Psoriasis and the Risk of Major Cardiovascular Events: Cohort Study Using the Clinical Practice Research Datalink

Incremental Cardiovascular Risk of Menopause in Women with Psoriasis, Psoriatic Arthritis or Spondyloarthritis?

PURPOSE OF THE REVIEW

This narrative review aims to discuss the most recent studies regarding the risk of cardiovascular disease (CVD) in women with psoriasis, psoriatic arthritis (PsA) and spondyloarthritis (SpA). In addition, the potential of menopause to modulate/increase CVD risk in women with these diseases will also be explored. It is of major interest to gain more understanding into this topic because it can have meaningful implications for screening and treatment of CVD risk in these women.

RECENT FINDINGS

Literature shows that psoriasis, PsA, SpA and menopause itself cause higher CVD risks and higher CVD prevalence. This is predominantly explained by the increase of chronic systemic inflammation. No existing literature conclusively demonstrates or studies specifically whether the menopause amplifies this effect caused by psoriasis, PsA, or SpA.

CONCLUSION

Differences in pathophysiology of psoriasis, SpA and PsA versus the menopausal transition could suggest that menopause may increase the risk of CVD. However, the hypothesis that menopause represents an additional CV risk factor in women with psoriasis, PsA and SpA still needs to be thoroughly investigated and more clinical studies are required for further understanding and conclusions.

The role of diet in the management of psoriasis: a scoping review

Psoriasis is a chronic, systemic, immune-mediated, inflammatory skin disease associated with significant comorbidities. Globally, there are an estimated 60 million people living with psoriasis (PLwP). There is a growing body of evidence on the role of diet in psoriasis management, and demand for dietary advice is high. However, there are no specific, evidence-based dietary guidelines. This scoping review summarises the literature on use and effectiveness of diet in the management of psoriasis to improve understanding of the evidence and assist PLwP and healthcare professionals (HCPs) to discuss diet. The findings were categorised into three themes: (1) dietary intakes of PLwP, (2) the perceived role of diet in psoriasis management and (3) dietary approaches to manage psoriasis symptoms. In cross-sectional studies PLwP were reported to have higher fat and lower fibre intakes compared with controls, and lower psoriasis severity was associated with higher fibre intake. However, research is limited. PLwP perceive diet to have an impact on symptoms and make dietary modifications which are often restrictive. Systematic reviews and RCTs found certain dietary approaches improved symptoms, but only in specific populations (e.g. PLwP with obesity and PLwP with coeliac disease), and evidence for supplement use is inconclusive. The grey literature provides limited guidance to PLwP; focusing on weight loss and associated comorbidities. Larger, controlled trials are required to determine dietary approaches for psoriasis management, especially in PLwP without obesity and non-coeliac PLwP. Further understanding of diet modification, information acquisition and experiences among PLwP will enhance holistic care for psoriasis management.

Risk of major adverse cardiovascular events and all-cause mortality among patients with psoriatic disease treated with tumor necrosis factor-α and interleukin-12/23 inhibitors: a nationwide population-based cohort study in Korea

PURPOSE

Few studies have investigated the impact of biologics on the risk of major adverse cardiovascular events (MACEs) among Korean patients with psoriatic diseases. We compared the risk of MACEs and all-cause mortality among patients with psoriatic disease treated with tumor necrosis factor (TNF)-α and interleukin (IL)-12/23 inhibitors in Korea.

METHODS

Patients with psoriatic disease prescribed with TNF-α and IL-12/23 inhibitors since 2016 were selected from the Korean National Health Insurance Service (NHIS) Database. Follow-up data for MACEs and all-cause mortality between 2016 and 2020 were collected. A total of 2886 individuals were included, including 1987 IL-12/23 inhibitor users and 899 TNF-α inhibitor users.

RESULTS

Compared with IL-12/23 inhibitor users, TNF-α inhibitor users had a higher prevalence of dyslipidemia and a significantly higher risk of all-cause mortality but not MACE. After controlling for age, female TNF-α inhibitor users had a significantly increased risk of all-cause mortality. Meanwhile, after controlling for sex, TNF-α inhibitor users aged 60 years or older demonstrated a significantly elevated risk of all-cause mortality. In conclusion, No statistically significant difference in MACE risk was observed between patients who used TNF-α and IL-12/23 inhibitors. Nevertheless, the use of IL-12/23 inhibitors, especially among older and female patients, resulted in a lower overall mortality.

Laboratory and clinical haemostatic aberrations in primary dermatologic disease: A review

Inflammatory dermatologic diseases have long been viewed as a "skin limited" disease process. Current literature on inflammatory dermatologic diseases investigates their relationship and influence on thromboembolic states and thromboembolic complications and the understanding of their pathophysiology and molecular mechanisms.Studies specifically discuss known inflammatory skin diseases including alopecia areata, vitiligo, psoriasis, hidradenitis suppurativa, atopic dermatitis, chronic spontaneous urticaria, and autoimmune bullous diseases, and their effects on systemic inflammation, associated cardiovascular comorbidities, and thromboembolic or hypercoagulable states. The limited current literature shows potential for links between inflammatory skin diseases and hypercoagulable states. Biomarkers such as F1 + 2, D-dimer, eosinophilic cationic protein, and PAI-1 are currently being studied to outline the mechanisms connecting inflammatory skin disease to the coagulation system. Further study and larger amounts of data are needed to draw definitive conclusions, especially when interpreting biomarkers alone such as PAI-1.The mechanisms, rates of systemic inflammation, and clinical outcomes of traditionally "skin limited" inflammatory diseases remain chronically understudied in dermatology. Many organ systems have well established connections between inflammatory disease and hypercoagulable states, but there are significant gaps in the literature regarding skin diseases. There is a significant need for comprehensive investigation of molecular mechanisms behind inflammatory dermatologic disease and hypercoagulability, how hypercoagulability effects clinical outcomes, and proper intervention to optimize patient outcomes.

Cold atmospheric plasma for chronic kidney disease-related skin disorders

BACKGROUND

An estimated 80% of individuals with chronic kidney disease (CKD) experience concomitant skin disorders, yet experimental research that elucidates the pathological changes in CKD-affected skin is limited. Cold atmospheric plasma (CAP) has shown promise in regulating keratinocyte proliferation, skin barrier function and anti-inflammatory activity. We hypothesize that CAP will emerge as a promising therapeutic avenue for CKD-related skin diseases.

METHODS

Male and female C57BL/6 mice were administered a 0.2% adenine diet to generate a CKD mouse model. Skin samples from dialysis patients were also collected. These models were used to investigate the pathological alterations in the renal glomeruli, tubules and epidermis. Subsequently, the potential impact of CAP on the stratum corneum, keratinocytes, skin hydration and inflammation in mice with CKD was examined.

RESULTS

Renal biopsies revealed glomerular and tubular atrophy, epithelial degeneration and necrosis in uriniferous tubules and significant renal interstitial fibrosis. Skin biopsies from patients with CKD and mice showed stratum corneum thickening, epidermis atrophy, skin hydration dysfunction and excessive inflammation. CAP attenuated skin atrophy, hydration dysfunction and inflammation in mice with CKD, as evidenced by the activated level of YAP1/β-catenin and Nrf-2/OH-1; enhanced expression of K5 and Ki67; increased levels of AQP3, collagen I and GLUT1; reduced infiltration of CD3+ T cells and diminished levels of IL-6 and TNF-α.

CONCLUSIONS

This study provides valuable insights into the pathological changes in skin associated with CKD in both patients and animal models. It also establishes that CAP has the potential to effectively mitigate skin atrophy, hydration dysfunction and inflammation, suggesting a novel therapeutic avenue for the treatment of CKD-related skin disorders.

