Psoriasis: an opportunity to identify cardiovascular risk

Ocular findings in patients with psoriasis: is it related to the side effects of treatment or to psoriasis itself? A case-control study

Objectives: To assess ocular abnormalities in psoriatic patients (new-cases versus patients under treatment) in comparison with healthy controls.Methods: A total of 200 psoriatic patients and 100 healthy controls were enrolled in this prospective, observational study. The demographic data of the individuals were recorded. Dermatological and ophthalmologic examinations were conducted; ocular surface disease index (OSDI), Schirmer's and tear break-up time (TBUT) values were also measured.Results: The mean values of TBUT and Schirmer's tests in patients were significantly lower than the controls and significantly higher scores of OSDI were observed among patients compared to the controls (p < .0001); dry eye disease was more frequent in the patients than the healthy subjects (p = .001). Other ocular findings including cataract and uveitis were not significantly different between the groups. Although no significant differences were found between the ocular findings of new cases and patients under treatment, ocular findings in cases under treatment were associated with the type of treatment and more frequent in those treated with methotrexate, followed by acitretin and biologic drugs.Conclusions: Ocular surface problems in psoriatic patients are more common than previously thought; in addition to the role of treatment modalities, psoriasis itself and a probable systemic inflammation may play an important role.Key PointsThere are limited case-control studies about ocular manifestations in psoriasis and also its pathogenesis is not yet clear.This study shows that ocular surface problems in psoriatic patients are higher than healthy subjects; in addition to the role of treatment modalities, psoriasis itself and a probable systemic inflammation may play a pivotal role.Regular ophthalmological evaluations are recommended in psoriatic patients especially those with more severe and chronic form of the disease, to prevent any complications.

Psoriasis and Cardiovascular Risk-Do Promising New Biomarkers Have Clinical Impact?

Epidemiological studies suggest an increased prevalence of cardiovascular disease (CVD) in patients with psoriasis (PS). Therefore, emphasis has lately been laid on the necessity for clinical evaluation of the risk of CVD in these patients. The systemic inflammatory markers C-reactive protein (CRP) and interleukin- (IL-) 6, which have long been used to predict future CVD in the general population, are increased manyfold in patients with PS. Lipid abnormalities characterized by elevated triglycerides, low HDL cholesterol, and higher concentrations of LDL cholesterol and its oxidized form are also prevalent in patients. There is a need for additional laboratory markers for the assessment of cardiovascular status of patients with PS. Due to frequent comorbid overweight and obesity, biologically active compounds produced by adipocytes may have an impact on monitoring the status of the cardiovascular system of patients with PS. For this purpose, two adipokines, adiponectin and leptin, have been most extensively studied. The review focuses on some inflammatory and oxidative stress aspects in patients with PS through the analysis of the impact of prominent adipokines and oxidized low-density lipoprotein (oxLDL) to assess their eligibility for clinical practice as markers of CVD risk in patients with PS.

Diagnosis and underdiagnosis of comorbidities in psoriasis patients - need for a multidisciplinary approach

BACKGROUND:

Psoriasis is an immune-mediated disease that manifests predominantly in the skin, although systemic involvement may also occur. Although associated comorbidities have long been recognized and despite several studies indicating psoriasis as an independent risk factor for cardiovascular events, little has been done in general medical practice regardind screening. In the United States, less than 50% of clinicians are aware of these recommendations.

OBJECTIVE:

To identify the prevalence of these comorbidities in 296 patients followed up at a university dermatology clinic.

METHODS:

Systematically investigated comorbidity frequencies were compared with general practitioners' registry frequencies. Clinical features correlated with comorbidities were also investigated.

RESULTS:

High prevalences of systematically investigated comorbidities such as hypertension (30%) and dyslipidemia (26.5%) were documented. Conversely, data from general practitioners' records showed that 33% of dyslipidemia cases were undiagnosed and indicated possible underdiagnosis of some comorbidities. Furthermore, an association was found between: the number of comorbidities and psoriasis duration, age and high body mass index an association was found between the number of comorbidities and psoriasis duration, age, high body mass index, waist circumference or waist-to-hip ratio. (p<0.05).

CONCLUSION:

Disease duration, age and high body mass index, waist circumference or waist-to-hip ratio are possible criteria for choosing which patients should be screened for comorbidities. Underdiagnosis of comorbidities by general practitioners highlights the need for a multidisciplinary approach in psoriasis management.

