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Introduction Psoriasis patients demonstrate high interest in the role of diet on their skin condition. However, data are lacking to describe dietary interventions among psoriasis patients and associated outcomes. This study aims to identify common dietary habits, interventions and perceptions among patients with psoriasis, and to examine patient-reported skin outcomes in response to these interventions. Methods We administered a 61-question survey to the National Psoriasis Foundation membership asking psoriasis patients about dietary habits, modifications, skin responses, and perceptions. Results A total of 1206 psoriasis patients responded to the survey. Compared to age- and sex-matched controls, psoriasis patients consumed significantly less sugar, whole grain fiber, dairy, and calcium (p

Author(s): Kazemi, Tiana; Farahnik, Benjamin; Koo, John; Beroukhim, Kourosh | Abstract: BackgroundRecent studies into the pathogenesis of psoriasis have identified the importance of interleukin 17 (IL-17) in disease activity and have thus provided a new target for biologic therapy. Ixekizumab, the most recent US Food and Drug Administration (FDA)-approved anti-IL-17 biologic agent, appears to be a promising medication for patients suffering from moderate-to-severe plaque psoriasis.MethodsWe reviewed the results of phase III trials for ixekizumab in order to assess the efficacy, safety, and impact on quality of life of this agent in the treatment of plaque psoriasis. Additionally, we compared these results to phase II and phase III trials for other biologic psoriasis medications including the anti-IL-23 agents tildrakizumab and guselkumab, the combined anti-IL-12 and anti-IL-23 agent ustekinumab, and the anti-IL-17 agents brodalumab and secukinumab.ResultsPooled results from individual studies demonstrate that among the most efficacious dosing regimens of these anti-interleukin therapies, ixekizumab achieves higher Psoriasis Area and Severity Index 75 rates and similar or higher static Physician Global Assessment 0-1 rates than the other anti-IL-17 and anti-IL-23 agents. The safety profile of ixekizumab is similar to these agents, with nasopharyngitis, upper respiratory infection, headache, arthralgia, and injection-site erythema as the most commonly reported adverse events.ConclusionIxekizumab is a highly efficacious, newly FDA-approved treatment for moderate-to-severe plaque psoriasis that demonstrates a robust clinical response, significant improvement in patient quality of life, and a favorable safety profile.

Author(s): Abrouk, Michael; Levin, Ethan; Brodsky, Merrick; Gandy, Jessica R; Nakamura, Mio; Zhu, Tian Hao; Farahnik, Benjamin; Koo, John; Bhutani, Tina | Abstract: Introduction:The 308 nm excimer laser is a widely used device throughout the field of dermatology for many diseases including psoriasis. Although the laser has demonstrated clinical efficacy, there is a lack of literature outlining the safety, efficacy, and patient acceptability of the excimer laser. Methods:A literature search on PubMed was used with combinations of the terms "excimer", "excimer laser", "308 nm", "psoriasis", "protocol", "safety", "efficacy", acceptability", "side effects", and "dose". The search results were included if they contained information pertaining to excimer laser and psoriasis treatment and description of the safety, efficacy, and patient acceptability of the treatment. Results:The 308 nm excimer laser is generally safe and well tolerated with minimal side effects including erythema, blistering, and pigmentary changes. It has a range of efficacies depending on the protocol used with several different treatment protocols, including the induration protocol, the minimal erythema dose protocol, and the newer minimal blistering dose protocol. Conclusion:Although the excimer laser is not a first-line treatment, it remains an excellent treatment option for psoriasis patients and has been demonstrated to be an effective treatment with little to no side effects.

