Increased risk of diabetes mellitus in relation to the severity of psoriasis, concomitant medication, and comorbidity: A nationwide population-based cohort study

Improvement in Cutaneous Conditions Can Benefit Some Health Conditions in the Elderly

As we are aging, a number of cutaneous and extracutaneous disorders will be developed. Although the pathogenesis of these aging-associated disorders is not clear yet, abnormalities in the skin are linked to some aging-associated disorders at least to some extent. Inflammatory dermatoses such as psoriasis and atopic dermatitis predispose to the development of cardiovascular diseases, obesity and type 2 diabetes. In addition, both chronologically aged skin and individuals with some aging-associated systemic conditions display altered epidermal function, such as reduced stratum corneum hydration levels, which can provoke cutaneous inflammation. Because aged skin exhibits higher expression levels of inflammatory cytokines, which play a pathogenic role in a variety of aging-associated health condition, the association of the skin with some aging-associated disorders is likely mediated by inflammation. This postulation is supported by the evidence that improvement in either epidermal function or inflammatory dermatoses can mitigate some aging-associated disorders such as mild cognitive impairment and insulin sensitivity. This perspective discusses the association of the skin with aging-associated disorders and highlights the potential of improvement in cutaneous conditions in the management of some health conditions in the elderly.

Knowledge Mapping and Research Hotspots of Comorbidities in Psoriasis: A Bibliometric Analysis from 2004 to 2022

Background and Objectives: Psoriasis is a chronic inflammatory disease whose impact on health is not only limited to the skin, but is also associated with multiple comorbidities. Early screening for comorbidities along with appropriate treatment plans can provide a positive prognosis for patients. This study aimed to summarize the knowledge structure in the field of psoriasis comorbidities and further explore its research hotspots and trends through bibliometrics. Materials and Methods: A search was conducted in the core collection of the Web of Science for literature on comorbidities of psoriasis from 2004 to 2022. VOSviewer and CiteSpace software were used for collaborative network analysis, co-citation analysis of references, and keyword co-occurrence analysis on these publications. Results: A total of 1803 papers written by 6741 authors from 81 countries was included. The publications have shown a progressive increase since 2004. The United States and Europe were at the forefront of this field. The most prolific institution was the University of California, and the most productive author was A. Armstrong. Research has focused on "psoriatic arthritis", "metabolic syndrome", "cardiovascular disease", "psychosomatic disease", "inflammatory bowel disease", "prevalence", "quality of life", and "risk factor" in the past 18 years. Keywords such as "biologics" and "systemic inflammation", have been widely used recently, suggesting current research hotspots and trends. Conclusions: Over the past 18 years, tremendous progress has been made in research on psoriasis comorbidity. However, collaborations among countries, institutions, and investigators are inadequate, and the study of the mechanisms of interaction between psoriasis and comorbidities and management of comorbidities is insufficient. The treatment of comorbidities with biologic agents, screening of comorbidities, and multidisciplinary co-management are predicted to be the focus of future research.

B7-H4 Polymorphism Influences the Prevalence of Diabetes Mellitus and Pro-Atherogenic Dyslipidemia in Patients with Psoriasis

Background: The co-inhibitory molecule B7-H4 is located in the genomic regions associated with type 1 diabetes (T1D) susceptibility. However, the correlation of B7-H4 with glycometabolism and dyslipidemia has never been studied. Objective: To explore the influence of B7-H4 polymorphism on the prevalence of diabetes mellitus (DM) and dyslipidemia in psoriasis. Methods: In this single-center cross-sectional study, we recruited 265 psoriatic patients receiving methotrexate (MTX) treatment. Thirteen single-nucleotide polymorphisms (SNPs) in B7-H4 were genotyped. Serum levels of total cholesterol (TC), triglycerides (TG), lipoprotein (a) (LP(a)), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein (LDL), apolipoprotein A1 (ApoA1), and apolipoprotein B (ApoB) were measured at baseline and week 12. Results: The GG genotype carriers of rs12025144 in B7-H4 had a higher prevalence of DM (57.14% vs. 17.71% vs. 18.67%, p = 0.0018), and had a poorer response to MTX in diabetic patients (p < 0.05), compared with AA or AG genotype carriers. The AG genotype of rs2066398 was associated with higher levels of pro-atherogenic lipids. MTX significantly downregulated the level of anti-atherogenic lipid ApoA1 in AA genotype carriers of rs2066398. Conclusions: The genotypes rs12025144 and rs2066398 in B7-H4 were correlated with a higher prevalence of DM and dyslipidemia in psoriasis, respectively.

Cardiometabolic multimorbidity is common among patients with psoriasis and is associated with poorer outcomes compared to those without comorbidity

BACKGROUND

Associations between cardiometabolic multimorbidity and response to therapy in psoriasis are unknown.

OBJECTIVE

Determine the associations of multimorbidity with response to biologic treatment in psoriasis patients.

METHODS

CorEvitas Psoriasis Registry participants who initiated biologic therapy and had 6-months follow-up were stratified by 0, 1, 2+ comorbidities (diabetes, hypertension, hyperlipidemia). Adjusted odds ratios (95% CIs) were calculated overall and separately by biologic class (TNFi, IL-17i, IL-12/23i + IL-23i), to assess the likelihood of achieving response for the 1 and 2+ groups vs. 0.

