Objective Measures of Psoriasis Severity Predict Mortality: A Prospective Population-Based Cohort Study

The role of adipokines in the pathogenesis of psoriasis - a focus on resistin, omentin-1 and vaspin

BACKGROUND

Psoriasis is a chronic immune-mediated skin condition with several types of manifestation, including psoriatic arthritis. In recent years, studies have demonstrated multiple molecules and mechanisms that play important roles in the pathophysiology of psoriasis. Studies have been conducted to determine the role of adipokines, bioactive peptides secreted by the adipose tissue, in the pathogenesis of inflammatory diseases. These studies have shown that adipokines are dysregulated in psoriasis and their abnormal expression profile could contribute to the inflammatory mechanisms observed in psoriasis.

AREAS COVERED

In this review, we discuss the immunomodulatory features of resistin, omentin-1, and vaspin, and discuss their potential involvement in the pathogenesis of psoriasis.

EXPERT OPINION

The adipokines resistin, omentin, and vaspin appear to be promising therapeutic targets in psoriasis. It is important to seek to block the action of resistin, either by blocking its receptors or by blocking its systemic effects with antibodies. In the case of omentin and vaspin, substances that are receptor mimetics of these adipokines should be sought and studies conducted of their analogues for the treatment of psoriasis. To introduce these therapies into clinical practice, multicentre clinical trials are required to confirm their efficacy and safety after initial studies in animal models.

Using Guidelines of Care to Lower Cardiovascular Risk in Patients with Psoriasis

National guidelines define psoriasis as a risk enhancer for cardiovascular disease and recommend increased monitoring and more intense management of cardiovascular risk factors in these patients, who face an increased burden of cardiovascular disease morbidity and mortality. Screening for modifiable cardiovascular risk factors, including blood pressure, weight, cholesterol, glucose, and smoking, can be efficiently incorporated into routine dermatology clinical practice. Partnerships with primary care providers and preventive cardiologists are essential to improving management of cardiovascular risk in patients with psoriasis.

Lifetime risk, life expectancy, loss-of-life expectancy, and lifetime healthcare expenditures for psoriasis in Taiwan: a nationwide cohort followed from 2000 to 2017

Background

Patients with psoriasis have a significant disease burden throughout the life course. Nevertheless, the lifetime risk and disease burden of psoriasis across the entire lifespan is rarely quantified in an easily understandable way.

Objective

To estimate the cumulative incidence rate, life expectancy, loss-of-life expectancy, and lifetime healthcare expenditures for incident psoriasis.

Design and methods

Using real-world nationwide data from the National Health Insurance Research Database of Taiwan for 2000-2017, along with the life tables of vital statistics, we estimated cumulative incidence rate, life expectancy, loss-of-life expectancy, and lifetime healthcare expenditures for those with psoriasis using a semi-parametric survival extrapolation method.

Results

A total of 217,924 new psoriasis cases were identified. The lifetime risk of psoriasis in patients aged 18-80 for both sexes decreased in Taiwan with a cumulative incidence rate of 7.93% in 2000 to 3.25% in 2017. The mean (±standard error) life expectancy after diagnosis was 27.11 (± 1.15) and 27.14 (±1.17) years for patients with moderate-to-severe psoriasis and psoriatic arthritis, respectively. Patients with moderate-to-severe psoriasis and psoriatic arthritis had a mean (±standard error) loss-of-life expectancy of 6.41 (±1.16) and 6.48 (±1.17) due to psoriasis, respectively. Male patients have higher lifetime and annual lifetime healthcare expenditures than female. Mean life expectancy, loss-of-life expectancy, and lifetime cost were relatively higher for younger patients.

Conclusion

Among psoriatic patients, patients with moderate-to-severe psoriasis and psoriatic arthritis had substantial years of life lost, particularly for younger patients. Our results provide a reliable estimation of lifetime disease burden, and these estimates will help health authorities in cost-effectiveness assessments of public health interventions and allocation of services resources to minimize loss-of-life expectancy, and lifetime healthcare expenditures in patients with psoriasis.

Incidence and prevalence of psoriasis in multiethnic Johor Bahru, Malaysia: a population-based cohort study using electronic health data routinely captured in the Teleprimary Care (TPC®) clinical information system from 2010 to 2020: Classification: Epidemiology

BACKGROUND

There are no population-based epidemiological data on psoriasis in Southeast Asia, including Malaysia.

OBJECTIVES

To determine the incidence and prevalence of psoriasis over 11 years in multiethnic Johor Bahru, Malaysia.

