CASE SERIES

Clinical Characteristics of 18 Patients with Psoriasisand Multiple Myeloma Identified Through DigitalHealth Crowdsourcing

Joy Q. Jin . Jenny M. Ahlstrom . Nathan W. Sweeney .

Wilson Liao

Received: May 20, 2020 / Published online: July 7, 2020� The Author(s) 2020

ABSTRACT

Psoriasis is a skin condition that affects over 100million people worldwide, while multiplemyeloma (MM) accounts for 10% of all hema-tologic malignancies in the US. There has beenlimited research on the intersection of psoriasisand MM, and clinicians often face difficultdecisions in treating patients diagnosed withboth conditions. For instance, the managementof psoriasis with systemic immunotherapies inMM patients can be challenging because ofconcern about immunosuppression and possi-ble worsening of MM. Online crowdsourcingplatforms have recently become innovativetools that can actively empower patients in

scientific research by enabling the contributionof health data. One such platform, HealthTree�,helps MM patients find optimal myelomatreatments and has registered[ 6000 patients,many of whom have uploaded medical recordsand genetic profiles. By taking advantage ofpatient health data available on HealthTree,researchers can gain a greater understanding ofthe clinical characteristics and treatmentresponses of patients diagnosed with psoriasisand MM. In this case series, we first report apsoriasis and MM patient treated with the IL-17inhibitor ixekizumab who demonstrated atemporary, 2-month improvement in MMbiomarkers (M-protein, kappa, and kappa:-lambda ratio). We then report on the clinicalcharacteristics of 18 patients with verified pro-files on HealthTree indicating concurrent pso-riasis and MM conditions. We surveyed gender,age, psoriasis type, psoriasis treatment history,myeloma type, myeloma genetic features, andmyeloma association with bone damage,hypercalcemia, or osteopenia. Four patientswere treated with systemic immunomodulatorsfor psoriasis, with responses suggesting thatthese therapies did not worsen MM progression.Our results validate crowdsourcing as a way toassess patient demographics and treatmentresponses for use in dermatology research. Weexamine the demographics of patients diag-nosed with psoriasis and MM and investigatethe use of systemic immunomodulators fortreatment of psoriasis in MM patients.

Digital Features To view digital features for this articlego to https://doi.org/10.6084/m9.figshare.12514808.

Electronic supplementary material The onlineversion of this article (https://doi.org/10.1007/s13555-020-00416-5) contains supplementary material, which isavailable to authorized users.

J. Q. JinSchool of Medicine, University of California SanFrancisco, San Francisco, USA

J. M. Ahlstrom � N. W. SweeneyMyeloma Crowd, CrowdCare Foundation, Lehi, UT,USA

W. Liao (&)Department of Dermatology, University ofCalifornia San Francisco, San Francisco, USAe-mail: Wilson.Liao@ucsf.edu

Dermatol Ther (Heidelb) (2020) 10:815–827

https://doi.org/10.1007/s13555-020-00416-5

Keywords: Crowdsource; HealthTree; IL-17;Ixekizumab; Multiple myeloma; Patientempowerment; Psoriasis; Systemic therapy

Key Summary Points

Why carry out this study?

There has been limited research on theintersection of psoriasis and multiplemyeloma (MM), and providers often facedifficult decisions in treating patientsdiagnosed with both conditions

Interleukin-17 (IL-17) has been identifiedas a cytokine that promotes both psoriasisand MM; however, the use of IL-17inhibitors in patients with MM has notbeen examined

By crowdsourcing patient health datausing the HealthTree platform, we cangain a greater understanding of theclinical characteristics and treatmentresponses of patients diagnosed with bothpsoriasis and MM

What was learned from the study?

