Relationship between smoking and the clinical severity of psoriasis

Prevalence of smoking, alcohol consumption and metabolic syndrome in patients with psoriasis

BACKGROUND

Coexistence of obesity, hypertension, insulin resistance and dyslipidemia is defined as metabolic syndrome (MBS), which is among the important risk indicators for cardiovascular diseases, diabetes and stroke. Smoking and alcohol consumption are the other factors which lead to an increase in the risk of cardiovascular disease.

OBJECTIVE

To investigate the prevalence of metabolic syndrome, smoking and alcohol consumption in psoriasis patients and the relationship between disease severity and these factors.

METHODS

This cross-sectional study enrolled 563 patients with chronic plaque-type psoriasis, all of which completed a questionnaire and underwent a complete physical examination. Data about MBS components, psoriasis severity/duration, smoking and alcohol consumption, and cardiovascular diseases were recorded.

RESULTS

A total of 563 patients with ages ranging from 18 to 78 years were evaluated. Metabolic syndrome was found in 12.6% of the patients [central obesity (38.7%), hypertension (14.3%), dyslipidemia (18.6%), diabetes (9.2%)], while 50.3% had smoking, and 3.3% had alcohol consumption. Patients with metabolic syndrome were older and more likely to have a longer disease duration than those without metabolic syndrome (p<0.05 for each). The prevalence of metabolic syndrome was higher in women than in men. Psoriasis was more severe in patients with central obesity, diabetes and smoking than in those without (p<0.05 for each).

STUDY LIMITATIONS

Retrospective design.

CONCLUSIONS

Our results indicate that MBS is a risk factor for psoriasis patients with advanced age. The relationship between disease severity and obesity, diabetes, and smoking in psoriasis patients indicates that the patients should be informed about the potential metabolic risks and receive therapies for behavioral changes besides anti-psoriatic treatment in order to minimize these risks.

Psoriasis and Cardiovascular Comorbidities: Focusing on Severe Vascular Events, Cardiovascular Risk Factors and Implications for Treatment

Psoriasis is a common and chronic inflammatory disease of the skin. It may impair the physical and psychosocial function of patients and lead to decreased quality of life. Traditionally, psoriasis has been regarded as a disease affecting only the skin and joints. More recently, studies have shown that psoriasis is a systemic inflammatory disorder which can be associated with various comorbidities. In particular, psoriasis is associated with an increased risk of developing severe vascular events such as myocardial infarction and stroke. In addition, the prevalence rates of cardiovascular risk factors are increased, including hypertension, diabetes mellitus, dyslipidemia, obesity, and metabolic syndrome. Consequently, mortality rates have been found to be increased and life expectancy decreased in patients with psoriasis, as compared to the general population. Various studies have also shown that systemic treatments for psoriasis, including methotrexate and tumor necrosis factor-α inhibitors, may significantly decrease cardiovascular risk. Mechanistically, the presence of common inflammatory pathways, secretion of adipokines, insulin resistance, angiogenesis, oxidative stress, microparticles, and hypercoagulability may explain the association between psoriasis and cardiometabolic disorders. In this article, we review the evidence regarding the association between psoriasis and cardiovascular comorbidities, focusing on severe vascular events, cardiovascular risk factors and implications for treatment.

Histological study on the effect of nicotine on adult male guinea pig thin skin

Tobacco smoking has been identified as an important factor in premature skin aging to detect the histological changes occurred in adult male guinea pig thin skin under the influence of low and high doses of nicotine; which constitutes approximately 0.6%–3.0% of the dry weight of tobacco. Fifteen adult male pigmented guinea pigs were equally divided into three groups: group I, control; group IIA, low dose nicotine treated; 3 mg/kg subcutaneously for 4 weeks; and group IIB, high dose nicotine treated; 6 mg/kg subcutaneously for 4 weeks. Specimens from the back thin skin were processed for light and electron microscopy. Nicotine administration revealed flattened dermo-epidermal junction and reduced rete ridges formation. Collagen bundles were disorganized with increased spaces between them. A reduction in the amount of elastic fibers in the dermis were also observed compared to group I. Ultrastructurally, keratinocytes had hyperchromatic nuclei, intracytoplasmic vacuoles, disruption of desmosomal junctions, irregular tonofilaments distribution, and increased inter-cellular spaces. These changes were more pronounced with high dose nicotine administration. The epidermal thickness was reduced in low dose nicotine administration. But, high dose nicotine administration revealed increased epidermal thickness compared to the control group. Nicotine induced structural changes of adult male guinea pig thin skin. These changes were more pronounced with high dose nicotine administration.

'New to me': changing patient understanding of psoriasis and identifying mechanisms of change. The Pso Well® patient materials mixed-methods feasibility study

Background

Psoriasis is an inflammatory long‐term condition involving comorbidities, unhealthy lifestyle and significant life impact. Patients’ understanding of psoriasis is limited and support lacking. The Common‐Sense Model of Self‐Regulation of Health and Illness emphasizes the role of illness and treatment beliefs on coping and self‐management. New ‘Pso Well^®’ patient materials informed by the model, addressed psoriasis as a long‐term condition, medication management and lifestyle behaviours.

Objectives

To investigate whether Pso Well^® materials (i) broaden understanding of psoriasis without increasing anxiety; (ii) are acceptable; and (iii) comprise features that appear to effect change.

Methods

The Revised Illness Perceptions Questionnaire (IPQ‐R modified) and the Hospital Anxiety and Depression Scale (HADS) were administered in patients before and after intervention. Numerical rating scales assessed perceptions of change in understanding and anxiety resulting from engagement with the materials. Qualitative interviews explored acceptability and perceived ‘active ingredients’.

Results

Fifty‐five patients completed pre‐ and postintervention questionnaires (56% female; median age 59 years). Postintervention, a large effect size was indicated in two IPQ‐R domains – illness coherence [t(55) = −3·48, P = 0·001 (two‐tailed), η² = 0·19] and personal control [t(55) = −2·98, P = 0·004 (two‐tailed), η² = 0·14] – and a medium effect in one, treatment control [t(55) = −2·08, P = 0·042 (two‐tailed), η² = 0·08]. HADS scores did not change. For numerical rating scales, 80% of participants reported increased understanding of psoriasis and none reported increased anxiety. Interviews with 19 patients indicated the materials were acceptable and usable. Factors reported to broaden understanding and promote engagement with self‐management included linking of related disease aspects, personally relevant content and high‐quality design.

