To the Editor: Secukinumab, an interleukin 17A inhibitor approved for the treatment of moderate-tosevere plaque psoriasis, has shown high levels of clinical efficacy and a favorable safety profile in both short-term and long-term clinical trials. However, in some studies in the real-life setting, secukinumab showed a 73%-78% drug survival at 12 months, shorter than that of other biologic agents, even among biologic-naive patients, and loss of effectiveness was the most common reason for discontinuation. 1-4 To evaluate drug survival of secukinumab in a daily practice setting, we retrospectively evaluated all psoriatic patients starting secukinumab during January 2016-February 2017 at 11 centers in 3 European countries and followed them until February 2018 (potentially with at least 1 year of observation period). Failure was defined as stopping secukinumab definitively or switching to a different therapy. Drug survival was analyzed using KaplaneMeier methodology. A total of 330 patients were included. Their median 6 standard deviation age was 51.9 6 14.6 years, 68% were male, and 19.6% were obese (body mass index [BMI] $30 kg/m 2); 21.5% of patients had a diagnosis of psoriatic arthritis, and 52.4% were biologic-experienced (24.5% with $2 prior biologics). All patients were treated with the 300-mg label dose, and there was no dose adjustment throughout the treatment. Concomitant systemic therapy was used in 12% of patients (mostly methotrexate). Overall drug survival of secukinumab was 83% after 12 months and 78.8% after 18 months (Fig 1, A). The dropout rate at 18 months was 20%: 12.4% of patients were lost to follow-up, 6.7% of patients stopped because of drug ineffectiveness, 0.3% of patients discontinued because of adverse events, and 0.6% of patients decided to quit the drug. Drug survival rates at 12 and 18 months were lower for biologic-experienced than biologic-naive patients (Fig 1, B) and lower in obese than nonobese patients. Patients treated with concomitant systemic therapies also showed a lower drug survival rate than those treated with secukinumab monotherapy at 12 months (79.5% vs 94.2%, respectively) and 18 months (53.7% vs 81.8%, respectively). Univariate Cox regression analysis of drug survival determinants showed that prior use of [1

four of them) or by RCM alone (evaluation performed by six of them) 1 year before and results were compared with the previous study. Mean sensitivity, specificity and overall diagnostic accuracy (ACC) and 95% CI were calculated for the specific diagnosis of different facial lesions (Table 1). As expected, considering the evaluation of the seven experts, the combination dermoscopy/RCM had a higher mean ACC for both malignant tumour (including LM/LMM) and LM/LMM of the face (84%, CI 80-89 and 84%, CI 79-89, respectively) than the two imaging techniques alone (74%, CI 68-80 for dermoscopy vs. 80%, CI 75-85 for RCM in case of LM/LMM and 75%, CI 68-80 for dermoscopy vs. 80%, CI 74-85 for RCM in case of malignant tumour). Notably, ACC increased for each investigator. The superiority of the ACC of the combination dermoscopy/RCM on the single imaging techniques for LM/LMM was also observed when comparing the current data to the results obtained in the previous study by all the 21 investigators. Considering all evaluations, the ACC increased from dermoscopy to RCM and to dermoscopy plus RCM. According to the CI, the combination dermoscopy/RCM improved both mean sensitivity and mean specificity of RCM alone for LM/LMM, whereas it highly improved mean sensitivity of dermoscopy alone but not its mean specificity (sensitivity of 65% CI 57-73, 82% CI 76-89 and 85% CI 80-91 and specificity of 88% CI 82-95, 77% CI 68-86 and 83% CI 75-91 for dermoscopy, RCM, and dermoscopy plus RCM, respectively). As already discussed, this fact was probably related to the presence of hyper-reflective dendritic Langerhans cells under RCM mistaken for neoplastic melanocytes in the epidermis of most misdiagnosed benign lesions. 9 Concerning the facial lesions other than LM/LMM, we also observed an increase in ACC with the combination dermoscopy/RCM (Table 1). In conclusion, this study shows that the integration of dermoscopy and RCM increases the ACC of both these techniques used alone for facial tumours. More in-depth studies should be carried out, even using machine learning techniques, for optimal integration of dermoscopic data with RCM data, in order to increase ACC by reducing possible false positives induced by the RCM examination. This study received the approval from the Ethical Committee of the University Hospital of Saint-Etienne (Institutional review board number 672016/CHUSTE).

Torres (2020) Secukinumab demonstrates improvements in absolute and relative psoriasis area severity indices in moderate-to-severe plaque psoriasis: results from a European, multicentric, retrospective, real-world study,

Background Knowledge regarding differences in care for psoriatic patients is limited. The aim of this study was to investigate factors influencing prescription of systemic treatments for patients with psoriasis with a special focus on socioeconomic factors.

Psoriasis is a multi-systemic chronic inflammatory disease that affects about 1.5-3% of the general population, of which almost 20% suffer from a moderate-severe form. Those patients can be treated with a systemic agent and in case of scarce response or contraindications, they may require a biologic therapy, such as tumor necrosis factor or interleukin-12/23 inhibitors. When also these agents fail, clinicians face a true therapeutic challenge. We report a case series of multi-failure 16 patients, successfully treated with secukinumab, a human monoclonal antibody that selectively neutralizes interleukin-17 A and is recently approved for the treatment of plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis.