Psoriasis and sport: a new ally?

Risk Factors for Psoriasis Flares: A Narrative Review

Psoriasis is a chronic inflammatory cutaneous disease with multifactorial pathogenesis involving both genetic and environmental factors as well as the innate and acquired immune response. Several triggering factors may exacerbate or worsen the disease. In this context, we performed a review manuscript with the aim of investigating current literature on psoriasis risk factors, also showing possible mechanisms by which they act on psoriasis. Globally, risk factors can be divided in classic risk factors (eg, mechanical stress, infections and dysbiosis of the skin, common drugs, environment and pollution, lifestyle, psychological stress, hormonal and metabolic alterations) which have long been known to be responsible for worsening and/or reoccurrence of psoriatic manifestations, and emerging risk factors (eg, biological drugs, immunotherapy for oncologic disease, Covid-19, and vaccines) defined as those newly identified risk factors. Accurate patient information and monitoring of risk factors as well as planned follow-ups may help to prevent and treat the worsening of psoriasis and consequently improve the quality of life of psoriatic patients.

Tolerability of low to moderate biomechanical stress during leisure sport activity in patients with psoriasis and psoriatic arthritis

OBJECTIVES

To assess the impact of low to moderate biomechanical stress on entheses in patients with psoriasis and psoriatic arthritis (PsA).

METHODS

We conducted a prospective interventional study on a cohort of psoriasis and PsA patients who underwent a 60 min badminton training session. Pain assessment by Visual Analogue Scale (VAS), physical examination of 29 entheses (SPARCC, LEI, MASES) and bilateral ultrasound at the lateral humeral epicondyle, inferior patellar pole and Achilles tendon were performed before and after training. Ultrasound changes were assessed using the OMERACT scoring system. A follow-up assessment of pain and adverse events was performed at 1 week.

RESULTS

Sixteen patients were included (n=7 PsA; n=9 psoriasis) and 196 entheseal ultrasound scans were acquired. At baseline, median VAS pain (IQR) was 0.5 cm (0-2.3) and the total number of tender entheses was 12/464. Mean (min; max) Disease Activity Index for Psoriatic Arthritis was 6.1 (0.8; 19) and 5/7 PsA patients had an Minimal Disease Activity status. After training, no significant change in VAS pain (0.0 cm (0.0-2.0)) nor in tender entheses (13/464) emerged. Four patients (n=2 PsA, n=2 psoriasis) developed a grade-1 power Doppler-signal at six entheses, which, however, remained non-tender. At 1 week, median VAS pain remained stable (0.0 cm (0.0-3.0); p>0.05) and only one participant with active PsA at baseline reported increased arthralgias in three joints.

CONCLUSIONS

Low to moderate physical strain, as in the context of leisure sport activity, seems well tolerated in psoriatic patients without increases in tenderness, pain and ultrasound-proven inflammation. Evidence-based recommendations for physical activity in PsA are direly needed and larger controlled studies should be conducted to define safe exercise thresholds.

The Role of Diet in Children with Psoriasis: Emerging Evidence and Current Issues

Psoriasis is an immune-mediated inflammatory systemic disease with skin tropism and chronic relapsing course; it is associated with an increased cardiovascular risk and with many metabolic comorbidities, emerging during childhood in 22–33% of cases. Diet influences the presentation and the clinical course of inflammatory diseases, including psoriasis; in particular, it was shown that a Mediterranean, gluten-free, or low-calorie diet may positively affect disease control in adult patients with psoriasis and adequate pharmacological therapy. These three dietary regimens may play a role also in children with psoriasis. It has been demonstrated that pediatric psoriasis is associated with psychological stress, celiac disease, and obesity, which may be positively influenced by these dietary regimens, respectively. Therefore, the expertise of multiple health figures (gastroenterologists, nutritionists, pediatricians, dermatologists) is required to plan a tailor-made dietary strategy, ensuring good growth, through an adequate intake of essential micro- and macronutrients and, at the same time, impacting the pro-inflammatory biochemical profile and on the associated cardiovascular risk of psoriasis disease.