Conclusions

High‐quality, theory‐based psoriasis materials are acceptable to patients and can improve understanding and sense of control without increasing anxiety.

What's already known about this topic?

Psoriasis is associated with comorbidities, unhealthy lifestyle and significant life impact.

Patients’ understanding of psoriasis is limited, self‐management support is lacking and disengagement from healthcare services is common.

What does this study add?

The new, theory‐informed Pso Well^® patient materials address psoriasis as a long‐term condition; medications management and lifestyle behaviour.

The Pso Well^® patient materials can increase understanding of psoriasis, promote feelings of self‐worth and encourage a desire to engage in self‐management and behaviour change, without increasing anxiety or depression.

What are the clinical implications of this work?

The Pso Well^® patient materials could support clinical consultations by helping patients recognize the remitting–relapsing nature of psoriasis.

This will help to improve understanding of the disease, as well as providing a clearer rationale for treatment adherence and lifestyle behaviour change.

Linked Comment: Prinsen. Br J Dermatol 2017; 177:616–617

The Clinical Profile of Patients with Psoriasis in Korea: A Nationwide Cross-Sectional Study (EPI-PSODE)

BACKGROUND

Psoriasis is an immune-mediated, chronic inflammatory disease affecting multiple aspects of patients' lives. Its epidemiology varies regionally; however, nationwide epidemiologic data on psoriasis depicting profile of Korean patients has not been available to date.

OBJECTIVE

To understand nationwide epidemiologic characteristics and clinical features of adult patients with psoriasis visited university hospitals in Korea.

METHODS

This multicenter, non-interventional, cross-sectional study recruited 1,278 adult patients with psoriasis across 25 centers in Korea in 2013. Various clinical data including PASI, BSA, DLQI, SF-36 and PASE were collected.

RESULTS

A total of 1,260 patients completed the study (male:female=1.47:1). The mean age was 47.0 years with a distribution mostly in the 50s (24.9%). Early onset (<40 years) of psoriasis accounted for 53.9% of patients. The mean disease duration was 109.2 months; mean body mass index was 23.9 kg/m2; and 12.7% of patients had a family history of psoriasis. Plaque and guttate types of psoriasis accounted for 85.8% and 8.4%, respectively. Patients with PASI ≥10 accounted for 24.9%; patients with body surface area ≥10 were 45.9%. Patients with DLQI ≥6 accounted for 78.8%. Between PASI <10 and PASI ≥10 groups, significant difference was noted in age at diagnosis, disease duration, blood pressure, waist circumference of female, and treatment experiences with phototherapy, systemic agents, and biologics.

CONCLUSION

This was the first nationwide epidemiologic study of patients with psoriasis in Korea and provides an overview of the epidemiologic characteristics and clinical profiles of this patient population.

Exploring the link between cadmium and psoriasis in a nationally representative sample

Psoriasis, a skin inflammatory disease, originates from dysregulated interactions of the immune system. Cadmium, an environment pollutant, increases the levels of inflammation markers and influences the immune system. To clarify the relationship between cadmium and psoriasis, 5,927 participants, ≥20 years, in the National Health and Nutrition Examination Survey (NHANES) 2003–2006 were studied. Psoriasis severity was assessed using self-reported dermatology questionnaires. Cadmium was measured using blood chemistry. Three adjusted models were applied for the interaction between serum cadmium and severity of psoriasis. Psoriasis patients had significantly higher blood cadmium (0.67 vs. 0.52 μg/L, p = 0.006). There was a strong linear increase in predicted blood cadmium values with an increase in severity of psoriasis (p for trend = 0.002). The β coefficient of the predicted serum cadmium in the “few patches to extensive psoriasis” group was 0.234 (p = 0.002) after adjusting covariates. Participants with severe psoriasis have higher blood cadmium. Environmental exposure to cadmium can predispose to the worsening of psoriasis. Although there are still limitations in this study, such as not included treatment data, these results have substantial public health implications for the general population, as they demonstrate the importance of cadmium exposure prevention, particularly among psoriasis patients.

Diagnosis and underdiagnosis of comorbidities in psoriasis patients - need for a multidisciplinary approach

BACKGROUND:

Psoriasis is an immune-mediated disease that manifests predominantly in the skin, although systemic involvement may also occur. Although associated comorbidities have long been recognized and despite several studies indicating psoriasis as an independent risk factor for cardiovascular events, little has been done in general medical practice regardind screening. In the United States, less than 50% of clinicians are aware of these recommendations.

OBJECTIVE:

To identify the prevalence of these comorbidities in 296 patients followed up at a university dermatology clinic.

METHODS:

Systematically investigated comorbidity frequencies were compared with general practitioners' registry frequencies. Clinical features correlated with comorbidities were also investigated.

RESULTS:

High prevalences of systematically investigated comorbidities such as hypertension (30%) and dyslipidemia (26.5%) were documented. Conversely, data from general practitioners' records showed that 33% of dyslipidemia cases were undiagnosed and indicated possible underdiagnosis of some comorbidities. Furthermore, an association was found between: the number of comorbidities and psoriasis duration, age and high body mass index an association was found between the number of comorbidities and psoriasis duration, age, high body mass index, waist circumference or waist-to-hip ratio. (p<0.05).

CONCLUSION:

Disease duration, age and high body mass index, waist circumference or waist-to-hip ratio are possible criteria for choosing which patients should be screened for comorbidities. Underdiagnosis of comorbidities by general practitioners highlights the need for a multidisciplinary approach in psoriasis management.

Myocardial scintigraphy - a method for detecting cardiac comorbidity in psoriasis patients?

BACKGROUND

In recent years, cardiac comorbidities in psoriasis patients have increasingly moved into the focus of clinical research. The objective of the present study was to evaluate myocardial scintigraphy as a screening method in patients with psoriasis.