We identified a patient with psoriasis andactive MM who was treated with the IL-17inhibitor ixekizumab and who thenexperienced a transient reduction in herMM serologic markers

To further study psoriasis and MM, weidentified 18 patients on HealthTree, aMM crowdsourcing platform. Weanalyzed information on gender, age,psoriasis type and treatment history,myeloma type and genetic features, andmyeloma association with bone damage,hypercalcemia, or osteopenia

Among the 18 subjects, 4 patients weretreated with a systemicimmunomodulator for psoriasis with noobvious worsening of MM progression

INTRODUCTION

Traditionally, patients have been difficult toengage in clinical research and analysis. How-ever, online crowdsourcing platforms havebecome innovative tools that can empower andactively engage patients in the research processby enabling the contribution of health data,ideas, and observations. Platforms such asCureTogether and Citizen Pscientist haveenrolled thousands of patients to generate de-identified patient data for clinical study [1]. Therecently launched HealthTree� platform, anonline ecosystem that helps multiple myelomapatients find their best myeloma treatments andaccelerate research toward a cure, has registered[6000 patients, many of whom have uploadedverified medical records and genetic profiles [2].

To date, there has been limited research onthe intersection between psoriasis and multiplemyeloma (MM), and providers often face diffi-cult decisions in treating patients diagnosedwith both conditions. Psoriasis is a chronicinflammatory skin disease that is estimated toaffect[ 100 million people worldwide [3]. MMaccounts for 10% of all hematologic malignan-cies, with[ 30,000 new cases diagnosed in theUS each year [4]. Although there are manyeffective systemic treatments for psoriasis,including therapies targeting tumor necrosisfactor a (TNF-a), interleukin 17 (IL-17), andinterleukin 23 (IL-23), the use of systemicagents in patients with malignancies is contro-versial because of concerns of immunosuppres-sion and potential cancer progression. This isparticularly true for hematologic malignancies,in which elevated rates of lymphoma inpatients receiving anti-TNF agents have beenreported [5].

Here, we present a case series analyzing thedeidentified health data of 18 patients enrolledin HealthTree who were diagnosed with psori-asis and MM. The study results indicate thatmedical research can be greatly enhanced bycrowdsourcing patient health data via onlineplatforms, especially for intersecting patientpopulations such as those diagnosed with bothMM and psoriasis. Our findings provide furtherinsight for the management of systemic

816 Dermatol Ther (Heidelb) (2020) 10:815–827

psoriatic therapies in patients with existingmyeloma. Consent for publication was receivedfrom the index patient; the digitally crowd-sourced patient data were determined to beexempt by the Western Institutional ReviewBoard (IRB) under exemption code 45 CFR §46.104(d)(2). This case report was conductedaccording to the principles of good clinicalpractice guidelines ICH GCP and according tothe ethical principles of the Declaration ofHelsinki.

CASE PRESENTATIONS

Index Case

We first evaluated Patient 1, a 52-year-oldfemale with a 30-year history of guttate psoriasiswithout psoriatic arthritis. Her psoriasis wasgenerally well managed with topical therapy(clobetasol and hydrocortisone creams) andheliotherapy.

At age 43, Patient 1 was diagnosed withDurie-Salmon stage 3A IgG kappa MM, withgenetic profiling showing trisomy 9 and 11,tetrasomy 15, and a t(14;20) translocation. Shewas found to have diffuse osteolytic lesionsthroughout the body, and subsequently under-went dexamethasone, cisplatin, doxorubicin,cyclophosphamide and etoposide (D-PACE) andbortezomib, thalidomide, and dexamethasone(VTD) chemotherapy treatment. Tandemautologous stem cell transplantation (ASCT)was performed, followed by a year of mainte-nance therapy with VTD and an additional yearwith dexamethasone, after which Patient 1achieved a complete remission (CR) approxi-mately 1 year after initial MM diagnosis. Dex-amethasone maintenance was startedimmediately for 1 year, and the patientremained in stringent CR with consistentmonitoring.

However, at age 48, despite no evidence ofactive myeloma on imaging, bone marrowbiopsy showed 5% presence of plasma cells,which is at the borderline level for MM recur-rence. Osteoporosis-preventing infusions weresubsequently administered every 3 months andmarkers were closely tracked for the following

4 years; M-protein and serum markers (e.g.,albumin, creatinine) remained stable, and noacute findings or evidence of active diseaseprogression was noted.

