Risk of Suicidality in People with Psoriasis: A Systematic Review and Meta-Analysis of Cohort Studies

Risk of breast cancer among patients with psoriasis: a systematic review and meta-analysis

Relevant evidence regarding the risk of incident breast cancer in patients with psoriasis is lacking. Hence, this systematic review and meta-analysis aimed to assess the risk of breast cancer in patients with psoriasis. We searched the PubMed, Cochrane Library, and Embase databases from inception to December 31, 2021, for relevant cohort studies without language limitations. The Newcastle-Ottawa Scale was used to determine the quality of the selected papers. A random-effects model meta-analysis was performed to obtain the pooled hazard ratio (HR) with a 95% confidence interval (CI) for breast cancer in relation to psoriasis. We also performed a subgroup analysis of patients with mild-to-moderate-to-severe psoriasis. We included seven cohort studies, all of which were considered high quality, and three of them provided data for meta-analysis. The risk for breast cancer did not increase among patients with psoriasis (pooled HR: 1.11, 95% CI 0.97-1.27; I2 = 67%). In the subgroup analysis, the risk for breast cancer did not significantly increase among patients with mild psoriasis (pooled HR: 1.04, 95% CI 0.97-1.12; I2 = 6%), and the risk for breast cancer did not significantly increase among those with moderate-to-severe psoriasis (pooled HR: 0.96, 95% CI 0.72-1.28; I2 = 0%). Patients with mild or moderate-to-severe psoriasis are not at an elevated risk of breast cancer.

Isotretinoin Exposure and Risk of Inflammatory Bowel Disease: A Systematic Review with Meta-Analysis and Trial Sequential Analysis

BACKGROUND

Cases of inflammatory bowel disease (IBD) following isotretinoin use have been reported previously, but whether isotretinoin exposure is associated with IBD has been unclear.

OBJECTIVE

The aim was to evaluate whether isotretinoin use is associated with IBD.

METHODS

We performed a systematic review and searched MEDLINE, Embase, and CENTRAL databases from inception to January 27, 2023 for relevant case-control and cohort studies. Our outcome was the pooled odds ratio (OR) for IBD and its two subtypes (Crohn disease and ulcerative colitis) in relation to isotretinoin exposure. We conducted a random-effects model meta-analysis and a sensitivity analysis by excluding low-quality studies. A subgroup analysis was undertaken by including studies considering antibiotic use. A trial sequential analysis (TSA) was performed to test the robustness of the conclusiveness of our results.

RESULTS

We included eight studies (four case-control and four cohort studies) with a total of 2,522,422 participants. The meta-analysis found no increased odds for IBD among patients receiving isotretinoin (OR 1.01; 95% confidence interval [CI] 0.80-1.27). Nor did the meta-analysis find increased odds for either Crohn disease (OR 0.87; 95% CI 0.65-1.15) or ulcerative colitis (OR 1.27; 95% CI 0.94-1.73) associated with isotretinoin exposure. The sensitivity and subgroup analyses produced similar results. In TSA, the Z-curve reached the futility boundaries when using relative risk reduction thresholds ranging from 5% to 15%.

CONCLUSION

This meta-analysis with TSA found no evidence of an association of isotretinoin use with IBD. Isotretinoin should not be withheld because of unnecessary concerns for the development of IBD.

PROSPERO REGISTRATION NO

CRD42022298886.

Risk for incident suicidality among psoriasis patients: a systematic review and meta-analysis

Previous meta-analyses have produced conflicting conclusions about suicidality risk among psoriasis patients. We aimed to update the evidence on the risk for the whole continuum of incident suicidality in psoriasis patients. We performed an update systematic review and meta-analysis and searched CENTRAL, PubMed, and Embase from January 1, 2017 to August 14, 2021 for relevant new cohort studies and incorporated new studies into our previous systematic review. Random-effects model meta-analysis was used to obtain pooled hazard ratio (HR) with 95% confidence interval (CI). Subgroup analysis was conducted according to age and disease severity. A total of 12 studies were included in this meta-analysis. We detected no significant differences in the risk for incident completed suicide (HR 1.33, 95% CI 0.91-1.95), suicide attempt (HR 1.22, 95% CI 0.96-1.56), suicidal behavior (HR 1.08, 95% CI 0.98-1.19), and suicide ideation (HR 1.74, 95% CI 0.99-3.06) between psoriasis patients and non-psoriatic controls. In the subgroup analysis based on age, an increased risk for incident suicide ideation was observed in pediatric subgroup (HR 1.50, 95% CI 1.12-2.03). The updated evidence suggests no increased risk for whole continuum of incident suicidality spectrum in psoriasis patients but an increased risk for incident suicide ideation among pediatric psoriasis patients. Involving mental health professionals may be crucial in psoriasis management especially in young patients.

Epidemiology of mental health comorbidity in patients with psoriasis: An analysis of trends from 1986 to 2019

BACKGROUND

The prevalence of mental disorders such as depression, anxiety, and suicide has increased in patients with psoriasis, although no study has systematically analyzed the epidemiology worldwide.

OBJECTIVE

To explore the prevalence and incidence of psoriasis with comorbid mental disorders (i.e., depression, anxiety, and suicide).

METHODS

Five databases from establishment through May 2022 were searched. Stata SE 15.1 was used for the data analysis. Subgroup, meta-regression, and sensitivity analyses were used to evaluate the heterogeneity of pooled studies.

RESULTS

We evaluated 56 studies in our research. The prevalence of depression, anxiety, and suicide in adults with psoriasis was 20%, 21%, and 0.77%. Patients with psoriasis in North America had a higher prevalence of depression and suicide, whereas those in South America had a higher prevalence of anxiety. The incidence of depression, anxiety, and suicide was 42.1, 24.7, and 2.6 per 1000 person-years in adults with psoriasis, respectively.

LIMITATIONS

All of the included studies were published in Chinese and English, causing a degree of selection bias.

CONCLUSION

These findings demonstrate the incidence and prevalence of comorbid mental disorders in patients with psoriasis, which may raise awareness among physicians and patients regarding the mental problems associated with psoriasis.

