Relationship between smoking and the clinical severity of psoriasis

Smoking and risk of incident psoriatic arthritis in US women

OBJECTIVES

Psoriatic arthritis (PsA) is an inflammatory arthritis that is associated with psoriasis. Previous studies have found an association between smoking and psoriasis, but the association with PsA is unclear. The authors aimed to evaluate the association between smoking and the risk of incident PsA in a large cohort of women.

METHODS

94 874 participants were included from the Nurses' Health Study II over a 14-year period (1991-2005). Information on smoking was collected biennially during follow-up. The incidence of clinician-diagnosed PsA was ascertained and confirmed by self-reported questionnaires.

RESULTS

During 1 303 970 person-years' follow-up, the authors identified 157 incident PsA cases. Among total participants, smoking was associated with an elevated risk of incident PsA. Compared with never smokers, the RR was 1.54 for past smokers (95% CI 1.06 to 2.24) and 3.13 for current smokers (95% CI 2.08 to 4.71). With increasing smoking duration or pack-years, the risk of PsA increased monotonically (p for trend <0.0001). The increase in risk was particularly significant for PsA cases with more severe phenotypes. Secondary analysis among participants developing psoriasis during the follow-up replicated the association, demonstrating an increased risk of PsA among psoriasis cases. The risk was significant for those with higher cumulative measures of smoking or PsA cases with more severe phenotypes.

CONCLUSION

In this study smoking was found to be associated with a risk of PsA and cumulative measures of smoking were also associated with a higher risk of PsA among women.

Psoriasis, a model of dermatologic psychosomatic disease: psychiatric implications and treatments

Psoriasis is a common dermatologic disorder with psychiatric comorbidity that often goes undetected and untreated. Psoriasis has higher associations with psychiatric illness than do other dermatologic conditions. We conducted a comprehensive qualitative review of all published medical literature on psoriasis and psychiatric comorbidities since 2005. We found that psoriasis patients suffer psychiatric and psychosocial morbidity that is not commensurate with the extent of cutaneous lesions. Biologic therapies and nonpharmacologic psychosocial interventions show promise in treating comorbid psychiatric illness. The main limitations of this review are the low quality of published studies and the infrequent use of basic science endpoints in reporting treatment outcomes. The literature examining the psychiatric comorbidity of psoriasis is expanding but remains of variable quality. Stronger studies will be necessary to more accurately estimate comorbidities and help identify and comprehensively treat suffering patients.

[Multiplatform application to determine presence of metabolic syndrome and cardiovascular risk in patients with psoriasis]

Traditionally, psoriasis was considered to be a purely cutaneous disease affecting otherwise healthy patients (except for joint involvement). Recent studies have, however, shown a relationship between psoriasis and cardiovascular disease, with increased mortality in patients who have severe forms of psoriasis. Dermatologists are thus in a position to play an important role in identifying patients at greater risk of cardiovascular disease and detecting potential risk factors that are, for the most part, manageable and avoidable. To this end, we designed a multiplatform application that provides a simple and intuitive tool to determine body mass index, whether or not metabolic syndrome is present, and cardiovascular risk. The application runs on iOS, Android, and the webpage of the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (AEDV).

Psoriasis in patients older than 65 years. A comparative study with younger adult psoriatic patients

OBJECTIVES

To examine the clinical characteristics of psoriasis, prevalence of comorbidities and quality of life in psoriasis patients older than 65 years and to compare them with younger adult psoriatic patients.

DESIGN

Prospective observational study of prevalence.

SETTING AND PARTICIPANTS

Patients older than 18 years with diagnosis of psoriasis attended at the Dermatology Department of the University Hospital of A Coruña (Galicia, Spain). A total of 371 patients were included (218 males and 153 females) with ages ranging from 18 to 85 years, of whom 70 were older than 65 years.

MEASUREMENTS

Demographic data, clinical characteristics and psoriasis treatment, history of hypertension, diabetes mellitus, smoking and alcohol consumption and quality of life impairment were registered. Body mass index, waist-hip ratio, left ventricular hypertrophy, average value of systolic and diastolic blood pressure, cholesterol, triglycerides and glucose blood levels were also measured.

RESULTS

Patients older than 65 years have statistically significant higher prevalence of hypertension, left ventricular hypertrophy, waist-hip ratio, diabetes mellitus and raised blood glucose levels. There was also association between clinical severity of psoriasis and smoking and alcohol intake as well as between quality of life and type of psoriasis treatment.

CONCLUSIONS

Psoriasis in patients older than 65 years represents a significant proportion of cases and its prevalence is expected to increase. Because these patients are more prone to suffer comorbidities and to develop adverse effects due to psoriasis treatment, attention to pharmacologic interactions and correction of cardiovascular risk factors and toxic habits should be especially taken in mind in this age group.

