Focus on Psoriasis: A Report from the European Academy of Dermatology and Venereology 31st Annual Congress (EADV)

• Kristian Reich’s lecture on Psoriasis – Pathophysiological Stratification intended to update the audience on personalized/individualized medicine in psoriasis. However, solid evidence to base individualized treatment of psoriasis is still limited. The lecture introduced the topic and its terminology apart from presenting some of the sparse valid data available on the subject. Today’s personalized medicine is based on knowledge of the patient’s disease/treatment history, the patient’s lifestyle, psoriasis phenotype (nails, comorbidity, arthritis, etc.), and wishes. Based on this knowledge, which Dr. Reich calls patient profiling, a good dermatologist will suggest specific treatments and interventions.
• Antonio Costanzo discussed the clinical and molecular evidence for psoriasis-associated comorbidities. Psoriasis disease is polygenic and multifactorial. As such, genes associated with psoriasis are also associated with comorbid conditions common among our patients (many affecting lymphocyte differentiation and regulation). By measuring the genetic connection between psoriasis and other diseases (common predisposing genes), the “diseasome” can be determined. The “diseasome” is the association between psoriasis and comorbidity. The same can be done with proteomics. The molecular comorbidity index (MCI) is a calculation of the strength of the association of two diseases in the diseasome using shared genetics or proteomics. MCI roughly corresponds to the prevalence of comorbidity in psoriasis. Dr. Costanzo emphasized the importance of always considering comorbidity, screening, and asking for cardiovascular risk factors and lifestyle habits.
• IPC Councilor Carle Paul discussed the psychological burden of psoriasis. Patients with psoriasis often feel anxious and ashamed, suffer from fatigue and low self-esteem, experience stigmatization, avoid intimate relationships, and restrict leisure activities, choosing social isolation. Studies have shown a high psychological burden of psoriasis, with 23% of patients suffering from anxiety and 14% from depression. Alexithymia, the limited ability to identify and communicate emotions, is common among patients with psoriasis. It is proposed that the development of alexithymia in patients with psoriasis could be a psychological defense mechanism against stigmatization. 25% of psoriasis patients are alexithymic vs. 10% of the general population.2 Alexithymia in psoriasis is associated with psoriasis on visible areas such as hands and face, depression, anxiety, and high alcohol consumption. Systemic treatment of psoriasis has shown that alexithymia is reversible in 50% of patients at one-year follow-ups.
• IPC Board Member Lluís Puig’s presentation asked the question, “Is There Still a Place for Classical Systemic Treatment?” Dr. Puig started the lecture by giving a short answer to the lecture’s title question, “Yes, but not for long.” Treatment choices are based on guidelines, safety, and efficacy. In the European Dermatological Forum (EDF), French, German, and Italian guidelines, classical systemic treatment is still central when initiating systemic treatment. However, in the more recent published guidelines, biologics may be used as a “first line label” under certain conditions (e.g., particularly severe disease, severe nail disease, or if treatment success is not expected on conventional/classic treatment). According to EMA, however, most biologicals are the first line in moderate to severe psoriasis, and access restrictions to these drugs should eventually be modified according to market price dynamics.
• IPC Vice President/President-Elect Hervé Bachelez discussed various ways to treat pustular psoriasis. Pustular psoriasis can be divided into three distinct entities; Acrodermatitis Continua of Hallopeau (ACH), localized Palmoplantar Pustular Psoriasis (PPP), and Generalized Pustular Psoriasis (GPP). GPP is a rare, mainly acute, sometimes life-threatening disease. The evidence for the efficacy of plaque psoriasis treatment for GPP is very weak. Acute GPP flare-ups are often self-limiting, making assessing treatment responses challenging in this rare condition. Acitretin, cyclosporine, methotrexate, and infliximab are potential first-line systemic treatments in adult GPP. It is even more challenging in children since disease with an early onset is often more severe. There is, as such, a very high need to determine the efficacy of systemic treatment in childhood GPP. For the time being, acitretin, cyclosporin, methotrexate, and etanercept can be used as first-line treatments. JDA 2018 GPP treatment guidelines confirm the high unmet need for evidence regarding treatment efficacy. These guidelines suggest systemic steroids as treatment when faced with life-threatening conditions (not otherwise used because of the risk of flare-ups as steroids are tapered).
