Background: Limited real-world data are available on upadacitinib drug survival in patients with atopic dermatitis (AD). Objectives: To investigate upadacitinib drug survival, and the reasons and predictors of drug discontinuation in AD patients. Methods: All consecutive patients aged 18–75 years, affected by moderate-to-severe AD, and treated with upadacitinib for more than 1 month at dermatological clinics were included during November 2020–August 2023. Upadacitinib survival was investigated through Kaplan–Meier survival analysis and the predictors through multivariable logistic regression analysis. Results: Overall, 325 adult AD patients (mean (SD) age, 38.6(15.6) years) had a 1-year and 1.5-year upadacitinib drug survival of 91.5% and 80.2%, respectively. The main reasons for drug discontinuation (25/325, 7.7%) were adverse events (4.9%), including cutaneous or infectious diseases (1.5%), such as acne and herpes zoster; blood test changes (1.2%), including hypercholesterolemia, creatine phosphokinase or liver enzyme elevation, and lymphopenia; urinary or respiratory infections (0.9%); deep venous thrombosis (0.3%); malignancies (0.3%); loss of consciousness (0.3%); and arthralgias (0.3%); followed by ineffectiveness (0.6%). No specific characteristic was significantly associated with an increased risk of upadacitinib discontinuation. Conclusions: Our findings show that upadacitinib was effective in moderate-to-severe AD after more than 1 year of continuous treatment but point to the need for clinical and laboratory monitoring of patients.

Scleromyxedema (SMX), the generalized and sclerodermic form of lichen myxedematous (LM), is a chronic mucinosis characterized by cutaneous manifestation and several systemic comorbidities. Treatment options are limited and there are no definitive therapeutic guidelines. We report a case of a 48-year-old man with scleromyxedema, associated with monoclonal gammopathy and arthritis, who has been successfully treated with intravenous immunoglobulins (IVIg), oral corticosteroids, and methotrexate (MTX). IVIg is the most used first-line therapy for SMX based on its efficacy and well-tolerated nature and has been used for a growing number of skin disorders. In our case, combining IVIg with oral prednisone and MTX allowed better control of skin disease and extra-cutaneous manifestations. To the best of our knowledge, this is the first case of a successful treatment for SMX with a combination of therapeutic strategies and a good safety profile.

Background/Objectives: Patients with a clinical diagnosis of severe psoriasis complicated by comorbidities such as cardiovascular disease, obesity, metabolic syndrome and/or with the involvement of high-impact areas constitute a clinical challenge. Tildrakizumab is a monoclonal antibody targeting the IL-23/Th17 axis with a proven record of efficacy and safety in these patients. Methods: Here we present four cases of patients with severe psoriasis and comorbidities including cardiovascular disease (Case 1), obesity (Cases 2 and 3), metabolic syndrome (Case 3), and/or high-impact areas (Cases 2–4). Three patients (Cases 1–3) had previously received biologics but developed secondary failure or loss of efficacy; one patient was bio-naïve (Case 4). Results: The treatment with tildrakizumab in all four patients led to a quick onset (by Week 4 in all cases) of complete and lasting (1 year in Case 1, 4 years in Case 2 and 2 years in Cases 3 and 4) remission with no adverse events reported. Conclusions: Tildrakizumab is a valuable therapeutic option for patients with psoriasis and complex clinical situations, and in particular, in cases with obesity and difficult-to-treat lesion locations such as hands, scalp and genitals. Therapeutic success is often linked to an improvement in patients’ quality of life.

Background/Objectives: Palmoplantar psoriasis (PP) is a challenging variant of psoriasis that affects high-impact areas such as palms and soles and significantly impairs quality of life despite often limited body surface involvement. Conventional topical and systemic therapies may be insufficient, and evidence on biologic treatments for this specific phenotype remains limited. Bimekizumab (BKZ), a monoclonal antibody targeting IL-17A and IL-17F, has shown high efficacy in plaque psoriasis. This study aimed to evaluate the real-world effectiveness and rapidity of action of BKZ in patients with palmoplantar psoriasis compared with patients with psoriasis vulgaris (PV). Methods: We conducted a multicenter retrospective cohort study using data from 22 Italian dermatological units within the IL-PSO (Italian Landscape-Psoriasis) database. Adult patients treated with BKZ between November 2022 and October 2024 were included and categorized into three groups: isolated PP, PP associated with PV (PP + PV), and PV without palmoplantar involvement. Clinical outcomes included the Psoriasis Area and Severity Index (PASI), Dermatology Life Quality Index (DLQI), and pruritus Visual Analogue Scale (VAS). Outcomes were assessed at baseline, week 4, and week 16. Results: A total of 47 patients were included. The baseline PASI was lower in the PP group compared with the PP + PV and PV groups, whereas the DLQI was highest in patients with isolated PP. Rapid clinical improvement was observed in all groups. The mean % PASI reduction at week 4 was 60.5%, 65.1%, and 77.0% in the PP, PP + PV, and PV groups, respectively, increasing to 94.8%, 90.4%, and 91.8% at week 16. The proportion of patients achieving complete clearance (PASI = 0) at week 16 was 73.3% (11/15), 68.2% (15/22), and 70.0% (7/10), respectively. Significant improvements were also observed in DLQI and pruritus scores over time. No significant safety concerns emerged. Conclusions: In this real-world multicenter cohort, bimekizumab demonstrated rapid and high efficacy in patients with palmoplantar psoriasis, both isolated and associated with psoriasis vulgaris. These findings support the use of BKZ as an effective therapeutic option for psoriasis involving high-impact areas, as the palmoplantar, although larger studies are needed to confirm these results.

Dear Editor, Hidradenitis suppurativa (HS) is a chronic inflammatory disease of the folliculoapocrine units. Biological therapies, historically led by the anti-tumor necrosis factor (TNF)-α antibody adalimumab, have transformed severe HS management. Recently, interleukin (IL)-17 inhibitors (secukinumab, bimekizumab) were also approved in Europe for moderate-to-severe HS. However, TNF-α blockade can paradoxically induce or exacerbate inflammatory skin and joint conditions, including psoriasis (incidence 1-5%) and psoriatic arthritis. We report a case of paradoxical inverse psoriasis and suspected early psoriatic arthritis induced by adalimumab in an HS patient, successfully managed by switching to secukinumab.

Background/Objectives: Patients with severe psoriasis complicated by comorbidities such as cardiovascular disease, obesity, metabolic syndrome and/or with the involvement of high-impact areas constitute a clinical challenge. Tildrakizumab is a monoclonal antibody targeting the IL-23/Th17 axis with a proven record of efficacy and safety in these patients. Case presentation: Here we present four cases of patients with severe psoriasis and comorbidities including cardiovascular disease (Case 1), obesity (Case 2 and 3), metabolic syndrome (Case 3), and/or high-impact areas (Cases 2-4). Three patients (Cases 1-3) had previously received biologics but developed secondary failure or loss of efficacy; one patient was bio-naïve (Case 4). The treatment with tildrakizumab in all four patients led to a quick onset of complete and lasting remission with no adverse events reported. Conclusions: Tildrakizumab is a valuable therapeutic option for patients with psoriasis and complex clinical situations, and in particular, in cases with obesity and difficult-to-treat lesion location. Therapeutic success is often linked to an improvement in patient’s quality of life.