METHODS

A population-based cohort study was made using the Teleprimary Care database between January 2010 and December 2020. Cases of psoriasis, identified by ICD-10 diagnostic codes, were validated by dermatologists. Annual prevalence and incidence were estimated and stratified by age, sex and ethnicity.

RESULTS

We identified 3932 people with dermatologist-confirmed psoriasis, including 1830 incident cases, among 1 164 724 Malaysians, yielding an 11-year prevalence of 0·34% [95% confidence interval (CI) 0·33-0·35] and incidence of 34·2 per 100 000 person-years (95% CI 32·6-35·8). Rates were higher in Indian patients; the prevalences were 0·54% (0·50-0·58) in Indian, 0·38% (0·36-0·40) in Chinese and 0·29% (0·28-0·30) in Malay patients, and the respective incidences per 100 000 person-years were 52·5 (47·3-57·7), 38·0 (34·1-41·8) and 30·0 (28·2-31·8). Rates were higher in males; the prevalence was 0·39% (0·37-0·41) in males and 0·29% (0·27-0·30) in females, and the respective incidences per 100 000 person-years were 40·7 (38·2-43·2) and 28·3 (26·4-30·3). Between 2010 and 2020, annual psoriasis prevalence and incidence increased steadily from 0·27% to 0·51% and from 27·8 to 60·9 per 100 000 person-years, respectively. Annual rates were consistently higher in male and Indian patients. Overall, psoriasis was significantly more common in males than females [odds ratio (OR) 1·37, 95% CI 1·29-1·46] and in Indian and Chinese patients vs. Malay (OR 1·85, 1·71-2·01 and OR 1·30, 1·20-1·41, respectively). Prevalence increased with age, with the highest rates in the groups aged 50-59 and 60-69 years at 0·67% and 0·66%, respectively. A modest bimodal trend in age of psoriasis onset was observed, with first and second peaks at 20-29 and 50-59 years. Disease onset was significantly earlier in females than males [mean (SD) 36·8 (17·3) vs. 42·0 (17·2) years, P < 0·001] and in Malay vs. Indian and Chinese patients [mean (SD): Malay 36·4 (17·5), Indian 40·8 (15·2), Chinese 47·4 (16·9) years, P < 0·001].

CONCLUSIONS

We found that psoriasis incidence and prevalence are increasing and varied by age, sex and ethnicity. Our findings should help inform healthcare planning and management for patients with psoriasis in Malaysia. What is already known about this topic? The incidence and prevalence of psoriasis are generally lower in Asian populations and children. There is a lack of agreement on sex-specific differences in psoriasis incidence and prevalence. There has been no population-based study on the incidence and prevalence of psoriasis in Southeast Asia, including Malaysia. There is no information on differences in psoriasis prevalence and incidence by sex, age and ethnicity in Malaysia. What does this study add? Psoriasis incidence and prevalence are increasing in the multiethnic population of Johor Bahru, Malaysia. Incidence and prevalence rates were higher in male than female patients and were consistently highest among Indian patients, followed by Chinese and Malay. A modest bimodality in the age of psoriasis onset was observed among the groups aged 20-29 and 50-59 years. Psoriasis onset was significantly later in male than female patients and in Chinese vs. Indian and Malay patients.

Specialist and Patient Perspectives on Strategies to Improve Cardiovascular Disease Prevention Among Persons Living with Psoriatic Disease

Background

Psoriasis is an immune-mediated disease associated with excess risk for cardiovascular disease (CVD). Guidelines recognize psoriasis as a CVD risk enhancer; however, psoriasis patients often do not have CVD risk factors identified nor managed.

Objective

This study examines strategies to improve CVD prevention care from the perspective of dermatologists and patients with psoriasis.

Methods

Qualitative interviews were conducted using the Consolidated Framework for Implementation Research to examine the perspectives of physicians (N = 16) and patients with psoriatic disease (N = 16) on barriers/facilitators to CVD prevention. Interviews were transcribed and coded using an integrated approach designed to enhance reliability and validity using NVivo software.

Results

We found three major themes suggesting areas to target for the future: (1) Appropriateness: perceptions of whether CVD care should be deployed in this setting by both clinicians and patients, (2) Feasibility: whether CVD prevention care could be integrated into the current structure of specialist practice, and (3) Care Coordination: an interest by all parties to better integrate a team approach in CVD preventative care to reduce duplicative efforts, work practically in an already existing system rather than reinventing the wheel, and progress with the patients' best interests in mind.

Conclusions

These findings will inform the design of a clinical trial comparing the effectiveness of specialist clinician implementation of CVD guideline-based prevention care in patients with psoriasis. Ultimately, this study aims to increase the lifespan and health of patients living with psoriatic disease by decreasing barriers to their receiving appropriate CVD prevention care.