PATIENTS AND METHODS

Assessment of various comorbidities in 50 psoriasis patients without clinical symptoms of cardiac disease. Myocardial scintigraphy was employed to detect cardiac risk/exercise-induced ischemia.

RESULTS

Twenty-eight patients (56 %) had pathological findings on myocardial scintigraphy. Fourteen individuals showed evidence of small-vessel disease (cardiac syndrome X). Other comorbidities included obesity, arterial hypertension, nicotine and alcohol abuse, as well as elevated CRP levels. Frequencies largely corresponded to those reported in the recent literature. There was no significant correlation between the severity of psoriasis or any comorbidities and pathological findings on myocardial scintigraphy.

CONCLUSIONS

Myocardial scintigraphy seems to be a very sensitive, noninvasive method for the early detection of cardiac comorbidities in psoriasis patients. However, determining its true diagnostic value will require larger studies with control subjects and control methods such as coronary angiography.

'I should have taken that further' - missed opportunities during cardiovascular risk assessment in patients with psoriasis in UK primary care settings: a mixed-methods study

BACKGROUND

Unhealthy lifestyle is common in psoriasis, contributing to worsening disease and increased cardiovascular disease (CVD) risk. CVD risk communication should improve patients' understanding of risk and risk-reducing behaviours; however, the effectiveness of risk screening is debated and evaluation currently limited.

OBJECTIVE

To examine the process of assessing for and communicating about CVD risk in the context of psoriasis.

DESIGN

Mixed-methods study in English general practices to (i) determine proportions of CVD risk factors among patients with psoriasis at risk assessment and (ii) examine patient and practitioner experiences of risk communication to identify salient 'process' issues. Audio recordings of consultations informed in-depth interviews with patients and practitioners using tape-assisted recall, analysed with framework analysis.

PARTICIPANTS

Patients with psoriasis (n = 287) undergoing CVD risk assessment; 29 patients and 12 practitioners interviewed.

RESULTS

A high proportion of patients had risk factor levels apparent at risk assessment above NICE recommendations: very high waist circumference (52%), obesity (35%), raised blood pressure (29%), smoking (18%) and excess alcohol consumption (18%). There was little evidence of personalized discussion about CVD risk and behaviour change support in consultations. Professionals reported a lack of training in behaviour change, while patients wanted to discuss CVD risk/risk reduction and believed practitioners to be influential in supporting lifestyle management.

CONCLUSIONS

Despite high levels of risk factors identified, opportunities may be missed in consultations to support patients with psoriasis to understand CVD risk/risk reduction. Practitioners need training in behaviour change techniques to capitalize on 'teachable moments' and increase the effectiveness of risk screening.

Psoriasis and smoking: links and risks

Smoking is a complex environmental exposure influenced by genetic, environmental, and social factors. Nicotine is the principal alkaloid in tobacco that mediates the addicting effects of tobacco products. Tobacco is a mixture of more than 7,000 chemicals, and smoking is recognized as a risk factor for many diseases in humans, including cardiovascular and pulmonary disease and several cancers, and is the single most preventable cause of mortality worldwide. A number of inflammatory immune-related conditions have been associated with smoking, including psoriasis. Smoking affects the onset of psoriasis. In a pooled analysis of 25 case-control studies, the odds ratio of psoriasis among smokers was 1.78 (95% confidence interval [CI]: 1.53-2.06). A dose-effect relationship is also documented. In a pooled analysis of three cohort studies, the risk of incident psoriasis was 1.81 (95% CI: 1.38-2.36) in those who smoked 1-14 cigarettes per day, and 2.29 (95% CI: 1.74-3.01) in those who smoked ≥25 cigarettes per day. Smoking also impacts on the clinical severity of psoriasis, its response to treatment, and explains some of the associated comorbidities, eg, cardiovascular disease, inflammatory bowel disease, and several cancers (especially those of the respiratory tract). Data on the role of smoking in psoriatic arthritis are less consistent compared with those concerning psoriasis. Several pathophysiological mechanisms may explain the association of psoriasis with smoking, including oxidative stress, interaction with signaling pathways active in psoriasis, and vascular influences. In conclusion, psoriasis is just one of the many diseases associated with smoking, but it is visible and disabling. Dermatologists could play a major role in reducing the health burden of smoking by influencing the patients to change their behavior.

Integrating lifestyle-focused approaches into psoriasis care: improving patient outcomes?

Psoriasis is one of the most well described cutaneous disorders, with a large body of literature devoted to describing its pathogenesis and treatment. In recent years, attention has turned toward the mechanisms by which lifestyle can impact psoriatic disease, and how lifestyle interventions may help to alleviate cutaneous, rheumatological, and comorbid disease in the setting of psoriasis. The following review explores our current understanding of the interaction between lifestyle factors and psoriasis and describes outcomes of interventions meant to target these factors.

A multileveled approach in psoriasis assessment and follow-up: A proposal for a tailored guide for the dermatological practice

BACKGROUND

Psoriasis is a complex and heterogeneous disease resulting from interactions between genetic, immunological, and environmental factors. To make the most optimal treatment decision, the dermatologist must therefore have a detailed overview of the patient's history and lifestyle.

OBJECTIVES

We sought to offer an overview of the various relevant aspects in clinical dermatological assessment of psoriasis patients, emphasizing the importance of a multidisciplinary and integrated clinical approach.

METHODS

We gathered information on psoriasis management and developed a tailored checklist covering all health-related aspects associated with psoriasis.

RESULTS

Demographics, personal and family history were elaborately described as well as drug history to discuss how they affect psoriasis management. Relevant patient information such as the vaccination status or cardiovascular profile were included in the checklist as well and treatment recommendations were adapted and updated in accordance with evidence-based literature. This checklist also emphasizes the importance of drug surveillance, proper follow-up and specialist referral, and why the dermatologist needs to address these health-related aspects when assessing psoriasis patients, going beyond optimal skin care.

CONCLUSIONS

Our comprehensive overview can be used as a consultation checklist for good clinical practice in psoriasis patient management and aid in treatment decision.

Psoriasis and Smoking: A Systematic Literature Review and Meta-Analysis With Qualitative Analysis of Effect of Smoking on Psoriasis Severity

BACKGROUND

Smoking has been associated with psoriasis prevalence and severity.