It is not always about gains: utilities and disutilities associated with treatment features in patients with moderate-to-severe psoriasis

BACKGROUND

Patient-centered care has been proposed as a strategy for improving treatment outcomes in the management of psoriasis and other chronic diseases. A more detailed understanding of patients' utilities and disutilities associated with treatment features may facilitate shared decision-making in the clinical encounter. The purpose of this study was to examine the features of psoriasis treatment that are most and least preferred by patients and to identify correlates of these preferences.

METHODS

A cross-sectional survey of 163 patients with moderate-to-severe psoriasis was conducted in a German academic medical center. We assessed patients' characteristics, elicited their preferences for a range of potential treatment features, and quantified preference scores (utilities) associated with each treatment feature using hierarchical Bayes estimation. After identifying the most and least preferred treatment features, we explored correlates of these preferences using multivariate regression models.

RESULTS

Mean preference scores (MPS) for the least preferred treatment features were consistently greater than those for the most preferred treatment features. Patients generally expressed strong preferences against prolonged treatments in the inpatient setting (MPS = -13.48) and those with a lower probability of benefit (MPS = -12.28), while treatments with a high probability of benefit (MPS = 10.51) were generally preferred. Younger patients and women were more concerned with treatment benefit as compared with older patients and men.

CONCLUSION

Both negative and positive preferences appear important for shared decision-making. Recognition of characteristics associated with strong negative preferences may be particularly useful in promoting patient-centered environments.

Smoking and pathogenesis of psoriasis: a review of oxidative, inflammatory and genetic mechanisms

Recent studies suggest that cigarette smoking may trigger the development of psoriasis through oxidative, inflammatory and genetic mechanisms. Smoking initiates formation of free radicals that stimulate cell signalling pathways active in psoriasis including mitogen-activated protein kinase (MAPK), nuclear factor-κB (NF-κB) and Janus kinase/signal transducers and activators of transcription (JAK-STAT). Smoking damages the skin by increasing formation of reactive oxygen species and decreasing the gene expression of antioxidants. Nicotine also stimulates innate immune cells integral to the pathogenesis of psoriasis including dendritic cells, macrophages and keratinocytes. These cells release cytokines that activate T lymphocytes and perpetuate a cycle of chronic inflammation. Smoking also enhances expression of genes known to confer an increased risk of psoriasis, including HLA-Cw6, HLA-DQA1*0201 and CYP1A1. Improved understanding of the possible link between smoking and psoriasis pathogenesis may provide further insight into mechanisms underlying smoking, psoriasis and risk of subsequent cardiovascular disease.

Psoriasis and vascular disease-risk factors and outcomes: a systematic review of the literature

BACKGROUND

Psoriasis afflicts 2-3% of the world's population. Affected patients commonly have risk factors for cardiovascular disease (CVD). In addition, psoriasis is independently associated with CVD and mortality.

PURPOSE

To determine which CVD risk factors are associated with psoriasis independent of confounders, whether psoriasis is associated with CVD independent of CVD risk factors, and whether there is increased mortality among patients with psoriasis.

DATA SOURCES

MEDLINE, Embase, and Cochrane Collaborations from inception through October 2009. We reviewed bibliographies of retrieved articles for additional references.

STUDY SELECTION

Cross-sectional, cohort-based, case-control, and randomized controlled trials which involved patients with psoriasis.

DATA EXTRACTION

Two investigators independently reviewed studies and resolved any discrepancies by consensus.

DATA SYNTHESIS

Of the 2,303 articles identified by literature search, 90 studies met inclusion criteria for this review; 15 were cohort-based studies, 45 were case-control, and 30 were cross-sectional.

LIMITATIONS

The quality of evidence was limited by study heterogeneity and lack of large scale prospective studies with long-term follow-up.

CONCLUSIONS

Patients with psoriasis demonstrate a higher prevalence of cardiovascular risk factors and appear to be at increased risk for ischemic heart disease, cerebrovascular disease, and peripheral arterial disease. This increase in vascular disease may be independent of shared risk factors and may contribute to the increase in all-cause mortality. Future research should aim to more confidently distinguish between a true causal relationship or merely an association resulting from multiple shared risk factors. Physicians should screen for and aggressively treat modifiable risk factors for CVD in patients with psoriasis.

