Talk:Psoriasis/GA1

GA Review

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Reviewer: Jfdwolff (talk · contribs) 21:10, 24 February 2014 (UTC)

I will do the GA review to make good on my promise to help out here. It might be a slightly slow process (1-2 sections/day) depending on my timetable. JFW | T@lk 21:10, 24 February 2014 (UTC)

No problem, take your time. Thank you for doing this by the way. TylerDurden8823 (talk) 01:05, 25 February 2014 (UTC)

Generally I am very impressed by the selection of the sources, which are practically all of MEDRS standards. JFW | T@lk 15:45, 26 February 2014 (UTC)

Great, I'll work on all of this in the next few days and after that we can reevaluate the article for GA. TylerDurden8823 (talk) 18:51, 28 February 2014 (UTC)

• Hi Jfdwolff, although I've seen your handiwork in many places, I don't believe we've had the opportunity to interact before; so, greetings! I've offered to help out with this GAN of psoriasis, and will attempt to address your concerns in the signs & symptoms, causes, mechanism & diagnosis sections. --LT910001 (talk) 01:57, 2 March 2014 (UTC)
  • Great, the more the merrier! JFW | T@lk 10:38, 2 March 2014 (UTC)
  • Tyler has respectfully reminded me that everything is ready. I will try to complete my final review before Sunday night, but I can't guarantee anything due to meatspace obligations. JFW | T@lk 21:51, 15 March 2014 (UTC)

TylerDurden8823 and LT910001, I have checked the points from my review, and only two items still require action (marked {{not done-t}}). Everything else looks fantastic and we're very close to GA. Hopefully these last points can be addressed with relative ease.

I plan to have a final readthrough for flow and style in the next 24h. I will spend a few minutes on "mechanism". JFW | [[User_talk:JfdwolffT@lk]] 13:33, 16 March 2014 (UTC)

Ready when you are. TylerDurden8823 (talk) 21:08, 16 March 2014 (UTC)

 Passed! Great work! JFW | T@lk 16:35, 17 March 2014 (UTC)

I am not sure whether the "classification" section is useful. I know WP:MEDMOS expects this, but I personally find that you need to introduce a lot of technical concepts to make these sections understandable. The ICD-10 codes are a bit of a distraction, and I wonder whether they might be better off in a table. JFW | T@lk 11:41, 2 March 2014 (UTC)

Please take another look at the Classification section and let me know if the table I put there is more like what you had in mind. TylerDurden8823 (talk) 20:23, 3 March 2014 (UTC)

That is much better. There is still the option of moving the ICD-10 table to the right margin. JFW | T@lk 21:51, 15 March 2014 (UTC)

Introduction

My comments on the introduction: JFW | T@lk 15:03, 26 February 2014 (UTC)

• Is there a stronger etymological source in any of the publications? The Online Etymology Dictionary isn't bad, but a stronger source would be ideal.

 Done-Replaced it with a book source. TylerDurden8823 (talk) 07:09, 2 March 2014 (UTC)

•  Done Same question about the five types: is the web page cited the only source for this?

These are discussed in more depth later in the article and have much better sourcing in that section. Is that sufficient? Or do we need better sourcing for it in the lead as well since it's discussed more later in the article? TylerDurden8823 (talk) 01:38, 2 March 2014 (UTC)

You're correct that the intro does not need separate referencing. There's the option of removing it altogether. JFW | T@lk 13:33, 16 March 2014 (UTC)

• Not all of the sections of the article are represented in the introduction (e.g. "Prognosis", "History" and "Research").

 Done Basically done-not quite sure how to work the history part in there, but the prognosis and research parts are now represented. TylerDurden8823 (talk) 22:01, 3 March 2014 (UTC)

• The sentence "The disorder is a chronic, recurring condition that varies in severity from minor localized patches to complete body coverage" seems out of place and repeats points made elsewhere in the introduction. I would suggest moving it upwards.
  •  Done This should be better now. TylerDurden8823 (talk) 02:22, 2 March 2014 (UTC)
• I'm not sure if rebound effect of steroids is common enough to warrant discussing in the introduction.
  •  Done This should be better now. TylerDurden8823 (talk) 02:22, 2 March 2014 (UTC)

Signs and symptoms

My comments on this section: JFW | T@lk 15:03, 26 February 2014 (UTC)

• The table is useful in some ways, but for skin conditions it might be appropriate to describe the lesions in prose.
  •  Done Agree. --LT910001 (talk) 01:57, 2 March 2014 (UTC)
•  Done It might be appropriate to describe the different recognised subtypes of psoriatic arthritis (there's four).