Identification of Hub Genes in Comorbidity of Psoriasis and Vitiligo Using Bioinformatics Analysis

Background

Psoriasis and vitiligo are two common autoimmune skin diseases with increased risk of comorbidities, but the common molecular mechanism about the occurrence of these two diseases is still unknown.

Objective

This study aimed to identify the combined genetic profiles and evaluate the potential mechanism underlying the occurrence of this complication.

Methods

The Gene Expression Omnibus (GEO) database was used to obtain the gene expression profiles of psoriasis (GSE30999) and vitiligo (GSE75819), and common differentially expressed genes (DEGs) were identified using GEO2R. DEGs were analyzed using functional enrichment analysis, protein-protein interaction (PPI) network and module construction, hub gene identification, and co-expression analysis. And hub genes were identified using Cytoscape software, and the gene expression of hub genes were validated in psoriasis (GSE13355) and vitiligo (GSE65127) datasets and immunohistochemistry at the clinical sample.

Results

A total of 164 common DEGs with the same trend (137 upregulated and 27 downregulated) were selected for subsequent analysis. Functional analysis emphasized the important roles of the cell cycle and mitotic cell division, cytoskeletal reorganization, and chromatin remodeling in the complications of these two diseases. Fourteen important hub genes were identified, including BUB1, CEP55, CDK1, TOP2A, CENPF, PBK, MELK, CCNB2, MAD2L1, NUSAP1, TTK, NEK2, CDKN3, and PTTG1. Cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) may be an important immune checkpoint in the pathogenesis of the comorbidities.

Conclusion

Our study identified hub genes and potential mechanisms underlying psoriasis and vitiligo complications. And we proposed a new spatio-temporal theory and the probable immune checkpoint for the pathogenesis of the comorbidity which may provide new ideas for the further research.

Epidemiology of lipid disturbances in psoriasis: An analysis of trends from 2006 to 2023

INTRODUCTION

A strong link has been established between psoriasis and lipid disturbances; however, no study has systematically examined their global epidemiology.

METHODS

We searched six databases from their inception up to October 1, 2023. Data analysis was conducted using Stata SE 15.1. We performed subgroup, meta-regression, and sensitivity analyses to assess the heterogeneity of the pooled studies.

RESULTS

Our review included 239 studies comprising 15,519,570 participants. The pooled prevalence rate of dyslipidemia among individuals with psoriasis was 38%.

CONCLUSION

Patients with severe psoriasis should undergo screening for lipid abnormalities. This can facilitate the early detection of lipid dysfunction and associated cardiovascular comorbidities.

Early Cerebral Microvasculature Impairment and Increased Body Mass Index in Patients with Psoriasis

Psoriasis induces systemic atherosclerosis, but its impact on cerebrovascular function remains unclear. However, stroke prevention must be considered in psoriasis, as it is commonly comorbid with classic cardiovascular risk factors. Thus, the aim of the study is to assess cerebral microvasculature function and its confounders in patients with psoriasis. The study protocol included cerebral autoregulation assessment with measurements of vasomotor reactivity reserve (VMRr) on the middle cerebral arteries with the use of a Transcranial Doppler (TCD) in 50 patients with psoriasis without cerebrovascular events (46; 21-74 years) and 26 healthy controls (41; 29-58 years). Analyses of VMRr relationships with the psoriasis course, comorbidities, inflammatory markers and intima-media thickness (IMT) were performed. The study showed that VMRr was lower (64% vs. 76%, p = 0.001), and the IMT was higher (0.65 vs. 0.52 mm, p = 0.001) in patients compared to controls. The patients were also characterized by a higher body mass index (BMI) and a higher level of Il-6 than the controls (29.14 vs. 25.76 kg/m2, p = 0.004 and 585 vs. 204 pg/mL, p < 0.001, respectively), but only BMI was independently impacting VMRr reduction (p = 0.02). In conclusion, early cerebral microvasculature dysfunction may occur in patients with psoriasis, and its extent is associated with an increase in BMI. Thus, body mass reduction should be strongly recommended for stroke prophylaxis in patients with psoriasis.

Psoriasis Comorbidities and Their Treatment Impact

Psoriasis, a systemic inflammatory disease classically presenting with cutaneous lesions, has significant involvement in other organ systems. This article explores the prevalence, clinical manifestations, screening mechanisms, and laboratory testing by which to evaluate these comorbidities. Treatment approach for these comorbidities must combine patient preference with established treatment algorithms while recognizing innovative therapeutics currently under development.

Performance of CHA2DS2-VASc and HAS-BLED in predicting stroke and bleeding in atrial fibrillation and cancer

Aims

To compare the predictive performance of CHA2DS2-VASc and HAS-BLED scores in atrial fibrillation (AF) patients with and without cancer.

Methods and results

Using data from the Clinical Practice Research Datalink in England, we performed a retrospective cohort study of patients with new diagnoses of AF from 2009 to 2019. Cancer was defined as history of breast, prostate, colorectal, lung, or haematological cancer. We calculated the CHA2DS2-VASc and HAS-BLED scores for the 1-year risk of stroke and major bleeding events. Scores performance was estimated by discrimination [area under the receiver operating characteristic curve (AUC)] and calibration plots. Of 141 796 patients with AF, 10.3% had cancer. The CHA2DS2-VASc score had good to modest discrimination in prostate cancer AUC = 0.74 (95% confidence interval: 0.71, 0.77), haematological cancer AUC = 0.71 (0.66, 0.76), colorectal cancer AUC = 0.70 (0.66, 0.75), breast cancer AUC = 0.70 (0.66, 0.74), and lung cancer AUC = 0.69 (0.60, 0.79), compared with no-cancer AUC = 0.73 (0.72, 0.74). HAS-BLED discrimination was poor in prostate cancer AUC = 0.58 (0.55, 0.61), haematological cancer AUC = 0.59 (0.55, 0.64), colorectal cancer AUC = 0.57 (0.53, 0.61), breast cancer AUC = 0.56 (0.52, 0.61), and lung cancer AUC = 0.59 (0.51, 0.67), compared with no-cancer AUC = 0.61 (0.60, 0.62). Both the CHA2DS2-VASc score and HAS-BLED score were well calibrated across all study cohorts.

Conclusion

Amongst certain cancer cohorts in the AF population, CHA2DS2-VASc performs similarly in predicting stroke to AF patients without cancer. Our findings highlight the importance of cancer diagnosis during the development of risk scores and opportunities to optimize the HAS-BLED risk score to better serve cancer patients with AF.

Association between psoriasis and atrial fibrillation: A Systematic review and meta-analysis

INTRODUCTION

Psoriasis is a prevalent inflammatory skin condition characterized by erythematous plaques with scaling. Recent research has demonstrated an increased risk of cardiovascular diseases in patients with psoriasis; however, current evidence on atrial fibrillation (AF) risk in psoriasis is limited.

MATERIALS AND METHODS

A systematic literature search was performed on major bibliographic databases to retrieve studies that evaluated AF risk in patients with psoriasis. The DerSimonian and Laird random effects model was used to pool the hazard ratios (HR) with 95 % confidence intervals (CI). Subgroup analysis was conducted by dividing the patients into mild and severe psoriasis groups. Publication bias was assessed by visual inspection and Egger's regression test. Statistical significance was set at p < 0.05.

RESULTS

Seven studies were included, with 10,974,668 participants (1,94,230 in the psoriasis group and 10,780,439 in the control group). Patients with psoriasis had a significantly higher risk of AF [Pooled HR: 1.28; 95 % CI: 1.20, 1.36; p < 0.00001]. In subgroup analysis, patients with severe psoriasis [HR: 1.32; 95 % CI: 1.23, 1.42; p < 0.00001] demonstrated a slightly higher risk of AF, although statistically insignificant (p = 0.17), than the mild psoriasis group [HR: 1.21; 95 % CI: 1.10, 1.33; p < 0.0001]. Egger's regression test showed no statistically significant publication bias (p = 0.24).