Engaging psoriasis patients in adherence and outcomes to topical treatments: A summary from the Symposium 'Tailoring topical psoriasis treatments to patients' needs and expectations' of the 30th EADV Congress 2021

This article is based on a presentation given by authors at the Satellite Symposium titled 'Tailoring topical psoriasis treatments to patients' needs and expectations' held during the 30^th European Academy of Dermatology and Venereology Congress. During this session, the factors affecting adherence and outcomes to topical treatments were presented, with a particular focus on the patients' point of view. Psoriasis is not just a skin condition. Psoriasis can cause negative psychosocial effects, such as depression and anxiety. The risk of suicidality in patients with psoriasis is higher than in the background population. Psychosocial comorbidities can be prevented by patient involvement in psoriasis management and need to be treated in a multidisciplinary manner. Adherence may be the largest barrier to treatment success with topical therapies. Improvement in several areas of disease management may lead to benefits in treatment adherence and hence clinical benefit. There are several treatment-related factors for non-adherence, such as patient dissatisfaction, side effects, treatment regimen or the drug vehicle. Delivering comprehensive treatment information to the patient will help develop realistic objectives and expectations. Patients need to be involved in the selection of treatment strategies, as psoriasis patients have various preferences for their use of topical treatments. A shared decision-making with the patient has been shown to improve medication adherence and treatment success. Prescribing therapy in line with a patient preference for treatment vehicle and improving the communication between healthcare professionals and patients may be key factors to maximize adherence. The calcipotriol (CAL) and betamethasone dipropionate (BDP) cream, a novel formulation of the CAL/BDP fixed-dose combination based on Poly-Aphron Dispersion (PAD) Technology, is a topical treatment of mild-to-moderate plaque psoriasis, including scalp psoriasis, that has high cosmetic acceptance and overall treatment satisfaction.

Increased risk of suicidality in patients with psoriasis: A Nationwide cohort study in Korea

BACKGROUND

Psoriasis has a devastating psychological impact on patients' quality of life. However, the relationship between suicidality and psoriasis remains unclear.

OBJECTIVE

This study analysed and compared the risk of suicidality (suicidal ideation, suicide attempt and completed suicide) between patients with psoriasis and the general population.

METHODS

This nationwide, population-based, retrospective, cohort study analysed the Korean National Health Insurance Service claim data from 2005 to 2018.

RESULTS

The study included 348,439 patients with psoriasis aged over 18 years and with age- and sex-matched controls. The risk of suicidality was higher in the psoriasis group than in the control group [adjusted hazard ratio (aHR) 1.21; 95% confidence interval (CI), 1.18-1.24]. The aHR of suicidality was higher in the psoriatic arthritis group (aHR, 1.46; 95% CI, 1.39-1.54) than in the psoriasis-alone group (aHR, 1.17; 95% CI, 1.13-1.20). However, the severity of psoriasis and suicidality showed no correlation (mild psoriasis group: aHR, 1.22; 95% CI, 1.18-1.25; moderate-to-severe psoriasis group: aHR, 1.16; 95% CI, 1.10-1.23).

CONCLUSION

Patients with psoriasis have an increased risk of suicidality. In particular, the presence of arthritis in patients had a more significant effect on the risk of suicidality.

Effect of asthma education on health outcomes in children: a systematic review

BACKGROUND

It remains unknown whether child-oriented asthma education is associated with better health outcomes. This meta-analysis investigated the effects of asthma education on hospitalisation and emergency department and clinic visits.

METHODS

We searched the Cochrane Library, PubMed and EMBASE for relevant studies from inception to 4 July 2021, and selected studies that reported hospitalisation or emergency department or clinic visits as outcomes. The participants were only children. Two authors independently selected the studies, assessed the quality of the included studies and retrieved the data. A third senior author was engaged to resolve disagreements. Fifteen longitudinal studies were included for the systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 was used as the standard of reporting (PRISMA registration ID is 284509).

FINDINGS

Compared with the control group, the asthma education group had 54% lower hospitalisation risk (95% CI 0.32 to 0.66), and 31% lower emergency department visit risk (95% CI 0.59 to 0.81). Sensitivity analysis showed that the asthma education group had a reduced clinic visit risk (risk ratio (RR)=0.80, 95% CI 0.67 to 0.97). Subgroup analysis showed that asthma education involving both children and parents/guardians was associated with fewer hospitalisations (RR=0.38, 95% CI 0.24 to 0.59) and emergency department visits (RR=0.69, 95% CI 0.57 to 0.83). Asthma education in hospitals or non-hospitals can reduce the risk of hospitalisation and emergency department visits. However, only education in the hospitals was associated with the reduction of clinical visits (RR=0.45, 95% CI 0.22 to 0.92).

INTERPRETATION

Education is effective for controlling asthma, especially for reducing hospitalisation and emergency department and clinic visits. Education involving both children and parents/guardians is more effective than that involving only children. The setting of asthma education does not impact its effect to a large extent.

Suicide risk and depression in patients with psoriasis

BACKGROUND

Psoriasis is associated with comorbid psychiatric conditions. However, its relationship with suicidality is not completely understood. The aim of this study was to analyze the prevalence and the correlates of depressive symptoms and suicide risk in patients with psoriasis.

METHODS

Adult psoriatic patients referring to the Outpatient Service of the Sant'Orsola-Malpighi Polyclinic were enrolled. Depressive symptoms and suicidality were assessed using the Patient Health Questionnaire (PHQ-9) and section C of Mini-International Neuropsychiatric Interview (M.I.N.I. 5.0.0). Psoriasis was evaluated using the Psoriasis Area and Severity Index (PASI), Body Surface Area (BSA) and the Dermatology Life Quality Index (DLQI).

RESULTS

The prevalence of depressive symptoms was 14.9% and that of suicidality 6.3%. PHQ-9 scores were higher in patients with moderate-to-severe psoriasis (PASI≥10, Mann-Whitney U Test=4014.5; P<0.001; BSA≥10, Mann-Whitney Test=3930.5; P<0.001) and poorer quality of life (Mann-Whitney Test=805.5; P=0.024). Moreover, PHQ-9 scores were higher in females (Mann-Whitney Test U=3612.5; P=0.008) and were unrelated to age (r<inf>s</inf>=-0.056, P=0.423). Conversely, suicide risk was significantly higher in younger patients (Mann-Whitney=744, P=0.013) and females (χ²=5.69, P=0.028), and was unrelated to psoriasis severity.