OBJECTIVE

To evaluate prevalence of smoking in patients with psoriasis and to examine the relationship between smoking and psoriasis severity.

METHODS

MEDLINE, EMBASE, and Cochrane databases (1960-2012) and conference proceedings (2010-2012) were systematically searched using keywords relevant to psoriasis and smoking. Controlled studies addressing psoriasis and smoking status were included. A meta-analysis for the relative risk of smoking in psoriasis patients was performed.

RESULTS

Meta-analysis identified a significant association between smoking and psoriasis with a relative risk of 1.88 (95% CI, 1.66-2.13) for smoking in patients with psoriasis versus patients without psoriasis. Eight articles of 11 with data on smoking and psoriasis severity suggested that severity increases with smoking status.

CONCLUSIONS

This literature review is in favor of a positive association between the prevalence of smoking and psoriasis as well as an association between smoking and severity of psoriasis.

The role of personal models in clinical management: Exploring health care providers' beliefs about psoriasis

OBJECTIVES

Individuals' illness representations, including beliefs about psoriasis (a complex immune-mediated condition), and their emotional responses to the condition guide self-management behaviour. It is also plausible that health care providers' illness representations guide their own management of psoriasis. Patients commonly report poor health care experiences related to psoriasis, and the role of health care providers' beliefs, emotions, as well as their knowledge, experiences and behaviours ('personal models') in this is unexplored. This study aimed explore health care providers' personal models of psoriasis.

DESIGN AND METHODS

Qualitative analysis of 23 semi-structured interviews with health care professionals providing care for psoriasis patients was performed. Purposive sampling achieved maximum variation regarding participant discipline, level of experience, gender and age. The self-regulatory/common sense model informed data collection and initial data analysis. Principles of framework analysis were used to generate predetermined and emergent key issues related to practitioners' personal models.

RESULTS

Three types of personal model emerged. Sophisticated-Linear Model: 70% of practitioners recognized psoriasis as a complex condition but managed it as a skin condition. Mixed Model: 17% of practitioners recognized/managed some elements of psoriasis as complex and some as a skin condition. Sophisticated-Sophisticated Model: 13% recognized and managed psoriasis as a complex condition. Across the data set, five themes emerged illustrating key patterns underpinning these different models including (1) Recognising complexity, (2) Putting skin first, (3) Taking on the complexities of psoriasis with the patient, (4) Aiming for clearance, and (5) Affective experiences within psoriasis consultations.

CONCLUSIONS

Health care providers recognized psoriasis as a complex condition but commonly reported managing psoriasis as a simple skin condition. Providers' beliefs and management approaches varied in the extent to which they were consistent with one another; and their emotional experiences during consultations may vary depending upon their personal model. Findings could inform future dermatology training programmes by highlighting the role of health care providers' illness representations in clinical management of the condition.

STATEMENT OF CONTRIBUTION

What is already known on this subject? Health behaviour is predicted by underlying beliefs and emotions associated with an illness and its treatment. Few studies have examined health care providers' beliefs and emotions about the illnesses they manage in clinical practice. Many patients are dissatisfied with dermatology consultations and wish to be treated holistically. What does this study add? Qualitative exploration of health care providers' beliefs/emotions revealed their personal models of psoriasis. Providers' personal models of psoriasis vary in coherence and are often skin rather than whole person focused. Further investigation of health care providers' models of psoriasis and their impact on health outcomes is needed.

Psoriasis: classical and emerging comorbidities

Psoriasis is a chronic inflammatory systemic disease. Evidence shows an association of psoriasis with arthritis, depression, inflammatory bowel disease and cardiovascular diseases. Recently, several other comorbid conditions have been proposed as related to the chronic inflammatory status of psoriasis. The understanding of these conditions and their treatments will certainly lead to better management of the disease. The present article aims to synthesize the knowledge in the literature about the classical and emerging comorbidities related to psoriasis.

Evidence-based Recommendations for the Management of Comorbidities in Rheumatoid Arthritis, Psoriasis, and Psoriatic Arthritis: Expert Opinion of the Canadian Dermatology-Rheumatology Comorbidity Initiative

Objective.

Comorbidities such as cardiovascular diseases (CVD), cancer, osteoporosis, and depression are often underrecognized in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), or psoriasis (PsO). Recommendations may improve identification and treatment of comorbidities. The Canadian Dermatology-Rheumatology Comorbidity Initiative reviewed the literature to develop practical evidence-based recommendations for management of comorbidities in patients with RA, PsA, and PsO.

Methods.

Eight main topics regarding comorbidities in RA, PsA, and PsO were developed. MEDLINE, EMBASE, and the Cochrane Library (1960–12/2012), together with abstracts from major rheumatology and dermatology congresses (2010–2012), were searched for relevant publications. Selected articles were analyzed and metaanalyses performed whenever possible. A meeting including rheumatologists, dermatologists, trainees/fellows, and invited experts was held to develop consensus-based recommendations using a Delphi process with prespecified cutoff agreement. Level of agreement was measured using a 10-point Likert scale (1 = no agreement, 10 = full agreement) and the potential effect of recommendations on daily clinical practice was considered. Grade of recommendation (ranging from A to D) was determined according to the Oxford Centre for Evidence-Based Medicine evidence levels.

Results.

A total of 17,575 articles were identified, of which 407 were reviewed. Recommendations were synthesized into 19 final recommendations ranging mainly from grade C to D, and relating to a large spectrum of comorbidities observed in clinical practice: CVD, obesity, osteoporosis, depression, infections, and cancer. Level of agreement ranged from 80.9% to 95.8%.

Conclusion.

These practical evidence-based recommendations can guide management of comorbidities in patients with RA, PsA, and PsO and optimize outcomes.

Comorbidities and cardiovascular risk factors in patients with psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease and its pathogenesis involves an interaction between genetic, environmental, and immunological factors. Recent studies have suggested that the chronic inflammatory nature of psoriasis may predispose to an association with other inflammatory diseases, especially cardiovascular diseases and metabolic disorders.

OBJECTIVES

To describe the demographic, clinical, epidemiological, and laboratory characteristics of a sample of psoriasis patients; to assess the prevalence of cardiovascular comorbidities in this group of patients; and to identify the cardiovascular risk profile using the Framingham risk score.