CONCLUSION

Our analysis demonstrated that patients with psoriasis are at a significantly higher risk of AF and hence should be closely monitored for AF. Further large-scale and multicenter randomized trials are warranted to validate the robustness of our findings.

The Impact of Interleukin-17 Inhibitors on Major Adverse Cardiovascular Events in Psoriasis or Psoriatic Arthritis Patients Naive to Biologic Agents: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

The objective of this systematic review is to determine the effects of IL-17 inhibitors on major adverse cardiovascular events (MACEs) in patients with either psoriasis (PsO) or psoriatic arthritis (PsA). A systematic literature search in three databases (Medline, Embase, and the Cochrane Library for Randomized Controlled Trials) was conducted on December 7, 2022 for randomized controlled trials of patients with PsO/PsA treated with IL-17 inhibitors that reported confirmed MACEs. Two reviewers screened titles and abstracts and identified papers for full-text review. Exclusion criteria included trials that included the previous use of biological disease-modifying anti-rheumatic drugs. The Mantel-Haenszel random-effect method was utilized to calculate risk ratios and heterogeneity was measured by χ2 test and I2 statistics. Funnel plot analysis was undertaken to detect potential publication bias. Of the 919 references identified, nine RCT studies were included in the meta-analysis (n=2,096 patients). There was no statistically significant correlation between the use of IL-17 inhibitors and change in risk of MACEs (Risk Ratio 0.56; 95% CI 0.15 to 2.14; p = 0.40). Subgroup analysis of secukinumab or ixekizumab also did not demonstrate these changes. Additionally, there was no detectable dose-dependent effect of IL-17 inhibitors. In conclusion, IL-17 inhibitor use is not correlated with a change in MACE risk in patients with PsO/PsA who previously did not receive biologic disease-modifying anti-rheumatic drugs.

Psoriasis may increase the risk of idiopathic pulmonary fibrosis: a two-sample Mendelian randomization study

BACKGROUND

Although some studies have indicated that Psoriasis could contribute to the risk of idiopathic pulmonary fibrosis (IPF), no study has reported a clear causal association between them. Our aim was to explore the potential relationship between Psoriasis and IPF using Mendelian randomization (MR) design.

METHODS

To explore a causal association between Psoriasis and IPF, we used genetic instruments from the largest available genome-wide association study (GWAS) of European ancestry, including psoriasis (5314 cases, 457,619 controls) and IPF (1028 cases, 196,986 controls). Our main analyses were conducted by inverse-variance weighted (IVW) method with random-effects model, with the other complementary four analyses: weighted median method, weighted mode, multivariable MR and MR-Egger approach.

RESULTS

The results of IVW methods demonstrated that genetically predicted psoriasis was significantly associated with higher odds of IPF, with an odds ratio (OR) of 1.09 (95%CI, 1.01-1.18; P = 0.02). Weighted median method, weighted mode and multivariable MR also demonstrated directionally similar results (P < 0.05), while the MR-Egger regression did not reveal the impact of psoriasis on IPF (OR = 1.09, 95%CI, 0.98-1.21; P = 0.11). In addition, both funnel plots and MR-Egger intercepts indicated no directional pleiotropic effects between psoriasis and IPF.

CONCLUSIONS

Our study provided potential evidence between genetically predicted psoriasis and IPF, which suggests that understanding the mutual risk factors between psoriasis and IPF can facilitate the clinical management of both diseases.

Immune-mediated inflammatory diseases and the risk of valvular heart disease: a Mendelian randomization study

BACKGROUND

Observational studies have suggested that immune-mediated inflammatory diseases (IMIDs) are associated with a higher risk of valvular heart disease (VHD). But the potential causal association is not clear. Therefore, we used Mendelian randomization (MR) analysis to assess the causal association of IMIDs with VHD risk.

METHODS

A two-sample MR analysis was performed to confirm the causal association of several common IMIDs (systemic lupus erythematosus, SLE; rheumatoid arthritis, RA; multiple sclerosis, MS; ankylosing spondylitis, AS; psoriasis, PSO; inflammatory bowel disease, IBD) with the risk of VHD. The exposure data is derived from published genome-wide association studies (GWASs) and outcome data come from the FinnGen database (47,003 cases and 182,971 controls). Inverse-variance weighted (IVW), MR-Egger, and weighted median methods were performed to assess the causal association. The study design applied univariable MR and multivariable MR.

RESULTS

The MR analysis indicated that several genetically predicted IMIDs increased the risk of VHD, including SLE (odds ratio (OR) = 1.014; 95% confidence interval (CI) =  < 1.001,1.028 > ; p = 0.036), RA (OR = 1.017; 95% CI =  < 1.002,1.031 > ; p = 0.025), and IBD (OR = 1.018; 95% CI =  < 1.002,1.033 > ; p = 0.023). Multivariable MR indicated that the adverse effect of these IMIDs on VHD was dampened to varying degrees after adjusting for smoking, obesity, coronary artery disease, and hypertension.

CONCLUSION

Our findings support the first genetic evidence of the causality of genetically predicted IMIDs with the risk of developing into VHD. Our results deliver a viewpoint that further active intervention needs to be explored to mitigate VHD risk in patients with SLE, RA, and IBD. Key Points • Genetically predicted systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and inflammatory bowel disease (IBD) are causally associated with valvular heart disease (VHD). • To reduce the risk of VHD in patients with SLE, RA, and IBD, active interventions should be further explored.

Prospective evaluation of cardiovascular risk and mortality in patients with psoriasis: An American population-based study

The association between psoriasis and cardiovascular disease (CVD) has long been discussed and continually refined. However, there is currently a lack of prospective studies on the cardiovascular risk attributed to psoriasis in the United States general population. Representative adult participants were selected from the National Health and Nutrition Examination Survey (NHANES). Risks of cardiovascular symptoms and diseases prevalence were evaluated between participants with and without psoriasis. The hazards for all-cause mortality and CVD mortality were stratified by psoriasis status. Mediation analysis was then conducted to identify potential mediators between psoriasis and cardiac death. Overall, 19 741 participants were included in the current study, 542 (2.7%) had psoriasis and 19 199 (97.3%) did not have psoriasis. After adjusting for known CVD risk factors, odds for hypertension (OR = 1.37, 95% CI: 1.13-1.66, p = 0.001), hypercholesterolemia (OR = 1.37, 95% CI: 1.13-1.64, p < 0.001) and angina pectoris (OR = 1.74, 95% CI: 1.11-2.60, p = 0.011) were higher in psoriasis patients. Compared with participants without psoriasis, moderate/severe but not mild patients showed significantly higher CVD mortality (HR = 2.55, 95% CI: 1.27-5.15, p = 0.009). This result was supported by subgroup analyses. Mediation analysis further suggested that the direct effect of moderate/severe psoriasis on CVD mortality accounted for 81.4% (65.8%-97.1%). Besides, the indirect effect might derive from disturbance of serum albumin, urea nitrogen and uric acid. Moderate-to-severe psoriasis is an independent risk factor for cardiovascular disease, making it necessary to regularly conduct cardiovascular disease-related examinations for patients with higher severity of psoriasis in clinical settings.

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.

