The edition · Dermatology
PASI 90 becomes the target, not the bonus
A new national psoriasis guideline makes near-clearance the primary goal and moves children onto biologics early. Also: six randomised trials fail to show any drug beats placebo in cutaneous sarcoidosis, two-thirds of children on insulin pumps have a skin complication, and a mixed psoriasis-eczema phenotype that responds to JAK1 inhibition after biologics have failed.
The edition in brief
Updated Saudi national guidelines on moderate-to-severe plaque psoriasis used GRADE methodology across 31 PICO questions and a literature search from 2020 to 2026, producing 27 recommendations and 4 good-practice statements. They strongly recommend PASI 90 rather than PASI 75 as the primary treatment target. For adults they recommend IL-17, IL-23, IL-12/23 and TNF-alpha inhibitors; for children they recommend early initiation of biologic therapy, naming etanercept, secukinumab, ixekizumab and adalimumab. A meta-analysis of six randomised placebo-controlled trials in cutaneous sarcoidosis, totalling 156 participants, found pharmacological therapy did not significantly improve clinical response (OR 2.24, 95% CI 0.73-6.90, p = 0.16). Quality of life showed a non-significant trend (OR 2.23, 0.87-5.73, p = 0.09) and serious adverse events did not differ (OR 0.97, 0.48-1.96). Risk of bias was moderate to high with low statistical heterogeneity. A meta-analysis of insulin-pump-related skin complications in children and adolescents with type 1 diabetes pooled five studies and 796 participants: any skin complication 63.8% (95% CI 47.8-77.2, I-squared 92.1%), scarring or insertion marks 36.7%, lipohypertrophy 24.1%, eczema or dermatitis-like reactions 16.6%, infection or folliculitis 8.6%, lipoatrophy 5.1%. A two-centre prospective study of 30 adults with overlapping psoriasis and atopic dermatitis found combined type 2 and type 3 immune activation in skin and blood with JAK1-STAT2/6 signalling. Responses to psoriasis-targeted (18 patients) and atopic dermatitis-targeted (15 patients) biologics were often inadequate, while JAK1 inhibitors achieved minimal disease activity over a median 17 months.
A national psoriasis guideline sets PASI 90 as the goal and puts children on biologics sooner
Adopt PASI 90 as the primary target in moderate-to-severe psoriasis — patients sitting between PASI 75 and 90 are no longer adequately treated — and consider biologics early in children rather than after conventional systemics.
Cutaneous sarcoidosis: six trials, 156 patients, and nothing beats placebo
Across six randomised trials and 156 patients, add-on pharmacological therapy for cutaneous sarcoidosis did not significantly beat placebo (OR 2.24, 95% CI 0.73 to 6.90) — treat, but with a stated review point and honesty about the evidence.
Two-thirds of children on insulin pumps have a skin problem
Around two-thirds of children using insulin pumps have a skin complication and a quarter have lipohypertrophy — examine the sites at every review, and think of the site before blaming adherence for erratic glucose control.
When a rash will not decide what it is
Ill-defined plaques with thin scale, excoriation and disproportionate itch may be a genuine overlap rather than an atypical presentation — record the ambiguity instead of forcing a label, because the label drives the drug.
The psoriasis-eczema overlap phenotype, and why JAK1 inhibition works where biologics did not
In adults with mixed psoriasis-eczema features and dual type 2 and type 3 inflammation, JAK1 inhibitors achieved minimal disease activity over a median 17 months where axis-specific biologics had failed — uncontrolled data in 30 patients, but a better reasoning path than trying another biologic.
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