CONCLUSIONS

Patients with moderate-to-severe psoriasis, especially females, should be screened for depression and suicidal ideation to support them with effective strategies to treat depressive symptoms.

Psoriasis and medical ramifications: A comprehensive analysis based on observational meta-analyses

Purpose

Based on a large number of systematic reviews and meta-analyses exploring the relationship between psoriasis and various health outcomes, we conducted an comprehensive analysis to assess the strength and evidence for the association between psoriasis and medical end-point ramifications in patients.

Methods

We searched related meta-analyses, investigating the links between psoriasis and medical ramifications from three databases. All summary effect sizes, 95% CIs, heterogeneity, and small-study effects in the included meta-analyses were recalculated. We assessed the methodological quality of included articles with the AMSTAR 2 tool and graded the epidemiological evidence. Subgroup analysis based on the severity of psoriasis and study design were also performed.

Results

A total of 38 articles comprising 85 unique meta-analyses were included in this study. Although 69 outcomes were statistically significant, only 8 outcomes (nonvascular dementia, ulcerative colitis, pediatric dyslipidemia, gestational diabetes, gestational hypertension, fracture, multiple sclerosis, and schizophrenia) showed a high quality of epidemiological evidence.

Conclusion

We found that psoriasis increased the risk of 69 health outcomes, and 8 outcomes were graded as high-quality evidence. No evidence was found that psoriasis was beneficial for any medical end point. However, to verify our results, more large-sample, multi-center prospective cohort studies are needed.

Prevalence and Odds of Anxiety Disorders and Anxiety Symptoms in Children and Adults with Psoriasis: Systematic Review and Meta-analysi

The magnitude of the association between psoriasis and depression has been evaluated, but not that between psoriasis and anxiety. The aim of this systematic review and meta-analysis was to examine the prevalence and odds of anxiety disorders and symptoms in patients with psoriasis. Five medical databases (Cochrane Database, EMBASE, PubMed, PsychINFO, ScienceDirect) were searched for relevant literature. A total of 101 eligible articles were identified. Meta-analysis revealed different prevalence rates depending on the type of anxiety disorder: 15% [95% confidence interval [CI] 9–21] for social anxiety disorder, 11% [9–14] for generalized anxiety disorder, and 9% [95% CI 8–10] for unspecified anxiety disorder. There were insufficient studies assessing other anxiety disorders to be able to draw any conclusions on their true prevalence. Meta-analysis also showed a high prevalence of anxiety symptoms (34% [95% CI 32–37]). Case-control studies showed a positive association between psoriasis and unspecified anxiety disorder (odds ratio 1.48 [1.18; 1.85]) and between psoriasis and anxiety symptoms (odds ratio 2.51 [2.02; 3.12]). All meta-analyses revealed an important heterogeneity, which could be explained in each case by methodological factors. The results of this study raise the necessity of screening for the presence of anxiety disorders, as previously recommended for depressive disorders, in patients with psoriasis and, if necessary, to refer such patients for evaluation by a mental health professional and appropriate treatment.

Epidemiology of Psoriasis and Comorbid Diseases: A Narrative Review

Psoriasis is a chronic autoimmune inflammatory disease that remains active for a long period, even for life in most patients. The impact of psoriasis on health is not only limited to the skin, but also influences multiple systems of the body, even mental health. With the increasing of literature on the association between psoriasis and extracutaneous systems, a better understanding of psoriasis as an autoimmune disease with systemic inflammation is created. Except for cardiometabolic diseases, gastrointestinal diseases, chronic kidney diseases, malignancy, and infections that have received much attention, the association between psoriasis and more systemic diseases, including the skin system, reproductive system, and oral and ocular systems has also been revealed, and mental health diseases draw more attention not just because of the negative mental and mood influence caused by skin lesions, but a common immune-inflammatory mechanism identified of the two systemic diseases. This review summarizes the epidemiological evidence supporting the association between psoriasis and important and/or newly reported systemic diseases in the past 5 years, and may help to comprehensively recognize the comorbidity burden related to psoriasis, further to improve the management of people with psoriasis.

Relationship between seasons and postpartum depression: A systematic review and meta-analysis of cohort studies

OBJECTIVE

As the reproduction season's effect on the mental health status is unknown, this study aims to explore the association between seasons and postpartum depression.

METHODS

A comprehensive search in databases, including PubMed, Cochrane Library, and EMBASE, was performed to identify studies reporting the relationship between reproduction season and postpartum depression. The latter was assessed using certain methods. Moreover, the study design and duration, sample size, the definition of four seasons, outcome assessment, method, and conclusion were extracted. Two independent authors screened the studies independently, and PRISMA 2020 was used as the reporting standard (PRISMA registration ID is 284524).

RESULTS

A total of five studies including 103,986 participants met our criteria. In the sensitivity analysis, the result of the meta-analysis shows that women who gave birth in spring, summer, or autumn had a lower risk of postpartum depression compared to those who gave birth in winter (RR: 0.83; 95% confidence interval [CI]: 0.78-0.88).

CONCLUSION

Women who gave birth in the other seasons were less likely to have postpartum depression compared to those who gave birth in winter. This result could help couples make overall decisions and help the puerpera take preventive measures against postpartum depression.

The Relationship between Alexithymia and Mental Health Is Fully Mediated by Anxiety and Depression in Patients with Psoriasis

Background: Psoriasis is a common skin disease that affects quality of life, especially mental health. Alexithymia has been considered a relevant feature in psoriasis patients. Moreover, psoriasis was found to be associated with negative psychological health, including anxiety and depression. As the pathways linking alexithymia and mental health remain unclear among patients with psoriasis, we aimed to examine the mediating role of anxiety and depression in the relationship between alexithymia and mental health in these patients. Methods: To explore our variables of interest, we used the Toronto Alexithymia Scale (TAS-20), the 12-Item Short Form Health Survey (SF-12), and the Hospital Anxiety and Depression Scale (HADS). Results: Forty-four percent of patients were alexithymic and reported higher anxiety and depression, and lower quality of life compared to non-alexithymic patients. Alexithymic patients also had lower educational attainment. A correlation analysis showed positive associations between alexithymia and both anxiety and depression, whereas mental and physical health were negatively associated with alexithymia. Moreover, anxiety and depression fully mediated the relationship between alexithymia and mental health. Conclusions: Our findings highlight the importance of assessing alexithymia and psychological distress in clinical practice to identify vulnerable patients and to implement interventions aimed at improving negative emotional states.