Tobacco smoke is related to Th17 generation with clinical implications for psoriasis patients

Environmental factors contribute to the increased prevalence of autoimmune diseases via T helper type-17 cell (Th17) activation. Tobacco smoking increases the risk of psoriasis, but the mechanisms are not clear. We evaluated the percentage of circulating Th17 among CD3(+) cells in peripheral blood mononuclear cells (PBMC) obtained from 27 healthy volunteers (2.58±0.80%), 33 smoker (3.55±1.33%) and 21 non-smoker (3.10±1.14%) patients with psoriasis to elucidate the relation between smoking and psoriasis. More smokers (19/33) than non-smokers (6/21) had high Th17 levels (Th17/CD3>3.38%, mean+1 SD of healthy volunteers). Tobacco smoke extract (TSE, 7μl/ml) induced Th17 generation from central memory T cells in vitro. TSE increased interleukin 17 and 22 expression. These findings demonstrate the relation between tobacco smoke and IL-17 and IL-22, which exacerbate psoriasis.

Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JYM, Lebwohl M, Leonardi CL, Lim HW, Van Voorhees AS, Beutner KR, Ryan C, Bhushan R. Guidelines of care for the management of psoriasis and psoriatic arthritis: section 6. Guidelines of care for the treatment of psoriasis and psoriatic arthritis: case-based presentations and evidence-based conclusions

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In the first 5 parts of the American Academy of Dermatology Psoriasis Guidelines of Care, we have presented evidence supporting the use of topical treatments, phototherapy, traditional systemic agents, and biological therapies for patients with psoriasis and psoriatic arthritis. In this sixth and final section of the Psoriasis Guidelines of Care, we will present cases to illustrate how to practically use these guidelines in specific clinical scenarios. We will describe the approach to treating patients with psoriasis across the entire spectrum of this fascinating disease from mild to moderate to severe, with and without psoriatic arthritis, based on the 5 prior published guidelines. Although specific therapeutic recommendations are given for each of the cases presented, it is important that treatment be tailored to meet individual patients' needs. In addition, we will update the prior 5 guidelines and address gaps in research and care that currently exist, while making suggestions for further studies that could be performed to help address these limitations in our knowledge base.

A prospective case-controlled cohort study of endothelial function in patients with moderate to severe psoriasis

BACKGROUND

There is well-documented evidence that patients with moderate and severe psoriasis have a significantly increased risk of cardiovascular disease (CVD). While this risk can, at least in part, be attributed to the high prevalence of traditional risk factors in the population with psoriasis, some epidemiological evidence suggests it may be independent of these.

OBJECTIVES

This prospective, case-controlled study investigates whether psoriasis is a risk factor for CVD using two, validated, sensitive markers of CVD, endothelial dysfunction and high-sensitivity C-reactive protein (hsCRP).

METHODS

Patients were recruited from a tertiary referral psoriasis clinic and exclusion criteria included established CVD and/or conventional risks for CVD. Preclinical CVD was assessed using flow-mediated brachial artery dilatation, which measures endothelial dysfunction, and hsCRP, a serological marker of atherosclerosis.

RESULTS

Sixty-four patients (22%) out of a total of 285 consecutive patients attending the severe psoriasis clinic were entered into the study. One hundred and sixty-one (56%) were excluded following identification of cardiovascular risk; 39 of the 161 (24%) had at least two cardiovascular risk factors. A further 16 (6%) patients were excluded because of established CVD. No statistically significant difference in endothelial dysfunction was observed between patients with psoriasis (n = 60) and healthy controls (n = 117) (P = 0·508). The hsCRP level was, however, significantly elevated in the psoriasis group (2·828 mg L(-1), SEM 0·219; controls 0·728 mg L(-1), SEM 0·142; P < 0·05).

CONCLUSION

This large, investigative study is the first to assess endothelial function in patients with psoriasis after exclusion of traditional risk factors for CVD. These data suggest that psoriasis per se is not a risk factor for CVD and that elevated hsCRP is possibly independent of atheroma risk. There was a high prevalence of traditional risk factors in our population with severe psoriasis.

Tobacco and the skin

Smoking negatively impacts the health of the skin as it does every organ system. This contribution reviews the effect of cigarette smoking on wound healing, wrinkling, and aging of the skin, skin cancer, psoriasis, and other inflammatory skin diseases, hidradenitis suppurativa, acne, alopecia, lupus erythematosus, polymorphous light eruption, and tobacco-associated oral lesions. Dermatologists need to encourage their patients to discontinue this deleterious habit.

Relationship between smoking-induced oxidative stress and the clinical severity of psoriasis

BACKGROUND

Psoriasis is a chronic and recurrent inflammatory skin disease, known as an oxidative stress condition. Smoking augments the risk of development of psoriasis. Although the relative importance of potential mechanisms of smoking-induced psoriasis is unknown, direct delivery of oxidants has been implicated in the pathogenesis of smoking-induced psoriasis.