RESULTS

Of 2,923 patients, 49.5%, 24.7% and 25.8% reported 0, 1 and 2+ comorbidities, respectively. Overall, likelihood of PASI75 was 18% (OR =0.82; 95%CI: 0.67, 1.00) and 23% (OR =0.77; 95%CI: 0.63, 0.96) lower in those with 1 and 2+ comorbidities, respectively, vs. 0. In those who initiated IL-17i, odds of PASI75 and PAS90 were 34% (OR =0.66; 95%CI: 0.48-0.91) and 35% (OR =0.65; 95%CI: 0.47-0.91) lower in the 2+ multimorbidity cohort. No significant associations were found among users of TNFi or IL-12/23i + IL-23i groups in the multimorbidity group.

LIMITATIONS

Patients may not be representative of all psoriasis patients.

CONCLUSION

Multimorbidity in psoriasis may decrease the likelihood of achieving treatment response to biologic therapy and should be considered when discussing treatment expectations with patients.

Identifying and managing psoriasis-associated comorbidities: the IMPACT research programme

Background

Psoriasis is a common, lifelong inflammatory skin disease, the severity of which can range from limited disease involving a small body surface area to extensive skin involvement. It is associated with high levels of physical and psychosocial disability and a range of comorbidities, including cardiovascular disease, and it is currently incurable.

Objectives

To (1) confirm which patients with psoriasis are at highest risk of developing additional long-term conditions and identify service use and costs to patient, (2) apply knowledge about risk of comorbid disease to the development of targeted screening services to reduce risk of further disease, (3) learn how patients with psoriasis cope with their condition and about their views of service provision, (4) identify the barriers to provision of best care for patients with psoriasis and (5) develop patient self-management resources and staff training packages to improve the lives of people with psoriasis.

Design

Mixed methods including two systematic reviews, one population cohort study, one primary care screening study, one discrete choice study, four qualitative studies and three mixed-methodology studies.

Setting

Primary care, secondary care and online surveys.

Participants

People with psoriasis and health-care professionals who manage patients with psoriasis.

Results

Prevalence rates for psoriasis vary by geographical location. Incidence in the UK was estimated to be between 1.30% and 2.60%. Knowledge about the cost-effectiveness of therapies is limited because high-quality clinical comparisons of interventions have not been done or involve short-term follow-up. After adjusting for known cardiovascular risk factors, psoriasis (including severe forms) was not found to be an independent risk factor for major cardiovascular events; however, co-occurrence of inflammatory arthritis was a risk factor. Traditional risk factors were high in patients with psoriasis. Large numbers of patients with suboptimal management of known risk factors were found by screening patients in primary care. Risk information was seldom discussed with patients as part of screening consultations, meaning that a traditional screening approach may not be effective in reducing comorbidities associated with psoriasis. Gaps in training of health-care practitioners to manage psoriasis effectively were identified, including knowledge about risk factors for comorbidities and methods of facilitating behavioural change. Theory-based, high-design-quality patient materials broadened patient understanding of psoriasis and self-management. A 1-day training course based on motivational interviewing principles was effective in increasing practitioner knowledge and changing consultation styles. The primary economic analysis indicated a high level of uncertainty. Sensitivity analysis indicated some situations when the interventions may be cost-effective. The interventions need to be assessed for long-term (cost-)effectiveness.

Limitations

The duration of patient follow-up in the study of cardiovascular disease was relatively short; as a result, future studies with longer follow-up are recommended.

Conclusions

Recognition of the nature of the psoriasis and its impact, knowledge of best practice and guideline use are all limited in those most likely to provide care for the majority of patients. Patients and practitioners are likely to benefit from the provision of appropriate support and/or training that broadens understanding of psoriasis as a complex condition and incorporates support for appropriate health behaviour change. Both interventions were feasible and acceptable to patients and practitioners. Cost-effectiveness remains to be explored.

Future work

Patient support materials have been created for patients and NHS providers. A 1-day training programme with training materials for dermatologists, specialist nurses and primary care practitioners has been designed. Spin-off research projects include a national study of responses to psoriasis therapy and a global study of the prevalence and incidence of psoriasis. A new clinical service is being developed locally based on the key findings of the Identification and Management of Psoriasis Associated ComorbidiTy (IMPACT) programme.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

Cardiometabolic Comorbidities in Patients With Psoriasis: Focusing on Risk, Biological Therapy, and Pathogenesis

Psoriasis is a chronic inflammatory disease characterized by erythematous scaly plaques, accompanied by systemic damage that leads to the development of multiple comorbidities. In particular, the association between psoriasis and cardiometabolic comorbidities, including cardiovascular diseases (CVDs), obesity, diabetes mellitus, and metabolic syndrome, has been verified in a considerable number of clinical trials. Moreover, the increased risk of cardiometabolic comorbidities positively correlates with psoriasis severity. Biologic therapy targeting inflammatory pathways or cytokines substantially improves the life quality of psoriasis patients and may affect cardiometabolic comorbidities by reducing their incidences. In this review, we focus on exploring the association between cardiometabolic comorbidities and psoriasis, and emphasize the benefits and precautions of biologic therapy in the management of psoriasis with cardiometabolic comorbidities. The pathogenic mechanisms of cardiometabolic comorbidities in psoriasis patients involve common genetic factors, lipid metabolism, insulin resistance, and shared inflammatory pathways such as tumor necrosis factor-α and interleukin-23/Th-17 pathways.