A study of awareness and screening behavior of cardiovascular risk factors in patients with psoriasis and dermatologists

Background

A number of studies have suggested an increased frequency of cardiovascular (CV) diseases in patients with psoriasis.

Objective

In this study, we assessed the awareness among psoriasis patients and dermatologists in private primary clinics about the increased CV risk linked to psoriasis, and examined the screening behaviors of dermatologists for CV risk factors in psoriasis patients.

Methods

We distributed questionnaires to dermatologists in primary clinics and to psoriasis patients about their awareness of the increased CV risk factors related with psoriasis.

Results

One hundred four patients and 50 dermatologists were included. 64.4% of patients and 92% of dermatologists answered that they know about the increased risk of CV diseases in psoriasis patients. However, far fewer dermatologists than expected followed the screening guidelines for CV risk factors. We found that the duration (p<0.0001) and severity (p<0.0001) of psoriasis were related to patient's awareness. A significant correlation between dermatologists' awareness and the number of psoriasis patients they treated each month was also observed (p<0.024).

Conclusion

This study may help promote the idea that psoriasis patients require education about their increased CV risk factors and that dermatologists require further education about screening practices to detect CV risk in psoriasis patients.

Serum YKL-40: a potential biomarker for psoriasis or endothelial dysfunction in psoriasis?

Psoriasis is a disease that can contribute to a risk of atherosclerosis. In several studies, impaired endothelial dysfunction (ED) is correlated with psoriasis. Serum YKL-40 is a new inflammatory biomarker of vascular damage, like ED and cardiovascular diseases. The aim of the study was to compare relevance of serum YKL-40 levels in psoriasis patients and healthy subjects according to ED diagnosis and identifiable cardiovascular risk factors. Sixty (31 female, 29 male) patients with plaque psoriasis, and 30 (18 female, 12 male) healthy controls were selected according to whether they had at least one or no identifiable risk factors for cardiovascular disease. All subjects were evaluated ultrasonographically for endothelial function and diagnosed as with or without ED and all groups compared for serum YKL-40 levels. YKL-40 levels of psoriatic patients with ED were higher than healthy controls with ED (P = <0.05). There were no statistical differences in between subjects without ED. YKL-40 levels of patients over age of 40 were higher than younger ones (P < 0.05). But in healthy controls, there were no differences. In comparison of cardiovascular risk-positive (RP) patients and RP healthy subjects, YKL-40 levels were higher in RP patients (P = <0.05). The elevation of plasma YKL-40 in psoriasis can be associated not only with inflammation of the disease, but also with ED. YKL-40 can be used as a marker for predicting and preventing cardiovascular diseases in RP psoriatic patients with age above 40.

Dyslipidemia in Psoriasis: A Case Controlled Study

Multiple observational studies have demonstrated associations of psoriasis with metabolic syndrome including obesity, diabetes, hypertension, dyslipidemia, and osteoporosis. However there is paucity of Indian studies on dyslipidemia in psoriasis. The aim of this study was to assess the serum lipids in psoriasis and to investigate the association of lipids with disease severity and its duration. 100 cases of psoriasis (75/M, 25/F), between 15 and 72 years, were recruited with age and sex matched 73 controls. Using Psoriasis Area Severity Index (PASI) cases were graded into mild, moderate, and severe psoriasis. Serum total cholesterol and triglycerides were analyzed using enzymatic method. Using independent t-test, significant elevation of serum cholesterol, triglycerides, high density lipoprotein (HDL) and very low density lipoprotein was observed (P < 0.05) when compared to controls. The levels of low density lipoproteins were comparable in cases and controls. Lipid aberrations in hypertensive patients were significant. There was a decrease in HDL levels with increase in disease severity. A fall in the levels of HDL was seen in cases with long term psoriasis. There is a strong association of dyslipidemia with psoriasis. There exist racial and ethnic variation in the prevalence of psoriasis; however, dyslipidemia is consistently seen in diverse population. Whether genetic factors are implicated in lipid derangements in psoriasis needs further research.

From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies

BACKGROUND

Many studies have identified cardiovascular risk factors in patients with psoriasis. Some psoriasis therapies may increase cardiovascular disease (CVD) and others may decrease CVD.

OBJECTIVE

We reviewed the literature to define the impact of common psoriasis therapies on cardiovascular measures and outcomes.