Assessing and Improving Psychological Well-Being in Psoriasis: Considerations for the Clinician

Psoriasis is a common chronic, systemic inflammatory disease, affecting approximately 2% of the population worldwide. Psoriasis is associated with profound psychosocial comorbidity with a burden that extends well beyond the physical signs and symptoms. Psychosocial comorbidities strongly associated with psoriasis include anxiety and depression, suicidal ideation, and substance misuse. There is a substantial unmet need for access to psychological support for people with skin disease in the UK. Recent reports found that while up to 98% of patients felt that their skin disease had affected their emotional or psychological well-being, only 18% sought help. This care gap is largely due to a lack of awareness about the limited available services alongside poor recognition, diagnosis, and triaging. Addressing psychosocial support needs starts with early identification, which can be complex and challenging. Once patients who need further support are identified, outcomes can be improved through prompt and effective treatment of inflammation, cognitive behavioural therapy, meditation and mindfulness-based therapy (including motivational interviewing), and to some extent psychotropic medication. Finally, resources for mental health support are notoriously limited, with dire consequences for patients. It is imperative that a proportion of the new funding promised for mental health services is bookmarked for dermatology patients and adequate provision of multidisciplinary psychodermatology teams to best serve the needs of this population. Ultimately, psoriasis is a complex condition with multifactorial psychological and biological drivers. Psoriasis is associated with high levels of distress, which is often under-recognized. Fully addressing this condition requires a holistic approach to the physical and psychosocial aspects to maximise adherence, efficacy, and optimise patient quality of life.

Association of COVID-19 vaccination with herpes zoster: a systematic review and meta-analysis

BACKGROUND

Following COVID-19 vaccination, several herpes zoster cases have been reported, making it critical to explore the association between herpes zoster and COVID-19 vaccination. This is especially true in the context of increasing the number of participants enrolled to receive COVID-19 vaccination.

RESEARCH DESIGN AND METHODS

Three databases, including the Cochrane Library, PubMed, and EMBASE, were searched for relevant studies before December 25, 2021, according to preliminarily determined inclusion and exclusion criteria without any language limitations. Four cohort studies were included in this systematic review and meta-analysis.

RESULTS

Compared with the placebo group, there was no evidence that the COVID-19 vaccination group was associated with increased incidence of herpes zoster (Risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.91 to 1.24). There is no evidence that the COVID-19 vaccination from Moderna is associated with the incidence of herpes zoster compared with vaccination from Pfizer (RR: 0.20; 95% CI: 0.01 to 2.99).

CONCLUSIONS

To date, there is no evidence of an association between covid-19 vaccination and herpes zoster.

Data Mining and Meta-Analysis of Psoriasis Based on Association Rules

Psoriasis is a common chronic and recurrent disease in dermatology, which has a great impact on the physical and mental health of patients. Meta-analysis can evaluate the effectiveness and safety of defubao in the treatment of psoriasis vulgaris. This article observes psoriasis skin lesions treated with topical defubao and the changes in blood vessels under dermoscopy. Considering that the Apriori algorithm and the existing improved algorithm have the problems of ignoring the weight and repeatedly scanning the database, this paper proposes a matrix association rule method based on random forest weighting. This method uses the random forest algorithm to assign weights to each item in the data set, and introduces matrix theory to convert the transaction data set into a matrix form and store it, thereby improving operating efficiency. This article included 11 studies, of which 7 studies used the indicator "Researcher's Overall Assessment" (IGA) to evaluate the efficacy, 5 studies used the "Patient Overall Assessment" (PGA) as the efficacy evaluation index, and Loss Area and Severity Index (PASI) was used as an observation index to evaluate the efficacy. Seven studies conducted safety comparisons. In this paper, IGA and PGA were used as evaluation indicators. The treatment effect of the defubao group was better than the calcipotriol group and the betamethasone group. The differences were statistically significant. The effect of the Fubao treatment for 8 weeks is significantly better than that of 4 weeks and 2 weeks, and the differences are statistically different. Using PASI as the evaluation index, a descriptive study was carried out, and it was found that after 4 weeks of treatment for psoriasis vulgaris, the average PASI reduction rate of patients was higher than that of the calcipotriol group and the betamethasone group. The safety evaluation found that after 8 weeks of treatment, the incidence of adverse events in the defubao group was significantly lower than that in the calcipotriol group.

Depression and suicidality in patients with psoriasis and the role of psoriatic arthritis; a cross-sectional study in a tertiary setting

BACKGROUND

Depression is overrepresented in psoriasis. However, it is not clear whether the presence of psoriatic arthritis (PsA) independently increases patients' depressive burden. Furthermore, current evidence regarding suicidality risk of psoriasis populations is conflicting and the role of PsA on suicidality outcomes in psoriasis is unknown.

OBJECTIVES

(i) To test whether PsA is associated with depression and lifetime suicidal ideation among patients with psoriasis; (ii) to capture different suicidal phenomena in these patients; and (iii) to investigate whether suicidality and depressive symptom severity are associated with clinical markers of psoriasis severity and chronicity.

METHODS

A cross-sectional survey of tertiary patients (n=219, aged 18-65 years) with dermatologist-confirmed chronic plaque psoriasis, of whom 84 had rheumatologist-confirmed PsA, was undertaken. The Hospital Anxiety and Depression Scale and Sheehan-Suicidality Tracking Scale were used to assess depression and lifetime suicidality respectively.

RESULTS

PsA presence was associated with depression in patients with psoriasis, independently of other physical comorbidities (adjusted Odds Ratio 2.92, 95% Confidence Interval 1.53-5.68). Furthermore, patients with PsA experienced significantly higher levels of anhedonia and anxiety, after controlling for psychiatric history. 48.8% of all participants reported lifetime suicidal ideation with or without intent; 21.3% reported suicidal planning and 9.4% suicide attempts. Lifetime suicidality prevalence did not differ between patients with and without PsA. Depressive symptom severity and lifetime suicidality scores were not associated with objective measures of psoriasis severity or treatment group.