Wouldn't that be more appropriate on the psoriatic arthritis page? They do have a discussion of psoriatic arthritis subtypes there and if we do it here as well, we run the risk of redundancy. TylerDurden8823 (talk) 22:09, 3 March 2014 (UTC)

• The "gallery" makes it possible to squeeze a number of images in a small space, which is great for the purposes of the article. I do wonder if one of them should be brought to the side and made slightly larger as a "close-up".
  •  Done Agree. --LT910001 (talk) 01:57, 2 March 2014 (UTC)

Causes

My comments on this section: JFW | T@lk 15:03, 26 February 2014 (UTC)

• The section should ideally be divided in discussion about possible underlying causes of the condition (and I would place "Genetics" before "HIV") and triggering/provoking factors.

 Done Partially done-switched order of genetics and HIV sections so far. Regarding dividing it into cause and triggering/provoking factors, wouldn't we say that the mechanism section is really what discusses the cause (which isn't fully understood)? We might consider renaming the mechanism section as causes and the current causes section as triggers or exacerbating factors or something to that effect. TylerDurden8823 (talk) 02:02, 2 March 2014 (UTC)

• The discussion about pathogenesis in HIV is quite technical, and may need a little bit more elaboration or explanatory terms.

 Done I think it's better now. Have another look when you're ready. TylerDurden8823 (talk) 02:16, 2 March 2014 (UTC)

• I don't know if the sources are clear on this, but are the medications listed considered "cause" or "trigger"? In other words, are they a sine qua non for the development of psoriasis or are they just one of numerous possible triggers?

 Done When I was looking through papers, it looked like it could be either one-exacerbating factor or a trigger. I don't know if any of them say it caused the first episode of the chronic disease and that it persisted afterward. My overall impression is that the medications are viewed as something that can precipitate the disease or perhaps induce a relapse in a psoriatic patient who is in a state of remission. TylerDurden8823 (talk) 02:16, 2 March 2014 (UTC)

If the sources are unclear then we should not be trying to create a distinction. Clinically it is difficult to say whether a particular exposure is a "sine qua non". JFW | T@lk 11:41, 2 March 2014 (UTC)

Mechanism

My comments on this section: JFW | T@lk 15:03, 26 February 2014 (UTC)

• "Compromised skin barrier function has a role in the pathogenesis of psoriasis." Does this mean that the disease compromises the skin barrier with an increased risk of skin infection, or is the disease thought to be caused by the fact that the skin a priori is unable to keep out bacterial nasties, leading to an exuberant immune response and increased keratinocyte production?

 Done Looking at the referenced papers again, it looks like altered skin barrier function is considered a marker of susceptibility for psoriasis development. TylerDurden8823 (talk) 02:17, 2 March 2014 (UTC)

• In the second paragraph, the fragment "immune cells move from the dermis to the epidermis" is repeated. Consider rephrase.
  •  Done This should be better now. TylerDurden8823 (talk) 02:23, 2 March 2014 (UTC)
• "Psoriasis does not seem to be a true autoimmune disease" seems out of place. It seems to address a presumption that it is an autoimmune disease; perhaps this presumption should be spelled out.

Okay, so I do have access to the NEJM paper and here is what it says: "A key question concerns the autoimmune nature of psoriasis and the contribution of autoreactive T cells to the disease process. Currently available data do not support the notion that psoriasis is a bona fide autoimmune disease. Psoriasis is prob- ably best placed within a spectrum of autoim- mune-related diseases characterized by chronic inflammation in the absence of known infec- tious agents or antigens.58" This seems like a contrast from other (including more recent) papers that I've seen that do seem to say that it is regarded as an autoimmune disease. I certainly respect the expert opinion of NEJM review articles and I know they're normally regarded as the gold standard, but I'll see if I can confirm with newer reviews if psoriasis is now regarded as autoimmune or not. TylerDurden8823 (talk) 02:27, 2 March 2014 (UTC)

There seems to be some disagreement in the literature about how to describe psoriasis (as autoimmune or as an immunoinflammatory dermatosis) Here are some review articles from various journals that are newer than the 2009 NEJM review article that classify psoriasis as autoimmune: 1. http://www.ncbi.nlm.nih.gov/pubmed/24434359 2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3771250/( this one specifically says psoriatic arthritis is autoimmune) 3. http://www.ncbi.nlm.nih.gov/pubmed/23420016 4. http://www.ncbi.nlm.nih.gov/pubmed/24101875 5. http://www.ncbi.nlm.nih.gov/pubmed/22428855 6. http://www.ncbi.nlm.nih.gov/pubmed/22044352 However, these are some other review articles that use terms like immunoinflammatory dermatosis or chronic relapsing immune-mediated disorder or similar terms, but do not specifically say "autoimmune" 1. http://www.ncbi.nlm.nih.gov/pubmed/22348323 2. http://www.ncbi.nlm.nih.gov/pubmed/22754278 3. http://www.ncbi.nlm.nih.gov/pubmed/23197207