RESULTS

Phototherapy has no major cardiovascular impact and may reduce levels of proinflammatory cytokines. Acitretin increases serum lipids and triglycerides, but has not been shown to increase cardiovascular risk. Cyclosporine A increases blood pressure, serum triglycerides, and total cholesterol. Methotrexate is associated with a decreased risk of CVD morbidity and mortality. Among the biologics, data for tumor necrosis factor inhibitors suggest an overall reduction in cardiovascular events. Most data on short-term ustekinumab use suggest no effect on major adverse cardiovascular events, however some authorities remain concerned. Nevertheless, ustekinumab use over a 4-year period shows a decrease in major adverse cardiovascular events when compared both with the general US population and with psoriatics in Great Britain.

LIMITATIONS

Most studies lack the power and randomization of large clinical trials and long-term follow-up periods. In addition, the increased risk of CVD associated with psoriasis itself is a confounding factor.

CONCLUSION

Some therapies for moderate to severe psoriasis, including methotrexate and tumor necrosis factor inhibitors, may reduce cardiovascular events in psoriatic patients. Ustekinumab appears to be neutral but there may be a long-term benefit. Appropriate patient counseling and selection and clinical follow-up are necessary to maximize safety with these agents. Further long-term study is necessary to quantify the benefits and risks associated with biologic therapies.

Cardiovascular aspects of psoriasis: an updated review

Psoriasis, a systemic inflammatory disease, is associated with enhanced atherosclerosis and risk of cardiovascular (CV) disease, which may account for higher morbidity and mortality rates in psoriatic patients. It especially applies to younger psoriatic patients with more severe disease, reducing their life expectancy. The aim of the study was to review the literature on CV disease in psoriasis as well as the pathogenic mechanisms shared between psoriasis and atherosclerosis. Moreover, case-control and cohort studies published between 2006 and 2011 were selected for meta-analysis. The meta-analysis indicates elevated risk of cardiovascular events in psoriatic patients in relation to non-psoriatic controls (OR 1.28; 95% CI 1.18-1.38). It is suggested that the treatment of the inflammatory processes involved in the pathogenesis of both psoriasis and atherosclerosis may be beneficial in reducing the CV risk in psoriatic patients. Further in-depth investigations, including prospective studies, are needed to enable more effective management of psoriatic patients in the future.

Increased gene expression of Toll-like receptor 4 on peripheral blood mononuclear cells in patients with psoriasis

BACKGROUND

A role for the innate immune system in driving the autoimmune T cell cascade in psoriasis has been proposed. Toll-like receptors-(TLR)-2 and -4 play a role in inflammation, atherosclerosis, and their specific role in psoriasis remains unclear.

OBJECTIVE

To evaluate TLR2 and TLR4 gene expression levels in peripheral blood mononuclear cells from psoriatic patients.

METHODS

Changes in TLR2 ⁄ 4 gene expressions were evaluated using quantitative real-time reverse transcription polymerase chain reaction in peripheral blood mononuclear cells, from twenty-one patients with severe psoriasis, and analysed whether there was any correlation with cytokine plasma levels (T-helper 0-, T-helper 1-, T-helper 2- or regulatory T cells-type), or Calprotectin and with S100A8 and S100A9 gene expression levels. Eleven non-psoriatic healthy controls were analysed.

RESULTS

A clear increase in TLR4 gene expression was observed (3.84 ± 0.93, n = 21) together with a moderate increase in TLR2 expression (1.522 ± 0.31, n = 21). Both TLR4 and TLR2 gene expressions were significantly augmented in psoriatic patients compared with controls (all P < 0.001). Correlations between TLR2 and S100A9 gene expressions (r = 0.5145, P = 0.0170, n = 21); and between TLR2 expression and plasma interleukin-2 (r = 0.5667, P = 0.0074); interleukin-4 (r = 0.4766, P = 0.0289), interleukin-10 (r = 0.4355, P = 0.0484) and interleukin-13 (r = 0.4603, P = 0.0358), were found. When patients with atheroma plaque were considered (n = 7), both TLR4 (3.47 ± 0.99, P = 0.0156) and TLR2 (1.63 ± 0.31, P = 0.0156) expressions were significantly increased vs. controls and correlated with plasma TNF-a (r = 0.8929, P = 0.0123, in both cases).

CONCLUSION

Differential TLR4 ⁄ 2 gene expressions on psoriatic peripheral blood mononuclear cells and correlations with regulatory and ⁄ or proinflammatory cytokines and ⁄ or damage-associated molecular pattern molecule S100A9 emphasize innate immune response role in psoriasis.

