Cardiometabolic Comorbidities and the Approach to Patients with Psoriasis

A dermatologist perspective in the pharmacological treatment of patients with psoriasis and psoriatic arthritis

INTRODUCTION

Psoriatic arthritis (PsA) is a chronic inflammatory disease associated with psoriasis in 20-30% of patients. PsA presents as a heterogeneous disease involving different domains and burdened by an important impact on function and quality of life.

AREAS COVERED

Dermatologists play an important role in the early detection of PsA because in most patients PsA develop after cutaneous psoriasis. The ideal goal of treating patients with PsA is to optimize the controls of symptoms, improve quality of life, and prevent structural damage and disability. The choice of treatment in patients with PsA should take into account also the skin signs and symptoms. Treatment options include NSAIDs, synthetic DMARDSs, anti-TNF-α agents, anti-IL-12/IL-23 agents, anti-IL-17 agents, PDE4 inhibitors, JAK inhibitors, and co-stimulatory blockers. A narrative review based on electronic searches on PubMed® database was performed. Original articles assessing either the role of the dermatologist in the management of PsA and the available treatments for PsA were included.

EXPERT OPINION

Among different treatments, some drugs show more efficacy in joint signs and symptoms, and poor response on the skin and vice versa. The perspective of the dermatologist in a multidisciplinary setting may provide a helpful tool in the management of patients with PsA.

What are the barriers to physical activity in patients with chronic plaque psoriasis?

Background

Psoriasis is associated with an increased risk of cardiovascular disease. Despite recommendation that exercise is important for cardiorespiratory fitness, patients with psoriasis avoid participation in physical activities for reasons that are, as yet, unclear.

Objectives

This study investigated the relationship between psoriasis‐specific experiences and self‐reported patterns of exercise, hypothesizing that individuals with psoriasis are less likely to engage in physical activity for reasons that are related to their psoriasis.

Methods

In total 404 patients with chronic plaque psoriasis were recruited. History, examination and physical activity were assessed for each participant.

Results

Overall, 52·8% (n = 188) of patients with psoriasis aged 18–65 years and 66% (n = 37) of those aged > 65 years engaged in less than the recommended amount of physical activity for cardiorespiratory fitness. As the severity and psychosocial impact of psoriasis increased, the participation in exercise (of all intensities) decreased. There was a significant negative correlation between Psoriasis Area and Severity Index and total activity in women aged 18–65 years (r = −0·19, 95% confidence interval −0·36 to 0; P = 0·04) and a significant negative correlation between physical activity and Dermatology Life Quality Index (DLQI) in all participants (r = −0·11, 95% confidence interval −0·21 to 0; P = 0·04). Individual components of the DLQI identified barriers to physical activity including skin sensitivity and reluctance to participate in leisure activities.

Conclusions

Psoriasis‐specific factors – severity, skin sensitivity, clothing choice, participation in social/leisure activities, and treatments – contribute to exercise avoidance and may augment the increased risk of cardiovascular disease in patients with psoriasis.

What is already known about this topic?

Psoriasis is associated with an increased prevalence of risk factors for cardiovascular disease.

Despite recommendation that exercise is important for cardiorespiratory fitness, patients with moderate‐to-severe psoriasis participate in very little physical exercise for reasons that are, as yet, unclear.

What does this study add?

This study quantifies the significant lack of engagement with exercise in the population of people with psoriasis.

Physical activity in those with psoriasis is significantly influenced by psoriasis severity, quality of life and a number of previously unrecognized psoriasis‐specific barriers.

What is the translational message?

Supporting patients with psoriasis to undertake regular physical activity could directly benefit weight management, cardiovascular disease and risk of metabolic syndrome, and increase wellbeing and psychosocial functioning.

Linked Comment:Jarrett.Br J Dermatol 2020; 183:988–989.

Plain language summary available online

Usefulness of the Psoriatic Arthritis Screening and Evaluation Questionnaire to Monitor Disease Activity in Management of Patients with Psoriasis: Findings from the EPI-PSODE Study

Background

Psoriasis and psoriatic arthritis (PsA) are included in the group of immune-mediated inflammatory diseases (IMIDs) caused by systemic inflammation; however, indicators for monitoring inflammatory activity in patients with psoriasis, such as the Psoriasis Area and Severity Index (PASI), are limited.

Objective

To determine whether the Psoriatic Arthritis Screening and Evaluation (PASE) questionnaire can be used to monitor disease activity in patients with psoriasis.

Methods

This was a multicenter, noninterventional, cross-sectional study. Demographic factors and PASI and PASE scores were collected to investigate associations between each.