OBJECTIVES

This study aimed to investigate the smoking-induced oxidative stress in psoriatic patients and its correlation with the severity of the disease.

METHODS

The levels of malondialdehyde (MDA) and superoxide dismutase (SOD) were measured in 25 psoriatic patients (10 smokers, 10 non-smokers and 5 ex-smokers) and 20 healthy control subjects (10 smokers and 10 non-smokers). Clinical severity of psoriasis was determined according to the Psoriasis Area Severity Index (PASI) score.

RESULTS

Our results showed a significant increase in serum MDA and decrease in the blood SOD levels in psoriatic patients compared with those in control subjects and those in smokers compared with those in non-smokers. The concentrations of MDA and SOD were significantly correlated with PASI score. There was a significant increase in PASI score in smoker patients compared with that in non-smokers and it increased with increasing the pack-years of smoking.

CONCLUSIONS

Our results indicate that smoking-induced oxidative damage resulting from increased reactive oxygen species production along with insufficient capacity of antioxidant mechanisms may be involved in the pathogenesis of psoriasis.

Cause-specific mortality in patients with severe psoriasis: a population-based cohort study in the U.K

BACKGROUND

Severe psoriasis is associated with excess mortality and increased risk of cardiovascular death. Population-based data evaluating cause-specific mortality in patients with psoriasis are limited.

OBJECTIVES

To describe cause-specific mortality in patients with severe psoriasis.

METHODS

We performed a cohort study from 1987 to 2002 of patients ≥18 years using the General Practice Research Database. We compared patients with a psoriasis code and a history of systemic therapy consistent with severe psoriasis (n=3603) with patients with no history of psoriasis (n=14,330). Age- and sex-adjusted Cox models were created for each of the leading causes of death defined by the Centers for Disease Control.

RESULTS

Patients with severe psoriasis were at increased risk of death from cardiovascular disease [hazard ratio (HR) 1·57, 95% confidence interval (CI) 1·26-1·96], malignancies (HR 1·41, 95% CI 1·07-1·86), chronic lower respiratory disease (HR 2·08, 95% CI 1·24-3·48), diabetes (HR 2·86, 95% CI 1·08-7·59), dementia (HR 3·64, 95% CI 1·36-9·72), infection (HR 1·65, 95% CI 1·26-2·18), kidney disease (HR 4·37, 95% CI 2·24-8·53) and unknown/missing causes (HR 1·43, 95% CI 1·09-1·89). The absolute and excess risk of death was highest for cardiovascular disease (61·9 and 3·5 deaths per 1000 patient-years, respectively).

CONCLUSIONS

Severe psoriasis is associated with an increased risk of death from a variety of causes, with cardiovascular death being the most common aetiology. These patients were also at increased risk of death from causes not previously reported, such as infection, kidney disease and dementia. Additional studies are necessary to determine the degree to which excess causes of death are due to psoriasis, its treatments, associated behaviours, or other factors.

Comorbidities in psoriasis patients

Psoriasis is a chronic inflammatory disorder that affects approximately 2% of the general population. Numerous studies have evaluated the increased prevalence of comorbid diseases and risk factors in psoriatic patients, including obesity, metabolic syndrome, cardiovascular disease, psoriatic arthritis, autoimmune disease, psychiatric illness, liver disease, smoking, malignancy, chronic obstructive pulmonary disease, sleep apnea, and alcohol abuse. Insight into the overlapping pathogenesis of these comorbidities of psoriasis highlights the importance of immune-mediated mechanisms in these disease states. Psoriasis, with its comorbidities, must be approached in a multidisciplinary manner to effectively and comprehensively understand, manage, and treat those with this complex disorder.

Psoriasis and cardiovascular disease

Current epidemiological data support the association between psoriasis and cardiovascular (CV) risk, in apparent correlation with psoriasis severity. Although less unanimously, evidence of an increased prevalence of CV diseases among psoriasis patients has been reported, including ischemic heart disease, cerebrovascular, peripheral vascular and heart structural disorders. In particular, various studies showed a correlation between psoriasis and major CV events (i.e., myocardial infarction, stroke), while others investigated subclinical changes of blood vessels, such as intima-media thickness increase, arterial stiffness and coronary artery calcification. A series of different mechanisms, like traditional CV risk or iatrogenic risk factors, inflammation, hemostasis dysregulation, hyperhomocysteinemia, and shared genetic susceptibility, are thought to underlie this epidemiological association. Among these elements, inflammation and its related cytokine milieu, including Th1-mediated response and Th17/Treg imbalance, C reactive protein and the newly implicated osteopontin are considered to play a primary role, even if yet to be fully understood.