Promises and pitfalls in implementation science from the perspective of US-based researchers: learning from a pre-mortem

BACKGROUND

Implementation science is at a sufficiently advanced stage that it is appropriate for the field to reflect on progress thus far in achieving its vision, with a goal of charting a path forward. In this debate, we offer such reflections and report on potential threats that might stymie progress, as well as opportunities to enhance the success and impact of the field, from the perspective of a group of US-based researchers.

MAIN BODY

Ten mid-career extramurally funded US-based researchers completed a "pre-mortem" or a group brainstorming exercise that leverages prospective hindsight to imagine that an event has already occurred and to generate an explanation for it - to reduce the likelihood of a poor outcome. We came to consensus on six key themes related to threats and opportunities for the field: (1) insufficient impact, (2) too much emphasis on being a "legitimate science," (3) re-creation of the evidence-to-practice gap, (4) difficulty balancing accessibility and field coherence, (5) inability to align timelines and priorities with partners, and (6) overly complex implementation strategies and approaches.

CONCLUSION

We submit this debate piece to generate further discussion with other implementation partners as our field continues to develop and evolve. We hope the key opportunities identified will enhance the future of implementation research in the USA and spark discussion across international groups. We will continue to learn with humility about how best to implement with the goal of achieving equitable population health impact at scale.

Body surface area affected by psoriasis and the risk for psoriatic arthritis: a prospective population-based cohort study

OBJECTIVE

Increasing psoriasis severity has been associated with comorbidities including cardiovascular disease. The objective of this study was to examine the association of psoriasis severity with the development of PsA.

METHODS

A prospective population-based cohort study was performed within The Health Improvement Network, a UK medical record database. Patients aged 25-60 years with a code for psoriasis were randomly selected between 2008 and 2011. Questionnaires were sent to their general practitioners to confirm the diagnosis of psoriasis and provide the patient's approximate body surface area (BSA). Incidence of PsA was calculated by BSA, and Cox proportional hazard ratios were used to examine the risk of developing PsA by BSA category after adjusting for other covariates.

RESULTS

Among 10 474 questionnaires sent, 9987 (95%) were returned, 9069 (91%) had confirmed psoriasis, and BSA was provided for 8881 patients: 52% had mild psoriasis, 36% moderate psoriasis and 12% severe psoriasis. The mean age was 46, and 49% were female. Mean follow-up time was 4.2 years (s.d. 2.1); the incidence of PsA was 5.4 cases per 1000 person-years. After adjusting for age and sex, BSA >10% [hazard ratio (HR) 2.01, 95% CI: 1.29, 3.13], BSA 3-10% (HR 1.44, 95% CI: 1.02, 2.03), obesity (HR 1.64, 95% CI: 1.19, 2.26) and depression (HR 1.68, 95% CI: 1.21, 2.33) were associated with incident PsA.

CONCLUSIONS

In this large prospective cohort study, BSA assessed by general practitioners was a strong predictor of developing PsA, and obesity and depression were additive risk factors.

Assessment of the Toronto Psoriatic Arthritis Screen 2 as a Screening Tool for Psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease affecting multiple organ systems and resulting in reduced quality of life for many patients. A screening tool would be useful, particularly in underserviced or research settings with limited access to dermatologists. The Toronto Psoriatic Arthritis Screen, version 2 (ToPAS 2) is a validated screening tool for psoriatic arthritis containing questions specific for psoriasis.

OBJECTIVES

To evaluate the performance of skin-specific questions from ToPAS 2 for the diagnosis of psoriasis.

METHODS

Participants aged >18 were recruited from Dermatology and Family Medicine clinics and completed the ToPAS 2 questionnaire prior to being examined by a dermatologist for psoriasis. Two scoring indexes were derived from the ToPAS 2 skin-related questions using backward selection regression models. Statistical analysis was performed using receiver operating characteristic (ROC) curves to measure their performances.

RESULTS

Two hundred and fifty eight participants were recruited. 32 (12%) were diagnosed with psoriasis by dermatologist assessment. Index 1 includes all 5 skin-related questions from ToPAS 2, while Index 2 includes three of the five questions. Both indexes demonstrate high specificity (82% to 92%), sensitivity (69% to 84%), and excellent negative predictive value (NPV) (>95%) for a diagnosis of psoriasis. The overall discriminatory power of these models is 0.823 (Index 1) and 0.875 (Index 2).