Risk of incident autoimmune diseases in patients with newly diagnosed psoriatic disease: a nationwide population-based study

There are limited large population-based cohort studies on the risk of incident autoimmune diseases among patients with newly diagnosed psoriatic disease. The objective of this study was to assess the risk of autoimmune diseases in patients with newly diagnosed psoriatic disease. Using the Korean National Health Insurance Service database, patients with newly diagnosed psoriatic disease between 2007 and 2019 were included. Comparators were randomly selected and matched according to age and sex. A total of 321,354 patients with psoriatic disease and 321,354 matched comparators were included in this study. Patients with psoriatic disease had a significantly higher risk of Crohn's disease [adjusted hazard ratio (aHR), 1.95; 95% confidence interval (CI) 1.42-2.67], ulcerative colitis (aHR, 1.65; 95% CI 1.39-1.96), systemic lupus erythematosus (aHR, 1.86; 95% CI 1.34-2.57), rheumatoid arthritis (aHR, 1.63; 95% CI 1.52-1.76), ankylosing spondylitis (aHR, 2.32; 95% CI 1.95-2.77), alopecia areata (aHR, 1.41; 95% CI 1.35-1.46), and type 1 diabetes (aHR, 1.23; 95% CI 1.11-1.37). However, the risk of Graves' disease, Hashimoto's disease, Sjögren's syndrome, and systemic sclerosis was not significantly different between the groups. In conclusion, patients with newly diagnosed psoriatic disease may have a significantly increased risk of incident autoimmune diseases.

Common Cancer Types and Risk of Stroke and Bleeding in Patients With Nonvalvular Atrial Fibrillation: A Population-Based Study in England

BACKGROUND

The association between cancer and stroke or bleeding outcomes in atrial fibrillation is unclear. We sought to examine how certain types of cancer influence the balance between stroke and bleeding risk in patients with nonvalvular atrial fibrillation (NVAF).

METHODS AND RESULTS

We estimated stroke and bleeding risk among adult patients with NVAF and certain types of cancer (breast, prostate, colorectal, lung, and hematological cancer) from 2009 to 2019 based on data from the UK Clinical Practice Research Datalink GOLD and Aurum databases. The control group included patients with NVAF only. Of 177 065 patients with NVAF, 11379 (6.4%) had cancer (1691 breast, 3955 prostate, 1666 colorectal, 2491 hematological, and 1576 lung). Compared with patients without cancer, stroke risk was higher in patients with breast cancer (adjusted hazard ratio [aHR], 1.20 [95% CI, 1.07-1.35) and with prostate cancer (aHR, 1.11 [95% CI, 1.01-1.12) if diagnosed within 6 months before NVAF. The risk of bleeding was increased in subjects with hematological cancer (aHR, 1.55 [95% CI, 1.40-1.71]), lung cancer (aHR, 1.49 [95% CI, 1.25, 1.77]), prostate cancer (aHR, 1.38 [95% CI, 1.28-1.49]), and colorectal cancer (aHR, 1.36 [95% CI, 1.21-1.53]), but not for subjects with breast cancer. The more recent the cancer diagnosis before NVAF diagnosis (within 6 months), the higher the risk of bleeding.

CONCLUSIONS

Breast and prostate cancer are associated with increased stroke risk, whereas in some cancer types, the risk of bleeding seemed to exceed stroke risk. In these patients, prescribing of oral anticoagulant should be carefully evaluated to balance bleeding and stroke risk.

2022 Taiwanese Dermatological Association (TDA), Taiwanese Association for Psoriasis and Skin Immunology (TAPSI), and Taiwan Society of cardiology (TSOC) joint consensus recommendations for the management of psoriatic disease with attention to cardiovascular comorbidities

Psoriatic disease is a chronic inflammatory disorder with skin and joint manifestations. Due to the persistent inflammatory state exhibited by patients with psoriasis, multiple systemic comorbidities occur more frequently in patients with psoriasis than in the general population, and the risk of cardiovascular (CV) diseases is significantly increased. As the pathophysiology of psoriatic disease is becoming better understood, the sharing of underlying pathogenic mechanisms between psoriatic and CV diseases is becoming increasingly apparent. Consequently, careful attention to CV comorbidities that already exist or may potentially develop is needed in the management of patients with psoriasis, particularly in the screening and primary prevention of CV disease and in treatment selection due to potential drug-drug and drug-disease interactions. Furthermore, as the use of effective biologic therapy and more aggressive oral systemic treatment for psoriatic disease is increasing, consideration of the potential positive and negative effects of oral and biologic treatment on CV disease is warranted. To improve outcomes and quality of care for patients with psoriasis, the Taiwanese Dermatological Association, the Taiwanese Association for Psoriasis and Skin Immunology, and the Taiwan Society of Cardiology established a Task Force of 20 clinicians from the fields of dermatology, cardiology, and rheumatology to jointly develop consensus expert recommendations for the management of patients with psoriatic disease with attention to CV comorbidities.

Association of psoriasis with chronic kidney disease and end-stage renal disease: a systematic review and meta-analysis

Background and objective

Previous studies have shown that patients with psoriasis are at higher risk of developing chronic kidney disease (CKD) and end-stage renal disease (ESRD) compared with general population; however, data on the differences in the occurrence of CKD and ESRD between patients with psoriasis and non-psoriatic controls are limited and inconsistent. The aim of this study was to carry out a comparison of the probability of suffering CKD and ESRD in patients with or without psoriasis by conducting a meta-analysis of cohort studies.

Methods

Cohort studies on PubMed, Web of Science, Embase and Cochrane Library by March, 2023 were searched for. The studies were screened according to pre-established inclusion criteria. Hazard ratios (HRs) and a 95% confidence intervals (CIs) for the renal outcomes among patients with psoriasis were calculated using the random-effect, generic inverse variance method. Subgroup analysis was related to the severity of psoriasis.

Results

A total of seven retrospective cohort studies were included, including 738,104 psoriasis patients and 3,443,438 non-psoriasis subjects, published from 2013 to 2020. Compared to controls without psoriasis, patients with psoriasis had an increased risk of CKD and ESRD, with pooled hazard ratios of 1.65 (95% CI, 1.29-2.12) and 1.37 (95% CI, 1.14-1.64), respectively. Besides, the incidence of CKD and ESRD is positively correlated with the severity of psoriasis.

Conclusion

This study showed that compared to patients without psoriasis, patients with psoriasis, especially those with severe psoriasis, had a significantly increased risk of developing CKD and ESRD. Considering the limitations of this meta-analysis, more high-quality and well-designed studies are needed in the future to validate our findings.

Severe Mental Illness Among Adults with Atopic Eczema or Psoriasis: Population-Based Matched Cohort Studies within UK Primary Care

Background

Existing research exploring associations between atopic eczema (AE) or psoriasis, and severe mental illness (SMI - ie, schizophrenia, bipolar disorder, other psychoses) is limited, with longitudinal evidence particularly scarce. Therefore, temporal directions of associations are unclear. We aimed to investigate associations between AE or psoriasis and incident SMI among adults.

Methods

We conducted matched cohort studies using primary care electronic health records (January 1997 to January 2020) from the UK Clinical Practice Research Datalink GOLD. We identified two cohorts: 1) adults (≥18 years) with and without AE and 2) adults with and without psoriasis. We matched (on age, sex, general practice) adults with AE or psoriasis with up to five adults without. We used Cox regression, stratified by matched set, to estimate hazard ratios (HRs) comparing incident SMI among adults with and without AE or psoriasis.

Results

We identified 1,023,232 adults with AE and 4,908,059 without, and 363,210 with psoriasis and 1,801,875 without. After adjusting for matching variables (age, sex, general practice) and potential confounders (deprivation, calendar period) both AE and psoriasis were associated with at least a 17% increased hazard of SMI (AE: HR=1.17,95% CI=1.12-1.22; psoriasis: HR=1.26,95% CI=1.18-1.35). After additionally adjusting for potential mediators (comorbidity burden, harmful alcohol use, smoking status, body mass index, and, in AE only, sleep problems and high-dose glucocorticoids), associations with SMI did not persist for AE (HR=0.98,95% CI=0.93-1.04), and were attenuated for psoriasis (HR=1.14,95% CI=1.05-1.23).

Conclusion

Our findings suggest adults with AE or psoriasis are at increased risk of SMI compared to matched comparators. After adjusting for potential mediators, associations with SMI did not persist for AE, and were attenuated for psoriasis, suggesting that the increased risk may be explained by mediating factors (eg, sleep problems). Our research highlights the importance of monitoring mental health in adults with AE or psoriasis.

