Advancements in the immunopathogenesis of psoriasis have identified interleukin (IL)-23 and IL-17 as fundamental contributors in the immune pathways of the disease. Leveraging these promising therapeutic targets has led to the emergence of a number of anti-IL-23 and -17 biologic agents with the potential to treat multiple conditions with common underlying pathology. The unprecedented clinical efficacy of these agents in the treatment of psoriasis has paved way for their evaluation in diseases such as psoriatic arthritis, Crohn's disease, rheumatoid arthritis, in addition to other immune-mediated conditions. Here we review the IL-23/IL-17 immune pathways and discuss the key clinical and safety data of the anti-IL-23 and anti-IL-17 biologic agents in psoriasis and other immune-mediated diseases.A number of immune-mediated diseases, while being clinically distinct, do share similar underlying pathophysiologic processes driven by a common subset of central molecules; this offers the valuable opportunity to treat a number of these important conditions through a few specific mutual therapeutic targets. The recent discovery of the critical roles of interleukin (IL)-23 and IL-17 in the pathogenesis of psoriasis plus numerous other immune-mediated diseases has made these two cytokines key therapeutic targets for newly developed biologic agents. This review provides a brief discussion of the IL-23/IL-17 immune axis, and will present key clinical and safety data of the anti-IL-23 and anti-IL-17 biologic agents in the treatment of common immune-mediated inflammatory conditions. THE IL-23/IL-17 IMMUNE AXISThrough the excellent research over the last decade by immunopathologists (James Krueger and Frank Nestle), the spectrum of immune mediators (cytokines) in psoriasis and other immunemediated conditions has improved significantly. IL-23 plays a central role in T-cell-mediated responses and has been deemed a key promoter of immune-mediated conditions. Sharing a common p40 subunit with IL-12 and a unique p19 subunit, the IL-23 heterodimer promotes signaling through both the IL-23 receptor (IL-23R) and IL-12Rb1 subunit of the IL-12 receptor (IL-12R) (Figure 1

Despite great therapeutic advancements in psoriasis, four notable difficult-to-treat areas including the scalp, nails, intertriginous (including genitals), and palmoplantar regions, pose a challenge to both physicians and patients. Localized disease of these specific body regions inflicts a significant burden on patients' quality of life and requires an adequate selection of treatments. Areas covered: This manuscript discusses appropriate therapies and important treatment considerations for these difficult-to-treat areas based on the available clinical data from the literature. Expert opinion: Clinical trials assessing therapies for the difficult-to-treat areas have been inadequate. With the first biological clinical trial for genital psoriasis pending publication, it is with hope that other biological agents will be evaluated for region-specific psoriasis. A greater understanding of the genetic and immunologic aspects of regional psoriasis, as well as identification of unique biomarkers, will further guide management decisions. For example, the recent discovery of the IL-36 receptor gene for generalized pustular psoriasis may prove valuable for other forms of psoriasis. Ultimately, identification of the most beneficial treatments for each psoriasis subtype and difficult-to-treat area will provide patients with maximal quality of life.

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Ischemic stroke is a rare yet devastating complication that may occur following cardiothoracic surgery. Fibrinolytic treatment is contraindicated due to elevated risk for hemorrhage. Mechanical thrombectomy entails a catheterized approach wherein the thrombus is physically removed from the vessel without the use of fibrinolytics, minimizing the possibility of intracranial hemorrhage. Here, we present two original cases of mechanical thrombectomy as treatment for patients experiencing emergent large vessel occlusion following cardiothoracic surgery. A literature review was conducted to determine current treatment guidelines, risk factors, and complications resulting from recanalization due to mechanical thrombectomy versus fibrinolytic therapy. One patient was admitted due to chronic, American College of Cardiology/American Heart Association stage D, New York Heart Association functional class IV heart failure and required complete, artificial hemodynamic support for two weeks and on the 19th day experienced neurologic decline secondary to a supraclinoid left internal carotid artery (ICA) occlusion. Mechanical thrombectomy resulted in distal reperfusion and neurologic improvement. The second patient presented with coronary artery disease and underwent triple coronary artery bypass grafting and endovein harvesting. On post-operative day 2, the patient experienced a left ICA occlusion extending to the cavernous ICA resulting in speech impairment and right-sided weakness. The patient was heparinized and underwent mechanical thrombectomy, resulting in immediate speech and muscle strength recovery. Medical advances allow mechanical thrombectomy to be performed in a timely and effective manner at specialized treatment centers. It offers endovascular treatment modalities to a unique patient population with postoperative stroke. In such patients, thrombectomy can safely provide reperfusion while reducing the risk of complications associated with conventional thrombolytics.

We report the first case of an 82-year-old woman with five basal cell carcinomas within a large nevus sebaceous of the trunk. Nevus sebaceous of Jadassohn is a congenital cutaneous hamartoma affecting 0.3% of newborns. Clinical diagnosis is based on its distinctive hairless, orange-brown appearance. Up to 51% of nevus sebaceous may exhibit secondary neoplasia, and basal cell carcinoma is thought to occur in approximately 1% of lesions. Our patient presented with an asymptomatic, pigmented verrucous plaque on the upper right back that had been present since birth. Histopathology of concerning papules within the nevus sebaceous were consistent with five basal cell carcinomas and two follicular adnexal neoplasms. The patient was treated with local excisions, topical imiquimod, and close monitoring.