METHODS

We conducted a cross-sectional study involving the assessment of 190 patients. Participants underwent history and physical examination. They also completed a specific questionnaire about epidemiological data, past medical history, and comorbidities. The cardiovascular risk profile was calculated using the Framingham risk score.

RESULTS

Patients' mean age was 51.5 ± 14 years, and the predominant clinical presentation was plaque psoriasis (78.4%). We found an increased prevalence of systemic hypertension, type 2 diabetes, metabolic syndrome, and obesity. Increased waist circumference was also found in addition to a considerable prevalence of depression, smoking, and regular alcohol intake. Patients' cardiovascular risk was high according to the Framingham risk score, and 47.2% of patients had moderate or high risk of fatal and non-fatal coronary events in 10 years.

CONCLUSIONS

Patients had high prevalence of cardiovascular comorbidities, and high cardiovascular risk according to the Framingham risk score. Further epidemiological studies are needed in Brazil for validation of our results.

Impact of a Performance Improvement CME activity on the care and treatment of patients with psoriasis

BACKGROUND

The Performance Improvement (PI) CME format improves physician performance in other specialties but data are lacking in dermatology.

OBJECTIVE

We sought to assess the impact of a PI CME activity on physician practice patterns for patients with psoriasis, which was developed, implemented, and evaluated by the American Academy of Dermatology (AAD), in part to assist dermatologists in fulfilling Part IV of their Maintenance of Certification requirements.

METHODS

In this PI CME activity, participants: (1) self-audited patient charts, which met inclusion criteria in stage A, and reflected on their results, benchmarked against peers; (2) reviewed educational materials in stage B and developed an improvement plan; and (3) self-audited a different set of patient charts following the plan's implementation. Aggregate stage A and C data were analyzed using χ(2) tests.

RESULTS

We found a statistically significant improvement in the advisement of patients with psoriasis regarding their increased risk for cardiovascular disease, to contact their primary care provider for cardiovascular risk assessment, and in shared decision making regarding the treatment plan. We also found an overall statistically significant improvement in history taking per the guidelines.

LIMITATIONS

Learner chart selection bias, self-reporting of chart data, and lack of a control group are limitations.

CONCLUSIONS

The AAD psoriasis PI CME activity demonstrated significantly improved dermatologists' documentation of patient's history, counseling of patients for lifestyle behaviors, and shared decision making.

Psoriasis and Diabetes: A Multicenter Study in 222078 Type 2 Diabetes Patients Reveals High Levels of Depression

OBJECTIVE

This study aimed to investigate the association between psoriasis and disease outcome in type 2 diabetes (T2D).

METHODS

222078 T2D patients (≥10 years old) from the prospective, multicenter diabetes patient registry were analyzed. Specific search items were used to identify psoriasis patients. Multiple regression models were fitted and adjusted for demographic confounder.

RESULTS

232 T2D patients had comorbid psoriasis. After adjusting psoriasis patients revealed a higher BMI (31.8 [31.0; 32.6] versus 30.6 [30.5; 30.6] kg/m2, p = 0.004) and HbA1c (64.8 [62.1; 67.6] versus 59.0 [58.9; 59.1] mmol/mol, p < 0.0001). Insulin was used more frequently (62.3 [55.7; 68.5] versus 50.9 [50.7; 51.1] %, p = 0.001), only OAD/GLP-1 was similar, and nonpharmacological treatment was less common (13.3 [9.5; 18.3] versus 21.9 [21.7; 22.1] %, p = 0.002). Severe hypoglycemia (0.31 [0.238; 0.399] versus 0.06 [0.057; 0.060] events per patient-year, p < 0.0001), hypertension (86.1 [81.1; 90.0] versus 68.0 [67.8; 68.2] %, p < 0.0001), and thyroid disease (14.0 [10.1; 19.2] versus 4.6 [4.5; 4.7] %, p < 0.0001) were more prevalent. Depression occurred more often (10.5 [7.1; 15.2] versus 2.8 [2.7; 2.8] %, p < 0.0001).

CONCLUSIONS

Clinical diabetes characteristics in psoriasis T2D patients were clearly worse compared to patients without psoriasis. Comorbid conditions and depression were more prevalent, and more intensive diabetes therapy was required.

Psoriasis and smoking: a systematic review and meta-analysis

Psoriasis is an inflammatory skin disease associated with increased cardiovascular comorbidity. Smoking is associated with an increased risk of cardiovascular disease, and prior studies have suggested that patients with psoriasis are more likely to be active smokers. Smoking may also be a risk factor in the development of psoriasis. We conducted a systematic review and meta-analysis to assess the prevalence of smoking among patients with psoriasis, and we reviewed the contribution of smoking to the incidence of psoriasis. A total of 25 prevalence and three incidence studies were identified. The meta-analysis of prevalence studies included a total of 146 934 patients with psoriasis and 529 111 patients without psoriasis. Random effects meta-analysis found an association between psoriasis and current smoking [pooled odds ratio (OR) 1·78, 95% confidence interval (CI) 1·52-2·06], as well as between psoriasis and former smoking (pooled OR 1·62, 95% CI 1·33-1·99). Meta-regression analysis did not reveal any sources of study heterogeneity, but a funnel plot suggested possible publication bias. A subset of studies also examined the association between moderate-to-severe psoriasis and smoking, with a pooled OR of 1·72 (95% CI 1·33-2·22) for prevalent smoking. The three incidence studies found an association between smoking and incidence of psoriasis, with a possible dose-effect of smoking intensity and duration on psoriasis incidence. These findings suggest that smoking is an independent risk factor for the development of psoriasis, and that patients with established psoriasis continue to smoke more than patients without psoriasis.

Providing lifestyle behaviour change support for patients with psoriasis: an assessment of the existing training competencies across medical and nursing health professionals

BACKGROUND

Psoriasis is associated with unhealthy lifestyle behaviours which contribute to psoriasis onset and severity. Health professionals who manage patients with psoriasis are well placed to support lifestyle change but few feel confident to do so. Little is known about the extent to which health promotion and lifestyle behaviour change (LBC) skills are included within post-qualification training curricula.