Beyond the Skin Plaques: Psoriasis and Its Cardiovascular Comorbidities

Psoriasis, a widely prevalent chronic disease of the skin and joints, has long been associated with far-reaching systemic ramifications and decreased quality of life. However, psoriasis is largely underdiagnosed and insufficiently treated. Classical risk factors predisposing to cardiovascular diseases, such as hypertension, diabetes, metabolic syndrome, and dyslipidemia, have been noted in patients with mild and severe psoriasis. Furthermore, the magnitude of the cardiovascular comorbidity and the need to screen for risk factors has often been ignored while considering the management options for psoriasis. This article has reviewed the cardiovascular implications of psoriasis from the shared pathogenesis behind these two diseases to the increased incidence of cardiovascular events, such as myocardial infarction, stroke, and other causes of vascular mortality. Additionally, the therapeutic targets of common inflammatory pathways, such as those involving tumor necrosis factor α (TNF-α), interleukin-12/interleukin-23 (IL-12/IL-23), and helper T cells 17 (Th17), have been discussed with an emphasis on their efficacy in controlling psoriasis and its cardiovascular consequences.

The Occurrence of Metabolic Risk Factors Stratified by Psoriasis Severity: A Swedish Population-Based Matched Cohort Study

Purpose

To assess the relative risk of metabolic risk factors in patients stratified by psoriasis severity compared with population controls.

Patients and Methods

A retrospective cohort study was conducted using national Swedish registers. Adult patients with psoriasis were selected if they had a dispensing of anti-psoriasis prescription (2007–2013) and at least one diagnosis within five years before the dispensing date. The patients with psoriasis were matched 1:10 to controls from the general population on birth year, sex, and county. The cohort was further divided into three disease severity groups (mild, moderate, or severe) based on their dispensed anti-psoriasis medication. Subjects were followed from the index date until censoring. We applied flexible parametric modeling to understand the risks of the incident comorbidities hypertension, hypercholesterolemia, and diabetes mellitus among patients with psoriasis from 6 months through 10 years. Hazard ratios and predicted risk (ie, 1 minus the survival probability) of comorbidities were reported.

Results

The hazard of hypertension, hypercholesterolemia, and diabetes mellitus is higher among psoriasis patients compared with population controls, and the hazard ratio increases with psoriasis severity. For example, HRs of hypertension for patients with mild, moderate, and severe psoriasis are 1.29 (95% CI: 1.27–1.32), 1.35 (95% CI: 1.32–1.38), and 1.73 (95% CI: 1.64–1.82), respectively. The predicted risk of hypertension, hypercholesterolemia, and diabetes mellitus among patients with severe psoriasis at year ten was 0.58 (95% CI: 0.56, 0.59), 0.33 (95% CI: 0.32, 0.35), and 0.21 (95% CI: 0.20, 0.23), respectively, while it was 0.42 (0.41, 0.43), 0.23 (0.22, 0.23), 0.11 (0.10, 0.11) among controls, respectively. The predicted risk at year ten was similar among patients with mild or moderate psoriasis.

Conclusion

The HRs and predicted risks of metabolic risk factors are higher among patients with psoriasis compared with matched controls and are more prominent among the severe psoriasis group.

Early diagnosis of psoriatic arthritis among psoriasis patients: clinical experience sharing

Background

The early detection of psoriatic arthritis (PSA) poses a challenge to rheumatologists, even when their diagnosis is aided by sonography. In order to facilitate early detection of PSA among patients with psoriasis (PSO), we retrospectively analyzed of the relationships between serological markers and comorbidities in 629 psoriatic patients, 102 of which had PSA, while the other 527 had PSO.

Results

Serological markers were found not to be useful in distinguishing between PSA and PSO (p > 0.05 for all comparisons). The prevalence rate of PSA among PSO patients was around 19.4%. Two components of metabolic syndrome—hyperlipidemia (2.94%) and gout (4.9%)—were significantly more prevalent in PSA patients than in PSO patients (p < 0.05). The odds ratio for PSA is 15.94 in patients with hyperlipidemia with a 95% confidence interval (CI) of 1.64–154.80; meanwhile, the odds ratio for PSA is 3.83 in patients with gout with a 95% CI of 1.19–12.31. Allergic rhinitis (5.88%) was more prevalent in PSA patients than in PSO patients (p < 0.01). The odds ratio was 8.17 in patients with allergic rhinitis with a 95% CI of 2.26–29.50. Plasma hs-miR-210-3p distinguishes PSA from PSO, and its levels can also be distinguished from PSA after treated with anti-TNFα biologics agents (both p < 0.05).

Conclusions

No clinical available serology markers, but hyperlipidemia, gout, axial spondylopathy (inflammatory back pain), or allergic rhinitis, could differentiate between psoriatic arthritis from psoriasis. Plasma hs-miR-210-3p and comorbidities may differentiate psoriatic arthritis from psoriasis.