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

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

The Impact of Diet and Physical Activity on Psoriasis: A Narrative Review of the Current Evidence

Psoriasis is an inflammatory disease with strong genetic links and numerous features of autoimmunity that are also influenced by environment and lifestyle, including nutritional factors and physical activity (PA), with regards to the condition of patients. Recent reports in the field of nutrigenomics indicate a significant impact of nutrients in modulating microRNAs. However, few studies have evaluated the effect of nutritional systems and PA on treating psoriasis. This narrative review updates information regarding the current dietary recommendations for individuals with psoriasis and discusses the role of diet and PA in psoriasis prevention and treatment. Application of nutrigenetics in psoriasis therapy is also discussed. The PubMed and Google Scholar databases were searched using the MeSH terms for "nutrigenomics", "dietetics", "diet therapy", "diet", "physical activity", and "exercise" in conjunction with the MeSH terms for "psoriasis" and "dermatology". Evidence has shown that patients with psoriasis should have a personalized anti-inflammatory diet. Psoriasis patients are less physically active; most performed exercises of low-to-moderate intensity and were less likely to undertake regular exercise. Identifying nutrigenomic discoveries and the current lifestyle interventions associated with psoriasis can help physicians and physical therapists develop educational programs to manage and protect against the disease.

The Essential Role of IL-17 as the Pathogenetic Link between Psoriasis and Metabolic-Associated Fatty Liver Disease

Interleukin 17 (IL-17) is an effector cytokine that plays a key role in the pathogenesis of both psoriasis and metabolic-associated fatty liver disease (MAFLD), a condition that is more prevalent and severe in patients with psoriasis. In liver inflammation, IL-17 is mainly produced by CD4+ T (TH17) and CD8+ T cells (Tc17), although numerous other cells (macrophages, natural killer cells, neutrophils and Tγδ cells) also contribute to the production of IL-17. In hepatocytes, IL-17 mediates systemic inflammation and the recruitment of inflammatory cells to the liver, and it is also implicated in the development of fibrosis and insulin resistance. IL-17 levels have been correlated with progression from MAFLD to steatohepatitis, cirrhosis, and even hepatocellular carcinoma. Clinical trials have shown that inhibiting IL-17A in patients with psoriasis could potentially contribute to the improvement of metabolic and liver parameters. A better understanding of the key factors involved in the pathogenesis of these chronic inflammatory processes could potentially lead to more efficient treatment for both psoriasis and MAFLD, and help to develop holistic strategies to improve the management of these patients.

The Role of Lifestyle and Nutrition in Psoriasis: Current Status of Knowledge and Interventions

Extrinsic environmental factors, including patient lifestyle (alcohol intake, smoking, stress, sleep disturbances, and sedentary habit), diet and single nutrients intake may affect psoriasis clinical presentation, severity, and course. All English language articles dealing with psoriasis and lifestyle factors or diet gathered by an extensive PubMed search were carefully examined in order to explore their impact on the disease. Current authoritative knowledge confirms that low‐calories, Mediterranean, and protein restricted/vegetarian diets may be beneficial. Psoriatic patients are also recommended to engage regular physical activity, to avoid alcohol intake and to consume fish rich in omega‐3 polyunsaturated fatty acids, as well as fruit and vegetables. Prebiotics and probiotics may also provide potential benefit, whereas vitamin D supplementation and gluten‐free diet are useful in selected cases only. Changing of dietary and lifestyle habits alone does not replace conventional treatment, but must be considered as an adjuvant. Physicians may play a crucial role, by adequately acknowledging psoriatic patients on the advantages of proper lifestyle and diet habits as well as providing clues to reliable sources of dietary advice.