Results

PASE data were available for 1,255 patients, of whom 498 (39.7%) had a score of ≥37. Compared with the group with PASE score <37, the group with score ≥37 had a higher proportion of women (34.9% vs. 48.8%, p<0.0001), older mean age at diagnosis (36.4 vs. 41.7 years, p<0.0001), more severe disease activity using PASI and body surface area measures (p=0.0021 and p=0.0008, respectively), and higher mean body mass index (23.7 vs. 24.1, p=0.0411). In a multiple linear regression model, PASE score was positively associated with cutaneous disease activity (p<0.0001).

Conclusion

After risk-adjustment, PASE was positively associated with PASI, which suggests that PASE can be sensitive to disease activity. Since psoriasis is regarded as one of the IMIDs, PASE may be utilized as a tool not only to screen PsA but also to monitor disease activity.

Higher Risk of Future Cardiovascular Events Among Patients with Psoriatic Arthritis Compared to Psoriatic Patients Between the Ages of 30-50

Introduction:

Psoriasis and Psoriatic Arthritis (PsA) are chronic diseases with a number of complications that, among others, may include alterations in the cardio-vascular system.

Methods:

The aim of this study was to evaluate the risk of Cardiovascular Diseases (CVD) in patients with psoriasis and psoriatic arthritis between the ages of 30-50. The research covered 95 outpatients and inpatients: 51 with plaque psoriasis (23 women and 28 men) and 44 with psoriasis and psoriatic arthritis (16 women and 28 men). The risk of cardio-vascular incident was evaluated with the use of the Framingham algorithm covering the age, total cholesterol, HDL cholesterol, blood pressure, the habit of smoking and diabetes. The 10-year risk of the occurrence of a cardio-vascular incident was higher in patients with psoriatic arthritis than in patients with plaque psoriasis (9,9% vs6,2%). A high risk of cardio-vascular events was observed in 35% men with psoriatic arthritis in comparison to 11% men with only psoriasis. In patients with plaque psoriasis, the increase in the risk of cardio-vascular incident was connected with the late beginning of psoriasis; whereas in the group of patients with psoriatic arthritis, the risk of cardio-vascular incident was connected with the intensification of psoriatic lesions.

Conclusion:

The patients with psoriasis, especially men with psoriatic arthritis, certainly require special medical care in terms of cardio-vascular diseases prevention.

Hidradenitis suppurativa, a review of pathogenesis, associations and management. Part 1

Hidradenitis suppurativa is a chronic, painful, autoinflammatory condition resulting in nodules, abscesses and sinus tracts. We present an evidence-based review providing new understanding of the pathogenesis of hidradenitis suppurativa and associated comorbidities. By the nature of their speciality, dermatologists are uniquely positioned to investigate and treat patients with this condition. Data collected from a subspecialty hidradenitis suppurativa clinic (N = 106) and experiences thereof are discussed in this review.

Diabetes mellitus and the skin

Several dermatoses are routinely associated with diabetes mellitus, especially in patients with chronic disease. This relationship can be easily proven in some skin disorders, but it is not so clear in others. Dermatoses such necrobiosis lipoidica, granuloma annulare, acanthosis nigricans and others are discussed in this text, with an emphasis on proven link with the diabetes or not, disease identification and treatment strategy used to control those dermatoses and diabetes.

Update in the management of pediatric psoriasis

PURPOSE OF REVIEW

Psoriasis is a multifactorial, chronic, inflammatory skin disease that may represent a therapeutic challenge in children. This review aims to provide a framework for the management of pediatric psoriasis, emphasizing in new insights and considerations for management. It will focus on new disease associations and innovative treatment modalities that challenge current approach of psoriasis in children.

RECENT FINDINGS

There is an increasing body of literature both in adults and in children linking psoriasis with different comorbidities. This new evidence points to the need of addressing psoriasis as a systemic disease and suggests the need for screening and creating awareness of possible associations. In a similar manner, newer medications are also being investigated in children. Recent publications report on the efficacy and safety of biologics for psoriasis in pediatric patients.

SUMMARY

The review provides better understanding of present and future risks of untreated and uncontrolled psoriasis in children and at the same time the benefits and risks of new treatments available.