Most articles seem to say autoimmune, but we could say that there is some degree of debate as to whether psoriasis is actually an autoimmune disease rather than use the 2009 article only and simply say it appears not to be since newer literature reviews have differing opinions on the matter. Let me know what you think. TylerDurden8823 (talk) 22:28, 3 March 2014 (UTC)

 Done I would revise the statement in "Mechanism" to reflect the controversy. JFW | T@lk 13:33, 16 March 2014 (UTC)

As it stands, I believe it is alright to put two MEDRS-sources side by side and state what they both say. Unfortunately there is no "head to head" source that examines both perspectives. JFW | T@lk 20:01, 16 March 2014 (UTC)

Yeah, I know. I just wanted to put a few sources for each to make sure both sides are well-represented and to show that this has been an ongoing debate for a number of years. TylerDurden8823 (talk) 20:34, 16 March 2014 (UTC)

• The section does enumerate the recognised immunological and pathological abnormalities, but at the moment the exact chain of events seems unclear. This may reflect a genuine lack of understanding in dermatological science, but I am wondering if there is any way the section could be made to stick together a little bit better.

I definitely think that's a part of it. It does appear to me that there are certainly gaps in understanding of the sequence of events in the pathogenesis of psoriasis. I'll see if I can find review articles that fill in some of these gaps. TylerDurden8823 (talk) 02:30, 2 March 2014 (UTC)

Often, a single major article is needed to form the backbone of these sections. NEJM is often good for this, but sometimes you will find the review in a core specialty journal. JFW | T@lk 11:41, 2 March 2014 (UTC)

I will review this in my final readthrough and try to weld it together a little bit. JFW | T@lk 13:33, 16 March 2014 (UTC)

Diagnosis

My comments on this section: JFW | T@lk 15:03, 26 February 2014 (UTC)

• "Skin from a biopsy will show clubbed rete pegs if positive for psoriasis." It bears pointing out that this is the microscopic appearance. I think understanding might be improved by elaborating on "rete pegs" and the clubbed appearances.

It should be clearer now that this is a microscopic finding. Working on clarifying what rete pegs are so that it's clearer for readers. TylerDurden8823 (talk) 08:06, 2 March 2014 (UTC)

We probably need a fairly comprehensive discussion (probably available in a single source, e.g. NEJM) that lists the cardinal findings on histology. Currently we are saying little about an inflammatory infiltrate. JFW | T@lk 11:41, 2 March 2014 (UTC)

 Done I hope the additions I made are sufficient. If not, let me know and I'll add more. TylerDurden8823 (talk) 01:46, 4 March 2014 (UTC)

• Auspitz's sign should probably be mentioned before discussing the histological appearances.

 Done TylerDurden8823 (talk) 07:27, 2 March 2014 (UTC)

• "Severity" - body surface area doesn't have a unit - is this meant to be a percentage? At the risk of being too verbose, it might be appropriate to say how the DLQI is derived.

Yes, from a brief search it appears that BSA is measured as a percentage of body surface area affected by psoriatic lesions to determine severity. I'll see if I can find out how DLQI is calculated or derived. TylerDurden8823 (talk) 08:11, 2 March 2014 (UTC)

 Done-This is fixed and now elaborated on. TylerDurden8823 (talk) 08:27, 2 March 2014 (UTC)

• "Classification" - the term "morphologic" might need to be explained. It is not quite clear what "This section" refers to. Is it a self-reference, and if so it seems the ICD-10 codes were removed.

I removed those because I did not know those were ICD-10 codes. That was unclear from how it was written before. I'll bring them back. TylerDurden8823 (talk) 07:30, 2 March 2014 (UTC)

 Done ICD-10 codes were replaced. TylerDurden8823 (talk) 08:04, 2 March 2014 (UTC)

See my comments above about the ICD-10 codes in the text. JFW | T@lk 11:41, 2 March 2014 (UTC)

 Done TylerDurden8823 (talk) 22:46, 3 March 2014 (UTC)

•  Done Subsection "nonpustular" seems to repeat some characteristics already covered elsewhere in the article.

Can you be more specific? Which parts are repetitive? TylerDurden8823 (talk) 22:30, 3 March 2014 (UTC)

Dealt with as a result of reorganisation. JFW | T@lk 13:33, 16 March 2014 (UTC)

• In general I am wondering if the clinical descriptions from the "classification" section wouldn't be more appropriate as subsections of "Signs and symptoms".

