Faculty Bibliography

Background: Despite their impressive efficacy in phase 3 trials, biologic agents for psoriasis (PsO) may lose efficacy over time. The factors associated with loss of efficacy have yet to be fully elucidated. Objective: We aimed to identify factors associated with PsO patients using multiple biologics in comparison to patients who used 1 biologic. We also reviewed the literature comparing the survival of different biologic agents for PsO. Methods: We examined clinical data from 222 psoriasis patients at the University of California San Francisco, of whom 51 reported use of 3 or more biologics and of whom 171 reported use of only a single biologic agent at the time of enrollment into a research database from 2006-2020. This study was IRB-approved at UCSF (#10-02830) and all subjects provided written informed consent. We performed univariate and multivariate regression analysis to identify significant demographic features, clinical features, and co-morbidities associated with multi-biologic use. We performed a literature review of studies comparing psoriasis biologic survival at 1, 2, and 5 years and factors associated with single biologic failure. Results: In univariate analysis, duration of PsO, initial presentation of PsO on the gluteal cleft, erythrodermic psoriasis, and acne were associated with using 3 or more biologics. In multivariate analysis, duration of PsO, erythrodermic psoriasis, and acne remained significant. Our review of biologic survival revealed differences according to biologic class. Conclusion: We identified novel factors associated with multi-biologic use in PsO. Further studies in this area are needed to achieve a precision medicine approach.

OBJECTIVE:To examine the association of biologic therapy use for psoriasis with incident psoriatic arthritis (PsA) diagnosis. METHODS:A retrospective cohort study was conducted in the OptumInsights Electronic Health Record Database between 2006 and 2017 among patients with psoriasis between the ages of 16 and 90 initiating a therapy for psoriasis (oral, biologic or phototherapy). The incidence of PsA was calculated within each therapy group. Multivariable Cox models were used to calculate the HR for biologic versus oral or phototherapy using biologics as a time-varying exposure and next in a propensity score-matched cohort. RESULTS:Among 1 93 709 patients with psoriasis without PsA, 14 569 biologic and 20 321 cumulative oral therapy and phototherapy initiations were identified. Mean age was lower among biologic initiators compared with oral/phototherapy initiators (45.9 vs 49.8). The incidence of PsA regardless of therapy exposure was 9.75 per 1000 person-years compared with 77.26 among biologic users, 61.99 among oral therapy users, 26.11 among phototherapy users and 5.85 among those without a prescription for one of the target therapies. Using a multivariable adjustment approach with time-varying exposure, adjusted HR (95% CI) for biologic users was 4.48 (4.23 to 4.75) compared with oral or phototherapy users. After propensity score matching, the HR (95% CI) was 2.14 (2.00 to 2.28). CONCLUSIONS:In this retrospective cohort study, biologic use was associated with the development of PsA among patients with psoriasis. This may be related to confounding by indication and protopathic bias. Prospective studies are needed to address this important question.

Cutaneous T cell lymphoma (CTCL) is a heterogeneous group of mature T cell neoplasms characterized by the accumulation of clonal malignant CD4+ T cells in the skin. The most common variant of CTCL, Mycosis Fungoides, is confined to the skin in early stages but can be accompanied by extracutaneous dissemination of malignant T cells to the blood and lymph nodes in advanced stages of disease. Sézary Syndrome, a leukemic form of disease is characterized by significant blood involvement. Little is known about the transcriptional and genomic relationship between skin and blood residing malignant T cells in CTCL. To identify and interrogate malignant clones in matched skin and blood from leukemic MF and SS patients, we combine T cell receptor clonotyping, with quantification of gene expression and cell surface markers at the single cell level. Our data reveals clonal evolution at a transcriptional and genetic level within the malignant populations of individual patients. We highlight highly consistent transcriptional signatures delineating skin-derived and blood-derived malignant T cells. Analysis of these two populations suggests that environmental cues, along with genetic aberrations, contribute to transcriptional profiles of malignant T cells. Our findings indicate that the skin microenvironment in CTCL promotes a transcriptional response supporting rapid malignant expansion, as opposed to the quiescent state observed in the blood, potentially influencing efficacy of therapies. These results provide insight into tissue-specific characteristics of cancerous cells and underscore the need to address the patients' individual malignant profiles at the time of therapy to eliminate all sub-clones.

Following the pivotal manuscript that outlined unique disease features half a century ago, investigators in the field of psoriatic arthritis (PsA) have extrapolated clinical trial data and molecular insights from the more expansive experience in rheumatoid arthritis (RA). As a result, many of the diagnostic approaches, imaging modalities, therapeutics and outcome measures paralleled (and at times became identical to) those developed for RA.

Psoriasis is a chronic inflammatory condition characterized by systemic immune dysregulation. Over the past several years, advances in genetics, microbiology, immunology, and mouse models have revealed the complex interplay between the heritable and microenvironmental factors that drive the development of psoriatic inflammation. In the first of this two-part review series, the authors will discuss the newest insights into the pathogenesis of psoriatic disease and highlight how the evolution of these scientific fields has paved the way for a more personalized approach to psoriatic disease treatment.