CONCLUSIONS

Skin-related questions from ToPAS 2 have discriminatory value in detecting psoriasis, specifically questions relating to a family history, a prior physician diagnosis of psoriasis or a rash consistent with images of plaque psoriasis. This study is a valuable step in developing a screening tool for psoriasis.

Psoriasis and its impact on the clinical outcome of patients with pulmonary embolism

BACKGROUND

An increased risk for venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep venous thrombosis, has been reported in psoriasis patients. The impact of psoriasis on prognosis of VTE patients is widely unknown.

METHODS

Hospitalized PE patients were stratified for psoriasis and the impact of psoriasis on outcome was investigated in the German nationwide inpatient sample of the years 2005-2017.

RESULTS

Overall, 1,076,384 hospitalizations of PE patients (53.7% females, median age 72.0 [60.0-80.0] years) were recorded in Germany 2005-2017. Among these, 3145 patients had psoriasis (0.3%). Psoriatic PE patients were younger (68.0 [57.0-76.0] vs. 72.0 [60.0-80.0] years,P < 0.001) and more often male (64.1% vs. 46.3%,P < 0.001). The prevalence of VTE risk factors, traditional cardiovascular risk factors and cardiovascular comorbidities was higher in psoriatic than in non-psoriatic individuals. Psoriatic PE patients showed a lower in-hospital case-fatality rate (11.1% vs. 16.0%,P < 0.001), confirmed by logistic regressions showing an independent association of psoriasis with reduced case-fatality rate (OR 0.73 [95%CI 0.65-0.82],P < 0.001), despite higher prevalence of pneumonia (24.8% vs. 23.2%,P = 0.029). Psoriasis was an independent predictor for gastro-intestinal bleeding (OR 1.35 [95%CI 1.04-1.75],P = 0.023) and transfusion of blood constituents (OR 1.23 [95%CI 1.11-1.36],P < 0.001).

CONCLUSIONS

PE patients with psoriasis were hospitalized in median four years earlier than those without. Although psoriasis was associated with an unfavorable cardiovascular-risk and VTE-risk profile in PE patients, our data demonstrate a lower in-hospital mortality in psoriatic PE, which might be mainly driven by younger age. Our findings may improve the clinical management of these patients and contribute evidence for relevant systemic manifestation of psoriasis.

TRANSLATIONAL PERSPECTIVE

An increased risk for venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep venous thrombosis, has been reported in psoriasis patients, but the impact of psoriasis on prognosis of VTE patients is widely unknown. PE patients with psoriasis were younger and psoriasis was associated with an unfavorable cardiovascular-risk and VTE-risk profile. In-hospital mortality was lower in psoriatic PE patients, which might be mainly driven by younger age. Our findings improve the clinical management of PE patients and contribute evidence for relevant systemic manifestation of psoriasis.

ONE SENTENCE SUMMARY

Psoriasis with chronic inflammation promotes PE development, is associated with an unfavorable cardiovascular and VTE-risk profile, but lower in-hospital mortality.

New Frontiers in Psoriatic Disease Research, Part II: Comorbidities and Targeted Therapies

Although psoriasis and psoriatic arthritis (PsA) have been classically considered to be diseases of the skin and joints, respectively, emerging evidence suggests that a combination of innate and environmental factors creates widespread immune dysfunction, affecting multiple organ systems. A greater understanding of the pathogenesis of psoriasis and the systemic effects of psoriatic inflammation has allowed for the development of new, more effective treatments. The second portion of this two-part review series examines the comorbidities associated with psoriasis and PsA as well as the most recent advances in targeted systemic therapies for these conditions.

Impact of Biological Agents on Imaging and Biomarkers of Cardiovascular Disease in Patients with Psoriasis: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials

BACKGROUND

The effect of biologics on the risk for cardiovascular disease in patients with psoriasis is still unclear despite their widespread use.

OBJECTIVE

The objective of this study was to examine the impact of licensed biological therapies on imaging and biomarkers of cardiovascular disease risk in patients with psoriasis by a systematic review and meta-analysis of placebo-controlled trials.

METHODS

A comprehensive search of studies published before 1 June 2020 was performed in Medline-Ovid, EMBASE, and CENTRAL using a predefined strategy to identify relevant articles.

RESULTS

Five studies were included for the final examination, and two studies were included in the meta-analysis. We did not find a significant reduction in aortic vascular inflammation in patients treated with adalimumab compared with those who received placebo at weeks 12-16. There was no beneficial effect on imaging biomarkers (aortic vascular inflammation or flow-mediated dilatation) of cardiovascular disease risk in patients exposed to biological therapies (adalimumab and secukinumab) compared with those exposed to placebo, except for ustekinumab showing a reduction in aortic vascular inflammation at week 12 but not at week 52 after the open-label extension period. The strongest reduction in blood-based cardiometabolic risk biomarkers was observed with adalimumab (CRP, TNF-α, IL-6, and GlycA) and phototherapy (CRP and IL-6) compared with that observed with placebo.