Background The Goeckerman regimen remains one of the oldest, most reliable treatment options for patients with moderate to severe psoriasis. Goeckerman therapy currently consists of exposure to ultraviolet B light and application of crude coal tar. The details of the procedure can be confusing and challenging to understand for the first-time patient or provider. Objective To present a freely available online guide and video on Goeckerman treatment that explains the regimen in a patient-oriented manner. Methods The Goeckerman protocol used at the University of California—San Francisco Psoriasis and Skin Treatment Center as well as available information from the literature were reviewed to design a comprehensive guide for patients receiving Goeckerman treatment. Results We created a printable guide and video resource that covers the supplies needed for Goeckerman regimen, the treatment procedure, expected results, how to monitor for adverse events, and discharge planning. Conclusion This new resource is beneficial for prospective patients planning to undergo Goeckerman treatment, healthcare providers, and trainees who want to learn more about this procedure. Online media and video delivers material in a way that is flexible and often familiar to patients.

Erythrodermic psoriasis (EP) is a rare and severe variant of psoriasis vulgaris, with an estimated prevalence of 1%–2.25% among psoriatic patients. The condition presents with distinct histopathologic and clinical findings, which include a generalized inflammatory erythema involving at least 75% of the body surface area. The pathogenesis of EP is not well understood; however, several studies suggest that the disease is associated with a predominantly T helper 2 (Th2) phenotype. Given the morbidity and potential mortality associated with the condition, there is a need for a better understanding of its pathophysiology. The management of EP begins with a comprehensive assessment of the patient’s presentation and often requires multidisciplinary supportive measures. In 2010, the medical board of the US National Psoriasis Foundation published consensus guidelines advocating the use of cyclosporine or infliximab as first-line therapy in unstable cases, with acitretin and methotrexate reserved for more stable cases. Since the time of that publication, additional information regarding the efficacy of newer agents has emerged. We review the latest data with regard to the treatment of EP, which includes biologic therapies such as ustekinumab and ixekizumab., Video abstract

Introduction Interleukin-17 inhibitors are the newest class of monoclonal antibodies approved by the US Food and Drug Administration for the treatment of psoriasis. Preclinical and Phase II studies of ixekizumab, a high-affinity anti-IL-17A monoclonal antibody, have proved promising. Methods We conducted an extensive literature search using the PubMed database to assess the efficacy and safety profile of ixekizumab. The search included the following key words: “psoriasis” and “IL-17” or “ixekizumab.” We also reviewed citations within articles to identify relevant sources. Results By week 12, the percentage of patients achieving a 75% improvement from baseline Psoriasis Area and Severity Index (PASI 75) was comparable among the three Phase III trials (UNCOVER-1, 89%; UNCOVER-2, 90%; UNCOVER-3, 87%). Ixekizumab continued to be efficacious through 60 weeks of treatment. The safety profile of ixekizumab was favorable; the most frequently reported adverse events consisted of nasopharyngitis, upper respiratory tract infection, injection-site reaction, and headache. Conclusion Overall, ixekizumab demonstrated rapid clinical improvement and favorable short-term safety profile in Phase III trials. The results support ixekizumab as an effective therapeutic option for patients with moderate-to-severe plaque-type psoriasis. Electronic supplementary material The online version of this article (doi:10.1007/s13555-016-0102-0) contains supplementary material, which is available to authorized users.

Author(s): Farahnik, Benjamin; Patel, Viraat; Beroukhim, Kourosh; Zhu, Tian Hao; Abrouk, Michael; Nakamura, Mio; Singh, Rasnik; Lee, Kristina; Bhutani, Tina; Koo, John | Abstract: Background:The efficacy and safety of biologic and phototherapy in treating moderate-to-severe psoriasis is well known. However, some patients may not respond well to biologic agents or phototherapy on their own and may require combination therapy. Skillfully combining a biologic agent and phototherapy may provide an additive improvement without much increase in risks. Objective:To summarize the current state of evidence for the efficacy and safety of combining biologics with phototherapy in the treatment of moderate-to-severe plaque psoriasis. Methods:We conducted an extensive search on Pubmed database for English language literature that evaluated the use of a combination of biologic and phototherapy for the treatment of moderate-to-severe psoriasis through January 2016. The search included the following key-words: psoriasis, etanercept, adalimumab, infliximab, ustekinumab, biologics, phototherapy, and combination therapy. Results:The primary literature included randomized controlled trials, a head-to-head study, open-label controlled and uncontrolled trials, case series, and case reports. Etanercept was used in over half of the reported cases, but other biologic agents used included ustekinumab, adalimumab, and infliximab. The vast majority of phototherapy was narrowband ultraviolet B (NBUVB) radiation. Most cases reported enhanced improvement with combination therapy. Serious adverse events throughout the study duration were reported in l3% of the patients. Long-term adverse events cannot be excluded. Conclusion:Combination of biologic and phototherapy appears to be a viable clinical strategy in the treatment of moderate-to-severe psoriasis not responsive to monotherapy, despite limitations in the data available. NBUVB in combination with biologics appears to be especially effective. However, the long-term impact of these combinations is yet to be determined.