Clinical factors predicting the therapeutic response to ustekinumab in patients with moderate to severe chronic plaque psoriasis

While ustekinumab has been widely used as an effective biologic for the treatment of chronic plaque psoriasis, no prospective studies have specifically investigated the clinical factors that may influence treatment outcomes with ustekinumab. This post-hoc analysis aimed to identify specific clinical factors that may influence treatment outcomes with ustekinumab in psoriasis patients. In the MARCOPOLO study, 102 Korean patients with moderate to severe psoriasis were analyzed to assess the influence of baseline characteristics as clinical factors on clinical response (improvement in Psoriasis Area and Severity Index by ≥75%/90% [PASI75/PASI90]) to ustekinumab. In addition, differences in PASI75 and PASI90 responses between the responder group and non-responders were evaluated at weeks 28 and 52. Multiple logistic regression analysis was used to determine adjusted clinical factors predicting treatment outcomes among patient characteristics. At week 28, there was a significant difference in PASI75/PASI90 response based on prior biologic experience, although the difference did not persist at week 52. In addition, after adjusting for the effects of relevant clinical factors, biologic experience was significantly associated with less PASI75 (odds ratio [OR] = 0.14, P = 0.001) and PASI90 (OR = 0.22, P = 0.036) responses at week 28. The presence of comorbidities was higher among non-responders than among PASI75/PASI90 responders at both weeks 28 and 52, but was not statistically significant. Previous biologic use was the only clinical factor predicting less response at week 28, although it did not influence the clinical response after week 52. Further studies are warranted to investigate the association between presence of comorbidities and clinical response.

Cardiovascular Disease Outcomes Associated with Three Major Inflammatory Dermatologic Diseases: A Propensity-Matched Case Control Study

Introduction

Inflammation is an established component of cardiovascular disease (CVD) and an underlying factor of several dermatologic conditions including rosacea, atopic dermatitis, and psoriasis. Identifying potential associations between these dermatologic and cardiovascular diseases can better inform holistic healthcare approaches. The objective of this study was to determine whether rosacea, psoriasis or atopic dermatitis are independent risk factors for CVD 1 year following diagnosis.

Methods

Using a large commercial claims database of 21,801,147 lives, we employed a propensity-matched logistic regression to evaluate the association between diagnoses of rosacea, psoriasis, or atopic dermatitis and a 1-year risk of being diagnosed with cardiovascular disease. Control patients were matched based on health-care utilization, age and overall health status as defined by a modified Deyo–Charlson comorbidity index.

Results

The analysis included 2105 rosacea, 622 atopic dermatitis, 1536 psoriasis, and 4263 control patients. Compared to propensity-matched controls, the adjusted odds of cardiovascular disease were not higher in patients with rosacea (odds ratio: 0.894, p = 0.2713), atopic dermatitis (OR 1.032, p = 0.8489), or psoriasis (OR 1.087, p = 0.4210). In univariate analysis, the unadjusted odds of cardiovascular disease was higher in patients with psoriasis (OR 1.223, p = 0.0347).

Conclusions

Limitations of this study include the short follow-up period and inclusion of only commercially insured patients limit the generalizability of these findings. In this large study of patients with rosacea, atopic dermatitis, and psoriasis, we did not detect an increased 1-year risk of cardiovascular disease after adjusting for confounders.

Electronic supplementary material

The online version of this article (doi:10.1007/s13555-016-0144-3) contains supplementary material, which is available to authorized users.

Nanoemulsion as a topical delivery system of antipsoriatic drugs

Nanoemulsion as a potential enhancer for the treatment of psoriasis.

Patients with psoriasis are at a higher risk of developing nonalcoholic fatty liver disease

BACKGROUND

Psoriasis is a chronic, immune-mediated inflammatory skin disease with many extracutaneous manifestations. Several recent studies have indicated an increased prevalence of nonalcoholic fatty liver disease (NAFLD) among patients with psoriasis. In the present study, we investigated the prevalence of NAFLD in a population of Iranian patients with psoriasis.

METHODS

NAFLD was assessed and graded using ultrasonography in 123 patients with psoriasis and 123 healthy controls (HCs) matched by age, sex and body mass index (BMI).

RESULTS

The prevalence of NAFLD was significantly higher in the psoriatic group compared with the HC group (65.6% vs. 35%, P < 0.01, OR = 3.53). Median NAFLD grade was significantly greater in patients with psoriasis compared with HCs (grade 2 vs. grade 1, P < 0.01). In patients with psoriasis, NAFLD was associated with a higher frequency of hypertension (16.5%), abnormal liver function test (LFT) results (16.4%) and metabolic syndrome (46.6%). Moreover, patients with psoriasis and NAFLD tended to have significantly higher values for BMI, waist circumference (WC), Psoriasis Activity and Severity Index (PASI), and levels of serum triglyceride, cholesterol, low-density lipoprotein and fasting blood sugar (FBS). Multivariate logistic regression revealed that WC, PASI, LFT abnormalities, hypertension and cigarette smoking were independent predictors of NAFLD grade.