Psoriasis: depression, anxiety, smoking, and drinking habits

Psoriasis is a chronic disease that can negatively impact many aspects of quality of life. Patients with psoriasis may suffer from pain and discomfort from the disease as well as psychological and social difficulties including stigmatization, embarrassment, and social inhibition. Anxiety, depression, smoking, and alcohol abuse have been found to have a higher prevalence among psoriasis patients than healthy controls. These comorbidities have also been found to have a directly negative impact on psoriasis. Awareness of the relationship between psoriasis, psychiatric disorders, and substance abuse is important for dermatologists, as these comorbidities can lead to poor compliance and treatment outcomes.

Update on the epidemiology and systemic treatment of psoriasis

Recent epidemiological observations reveal that the prevalence of psoriasis increases more rapidly in young women compared with young men, and that the prevalence of psoriasis may decrease in the elderly. Emerging evidence suggests that some potentially modifiable exposures, such as smoking, stress and obesity, may increase a patient's risk of developing psoriasis. The evolving literature suggests that psoriasis is associated with multiple other diseases, including cancer, cardiovascular disease, diabetes and psychiatric disease, and that psoriasis itself may be an independent risk factor for developing atherosclerosis and myocardial infarction. The treatment of moderate-to-severe psoriasis is undergoing a revolution with the advent of biological therapies that target the immunopathogenesis of psoriasis, such as tumor necrosis factor-alpha and T-cell function. The pharmacokinetics, pharmacodynamics, efficacy and safety profiles vary among biologicals and, therefore, drug and patient factors are important in selecting the optimum therapy. In this article, we focus on recent developments in the epidemiology and systemic treatment of psoriasis.

Cardiovascular Disease and Risk Factors in Patients with Psoriasis and Psoriatic Arthritis

Objective.

Patients with psoriasis and psoriatic arthritis (PsA) have an increased incidence of cardiovascular disease (CVD) and cardiovascular risk factors such as smoking, hypertension, and metabolic syndrome compared to the normal population. Patients with psoriasis and PsA may also have increased risk from nonconventional risk factors such as raised levels of homocysteine and excessive alcohol consumption. We conducted a comprehensive review of the literature on CVD and all cardiovascular risk factors in patients with psoriasis and PsA.

Methods.

Data sources: All studies identified from a Medline (www.ncbi.nlm.nih.gov) search pertaining to CVD, individual risk factors in psoriasis, and PsA were included. Study selection: Studies included a healthy reference population, were published between 1975 and 2009, and were written in English.

Results.

Our search yielded 14 studies that documented rates of CVD in patients with psoriasis and PsA compared to controls. Substantial evidence points to elevated risk of CVD in patients with psoriasis and PsA.

Conclusion.

It remains difficult to conclude if risk factors are caused by psoriasis or share a common pathogenesis. Physicians treating patients with psoriasis and PsA must be aware of all potential cardiovascular risk factors in their patients.

Integrative dermatology for psoriasis: facts and controversies

Recommendations for changes in diet and lifestyle are not meant to supplant conventional therapy but to integrate with it and, hopefully, improve response to treatment. At the same time, integrative approaches permit the patient to depend less on more expensive and potentially harmful pharmaceutical and medical approaches. Manipulation of diet and lifestyle may actually diminish the effect of underlying predisposing or etiologic factors and simultaneously treat serious comorbidities. Topics include alcohol, smoking, body composition, sleep and stress, diet and nutrients, and exercise.

Immune mechanisms of psoriasis. New strategies of biotherapy

Psoriasis is a chronic skin disease - according to numerous studies, about 2% of the population suffer from it. Psoriasis degrades the life quality, and such concomitant pathologies as metabolic disorders, cardiovascular diseases and depression shorten the life expectancy of psoriasis patients. Substantial progress has been achieved today in understanding the mechanisms of the disease, searching for new treatment techniques and standardizing the disease severity According to the recent studies, psoriasis belongs to immune-dependent diseases with genetic predisposition to its development. Dendritic cells and T lymphocytes play an important part in psoriasis development. Their interaction launches a number of mechanisms ultimately leading to the inflammatory process development and formation of psoriatic skin affections. Such cytokines as IL-12, IL-23, IFN-y and TNF-a secreted by immunocompetent cells serve as mediators during such processes. An advanced therapeutic approach to the treatment of psoriasis means creating pathogenetically important cytokine specific monoclonal antibodies and placing them into the body Today there are drugs successfully blocking the development of psoriatic skin affections by means of specific binding of IL-12, IL-23 and TNF-a cytokines. Drugs called ustekinumab and ABT-874 confirmed their therapeutic activity with regard to psoriasis at Phases 2 and 3 of clinical trials. In the course of further trials, ustekinumab also demonstrated a safety profile comparable to that of placebo.