CONCLUSION

These data suggest that joint involvement in psoriasis is associated with higher depressive burden. There is a need for routine depression screening among patients with psoriasis, in particular when PsA is present. Anhedonia appears to be a particularly relevant symptom in the depression phenotype of this population. We did not find a statistically significant association between PsA and suicidality. Nevertheless, suicidality rates in tertiary patients with psoriasis appear to be higher than in the general population. Suicidality monitoring is recommended to help in reducing future psychiatric morbidity and mortality in patients with psoriasis.

Cutaneous and Systemic Psoriasis: Classifications and Classification for the Distinction

Psoriasis is a chronic multisystem inflammatory disease that affects ~0.1–1.5% of the world population. The classic cutaneous manifestation of psoriasis is scaly erythematous plaques, limited or widely distributed. Moreover, psoriasis could be associated with comorbidities like psoriatic arthritis, metabolic syndrome, diabetes, cardiovascular disease, nephropathy, bowel disease, and brain diseases. In this review, we suggest that psoriasis should be classified as cutaneous psoriasis or systemic psoriasis and propose the classification for distinction. This would help to better understand and manage psoriasis.

The Relationship Between Fragility Fractures and Pain Experience: A Systematic Review

Purpose: This systematic review is conducted to explore the relationship between fragility fractures and pain experience.

Methods: We searched for relevant studies on Pubmed, Embase, Web of Science, and the Cochrane library without restrictions on language from inception until February 4th, 2021. The risk of bias and methodological quality was evaluated using the Newcastle-Ottawa Scale and ROBINS-I tool.

Results: Twenty-one studies were included in this systematic review. The so-called study reported participants with continuous post-fracture pain. The included studies showed that post- fractured pain can decrease with time, however, the continual pain can last at least 1 year even longer, and some participants would need to self-manage pain. Moreover, the limited range of motion was considered as a factor that might distress the normal development of daily activities.

Conclusions: The current evidence could not fully support that pain continues to influence patients' lives after a fragility fracture. However, it still showed the pain might come with fracture. The findings also could be useful to help health care providers better recognize and manage this clinical consequence of fractures. Nonetheless, future large-scale longitudinal studies will be required to evaluate the long-term effects of pain in fragility fractures.

Association of Skin Psoriasis and Somatic Comorbidity With the Development of Psychiatric Illness in a Nationwide Swedish Study

Importance

Psoriasis is a complex systemic disease with skin involvement, somatic comorbidity, and psychiatric illness (PI). Although this view of psoriasis is widely accepted, potential synergies within this triad of symptoms have not been adequately investigated.

Objectives

To investigate the independent association of skin psoriasis and somatic comorbidity with the development of PI and to assess whether skin psoriasis and somatic comorbidity act synergistically to produce a risk of PI that is greater than the additive associations.

Design, Setting, and Participants

Participants were enrolled between January 2005 and December 2010, in this retrospective matched case-control study using secondary (ie, administrative), population-based registry data from Swedish patients in routine clinical care. The dates of analysis were March 2017 to December 2019. Participants were patients with skin psoriasis and control participants without psoriasis matched on age, sex, and municipality, who were all free of preexisting PI.

Exposures

Presence of skin psoriasis and somatic comorbidity (captured through the Charlson Comorbidity Index and the Elixhauser Comorbidity Index).

Main Outcomes and Measures

Risk of PI onset (composite of depression, anxiety, and suicidality) is shown using Kaplan-Meier curves stratified by the presence of skin psoriasis and somatic comorbidity. Adjusted associations of skin psoriasis and somatic comorbidity with the development of PI were analyzed using Cox proportional hazards regression models, including interactions to assess synergistic associations. The 3 components of PI were also assessed individually.

Results

A total of 93 239 patients with skin psoriasis (mean [SD] age, 54 [17] years; 47 475 men [51%]) and 1 387 495 control participants (mean [SD] age, 54 [16] years; 702 332 men [51%]) were included in the study. As expected, patients with skin psoriasis were more likely to have somatic comorbidity and PI than control participants. Compared with those without skin psoriasis or somatic comorbidity, patients with psoriasis without somatic comorbidity had a 1.32 times higher risk of PI onset (hazard ratio [HR], 1.32; 95% CI, 1.27-1.36; P < .001), whereas patients with psoriasis with somatic comorbidity had a 2.56 times higher risk of PI onset (HR, 2.56; 95% CI, 2.46-2.66; P < .001). No synergistic associations of skin psoriasis and somatic comorbidity with the development of PI were found (HR, 0.93; 95% CI, 0.81-1.04; P = .21).

Conclusions and Relevance

This study found that somatic comorbidity appeared to alter PI onset even more than skin psoriasis. The observed association of skin psoriasis and somatic comorbidity with the development of PI reinforces the need for proactive, holistic treatment of patients with psoriasis.

Suicidal risks with psoriasis and atopic dermatitis: Systematic review and meta-analysis

OBJECTIVE

Evidence of increased suicidal risk in association with psoriasis is growing, but findings concerning atopic dermatitis are inconsistent.

METHODS

We systematically reviewed reports of suicidal ideation, attempts, or suicides among subjects diagnosed with psoriasis or atopic dermatitis compared to healthy controls or persons with other illnesses. Reported rates of suicidal ideation and behavior were compared among the groups, using meta-analyses to compare suicidal rates with dermatologic patients versus controls, as well as between dermatological diagnoses.

RESULTS

Mean rates of suicidal ideation with psoriasis were 1.60-fold (13.9%/8.67%) above controls, and with atopic dermatitis, 1.84-fold higher (16.8%/9.12%); meta-analyses found similar differences: psoriasis (OR = 1.97 [CI: 1.26-3.08]; p = 0.003) and atopic dermatitis (OR = 2.62 [1.32-5.19]; p = 0.006). For suicidal acts, with psoriasis, mean rates versus controls were 2.51-fold higher (3.34%/1.33%), and 2.81-fold higher (5.03%/1.79%) with atopic dermatitis; meta-analyses found significantly more suicidal acts with psoriasis (OR = 1.42 [1.05-1.92]; p = 0.02) and a similar tendency with atopic dermatitis (OR = 1.53 [0.96-2.45]; p = 0.08).