Key Points • Clinical manifestations and comorbidities are different between psoriatic arthritis and psoriasis only patients. • Traditional serology markers are similar between psoriatic arthritis and psoriasis-only patients. • Plasma hs-miR-210-3p distinguishes PSA from PSO, and its levels can also be distinguished from PSA after treated with anti-TNFα biologics agents in our study.

Electronic supplementary material

The online version of this article (10.1007/s10067-020-05132-1) contains supplementary material, which is available to authorized users.

Psoriasis and cardiovascular disorders: association or epiphenomenon? Meta-analysis of observational studies

Psoriasis is a chronic inflammatory disease believed to be correlated with numerous cardiovascular risk factors including increased blood pressure, elevated blood cholesterol level, diabetes, inactivity, high body mass index (obesity) and dyslipidaemia. The present meta-analysis intends to assess the association between psoriasis and cardiovascular risk factors. Three hundred and fifty articles were primarily screened using NCBI MEDLINE/PubMed and Cochrane library from its inception until June 30, 2018. Of these, 26 observational studies depending upon the inclusion and exclusion criteria were included in the study with 17,672 psoriasis patients and 66,407 non-psoriasis subjects. The psoriasis patients were found to be at significantly increased risk of systolic blood pressure (SBP) [ORs 2.31 (95% CI 1.12, 4.74)], diastolic blood pressure (DBP) [ORs 2.31 (95% CI 1.58, 3.38)], abdominal obesity [ORs 1.90 (95% CI 1.45, 2.50)] and triglycerides [ORs 1.80 (95% CI 1.29, 2.51)] as compared to non-psoriasis subjects. The subgroup analyses of studies based on the continents revealed that psoriasis patients from Middle East are prone to higher risk factors of CVD including increased levels of triglyceride, cholesterol, DBP, SBP, fasting blood sugar, body mass index and decreased HDL levels, whereas psoriasis patients from European population reported increased LDL-C and waist circumference. The present study supports a significant association between psoriasis and incidence of major adverse cardiovascular events. Contrary to the previous literature, our finding suggests that hypertension is a highly associative condition in psoriasis. The findings of this study could be validated amongst well-defined cohorts of patients with psoriasis individually in different regions to confirm the implication of the study.

Addictive behaviors, cardiovascular and metabolic comorbidities in North African psoriatic patients: case-control study

We propose to study the epidemiological aspects of North African psoriasis and determine the cardiovascular comorbidities and addictive behaviors associated with psoriasis. This is a North African case-control study which was conducted over a five year period (October 2008 through August 2013), involving 671 psoriatic patients and 1,242 controls identified in various Algerian, Tunisian and Moroccan university hospitals. For each patient, epidemiological characteristic, addictive behaviors, and cardiovascular pathologies associated with psoriasis were noted. Six hundred and seventy one psoriasis patients and 1,242 controls were included in this study. The average age was 47.24 years and the M/F sex-ratio was 1.11 (354 men and 317 women). Statistical analysis showed that psoriasis patients were more likely to develop addictive behaviors than controls (smoking p<10-5 and alcohol consumption: p < 10-5), together with dyslipidemia (30.1% of patients p < 10-5), obesity (23.8% of patients p < 10-4), hypertension (22.3% of patients p < 10-5), diabetes (21.7% of occurrences p < 10-5) and metabolic syndrome (37.4% of patients p<10-5). The relative risk for developing psoriasis was 1.9 in hypertensive patients, 1.7 in diabetic patients, 3.9 in dyslipidemic patients, 1.8 in obese patients, 2.6 in those with metabolic syndrome, 2.1 in smokers and 2.8 in alcoholics. Our work confirms the high incidence of addictive behaviors and of cardiovascular and metabolic comorbidities during the North-African psoriasis, hence the need for a multidisciplinary comprehensive care based on a guideline suited to the characteristics of North-African psoriatic patients.

The association between psoriasis and diabetes mellitus: A systematic review and meta-analysis

BACKGROUND

Psoriasis is an immune-mediated chronic inflammatory skin disease with unknown etiology. Current findings demonstrate that psoriatic patients are at higher risk of other systemic disorders such as diabetes mellitus. The present study was conducted to evaluate the association between psoriasis and diabetes mellitus.

METHOD

The current study was conducted based on preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. Using MeSH keywords we searched online databases of PubMed, Scopus, Web of Science, Science Direct, Embase, CINAHL, Cochrane Library, EBSCO and Google scholar search engine and the reference list of the retrieved articles until June 2018. Heterogeneity among studies was assessed using Cochran's Q test and I² index and the random effects model was used to estimate Odds Ratio (OR) and 95% confidence interval (CI). Data were analyzed using Comprehensive Meta-Analysis (CMA) software version 2.

RESULTS

Analysis of 38 eligible studies involving 922870 cases and 12808071 controls suggested the estimated OR to be 1.69 (95% Confidence Interval [CI]: 1.51-1.89; P < 0.001). Subgroup analysis was conducted based on study design and country of study and was significant (test for subgroup differences: P = 0.025 and P < 0.001, respectively).