Recent studies have suggested that the intestinal microbiome plays an important role in modulating risk of several chronic diseases, including inflammatory bowel disease, obesity, type 2 diabetes, cardiovascular disease, and cancer. At the same time, it is now understood that diet plays a significant role in shaping the microbiome, with experiments showing that dietary alterations can induce large, temporary microbial shifts within 24 h. Given this association, there may be significant therapeutic utility in altering microbial composition through diet. This review systematically evaluates current data regarding the effects of several common dietary components on intestinal microbiota. We show that consumption of particular types of food produces predictable shifts in existing host bacterial genera. Furthermore, the identity of these bacteria affects host immune and metabolic parameters, with broad implications for human health. Familiarity with these associations will be of tremendous use to the practitioner as well as the patient.

Atopic dermatitis (AD) is a common inflammatory dermatosis characterized by pruritus, erythema, induration, and lichenification. Current treatment options for generalized atopic dermatitis are limited and have potentially serious adverse effects, especially in patients with severe, chronic AD who frequently require systemic anti-inflammatory agents. Apremilast, an oral phosphodiesterase-4 inhibitor, was FDA approved in September 2014 for the treatment of moderate-to-severe plaque psoriasis. However, its upstream anti-inflammatory effects, ease of use as an oral agent, and mild side-effect profile make it an interesting treatment option for AD as well. Herein, we present a patient with a life-long history of AD recalcitrant to topical steroids and cyclosporine who attained subjective and objective improvement in pruritus and erythema after 10-week treatment with apremilast.

Background: Striae gravidarum (SG) are atrophic linear scars that represent one of the most common connective tissue changes during pregnancy. SG can cause emotional and psychological distress for many women. Research on risk factors, prevention, and management of SG has been often inconclusive. Methods: We conducted a literature search using textbooks, PubMed, and Medline databases to assess research performed on the risk factors, prevention, and management of SG. The search included the following key words: striae gravidarum, pregnancy stretch marks, and pregnancy stretch. We also reviewed citations within articles to identify relevant sources. Results: Younger age, maternal and family history of SG, increased pre-pregnancy and pre-delivery weight, and increased birth weight were the most significant risk factors identified for SG. Although few studies have confirmed effective prevention methods, Centella asiatica extract, hyaluronic acid, and daily massages showed some promise. Treatment for general striae has greatly improved over the last few years. Topical tretinoin ≥0.05% has demonstrated up to 47% improvement of SG and non-ablative fractional lasers have consistently demonstrated 50 to 75% improvement in treated lesions of striae distensae. Conclusion: Overall, SG has seen a resurgence in research over the last few years with promising data being released. Results of recent studies provide dermatologists with new options for the many women who are affected by these disfiguring marks of pregnancy. Keywords: Striae gravidarum, pregnancy, stretch marks, striae distensae

IL-17 is involved in the pathogenesis of several autoimmune diseases, however its role in vitiligo has not been well defined. Emerging human and mouse studies have demonstrated that systemic, tissue, and cellular levels of IL-17 are elevated in vitiligo. Many studies have also shown significant positive correlations between these levels and disease activity, extent, and severity. Treatments that improve vitiligo, such as ultraviolet B phototherapy, also modulate IL-17 levels. This review synthesizes our current understanding of how IL-17 may influence the pathogenesis of autoimmune vitiligo at the molecular level. This has implications for defining new vitiligo biomarkers and treatments.