 Done A very reasonable suggestion; have made this change. --LT910001 (talk) 01:58, 2 March 2014 (UTC)

Management

My comments on this section: JFW | T@lk 15:03, 26 February 2014 (UTC)

• "A 2013 review concluded that [...]" can probably be omitted; the same applies to the discussion about the Cochrane review.
  •  Done This should be better now. TylerDurden8823 (talk) 02:23, 2 March 2014 (UTC)
• In "phototherapy" (in the sentence on PUVA+acitretin), I cannot find the Hankin CS et al (2010) source on Pubmed and I am not sure from the title whether it is a secondary source.
  •  Done This is fixed now. I replaced it with two PubMed-indexed review article sources. TylerDurden8823 (talk) 23:35, 3 March 2014 (UTC)
• In "systemic agents", the first paragraph has no references. Is it primarily a summary of what follows?
  •  Done Added a review article source to verify that non-biologic systemic therapy is reserved for psoriasis sufferers who have failed topical therapies and phototherapy treatments and that liver/blood monitoring is important in individuals on these systemic treatments. The bit about pregnancy is discussed later in the same section with a reference, so I don't think we need to put a reference there twice for the same thing since it's really more of an introductory paragraph. TylerDurden8823 (talk) 06:07, 4 March 2014 (UTC)
• I would elaborate on "post-surgical events". Does it mean that it can cause complications if someone taking metrotrexate requires surgery?
  •  Done-I removed it instead. This was just a case report of ulcerations and eventration possibly associated with methotrexate use (but no definitive link was established in the paper). I think it's not really noteworthy enough to be in the Psoriasis article. It might be more appropriate in the Methotrexate article. I also came across a review article (the one I added to the beginning paragraph of the section) that states methotrexate is okay before surgery. TylerDurden8823 (talk) 23:45, 3 March 2014 (UTC)
• I would link to monoclonal antibody somewhere to give readers a chance to figure out how they are produced.

 Done It was wikilinked in this sentence: Efalizumab is a monoclonal antibody (MAb) that specifically targets the CD11a subunit of LFA-1.[62], but I moved it earlier. TylerDurden8823 (talk) 06:08, 4 March 2014 (UTC)

• "The severity of psoriasis symptoms may also be influenced by lifestyle habits related to alcohol, smoking, weight, sleep, stress and exercise" doesn't strike me as particularly controversial. Is there a particular reason why it was placed here (apart from the title of the reference that supports it)?
  •  Done. Agreed, this is already mentioned elsewhere in the article and is not controversial. TylerDurden8823 (talk) 02:23, 2 March 2014 (UTC)
• There is no mention of climatotherapy. There are regular tours to the Dead Sea for people with psoriasis and other cutaneous conditions; there are some secondary sources that discuss this (doi:10.1016/j.clindermatol.2007.10.023, doi:10.1016/j.semarthrit.2012.02.006)
  •  Done-this is definitely incorporated into the article now. TylerDurden8823 (talk) 09:06, 7 March 2014 (UTC)

Prognosis

My comments on this section: JFW | T@lk 15:45, 26 February 2014 (UTC)

• The opening paragraph seems duplicative in its description of disease severity and distribution. Could it be moved to (or integrated with) "signs and symptoms"?

 Done I just removed it. As you said, it's repetitive and not really necessary. I don't think it contributed much to the article. TylerDurden8823 (talk) 03:32, 2 March 2014 (UTC)

• The second paragraph currently doesn't have a source.

First sentence already does, but I agree that it would probably benefit from some more. TylerDurden8823 (talk) 03:30, 2 March 2014 (UTC)

 Done It would be preferable to have a source, however logical it sounds. JFW | T@lk 13:33, 16 March 2014 (UTC)

Not sure I understand since the second paragraph does have sources now. Did you mean the first paragraph of the prognosis section? If so, I've added them. TylerDurden8823 (talk) 18:44, 16 March 2014 (UTC)

Indeed. The Parrish source is excellent for this. Sorry for the confusion. JFW | T@lk 19:23, 16 March 2014 (UTC)

• The sections "Autoimmune comorbidities" and "Cancer" are very short, and perhaps the content on comorbidities could be covered in a single section.

 Done -These are merged now. TylerDurden8823 (talk) 20:35, 3 March 2014 (UTC)

• In "cancer", "mildly increased risk" is not very specific. Might it be an idea to give some relative risks from the source?