Aortic arterial stiffness is a moderate predictor of cardiovascular disease in patients with psoriasis vulgaris

Psoriasis is associated with an increased risk of atherosclerosis. Endothelial dysfunction is the critical early step in the process of atherogenesis, and it is commonly investigated by measuring arterial stiffness. We aimed to investigate the relationship between arterial stiffness and high-sensitivity C-reactive protein (hsCRP) in patients with psoriasis. A total of 32 patients with psoriasis and 35 patients with other skin diseases were included in the study. The hsCRP levels and arterial stiffness measurements were compared. Arterial stiffness was significantly different between the 2 groups (P = .01). Arterial stiffness was not associated with the duration of the disease or the disease activity (P = .34 and .64, respectively). In patients with psoriasis, arterial stiffness correlated positively with age, sex, body mass index, diastolic blood pressure, and hsCRP level (P < .05). These findings provide further evidence of a link between inflammation, premature atherosclerosis, and psoriasis.

Serum methylglyoxal level and its association with oxidative stress and disease severity in patients with psoriasis

Psoriasis vulgaris (PV), a chronic inflammatory skin disease, is a condition of increased oxidative stress (OxS). However, interest related to oxidative and carbonyl stress damages to proteins, such as the formation of advanced glycation end products (AGEs) and their precursor molecule methylglyoxal (MG) has been modest. The objective of this study was to compare the systemic levels of OxS markers in patients with PV and healthy controls (Co) and to investigate their correlation with the serum level of MG. Total peroxide concentration (TPX) and total antioxidant capacity (TAC) were estimated by means of spectrophotometry. The TPX and TAC ratio was regarded as OxS index (OSI). MG level was determined using ELISA. Compared to Co, patients with PV had significantly increased blood levels of TPX (P < 0.0001), OSI (P < 0.0001), and MG (P = 0.01), and lower TAC levels (P < 0.0001). Increase in body mass index (BMI) appeared to contribute to this imbalance as TAC levels decreased with increasing BMI (r = -0.252, P < 0.01). Increased TPX concentration was associated with higher serum level of MG (r = 0.610, P = 0.004), the latter being positively correlated with psoriasis area and severity index (r = 0.577, P = 0.008). In performed multivariate regression analysis, TPX, TAC, and OSI were all significant predictors of MG level. Our study gave further proof of increased systemic psoriasis-related OxS. MG serum level, reflecting simultaneously OxS as well as carbonyl stress status, could be used as a marker of disease activity in clinical trials while looking for new systemic therapies for psoriasis.

Decreased plasma levels of clusterin in patients with psoriasis

INTRODUCTION AND OBJECTIVES

Psoriasis is a chronic inflammatory disease that has been linked to increased cardiovascular risk. The glycoprotein clusterin (apolipoprotein J) is a component of high-density lipoproteins and has a protective role in atherosclerosis. The aim of the present study was to evaluate the plasma levels of clusterin and the proinflammatory cytokine macrophage migration inhibitory factor (MIF) in patients with severe psoriasis, comparing groups of patients with different risks of cardiovascular disease.

MATERIAL AND METHODS

Twenty-one patients with severe psoriasis (psoriasis area severity index and body surface area>10) and 11 healthy controls with no dermatologic disease were studied. Cardiovascular risk factors were assessed according to the Adult Treatment Panel (ATP) III criteria. Subclinical carotid atheromatosis was assessed by Doppler ultrasonography of the carotid arteries. Plasma clusterin and MIF levels were measured by enzyme-linked immunosorbent assay.

RESULTS

ATP-III criteria for metabolic syndrome were met by 47% of the patients, and 33% had carotid atheromatous plaque. Mean (SD) clusterin plasma levels were significantly lower in patients with psoriasis compared with controls (81.39 [27.30] μg/mL for the 21 patients vs 117 [21.6] μg/mL for the 11 controls; P=.0017). MIF plasma levels (ng/ml) were significantly higher in patients with atheromatous plaque compared with controls (53.22 [29.02] for the 6 patients with plaque vs 34.21 [9.65] for the 11 controls; P=.0394).

CONCLUSIONS

The decreased plasma levels of clusterin in psoriatic patients suggested an association with the disease and might be an indicator of systemic inflammatory activity. Increased levels of MIF appear to be associated with cardiovascular risk factors and carotid atheromatous plaque.