CONCLUSIONS

Randomized controlled trials show that ustekinumab reduces aortic vascular inflammation and that TNF-α inhibitors and phototherapy reduce CRP and IL-6. These surrogate marker findings require randomized controlled trials evaluating cardiovascular events to inform clinical practice.

Chronic Systemic Inflammatory Skin Disease as a Risk Factor for Cardiovascular Disease

Chronic systemic skin disease and cardiovascular disease are multisystem disorders which have been associated with each other for centuries. Recent research has strengthened this association, particularly in systemic inflammatory disease. Here we explore the current literature on psoriasis, hidradenitis suppurativa, lupus erythematosus, acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. Psoriasis is a chronic inflammatory disorder that has been labeled as a risk-modifier for hyperlipidemia and coronary artery disease by the American College of Cardiology ACC lipid guidelines. Cardiovascular disease is also found at a significantly higher rate in patients with hidradenitis suppurativa and lupus erythematosus. Some associations have even been noted between cardiovascular disease and acanthosis nigricans, atopic dermatitis, and bullous pemphigoid. While many of these associations have been attributed to a shared underlying disease process such as chronic systemic inflammation and shared underlying risk factors, these dermatologic manifestations can help to identify patients at higher risk for cardiovascular disease.

Reduced risk of mortality associated with systemic psoriasis treatment in the Psoriasis Longitudinal Assessment and Registry (PSOLAR): A nested case-control analysis

BACKGROUND

The effects of systemic therapy on mortality risk among patients with psoriasis are not fully understood.

OBJECTIVE

To evaluate the impact of systemic treatment on mortality risk in patients enrolled in the Psoriasis Longitudinal Assessment and Registry.

METHODS

Nested case-control analyses were performed to estimate mortality risk. Cases were defined as patients who died while participating in the Psoriasis Longitudinal Assessment and Registry. Cases were matched (1:4) with controls by age, race, sex, and geographic region. Evaluated treatments included methotrexate, ustekinumab, and tumor necrosis factor α inhibitors. Exposure was defined as at least 1 dose of treatment within 3 months before death and was stratified by duration of therapy.

RESULTS

Among 12,090 patients, 341 deaths occurred, matched to 1364 controls. Biologic treatment within the preceding 3 months was protective against mortality versus no exposure: odds ratio (OR) for exposure of less than 1 year, 0.08 (95% confidence interval [CI], 0.03-0.23); OR for exposure of 1 year or longer, 0.09 (95% CI, 0.06-0.13). Methotrexate was protective against mortality only with exposure for 1 year or longer (OR, 0.08; 95% CI, 0.02-0.28).

LIMITATIONS

Observational studies are subject to unmeasured confounding.

CONCLUSIONS

Biologic therapy was associated with reduced mortality risk in patients with moderate to severe psoriasis, regardless of treatment duration; methotrexate reduced risk only with exposure for 1 year or longer.

National Psoriasis Foundation COVID-19 Task Force Guidance for Management of Psoriatic Disease During the Pandemic: Version 1

Objective

To provide guidance about management of psoriatic disease during the coronavirus disease 2019 (COVID-19) pandemic.

Study design

A task force (TF) of 18 physician voting members with expertise in dermatology, rheumatology, epidemiology, infectious diseases, and critical care was convened. The TF was supplemented by nonvoting members, which included fellows and National Psoriasis Foundation (NPF) staff. Clinical questions relevant to the psoriatic disease community were informed by questions received by the NPF. A Delphi process was conducted.

Results

The TF approved 22 guidance statements. The average of the votes was within the category of agreement for all statements. All guidance statements proposed were recommended, 9 with high consensus and 13 with moderate consensus.

Limitations

The evidence behind many guidance statements is limited in quality.

Conclusion

These statements provide guidance for the management of patients with psoriatic disease on topics ranging from how the disease and its treatments impact COVID-19 risk and outcome, how medical care can be optimized during the pandemic, what patients should do to lower their risk of getting infected with severe acute respiratory syndrome coronavirus 2 and what they should do if they develop COVID-19. The guidance is intended to be a living document that will be updated by the TF as data emerge.