Relationships between obesity and the clinical severity of psoriasis in Taiwan

BACKGROUND

Obesity has been found to be associated with an increased risk of psoriasis in general population. However, studies addressing the relationship between obesity and clinical severity of psoriasis are still scarce, especially in Asian people.

OBJECTIVES

In this study, we investigated the relationship between levels of obesity and the clinical severity of psoriasis in Taiwanese psoriasis patients.

METHODS

This was a hospital-based cross-sectional study. A total of 399 patients with chronic plaque psoriasis were recruited. Their body mass index (BMI) was calculated as weight in kilograms divided by height in metres squared and was categorized into four groups (BMI < 24, normal; 24 <or= BMI < 27, overweight; 27 <or= BMI < 30, mild obesity; and BMI >or= 30, moderate-to-severe obesity). Disease severity was assessed by Psoriasis Area and Severity Index. Cumulative logistic regression models were used to estimate the association between BMI and Psoriasis Area and Severity Index.

RESULTS

After adjusting for potential confounders (age, gender, cigarette smoking and duration of disease), moderate-to-severe obesity was significantly associated with an increased risk of clinically more severe psoriasis when compared with normal BMI [odds ratio, 2.70; 95% confidence interval,1.42-5.11]. There is a significant linear trend for clinically more severe psoriasis across increasing of BMI categories (P for trend = 0.004). The effect of obesity on the severity of psoriasis was greater in men than in women (test for interaction, P = 0.03).

CONCLUSIONS

In psoriasis patients, obesity is associated with a more severe disease, especially in men. Bodyweight control may be important for the management of psoriasis.

Cardiovascular risk factors in high-need psoriasis patients and its implications for biological therapies

BACKGROUND

The associations between psoriasis and cardiovascular risk factors are reported to be stronger as psoriasis severity increases. This makes studying cardiovascular risk factors in high-need psoriasis patients, eligible for biological therapy, interesting.

OBJECTIVE

To survey the prevalence of cardiovascular risk factors in high-need psoriasis patients and to compare these data to patients with other dermatological diseases. Furthermore, the implications of these findings for treatment with biologics were outlined.

METHODS

The prevalence of cardiovascular risk factors was investigated in a high-need psoriatic patient cohort and compared to patients with other skin diseases who filled out a questionnaire about the presence of cardiovascular risk factors.

RESULTS

A significantly higher prevalence of obesity, smoking, and hypertension was found for the high-need psoriatic patients' cohort compared with non-psoriatic controls. Striking differences were found with respect to body mass index and obesity, as 35.5% of all high-need psoriatic patients were obese.

CONCLUSIONS

High-need psoriatic patients show a high prevalence of cardiovascular risk factors, and may consequently be predisposed to cardiovascular diseases. As this is relevant for therapy management in daily clinical practice, especially biologics, cardiovascular risk should be evaluated for each high-need psoriasis patient before and during systemic treatment.

Long-term prognosis in patients with psoriasis

Psoriasis is a chronic, inflammatory, immune-mediated skin disease associated with substantial comorbidity. Traditional comorbid conditions include psychological/psychiatric disorders, psoriatic arthritis and inflammatory bowel disease. Increasingly, an association with metabolic dysfunction, including obesity and the metabolic syndrome, and cardiovascular disease, with consequent effects on morbidity and mortality, has been recognized in psoriasis. The underlying inflammatory mechanisms of both psoriasis and psoriasis-associated comorbidities involve mediation by proinflammatory T-helper type 1 cytokines. For effective management of psoriasis and related comorbidities, an integrated approach targeting both cutaneous and systemic inflammation may be beneficial, and strategies to improve overall management of the patient should be encouraged to reduce the disease burden. This paper discusses the emerging role of biological agents in this approach, and offers an appreciation of the role of existing anti-psoriasis and adjunctive therapies.

Combined effects of HLA-Cw6 and cigarette smoking in psoriasis vulgaris: a hospital-based case-control study in China

BACKGROUND

Psoriasis is not only related to genetic factors but also to environmental factors. However, the combined effect of genetic and environmental factors in the development of psoriasis has still been unclear.

OBJECTIVE

The study was to analyze the combined effect of HLA-Cw6 and smoking on psoriasis vulgaris.

METHODS

A hospital-based case-control was conducted study. One hundred seventy-eight cases and 178 controls received this epidemiological investigation and HLA typing by polymerase chain reaction utilizing sequence-specific primers.