Co-morbidities in psoriasis: a hospital-based case-control study

BACKGROUND

Recent researches show that psoriasis is frequently associated with systemic co-morbidities.

OBJECTIVES

This study aimed to identify possible associated co-morbidities in psoriatic patients stratified by age and sex.

METHODS

In this retrospective hospital-based case-control study, patients diagnosed as psoriasis at the Kaohsiung Veterans General Hospital in Taiwan between January 2008 and December 2009 were enrolled as cases and classified into severe and mild based on their use of systemic therapy. The controls were the patients without psoriasis matched the cases in 1 : 1 ratio with same birth year, sex and calendar date. Odds ratios (ORs) and 95% confidence intervals (CIs) from the conditional logistic regression method were used to assess the risk of co-morbidities between psoriatic and non-psoriatic patients.

RESULTS

A total of 447 cases and 447 matched controls, with mean age of 51.3 ± 18.3 years and male-to-female ratio of 2.17 : 1 were enrolled. The ratio of mild-to-severe was 3.5 : 1. Compared with non-psoriatic patients, psoriatic patients had significantly higher OR of hypertension (1.85), diabetes mellitus (2.88) and obesity (1.66). Among those aged ≥51 years old, there was significant risk in male psoriatic patients with ischaemic and hypertensive heart disease (IHHD) (OR = 2.167) after eliminating female IHHD psoriatic patients (OR = 0.125). Psoriasis was significantly negatively associated with cancers (OR = 0.267). Psoriasis patients often had the usual drinking habit (OR = 2.23) and seldom had an occasional drinking habit (OR = 0.25).

CONCLUSIONS

Psoriasis is strongly associated with hypertension, diabetes mellitus and obesity. The association between psoriasis and IHHD, stroke, cancers, smoking and alcohol habits warrant more investigation.

Psoriasis and risk of nonfatal cardiovascular disease in U.S. women: a cohort study

BACKGROUND

Psoriasis has been linked to cardiovascular comorbidities in cross-sectional studies, but evidence regarding the association between psoriasis and incident cardiovascular disease (CVD) is limited.

OBJECTIVES

To make a prospective evaluation of the association between psoriasis and risk of incident nonfatal CVD.

METHODS

Participants (n = 96, 008) were included from the Nurses' Health Study II, and followed for 18 years. Information on physician-diagnosed psoriasis was obtained by self-report and diagnosis was confirmed by supplementary questionnaires. We included 2463 individuals with self-reported psoriasis and a subsample of 1242 with validated psoriasis. The main outcome was incident nonfatal CVD events [nonfatal myocardial infarction (MI) and nonfatal stroke], ascertained by biennial questionnaires and confirmed.

RESULTS

During 1 709 069 person-years of follow-up, 713 incident nonfatal CVD events were confirmed. Psoriasis was associated with a significantly increased multivariate-adjusted hazard ratio (HR) of nonfatal CVD, 1·55 [95% confidence interval (CI): 1·04-2·31]. HRs for nonfatal MI and stroke were 1·70 (95% CI: 1·01-2·84) and 1·45 (95% CI: 0·80-2·65), respectively. The association remained consistent in a sensitivity analysis of confirmed psoriasis (HR: 2·06, 95% CI: 1·31-3·26). For individuals with concomitant psoriatic arthritis, the risk of nonfatal CVD was even higher (HR: 3·47; 95% CI: 1·85-6·51). Women diagnosed with psoriasis at < 40 years of age or with duration of psoriasis ≥ 9 years had substantial elevations in CVD risk: HR: 3·26 (95% CI: 1·21-8·75) and 3·09 (95% CI: 1·15-8·29), respectively.

CONCLUSIONS

Psoriasis is an independent predictor for nonfatal CVD among women, with particularly high risk for those with longer duration of psoriasis and concomitant psoriatic arthritis.

Cardiovascular comorbiditiy in psoriasis

The chronic inflammatory nature of psoriasis is also thought to predispose patients to other diseases with an inflammatory component, the most notable being cardiovascular and metabolic (cardiometabolite) disorders. This concept is supported by studies showing that psoriasis is associated with cardiovascular risk factors like diabetes, obesity, hypertension, dyslipidemia, smoking and diseases including MI. Given the increased prevalence of cardiovascular co morbidities in patients, dermatologists treating psoriasis need to approach the disease as a potentially multisystem disorder and must alert these patients to the potentially negative effects of their disease.