CONCLUSIONS

The study findings support emerging evidence of increased risk of suicidal ideation and behavior with psoriasis and extend it to increased risk of suicidal ideation and a trend toward increased suicidal acts with atopic dermatitis.

The Risk of Systemic Diseases in Those with Psoriasis and Psoriatic Arthritis: From Mechanisms to Clinic

Psoriasis and psoriatic arthritis (PsA) have been recently considered as chronic systemic inflammatory disorders. Over the past decades, enormous evidence indicates that patients with psoriasis and PsA have a higher risk of developing various comorbidities including cardiovascular disease, metabolic disease, cancers, infections, autoimmune disease, and psychiatric diseases. However, reported risks of some comorbidities in those with psoriasis and PsA are somewhat different according to the research design. Moreover, pathomechanisms underlying comorbidities of those with psoriasis and PsA remain poorly elucidated. The purpose of this review is to provide the most updated comprehensive view of the risk of systemic comorbidities in those with psoriasis and PsA. Molecular mechanisms associated with the development of various comorbidities in those with psoriasis and PsA are also reviewed based on recent laboratory and clinical investigations. Identifying the risk of systemic comorbidities and its associated pathomechanisms in those with psoriasis and PsA could provide a sufficient basis to use a multi-disciplinary approach for treating patients with psoriasis and PsA.

Determinants of Suicidality in the European General Population: A Systematic Review and Meta-Analysis

Close to one million people commit suicide each year, with suicidal attempts being the main risk factor for suicide. The aim of this systematic review and meta-analysis is to achieve a greater understanding of suicidality in the general population of Europe by studying associated factors and their statistical significance with suicidality, as well as the effect of the temporal moment in which suicidality is observed in a relationship. A search strategy was carried out in electronic databases: Proquest's Psychology Database, Scopus, PsycINFO, Medline and Embase. Odds ratios (ORs), publication bias, influential studies on heterogeneity and analysis moderators were calculated. Twenty-six studies were included after meeting the inclusion criteria. Factors statistically associated with suicidality are female gender, age over 65 years, unemployment, low social support, adulthood adversity, childhood adversity, family history of mental disorder, any affective disorder, major depression, anxiety/stress/somatoform disorders, tobacco and substance use, any mental disorder and body mass index. As a limitation, a high heterogeneity between studies was found. Factors associated with suicidality in the general population are relevant for understanding the suicidal phenomenon.

Risk for Suicidal Behavior Among Psoriasis Patients: A Nationwide Cohort Study

BACKGROUND

The link between psoriasis and suicidality remains elusive and understudied.

OBJECTIVE

The aim was to assess the risk of suicidal behavior in psoriasis patients.

METHODS

We used Taiwan's National Health Insurance Research Database to conduct a nationwide retrospective cohort study to examine the risk for suicidal behavior among psoriasis patients. We performed subgroup analyses based on the severity of psoriasis and psoriatic arthritis.

RESULTS

We included 169,909 psoriasis patients (including 13,959 with concomitant psoriatic arthritis and 155,950 with psoriasis alone) and 169,909 matched nonpsoriasis controls. Suicidal behavior occurred in 104 and 89 subjects in the psoriasis group and nonpsoriasis controls, respectively; we found no significantly increased risk for suicidal behavior among psoriasis patients when compared to nonpsoriasis controls [adjusted hazard ratio (HR) 1.17, 95% confidence interval (CI) 0.88‒1.55]. The subgroup analysis showed no significantly increased risk for suicidal behavior in both the severe psoriasis group (adjusted HR 0.92, 95% CI 0.51-1.64) and the mild psoriasis group (adjusted HR 1.26, 95% CI 0.91‒1.75) when compared to nonpsoriasis controls. Also, we found no significant increased risk for suicidal behavior in the group of psoriasis patients who also had psoriatic arthritis (adjusted HR 2.00, 95% CI 0.68‒5.85) and in the group of patients with psoriasis alone (adjusted HR 1.12, 95% CI 0.83‒1.50) when compared to nonpsoriasis controls.

CONCLUSION

In a Taiwanese setting, no link between psoriasis or psoriatic arthritis and suicidal behavior was detected.

Combination of targeted UVB phototherapy and calcipotriene versus targeted UVB alone in psoriasis: systematic review and meta-analysis of randomized controlled trials

Background: Targeted UVB and topical calcipotriene have frequently been used in the treatment of psoriasis, but the joint effect of calcipotriene and targeted UVB has been controversial.Objectives: The purpose of this study was to systematically evaluate whether the efficacy of the combined use of targeted UVB and calcipotriene is superior to the targeted UVB alone.Methods: We performed systematic review and meta-analysis of randomized controlled trials (RCTs) in patients with plaque-type psoriasis through searching the defined key words in the PubMed, EMBase, and Cochrane Central Register databases. Pooled mean difference of the Psoriasis Area and Severity Index (PASI) relative change (%) was estimated using a random effect model. The quality of included studies and publication bias were assessed using the Jadad scale and the Egger's test, respectively.Results: A total of five RCTs including 182 patients were included in the systematic review. The mean difference of the PASI relative change (%) between the combined therapy versus the targeted UVB alone was -22.68 (95%CI: -37.12 to -8.24; p = .002). Publication bias was not supported by the Egger's test (p = .424).Conclusion: Addition of calcipotriene ointment may improve the efficacy of the targeted UVB phototherapy in the treatment of plaque-type psoriasis.