Clinical and nutritional management of very-low-calorie ketogenic diet (VLCKD) in patients with psoriasis and obesity: a practical guide for the nutritionist

Psoriasis is an immune-mediated inflammatory skin disease associated with multiple comorbidities. Considered one of the most common inflammatory skin diseases among the general population, it not only affects the skin, but also negatively impacts other organs and joints. In addition, psoriasis has been associated with several chronic cardio-metabolic diseases such as obesity, which would seem to be (i) a risk factor for the onset of psoriasis and (ii) a worsening factor of the severity of the disease. Weight loss appears to improve severity in overweight patients. Recently proposed as an obesity management nutritional strategy, the very-low-calorie ketogenic diet (VLCKD) has demonstrated significant effects in reducing inflammatory processes. In the current review, we describe the evidence available on psoriasis and VLCKD, and provide a practical guide to the prescription of VLCKD in the different phases, evaluation and management of possible adverse events, and the importance of physical activity as a lifestyle modification to reduce psoriasis and associated comorbidities. Randomized control trials are, however, necessary to determine the most effective VLCKD protocol for patients with obesity and psoriasis, optimal protocol duration, composition of micronutrients and macronutrients, choice of special supplements, and management of carbohydrate reintroduction.

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.

Guselkumab is efficacious and safe in psoriasis patients who failed anti-IL17: a 52-week real-life study

BACKGROUND

Interleukin (IL)23/Th17 axis is the leading actor of psoriasis pathogenesis. Guselkumab is the first anti-IL23 approved for psoriasis. Anti-IL23 and anti-IL17 partially share their therapeutic target currently appearing as the most efficacious available psoriasis treatments. Real-life data on guselkumab performance in anti-IL17 failure patients are scant.

METHODS

A 52-week real-life single-center retrospective study was performed to evaluate the long-term efficacy and safety of guselkumab in patients who previously failed anti-IL17.

RESULTS

A total of 44 patients were enrolled (28 male, 63.6%; mean age 59.0 ± 10.2years). A statistically significant improvement of Psoriasis Area Severity Index (PASI) and Body Surface Area (BSA) was assessed at each follow-up (PASI decreased from 13.9 ± 8.1 to 0.9 ± 0.7 at week52 while BSA from 24.3 ± 19.6 to 1.3 ± 1.4, p < 0.001). Nail Psoriasis Severity Index (NAPSI) improvement was collected as well, even if being statistically significative only at week28 and thereafter [2.9 ± 6.2 at baseline, 0.9 ± 1.5 at week28, (p < 0.05)]. Only 3(6.8%) patients discontinued guselkumab due to secondary inefficacy. No cases of serious Adverse Events were assessed.

CONCLUSION

Our real-life study confirmed the efficacy and safety of guselkumab in daily clinical practice suggesting it as a valuable weapon also in psoriasis patients who previously failed anti-IL17 treatments.

Non-Alcoholic Fatty Liver Disease (NAFLD) in Patients with Psoriasis: A Review of the Hepatic Effects of Systemic Therapies

There is increasing interest in the association between psoriasis and non-alcoholic fatty liver disease (NAFLD), which is a prevalent liver disease characterized by excessive fat storage and inflammation that can progress to fibrosis and cancer. Patients with psoriasis have a two-fold higher risk to develop NAFLD and a higher risk to progress to more severe liver disease. Psoriasis and NAFLD share common risk factors such as smoking, alcohol consumption, and the presence of metabolic syndrome and its component disorders. In addition, both psoriasis and NAFLD hinge upon a systemic low-grade inflammation that can lead to a vicious cycle of progressive liver damage in NAFLD as well as worsening of the underlying psoriasis. Other important shared pathophysiological pathways include peripheral insulin resistance and oxidative stress. NAFLD should receive clinical awareness as important comorbidity in psoriasis. In this review, we assess the recent literature on the epidemiological and pathophysiological relationship of psoriasis and NAFLD, discuss the clinical implications of NAFLD in psoriasis patients, and summarize the hepatotoxic and hepatoprotective potential of systemic psoriasis therapies.