CONCLUSIONS

Our study indicated the significant association between psoriasis and diabetes. Therefore, psoriasis is a systemic disorder and other comorbidities should be considered in the management of patients with psoriasis.

Type 2 diabetes and psoriasis: links and risks

Psoriasis (PsO) is one of the most common chronic inflammatory skin diseases with a world prevalence of 2%-4%. The increasing knowledge of the mechanisms driving PsO has raised focus on existing links to metabolic syndrome and type 2 diabetes (T2D). We reviewed the existing literature of the prevalence and risk of T2D in patients with PsO. The studies reviewed were mainly large retrospective cohort and case-control studies, showing an increased prevalence of T2D in PsO patients compared to controls, particularly in late onset (type 2) PsO. T2D prevalence did not correlate to patient age or severity of PsO in the reviewed studies. Conclusively, T2D was found to be more prevalent in patients with PsO compared to the background population. Several mechanisms involved in lipid transportation seem to be upregulated in PsO patients. Physicians play a key role concerning information about known comorbidity and promotion of early prophylaxis in patients with PsO.

Psoriasis is associated with a greater risk for cardiovascular procedure and surgery in patients with hypertension: A nationwide cohort study

Psoriasis increases the incidence of hypertension and cardiovascular disease. However, its effect on the course of cardiovascular disease remains unknown. To investigate whether patients with psoriasis and hypertension have a higher requirement for cardiovascular procedure and surgery than patients with hypertension but without psoriasis, we used the Taiwan National Health Insurance Research Database to identify patients with new-onset hypertension during 2005-2006. Among these patients, those with psoriasis (n = 4039) were matched in a 1:1 ratio by age and sex with patients without psoriasis. The association between psoriasis and cardiovascular interventions was examined using time-varying Cox proportional hazards models. The mean follow-up period was 5.62 years. Psoriasis was associated with an increased risk for cardiovascular procedure and surgery in patients with hypertension (adjusted hazard ratio [aHR], 1.28; 95% confidence interval [CI], 1.07-1.53). When no psoriasis served as a reference group, the aHRs were higher for women than for men, and for patients aged 50-64 years than for younger and older patients. Patients with severe psoriasis or psoriatic arthritis tended to have higher risks of cardiovascular procedure and surgery than patients with mild psoriasis (aHR, 1.22; 95% CI, 0.98-1.51) or patients without psoriatic arthritis (aHR, 1.15; 95% CI, 0.84-1.58), respectively, did, although not reaching statistical significance. In conclusion, patients with hypertension and psoriasis had a greater requirement for cardiovascular interventions than hypertensive patients without psoriasis. More intense assessments for cardiovascular interventions may be necessary in patients with concurrent hypertension and psoriasis than general hypertension patients.

Association between physical activity and risk of prevalent psoriasis: A MOOSE-compliant meta-analysis

Psoriasis is a common chronic relapsing immune-mediated inflammatory disease, whose prevalence has increased in recent years. Some physicians believe that physical activity is associated with numerous health-related benefits in adults with dermatoses. While numerous studies have suggested an association between psoriasis and physical activity, others have yielded contradictory results. The aim of our study was to evaluate the association between the level of physical activity and prevalence of psoriasis.A comprehensive search of the literature was performed from January 1970 to February 2017 using EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials electronic databases. Studies published in English were reviewed to identify the contribution of intensity of physical activity on the prevalence of psoriasis.The search strategy yielded 1100 relevant studies, among which 13 observational studies were included. We found that patients with psoriasis exercise significantly less vigorously than controls (relative risk [RR]: 0.76; 95% confidence interval [CI]: 0.67-0.85; P < .00001). Predominantly, these patients exercised at moderate intensity (RR: 0.40; 95% CI: 0.18-0.90; P = .03). Some patients had lesser degree of movement, and some exercised strenuously. There were no significant differences observed in the intensity of exercise performed by controls (RR: 0.90; 95% CI: 0.46-1.77; P = .76). The 3 studies found the frequency of regular exercise differed significantly between patients with psoriasis and controls (RR: 0.88; 95% CI: 0.82-0.95; P = .0007).Different severities of psoriasis have different influences on patients' physical activity levels. Patients with a higher proportion of psoriatic lesions and self-awareness were associated with lower-intensity exercises. Our meta-analysis highlights the fact that intense physical activity may lower the prevalence of psoriasis.

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

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

Psoriasis is associated with risk of obstructive sleep apnea independently from metabolic parameters and other comorbidities: a large hospital-based case-control study

PURPOSE

Obstructive sleep apnea (OSA) represents a breathing disorder during sleep with significant health consequences. Few studies have examined the prevalence of OSA in psoriatic patients and whether OSA may be associated with psoriasis risk. We aimed to explore: (1) the inverse relationship, that is whether psoriasis might represent an independent predictor of OSA and its severity considering important predisposing factors and (2) the psoriatic phenotype related to severe OSA.

METHODS

In a large hospital-based case-control study, we examined a total of 253 patients with OSA and a control group of 104 subjects without OSA, who underwent full nocturnal polysomnography and dermatologic examination.