OBJECTIVES

This study aimed to systematically examine the content of post-qualification U.K. training curricula for health professionals across General Practice and Dermatology for evidence of behaviour change skills relating to the promotion of healthy lifestyles.

METHODS

Core curricula documents from professional organizations were analysed for content to examine the extent to which curricula: (1) mentioned health promotion and LBC as part of the professional role; and/or (2) included health promotion and LBC as explicit training competencies or requirements for qualification.

RESULTS

Of the 11 core curricula documents analysed, we found 67 occurrences of terms related to LBC and health promotion. Most were in the General Practitioner curriculum (n = 42; 62·7%), followed by the Dermatology Specialist Nurse curriculum (n = 14; 20·9%) and Dermatologist curriculum (n = 11; 16·4%). No occurrences were found in the General Practitioner with a Special Interest in Dermatology curriculum. LBC knowledge, skills and attitudes were not clearly specified and only basic level LBC competencies were included.

CONCLUSIONS

Development of post-qualification curricula would ensure health professionals are equipped with the necessary knowledge, skills and attitudes to support LBC for patients with psoriasis. This is of particular relevance, given the evidence linking unhealthy lifestyles with psoriasis outcomes.

Combined effects of the BDNF rs6265 (Val66Met) polymorphism and environment risk factors on psoriasis vulgaris

Smoking, alcohol consumption and higher body mass index (BMI) are well established risk factors for psoriasis and also associated with the clinical traits of the disease. And the genetic influences on these three risk factors indeed exist. Previously studies have demonstrated these risk factors related genetic variants may also play a role in the development of risk factors-related diseases. Then we performed a hospital-based study in order to evaluate the combined effect of the risk factors and their related polymorphism rs6265 in brain-derived neurotrophic factor (BDNF) gene on psoriasis vulgaris (PV) risk and clinic traits. The case-control study involved 660 subjects including 345 cases and 315 controls in Chinese Han population. The variant of rs6265 was typed by SNaPshot Multiplex Kit (Applied Biosystems Co., USA). We confirmed that higher BMI (≥25), smoking and alcohol consumption were risk factors for PV, and the estimated ORs were 1.63(95 % confidence interval (CI); 1.12-2.37), 2.09(95 % CI; 1.44-3.03) and 1.65(95 % CI; 1.15-2.37) respectively. Genotype and allele distributions did not differ significantly between case and control. However, we found combined effect of rs6265 genotype (GG) and higher BMI (≥25) increased risk of PV (OR = 2.09; 95 % CI, 1.02-4.28; P < 0.05; adjusted OR = 3.19; 95 % CI, 1.37-7.45; P < 0.05) and clinically severity of PV (OR = 2.71; 95 % CI, 1.09-6.72; P < 0.05; adjusted OR = 1.25; 95 % CI, 1.10-1.40; P < 0.05). But none such significant combined effect was observed between others genotype (AA and AG) and other risk factors. In conclusions, the combined effect of BDNF rs6265 genotype (GG) and higher BMI may increases the risk and clinical severity of PV in Chinese Han population.

Prevalence of psoriasis among adults in the U.S.: 2003-2006 and 2009-2010 National Health and Nutrition Examination Surveys

BACKGROUND

A 2010 CDC-sponsored consultation of psoriasis, psoriatic arthritis, and public health experts developed a public health agenda for psoriasis and psoriatic arthritis indicating that additional population-based research is needed to better characterize psoriasis in the population.

PURPOSE

To better characterize the burden of psoriasis in the U.S. using recent population-based, cross-sectional data in this 2012 analysis.

METHODS

A subset of 10,676 adults aged 20-59 years from the 2003-2006 and 2009-2010 National Health and Nutrition Examination Surveys was used to examine psoriasis prevalence, severity, disparities, health-related quality of life, and selected comorbidities.

RESULTS

The overall prevalence of psoriasis was 3.1% (95% CI=2.6, 3.6); extrapolating to older adults suggests that 6.7 million adults aged ≥20 years are affected. Psoriasis was significantly more prevalent among non-Hispanic whites than other race/ethnicity subgroups, as well as among those with arthritis. Approximately 82% reported no/little or mild disease; the impact of psoriasis on daily life increased with disease severity (p=0.0001 for trend). Those with psoriasis reported significantly more frequent mental distress or mild to severe depression than those without psoriasis. Psoriasis was also significantly associated with obesity and former smoking status.

CONCLUSIONS

Psoriasis is a large public health problem. Further characterizing psoriasis from a public health perspective will require better survey questions and inclusion of these questions in national surveys.

Demography, baseline disease characteristics and treatment history of patients with psoriasis enrolled in a multicentre, prospective, disease-based registry (PSOLAR)

BACKGROUND

Psoriasis is associated with several comorbidities and behavioural risk factors.

OBJECTIVES

To evaluate demographic and disease characteristics in patients enrolled in the Psoriasis Longitudinal Assessment and Registry (PSOLAR).

METHODS

PSOLAR is a global, prospective, longitudinal, disease-based registry that includes a postmarketing commitment to evaluate safety in patients with psoriasis. Enrolled patients had to be receiving, or be eligible to receive, conventional systemic or biological agents. Demographic/disease characteristics, medical histories, lifestyle risk factors and previous treatments are collected at enrolment. Efficacy and safety data are collected every 6 months for 8 years, and data are extracted annually. Selected parameters are evaluated by age quartile using post hoc analyses.

RESULTS

As of 23 August 2012, 11 900 patients were enrolled at 301 sites in North America, Europe and Latin America. Over half of the PSOLAR population (54·7%) is male, with a mean age of 48·6 years and mean body mass index of 30·9 kg m(-2) at enrolment. Mean duration of disease at enrolment was 17·5 years, and mean Physician's Global Assessment score was 2·0. Psoriatic arthritis (35·5%) and cardiovascular diseases (38·2%) were highly prevalent. Diabetes mellitus type II was reported in 11·4% of patients. Depression and anxiety were noted in 14·7% and 11·1% of patients, respectively; 79·0% reported any alcohol use and 56·7% reported smoking or a history of smoking. The occurrence of most comorbidities, including cardiovascular disease and risk factors, increased with age.