A Randomized Placebo-Controlled Trial of Secukinumab on Aortic Vascular Inflammation in Moderate-to-Severe Plaque Psoriasis (VIP-S)

Psoriasis, a chronic immune-mediated disease, is associated with an increased risk of cardiovascular events and mortality. Secukinumab selectively neutralizes IL-17A and has reported high efficacy with a favorable safety profile in various psoriatic disease manifestations. Subsequent to the 12-week randomized, placebo-controlled, double-blind treatment period, patients with moderate-to-severe psoriasis received secukinumab for 40 weeks. Vascular inflammation using 18F-2-fluorodeoxyglucose-positron emission tomography/computed tomography imaging and blood-based cardiometabolic was assessed at week 0, 12, and 52. The difference in change in aortic inflammation from baseline to week 12 for secukinumab (n = 46) versus placebo (n = 45) was -0.053 (95% confidence interval = -0.169 to 0.064; P= 0.37). Small increases in total cholesterol, low-density lipoprotein, and low-density lipoprotein particles, but no changes in markers of inflammation, adiposity, insulin resistance, or predictors of diabetes, were observed with secukinumab treatment compared with placebo. At week 52, reductions in TNF-α (P= 0.0063) and ferritin (P= 0.0354), and an increase in fetuin-A (P= 0.0024), were observed with secukinumab treatment compared with baseline. No significant changes in aortic inflammation or markers of advanced lipoprotein characterization, adiposity, or insulin resistance were observed with secukinumab treatment compared with baseline. Secukinumab exhibited a neutral impact on aortic vascular inflammation and biomarkers of cardiometabolic disease after 52 weeks of treatment.

Psoriasis severity matters when dealing with all-cause mortality in psoriasis patients: a record linkage analysis in Northern Italy

Psoriasis has been linked with several comorbidities and increased all-cause mortality compared with the general population. Data are still limited concerning mortality especially from Southern European countries. Between January 2012 and December 2018, we conducted a retrospective cohort study on psoriasis patients and population controls in Northern Italy. Through record linkage of health-care databases, psoriasis cases were identified, and their morbidity and mortality were compared with the general population. The Charlson index was used as an index of comorbidities. Standardized mortality ratios (SMR) were estimated for overall psoriasis cases and for patients with mild vs moderate-to-severe disease, separately. We identified 12,693 psoriasis patients (mean age: 60.8 ± 16.3 years). They had a significantly higher Charlson index compared with the general population (p < 0.001). In spite of the higher rate of comorbidities, age-specific SMR was not increased in the psoriasis population as a whole (1.04 (95% CI 0.89-1.20)) or in people with mild psoriasis. However, a 40% higher than the expected risk of all-cause mortality was documented in individuals with moderate-to-severe psoriasis (SMR: 1.41; 95% CI 1.12-1.75). Notably, an excess mortality in these patients occurred as early as age 40-49 years. The proportion of deaths from malignancies and cardiovascular diseases was remarkably high. Our results support the notion that psoriasis severity influences mortality and indicate that patients with psoriasis, especially those with severe disease, should receive appropriate screening and health education.

A Phase IV, Randomized, Double-Blind, Placebo-Controlled Crossover Study of the Effects of Ustekinumab on Vascular Inflammation in Psoriasis (the VIP-U Trial)

Psoriasis is a T helper type 17 autoimmune disease associated with an increased risk cardiovascular events and mortality. Ustekinumab, an antibody to p40, blocks cytokines IL-12 and IL-23, and is a highly effective and safe treatment for psoriasis. We conducted a randomized double-blinded placebo-controlled trial to determine the effect of ustekinumab on aortic vascular inflammation (AVI) measured by imaging, and key biomarkers of inflammation, lipid, and glucose metabolism in the blood of patients with moderate-to-severe psoriasis. A total of 43 patients were randomized, and at week 12, ustekinumab-treated patients had a -18.65% (95% confidence interval = -29.45% to -7.85%) reduction in AVI, a reduction in inflammatory biomarkers, and an increase in apolipoprotein B lipoproteins compared with placebo. At week 12, placebo patients were crossed over such that all patients received ustekinumab for 52 weeks. At the end of 52 weeks of ustekinumab treatment, there was no change in AVI compared with baseline, inflammatory markers were reduced, and there were increases in selected measures of lipids and leptin. These results show that blockade of IL-12 and/or IL-23 may transiently reduce AVI, with more durable reduction in inflammatory cytokines associated with cardiovascular disease.