Beyond skin deep: addressing comorbidities in psoriasis

Psoriasis is a chronic inflammatory disease that is commonly encountered in primary care and is associated with significant morbidity that extends beyond the skin manifestations. Psoriasis is associated with an elevated risk of psoriatic arthritis, cardiovascular disease, obesity, insulin resistance, mental health disorders, certain types of malignancy, inflammatory bowel disease and other immune-related disorders, and hepatic and renal disease. Enhanced recognition of these comorbidities may lead to earlier diagnosis and potentially better overall health outcomes. Psoriatic nail involvement, severe skin disease and obesity are associated with a greater risk of psoriatic arthritis. Individuals with psoriasis should be routinely screened for psoriatic arthritis to allow for early intervention to improve long term prognosis. Life expectancy is reduced in people with psoriasis due to a variety of causes, with cardiovascular disease and malignancy being the most common aetiologies. Psoriasis affects several factors that contribute to worsened quality of life and increased risk of depression and anxiety. Effective therapies are now available that have been shown to concurrently improve skin disease, quality of life and psychiatric symptoms. As the concordance between psychosocial impact and objective disease severity does not always correlate, it is essential to tailor management strategies specifically to the needs of each individual. Cigarette smoking and excess alcohol consumption are among the most important modifiable risk factors that increase the likelihood of psoriasis development and severity of skin disease. This provides a compelling rationale for smoking cessation and limiting alcohol intake in people with psoriasis beyond their traditional harmful health consequences.

Association of acute kidney injury with frailty in elderly population: a systematic review and meta-analysis

Aim: The objective of this study was to assess whether an elderly patient's frailty was associated with acute kidney injury (AKI) and to examine whether severe frailty group had an increased risk of AKI than mild-moderate group.Methods: We searched The Cochrane Library, PubMed, and EMBASE for relevant studies without language limitations before 1 March 2019 with a priori defined inclusion and exclusion criteria. Five population-based cohort studies were included for systematic review and meta-analysis.Results: Compared with the control group, the frailty group is significantly associated AKI (Odds Ratio = 2.05; 95% CI: 1.23-3.43). The moderate-severe frailty group has an increased risk of AKI than mild frailty group (Hazard Ratio = 2.87; 95% CI: 1.60-5.17.Conclusion: In conclusion, the available best evidence support an association between frailty and AKI among elder patients, thus relevant interventions should be taken among elderly under potential risk of AKI.

Effects of fish oil supplement on psoriasis: a meta-analysis of randomized controlled trials

BACKGROUND

Fish oils, which contain omega-3 polyunsaturated fatty acids as the active ingredients, possess anti-inflammatory activities and may have therapeutic potential in diseases with an inflammatory etiology. Fish oil supplement has been advocated for treating psoriasis which is a chronic inflammatory dermatosis.

OBJECTIVE

We aimed to investigate the effects of fish oil supplement on psoriasis.

METHODS

We searched CENTRAL, Embase and MEDLINE on 24 January 2018 for randomized control trials (RCTs) on the effects of fish oil supplement in treating psoriasis. The Cochrane Collaboration's tool was used to assess the risk of bias of included RCTs. We performed a random-effects model meta-analysis to obtain the pooled treatment effect estimates.

RESULTS

We included 13 RCTs with 625 participants. Three RCTs involving 337 participants provided usable data for meta-analysis. Fish oil supplement did not significantly reduce the severity of psoriasis when assessed by Psoriasis Area and Severity Index score (mean difference - 0.28; 95% confidence interval - 1.74 to 1.19).

CONCLUSION

The current evidence does not support the use of fish oil supplement in treating psoriasis.

Association of Psoriasis With Inflammatory Bowel Disease: A Systematic Review and Meta-analysis

Importance

Patients with psoriasis may experience comorbidities involving cardiovascular diseases, chronic kidney disease, uveitis, psychiatric disturbances, and metabolic syndrome. However, the association between psoriasis and inflammatory bowel disease (IBD) has been largely unclear.

Objective

To investigate the association of psoriasis with IBD.

Data Sources

For this systematic review and meta-analysis, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant studies from inception to January 17, 2018.

Study Selection

Case-control, cross-sectional, or cohort studies that examined either the odds or risk of IBD in patients with psoriasis were included. No geographic or language limitations were used in the search.

Data Extraction and Synthesis

The PRISMA and MOOSE guidelines were followed for data extraction. The Newcastle-Ottawa Scale was used to evaluate the risk of bias of included studies. Crohn disease and ulcerative colitis were analyzed separately and random-effects model meta-analysis was conducted. A subgroup analysis was performed on psoriatic arthritis.

Main Outcomes and Measures

The risk and odds of IBD, Crohn disease, and ulcerative colitis in patients with psoriasis.

Results

A total of 5 case-control or cross-sectional studies and 4 cohort studies with 7 794 087 study participants were included. Significant associations were found between psoriasis and Crohn disease (odds ratio, 1.70; 95% CI, 1.20-2.40) and between psoriasis and ulcerative colitis (odds ratio, 1.75; 95% CI, 1.49-2.05). Patients with psoriasis had an increased risk of Crohn disease (risk ratio, 2.53; 95% CI, 1.65-3.89) and ulcerative colitis (risk ratio, 1.71; 95% CI, 1.55-1.89).

Conclusions and Relevance

These findings suggest that psoriasis is significantly associated with IBD. Gastroenterology consultation may be indicated when patients with psoriasis present with bowel symptoms.

Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities

Psoriasis is a chronic, inflammatory, multisystem disease that affects up to 3.2% of the US population. This guideline addresses important clinical questions that arise in psoriasis management and care, providing recommendations on the basis of available evidence.

Psoriasis and suicidality: A review of the literature

Psoriasis is a chronic systemic inflammatory skin disease, which has been associated with an increased risk of numerous medical and psychiatric comorbidities, including suicidality. Suicidality, which can be divided into the categories of suicidal ideation, suicide attempt, and completed suicide, is highly prevalent in the psoriasis population, and multiple studies have been published on the subject of psoriasis and suicidal ideation and behavior (SIB), including two recent meta-analyses. However, the available literature is limited and inconsistent, and the association between the two remains incompletely understood. The present review aims to cohesively synthesize and summarize the available evidence, while making a clinically relevant distinction between the sub-categories of suicidality, by examining not only the epidemiology of the association but also the plausible molecular mechanisms and the potential influence of biologic therapies. Additionally, this review aims to critically examine and understand the potential contribution of depression in the psoriasis and suicidality relationship. This will allow us to better understand the complex and multi-faceted relationship between psoriasis and suicidality, to identify those who may be most at risk for SIB, to make evidence-based clinical decisions regarding treatment and management, and to more completely address the needs of psoriasis patients.

