Asia have estimated a prevalence ranging from 0.05 to 0.47%.3.

Introduction In order to manage skin conditions at a national referral hospital level in Kenya, specialized dermatology services, such as dermatologic surgery, dermatopathology, phototherapy, and sub-specialty care, should be offered, as is typically available in referral hospitals around the world. A Kenyan patient with prurigo nodularis, whose severe itch remitted after phototherapy treatment at the University of California, San Francisco (UCSF), inspired the development of a phototherapy service at Academic Model Providing Access to Healthcare (AMPATH), a partnership in Western Kenya between Moi Teaching and Referral Hospital, Moi University College of Health Sciences, and a consortium of North American academic medical centers. Methods Initial project funds were raised through a crowdfunding campaign and fundraising events. A new narrowband ultraviolet B phototherapy unit and replacement bulbs were donated and air shipped to Eldoret, Kenya. A team of dermatologists and phototherapy nurses from UCSF conducted a 2-day training session. US-based dermatologists affiliated with AMPATH provide ongoing support through regular communication and on-site visits. Results Early in implementation, challenges faced included training clinical staff with limited experience in phototherapy and improving communication between nurses and clinicians. More recent challenges include frequent rotation of specialty clinic nurses in the dermatology clinic, adaptation of phototherapy guidelines to balance patient volume with service delivery capacity, and training assessment of disease activity in darkly pigmented skin. Conclusion Strategies that have been helpful in addressing implementation challenges include: increasing on-site and remote training opportunities for clinicians and nurses, developing a tiered payment schema, educating patients to combat misconceptions about phototherapy, dynamic phototherapy referral guidelines to accommodate service delivery capacity, and prioritizing the engagement of a multidisciplinary team.

Patients with psoriasis have high rates of depression and may be at increased risk for suicidal ideation and behavior (SIB). Attempted and completed suicides during clinical trials and other studies of psoriasis therapies, including brodalumab, highlight the importance of understanding psychiatric risk factors in patients with psoriasis. Recent meta-analyses, research studies, and published data from brodalumab clinical studies were reviewed. We also summarize research on effects of brodalumab on depression symptoms and occurrences of SIB in brodalumab clinical trials. Psoriasis elevates the risk for depression and possible suicide. Brodalumab has a boxed suicide warning; however, it states that there is no established causal association between treatment with brodalumab and increased risk for SIB. Clinicians are urged to evaluate patients with psoriasis for psychiatric risk factors regardless of their therapy and to consider the package insert and a comprehensive evaluation of relevant literature to make a well-balanced decision.

Biologics such as dupilumab are a highly efficacious and relatively safe treatment option for patients with recalcitrant immune-mediated disease; however, because of their modulation of the immune system, biologics have been associated with severe infections, including reactivation of latent hepatitis B virus (HBV).1, 2, 3 As a result of the increased morbidity and mortality associated with active HBV, physicians are often reluctant to prescribe biologics in patients with chronic HBV infection. Dupilumab is the first biologic therapy approved for the treatment of moderate-to-severe atopic dermatitis (AD).4 We present 2 cases of patients with AD and chronic HBV treated with dupilumab while receiving concomitant therapy for HBV.

Introduction: Psoriasis is a chronic, immune-mediated disease with significant associated comorbidities. Its pathogenesis is likely multifactorial, however, the interleukin-23/T helper 17 pathway has been identified as a critical axis in its pathogenesis. Interleukin-17A is the primary effector of this pathway and overexpression of IL-17A results in epidermal hyperplasia and an overly robust inflammatory response, resulting in the skin plaques and systemic inflammation seen in psoriasis. Targeted anti IL-17 therapies have demonstrated efficacy in the treatment of moderate-to-severe plaque psoriasis.Areas covered: A PubMed search was conducted for relevant literature. Secukinumab, ixekizumab, and brodalumab are anti IL-17 inhibitors currently approved for the treatment of moderate-to-severe plaque psoriasis. The efficacy and safety data from key phase III clinical trials are reviewed here.Expert opinion: By targeting a key mediator of the interleukin-23/T helper 17 pathway, IL-17 antagonists are an effective treatment for plaque psoriasis. It has demonstrated efficacy and a favorable safety profile in key phase III clinical trials. In addition to efficacy, IL-17 antagonists have also shown long-term maintenance of treatment response and a quick onset of action. The efficacy of IL-17 inhibitors in the treatment of moderate-to-severe psoriasis underscores the importance of the IL-23/Th17 pathway in the pathogenesis of psoriasis.

Numerous biologic medications are available to treat psoriasis and psoriatic arthritis; however, many patients experience differential responses of their skin and joints to the same agent. In patients who do not respond to biologic monotherapy or combination of a biologic with an oral systemic agent, dual biologic therapy is a possible treatment option. Dual biologic therapy is rarely reported in the psoriatic literature (Table I).1, 2, 3, 4, 5, 6 We present a patient with severe psoriatic skin and joint disease who has been treated with multiple combinations of dual biologic therapy, including ustekinumab plus etanercept for 12 months, secukinumab plus etanercept for 6 months, and guselkumab plus etanercept for 15 months. Throughout the patient's treatment, adverse events only occurred with the ustekinumab plus etanercept combination and consisted of an increased incidence of urinary tract and upper respiratory infections, including a hospitalization for H2N1 flu. Table I Reported cases of dual biologic therapy for psoriasis and psoriatic arthritis

The IL17A inhibitor secukinumab is efficacious for the treatment of psoriasis. In order to define its mechanism of action, it is important to understand its impact on psoriatic whole skin tissue as well as specific skin-resident immune cell populations such as T lymphocytes. In this study, we treated 15 moderate-to-severe plaque psoriasis patients with secukinumab and characterized the longitudinal transcriptomic changes of whole lesional skin tissue and cutaneous CD4+ T effector cells (Teffs), CD4+ T regulatory cells (Tregs), and CD8+ T effector cells during 12 weeks of treatment. Secukinumab was clinically effective, with 100%, 47%, and 27% of patients in the study achieving PASI75, PASI90, and PASI100 by week 12, respectively. At baseline prior to treatment, we observed that IL17A overexpression predominates in psoriatic CD8+ T cells rather than Teffs, supporting the importance of IL-17-secreting CD8+ T cells (Tc17) compared to IL-17-secreting CD4+ T cells (Th17) cells in the pathogenesis of psoriasis. Although secukinumab targets only IL17A, we observed rapid reduction of IL17A, IL17F, IL23A, IL23R, and IFNG expression in lesional skin as soon as 2 weeks after initiation of treatment and normalization of expression by week 12. Secukinumab treatment resulted in resolution of 89-97% of psoriasis-associated expression differences in both bulk tissue and T cell subsets by week 12 of treatment. Overall, secukinumab appears to rapidly reverse many of the molecular hallmarks of psoriasis.