Chronic skin-specific inflammation promotes vascular inflammation and thrombosis

Patients with psoriasis have systemic and vascular inflammation and are at increased risk for myocardial infarction, stroke, and cardiovascular death. However, the underlying mechanism(s) mediating the link between psoriasis and vascular disease is incompletely defined. This study sought to determine whether chronic skin-specific inflammation has the capacity to promote vascular inflammation and thrombosis. Using the KC-Tie2 doxycycline-repressible (Dox-off) murine model of psoriasiform skin disease, spontaneous aortic root inflammation was observed in 33% of KC-Tie2 compared with 0% of control mice by 12 months of age (P=0.04) and was characterized by the accumulation of macrophages, T lymphocytes, and B lymphocytes, as well as by reduced collagen content and increased elastin breaks. Importantly, aortic inflammation was preceded by increases in serum tumor necrosis factor-α, IL-17A, vascular endothelial growth factor, IL-12, monocyte chemotactic protein-1, and S100A8/A9, as well as splenic and circulating CD11b(+)Ly-6C(hi) pro-inflammatory monocytes. Doxycycline treatment of old mice with severe skin disease eliminated skin inflammation and the presence of aortic root lesion in 1-year-old KC-Tie2 animals. Given the bidirectional link between inflammation and thrombosis, arterial thrombosis was assessed in KC-Tie2 and control mice; mean time to occlusive thrombus formation was shortened by 64% (P=0.002) in KC-Tie2 animals; and doxycycline treatment returned thrombosis clotting times to that of control mice (P=0.69). These findings demonstrate that sustained skin-specific inflammation promotes aortic root inflammation and thrombosis and suggest that aggressive treatment of skin inflammation may attenuate pro-inflammatory and pro-thrombotic pathways that produce cardiovascular disease in psoriasis patients.

Obesity and the skin

Obesity is a serious global health problem, perhaps the biggest public health issue of our times. Excess body weight may be a factor in carcinogenesis in general, as well as contributing to the pathogenesis of metabolic, cardiovascular and musculoskeletal disorders. Obesity also has many cutaneous features, which form the basis for this review article. Many of these clinical entities are common to the majority of obese patients, e.g. striae distensae, plantar hyperkeratosis and an increased risk of skin infections. However, it may also be associated with poor wound healing, malignant melanoma and an increased risk of inflammatory dermatoses, such as psoriasis, as well as some rarer disorders. Therapeutic interventions for obesity, whether over-the-counter, prescription medicines or surgical interventions, are increasingly commonplace. All of these treatment modalities potentially have dermatological side-effects too.

[Genetics of contact allergy]

The genetics of contact allergy (CA) is still only partly understood, despite decades of research. This might be due to inadequately defined phenotypes used in the past. Therefore we suggested studying an extreme phenotype, namely, polysensitization (sensitization to 3 or more unrelated allergens). Another approach to unravel the genetics of CA has been the study of candidate genes. In this review, we summarize studies on the associations between genetic variation (e.g. SNPs) in certain candidate genes and CA. The following polymorphisms and mutations were studied: (1) filaggrin, (2) N-acetyltransferase (NAT1 and 2), (3) glutathione-S-transferase (GST M and T), (4) manganese superoxide dismutase, (5) angiotensin-converting enzyme (ACE), (6) tumor necrosis factor (TNF), and (7) interleukin-16 (IL16). The polymorphisms of NAT1/2, GST M/T, ACE, TNF, and IL16 were shown to be associated with an increased risk of CA. In one of our studies, the increased risk conferred by the TNF and IL16 polymorphisms was confined to polysensitized individuals. Other relevant candidate genes may be identified by studying diseases related to CA in terms of clinical symptoms, a more general pathology (inflammation) and possibly an overlapping genetic background, such as irritant contact dermatitis.