At age 52, Patient 1 was noted to have asharp increase in MM biomarkers, includingkappa and urine paraprotein. She also devel-oped a psoriatic flare with lesions noted on theposterior neck, right lower abdomen, and chest.There was mild scaling and induration of pso-riatic lesions, and she was prescribed topicalcreams and started on ixekizumab therapy.Ixekizumab was selected based on its estab-lished efficacy in psoriasis and studies suggest-ing a pathogenic role for IL-17 in theprogression of MM [6]. Twelve days after thefirst loading dose injection of ixekizumab, thepatient developed urticarial wheals appearingon the abdomen, trunk, and head and neck.This eruption resolved after a 1-week course ofprednisone 40 mg and fexofenadine. In thepatient’s first MM biomarker assessment afterthe start of ixekizumab, drops in her kappa:-lambda ratio, kappa free light chain, andM-protein levels were observed (Fig. 1). A fur-ther decrease in these clinical markers wasfound in a second assessment 2 weeks later.Thereafter, these markers fluctuated in a rangebelow the highest peak. The patient reportedminimal efficacy of ixekizumab for her psoriasisand thus decided to discontinue use after2 months.

Case Series Using Digital Crowdsourcing

To further understand clinical features andtreatment responses among patients with bothMM and psoriasis, health data crowdsourced onHealthTree were used. A total of 1505 Health-Tree enrollees had verified physician diagnosesof myeloma, and psoriasis was present in 4.9%(n = 73) of this population. Surprisingly, psori-asis was one of the most frequent co-morbiditiesfound in the HealthTree myeloma patientpopulation, alongside conditions such asosteopenia, inflammatory bowel disease, andgout. Our questionnaire (Table S1) was admin-istered to HealthTree patients (n = 73) withverified health records showing diagnosis of

Dermatol Ther (Heidelb) (2020) 10:815–827 817

both psoriasis and MM. The questionnaireyielded 18 complete responses, including fromPatient 1 described above. Findings pertainingto psoriasis are summarized in Table 1, whilemyeloma features are summarized in Table 2.Characteristics evaluated in the questionnaireinclude gender, current age, age of diagnosis,psoriasis type, psoriasis treatment history,myeloma type and genetic features, and mye-loma association with bone damage, hypercal-cemia, or osteopenia.

Among respondents, the mean age of psori-asis diagnosis was 35.9 (SD 8.2), while the meanage of myeloma diagnosis was 57.1 (SD 8.6). Inmost patients, diagnosis of psoriasis occurredwell before diagnosis of myeloma (mean differ-ence of 21.2 years). Seven out of 18 respondentsidentified as female (38.9%), and the mostcommon type of psoriasis diagnosed was plaque

(44.4%), followed by palm/sole (16.7%), guttate(11.1%), and inverse (5.6%). Two patients(11.1%) indicated that their psoriasis treatment(topical steroids) had improved their MM, and33.3% indicated they were uncertain. Nopatients reported that psoriasis treatment hadnegatively influenced myeloma progression,and 50% were uncertain. Psoriasis treatmentswere most commonly topical steroids, followedby tar, phototherapy, heliotherapy, and anti-fungal or immunosuppressive agents.

Myeloma diagnoses included MM (72.2%),smoldering myeloma (33.3%), and monoclonalgammopathy of undetermined significance(27.8%)—several patients were diagnosed withmultiple subtypes. The types of myeloma rep-resented included IgG kappa (50.0%), IgA kappa(11.1%), IgA lambda (11.1%), and IgM lambda(5.6%) as well as 22.2% uncertain. Among

Fig. 1 Myeloma markers for Patient 1. Standard myelomaprognostic laboratory tests, including M-protein, kappafree light chain (FLC), and kappa/lambda FLC ratio weretracked across the ixekizumab treatment start and end

date. The double arrows indicate the period of ixekizumabtreatment from September 2019 to December 2019

818 Dermatol Ther (Heidelb) (2020) 10:815–827

Table1

Psoriasischaracteristicsam

ongsurvey

respondents

Gender

Age

(years)

Physician

confi

rmed

Age

aton

set

Type

Current

BSA

(%)

Maxim

umBSA

(%)

Current

treatm

ent(s)

Prior

treatm

ent(s)

Psoriasis

treatm

ent

improved

MM

Psoriasis

treatm

ent

worsened

MM

Patient

1

F52

Yes

22Guttate

\1

\1

Ixekizum

abTopical

steroids,

heliotherapy,tar

Yes (2

months)

No

Patient

2

M47

Yes

45Unsure

\1

\1

Tacrolim

usTopicalsteroids

No

No

Patient

3

M58

Yes

Unsure

Unsure

\1

1–5

Ketoconazole

None

No

Unsure

Patient

4

F64

Yes

62Inverse,

Palm/

Sole,

Plaque

1–5

[5

UVB

phototherapy

Topicalsteroids

Unsure

Unsure

Patient

5

M64

Yes

20Unsure

\1

1–5

Topical

steroids,

SCT

Tar,topicalsteroids,U

VB

phototherapy

No

No

Patient

6

F72

Yes

60Unsure

[5

[5

Aprem

ilast

Topical

steroids,

secukinumab,

adalimum

ab,ibuprofen,

methotrexate,UVB

phototherapy

No

No

Patient

7

M69

Yes

25Palm/

Sole

1–5

[5

Topical

steroids

None

No

No

Patient

8

M66

Yes

35Plaque

\1

1–5

None

Topicalsteroids

Unsure

Unsure

Patient

9

F67

Yes

20Guttate

\1

1–5

Tar

Tar,k

etoconazole

Unsure

Unsure

Patient

10

F66

Yes

56Plaque

\1

Unsure

Ustekinumab

Topical

steroids

No

No

Dermatol Ther (Heidelb) (2020) 10:815–827 819

Table1

continued

Gender

Age

(years)

Physician

confi

rmed

Age

aton

set

Type

Current

BSA

(%)

Maxim

umBSA

(%)

Current

treatm

ent(s)

Prior

treatm

ent(s)

Psoriasis

treatm

ent

improved

MM

Psoriasis

treatm

ent

worsened

MM

Patient

11

M61

Yes

36Plaque

1–5

[5

None

Topicalsteroids,tar,U

VB

phototherapy

Unsure

Unsure

Patient

12

M68

Yes

40Plaque

1–5

[5

Topical

steroids

Topicalsteroids

Yes

Unsure

Patient

13

F70

Yes

45Palm/sole

\1

\1

Topical

steroids

None

No

Unsure

Patient

14

M48

Yes

12Plaque

\1

\1

None

Non-steroid

topics,

heliotherapy

No

No

Patient

15

M65

Yes

37Plaque

\1

\1

None

Tar,topicalsteroids

No

Unsure

Patient

16

M59

Yes

36Plaque

\1

\1

None

Certolizum

abUnsure

No

Patient

17

F55

Yes

12Plaque

\1

1-5

None

Tar

Unsure

Unsure

Patient

18

M75

Yes

45Unsure

Unsure

Unsure

Topical

steroids

Unsure

No

No

Survey

questionsweresent

topatientsviaHealth

Tree,aplatform

that

allowspatientsto

navigate

myelomaover

thelifetim

eof

theirdisease.Row

shighlighted

initalicsindicate

thefour

patientswho

received

system

ictherapyforpsoriasistreatm

ent

BSA

,bodysurfacearea

820 Dermatol Ther (Heidelb) (2020) 10:815–827

Table2

Myelomacharacteristicsam

ongsurvey

respondents

Diagnosis

Age

ofdiagno

sis

MM

type

Genetics(atdiagno

sis)

Genetics

(current)

Bon

edamage

Hypercalcem

iaOsteopenia

Patient1

MM

43IgG

kappa

t(14;20)—

10%

Trisomy9

Trisomy11

Del(17p)

Del(13q)

Trisomy11–6

7%

Tetrasomy

15–7

4%

Tetrasomy9–

68%

Yes

No

Yes

Patient2

Smoldering

45IgG

kappa

Del(13q)

Trisomy3

Trisomy5

Trisomy11

CD138—

3%

Unsure

No

No

No

Patient3

MGUS,

MM

56Unsure

Gain1q21

Trisomy9

CD13860%

CD138—

5%No

No

Unsure

Patient4

MGUS,

smoldering

63IgM lambda

t(14;20)

Trisomy17

Unsure

No

No

Yes

Patient5

Smoldering,M

M61

IgG

kappa

Gain1q21

Del(1p)

Del(13q)/monosom

y13

t(14;16)

t(14;16)

t(14;20)

No

No

No

Patient6

MGUS

71Unsure

Unsure

Unsure

Unsure

Unsure

Unsure

Patient7

MM

61IgG

kappa

Unsure

Unsure

Yes

No

No

Dermatol Ther (Heidelb) (2020) 10:815–827 821

Table2

continued

Diagnosis

Age

ofdiagno

sis

MM

type

Genetics(atdiagno

sis)

Genetics

(current)

Bon

edamage

Hypercalcem

iaOsteopenia

Patient8

Smoldering,M

M62

IgA

kappa

Del(13q)/monosom

y13

Trisomy15–6

0%

Trisomy9–

80%

Trisomy7–

60%

Unsure

No

No

No

Patient9

MM

62Unsure

Del(13q)/monosom

y

13–1

1%

t(11;14)—16%

Unsure

No

Yes

Yes

Patient

10

MGUS

60IgAkappa

Unsure

Unsure

Unsure

Unsure

Unsure

Patient

11

MM

58IgG

kappa

11;14

Cytoplasm

ickappa—

6%

CD20

CD138—

5%

t(11;14)

Yes

No

No

Patient

12

MGUS,

MM

62IgG

kappa

CD38

CD138

Cytoplasm

ickappa

Unsure

No

No

Yes

Patient

13

MM

47IgAlambda

Del(17)—33%

Unsure

No

No

No

Patient

14

MM

45IgAlambda

Unsure

Unsure

Unsure

Unsure

Unsure

Patient

15

Smoldering,M

M63

IgG

kappa

t(11;14)—17%

Unsure

Yes

No

No

822 Dermatol Ther (Heidelb) (2020) 10:815–827

Table2

continued

Diagnosis

Age

ofdiagno

sis

MM

type

Genetics(atdiagno

sis)

Genetics

(current)

Bon

edamage

Hypercalcem

iaOsteopenia

Patient

16

Smoldering

46IgG

kappa

Del(13q)—

26%

Trisomy3,

7

Trisomy5,

9,15–9

3%

Gain1q21—2%

Del(13q)—

26%

No

No

Yes

Patient

17

MM

53Unsure

Del(17p)

t(11;14)

CD138

CD38

Cytoplasm

ickappa—

42%

None

Yes

Yes

Yes

Patient

18

MM

69IgG

kappa

t(11;14)

t(11;14)—44%

Gain1q21—30%

No

Yes

Unsure

Survey

questionsweresent

topatientsviaHealth

Tree,aplatform

that

allowspatientsto

navigate

myelomaover

thelifetim

eof

theirdisease

Dermatol Ther (Heidelb) (2020) 10:815–827 823

respondents, 29.4% reported bone damage (e.g.,fracture), 16.7% reported hypercalcemia, and33.3% reported osteopenia.

Out of all respondents, Patients 1, 6, 10, and16 had received treatment with systemic thera-pies: ixekizumab (anti-IL17), apremilast (anti-PDE4), ustekinumab (anti-IL12/IL23), and cer-tolizumab (anti-TNF), respectively. These fourpatients affirmed that systemic psoriasis treat-ment did not worsen their initial MM, with twopatients demonstrating temporary or unclearimprovement in MM control following systemictherapy. No other differences specific to thissubgroup of patients were found.

Consent for publication was received fromthe index patient; the digitally crowdsourcedpatient data were determined to be exempt bythe Western Institutional Review Board (IRB)under exemption code 45 CFR § 46.104(d)(2).This case report was conducted according to theprinciples of good clinical practice guidelinesICH GCP and according to the ethical principlesof the Declaration of Helsinki.