Increased risk of atrial fibrillation in patients with psoriasis: A meta-analysis of observational studies

BACKGROUND

Several epidemiological studies have shown that psoriasis increases the risk of developing atrial fibrillation but evidence of this is still scarce.

AIMS

Our objective was to systematically review, synthesise and critique the epidemiological studies that provided information about the relationship between psoriasis and atrial fibrillation risk.

METHODS

We searched through PubMed, EMBASE and the bibliographies for articles published between 1 January 2000, and 1 November 2017, that reported on the association between psoriasis and atrial fibrillation. All abstracts, full-text articles and sources were reviewed with duplicate data excluded. Summary relative risks (RRs) with 95% CI were pooled using a random effects model.

RESULTS

We identified 252 articles, of these eight unique abstracts underwent full-text review. We finally selected six out of these eight studies comprising 11,187 atrial fibrillation patients. The overall pooled relative risk (RR) of atrial fibrillation was 1.39 (95% CI: 1.257-1.523, P < 0.0001) with significant heterogeneity (I2 = 80.316, Q = 45.723, τ2 = 0.017, P < 0.0001) for the random effects model. In subgroup analysis, the greater risk was found in studies from North America, RR 1.482 (95% CI: 1.119-1.964, P < 0.05), whereas a moderate risk was observed in studies from Europe RR 1.43 (95% CI: 1.269-1.628, P < 0.0001).

LIMITATIONS

We were only able to include six studies with 11,178 atrial fibrillation patients, because only a few such studies have been published.

CONCLUSION

Our results showed that psoriasis is significantly associated with an increased risk of developing atrial fibrillation. Therefore, physicians should monitor patient's physical condition on a timely basis.

Early intervention in psoriasis: Where do we go from here?

Patients with psoriasis often have comorbidities and are at increased risk of developing several complications compared with the general population. Knowledge on the role of immune mediators and systemic inflammation in psoriasis has led to the hypothesis that early intervention with systemic therapy has the potential to modify the course of the disease and reduce the risk of long-term adverse outcomes. In this article, we address some potential issues that need to be considered before early intervention can be implemented routinely. The first is determining what constitutes "early" intervention for psoriasis. A second point is whether the intervention should be considered for patients with early disease or for selected subsets based on risk stratification. A third important consideration is defining success for early intervention. Finally, adoption of early and effective intervention should be based on high-level evidence. Ideally, randomized trials would be the best strategy to compare early vs. late systemic treatment in patients with psoriasis, probably using the frequency of long-term outcomes as primary endpoint, with cutaneous and pharmacoeconomic outcomes assessed secondarily.

Psoriasis and cardiovascular disease risk in European and East Asian populations: evidence from meta-analysis and Mendelian randomization analysis

BACKGROUND

Psoriasis has been linked to cardiovascular disease (CVD), including coronary artery disease (CAD), myocardial infarction (MI), and heart failure (HF). However, available studies regarding this relationship have shown inconsistent results. Therefore, in this report, we performed a comprehensive review of the literature to assess the effects of psoriasis on risk of these CVDs.

METHODS

A search of literature until 24 December 2021 was done in PubMed, the Cochrane Library, Web of Science, Google Scholar, and Embase. Within European and East Asian populations, meta-analyses of observational studies assessing correlations between psoriasis and various CVD risk factors were conducted. Mendelian randomization (MR) was then employed to assess the causative impact of genetic pre-disposition for psoriasis on these CVD risk factors.

RESULTS

The results of the meta-analyses indicated that, in both the European and East Asian populations, psoriasis was significantly linked to an elevated risk in the incidence of CAD (RR = 1.51, 95% confidence interval (CI): 1.04-2.18, p = 0.028 and RR = 1.91, 95% CI: 1.62-2.25, p < 0.001) and MI (RR = 1.23, 95% CI: 1.04-1.46, p = 0.017 and RR = 2.17, 95% CI: 1.44-3.28, p < 0.001). A positive genetic relationship of psoriasis with CAD was found in European individuals (IVW OR:1.03; 95% CI: 1.01-1.06, p = 0.005) and in East Asian individuals (IVW OR:1.18; 95% CI: 1.03-1.32, p = 0.031). We also established that psoriasis was causally linked with an elevated risk of MI (IVW OR:1.05; 95% CI: 1.01-1.09, p = 0.026) in the European population as determined using an MR approach. Moreover, our MR results were congruent with the null findings from the meta-analysis assessing associations of psoriasis with HF risk.

CONCLUSIONS

This research work provides preliminary evidence that psoriasis and CVD have a common genetic origin and that targeted psoriasis treatment might improve cardiovascular outcomes. These results not only increase our knowledge of the genetic underpinnings linking a comorbidity of psoriasis with CVD but also suggests a novel approach for CVD prevention.

Traditional and Non-traditional Cardiovascular Risk Factors and Cardiovascular Disease in Women with Psoriasis

Women with cardiovascular disease are underdiagnos-ed, undertreated and under-represented in research. Even though the increased risk of cardiovascular disease among patients with psoriasis is well establi-shed, only a few studies have examined women with psoriasis. This study examined the prevalence of cardio-vascular risk factors and cardiovascular disease among women with psoriasis. Using the Copenhagen City Heart Study and the Copenhagen General Population Study, 66,420 women were included in a cross-sectional design. Of these, 374 (0.56%) women had hospital-diagnosed psoriasis. Women with vs with-out hospital-diagnosed psoriasis had higher odds ratios of having traditional cardiovascular risk factors, including hypertriglyceridaemia, smoking, obesity, type 2 diabetes, and low physical activity, and of having non-traditional cardiovascular risk factors, including low level of education, high level of psycho-social stress, and low-grade inflammation. Compared with women from the general population, the multi-variable adjusted odds ratio of heart failure and ischaemic cerebrovascular disease in women with hospital-diagnosed psoriasis was 2.51 (95% confidence interval 1.33-4.73) and 2.06 (1.27-3.35). In conclusion, women with hospital-diagnosed psoriasis have a higher prevalence of traditional and non- traditional cardiovascular risk factors, and increased risk of heart failure and ischaemic cerebrovascular disease, even after adjusting for these cardiovascular risk factors.

The Association Between Psoriasis and Risk of Cardiovascular Disease: A Mendelian Randomization Analysis

Background

A large number of observational studies showed that patients with psoriasis have a higher risk of cardiovascular disease (CVD), but most studies did not fully adjust for confounding factors, so it is not clear whether the risk of CVD is directly attributed to psoriasis. We used Mendelian randomization (MR) to evaluate the potential causal relationship between psoriasis and CVD.

Methods

We used genetic instruments from the genome-wide association study (GWAS) of European descent for psoriasis to investigate its relationship with CVD. Inverse variance-weighted (IVW) MR analyses were used for the primary analysis. In addition, a variety of other methods were used to replicate the analysis.

Results

The fixed-effects IVW method indicated that genetic susceptibility to psoriasis was associated with a higher risk of heart failure (HF) [odds ratio (OR) = 1.04; 95% CI, 1.01–1.06, P = 2.72E-03], atrial fibrillation (AF) (OR = 1.04; 95% CI, 1.02–1.07, P = 3.27E-04), myocardial infarction (MI) (OR = 1.07; 95% CI, 1.01–1.12, P = 0.01), valvular heart disease (VHD) (OR = 1.001; 95% CI, 1.000–1.002, P = 1.85E-03), and large artery stroke (LAS) (OR = 1.11; 95% CI, 1.05–1.18, P = 5.37E-04) but not with the other two subtypes of ischemic stroke (IS) [cardioembolic stroke (CES) (OR = 1.03; 95% CI, 0.98–1.07, P = 0.27) and small vessel stroke (SVS) (OR = 1.00; 95% CI, 0.95–1.07), P = 0.88)]. Sensitivity analysis found weak evidence of horizontal diversity and heterogeneity to ensure the stability of the results.