Genetic factors in contact allergy--review and future goals

The genetics of contact allergy are still only partly understood, despite decades of research; this might be a consequence of inadequately defined phenotypes used in the past. A recommendation is to study an extreme phenotype, namely, polysensitization (sensitization to three or more unrelated allergens). Another approach to unravel the genetics of contact allergy is the study of candidate genes. In this review, we summarize studies on the associations between genetic variation (e.g. single-nucleotide polymorphisms) in certain candidate genes and contact allergy. Polymorphisms and mutations affecting the following proteins were studied: (i) filaggrin; (ii) N-acetyltransferase (NAT) 1 and 2; (iii) glutathione-S-transferase (GST) M and T; (iv) manganese superoxide dismutase; (v) angiotensin-converting enzyme (ACE); (vi) tumour necrosis factor (TNF); and (vii) interleukin-16 (IL-16). The polymorphisms of NAT1, NAT2, GSTM, GSTT, ACE, TNF and IL-16 were shown to be associated with an increased risk of contact allergy. In one of our studies, the increased risk conferred by the TNF and IL-16 polymorphisms was confined to polysensitized individuals. Other relevant candidate genes may be identified by studying diseases related to contact allergy in terms of clinical symptoms, a more general pathology (inflammation), and possibly an overlapping genetic background, such as irritant contact dermatitis.

Common oral mucosal diseases, systemic inflammation, and cardiovascular diseases in a large cross-sectional US survey

BACKGROUND

Inflammation of the gingivae (periodontitis) has been associated with raised serum biomarkers of inflammation, sub-clinical markers of atherosclerosis, and increased risk of and/or mortality from cardiovascular disease (CVD). There remain little information regarding the association between other common oral inflammatory disease, systemic inflammation, and CVD. The objective of the study was to assess the association between common oral mucosal diseases, circulating markers of inflammation, and increased prevalence of CVD in a cross-sectional survey of a nationally representative sample of the noninstitutionalized civilians in the United States.

METHODS

Data for this study are from 17,223 men and women aged ≥ 17 years who received oral examination as part of the Third National Health and Nutrition Examination Survey. The primary and secondary outcome measures were the association of oral mucosal diseases with raised serum levels of C-reactive protein/fibrinogen and increased prevalence of CVD, respectively. Adjustment for common confounding factors was performed.

RESULTS

Having oral mucosal disease was associated with systemic inflammation (serum levels of C-reactive protein ≥ 10 mg/dL) (odds ratio 1.41, 95% CI 1.02-1.94). Individuals with oral mucosal disease were 1.36 times (95% CI 1.02-1.80) more likely to have history of myocardial infarction and 1.33 times (95% CI 1.03-1.71) more likely to report angina than unaffected individuals. All associations were independent of common confounding factors.

CONCLUSIONS

This is the first study to suggest that common oral mucosal diseases are independently associated with raised markers of systemic inflammation and history of CVD.

Pathogenic mechanisms shared between psoriasis and cardiovascular disease

Psoriasis is associated with an increased risk of cardiovascular disease, a hallmark of which is atherosclerosis. The objective of this study was to review the pertinent literature and highlight pathogenic mechanisms shared between psoriasis and atherosclerosis in an effort to advocate early therapeutic or preventive measures. We conducted a review of the current literature available from several biomedical search databases focusing on the developmental processes common between psoriasis and atherosclerosis. Our results revealed that the pathogenic mechanisms shared between the two diseases converged onto "inflammation" phenomenon. Within the lymph nodes, antigen-presenting cells activate naive T-cells to increase expression of LFA-1 following which activated T-cells migrate to blood vessel and adhere to endothelium. Extravasation occurs mediated by LFA-1 and ICAM-1 (or CD2 and LFA-3) and activated T-cells interact with dendritic cells (and macrophages and keratinocytes in psoriasis or smooth muscle cells in atherosclerosis). These cells further secrete chemokines and cytokines that contribute to the inflammatory environment, resulting in the formation of psoriatic plaque or atherosclerotic plaque. Additionally, some studies indicated clinical improvement in psoriasis condition with treatment of associated hyperlipidemia. In conclusion, therapeutic or preventive strategies that both reduce hyperlipidemia and suppress inflammation provide potentially useful approaches in the management of both diseases.

Association between Psoriasis and Cardiovascular Risk Factors in Korean Patients

BACKGROUND

Previous studies have shown a possible association between psoriasis and cardiovascular risk factors.

OBJECTIVE

We wanted to study the association between psoriasis and cardiovascular risk factors, including metabolic syndrome.

METHODS

We determined the relationship of psoriasis with the cardiovascular risk factors, metabolic syndrome and cardiovascular disease. For the proper level of low-density lipoprotein (LDL) cholesterol, we calculated the proportion of psoriasis patients who needed lifestyle changes or drug therapy.