Psoriatic arthritis and physical activity: a systematic review

INTRODUCTION

The positive effects of physical activity in both rheumatoid arthritis and ankylosing spondylitis have been proven, but no clear data is yet published regarding psoriatic arthritis (PsA). The aims of this study were (i) to assess the level of physical activity (PA) in these patients and (ii) to review the effects of PA on articular disease, extra articular symptoms, and overall well-being.

METHODS

The research strategy was performed on Pubmed, Cochrane, PEDro databases using the following keywords: "psoriatic arthritis AND physical activity" without restriction. The PRISMA methodology was used to select and analyze articles. We searched for all studies published online and in English before January 2021.

RESULTS

A total of 319 studies were retrieved by our search but only 13 could be included. Two reports showed that 17 and 68% of patients reported practicing regularly physical activity. Exercise improved the BASDAI (Bath Ankylosing Spondylitis Disease Activity Index), the general symptoms (pain and fatigue), and the quality of life. Muscle strength and some of cardiovascular comorbidities were also improved. While the studies concerning the risk of enthesitis or flare induced by physical activity are conflicting, recent clinical trials did not mention any adverse event. Finally, rehabilitation programs were associated with a reduction mainly of pain and fatigue.

CONCLUSION

Studies show clear beneficial effects of exercise in PsA on disease activity, on well-being, and on comorbidities, and they seem to outweigh the risk of enthesitis induced by mechanical stress. Further investigations are necessary to confirm these results and to precise the modalities of exercise. Key Points • Psoriatic arthritis patients have a sedentary lifestyle • Physical activity has beneficial effects on disease activity, well-being and reduced some cardiovascular risk factor in psoriatic arthritis • Risk of enthesitis and flares is low with exercise in psoriatic arthritis.

Mutual Influence of Psoriasis and Sport

The link between psoriasis and sport is a controversial issue. The topic has been poorly investigated, and nowadays there are many unsolved questions, dealing with the role of psoriasis in influencing the sporting habits of patients and, vice versa, the impact of sport activity on course, severity and extent of the disease, with particular regard to the indirect benefits on cardiovascular risk and metabolic syndrome. Moreover, the role of physical activity on patients’ quality of life and the potential limitations on physical activity due to joint involvement have not been well elucidated until now. In this narrative review we will try to provide answers to these queries.

Optimal Management of Plaque Psoriasis in Adolescents: Current Perspectives

The skin is at the interface between the body and its environment and is therefore at the center of adolescent concerns during this period of identity formation and increased awareness of body image issues, and stigmatization. Managing an adolescent with psoriasis involves managing the illness and the individual during their transition from being an older child to a young adult. In addition to ensuring that the patient adheres to treatments and is engaged with the therapeutic strategy, dermatologists may also need to manage issues linked to unspoken suffering or conflicts between the adolescent and their parents, who are often present during consultations. The impact of psoriasis on the social interactions, school life and sexuality of the patients, together with the influence of the internet and social networks, also have to be taken into account. In this review, we summarize the epidemiologic, clinical, and therapeutic data available on psoriasis in adolescents, and propose specific management strategies, adapted to the 21st century, for patients in this age group.

May COVID-19 outbreaks lead to a worsening of skin chronic inflammatory conditions?

The emergence of the novel betaCoronavirus has raised serious concerns due to the virus rapid dissemination worldwide. Many areas throughout the world are now experiencing the COVID 19 outbreaks with government and policy authorities taking many aggressive isolation or restriction measures, drastically reducing also patient's visits and limiting only to the most urgent ones such as oncological visits or emergencies. Several studies have demonstrated a relationship between increased weight, obesity, diabetes, hypertension and inflammatory skin diseases. Furthermore, weight loss interventions have been shown to improve psoriasis, as well as hidradenitis suppurativa, and increase responsiveness to treatment of this conditions. We suppose that due to aggressive isolation or restriction measures, in the next future dermatologist will face with a common worsening of chronic skin inflammatory conditions due to reduced physical activities, increased intake of calories with the derived increase body weight and always more frequent treatment discontinuation. It is time to start potential preventive strategies which could limit the expected negative impact of COVID-19 related quarantine on skin diseases.