 Done -This should be specific enough now. TylerDurden8823 (talk) 21:03, 3 March 2014 (UTC)

• In "cardiovascular comorbidities", the words "Metabolic syndrome" occur without further elaboration, followed by the Raychaudhuri SK et al (2014) reference. I'm sure there's something you wanted to say there.
  •  Done-this should be better now. TylerDurden8823 (talk) 02:25, 4 March 2014 (UTC)
• In "cardiovascular comorbidities", it is ambiguous whether treatment for hypercholesterolaemia improves the cardiovascular risk or the cutaneous symptoms. The source implies that it's only the latter.
  •  Done-this should be better now. It appears to improve both cutaneous symptoms and cardiovascular risk (or at least cardiovascular risk factors-the paper did not specifically address if treatment of hyperlipidemia results in fewer cardiovascular events or mortality due to cardiovascular events). TylerDurden8823 (talk) 06:25, 7 March 2014 (UTC)

Epidemiology

My comments on this section: JFW | T@lk 15:45, 26 February 2014 (UTC)

• I wonder whether the prevalence figure should be mentioned earlier in the section.
  •  Done TylerDurden8823 (talk) 03:38, 2 March 2014 (UTC)
• The sentence "Psoriasis is more common [...]" is quite long and strings together a lot of technically unrelated facts. It might be better to break it up a bit.

 Done This should be better now. I put it that way with the link being the various factors that make it more likely for a given individual to have psoriasis, but I suppose I can see how it would be better to break it up. TylerDurden8823 (talk) 03:37, 2 March 2014 (UTC)

History

My comments on this section: JFW | T@lk 15:45, 26 February 2014 (UTC)

•  Done Does the Gruber et al source state who speculated that tzara'ath was the same as psoriasis? Just curious - might be worth including. Does the Benedek source mention this at all?

The Benedek source does not discuss this aspect of the history. This book source that I added to the beginning of the article (http://books.google.com/books?id=RN-B2g2YjmAC&pg=PA4&lpg=PA4#v=onepage&q&f=false) discusses that it is well-accepted that the Hebrew term "tzara'ath" was used for a spectrum of dermatological diseases in addition to leprosy and probably included psoriasis. There are two papers referenced in this book for the statement that tzara'ath refers to these conditions-a 1986 paper from Glickman, FS and the 1955 Meenan paper we have in the history section. Unfortunately, I'm unable to access the full text of either of these papers, so I am unable to verify what these papers say about the topic. TylerDurden8823 (talk) 06:35, 4 March 2014 (UTC)

Unfortunately, the Glickman source also does not specify who speculated that zaraath was the same as psoriasis. It actually says (in a matter of fact tone) that zaraath in Hebrew stands for leprosy and that it has been suggested that this archaic Hebrew word for leprosy may have been used for people with a variety of skin disorders including psoriasis. However, regarding who is doing this suggesting? This is never specifically mentioned and it is unclear to me if biblical scholars, medical scientists, or both communities put forward this suggestion. TylerDurden8823 (talk) 06:37, 7 March 2014 (UTC)

If the sources can't confirm who postulated this, no worries. JFW | T@lk 13:33, 16 March 2014 (UTC)

• Similarly, does Benedek provide any information on historical therapies? I would be surprised if it didn't!

 Done Benedek part II does have some discussion of historical treatments and I've incorporated that into the history section. TylerDurden8823 (talk) 06:52, 7 March 2014 (UTC)

Society and culture

My comments on this section: JFW | T@lk 15:45, 26 February 2014 (UTC)

•  Done The references are somewhat weak, but then this is usually verifiable content in an area where sources are not abundant.

Agreed, I really didn't mess with that section much, but I'll see if I can scare up some better sources. TylerDurden8823 (talk) 01:28, 2 March 2014 (UTC)

This might be a better source, but I don't have access to it. http://www.ncbi.nlm.nih.gov/pubmed/21362781 TylerDurden8823 (talk) 06:55, 4 March 2014 (UTC)

Not a breaking point. JFW | T@lk 13:33, 16 March 2014 (UTC)

Research

My comments on this section: JFW | T@lk 15:45, 26 February 2014 (UTC)

• The first paragraph is unsourced. I think this content does require a source.
  •  Done TylerDurden8823 (talk) 02:57, 4 March 2014 (UTC)
• The content focuses on immunological therapy. Do the sources discuss any other emerging theories and/or treatments under development?
  •  Done-Yes, it looks like most of the research out there targeted at therapies seems to be focusing on targeting different aspects of cellular signaling or the immune system. I did add brief mention of research into the role of insulin resistance in the pathogenesis of psoriasis and investigation of antioxidants as treatment. TylerDurden8823 (talk) 02:57, 4 March 2014 (UTC)