On June 30th 2015, the FDA instituted a new system for the categorization of drug safety during pregnancy and lactation, known as the Pregnancy and Lactation Labeling Rule (PLLR), which replaces the "A, B, C, D, X" pregnancy labeling categories. The new rule will apply to all newly approved prescription medications, with a staggered phase-in for prescription drugs approved prior to the effective date. In this article, we provide a brief description of the major changes introduced by the PLLR and discuss the major implication of this new categorization system for clinical dermatologists.

Background PUVA treatment is photochemotherapy for psoriasis that combines psoralen with UVA radiation. Although PUVA is a very effective treatment option for psoriasis, there is an absence of patient resources explaining and demonstrating the process of PUVA. Studies have shown that patients who viewed videos explaining the treatment procedures for various medical conditions had a greater understanding of their treatment and were more active participants in their health. Objective To present a freely available online guide and video on PUVA treatment designed for patient education on PUVA. Methods The PUVA treatment protocol used at the University of California—San Francisco Psoriasis and Skin Treatment Center as well as available information from the literature was reviewed to design a comprehensive guide for patients receiving PUVA treatment. Results We created a printable guide and video resource that reviews the benefits and risks of PUVA, discusses the three types of PUVA (hand–foot soak, full body soak, and systemic), demonstrates the PUVA process, and provides practical tips for safe use. Conclusion Online media and video delivers material in a way that is flexible and often familiar to patients. This new format is beneficial for prospective patients planning to undergo PUVA treatment, health-care providers, and trainees who want to learn more about this treatment.

Background An increasing number of injectable biologics are now available for the treatment of psoriasis. However, for individuals who have never received this therapy, the process of performing a self-injection can be daunting. There is lack of patient educational material on how to perform and optimize this treatment. Objective The objective of this study is to present a freely available online guide and video on biologic injections that is informative to patients and increases the success and compliance of patients starting this therapy. Methods The self-injection technique taught at the University of California—San Francisco Psoriasis and Skin Treatment Center as well as available information from the literature were reviewed to design a practical guide for patients receiving biologic injections. Results We created a printable guide and video resource that describes how to improve the injection process, pain management, travel planning, and common concerns with biologic injectables. Conclusion This guide is beneficial for patients who wish to improve their experience with biologic self-injections, for healthcare providers who prescribe these treatments, and for trainees learning about this modality.

Introduction Interleukin (IL)-17 inhibitors are the most recent class of monoclonal antibodies approved by the FDA for psoriasis treatment. Preclinical and phase II studies of brodalumab, a high-affinity IL-17 receptor monoclonal antibody, have been encouraging. Methods We conducted a literature search using the PubMed database in order to assess the efficacy and safety profile of brodalumab. The search included the following key words: “psoriasis” and “IL-17” or “brodalumab.” We also reviewed citations within articles to identify relevant sources. Results At week 12, the proportion of patients attaining a 75% improvement from the baseline Psoriasis Area and Severity Index (PASI 75) was similar among the three phase III trials (AMAGINE-1, 83%; AMAGINE-2, 86%; AMAGINE-3, 85%). Brodalumab remained efficacious through 52 weeks of treatment. It maintained a satisfactory safety profile; the most frequently reported adverse events consisted of nasopharyngitis, headache, upper respiratory tract infection, and arthralgia. Conclusion Use of brodalumab revealed prompt clinical improvement and a favorable short-term safety profile in phase III trials, although further extension studies are needed to assess long-term safety. Based on the results, brodalumab appears to be a potent therapeutic option for patients with moderate-to-severe plaque-type psoriasis.