RESULTS

The prevalence of psoriasis was significantly greater in OSA patients than in controls (p = 0.03). Psoriasis was associated with OSA risk (p = 0.04) but not severity of OSA, sleepiness severity or sleep efficiency, independently from age, gender, anthropometric features, and significant comorbidities. The phenotype of a psoriatic patient suffering from severe OSA is not different from that of a patient with severe OSA and is not associated with psoriasis severity indexes. OSA psoriatic patients were not compliant with CPAP treatment in comparison with OSA patients without psoriasis.

CONCLUSION

Psoriasis may represent an independent risk factor for OSA above and beyond significant comorbidities, anthropometric and metabolic parameters. Physicians should be aware of the bi-directional association of psoriasis and OSA. Managing psoriasis may be a potential target for preventing OSA as well as the potential cardiovascular mortality related to OSA and psoriasis.

A case report of hereditary neuropathy with liability to pressure palsies accompanied by type 2 diabetes mellitus and psoriasis

RATIONALE

Hereditary neuropathy with liability to pressure palsy (HNPP) is an episodic, multifocal neuropathy, with a typical clinical presentation of recurrent transient pressure palsies, which is induced by a PMP22 deletion. Another neuropathy caused by a PMP22 duplication is Charcot-Marie-Tooth disease type 1A (CMT1A). PMP22 is a gene coding a protein called peripheral myelin protein 22 (PMP22), which plays an essential role in the formation and maintenance of compact myelin. Coexistence of type 2 diabetes mellitus (T2DM) and CMT1A has been reported in many work, however HNPP patients with T2DM are rare, and comorbidity of HNPP and psoriasis has not been reported previously. Electrophysiological features of HNPP has been found progressing with aging. Patient concerns: Here we present a 20-year-old man who exhibited lower extremity weakness and foot drop as the initial manifestation.

DIAGNOSES

HNPP was diagnosed on the basis of clinical features, positive sural nerve biopsy findings, and genetic testing results. Moreover, physical examination, blood/urine glucose test, and diabetes-related autoantibodies investigations demonstrated that he had psoriasis and T2DM. The electrophysiological manifestations revealed profound demyelinating injuries and axonal injuries in distal peripheral nerves and facial nerves, which were more severe than general HNPP cases.

INTERVENTIONS

The young patient was treated with continuous subcutaneous insulin infusion and blood glucose monitoring, and then transferred to oral acarbose therapy. The psoriatic lesions were treated with calcipotriol ointment.

OUTCOMES

In the follow-up, the right leg weakness was alleviated, and his gait was improved.

LESSONS

The findings indicate that diabetes mellitus may have an impact on the severity of HNPP. Physicians should consider that worsening of symptoms might result from newly diagnosed diabetes mellitus while treating patients with HNPP.

Management of the psychological comorbidities of dermatological conditions: practitioners' guidelines

Dermatological disease can be devastating for patients, and although dermatologists are focused on remedying the cutaneous manifestations of these conditions, it is easy to miss the psychological suffering lurking below. Studies reveal that psychiatric comorbidity in dermatology is highly prevalent. Undetected psychopathology can greatly decrease a patient's quality of life and even contribute significantly to the clinical severity of their skin disease. For these reasons, it is vital that practitioners learn to detect psychological distress when it is present, and it is equally essential that they understand the treatment options available for effective intervention. Without training in psychiatric diagnosis and psychopharmacology, dermatologists can easily feel overwhelmed or out of their comfort zone when faced with the need to manage such conditions, but with the negative stigma associated with psychiatric disease in general, a psychiatric referral is often refused by patients, and the dermatologist is thus left with the responsibility. Uncertainty abounds in such situations, but this review seeks to alleviate the discomfort with psychodermatological disease and share practical and impactful recommendations to assist in diagnosis and treatment. In a busy dermatology clinic, the key is effective and efficient screening, combined with a repertoire of pharmacological and non-pharmacological treatment options that can be dispersed through an algorithmic approach according to the specific findings of that screening. By implementing these recommendations into practice, dermatologists may begin to gain comfort with the management of psychocutaneous disease and, as a specialty, may expand to fill a hole in patient care that is truly significant for patients, their families, and our communities as a whole.

The impact of PASI 75 and PASI 90 on quality of life in moderate to severe psoriasis patients

BACKGROUND

It is well known that psoriasis significantly impacts patients' quality of life (QoL). With the introduction of improved treatment modalities with biologic agents, more patients with moderate to severe psoriasis are able to achieve better results as measured by the Psoriasis Area and Severity Index (PASI). PASI 75 indicates a 75% or greater reduction in PASI scores from baseline and is indicative of excellent disease improvement. With newer biologic agents such as secukinumab, ixekizumab and brodalumab, patients are now capable of achieving PASI 90, introducing additional clinical decisions for physicians when considering treatment options. However, little is known regarding how the difference between achieving PASI-75 versus PASI-90 impacts patients' QoL.

OBJECTIVES

The purpose of this study was to compare how achieving PASI 75 versus PASI 90 impacts QoL for patients with moderate to severe plaque psoriasis by using validated psychometric instruments that have been widely used in both dermatologic and non-dermatologic settings.