Translating Knowledge of IL-23 Targeting into New Solutions for Psoriasis Treatment

Following a brief introduction by Prof Lambert, the symposium started with an in-depth review of the current unmet needs in the clinical management of psoriasis, provided by Prof Radtke, who also reported on the multiple and cumulative negative effects of the condition on patients’ health, activity engagement, family relationships, and overall quality of life (QoL). Prof Radtke went on to describe the factors contributing to the burden of psoriasis, other than disease severity, and highlighted the importance of taking a holistic approach to the management of the condition that takes into consideration the individual patient’s expectations and needs. Prof Lambert continued the symposium with an overview of the core pathways involved in disease pathogenesis in relation to the development of novel targeted immunotherapies. Prof Lambert reviewed the current clinical paradigms for the treatment of psoriasis, including targeted biological therapies, such as TNF-α inhibitors and newer agents acting on IL-17 and IL-23, which research shows may represent a more effective approach to the treatment of psoriasis and other autoimmune inflammatory disorders. The latest Phase III clinical trial data on therapies selectively targeting the upstream cytokine IL-23 were then presented by Dr Piaserico, with a focus on the monoclonal antibodies guselkumab, risankizumab, and tildrakizumab, and their potential to achieve consistent rates of skin clearance long-term, with the added benefit of prolonged dose intervals and intermittent treatment in some patients.

Psoriasis and mortality in the United States: Data from the National Health and Nutrition Examination Survey

BACKGROUND

Psoriasis is a multifactorial disease that has been associated with multiple systemic disorders. Despite its role in mediating cardiovascular, metabolic, and pulmonary disorders, few studies have examined the independent mortality risk associated with psoriasis.

OBJECTIVE

To determine the independent relationship between psoriasis and all-cause mortality in a nationally representative sample of the US population.

METHODS

Retrospective population-based cohort study of adults and adolescents older than 10 years (N = 13 031) who participated in National Health and Nutrition Examination Surveys (2003-2006 and 2009-2010). Psoriasis status was determined from a self-reported medical history questionnaire. Mortality data are linked from national databases.

RESULTS

Psoriasis was present in 2.7% of the study population. Over an average median follow-up of 52.3 months, psoriasis was significantly associated with increased mortality risk (HR, 1.99; 95% CI, 1.01-3.93; P = .047) with adjustment for demographics, smoking, and comorbidities including cardiovascular disease, diabetes, chronic obstructive pulmonary disease, cancer, chronic kidney disease, and stroke. These comorbidities mediated 15.5%, 5.9%, 8.7%, 11.7%, 4.2%, and 4.7% of the association between psoriasis and mortality, respectively.

CONCLUSION

Psoriasis is independently associated with an increased risk of mortality. This relationship is partially mediated by an increased prevalence of the cardiovascular, infectious, and neoplastic disorders seen among patients with psoriasis.

Incidence and prevalence of psoriasis in Israel between 2011 and 2017

BACKGROUND

Psoriasis is a common chronic inflammatory skin disease associated with a heavy burden of morbidity, disability and cost. The occurrence of the disease in Israel has not been previously investigated.

OBJECTIVES

To provide standardized estimates of trends in psoriasis incidence, prevalence and mortality among patients in Israel between 2011 and 2017.

METHODS

Using electronic health records from Clalit Health Services, the largest nationwide public health provider in Israel, we conducted a population-based study investigating trends in the annual incidence and prevalence of psoriasis between the years 2011 and 2017. We report age- and sex-adjusted rates, using the standard European population as a reference.

RESULTS

We identified 71 094 incident psoriasis cases. The mean (SD) age of onset was 42.4 (21.0) years with a bimodal distribution, peaking in the early '30s and early '60s. Late-onset psoriasis, occurring after 40 years of age, accounted for 51.1% of incident cases. The annual psoriasis incidence rate was constant throughout the study period (280/100 000 person-years). Psoriasis prevalence rose from 2.5% in 2011 to 3.8% in 2017.

CONCLUSIONS

Psoriasis prevalence is increasing in Israel, although its incidence is stable. Clinicians and policymakers should plan to address the growing demands in the clinical, economic and societal burden of psoriasis.

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.

All-cause and cause-specific mortality in psoriasis: A systematic review and meta-analysis

BACKGROUND

An overview of mortality risk associated with psoriasis is lacking.

OBJECTIVE

To perform a systematic review and meta-analysis of mortality risk in psoriasis.