RESULTS

The risk of psoriasis was related to smoking, the adjusted odds ratio (OR) being 2.07 (P < 0.01), and there is a graded positive association between the risk of psoriasis and intensity or duration of smoking. Stressful life events increased the risk of psoriasis (OR = 7.87, P < 0.01). We found the waist-hip ratio (WHR) increased the risk of psoriasis vulgaris, and OR was 2.67 (P < 0.01) in China. Individuals harboring the HLA-Cw6 gene obviously increased the risk of psoriasis, OR being 9.93 (P < 0.01) after adjusted for potential confounder factors, while the OR of psoriasis for HLA-B57 was 2.41 (P < 0.05). Significant combined effect between HLA-Cw6 and HLA-B57 for psoriasis was found (OR = 10.51, P < 0.01). A striking finding is that the risk of psoriasis for smokers with HLA-Cw6 increased about 11-fold than non-smokers without HLA-Cw6, and the risk increased some 20-fold in individuals with HLA-Cw6 having stressful life events compared with one without HLA-Cw6 and stressful life events.

CONCLUSION

Our study suggested that the combined effect between HLA-Cw6 and cigarette smoking or stressful life events may play an important role in the development of psoriasis vulgaris in Han Chinese population.

Psoriasis comorbidities

Psoriasis is a chronic and debilitating inflammatory disease associated with serious comorbidities. Psoriasis can have a significant impact on a patient's quality of life and is associated with loss of productivity, depression, and an increased prevalence of malignancy. Emerging comorbidities of psoriasis include cardiovascular disease and metabolic syndrome. Psoriasis patients have an increased prevalence of the core components of metabolic syndrome, including obesity, dyslipidemia, and insulin resistance. The relationship between psoriasis and comorbidities such as metabolic syndrome and cardiovascular disease is likely linked to the underlying chronic inflammatory nature of psoriasis. The molecular mechanisms involved in psoriasis-associated dysregulation of metabolic function are believed to be due, in large part, to the action of increased levels of proinflammatory factors, such as tumor necrosis factor-alpha, that are central to the pathogenesis of psoriasis. Recent studies investigating the effects of tumor necrosis factor antagonists on the treatment of cardiovascular disease and metabolic syndrome support this concept.

Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics

Psoriasis is a common, chronic, inflammatory, multisystem disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this first of 5 sections of the guidelines of care for psoriasis, we discuss the classification of psoriasis; associated comorbidities including autoimmune diseases, cardiovascular risk, psychiatric/psychologic issues, and cancer risk; along with assessment tools for skin disease and quality-of-life issues. Finally, we will discuss the safety and efficacy of the biologic treatments used to treat patients with psoriasis.

Psoriasis and vascular disease: an unsolved mystery

Psoriasis is an immune disease most commonly recognized for its skin and joint manifestations. These produce significant physical, social, and psychological distress in affected patients and resultant reductions in their quality of life. As expected, these concerns are vital in providing symptomatic improvement and in selecting an individualized therapy. Yet, the approach in management of these patients is likely to change given the growing body of evidence linking psoriasis and vascular disease. Stemming from an anecdotally described relationship, the association between psoriasis and vascular disease has become a focus of current research to further elucidate the pathophysiology underlying and connecting these two diseases. This article includes a review of the classical cardiovascular risk factors, the atherothrombotic markers, and the environmental stressors associated with psoriasis, as well as a critical review of the observed vascular diseases, the proposed mechanism of atherosclerosis, and the benefits of treatment of psoriasis.

National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening

There have been several articles and reports in recent months about comorbidities and risks that affect psoriasis patients in addition to their underlying disease. This piece reviews the current literature and begins to address what should be done with this new information by updating the clinician about what health screening tests, preventative exams, and referrals should be considered in this population.

Psoriasis: epidemiology

Psoriasis is a chronic, inflammatory and hyperproliferative skin disease with a genetic basis. While epidermal hyperplasia and altered keratinocyte differentiation are prominent features, considerable evidence indicates that psoriasis is immunologically mediated. Recently, the identification of HLA-Cw6 as the disease allele conferring susceptibility to psoriasis has provided a focus for elucidation of these events. In this article, we will focus on the epidemiology of psoriasis and its associated arthritis.

Smokers report more psoriasis, but not atopic dermatitis or hand eczema: results from a Norwegian population survey among adults

BACKGROUND

Many reports indicate that skin diseases are affected by lifestyle factors.

OBJECTIVE

To examine the relationship between reported skin diagnoses, smoking and alcohol consumption in an urban population.

METHODS

Cross-sectional questionnaire-based health study among 18,747 adults in Oslo.