METHODS

Two separate open-label clinical trials were conducted to specifically assess QoL in patients with moderate to severe psoriasis on adalimumab or ustekinumab over 24 weeks. In addition to clinical assessments of psoriasis, patients completed two surveys: The Psychological General Well-Being (PGWB) Index and the Dermatology Life Quality Index (DLQI). Changes in total PGWB score and DLQI score at weeks 12 and 24 compared to baseline were compared between groups achieving PASI 75 and PASI 90.

RESULTS

There was no statistically significant difference in PGWB scores between patients achieving PASI 75 and patients achieving PASI 90 in the adalimumab treatment group (week 12 p = .21, but there was at week 24 p = .05). There was a statistically significant difference in DLQI between the patients achieving PASI 75 and the patients achieving PASI 90 in the adalimumab treatment group at week 24 (p = .01), but not week 12 (p = .11). There was no statistically significant difference in PGWB scores between patients achieving PASI 75 and patients achieving PASI 90 in the ustekinumab treatment group (week 12 p = .11, week 24 p = .35). There was no statistically significant difference in DLQI between the patients achieving PASI 75 and the patients achieving PASI 90 in the ustekinumab treatment group at week 24 (week 12 p = .49, week 24 p = .11).

CONCLUSIONS

There has been tremendous attention surrounding newer biologic agents that can achieve PASI 90 and even PASI 100. Although the results are impressive with regard to physical improvement of psoriasis, there may not be a clinically significant difference in QoL when comparing patients who achieve PASI-75 versus PASI 90.

Increased risk of aortic aneurysm (AA) in relation to the severity of psoriasis: A national population-based matched-cohort study

BACKGROUND

Inflammation of systemic and vascular tissues besides the skin in psoriasis is associated with cardiovascular morbidity and mortality.

OBJECTIVE

We sought to investigate whether or not patients with psoriasis have an increased risk of aortic aneurysm (AA).

METHODS

This population-based cohort study identified 34,301 patients with psoriasis in the Taiwan National Health Insurance Research Database during 2004 to 2006, who were matched for age and sex with 137,204 control subjects without psoriasis from the Taiwan Longitudinal Health Insurance Database 2000. Each individual was individually followed up for 5 years to identify those who subsequently developed AA.

RESULTS

After adjusting for medical history and medication use, patients with psoriasis were at increased overall risk of AA (adjusted hazard ratio [HR] 1.80; 95% confidence interval 1.25-2.61). The risk for AA increased with the severity of psoriasis. The adjusted HRs were higher for male than female patients (adjusted HR 1.84 vs 1.56), and for patients younger than 50 years versus older patients (adjusted HR 2.81 vs 1.64).

LIMITATIONS

There is a lack of information regarding patients' Psoriasis Area and Severity Index score, daily tobacco use, or alcohol consumption.

CONCLUSION

Patients with psoriasis are predisposed to developing AA: this risk increases with psoriasis severity and is independent of established cardiovascular risk factors.

[New populations at increased cardiovascular risk: Cardiovascular disease in dermatological diseases]

The increased cardiovascular risk in some dermatological diseases has been demonstrated in recent decades. Diseases such as psoriasis and systemic lupus erythematosus are currently included in the guidelines for prevention of cardiovascular disease. Other diseases such as androgenic alopecia, polycystic ovary syndrome, hidradenitis suppurativa or lichen planus have numerous studies that point to an increased risk, however, they have not been included in these guidelines. In this article we review the evidence supporting this association, in order to alert the clinician to the need for greater control in cardiovascular risk factors in these patients.

Immunosuppressive medication use and risk of herpes zoster (HZ) in patients with systemic lupus erythematosus (SLE): A nationwide case-control study

BACKGROUND

The association between immunosuppressive medication use and herpes zoster (HZ) in patients with systemic lupus erythematosus (SLE) has not been clearly defined.

OBJECTIVE

We evaluated the risk of HZ in patients with SLE treated with different immunosuppressants.

METHODS

A nationwide population-based case-control study was conducted using the Taiwanese National Health Insurance Research Database. Cases (1555 patients with SLE who developed HZ) and controls (3049 age- and sex-matched patients with SLE but without HZ) were analyzed for use of various immunosuppressive medications in the preceding 3-month period, and dose-response relationships were determined. Logistic regression was performed to estimate the adjusted odds ratio for HZ development.

RESULTS

Medications associated with greater HZ risk in patients with SLE included oral corticosteroids, intravenous methylprednisolone, hydroxychloroquine, oral cyclophosphamide, intravenous cyclophosphamide, azathioprine, methotrexate, and mycophenolate mofetil. Combination immunosuppressive therapy was common in patients with SLE and was associated with greatly increased HZ risk. For oral corticosteroids and hydroxychloroquine, the risk of HZ was strongly dependent on the medication dose.

LIMITATIONS

This study is retrospective in nature.

CONCLUSION

Recent immunosuppressive medication use is associated with increased HZ risk in patients with SLE, particularly those receiving high-dose oral corticosteroids and multiagent immunosuppressive therapy.

High mobility group box 1 is increased in the sera of psoriatic patients with disease progression

BACKGROUND

Psoriasis vulgaris (PV) is an autoimmune-related chronic inflammatory disease, which appears mostly in skin, but also affects the vascular and metabolic system. The incidence of PV is 2-3% in the general population and there is still no possibility to cure. Trigger factors have been identified to initiate and maintain inflammation in the skin, which is characterized by Th1-, Th17- and Th22- cells.