DISCUSSION AND CONCLUSIONS

To our knowledge, no studies have examinedthe clinical characteristics and treatment ofpatients diagnosed with both psoriasis andmyeloma, prompting our examination of thissubpopulation using HealthTree. MM is ahematologic cancer of terminally differentiatedplasma cells with an increasing global burden,accounting for approximately 10% of allhematologic malignancies in the US in 2017 [7].Patients present with a distinct set of symptomsindicating monoclonal gammopathy as thecause of end-organ damage, including hyper-calcemia, renal insufficiency, anemia, and bonedisease with lytic lesions. In combination withthese clinical features, a diagnosis is madebasedon blood and urine laboratory tests,imaging, and bone marrow aspiration or biopsy.While smoldering myeloma and monoclonalgammopathy of undetermined significance(MGUS) often precede MM, treatment is nottypically initiated until disease progresses toMM, a more symptomatic state. Followingdiagnostic workup and risk stratification,

treatment strategy typically involveschemotherapy followed by autologous stem celltransplantation or immunomodulatory main-tenance to prevent future MM recurrence.Patients are followed with prognostic markersincluding M-protein, bone marrow biopsy, andkappa and lambda free light chain (FLC) con-centrations to assess for myeloma progression.

Among respondents who did know theirmyeloma genetic diagnosis, only four sub-types—IgG kappa, IgA kappa, IgA lambda, andIgM lambda—out of ten possible subtypes wererepresented. The majority of respondents wereIgG kappa, which suggests that future researchis needed to determine whether patients withcertain myeloma subtypes may have a predis-position toward the development of psoriasis,or vice versa.

Our case series gives important insights forpatients with a dual diagnosis of psoriasis andMM. Epidemiologic studies have shown thatpsoriatic patients have elevated risks for theincidence of certain cancers such as lymphoma,possibly due to chronic inflammatory processes[8]. Regarding MM, a study of[ 890,000 psori-asis patients and 4.4 million age- and sex-mat-ched controls showed an elevated incidence ofMM in psoriasis patients (HR 1.26 [95% CI1.07–1.48]) [9]. Moreover, the use of certainsystemic immunotherapies for the managementof psoriasis may increase the risk of cancer. Forexample, use of anti TNF-a biologics has beenassociated with increased non-melanoma skincancer rates, particularly for cutaneous squa-mous cell carcinoma [10].

Several immunomodulators and biologictherapies for psoriasis currently exist, includingbut not limited to adalimumab, etanercept,infliximab, certolizumab, tildrakizumab,guselkumab, risankizumab, ustekinumab, bro-dalumab, ixekizumab, and secukinumab. Whilethe literature has not reported on the use ofbiologic therapies for the specific managementof psoriasis in patients affected by MM, the useof these biologics has been studied in MMpatients with other diseases of immune etiol-ogy, including Crohn’s disease and rheumaticarthritis. In two case studies of MM patientswith Crohn’s disease, neither adalimumab norinfliximab worsened MM symptom severity,

824 Dermatol Ther (Heidelb) (2020) 10:815–827

while etanercept used for rheumatic arthritiswas non-significantly associated with reducedrisk of MM in a retrospective case-control study[11–13]. No other studies examined the use ofbiologics for psoriasis in patients with MM,pointing to the need for additional research onimmunomodulatory biologics in patients withpsoriasis and MM.

Our index patient with psoriasis and MMwastreated with ixekizumab, an IL-17 inhibitor. IL-17 is a known molecular driver of psoriasis, andrecent preclinical research has also implicatedthe involvement of IL-17 in MM disease pro-gression [14, 15]. For instance, anti-IL-17Ahuman monoclonal antibody (mAb) adminis-tration has demonstrated the ability to reduceMM proliferation, growth, and progressive bonedamage in mice [15]. In this study, Prabhalaet al. demonstrated that anti-IL-17A mAbdownregulates MM cell growth by blocking IL-6production and significantly reducing osteo-clast proliferation. Immune-competent mousestudies showed a significant reduction in tumorvolume following subcutaneous mAb injection.Earlier studies further elucidated the role of IL-17 production by T-helper 17 (TH17) cells inpromoting MM cell growth and contributing togeneral immune dysfunction [14]. IL-17 leads tomyeloma cell colony formation, adhesion tobone marrow stromal cells, and significantlyincreased growth in vivo in murine xenograftmodels using MM patient tissue. Interestingly, arecent publication by Duffield et al. indicatedthat in classical Hodgkin lymphoma the IL-17/IL-23 axis is also key to the ongoing pathogen-esis, which is resistant to checkpoint inhibitionby existing anti-PD-1 drugs [16]. Therefore,further study of anti-IL-17 biologic use in pso-riasis patients with MM, and potentially otherhematologic malignancies, is warranted. Ourfirst patient demonstrated temporary improve-ment in her MM biomarkers after startingixekizumab, but discontinued ixekizumab after2 months because of lack of psoriasis efficacyand unclear effect of ixekizumab on her MMbiomarkers in the long term. It will be inter-esting to determine whether IL-17 blockade isbeneficial in blocking the progression of thesemalignancies and whether such therapy can besafely used in the setting of psoriasis or other

anti-IL-17 approved conditions such as psoriaticarthritis and ankylosing spondylitis.

