Several new biological agents have been introduced for the treatment of psoriasis in the last few years. These include alefaceft, efalizumab, and the anti-TNF agents etanercept, infliximab, and adalimumab. In a recent paper from Brimhall et al published in the August issue of the British Journal of Dermatology, the authors performed a metha-analysis on the safety and efficacy of all these agents (except adalumimab, that was not approved for this indication when the study was done). They searched for randomized, controlled, double-blind, monotherapy trials that had been done until July 2006 , and finally selected 16 studies including 7931 patients (5454 treatment and 2477 placebo patients): 3 trials of alefacept (n = 1289), 5 trials of efalizumab (n = 3130), 4 trials of etanercept (n = 2017) and 4 trials of infliximab (n = 1495).

They observed that the relative risk (compared with placebo) of PASI 75 achievement was, respectively, 4, 7, 12 and 19 for maintenance doses of alefacept, efalizumab, etanercept and infliximab. In addition, they calculated that the number needed to treat to obtain at least a patient with a PASI 75 improvement was 8 for alefacept, 4 for efalizumab, 3 for etanercept, and 2 for infliximab. Therefore they found that the efficacy of these treatments was in decreasing order of rank: infliximab, etanercept, efalizumab and alefacept. The authors stress that these were not head to head trials, and therefore future studies will add more information on these data of efficacy.

When dealing with safety the authors found that there was a statistically significant increased risk of adverse events (compared with placebo) with alefacept (9% more), efalizumab (15% more), and infliximab (18% more). Common adverse events with with alefaceft were pharyngitis, chills and headache. Severe adverse events were uncommon, but they found coronary artery disorder (n = 4), cellulitis (n = 3) and myocardial infarction (n = 3). For efaluzimab they found that common adverse events were headaches, infection and chills. Severe adverse events from efaluzimab reported in FDA reviews included hospitalization for psoriasis flare (n = 17), serious infection (n = 7), and thrombocytopenia (n = 5). Etanercept common adverse events included injection-site reaction, headache and upper respiratory tract infection. The most common severe adverse events in etanercept treated patients were malignancy (n = 10), serious infection (n = 4) and worsening psoriasis (n = 3). Infliximab common adverse events were upper respiratory tract infection, headache, increased hepatic enzymes and infection. Some of the most common severe adverse events reported with infliximab were malignancy (n = 12), serious infection (n = 6), serious infusion reaction (n = 4) and lupus-like syndrome (n = 4). The authors calculated that the number needed to harm (this is the total number of patients that had to be treated to get any adverse event) was 15 for alefacept, 9 for efalizumab, 46 for etanercept, and 9 for infliximab. Therefore they found that the safety of these treatments was in decreasing order of rank: etanercept, alefacept, efalizumab, and infliximab.

Limitations of this study include that it has been done on a short term treatment basis (most are only 12 weeks), and that there is a short follow-up for adverse events (10–30 weeks). It is based on clinical trials and does not fully reflect ‘real life’ treatments.

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Several factors have been traditionally described as triggers of psoriasis. These include among others stress, infections, trauma, alcohol consumption, and drugs. Among these the most frequently cited in the literature are beta-blockers, angiotensin-converting
enzyme inhibitors, antimalarials, nonsteroidal anti-inflammatory drugs, lithium, as well as withdrawal of systemic steroids.

To explore the potential association between the risks of developing psoriasis for the first time with the intake of beta-blockers or other antihypertensive drugs a group from Switzerland performed a large case-control study that was recently published in the British Journal of Dermatology. The authors used a large database from general practitioners in the U.K. They identified 36.702 patients who had been diagnosed of psoriasis for the first time between 1994 and 2005, and used the same number of matched controls. They assessed the exposure history for beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin II antagonists, calcium channel blockers, diuretics or clonidine.

The authors found that there was no increased risk of psoriasis among patients that used any of the antihypertensive medications. In relation to beta-blokers they found that current long-term use of these medications was associated with a relative risk estimate of 1,10 (95% CI 1,01–1,20). So, in conclusion this large study does not support that the use of beta-blocker may induce the development or trigger psoriasis. (more…)

A recent study published in the Journal of Infectious Diseases reveals that anal infection with human papillomavirus (HPV) is fequent among heterosexual men. Previous studies have shown that the prevalence of anal HPV infection can be more than 50% in heterosexual men with HIV infection and men who have sex with men.

The investigators (from several centers across the US) studied a cohort of 463 men aged 18-40, who reported having sex with a woman in the preceding year. These men completed a questionnaire, and were sampled for HPV DNA on genital and anal skin using PCR based techniques. When HPV was detected further genotyping was done.

241 of the men were excluded (if they acknowledged having had sex with men or had not been asked or had refused to answer questions about it.or did not answer the question). Of the 222 men that were finally included in the study anal HPV infection was found in 24.8% (n=55). Of these 55 men, 29.1% (n=16) had only an anal infection while most of them (70.9%, n= 39) had both an anal and another anatomical site (or semen) infection. Only nine men had warts (reported by clinician) at any site, and none had visible lesions at anal sites. Oncogenic HPV were found in 5.9% of men with anal infection, but in men with anal canal infection this rate rose up to 33.3%.

Risk factors associated with anal HPVinfection were the lifetime number of female sex partners and the frequency of sex with females during the preceding month.

In summary the data from this study show that about one in four heterosexual men can be infected by HPV and, that in many cases, these can be of the oncogenic subtypes. These data are important because many physicians do not consider anal HPV infection an important issue in heterosexual men or in men non-infected by the HIV. (more…)