Conclusion

Our study provided evidence for a potential causal link between psoriasis and CVD. These findings partly suggest that early monitoring of cardiovascular risk in patients with psoriasis is intentional.

[Translated article] Practical Update of the Guidelines Published by the Psoriasis Group of the Spanish Academy of Dermatology and Venereology (GPs) on the Treatment of Psoriasis With Biologic Agents: Part 2-Management of Special Populations, Patients With Comorbid Conditions, and Risk

BACKGROUND AND OBJECTIVES

Since its inception, the Psoriasis Group (GPs) of the Spanish Academy of Dermatology and Venereology (AEDV) has worked to continuously update recommendations for the treatment of psoriasis based on the best available evidence and incorporating proposals arising from and aimed at clinical practice. An updated GPs consensus document on the treatment of moderate to severe psoriasis was needed because of changes in the treatment paradigm and the approval in recent years of a large number of new biologic agents.

METHODOLOGY

The consensus document was developed using the nominal group technique complemented by a scoping review. First, a designated coordinator selected a group of GPs members for the panel based on their experience and knowledge of psoriasis. The coordinator defined the objectives and key points for the document and, with the help of a documentalist, conducted a scoping review of articles in Medline, Embase, and the Cochrane Library up to January 2021. The review included systematic reviews and meta-analyses as well as clinical trials not included in those studies and high-quality real-world studies. National and international clinical practice guidelines and consensus documents on the management of moderate to severe psoriasis were also reviewed. The coordinator then drew up a set of proposed recommendations, which were discussed and modified in a nominal group meeting. After several review processes, including external review by other GPs members, the final document was drafted.

RESULTS

The present guidelines include updated recommendations on assessing the severity of psoriasis and criteria for the indication of systemic treatment. They also include general principles for the treatment of patients with moderate to severe psoriasis and define treatment goals for these patients as well as criteria for the indication and selection of initial and subsequent therapies Practical issues, such as treatment failure and maintenance of response, are also addressed.

Cardiac and Sudomotor Autonomic Function in Subjects with Psoriasis With and Without Metabolic Syndrome

Purpose: Studies have shown that subjects with psoriasis (PsO) are associated with an increased risk of developing metabolic syndrome (MetS), diabetes, and cardiovascular disease. In addition, MetS and diabetes are associated with autonomic dysfunction (AD). The aim of this study was to investigate cardiac and sudomotor autonomic function in subjects with PsO and without diabetes. Methods: A cross-sectional study was performed in 20 subjects with PsO, compared with age- and sex-matched 21 healthy controls, and 20 subjects with MetS. Subjects underwent skin evaluation by dermatologist, glycated hemoglobin (HbA1c), insulin, glucose, and lipid levels, sudomotor function testing with Sudoscan^™ device (Impeto Medical, Paris, France), and cardiac autonomic function testing with ANSAR device (ANX 3.0; ANSAR Group, Inc., Philadelphia, PA). Quality of Life (QOL) and peripheral neurologic function were also assessed. Results: Participants with PsO were significantly more obese, had higher levels of fasting insulin and triglycerides, and were more insulin resistant when compared to controls. Subjects with PsO showed significantly worse cardiac autonomic function when compared to control and MetS groups. Sudomotor function and QOL scores were similar between the groups. Subgroup analysis of PsO subjects without MetS criteria (n = 15) showed persistent significantly deteriorated cardiac autonomic function when compared to the other two groups. Conclusion: This study suggests an association between PsO and cardiac AD, independent of the presence of overt dysglycemia and MetS. Additional larger studies are needed to clarify the significance of these findings and the relationship between PsO, AD, and metabolic disease.

Psoriasis Increased the Risk of Adverse Cardiovascular Outcomes: A New Systematic Review and Meta-Analysis of Cohort Study

Background

Several studies have investigated the relationship between psoriasis and adverse cardiovascular outcomes. Previous meta-analyses have shown psoriasis to be a risk factor for adverse cardiovascular outcomes. However, the relationship has become uncertain with the emergence of many new studies.

Objective

This study aimed to conduct an updated meta-analysis on cohort studies about the relationship between psoriasis and adverse cardiovascular outcomes.

Methods

Electronic databases (accessed till January 2022) were searched systematically for cohort studies assessing the cardiovascular risk in psoriasis patients. This was a meta-analysis using a random-effect model; pooled analyses of several cardiovascular outcomes were also conducted.

Results

A total of 31 [hazard ratio (HR), 23; rate ratio (RR), 8] studies involving 665,009 patients with psoriasis and 17,902,757 non-psoriatic control subjects were included for the meta analysis. The pooled analyses according to each cardiovascular outcome revealed that pooled RR of patients for developing myocardial infarction, stroke, cardiovascular death, ischemic heart disease, thromboembolism and arrhythmia were 1.17 (95% confidence interval [CI], 1.11–1.24), 1.19 (95% CI, 1.11–1.27), 1.46 (95% CI, 1.26–1.69), 1.17 (95% CI, 1.02–1.34), 1.36 (95% CI, 1.20–1.55) and 1.35 (95% CI, 1.30–1.40), respectively. Meanwhile, the pooled RR of patients with mild and severe psoriasis for developing adverse cardiovascular outcomes were 1.18 (95% CI, 1.13–1.24) and 1.41 (95% CI, 1.31–1.52), respectively.

Conclusion

The pooled analyses revealed that psoriasis is associated with all adverse cardiovascular outcomes of interest, especially in severe patients. Psoriasis remains an independent risk factor for adverse cardiovascular outcomes, which needs more attention from clinicians.

Can Biological Drugs Diminish the Risk of Sarcopenia in Psoriatic Patients?

Sarcopenia and psoriasis are different inflammatory diseases that share common comorbidities (e.g., cardiovascular diseases, metabolic syndrome, obesity, autoimmune diseases, depression). Psoriasis is a dermatosis involving the skin, joints, and nails. Its estimated prevalence is 2–4%, and the possibility of progression to psoriatic arthritis reaches 6–42%. Sarcopenia is defined as reduced muscle strength, muscle quantity, and physical performance due to non-ageing related causes. It affects up to 10% of the general population. We conducted a review of the literature to provide up-to-date information about the risk of sarcopenia in psoriasis and to identify risk factors that increase this risk. The search of the literature allowed us to include 51 publications, but only five cross-sectional studies provided quantitative results on the rates of sarcopenia in psoriasis. The prevalence of sarcopenia in psoriasis varied from 9.1% to 61.7%. This wide range was caused by different definitions of sarcopenia and different cut-off values across studies. Prognostic factors include lean mass and fat mass. Further research based on the European Working Group on Sarcopenia in Older People guidelines is required. Such studies should include not only muscle mass and strength but also other factors that may influence the occurrence of sarcopenia and inflammatory markers.

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.

Homocysteine Is a Marker of Increased Cardio-Cerebrovascular Disease Risk in Psoriatic Patients, but It Does Not Reflect the Effect of Biological Therapy in the Longitudinal Observation

BACKGROUND

Psoriasis is linked to atherosclerosis. Homocysteine (HCYS) has been identified as a marker of increased risk of cardio-cerebrovascular diseases (CCVD) in population.

OBJECTIVE

The aim of the study was to determine whether elevated HCYS serves as a marker of increased CCVD in psoriasis and whether biological therapy for long-term monitoring influences HCYS levels.

METHODS

Clinical data, laboratory tests, and comorbid diagnoses were summarized for the two groups of patients based on entrance HCYS levels. Patients (n = 76) were included in the follow-up gradually over a period of 5 years.

