Viewpoint on handling anti-TNF failure in psoriasis

An association among the occurrence of antidrug antibodies (ADAs), diminished trough serum drug levels (TSDLs) and non-response or loss of response has been described for several tumor necrosis factor alpha (TNF) blocking agents in a variety of diseases, including psoriasis. In a series of ten psoriasis patients with primary or secondary failure, or adverse reactions during anti-TNF therapy, we measured ADAs and TSDLs in patient serum using radioimmunoassay and ELISA, respectively. By proposing a treatment algorithm derived from research in this field, we show that measuring ADAs and TSDLs in psoriasis patients provides a more structured approach to clinical decision making for psoriasis patients who fail anti-TNF therapy

Applying Toyota production systemprinciples and tools at the Ghent University hospital

For the last decades many organizations started using Lean as their major business strategy for organizing and improving their operational activities. Results in manufacturing have been very good, but nowadays also service and office environments start to realize that the Toyota Production System, which is the basis of Lean, is a universal approach. Healthcare institutions in the U.K. and the U.S.A. have already been applying lean principles to some degree. This paper describes the findings of our exploratory research on lean in service and healthcare showing how one department from the Ghent University Hospital in Belgium started to implement lean, resulting in significant performance improvements. After a brief discussion on the different elements of the Toyota Production System, we will show how they were adapted and applied in a service environment

Real-life effectiveness of once-daily calcipotriol and betamethasone dipropionate gel vs. ointment formulations in psoriasis vulgaris: final analysis of the 52-week PRO-long study

Background: Topical therapies are the mainstay of treatment for psoriasis vulgaris. The fixed combination of calcipotriol (Cal) 50 mu g/g plus betamethasone 0.5 mg/g (as dipropionate; BD) is a first-line topical treatment and available as a gel or ointment. The use of these fixed combination products was compared in PRO-long, a long-term noninterventional study, for which interim results (4 and 12 weeks) have previously been reported. Objective: To describe and compare patients' perspectives on the fixed combination gel and ointment formulations; to include efficacy, adherence behaviour, treatment satisfaction and health-related quality of life (HRQoL) aspects during long-term real-life psoriasis management. Methods: PRO-long was a multicentre, prospective, observational, 52-week study of patients prescribed fixed combination Cal/BD gel or ointment in clinical practice. For final analysis the following were assessed at weeks 24, 36 and 52: differences in the proportion of patients with 'mild'/'very mild' disease according to patient's global assessment of disease severity, adherence behaviour, treatment satisfaction (nine-item treatment satisfaction questionnaire for medication) and HRQoL (Skindex-29). Results: Patients (n = 328) were prescribed once-daily Cal/BD gel (n = 152) or ointment (n = 176). At week 52, a higher proportion of patients reported that the severity of their psoriasis was 'mild'/'very mild' vs. baseline (gel: 60.2 vs. 47.1%; ointment: 58.8 vs. 42.4%), with greater treatment satisfaction reported in patients using gel vs. those using ointment. A higher proportion of patients found the gel 'easy' to use compared with the ointment (66.7 vs. 45.2%). Daily application of treatment took <= 5 min for 86.1% of patients using gel and 71.0% of patients using ointment. Conclusion: This real-life study has demonstrated similar effectiveness between the Cal/BD formulations. However, over a 52-week treatment period, patients reported greater treatment satisfaction with the gel, which was considered easier to use, faster to apply and overall a more convenient product

Adapting curriculum for autism in art education

Autism Spectrum Disorder (ASD) describes a complex group of brain development disorders characterized by difficulties in social interaction, communication and behavior. ASD is one of the nation\u27s leading disorders, affecting nearly one in every 68 children (Centers for Disease Control Prevention, 2017). Currently there is limited understanding and research in ways ASD is being promoted and integrated within art education. This limitation has led to blurred understandings in how art educators can adapt materials, projects, and roles of paraprofessionals within the classroom. Societal views on ASD often deny the giftedness of these children and fail to see the effects that ASD dependence has on helping these students be successful. Many students with ASD are dependent on certified individuals within education to constantly help them find their unique path of learning. It is urgent that we deepen our research and understanding of how ASD students can be best served throughout their k-12 art education endeavors. This research will help identify where further applications should continue exploring the current areas lacking adequate ASD awareness within K-12 art education classrooms

Measuring the Impact of Vitiligo: Behind the White Spots

The impact of vitiligo is generally believed to be underestimated. Salzes et al. propose a questionnaire to measure the actual burden of vitiligo. Using a stepwise approach they constructed and validated this instrument taking into account the differences between fair and dark skin phototypes. It is a promising approach that can be implemented on an international scale