RESULTS

This study included 197 patients with psoriasis and 401 controls. We found a higher prevalence of metabolic syndrome (17.8%, p=0.021), cardiovascular disease (4.6%, p=0.044), hypertension (32.5%, p=0.000) and hyperlipidemia (22.3%, p=0.025) in patients with psoriasis, as compared with that of the controls. To maintain proper LDL levels, 25.3% of the psoriasis patients needed lifestyle changes and 11.7% needed drug therapy.

CONCLUSION

Our results demonstrate a possible association between psoriasis and cardiovascular diseases and their risk factors (metabolic syndrome, hypertension and hyperlipidemia) in Korean patients. We also demonstrated that a substantial portion of patients with psoriasis need lifestyle changes and drug therapy to prevent cardiovascular events. Further studies will be necessary to establish the association and causality between psoriasis and the cardiovascular risk factors.

Psoriasis and cardiovascular disease

Current epidemiological data support the association between psoriasis and cardiovascular (CV) risk, in apparent correlation with psoriasis severity. Although less unanimously, evidence of an increased prevalence of CV diseases among psoriasis patients has been reported, including ischemic heart disease, cerebrovascular, peripheral vascular and heart structural disorders. In particular, various studies showed a correlation between psoriasis and major CV events (i.e., myocardial infarction, stroke), while others investigated subclinical changes of blood vessels, such as intima-media thickness increase, arterial stiffness and coronary artery calcification. A series of different mechanisms, like traditional CV risk or iatrogenic risk factors, inflammation, hemostasis dysregulation, hyperhomocysteinemia, and shared genetic susceptibility, are thought to underlie this epidemiological association. Among these elements, inflammation and its related cytokine milieu, including Th1-mediated response and Th17/Treg imbalance, C reactive protein and the newly implicated osteopontin are considered to play a primary role, even if yet to be fully understood.

Psoriasis and systemic inflammation: underdiagnosed enthesopathy

Our understanding of the pathogenesis of psoriasis is changing rapidly and the traditional view that it is a disease limited to the skin continues to be challenged. Indeed, there is convincing evidence that psoriasis patients have a higher prevalence of comorbid disease, particularly cardio-metabolic disorders and psoriatic arthritis (PsA). The results of recent investigations into psoriasis and cardiovascular or metabolic comorbidities provide increasing evidence for a possible shared pathogenic mechanism for these disorders, linked by an underlying chronic systemic inflammatory state. This highlights the importance of investigating associated comorbidities beyond skin manifestations. Psoriatic arthritis is a chronic inflammatory arthropathy that can occur in association with psoriasis and most commonly affects the distal joints in the hands and feet. Skin lesions precede arthritic symptoms in approximately 75% of cases; typically, the cutaneous manifestations of the disease develop 10 years prior to the onset of joint symptoms. This disease course, therefore, provides a potential window of opportunity to initiate effective and aggressive therapies to prevent long-term damage, if symptoms of PsA can be detected early. One of the major features of PsA is enthesitis, yet clinically asymptomatic cases of entheseal abnormalities are likely to go undiagnosed. This concept was evaluated in a prospective study in which entheseal changes in clinically asymptomatic psoriasis patients were compared with findings from a control group. Ultrasonography detected a significantly higher incidence of entheseal abnormalities in patients with psoriasis, despite the absence of clinical symptoms of arthropathy. Ongoing monitoring of these patients has also revealed that a higher baseline score for enthesitis may be associated with a more severe psoriasis outcome. These findings demonstrate that detecting early signs of PsA in asymptomatic patients with psoriasis may have the potential to positively influence disease prognosis and ultimately clinical outcome. Dermatologists can, therefore, play a key role in the early detection and management of PsA.

More than skin deep: atherosclerosis as a systemic manifestation of psoriasis

There is now growing evidence that psoriasis, like other inflammatory diseases such as rheumatoid arthritis and systemic lupus erythematosus, is a systemic disorder that is associated with enhanced atherosclerosis and risk of coronary artery disease. Here we summarize the available epidemiological evidence for this association and analyse pathogenic features that are common to psoriasis and atherosclerosis. Further prospective studies are urgently needed to extend knowledge of the risk of cardiovascular morbidity and mortality in patients with psoriasis and to confirm the degree to which treatment of psoriasis reduces this risk. Nevertheless, existing data are sufficient to indicate that severe psoriasis should be more widely recognized as a potential risk factor for cardiovascular disease and should be considered with the established factors when formulating strategies for the management of cardiovascular risk.