Purpose

To understand the changes in the microbiome in psoriatic disease, we conducted a systematic review of studies comparing the skin and gut microbiota in psoriatic individuals and healthy controls.

Findings

Our review of studies pertaining to the cutaneous microbiome showed a trend towards an increased relative abundance of Streptococcus and a decreased level of Propionibacterium in psoriasis patients compared to controls. In the gut microbiome, the ratio of Firmicutes and Bacteroidetes was perturbed in psoriatic individuals compared to healthy controls. Actinobacteria was also relatively underrepresented in psoriasis patients relative to healthy individuals.

Summary

Although the field of the psoriatic microbiome is relatively new, these first studies reveal interesting differences in microbiome composition that may be associated with the development of psoriatic comorbidities and serve as novel therapeutic targets.

Metabolomics is an emerging new "omics" field involving the systematic analysis of the metabolites in a biologic system. These metabolites provide a molecular snapshot of cellular activity and are thus important for understanding the functional changes in metabolic pathways that drive disease. Recently, metabolomics has been used to study the local and systemic metabolic changes in psoriasis and its cardiometabolic comorbidities. Such studies have revealed novel insights into disease pathogenesis and suggest new biochemical signatures that may be used as a marker of psoriatic disease. This review will discuss common strategies in metabolomics analysis, current findings in the metabolomics of psoriasis, and emerging trends in psoriatic metabolomics.

Skin of colored patients with psoriasis are more likely to remain undiagnosed and experience a greater impact on quality of life than their white counterparts. A better understanding of the ethno-racial differences in the presentation of psoriasis can help address these disparities. To compare the prevalence of psoriatic subtypes (plaque, guttate, pustular, erythrodermic, palmoplantar, and inverse) and lesion locations in Caucasian, Asian, and Hispanic/Latino patients, we analyzed cross-sectional, patient-reported, physician-reviewed survey data from 882 adult and 16 pediatric psoriasis patients seen at the University of California, San Francisco Department of Dermatology between 2006 and 2016. Multivariate logistic regression was used to compare the prevalence of psoriasis subtypes and lesional distributions amongst the ethno-racial groups. Asians and Hispanics/Latinos had higher odds of having pustular psoriasis compared to Caucasians (OR=4.36 [95%CI: 1.24-17.62], P=0.026; and OR=5.94 [95%CI: 1.03-31.03], P=0.036, respectively). Asians also had a higher frequency of erythrodermic psoriasis (OR=5.56 [95%CI: 1.41-27.17], P=0.018), but a lower frequency of inverse psoriasis compared to Caucasians (OR=0.26 [95%CI: 0.06-0.80], P=0.036). These differences may relate to genetic or environmental factors or access to care. Clinician awareness of ethno-racial differences in psoriasis subtype and lesion location can facilitate earlier diagnosis and therapeutic intervention.

Introduction

The ability to perform psoriasis skin assessments remotely through digital image-based psoriasis area and severity index (DIB-PASI) would be a valuable tool for psoriasis clinical trials. An ideal teledermatological assessment would be robust across patients of diverse skin tones as well as across assessors of varying experience levels. In this pilot study, we evaluated the reliability of face-to-face (FTF) versus DIB-PASI scores determined by trained clinical assessors with a spectrum of experience and with patients of different skin tones.

Methods

Fourteen subjects of varying skin tones with moderate-to-severe plaque psoriasis were treated with adalimumab. In-person PASI assessments and digital photography were performed in the clinic at weeks 0, 12, and 24. Photographs were reviewed by four independent assessors to derive a digital image-based PASI score. The concordance of face-to-face PASI (FTF-PASI) and DIB-PASI were analyzed across patient and assessor factors.

Results

Overall concordance between FTF-PASI and DIB-PASI was high (ICC 0.82, p < 0.0001), with good agreement across individual assessors. When analyzed by PASI score component or body region, digital assessors also demonstrated good agreement with the FTF assessor. Similarly, DIB-PASI showed high concordance with FTF-PASI for patients with light skin tones and patients with medium-to-dark skin tones, and across clinical training levels.

Conclusion

Overall, PASI scores derived from digital images showed good agreement with those determined in person. Importantly, these remote assessments were reliable for both light and medium-to-dark skin tones, and robust to training level of the assessor. The findings from this pilot study lay the foundation for expanding teledermatology-based clinical trials for patients with psoriasis and enabling accurate, remote monitoring of disease severity and therapy response.

Introduction

Intense nocturnal pruritus as well as the complex pathophysiology of atopic dermatitis (AD) can severely affect sleep and become a major factor in negatively impacting quality of life in adults. However, much of the literature on sleep disturbance in AD patients is on the pediatric population, and it is not well studied in adults. Furthermore, limited studies are available to guide effective management of sleep disturbance in AD in general. We review the literature to present the studies that have investigated the relationship between AD and its effect on sleep in adults and provide an approach for clinicians caring for this population.

Methods

A systematic literature search was conducted through the PubMed and EMBASE databases using the search terms "atopic dermatitis" OR "eczema" AND "sleep." The articles generated by the search and their references were reviewed.

Results

A high prevalence of sleep disturbance is experienced by adults with AD. The likelihood of sleep disturbance is much higher in patients with AD compared to those without AD. Sleep disturbance appears to worsen with AD severity. Pruritus and scratching appear to be large contributors to sleep disturbance in adult patients with AD.

Conclusion

It is important that clinicians evaluate the severity of AD and ask general questions about itching, sleep, impact on daily activities, and persistence of disease during each patient visit and follow-up with the complaint of sleep disturbance. Management of sleep disturbance in AD should focus on adequate disease control of AD as well as possible medical interventions to help improve sleep. The pathophysiology of sleep disturbance in AD is extremely complex, and further research is needed to better understand the interplay of the immune system, circadian rhythm, and environmental factors implicated in both AD and sleep.

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.