RESULTS

For current smokers, odds ratio for reporting psoriasis was 1.49 (95% CI 1.11-2.00) for males, and 1.48 (95% CI 1.15-1.91) for females, as compared to never smokers. There was no association between reported atopic dermatitis or hand eczema and smoking. High consumption of cigarettes was associated with an increased reporting of psoriasis in men, but not women. Reporting drinking alcohol 4-7 times per week was crudely associated with reporting psoriasis in men, but not in the adjusted model.

CONCLUSION

Cigarette smoking was associated with reported psoriasis, but not with atopic dermatitis or hand eczema.

Smoking and the risk of psoriasis in women: Nurses' Health Study II

BACKGROUND

Psoriasis is a common, chronic, inflammatory skin disorder. Smoking may increase the risk of psoriasis, but no prospective data are available on this relation.

METHODS

We prospectively examined over a 14-year time period (1991-2005) the relation between smoking status, duration, intensity, cessation, and exposure to secondhand smoke, and incident psoriasis in 78,532 women from the Nurses Health Study II. The primary outcome was incident, self-reported, physician-diagnosed psoriasis.

RESULTS

We documented 887 incident cases of psoriasis. Compared with those who had never smoked, the multivariate relative risk (RR) of psoriasis was 1.78 (95% confidence interval [CI], 1.46 to 2.16) for current smokers and 1.37 (95% CI, 1.17 to 1.59) for past smokers. Compared with nonsmokers, the multivariate RR of psoriasis was 1.60 (95% CI, 1.31 to 1.97) for those who had smoked 11-20 pack-years and 2.05 (95% CI, 1.66 to 2.53) for those who had smoked > or =21 pack-years. Compared with never smokers, the multivariate RR of psoriasis was 1.61 (95% CI, 1.30 to 2.00) for those who quit smoking <10 years ago, 1.31 (95% CI, 1.05 to 1.64) for 10-19 years ago, and 1.15 (95% CI, 0.88 to 1.51) for > or =20 years ago. Prenatal and childhood exposure to passive smoke was associated with an increased risk of psoriasis.

CONCLUSIONS

In this prospective analysis, current and past smoking, and cumulative measures of smoking were associated with the incidence of psoriasis. The risk of incident psoriasis among former smokers decreases nearly to that of never smokers 20 years after cessation.

Heart disease in psoriasis

Psoriasis has been traditionally viewed as an inflammatory skin disorder of unknown origin. Recent advances in the immunopathogenesis and genetics of psoriasis have broadened our understanding of psoriasis. Psoriasis is now considered a systemic inflammatory condition analogous to other inflammatory immune disorders. Patients with other immune disorders, such as systemic lupus erythematosus or rheumatoid arthritis, are known to be at increased risk of heart disease. Similarly, patients with psoriasis may carry an excess risk of heart disease, which would represent an important previously unrecognized cause of morbidity and mortality. This review summarizes the current evidence for an increased cardiovascular risk in patients with psoriasis and outlines deficits in our knowledge in this area.

Unfavorable cardiovascular risk profiles in untreated and treated psoriasis patients

Psoriasis is a chronic inflammatory skin disease that is associated with an increased cardiovascular risk profile. The systemic inflammation present in psoriasis, various systemic treatments for psoriasis and an increased prevalence of unhealthy life style factors may all contribute to this unfavorable risk profile. The purpose of this article is to provide an overview of what is known about these risk factors in psoriasis, the way they influence the cardiovascular risk of psoriasis patients, and what can be done to reduce this risk. Genetic studies demonstrate that psoriasis and cardiovascular disease share common pathogenic features in which, for example inflammatory cytokines like TNF-alpha and IL-1 play an important role. The chronic inflammation in psoriasis has an unfavorable effect on the cardiovascular risk profile. Multiple cardiovascular risk factors seem to be influenced; the blood pressure, oxidative stress, dyslipidemia, endothelial cell dysfunction, homocysteine levels and blood platelet adhesion. Moreover, classic cardiovascular risk factors like smoking and obesity that have an increased prevalence among patients with psoriasis, indirectly also worsen the cardiovascular risk profile by stimulating the psoriasis activity. Systemic treatments in psoriasis reduce the cardiovascular risk by diminishing the inflammation, but it should be taken into account that most therapies also have adverse cardiovascular effects like dyslipidemia, hyperhomocysteinemia and hypertension. As a consequence preventive measures may be indicated at least during long-term treatments. Prospective research is warranted to accurately estimate the increased cardiovascular risk in psoriasis, to determine the underlying processes and to consider preventive measures according to the absolute risk of cardiovascular disease. The present overview provides data to advice health care providers to pay more attention to the cardiovascular risk profile in psoriasis patients.