Endocrinological disorders and inflammatory skin diseases during COVID-19 outbreak: a review of the literature

INTRODUCTION

In the next future, dermatologists, endocrinologist and physicians may cope with the impact of extent SARS-CoV-2 (COVID-19) infection over chronic inflammatory skin diseases and their treatment. COVID-19 pandemic obliged many countries to impose social restrictions, resulting in the need to adapt daily lifestyle habits and working activities. These changes have drastically reduced physical activity and social interactions, with the possible increase of anxiety, eating disorders and weight gain.

EVIDENCE ACQUISITION

We searched for relevant studies (trials, real-life studies and case reports, meta-analysis, pooled data analysis, reviews) on endocrine disorders and inflammatory skin diseases. The database used was PubMed. The studies included were those published in the English language between January 1, 2018 and May 5, 2020.

EVIDENCE SYNTHESIS

Several studies have been previously showed the association of overweight and obesity, with the metabolic syndrome and insulin-resistance. It has been demonstrated how these conditions correlate with the worsening of such chronic inflammatory skin diseases, such as psoriasis, hidradenitis suppurativa and acne. Many evidences suggest an important role of adipose tissue in the production of pro-inflammatory cytokines (Leptin, adiponectin, TNFα, IL-6, MCP-1, PAI-1), involved in the pathogenesis and the exacerbations of these skin diseases. In addition, we should expect an increasing incidence rate of hypovitaminosis D in the next future due to reduced sun exposure caused by isolation at home and missed holidays. Scientific evidences already show the important immunomodulating role of vitamin D in inflammatory skin diseases.

CONCLUSIONS

Our study pays attention on medium-long term effects of COVID-19 outbreak on inflammatory skin disorders, due to the lifestyle changes. In such context this review considers how a multidisciplinary approach, involving dermatologists, nutritionists and endocrinologists, may lead to a better management of dermatologic patients.

Very low-calorie ketogenic diet (VLCKD) in patients with psoriasis and obesity: an update for dermatologists and nutritionists

Psoriasis is a chronic skin immune-mediated disease with systemic pro-inflammatory activation; both genetic and lifestyles factors contribute to its pathogenesis and severity. In this context, nutrition plays a significant role, per se, in psoriasis' pathogenesis. Obesity is another important risk factor for psoriasis, and weight reduction may improve psoriasis' clinical severity. The excess body weight, particularly visceral fat mass, can affect both drug's pharmacokinetics and pharmacodynamics. Therefore, psoriasis and obesity share a certain degree of synergy, and the chronic inflammatory state represents the basis of this vicious cycle. Evidence reported that nutrition has different impact on the clinical severity of psoriasis, though some specific diets have been more investigated in clinical studies compared to others. Diets with systemic anti-inflammatory properties seem to have a higher effect on improving the clinical severity of psoriasis. Of interest, very-low-calorie ketogenic diet (VLCKD), through the production of ketone bodies, has been associated with both a significant reduction of body weight and inflammatory state. VLCKD leading to both weight loss and reduction of systemic inflammation may decrease the exacerbation of the clinical manifestations or even it may block the trigger of psoriatic disease. This dietary pattern could represent a potential first-line treatment in psoriatic patients with obesity. The review aims to summarize the current evidence regarding VLCKD and psoriasis with specific reference to antioxidant and anti-inflammatory effects of this dietary pattern.

Psoriasis and Its Impact on In-Hospital Outcome in Patients Hospitalized with Acute Kidney Injury

BACKGROUND

Psoriasis is a chronic inflammatory disease which affects the body far beyond the skin. Whereas there is solid evidence that chronic skin inflammation in psoriasis drives cardiovascular disease, the impact on renal impairment and acute kidney injury (AKI) is still unclear. We aimed to analyze the impact of psoriasis on the in-hospital outcome of patients hospitalized with AKI.