HealthTree is a powerful tool that enablesthe clinical study of health data from myelomapatients who are also diagnosed with otherconditions, including psoriasis. This case seriesis an example of how crowdsourcing can facili-tate the easy collection of deidentified clinicaldata of patients across the globe to enableresearch and analysis for accelerated treatmentfindings and practices. For instance, the preva-lence of psoriasis and myeloma is between0.91% and 3.15% in the US, respectively, andthe co-occurrence would have been even rarer,but HealthTree allowed us to quickly reach ourtarget demographic for clinical study [17]. Thisincludes the gathering of valuable clinicalcharacteristics—for instance, our study reportsthat patients generally develop psoriasis muchearlier than MM with an average difference of21.2 years in time of diagnosis, which hasimplications for close monitoring of psoriasistherapies given new malignant diagnoses.

Our survey results show that among the fourpatients who had been treated with systemicimmunotherapies for psoriasis, none reportedthe worsening of myeloma during the studyperiod. Encouragingly, two patients indicated atemporary (Patient 1) or unclear (Patient 16)improvement in MM progression as indicatedby the prognostic markers described above (M-protein, kappa FLC, and kappa to lambda FLCratios). Specifically, Patient 1 was treated withixekizumab, an IL-17 inhibitor, and demon-strated a temporary improvement in her mye-loma prognostic markers for 2 months beforereverting back to her original trajectory. There-fore, our results warrant further investigation ofthe use of systemic immunotherapies such asixekizumab in treating patients with psoriasisand MM.

In conclusion, the analysis of crowdsourcedhealth data through platforms such as Health-Tree can yield significant results for treatmentof dermatologic conditions such as psoriasis.This case series is the first to examine the clin-ical characteristics and treatment of patientsdiagnosed with both psoriasis and MM.Encouraging results from four patients in thisstudy indicate that systemic biologic

Dermatol Ther (Heidelb) (2020) 10:815–827 825

immunotherapies for psoriasis can potentiallybe used in individuals with comorbid malig-nancies such as MM. Further research in thisarea, particularly the use of anti-IL-17 biologics,should be explored.

ACKNOWLEDGEMENTS

We thank the participants of the study.

Funding. No funding or sponsorship wasreceived for this study or publication of thisarticle. Wilson Liao is funded in part by grantsfrom the National Institutes of Health(U01AI119125) and has served as a researchinvestigator for Abbvie, Amgen, Janssen,Novartis, Pfizer, Regeneron, Sanofi, and TRexBio. Jenny M. Ahlstrom has served as a patientadvisor for BMS, Amgen, Takeda, and Janssen.Myeloma Crowd has received funding forHealthTree from Takeda, Sanofi, and GSK.

Authorship. All named authors meet theInternational Committee of Medical JournalEditors (ICMJE) criteria for authorship for thisarticle, take responsibility for the integrity ofthe work as a whole, and have given theirapproval for this version to be published.

Disclosures. Joy Q. Jin, Jenny M. Ahlstrom,Nathan W. Sweeney have nothing to disclose.Wilson Liao is a member of the journal’s Edi-torial Board.

Compliance with Ethics Guidelines. Con-sent for publication was received from the indexpatient; the digitally crowdsourced patient datawere determined to be exempt by the WesternInstitutional Review Board (IRB) under exemp-tion code 45 CFR § 46.104(d)(2). This casereport was conducted according to the princi-ples of good clinical practice guidelines ICHGCP and according to the ethical principles ofthe Declaration of Helsinki.

Open Access. This article is licensed under aCreative Commons Attribution-NonCommer-cial 4.0 International License, which permitsany non-commercial use, sharing, adaptation,

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