RESULTS

The psoriatic patients with normal (54%) and elevated (46%) HCYS before biological treatment did not vary in clinical data, laboratory tests, treatment, and comorbid diagnoses apart from CCVD. Elevated HCYS group showed a four-fold excess of CCVD (OR 4.2, 95%CI 1.21-4.86, p=0.024). HCYS levels in the longitudinal observation did not vary.

CONCLUSION

An increased CCVD risk, independent of other risk factors, is present in psoriatic patients with elevated HCYS. The HCYS level was not influenced by biological therapy in longitudinal observation. Further studies are needed to explore if elevated HCYS could serve as a marker of increased CCVD in any stage of psoriasis and if it should be included in classical screening strategies.

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.

Psoriasis as an Immune-Mediated and Inflammatory Systemic Disease: From Pathophysiology to Novel Therapeutic Approaches

Psoriasis is an immune-mediated inflammatory disease, with a chronic relapsing-remitting course, which affects 2–3% of the worldwide population. The progressive acquisitions of the inflammatory pathways involved in the development of psoriasis have led to the identification of the key molecules of the psoriatic inflammatory cascade. At the same time, psoriasis therapy has radically evolved with the introduction of target molecules able to modify the natural history of the disease, acting specifically on these inflammatory pathways. For these reasons, biologics have been demonstrated to be drugs able to change the disease’s natural history, as they reduce the inflammatory background to avoid irreversible organ damage and prevent systemic complications. However, several issues related to the use of biologics in patients with systemic comorbidities, remain open. All these data reflect the extraordinary potentiality of biologics, but also the unmet medical need to improve our knowledge on the long-term risk related to continuous use of these drugs, and their administration in special populations. This narrative review aims to highlight both the efficacy and safety profile of biologics in psoriasis, starting from pathophysiology and moving towards their clinical application.

Inflammatory skin diseases and the risk of chronic kidney disease: population-based case-control and cohort analyses

BACKGROUND

Emerging evidence suggests an association between common inflammatory skin diseases and chronic kidney disease (CKD).

OBJECTIVES

To explore the association between CKD stages 3-5 (CKD3-5) and atopic eczema, psoriasis, rosacea and hidradenitis suppurativa.

METHODS

We undertook two complementary analyses; a prevalent case-control study and a cohort study using routinely collected primary care data [UK Clinical Practice Research Datalink (CPRD)]. We matched individuals with CKD3-5 in CPRD in March 2018 with up to five individuals without CKD for general practitioner practice, age and sex. We compared the prevalence of CKD3-5 among individuals with and without each inflammatory skin disease. We included individuals in CPRD with diabetes mellitus (2004-2018) in a cohort analysis to compare the incidence of CKD3-5 among people with and without atopic eczema and psoriasis.

RESULTS

Our study included 56 602 cases with CKD3-5 and 268 305 controls. Cases were more likely than controls to have a history of atopic eczema [odds ratio (OR) 1·14, 99% confidence interval (CI) 1·11-1·17], psoriasis (OR 1·13, 99% CI 1·08-1·19) or hidradenitis suppurativa (OR 1·49, 99% CI 1·19-1·85), but were slightly less likely to have been diagnosed with rosacea (OR 0·92, 99% CI 0·87-0·97), after adjusting for age, sex, practice (matching factors), index of multiple deprivation, diabetes, smoking, harmful alcohol use and obesity. Results remained similar after adjusting for hypertension and cardiovascular disease. In the cohort with diabetes (N = 335 827), there was no evidence that CKD3-5 incidence was associated with atopic eczema or psoriasis.

CONCLUSIONS

Atopic eczema, psoriasis and hidradenitis suppurativa are weakly associated with CKD3-5. Future research is needed to elucidate potential mechanisms and the clinical significance of our findings.

Psoriasis and Atherosclerosis-Skin, Joints, and Cardiovascular Story of Two Plaques in Relation to the Treatment with Biologics

It is known that both psoriasis (PSO) limited to the skin and psoriatic arthritis (PSA) increase the risk of cardiovascular complications and atherosclerosis progression by inducing systemic inflammatory response. In recent decades, the introduction of biological medications directed initially against TNF-α and, later, different targets in the inflammatory cascade brought a significant breakthrough in the efficacy of PSO/PSA treatment. In this review, we present and discuss the most recent findings related to the interplay between the genetics and immunology mechanisms involved in PSO and PSA, atherosclerosis and the development of cardiac dysfunction, as well as the current PSO/PSA treatment in view of cardiovascular safety and prognosis.

TNF-α blockade may lead to improvement of vascular function in psoriasis patients

Psoriasis is one of the most common chronic inflammatory skin diseases and at the same time a risk factor for cardiovascular disease. Interleukin-17A (IL-17A)-mediated inflammation in psoriasis may lead to vascular dysfunction. This study aimed at investigating whether anti-inflammatory treatment by tumor necrosis factor (TNF)-α blockade alters vascular function in psoriasis patients. A total of 11 patients with psoriasis who underwent treatment with either adalimumab (n = 8) or etanercept (n = 3), 10 healthy control individuals and 14 patients with coronary artery disease (CAD) were included in this study. Treatment response was assessed using the Psoriasis Area and Severity Index (PASI) score. Endothelial reactivity and resting endothelium-dependent vascular tone were assessed by ultrasound measurement of flow-mediated dilation (FMD) and low-flow-mediated constriction (l-FMC), respectively. FMD was slightly impaired in psoriasis patients compared to healthy controls. Anti-TNF-α treatment did not significantly change FMD levels. Psoriasis patients showed a trend towards increased baseline vascular activity compared to healthy controls. Anti-TNF-α treatment significantly improved l-FMC in psoriasis patients. Noteworthy, both FMD and l-FMC in psoriasis patients were comparable to those in patients with CAD; however, an important influence of age differences between the groups or co-existent classical cardiovascular risk factors on FMD and l-FMC cannot be ruled out by our small study. The results suggest that anti-inflammatory treatment with TNF-α blockade improves vascular function in patients with psoriasis, mainly by altering baseline vascular tone. Further studies will be necessary to establish the potentially protective impact of anti-inflammatory therapy on vascular function in patients with chronic inflammatory diseases.

The relation between visceral fat markers and cardiometabolic disease risks in psoriasis patients

OBJECTIVE:

Psoriasis is a chronic, inflammatory disease that appears with variable trigger factors. We know that obesity and other metabolic syndrome criteria are high in psoriasis patients. The aim of this study is to evaluate the relationship between visceral fat markers, risk of cardiometabolic disease, and psoriasis area severity index (PASI) in individuals with and without psoriasis.

METHODS:

A total of 203 subjects, 102 psoriasis patients and 101 healthy individuals, were included in the study. Lipid accumulation product (LAP) index, visceral adiposity index (VAI), plasma atherogenicity index (PAI), body mass index (BMI), PASI, triglyceride (TG), and high-density lipoprotein cholesterol (HDL-c) values were measured.

RESULTS:

LAP index, VAI, PAI, BMI, and TG levels were significantly high (p<0.001) and HDL-c levels were significantly low (p=0.009) in patients with psoriasis compared to healthy individuals.

CONCLUSION:

LAP index, VAI, and PAI calculations can be recommended as a potential biomarker for early diagnosis of cardiometabolic diseases common in patients with psoriasis.

The Association Between Psoriasis and Cardiovascular Diseases

Cardiovascular diseases and psoriasis have been well established as separate entities, however, there is uncertainty with regards to a link between the two diseases. A few environmental, psychological and social factors have been implicated as potential common risk factors that may exacerbate the two diseases, and an array of complex immune and non-immune inflammatory mediators can potentially explain a plausible link. Pharmacotherapy has also played a role in establishing a potential association, especially with the advent of biological agents which directly act on inflammatory factors shared by the two diseases. This review will look at existing evidence and ascertain a potential correlation between the two.

