Background Evidence of factors associated with psoriasis from large population-based cohort studies is scarce. Objective We aimed to explore the risk factors of late-onset psoriasis. Methods This study included 487,835 Japanese participants aged 40-107 years, who were followed prospectively from 2012 to 2018 using individually linked databases between annual health checkups and medical claims. Results During the study period, 2793 patients (0.57%) newly developed psoriasis; 13.8% had moderate-to-severe psoriasis. In the multivariate analysis, factors associated with psoriasis onset were age (hazard ratio [HR] 1.11 {95% confidence interval [CI]: 1.06-1.16}), male sex (HR: 1.11 [95% CI: 1.02-1.21]), body mass index (HR: 1.09 [95% CI: 1.05-1.14]), smoking (HR: 1.46 [95% CI: 1.31-1.63]), not exercising ≥1 hour per week (HR: 1.13 [95% CI: 1.05-1.22]), and gamma-glutamyl transpeptidase (HR: 1.04 [95% CI: 1.01-1.06]). When we used weight increment of ≥10 kg since the age of 20 years instead of body mass index in the multivariate model, this was also a risk factor (HR: 1.12 [95% CI: 1.04-1.21]). Limitations This study targeted people aged >40 years, thereby narrowing the search to the risk factors of late-onset psoriasis. Conclusion We showed that increasing age, male sex, body mass index, smoking, low physical activity, weight gain, and gamma-glutamyl transpeptidase are associated with late-onset development of psoriasis and revealed a relationship between liver dysfunction and psoriasis development.

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Plasma exchange is a therapeutic option in severe cases of pemphigus. Both centrifugal plasmapheresis and double filtration plasmapheresis (DFPP) are available, but the latter, newer, procedure currently prevails because of its safety advantage (1, 2). In DFPP, immunoglobulins (Igs) are selectively removed, while minimizing the loss of albumin (3). In several studies, the removal rates (RRs) of anti-desmoglein (Dsg) 1 and Dsg3 autoantibodies have been estimated by using serum antibody titres immediately before and after plasmapheresis (3). This simple estimation is designated RRl in the present study. Given the data for anti-Dsg titres and Ig amounts in the exchanged effluents, however, we can calculate the corrected or compensated RR, named RR2 in this study, which reflects the elimination efficacy of antibodies more accurately than RRl. RR2 of pemphigus autoantibodies has been reported only in centrifugal plasmapheresis (4), but not in DFPP. This study examined RR2 of anti-Dsg 1 autoantibody with reference to total immunoglobulins (Igs) in 4 cycles of DFPP performed in 2 patients with pemphigus foliaceus (PF). PATIENTS AND METHODSTwo patients with PF were etirolled in this study.Case 1. Case 1 was an 85-year-old Japanese man with erosions on his trutik and extremities. There was no involvement of the oral mucous membrane. He had had chronic myelomonocytic leukaemia for 6 months without treatment. Immediately before the start of DFPP, the enzyme-linked immunosorbent assay (ELISA) titres for Dsgl and Dsg3 were 2,031 and <5 indices, respectively. Following administration of prednisolone (60 mg daily) and mizoribine (100 mg daily), DFPP was implemented twice in total on 2 consecutive days. Itnmediately after the second DFPP, anti-Dsgl antibody was decreased dramatically to 220 index, with therapeutic success. However, the patient had severe sepsis, with serum IgG lowered from 1,320 to 407 mg/ dl. Blood culture and culture of the tip of the central venous catheter was positive for Staphylococcus aureus. Serum albumin and fibrinogen levels were decreased from 3.5 to 2.5 g/dl, and 87 to >50 mg/dl, respectively. Over a period of 2 months after DFPP, prednisolone was tapered to 30 mg/day without clinical recurrence.Case 2. Case 2 was a 48-year-old Japanese man who had had PF for 2 years, which was controlled with oral prednisolone (20-60 mg daily) plus cyclosporine (150 mg daily). However, flaccid vesicles and erosions continued to recur Because of the adverse effects of corticosteroids (pulmonary embolism and avascular necrosis of the femoral bone), and of intravenous high-dose Ig (thrombocytopaenia, platelet count <50,000 ul), 2 courses of DFPP were implemented on 2 consecutive days. The ELISA titre for anti-Dsgl autoantibody was decreased from 88 to 18 and anti-Dsg3 antibody to <5, with therapeutic success. Serum albumin and fibrinogen levels were decreased from 4.0 to 3.7 g/dl, and 274 to 220 mg/dl, respectively. For 3 months after DFPP, no recurrence of symptoms was observed with prednisolone (20 mg/day) plus cyclo...

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