Recently, it has emerged a strong association between increased adiposity, obesity, and psoriasis. Body Mass Index (BMI) is a simple index of weight-for-height that is commonly used to classify underweight, overweight and obesity in adults. Psoriasis has also been associated with systemic obesity-related disorders including type 2 diabetes, hypertension, ischemic heart disease, and combined hyperlipidemia, as a part of metabolic syndrome. Not only the obesity may be associated with higher psoriasis incidence and activity, and prevalence of obesity-related syndromes, but it may also influence the therapeutic approach to disease and the clinical response to systemic treatment. Consequently, the approach of the experienced dermatologist will take into account all the aspects of the patient clinical conditions including the analysis of BMI for the choice of the best suitable therapy.

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Erythrodermic psoriasis treated with ustekinumab: An Italian multicenter retrospective analysis Dear Editor, Erythrodermic psoriasis (EP) is one of the most severe cutaneous conditions which may lead to serious morbidity and even mortality. This condition is often difficult to manage and, due to its rarity (estimated prevalence 1-2.25% of psoriatic patients) there is a lack of high-quality medical literature examining treatment options [1]. Data on the use of biologics in EP are very sparse because erythroderma represented exclusion criteria in all the main studies investigating biologics efficacy and safety in psoriasis [1,2]. Until now only two retrospective studies have tried to assess the efficacy and safety of anti-TNF-a in EP with promising results [3,4]. Here we report the results from a multicenter, retrospective analysis of patients with EP treated with ustekinumab in 9 Italian Dermatology Hospital Departments. Data of 22 patients with EP (defined as a generalized, inflammatory erythematous dermatosis, with or without associated exfoliation lasting for at least 3 months involving at least 75% of the body surface area, with the characteristic clinical and/or histological features of psoriasis and the exclusion of the other main differential diagnoses for erythroderma) [1], treated with ustekinumab between February 2010 and July 2014, were included. Each patient has been evaluated with the Psoriasis Area and Severity Index (PASI), before and after 4, 16 and 28 weeks of treatment. Baseline characteristics of the study population are summarized in Table 1. 19 patients have a positive personal history of plaque type psoriasis while 3 experienced erythroderma since the beginning of the disease. In the latter cases diagnosis of EP was made excluding other possible causes of erythroderma. Patients received ustekinumab at weeks 0, 4 and then every 12 weeks. 16 patients (weighting 100 kg) received ustekinumab 45 mg while 6 (weighting >100 kg) 90 mg.

Nail psoriasis is common in adult psoriatic patients. Although several new drugs have recently been introduced for the treatment of skin psoriasis, treatment of nail psoriasis still remains a challenge. Topical treatments (e.g., corticosteroids, tazarotene, 5-fluorouracil, calcipotriol) are the first line in the management of skin psoriasis. The efficacy of these drugs in nail disease, however, is limited, mainly due to the difficulty in penetrating the nail bed and nail matrix. In cases of nail disease resistant to topical treatment, methotrexate, ciclosporin, acitretin, or biological agents can be used. The present authors introduce a 73-year-old patient affected by impressive psoriatic nail disease involving all her fingernails and toenails treated by acitretin, a traditional systemic treatment. After 2 months of treatment there was a marked improvement. The clinical improvement of the nails was progressive and 6 months later it was stable and satisfactory. The remarkable response to treatment in this case suggests that oral acitretin, in association to urea nail lacquer, might be useful in the management of disabling severe nail psoriasis even in absence of severe cutaneous involvement.

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