Mapping risk factors for cumulative life course impairment in patients with chronic skin diseases - a systematic review

Patients with chronic skin diseases suffer from physical and psychosocial impairments which can lead to a cumulative life-long burden. Therefore, the concept of cumulative life course impairment (CLCI) was introduced, referring to the non-reversible damage due to the persistent life-long burden. This systematic review (PROSPERO registry number: CRD42020179141) aimed at mapping the risk factors and the associated burden over time in patients with psoriasis, atopic dermatitis (AD) and hidradenitis suppurativa (HS). Three electronic databases were searched (date of the last search: December 2019). Studies with a longitudinal study design that assessed the association between a risk factor and the associated burden over time in patients with psoriasis, AD and HS were included. Quality assessment of the included studies was done using Critical Appraisal Skills Programme (CASP) checklists. In total, 40 publications reflecting 25 different studies were included: nine studies addressed patients with psoriasis, 13 patients with AD, two studies included patients with HS and one study enrolled patients with psoriasis and AD, respectively. Twenty-two potential risk factors with underlying evidence were found in this review. These risk factors include mainly sociodemographic (such as age or gender) and clinical (such as disease severity or comorbidities) variables. Disease severity and comorbidities were the most often studied risk factors, while only a few studies evaluated psychosocial risk factors over time. Patients with chronic skin diseases are at high risk to develop a life-long negative impact from the disease. However, there is a lack of data that evaluates the psychosocial burden and its influence on the patients' life course over time. The risk factors found in this review help to identify patients at risk, to treat them adequately and, ultimately, to prevent CLCI. These results can be the basis to develop a highly needed tool to assess the risk for CLCI in the future.

Psoriasis

Psoriasis is a common, chronic papulosquamous skin disease occurring worldwide, presenting at any age, and leading to a substantial burden for individuals and society. It is associated with several important medical conditions, including depression, psoriatic arthritis, and cardiometabolic syndrome. Its most common form, chronic plaque or psoriasis vulgaris, is a consequence of genetic susceptibility, particularly in the presence of the HLA-C*06:02 risk allele, and of environmental triggers such as streptococcal infection, stress, smoking, obesity, and alcohol consumption. There are several phenotypes and research has separated pustular from chronic plaque forms. Immunological and genetic studies have identified IL-17 and IL-23 as key drivers of psoriasis pathogenesis. Immune targeting of these cytokines and of TNFα by biological therapies has revolutionised the care of severe chronic plaque disease. Psoriasis cannot currently be cured, but management should aim to minimise physical and psychological harm by treating patients early in the disease process, identifying and preventing associated multimorbidity, instilling lifestyle modifications, and employing a personalised approach to treatment.

Novel anti-inflammatory therapies to reduce cardiovascular burden of psoriasis

Psoriasis mainly affects the skin and joints and has serious impacts on the physical, emotional, and financial life of patients. Recent studies have demonstrated that other comorbidities are frequently detected in psoriatic patients. A strong association with the development of cardiovascular diseases, such as hypertension, myocardial infarction, and stroke is responsible for the shortened (by 4.5‐5 years) life expectancy of severe psoriatic patients. Systemic inflammation plays an important role in the interrelationship between psoriasis and atherosclerotic plaque formation, which is a common immunopathogenic pathway that explains the multiorgan involvement in psoriasis. As far life‐threatening cardiovascular diseases are very often symptom‐free, the treating dermatologist's responsibility is to initiate interdisciplinary holistic patient care, which may lead to directly saved patients' lives. Holistic care of severe psoriatic patients should include regular cardiac monitoring using cardiovascular imaging modalities and functional testing to detect even subclinical coronary artery disease. Effective anti‐inflammatory treatment with biologic therapies may have beneficial effects on the cardiovascular state and may reduce the incidence of cardiac events. The authors review the latest findings on the shared immunopathogenic background of psoriasis and cardiovascular diseases and discuss the available data about the cardiovascular responses to the currently used biologic treatments.

Risk of hospitalization and death due to infection in people with psoriasis: a population-based cohort study using the Clinical Practice Research Datalink

BACKGROUND

Psoriasis is associated with risk factors for serious infections, but the independent relationship between psoriasis and serious infection is as yet unclear.

OBJECTIVES

To determine whether people with psoriasis have a higher risk of hospitalization due to any infection, respiratory infections, soft-tissue and skin infections, or a higher risk of death due to infection.

METHODS

We conducted a cohort study of people (≥ 18 years) with psoriasis using the UK Clinical Practice Research Datalink (CPRD GOLD) linked to Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality records between 1 April 2003 and 31 December 2016, and matched with up to six comparators on age, sex and general practice. Hospitalization was ascertained from HES records; death was ascertained from ONS mortality records. Stratified Cox proportional hazard models were estimated, with stepwise adjustment in different models for potential confounders or mediators between psoriasis and serious infection.

RESULTS

There were 69 315 people with psoriasis and 338 620 comparators who were followed up for a median (interquartile range) of 4·9 (5·9) and 5·1 (6·3) years, respectively. People with psoriasis had a higher incidence rate of serious infection [20·5 per 1000 person-years, 95% confidence interval (CI) 20·0-21·0, n = 7631] compared with those without psoriasis (16·1 per 1000 person-years, 95% CI 15·9-16·3, n = 30 761). The fully adjusted hazard ratio for the association between psoriasis and serious infection was 1·36 (95% CI 1·31-1·40), with similar results across the other outcomes.

CONCLUSIONS

Psoriasis is associated with a small increase in the risk of serious infection. Further research is needed to understand how psoriasis predisposes to a higher risk of infection.

Progress to Date in Advancing Stratified Medicine in Psoriasis

Stratified medicine is the tailoring of treatment to the individual characteristics of each patient. This is a challenging task in the context of psoriasis, a complex disease with a variety of phenotypic presentations and a comorbidity burden that extends beyond cutaneous manifestations. In recent years, considerable progress has been made in understanding the immunology of psoriasis, and this has informed the development of increasingly precise and efficacious therapies. However, not all patients respond to biologic therapy, and access is limited to patients with moderate to severe disease. However, subpopulations of patients are emerging with distinct patterns of response to therapy, largely determined by clinical and pharmacogenomic factors. Despite progress to date, the natural history of psoriasis remains poorly understood. It is likely that disease onset, progression, development of comorbidities and response to therapy are due to a combination of genetic, inflammatory and environmental factors. We envision that a greater understanding of the natural history of psoriasis will be a key factor in progressing a stratified medicine approach to patient care, as will earlier intervention in the course of the disease.

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

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

The impact of smoking on prevalence of psoriasis and psoriatic arthritis

Objectives

In this systematic literature review and meta-analysis, we aimed to investigate the impact of cigarette smoking on the prevalence and incidence of psoriasis and psoriatic arthritis (PsA).

Method

We performed a systematic literature review using the MEDLINE, EMBASE and Cochrane Central Register databases. The literature included publications from January 1980 to July 2019. The studies that provided clear information on the number of patients with ever smoking data were included in the meta-analysis.

Results

The systematic literature review identified 52 and 24 articles for the prevalence of smoking in psoriasis and PsA, respectively. Of these, 16 articles on psoriasis and three and four (general population and psoriasis, respectively) articles on PsA met the criteria and were included in the meta-analysis. The prevalence of ever smoking was increased in psoriasis compared with the general population (OR: 1.84; 95% CI: 1.4, 2.3). For PsA the prevalence of ever smoking was reduced in psoriasis patients (OR: 0.70; 95% CI: 0.60, 0.81), but not changed compared with the general population (OR: 1.10; 95% CI: 0.92, 1.32).

Conclusion

This meta-analysis showed that ever smoking increases the risk of psoriasis in the general population, but may reduce the risk of PsA in psoriasis patients. The latter may be also due to the collider effect. Whether smoking cessation neutralizes the risk of developing psoriasis requires a well-defined smoking data collection for the past history and this is currently unavailable in the literature.