JAK3 as an emerging target for topical treatment of inflammatory skin diseases

The recent interest and elucidation of the JAK/STAT signaling pathway created new targets for the treatment of inflammatory skin diseases (ISDs). JAK inhibitors in oral and topical formulations have shown beneficial results in psoriasis and alopecia areata. Patients suffering from other ISDs might also benefit from JAK inhibition. Given the development of specific JAK inhibitors, the expression patterns of JAKs in different ISDs needs to be clarified. We aimed to analyze the expression of JAK/STAT family members in a set of prevalent ISDs: psoriasis, lichen planus (LP), cutaneous lupus erythematosus (CLE), atopic dermatitis (AD), pyoderma gangrenosum (PG) and alopecia areata (AA) versus healthy controls for (p) JAK1, (p) JAK2, (p) JAK3, (p) TYK2, pSTAT1, pSTAT2 and pSTAT3. The epidermis carried in all ISDs, except for CLE, a strong JAK3 signature. The dermal infiltrate showed a more diverse expression pattern. JAK1, JAK2 and JAK3 were significantly overexpressed in PG and AD suggesting the need for pan-JAK inhibitors. In contrast, psoriasis and LP showed only JAK1 and JAK3 upregulation, while AA and CLE were characterized by a single dermal JAK signal (pJAK3 and pJAK1, respectively). This indicates that the latter diseases may benefit from more targeted JAK inhibitors. Our in vitro keratinocyte psoriasis model displayed reversal of the psoriatic JAK profile following tofacitinib treatment. This direct interaction with keratinocytes may decrease the need for deep skin penetration of topical JAK inhibitors in order to exert its effects on dermal immune cells. In conclusion, these results point to the important contribution of the JAK/STAT pathway in several ISDs. Considering the epidermal JAK3 expression levels, great interest should go to the investigation of topical JAK3 inhibitors as therapeutic option of ISDs

Comparison of personality traits among patients with psoriasis, atopic dermatitis, and stress: a pilot study

Background: Psoriasis and atopic dermatitis are chronic skin diseases that greatly affect the quality of life. Both diseases can be triggered or exacerbated by stress. Objective: We aimed to differentiate personality traits between patients with chronic skin conditions and people treated for stress in a pilot study. Methods: Patients participating voluntarily in educational programs in Belgium and Switzerland were recruited to complete personality trait questionnaires, including the Temperament and Character Inventory (TCI) and the Tridimensional Personality Questionnaire (TPQ). A comparison was made with patients treated for work-related stress. Results: A total of 48 and 91 patients suffering from skin diseases and work-related stress, respectively, were included in the study. Based on the questionnaires, we found that dermatology patients were less persistent and impulsive than those with work-related stress. Dermatology patients also exhibited more rigidness and less focus on performance. Finally, patients with work-related stress seem more likely to change in response to health-promoting programs than patients with chronic dermatoses. Conclusion: Patients with chronic skin diseases may perceive and cope with stress differently in comparison to patients with work-related stress due to inherent personality traits. Therefore, stress coping mechanisms may differ among different diseases. More research is needed into the design of educational interventions and the impact of personality traits in disease-specific groups

Learning from success and failure: biologics for non-approved skin diseases

The impressive potential of biologics has been demonstrated in psoriasis, hidradenitis suppurativa, and urticaria. Numerous biologicals are entering the field for a restricted number of skin disorders. Off-label use of biologics in other recalcitrant skin diseases has increased. Mounting data point to the potential of already existing biologics acting on the IL-17/IL-23 pathway in skin disorders with epidermal hyperkeratosis (e.g., pityriasis rubra pilaris), acneiform inflammation (e.g., hidradenitis suppurativa), and loss of mucosal integrity (e.g., aphthosis). TNF-alpha blockers are also effective in the latter conditions but seem of particular value in granulomatous (e.g., granuloma annulare) and neutrophilic disorders (e.g., pyoderma gangrenosum). Failure of IL-17 blockade in skin diseases resulting from immune-mediated cell destruction (e.g., alopecia areata and vitiligo) illustrates its limited involvement in Th1-dependent skin immunology. Overall, disappointing results of TNF-alpha blockers in alopecia areata and vitiligo point to the same conclusion although promising results in toxic epidermal necrolysis suggest TNF-alpha exerts at least some in vivo Th1-related activities. Acting on both the Th1 and Th17 pathway, ustekinumab has a rather broad potential with interesting results in lupus and alopecia areata. The efficacy of omalizumab in bullous pemphigoid has revealed an IgE-mediated recruitment of eosinophils leading to bullae formation. Reconsidering reimbursement criteria for less common but severe diseases seems appropriate if substantial evidence is available (e.g., pityriasis rubra pilaris). For other disorders, investigator-and industry-initiated randomized clinical trials should be stimulated. They are likely to improve patient outcome and advance our understanding of challenging skin disorders

Current and emerging therapy for the management of vitiligo

Vitiligo is an acquired cutaneous disorder of pigmentation, with an incidence of 0.5% to 2% worldwide. There are three major hypotheses for the pathogenesis of vitiligo that are not exclusive of each other: biochemical/cytotoxic, neural and autoimmune. Recent data provide strong evidence supporting an autoimmune pathogenesis of vitiligo. As vitiligo can have a major effect on quality of life, treatment can be considered and should preferably begin early when the disease is active. Current treatment modalities are directed towards stopping progression of the disease and achieving repigmentation. Therapies include corticosteroids, topical immunomodulators, photo(chemo)therapy, surgery, combination therapies and depigmentation of normally pigmented skin. Topical class 3 corticosteroids can be used for localized vitiligo. The use of topical immunomodulators (TIMs) in vitiligo seems to be equally effective as topical steroids, especially when used in the face and neck region. In photo(chemo)therapy, narrowband ultraviolet-B therapy (NB-UVB) seems to be superior to psoralen ultraviolet-A therapy (PUVA) and broadband UVB. In surgical techniques, split-thickness grafting and epidermal blister grafting were shown to be effective methods, although the non-cultured epidermal suspension technique has many advantages and seems to be a promising development. Depigmentation therapy can be considered if vitiligo affects more than 60% to 80% of the body. Complementary therapies such as Polypodium leucotomos show promising results in combination with UVB therapy. No causative treatment for vitiligo is currently available. More randomized controlled trials on the treatment of vitiligo are necessary