OBJECTIVE

We hypothesize that the damage-associated molecular pattern (DAMP) molecule high mobility group box 1 (HMGB1) plays a role in the pathogenesis of PV. HMGB1 is a DNA-binding protein located in the nucleus, which acquires cytokine-like properties once released from the cell upon necrotic cell death or actively secreted by immune cells in inflammation and cancer.

METHODS

We recruited 90 psoriatic patients under and without therapy with mild, intermediate and severe progression of disease, defined by the Psoriasis Area Severity Index. Serum levels of HMGB1 in patients with PV were detected by enzyme-linked immunosorbent assay (ELISA).

RESULTS

Our results show an increased level of HMGB1 in the sera of patients with PV in comparison to healthy donors. Furthermore, our analyses reveal that HMGB1 levels are significantly increased with disease progression and are downregulated after standard therapies for PV have been conducted.

CONCLUSION

Our data provide insights into a possible role of HMGB1 for inflammation in PV.

Risks of hypertension associated with cyclosporine, nonsteroidal anti-inflammatory drugs, and systemic glucocorticoids in patients with psoriasis: a nationwide population-based nested case-control study in Taiwan

PURPOSE

Patients with psoriasis and/or psoriatic arthritis (PsA) are known to have increased cardiovascular morbidity and mortality. Hypertension, an important risk factor for cardiovascular disease, is highly prevalent in patients with psoriasis and/or PsA. The effects of anti-psoriatic medications - including cyclosporine, nonsteroidal anti-inflammatory drugs, and glucocorticoids - on hypertension remain unclear. We examined whether such medication exposure was associated with hypertension in psoriasis patients.

METHODS

This population-based, nested case-control study analyzed data from an inception psoriasis cohort identified from Taiwan's National Health Insurance Research Database, 2000-2010. A total of 1530 patients with newly diagnosed hypertension and 4542 age- and gender-matched controls were included in the analysis. Conditional logistic regressions were applied to estimate the effects of drug of interest on hypertension.

RESULTS

After adjusting for potential confounders, patients with current use of cyclosporine [odds ratio (OR) = 7.13; 95% confidence interval (CI) 1.85-27.49], nonsteroidal anti-inflammatory drugs (OR = 2.2; 95% CI 1.95-2.49), or systemic glucocorticoids (OR = 1.42; 95% CI 1.23-1.64) showed an increased risk of hypertension as compared to those not exposed to these drugs. Moreover, an increasing dose or combined use of nonsteroidal anti-inflammatory drugs and glucocorticoids was associated with increased hypertension risk. The risk of hypertension associated with glucocorticoids, or combined use was greatest among patients aged 49 years or less.

CONCLUSIONS

The use of cyclosporine, nonsteroidal anti-inflammatory drugs, or glucocorticoid was associated with hypertension in patients with psoriasis and/or PsA. These study results inform physicians on the importance of early identification of hypertension during therapy with such medication.

Exploring the Physiological Link between Psoriasis and Mood Disorders

Psoriasis is a chronic, immune-mediated skin condition with a high rate of psychiatric comorbidity, which often goes unrecognized. Beyond the negative consequences of mood disorders like depression and anxiety on patient quality of life, evidence suggests that these conditions can worsen the severity of psoriatic disease. The mechanisms behind this relationship are not entirely understood, but inflammation seems to be a key feature linking psoriasis with mood disorders, and physiologic modulators of this inflammation, including the hypothalamic-pituitary-adrenal axis and sympathetic nervous system, demonstrate changes with psychopathology that may be contributory. Cyclical disruptions in the secretion of the sleep hormone, melatonin, are also observed in both depression and psoriasis, and with well-recognized anti-inflammatory and antioxidant activity, this aberration may represent a shared contributor to both conditions as well as common comorbidities like diabetes and cardiovascular disease. While understanding the complexities of the biological mechanisms at play will be key in optimizing the management of patients with comorbid psoriasis and depression/anxiety, one thing is certain: recognition of psychiatric comorbidity is an imperative first step in effectively treating these patients as a whole. Evidence that improvement in mood decreases psoriasis severity underscores how psychological awareness can be critical to clinicians in their practice.

Treating Psoriasis During Pregnancy: Safety and Efficacy of Treatments

Psoriasis is a chronic inflammatory disease with a well-documented negative effect on the quality of life of affected patients. Psoriasis often occurs in the reproductive years, during which the issue of pregnancy needs to be addressed. The course of psoriasis during pregnancy is unpredictable, and many patients face the challenge of needing treatment during pregnancy. In this review we provide an overview of the key considerations for managing psoriasis in pregnant women, covering the potential effects of active psoriasis and co-morbid conditions on the health of the mother and fetus, as well as the effects of psoriasis treatment options on the developing fetus. Although there are no robust data on the safety of systemic treatment of pregnant women, increasing evidence regarding the safety of cyclosporine (ciclosporin) treatment as well as anti-tumor necrosis factor-α is available and should be considered in pregnant women with moderate to severe psoriasis unresponsive to local corticosteroids and UVB light treatment.