METHODS

In this retrospective database study, we investigated data on characteristics, comorbidities, and in-hospital outcomes for all hospitalized patients with AKI stratified for concomitant psoriasis, which were collected by the Federal Office of Statistics in Germany between 2005 and 2016.

RESULTS

Among the 3,162,449 patients treated for AKI in German hospitals between 2005 and 2016, 11,985 patients (0.4%) additionally suffered from psoriasis. While the annual number of AKI patients with psoriasis increased significantly from 485 cases (4.0%) in 2005 to 1902 (15.9%) in 2016 (p < 0.001), the in-hospital mortality decreased substantially (from 24.9% in 2005 to 17.4% in 2016; p < 0.001). AKI patients with concomitant psoriasis were younger (70 (IQR; 60-78) vs. 76 (67-83) years; p < 0.001) and were more often treated with dialysis (16.3% vs. 13.6%, p < 0.001). Presence of psoriasis in AKI patients was associated with reduced prevalence of myocardial infarction (OR 0.62; p < 0.001), stroke (OR 0.85; p = 0.013), and in-hospital mortality (OR 0.75; p < 0.001).

CONCLUSIONS

AKI patients with psoriasis were hospitalized in median 6 years earlier than those without. Despite younger age, we detected higher use of kidney replacement therapy in patients with psoriasis, indicating a more severe course of AKI. Our findings might improve management of these patients and contribute evidence for extracutaneous, systemic manifestations of psoriasis.

Patients' demographic and socioeconomic characteristics influence the therapeutic decision-making process in psoriasis

Background

Knowledge regarding differences in care for psoriatic patients is limited. The aim of this study was to investigate factors influencing prescription of systemic treatments for patients with psoriasis with a special focus on socioeconomic factors.

Methods and findings

This was a non-interventional, cross-sectional study, conducted in 18 Italian University and/or hospital centers with psoriasis-specialized units. Questionnaires evaluating demographic and socioeconomic characteristics were administered to participants. Overall, 1880 consecutive patients affected by mild-to-severe psoriasis were recruited. Univariate and multivariable logistic regression analyses of systemic therapy prescription, with a special focus on biologics, accounting for the above mentioned characteristics were performed. Our analysis showed that all analyzed patients’ characteristics were significantly associated with biological therapy compared to non-biological systemic one. Particularly, women were less likely to receive biologics than men (OR = 0.66; 95% CI, 0.57–0.77). Elderly patients (≥65 years) and subjects with a BMI ≥30 had lower odds to receive biologics respect to adults (≥35–64 years) (OR = 0.33; 95% CI, 0.25–0.40), and subjects with BMI≥25<30 (OR = 0.64; 95% CI, 0.53–0.77), respectively. Northern and Southern patients were both less likely to receive biologics than Central patients (OR = 0.75; 95% CI, 0.63–0.89, and OR = 0.56; 95% CI,0.47–0.68, respectively). Lower economic profile and never reading books were both associated with decreased odds of receiving biological therapy.

Conclusions

This study shows that sex, age, comorbidities, and socioeconomic characteristics influence the prescription of systemic treatments in psoriasis, highlighting that there are still unmet needs influencing the therapeutic decision-making process that have to be addressed.

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

Background

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

Objectives

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

Methods

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

Results

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

Conclusions

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

What is already known about this topic?

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

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

What does this study add?

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

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

What is the translational message?