CONCLUSIONS

Our findings warrant a detailed assessment of metabolic comorbidities including NAFLD in patients with a primary diagnosis of psoriasis. Lifestyle modifications, including weight loss and smoking cessation, may be necessary for patients with psoriasis to decrease the risk and severity of NAFLD.

Management of moderate to severe psoriasis in patients with metabolic comorbidities

Psoriasis is a chronic inflammatory skin disease affecting 2–3% of worldwide population. The extent of skin involvement is variable, ranging from a few localized plaques to generalized involvement. Moderate to severe psoriasis (>10% of body surface area) is frequently associated with psoriatic arthritis and metabolic diseases, like abdominal obesity, diabetes, non-alcoholic fatty liver disease, dyslipidemia, metabolic syndrome, and chronic kidney disease. A common genetic background as well as several acquired risk factors links psoriasis to comorbidities. From a clinical prespective, the understanding of the patients in the context of these comorbidities is very important to ensure that treatment is tailored to meet the individual patient needs. Indeed, some pharmacological treatments may negatively affect cardio-metabolic comorbidities, and have important interactions with drugs that are commonly used to treat them. Non-pharmacological intervention such as diet, smoking cessation, and physical exercise could both improve the response to treatments for psoriasis and reduce the cardiovascular risk.

Metabolic syndrome in psoriatic arthritis patients: a cross-sectional study

OBJECTIVES

The major objective of our study was to assess the prevalence of metabolic syndrome in Indian patients with psoriatic arthritis.

METHOD

This was a one-time survey involving no follow-up. The study was performed among outpatients attending the speciality clinics of an institutional tertiary referral centre. A consecutive sample of 100 patients diagnosed as having psoriatic arthritis in our clinics was included in the study. Height, weight, body mass index, blood pressure and waist circumference of patients were measured at the enrolment visit. Venous samples were taken after 8 h of overnight fasting for the estimation of serum cholesterol, triglycerides and plasma glucose levels. The primary study outcome was the prevalence of metabolic syndrome in the study population.

RESULTS

Fifty-eight and 59 patients had metabolic syndrome according to the Adult Treatment Panel III criteria and the consensus definition of metabolic syndrome for adult Asian patients, respectively. Patients with metabolic syndrome were older (P < 0.001), with longer duration of psoriasis (P = 0.017), and higher Bath Ankylosing Spondylitis Activity Index (P = 0.016) than those without metabolic syndrome.

CONCLUSIONS

Metabolic syndrome is common in Asian Indian patients with psoriatic arthritis, especially in those with long-standing psoriasis and active joint disease.

Effect of narrowband ultraviolet B therapy on inflammatory markers and body fat composition in moderate to severe psoriasis

BACKGROUND

Previous studies have shown increased prevalence of metabolic syndrome in patients with psoriasis.

OBJECTIVES

To characterize the anthropometric and metabolic profile of Spanish patients with moderate to severe psoriasis compared with controls without psoriasis matched for gender, age and body mass index (BMI), and to evaluate the impact of narrowband ultraviolet B (NB-UVB) therapy on patient profiles.

METHODS

Baseline waist circumference, body fat composition, lipid, carbohydrate and calcium metabolism profile, inflammation markers, homocysteine, vitamins D, B(6) and B(12) and folic acid of 50 patients with psoriasis and 50 matched controls were recorded then evaluated after NB-UVB in patients with psoriasis and correlated with clinical outcome.

RESULTS

Despite very similar BMIs, 54% of patients met International Diabetes Foundation criteria for metabolic syndrome compared with 42% of controls (P = 0·01); body fat was 29·9% in patients and 28·0% in controls (P = 0·037), correlating with waist circumference; while patient atherogenic profiles were less favourable, with higher apolipoprotein B and low density lipoprotein cholesterol than controls, and both patients and controls showed insufficient vitamin D serum levels (< 20 ng mL(-1)). Mean improvement of Psoriasis Area and Severity Index (PASI) after NB-UVB was 78·2%. Ferritin, B(12) and C-reactive protein decreased significantly after NB-UVB therapy. Vitamin D levels reached adequate levels after phototherapy; however, no relationship with PASI improvement was observed.

CONCLUSIONS

We characterized inflammatory and atherogenic profiles of Spanish patients with psoriasis compared with matched controls. After NB-UVB therapy we demonstrated improvement in psoriasis and some systemic inflammation markers, which were not mediated by enhancement of vitamin D synthesis.

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

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