CONCLUSIONS

In the PSOLAR population, multiple and age-appropriate comorbidities are associated with psoriasis and may affect the selection of psoriasis treatments.

Role of AhR/ARNT system in skin homeostasis

Aryl hydrocarbon receptor (AhR) is a ligand-dependent transcription factor that binds to structurally diverse synthetic and naturally occurring chemicals including dioxins, flavonoids, tryptophan photoproducts, and Malassezia metabolites. Upon binding to its ligands, cytoplasmic AhR translocates to the nucleus, heterodimerizes with aryl hydrocarbon receptor nuclear translocator (ARNT), and mediates numerous biological and toxicological effects by inducing the transcription of various AhR-responsive genes. AhR ligation controls oxidation/antioxidation, epidermal barrier function, photo-induced response, melanogenesis, and innate immunity. This review summarizes recent advances in the understanding of the regulatory mechanisms of skin homeostasis mediated by the AhR/ARNT system.

Severity of Psoriasis Among Adult Males is Associated with Smoking, Not with Alcohol Use

Context:

Lifestyle factors such as tobacco smoking and alcohol use can affect the presentation and course of psoriasis. There is a paucity of data on this subject from India.

Aims:

To find out whether increased severity of psoriasis in adult Indian males is associated with tobacco smoking and alcohol use.

Settings and Design:

Cross-sectional study in the Department of Dermatology of a Tertiary Care Teaching Hospital.

Subjects and Methods:

Male patients above 18 years of age attending a psoriasis clinic between March 2007 and May 2009 were studied. Severity of psoriasis (measured using Psoriasis Area and Severity Index – PASI) among smokers and non-smokers was compared. We also studied the correlation between severity of psoriasis and nicotine dependence (measured using Fagerström Test for Nicotine Dependence) and alcohol use disorders (measured using Alcohol Use Disorders Identification Test–AUDIT).

Statistical Analysis:

Z-test, Odd's ratio, Chi-square test, Spearman's correlation coefficient.

Results:

Of a total of 338 patients, 148 were smokers and 173 used to consume alcohol. Mean PASI score of smokers was more than that of non-smokers (Z-test, z = −2.617, P = 0.009). Those with severe psoriasis were more likely to be smokers (χ² = 5.47, P = 0.02, OR = 1.8, Confidence Interval 1.09-2.962). There was a significant correlation between PASI scores and Fagerström score (Spearman's correlation coefficient = 0.164, P < 0.01). Mean PASI scores of persons who used to consume alcohol and those who did not were comparable.(Z-test, z = −0.458, P = 0.647). There was no association between severity of psoriasis and alcohol consumption.(χ² = 0.255, P = 0.613, Odds Ratio = 1.14, CI 0.696-1.866). There was no correlation between PASI scores and AUDIT scores (Spearman's correlation coefficient = 0.024, P > 0.05).

Conclusions:

Increased severity of psoriasis among adult males is associated with tobacco smoking, but not with alcohol use.

Combined effect between CHRNB3-CHRNA6 region gene variant (rs6474412) and smoking in psoriasis vulgaris severity

BACKGROUND

Many factors associated with causing psoriasis have been reported, such as the genetic and environmental factors. Smoking is one of the well-established environmental risk factors for psoriasis and also associated with the disease severity. In addition, several studies of psoriasis and psoriatic arthritis have documented gene-environment interactions involving smoking behavior. Although gene polymorphisms on nicotinic acetylcholine receptor subunits CHRNB3-CHRNA6 region gene have been found to correlate with smoking behavior and lung cancer susceptibility in Chinese Han population, the combined effect between the smoking-related genetic variants and smoking behavior on psoriasis vulgaris (PV) has been unreported.

OBJECTIVE

To evaluate the combined effect of the smoking-related (rs6474412-C/T) polymorphism on CHRNB3-CHRNA6 region gene and smoking behavior on PV risk and clinic traits in Chinese Han population.

METHODS

A hospital-based case-control study including 672 subjects (355 PV cases and 317 controls) was conducted. The variant of rs6474412 was typed by SNaPshot Multiplex Kit (Applied Biosystems Co., USA).

RESULTS

The higher body mass index (BMI≥25), smoking behavior and alcohol consumption were risk factors for PV, and the estimated ORs were 1.55 (95% CI, 1.09-2.29), 1.74 (95% CI, 1.22-2.49) and 1.81 (95% CI, 1.25-2.62) respectively. The smoking patients had more severe conditions than non-smokers (OR=1.71, 95% CI, 1.08-2.70, P=0.020). The alleles and genotypes of rs6474412 were not associated with risk of PV, but the combined effect of rs6474412 genotype (TT) and smoking behavior increased severity of PV (OR=5.95; 95% CI, 1.39-25.31; P<0.05; adjusted OR=2.20; 95% CI, 1.55-3.14; P<0.001).

CONCLUSIONS

Our results demonstrate that the combined effect of rs6474412-C/T polymorphism in smoking-related CHRNB3-CHRNA6 region gene and smoking behavior may not confer risk to PV, but may have impact on PV severity in Chinese Han population.

Clinical and histologic diagnostic guidelines for psoriasis: a critical review

Psoriasis is a common inflammatory skin disease that is associated with joint, psychiatric, and cardiovascular comorbidities. Diagnosis of plaque psoriasis is dependent primarily on characteristic physical findings and history. Given the varied clinical presentations of psoriasis and its mimicry to other papulosquamous skin diseases, it may be difficult for nondermatologists to diagnose psoriasis. Currently, no diagnostic criteria for plaque psoriasis have been validated in clinical studies. In this paper, we provide diagnostic guidelines for the nondermatologist to aid them in recognizing psoriasis.

Smoking and delay to diagnosis are associated with poorer functional outcome in psoriatic arthritis

OBJECTIVE

To identify predictors of poorer physical function in established psoriatic arthritis (PsA).

METHODS

PsA patients with disease duration of ≥10 years were identified from the Bath longitudinal cohort. Physical function was assessed using the Stanford Health Assessment Questionnaire (HAQ). Sex, age at diagnosis, duration of symptoms prior to diagnosis, smoking, treatment and year of diagnosis were included in a multivariable regression analysis to identify associations with HAQ.