Background/Purpose: Psoriasis (PsO) is an inflammatory, immune-mediated skin disorder affecting ~3% of the population worldwide. It is associated with multiple comorbidities, including psoriatic arthritis (PsA), which occurs in up to a third of patients. While genes contribute to the pathogenesis of psoriatic disease, twin studies demonstrate substantial discordance in PsO and PsA, suggesting that epigenetics and environmental factors play a significant role. In fact, there is increasing evidence that the microbiome has an impact on psoriatic disease pathogenesis. However, prior investigations were performed in populations of unrelated individuals and could not discern environmental from genetic influences. To characterize the host-microbiome relationship, we studied the gut and skin microbiome of monozygotic (MZ) twins discordant for psoriatic disease in order to determine disease-specific microbial perturbations that are independent of host-genes.
Method(s): Stool and skin swabs were collected from subjects with psoriatic disease and their unaffected MZ twin siblings (pairs=9, n=18). Non-lesional (NL) or healthy skin was swabbed at three separate sites: bicep, scalp, and elbow/forearm. Fecal samples underwent shotgun metagenomic sequencing to deeply characterize the gut microbiome taxonomy and functional pathways at high resolution. Sequences were processed with the HUMAnN and MetaPhlAn2 pipelines. Skin swab samples underwent 16S rRNA sequencing to characterize the cutaneous bacterial microbiome. Forward sequences were processed with the QIIME2 pipeline and SILVA reference database. Downstream computational analysis was performed using several libraries in R, including DESeq2.
Result(s): In gut samples, the relative abundance of Ruminococcus bromii species was significantly reduced and two pathways related to tetrahydrofolate biosynthesis were upregulated in psoriatic twins compared to their corresponding unaffected siblings (Fig 1; p< 0.05, Mann-Whitney). In NL skin samples from psoriatic twins, there was a significant reduction in alpha diversity and beta diversity differences in microbial communities of the scalp, but not the bicep or elbow/forearm, compared to healthy samples from unaffected twins (Fig 2A-B; p< 0.05, Mann-Whitney and Permanova). Differential analysis of taxa in the scalp identified a higher abundance of the Bacillales order and related taxa, as well as a lower abundance of the Deinococcus genus and related taxa in psoriatic twins compared to their unaffected siblings (Fig 2C; p< 0.05 with FDR correction).
Conclusion(s): This is the first study exploring microbial differences in MZ twins discordant for psoriatic disease. In agreement with our previous results, we found that Ruminococcus is reduced or virtually absent in the gut of psoriatic patients, and may therefore be associated with psoriatic disease. Additionally, we discovered that even healthyappearing NL skin of psoriatic subjects, particularly in the scalp, exhibited microbial perturbations and decreased diversity compared to unaffected twins. A further understanding of these changes and their downstream effects should shed light into the pathogenesis of psoriatic disease beyond genetic susceptibility

Background/Purpose: Patients with immune mediated inflammatory disorders (IMIDs) have an inherently heightened susceptibility to infection and may be considered high risk for developing COVID-19. While data regarding the COVID-19 vaccine's immunogenicity in an immunocompetent adult population is rapidly emerging, the ability of IMID patients to adequately respond to these vaccines is not known. Here, we investigate the humoral and cellular immune response to mRNA COVID-19 vaccines in patients with IMIDs on immunomodulatory treatment Methods: Patients with immune mediated inflammatory disorders (IMIDs) have an inherently heightened susceptibility to infection and may be considered high risk for developing COVID-19. While data regarding the COVID-19 vaccine's immunogenicity in an immunocompetent adult population is rapidly emerging, the ability of IMID patients to adequately respond to these vaccines is not known. Here, we investigate the humoral and cellular immune response to mRNA COVID-19 vaccines in patients with IMIDs on immunomodulatory treatment.
Result(s): The NY cohort baseline characteristics are found in Table 1. The Erlangen cohort consisted of 182 healthy subjects, 11 subjects with IMID receiving TNFi monotherapy, and 20 subjects with IMID on MTX monotherapy. In both cohorts, healthy individuals and those with IMID not on MTX were similar in age, while those IMID patients receiving MTX were generally older. In the NY cohort, of the healthy participants, 96.3% demonstrated adequate humoral immune response. Patients with IMID not on MTX achieved a similar rate of high antibody response rate (91.8%), while those on MTX had a lower rate of adequate humoral response (75.0%) (Figure 1A). This remains true even after the exclusion of patients who had evidence of prior COVID-19 infection (P= 0.014). Of note, 3 out of the 4 IMID patients receiving rituximab did not produce an adequate response. Similarly, in the Erlangen validation cohort, 98.3% of healthy controls, 90.9% of patients with IMID receiving TNFi monotherapy, and 50.0% receiving MTX monotherapy achieved adequate immunogenicity (Figure 1B). These differences remain significant when combining the cohorts, using a stricter definition of adequate response, and in a subgroup analysis by age. Cellular response was also analyzed in a subgroup of the NY cohort before and after second vaccination. Activated CD8+ T cells (CD8+ T cells expressing Ki67 and CD38) and the granzyme B-producing subset of these activated CD8+ T cells, were induced in immunocompetent adults and those with IMID not on MTX, but not induced in patients receiving MTX (Figure 2).
Conclusion(s): In two independent cohorts of IMID patients, MTX, a widely used immunomodulator for the treatment of several IMIDs, adversely affected humoral and cellular immune response to COVID-19 mRNA vaccines. Although precise cut offs for immunogenicity that correlate with vaccine efficacy are yet to be established, our findings suggest that different strategies may need to be explored in patients with IMID taking MTX to increase the chances of immunization efficacy against SARS-CoV-2, as has been demonstrated for other viral vaccines