Drug survival of biologics in treating psoriasis: a meta-analysis of real-world evidence

Drug survival of biologics represents their real-world effectiveness and safety. We conducted a meta-analysis of real-world evidence on the drug survival of biologics in treating psoriasis. We searched the PubMed, CENTRAL, and EMBASE databases from inception to 7th October 2017 for studies reporting the annual drug survival for at least 1 year. Two authors independently screened and selected relevant studies, and assessed their risk of bias. A third author was available for arbitrating discrepancies. We conducted a random-effects model meta-analysis to obtain the respective pooled drug survival from year 1 to 4. We conducted subgroup analysis on biologic-naïve subjects, discontinuation for loss of efficacy and adverse effects. We included 37 studies with 32,631 subjects. The drug survival for all biologics decreased with time, dropping from 66% at year 1 to 41% at year 4 for etanercept, from 69% to 47% for adalimumab, from 61% to 42% for infliximab, and from 82% to 56% for ustekinumab. Ustekinumab was associated with the highest drug survival in all and biologic-naïve subjects. Etanercept was associated with the lowest drug survival and was most commonly discontinued for loss of efficacy. Infliximab was most frequently associated with discontinuation for adverse effects. Clinicians may use this study as a reference in treating psoriasis.

Psychiatric morbidity and suicidal behaviour in psoriasis: a primary care cohort study

BACKGROUND

Psychological distress among people with psoriasis may lead to elevated risks of suicide and nonfatal self-harm.

OBJECTIVES

To investigate psychiatric comorbidity, psychotropic medication prescribing and risk of suicidality in people with psoriasis.

METHODS

A cohort of patients with psoriasis (1998-2014) was delineated using the Clinical Practice Research Datalink, with linkage to Hospital Episode Statistics and Office for National Statistics mortality records. Each patient with psoriasis was matched with up to 20 patients without psoriasis on age, sex and general practice. A stratified Cox regression model was used to estimate the hazard ratios (HRs) for suicide or nonfatal self-harm risks adjusted for socioeconomic status.

RESULTS

At baseline, among 56 961 and 876 919 patients with and without psoriasis, higher prevalence for histories of alcohol misuse, bipolar disorder, depression, anxiety disorders, self-harm and psychotropic drug prescription were observed. The deprivation-adjusted HR indicated lower suicide risk in people with psoriasis [HR 0·59, 95% confidence interval (CI) 0·41-0·85]. The risk of suicide varied according to age: it was lower in people with psoriasis diagnosed at ≥ 40 years (HR 0·38, 95% CI 0·21-0·66), whereas there was no difference in risk of suicide in people with psoriasis diagnosed before age 40 years (HR 0·92, 95% CI 0·58-1·46). Conversely, there was a small increased risk for self-harm (HR 1·15, 95% CI 1·04-1·27) associated with psoriasis.

CONCLUSIONS

The prevalence of mental illness was raised in people with psoriasis, and this may lead to a greater risk of self-harm. Nevertheless, having psoriasis does not appear to be associated with an increased risk of suicide. Healthcare professionals caring for patients with psoriasis should continue to monitor and tackle effectively the psychological needs of these individuals.

Psychological stress and psoriasis: a systematic review and meta-analysis

BACKGROUND

Psychological stress has long been linked with the exacerbation/onset of psoriasis.

OBJECTIVES

To determine if antecedent psychological stress is associated with the exacerbation/onset of psoriasis.

METHODS

A search of the PubMed, PsycINFO, Cochrane library and ClinicalTrials.gov databases was performed. Surveys evaluating beliefs about stress reactivity were analysed separately. Suitable studies were meta-analysed.

RESULTS

Thirty-nine studies (32 537 patients) were included: 19 surveys, seven cross-sectional studies, 12 case-control studies and one cohort study. Forty-six per cent of patients believed their disease was stress reactive and 54% recalled preceding stressful events. Case-control studies evaluating stressful events rates prior to the exacerbation (n = 6) or onset (n = 6) of psoriasis varied in time lag to recollection (≤ 9 months to ≥ 5 years). Pooling five studies evaluating stressful events preceding onset of psoriasis gave an odds ratio (OR) of 3·4 [95% confidence interval (CI) 1·8-6·4; I² = 87%]; the only study evaluating a documented stress disorder diagnosis reported similar rates between patients and controls (OR 1·2, 95% CI 0·8-1·8). Four studies evaluating stressful events prior to psoriasis exacerbation reported comparable rates with controls, whereas two found more frequent/severe preceding events among patients with psoriasis. A small prospective cohort study reported a modest association between stress levels and exacerbation of psoriasis (r = 0·28, P < 0·05).

CONCLUSIONS

The association between preceding stress and exacerbation/onset of psoriasis is based primarily on retrospective studies with many limitations. No convincing evidence exists that preceding stress is strongly associated with exacerbation/onset of psoriasis.

Prevalence and predictors of depressive symptoms among attendees of a tertiary care dermatology clinic in Muscat, Oman

BACKGROUND

Various studies have suggested that depression is more prevalent among patients with skin disorders than in the general population. Most of the studies addressing this subject involve Euro-American populations.

OBJECTIVES

The present study aimed to estimate the prevalence of depressive symptoms among patients with dermatological disorders and, then, to decipher the clinical-demographic factors associated with depressive symptoms.

METHODS

A cross-sectional analytical study was conducted among a random sample of patients attending a dermatology clinic in Muscat. The Patient Health Questionnaire-9 (PHQ-9) was used to screen for depressive symptoms. A logistic regression model was used to find the adjusted and unadjusted odds ratios (ORs).

RESULTS

A total of 260 patients participated in this study, with a response rate of 81%. The prevalence of depression symptoms was 24%. According to regression analysis, family history of depression, comorbid medical disorders, and treatment with topicals or isotretinoin were significant predictors of depression (OR = 9.41, 95% confidence interval [CI]: 2.27-39.05, P = 0.002; OR = 2.0, 95% CI: 1.2-3.21, P = 0.05; OR = 2.28, 95% CI: 1.09-4.76, P = 0.028; and OR = 2.78; 95% CI: 1.08-7.19, P = 0.035, respectively).

CONCLUSION

This study indicates that depressive symptoms are common among patients with dermatological disorders in Oman, particularly in those with a family history of depression and medical comorbidities, and those who use a specific dermatological medication. Screening for depression in patients attending dermatology clinics is essential in order to detect and promptly treat patients suffering from depression.