RESULTS

267 patients were identified for inclusion. The median age was 56 years (IQR 45-63), median disease duration was 13 years (IQR 10-18) and median HAQ score was 0.63 (IQR 0.13-1.25). The model predicted significant increases in HAQ related to smoking (0.23, 95% CI 0.04 to 0.42), age >50 years at diagnosis (0.27, 95% CI 0.03 to 0.51), symptom duration of ≥1 year before diagnosis (0.22, 95% CI 0.02 to 0.42), female sex (0.39, 95% CI 0.20 to 0.57) and history of treatment with an anti-TNF agent (0.63, 95% CI 0.32 to 0.93) at follow-up.

CONCLUSIONS

Smoking, delay to diagnosis, older age at diagnosis, female sex and a history of anti-TNF treatment are associated with worse physical function in established PsA.

The role of focal infections in the pathogenesis of psoriasis and chronic urticaria

INTRODUCTION

The Focal Infection Theory, originally presented at the beginning of the 20(th) century, postulates that systemic diseases can be caused by microorganisms that arise from the focus of infection. Foci of infections have been described as sinuses, adenoids, tonsils, teeth, genitourinary tract, gall bladder and kidneys. A focus of infection is defined as the area that can occur in any part of the body, contains a pathogen (microorganism) and is usually asymptomatic. There are discordant opinions about the role of focal infections in the pathogenesis of psoriasis and urticaria.

AIM

To establish whether there is a higher incidence of focal infections in patients with chronic urticaria and psoriasis.

MATERIAL AND METHODS

We retrospectively reviewed 129 patients with a history of psoriasis and chronic urticaria: 58 women and 71 men treated in the Department of Dermatology of the Jagiellonian University Medical College in Krakow.

RESULTS

In the analyzed group, 11 patients had a dental consultation, 58 - laryngological consultation and 29 women had a gynecological consultation. The most common examples of focal infection were tonsillitis, upper respiratory tract infections, sinusitis, dental caries and genitourinary tract infections. Aggravating factors were similar to previously described.

CONCLUSIONS

A high incidence of focal infections in patients with psoriasis and urticaria suggests that infections may play a significant role in the pathogenesis of these skin disorders. Treatment of infection foci may play the key role in the remission of skin changes.

Nuclear hormone receptor functions in keratinocyte and melanocyte homeostasis, epidermal carcinogenesis and melanomagenesis

Skin homeostasis is maintained, in part, through regulation of gene expression orchestrated by type II nuclear hormone receptors in a cell and context specific manner. This group of transcriptional regulators is implicated in various cellular processes including epidermal proliferation, differentiation, permeability barrier formation, follicular cycling and inflammatory responses. Endogenous ligands for the receptors regulate actions during skin development and maintenance of tissue homeostasis. Type II nuclear receptor signaling is also important for cellular crosstalk between multiple cell types in the skin. Overall, these nuclear receptors are critical players in keratinocyte and melanocyte biology and present targets for cutaneous disease management.

Modifiable lifestyle factors associated with metabolic syndrome in patients with psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory skin disease, which is associated with obesity and with cardiovascular morbidity and mortality.

AIM

To evaluate modifiable lifestyle factors including stress level, physical activity and nutrition, which may be associated with metabolic syndrome in patients with psoriasis.

METHODS

In total, 65 patients with psoriasis and 52 control subjects from our university dermatology clinic were enrolled in this case-control pilot study. The study questionnaire included the Perceived Stress Scale (PSS), the Godin Leisure-Time Exercise Questionnaire (GLTEQ) and the Rapid Eating Assessment for patients (REAP). For subjects with psoriasis, the Psoriasis Area and Severity Index (PASI) was measured.

RESULTS

Subjects with psoriasis (mean BMI 27.72) displayed a trend towards a higher BMI compared with controls (mean BMI 25.67). Subjects with psoriasis were not found to have an increased prevalence of self-reported metabolic syndrome-associated diseases including diabetes, heart disease, high cholesterol, hypertension or stroke compared with controls (P=0.25, P=0.46, P=0.96, P=0.26, and P=0.16, respectively). There was no significant difference in exercise or stress between patients with psoriasis and controls (P=0.06 and P=0.26, respectively). However, compared with controls, subjects with psoriasis (mean REAP score=2.23) did report poorer overall nutrition as assessed by the REAP score (mean=2.38, P<0.01). Among subjects with psoriasis, the factors of stress, smoking and systemic therapy were associated with increased PASI (r=0.13, r=3.47 and r=3.19, respectively).

CONCLUSIONS

Our study suggests that poor dietary and exercise habits may be factors contributing to obesity and metabolic syndrome in patients with psoriasis. Further studies with larger numbers are needed to confirm these results.

Pilot study on which foods should be avoided by patients with psoriasis

FUNDAMENT: Psoriasis is a chronic inflammatory systemic disease mediated by immune factors. We will explore the foods that act on these factors contributing to psoriasis. As a systemic disease, which shares the same pathophysiological substrate with other comorbidities, diet also leads to worsening of comorbidities.

OBJECTIVE

To indicate a group of foods that can act as a factor of manifestation and/or aggravation of psoriasis and, at the same time, enable strategies for individuals to introduce these foods to their diet.

METHODS

43 patients with various forms of psoriasis (excluding pustular and erythrodermic psoriasis) were selected and answered a questionnaire about their eating habits in the first visit, with special attention to the consumption of black coffee, black tea, chocolate, yerba mate, pepper, smoked foods, beef and flavor enhancer (monosodium glutamate). Next, the patient was instructed to suspend alcoholic drinks and tobacco.

RESULTS

Beef is the most consumed food by patients followed by MSG (monosodium glutamate), which exists in processed foods, yerba matte, black coffee, chocolate, smoked foods, pepper and black tea. 88.37% noticed reduced scaling and erythema, milder outbreaks during the year and improved quality of life; 11.63% (5 patients) did not notice any effects on the skin.

CONCLUSION

We found poor dietary intake in patients with psoriasis. In addition to receiving proper scientific advice, patients need to be educated regarding their eating habits for a better quality of life and as an adjuvant to the drug therapy.