METHODS

We included studies reporting all-cause or cause-specific mortality risk estimates in psoriasis patients compared with general population or subjects free of psoriasis. We calculated pooled relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

We included 12 studies. The pooled RRs for all-cause mortality were 1.21 (95% CI 1.14-1.28) in psoriasis, 1.13 (95% CI 1.09-1.16) in mild psoriasis, and 1.52 (95% CI 1.35-1.71) in severe psoriasis. The pooled RRs for cardiovascular mortality were 1.15 (95% CI 1.09-1.21) in psoriasis, 1.05 (95% CI 0.92-1.20) in mild psoriasis, and 1.38 (95% CI 1.09-1.74) in severe psoriasis. For noncardiovascular causes, mortality risk from liver disease, kidney disease, and infection was significantly increased in psoriasis, regardless of disease severity. The mortality risk in liver and kidney disease was the highest. There was also a significantly increased mortality risk associated with neoplasms in severe psoriasis patients and chronic lower respiratory disease in all and mild psoriasis patients.

LIMITATIONS

Although associations were consistent, their magnitude was heterogenous.

CONCLUSION

Psoriasis is associated with an increased risk for mortality from all causes (in a dose-response manner with disease severity) and from several specific causes.

Psoriasis and cardiovascular disease: the elusive link

Psoriasis, an autoimmune inflammatory disease, with its most common coexisting condition, psoriatic arthritis, seem to be more than just a local skin or joint disease, as evidence has accumulated over the years that it is associated with cardiovascular disease (CVD), which may confer an increased cardiovascular event and death rate. The data come mostly from observational studies and meta-analyses and indicate a potential pathogenetic link between these two systemic diseases, however definite proof of this detrimental relationship awaits further prospective studies. Newer anti-psoriatic biologic therapies seem to confer a cardiovascular benefit, but this needs future randomized controlled studies to confirm. All these intricate issues of a potential link between psoriasis and CVD are discussed and elaborated in this overview, in an attempt to shed further light on pivotal aspects of the association between psoriasis and CVD.

Building a Citizen Pscientist: Advancing Patient-Centered Psoriasis Research by Empowering Patients as Contributors and Analysts

Introduction

To design and implement a novel cloud-based digital platform that allows psoriatic patients and researchers to engage in the research process.

Methods

Citizen Pscientist (CP) was created by the National Psoriasis Foundation (NPF) to support and educate the global psoriatic disease community, where patients and researchers have the ability to analyze data. Psoriatic patients were invited to enroll in CP and contribute health data to a cloud database by responding to a 59-question online survey. They were then invited to perform their own analyses of the data using built-in visualization tools allowing for the creation of “discovery charts.” These charts were posted on the CP website allowing for further discussion.

Results

As of May 2017, 3534 patients have enrolled in CP and have collectively contributed over 200,000 data points on their health status. Patients posted 70 discovery charts, generating 209 discussion comments.

Conclusion

With the growing influence of the internet and technology in society, medical research can be enhanced by crowdsourcing and online patient portals. Patient discovery charts focused on the topics of psoriatic disease demographics, clinical features, environmental triggers, and quality of life. Patients noted that the CP platform adds to their well-being and allows them to express what research questions matter most to them in a direct and quantifiable way. The implementation of CP is a successful and novel method of allowing patients to engage in research. Thus, CP is an important tool to promote patient-centered psoriatic disease research.

Psoriasis and the risk of diabetes: A prospective population-based cohort study

BACKGROUND

Data evaluating the impact of objectively measured psoriasis severity on type 2 diabetes mellitus (T2DM) risk are lacking.

OBJECTIVE

To determine the risk for T2DM in patients with psoriasis compared with that in adults without psoriasis, stratified by categories of directly assessed body surface area (BSA) affected by psoriasis.

METHODS

A prospective, population-based, cohort study from the United Kingdom in which 8124 adults with psoriasis and 76,599 adults without psoriasis were followed prospectively for approximately 4 years.

RESULTS

There were 280 incident cases of diabetes in the psoriasis group (3.44%) and 1867 incident cases of diabetes in those without psoriasis (2.44%). After adjustment for age, sex and body mass index, the hazard ratios for development of incident diabetes were 1.21 (95% confidence interval [CI], 1.01-1.44), 1.01 (95% CI, 0.81-1.26), and 1.64 (95% CI, 1.23-2.18) in the groups with 2% or less of their BSA affected, 3% to 10% of their BSA affected, and 10% or more of their BSA affected compared with in the groups without psoriasis, respectively (P = .004 for trend). Worldwide, we estimate an additional 125,650 new diagnoses of T2DM per year in patients with psoriasis as compared with in those without psoriasis.

LIMITATIONS

Relatively short-term follow-up and exclusion of prevalence cases, which may have masked associations in patients with less extensive psoriasis.

CONCLUSION

Clinicians may measure BSA affected by psoriasis to target diabetes prevention efforts for patients with psoriasis.