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

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

Plain language summary available online

Psoriatic arthritis onset in psoriatic patients receiving UV phototherapy in Italy

BACKGROUND

Psoriasis is a chronic, recurrent, and immune-mediated inflammatory disease that affects 2-3% of the world population. A substantial proportion of patients with psoriasis, approximately 40%, develop a form of inflammatory arthritis known as psoriatic arthritis (PsA), the arthritis follows the development of psoriasis, and it will develop simultaneously or possibly before the appearance of skin lesions. The presence of PsA indicates a need for more active intervention rather than purely topical therapies or UV-based therapies. The aim of this multicenter, retrospective, epidemiological study was to estimate the incidence of PsA in psoriatic patients receiving UV treatment as monotherapy.

METHODS

A retrospective epidemiological study was performed in 8 dermatological reference center, located throughout Italy (2 from Northern, 3 from Center, 3 from Southern); a period of 1 year was considered. Data from the overall study population including 326 patients with a diagnosis of psoriasis were analyzed. Furthermore, data coming from follow-up visits, including screening for PsA onset through specific questionnaires were analyzed.

RESULTS

PsA screening was positive in 27 patients (8.3%), whereas PsA diagnosis was confirmed by a rheumatologist in only 22/27 (81.5%) being therefore found in 22/326 (6.7%). Patients diagnosed with PsA had a statistically significantly higher abdominal circumference (96±15.3 vs. 88.9±18.3, P=0.048) and more commonly presented a positive past medical history for phototherapy (90.9% vs. 57.6% P=0.004).

CONCLUSIONS

Our study showed that phototherapy is not able to prevent or slow down the risk of PsA development in psoriatic patients. PsA screening should be always carried out in those patients even if asymptomatic, especially in obese subjects which are at great risk to develop PsA due to their increased systemic inflammatory state.

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

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

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Coffee consumption, metabolic syndrome and clinical severity of psoriasis: good or bad stuff?

Despite the wide consumption of coffee, its anti-inflammatory effect on clinical severity of psoriasis is still debatable. The aim of this study was to evaluate the association between the coffee consumption and clinical severity of psoriasis in a sample of patients stratified according to the presence of the metabolic syndrome (MetS) and smoking. This cross-sectional case-control observational study was conducted on 221 treatment-naïve psoriatic patients. Lifestyle habits, anthropometric measures, clinical and biochemical evaluations were obtained. Clinical severity of psoriasis was assessed by Psoriasis Area and Severity Index (PASI) score. Data on energy caloric intake and coffee consumption were collected using a 7-day food diary record. The coffee consumption was analyzed as coffee intake (consumers and non-consumers) and daily servings (range 0-4 servings/day). Coffee consumers have a lower PASI score vs non-consumers (p < 0.001). The lowest PASI score and MetS prevalence were found in patients consuming 3 cups of coffee/day (p < 0.001), which was also the most common daily serving (34.8%), whereas the highest PASI score was found among those drinking ≥ 4 cups/day. Grouping the case patients according to smoking and MetS, the best odds of PASI score was observed in those drinking 3 cups of coffee per day and no smokers, after adjusting for total energy intake (OR 74.8; p < 0.001). As a novel finding, we reported a negative association between coffee intake, MetS prevalence and clinical severity of psoriasis. The evaluation of the anti-inflammatory effect of coffee on clinical severity of psoriasis, whose metabolic risk increases along with its clinical severity, could be of great importance from a public health perspective.

Insulin resistance and skin diseases

In medical practice, almost every clinician may encounter patients with skin disease. However, it is not always easy for physicians of all specialties to face the daily task of determining the nature and clinical implication of dermatologic manifestations. Are they confined to the skin, representing a pure dermatologic event? Or are they also markers of internal conditions relating to the patient's overall health? In this review, we will discuss the principal cutaneous conditions which have been linked to metabolic alterations. Particularly, since insulin has an important role in homeostasis and physiology of the skin, we will focus on the relationships between insulin resistance (IR) and skin diseases, analyzing strongly IR-associated conditions such as acanthosis nigricans, acne, and psoriasis, without neglecting emerging and potential scenarios as the ones represented by hidradenitis suppurativa, androgenetic alopecia, and hirsutism.

Management of moderate to severe psoriasis in patients with metabolic comorbidities

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