• IPC Councilor Tiago Torres presented how to manage difficult-to-treat locations, which are usually regarded as having a high impact on patient well-being, such as the skin on the scalp, fingers, face, genitals, intertriginous areas, hands, nails, and feet. Palmoplantar and nail psoriasis may be more challenging to treat. High psychosocial importance and loss of function do, however, demand higher treatment efficacy when treating these sites, which may be more difficult to achieve. Physicians frequently underestimate the burden of psoriasis disease. Difficult-to-treat locations are associated with lower quality of life and a more significant disease burden. Common evaluation tools such as PASI may “miss” these areas – specific evaluation tools are preferable. The goal when addressing difficult-to-treat locations should be clear or almost clear lesions.
• Nikolai Dyrberg Loft examined biosimilars in psoriasis. Biosimilars are as effective and as safe as originators. Long-term data and pharmacovigilance data are still needed. One switch is not inferior to a non-switch – but clinicians need to be aware of possible nocebo effects. Multiple switches should still be assessed to attain more robust evidence of their safety and efficacy. The reason for switching is to lower the cost of treating disease – without price reductions, switches cannot be motivated.
• Enikö Sonkoly presented the IL-23-Th17-Th1 immunologic process in psoriasis skin and illustrated how biologics target cytokines or cytokine receptors in this process. She then introduced the concept of targeting intracellular pathways – a fundamentally different approach to treatment (biologics having extracellular targets). Intracellular pathways are not necessarily specific since they may be active in many different cell types. Another difference comparing biologics to small molecules is size; because of their smaller size (molecular weight <1000 DA), small molecules may be administered orally and in topical treatments.
• Jose-Manuel Carrascosa discussed pathophysiology as a part of the EADV’s Training and Educational Forum. Psoriasis pathogenesis and treatment development is a translational medicine success story. Nowadays, it is rare to see patients admitted to the hospital because of severe psoriasis, which could be quite common in the past. Medical research has led to the continuous development of new therapeutic drugs leading to benefits for psoriasis patients. The foundation of the modern view of psoriasis pathogenesis is based on research from early in this millennium, as described in a Nature publication in 2007, where psoriasis was presented as the result of an interaction between innate and adaptive immunity. The importance of innate immunity and cell types such as dendritic cells, neutrophils, and keratinocytes must be underlined apart from the more well-known functions of adaptive immunity, including the Th17 cells. The keratinocytes are not only barrier cells but also key players in innate immunity. In 2009, Nestle et al. published an article in the New England Journal of Medicine presenting a model of psoriasis pathogenesis; this model’s basic principle is valid today.
• IPC Councilor Curdin Conrad‘s presentation focused on the stratification of patients, disease subtypes, disease memory, and potential disease modification. The optimal choice of therapy can be drug-related (dependent on efficacy, half-life, safety, tolerability/convenience), patient-related (dependent on compliance, age, sex, child-bearing potential), or disease-related (dependent on disease variant, comorbidity, disease course). These factors often overlap. No single treatment option is effective or appropriate for all patients, although a significant proportion of plaque psoriasis patients can reach PASI 100 with modern IL-23i and IL-17i biologics.
• IPC Honorary Founder Christopher Griffiths presented on psoriasis and global health in this joint EADV/AAD session. Prof. Griffiths, the director of The Global Psoriasis Atlas (GPA), presented the GPA history, structure, achievements, current work, and how the GPA functions as an exemplar. Ten years ago, Prof. Griffiths co-authored a systematic review of global psoriasis epidemiology,1 which cast light on the significant global gaps in knowledge on psoriasis. The WHO global psoriasis report identified research on “global incidence and prevalence” as areas in need of further research, which also contributed to the foundation of the GPA – global reports on mental health prevalence and incidence serving as an example for the work that was to be done. The GPA has numerous ongoing projects, including epidemiological projects and comorbidity studies in countries such as Malaysia, Qatar, Newfoundland, and Myanmar. Prof. Griffiths encouraged dermatologists with an interest in psoriasis to engage with the GPA on social media or to get involved in GPA work by contacting them.

For a more in-depth read, please download the full report.