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Felix PAO, Sampaio AL, Silva BL, Viana ALP. Early intervention in psoriasis: Where do we go from here? Front Med (Lausanne) 2022; 9:1027347. [PMID: 36530901 PMCID: PMC9751903 DOI: 10.3389/fmed.2022.1027347] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 11/16/2022] [Indexed: 04/16/2024] Open
Abstract
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.
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Affiliation(s)
| | - Ana Luisa Sampaio
- Dermatology Department, Hospital Universitário Pedro Ernesto, Rio de Janeiro State University, Rio de Janeiro, Brazil
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2
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Badaiki W, Penney M, Pyper E, Lester K, Skeard J, Shin J, Fisher B, Gulliver S, Gulliver W, Rahman P. Real World Studies of Psoriasis and Mental Illness in Newfoundland and Labrador. J Cutan Med Surg 2022; 26:494-501. [PMID: 35938546 PMCID: PMC9476230 DOI: 10.1177/12034754221117736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Psoriasis is a chronic, immune-mediated inflammatory disease with an implied connection to psychiatric disorders. Objective This study aims to illustrate an association between psoriasis and psychiatric disorders using real world data gathered from the Newfoundland and Labrador population. Methods Data on 15,100 patients with psoriasis and 75,500 controls (1:5) was collected from the Newfoundland and Labrador Centre for Health Information’s Electronic Health Records. The cases and controls were matched for age, sex, and geography. Indicators for psychiatric disorders include diagnosis of mental illnesses from physician’s visits and hospitalization records (all coded for mental health using ICD-9 and ICD-10 codes). Results 9,991 (66.2%) cases were identified to have at least one visit with a diagnostic code for mental illness compared to 42,276 (56.0%), P < .0001 in the control group. The percentage of people coded for anxiety was 36.50% compared to 28.95%, P < .0001; depression was 37.04% compared to 30.19%, P < .0001; and adjustment disorder was 6.89% versus 5.48%, P < .0001, among those with and without psoriasis, respectively. The greatest risk for anxiety [OR 1.4 (1.20, 1.67)] and depression [OR 1.65 (1.36, 2.00)] among psoriasis patients was between the 0 to 20 age group. Women with psoriasis are more likely to have anxiety [OR 1.08 (1.03, 1.13)], depression [OR 1.04 (1.01, 1.09)] and adjustment disorder [OR 1.07 (0.98, 1.17)] compared to female controls. Conclusion Our result shows that patients with psoriasis have an increased prevalence of mental illness. Using real world data to carry out further investigations will better elucidate this association and provide an increased understanding of the association between psoriasis and mental disorders.
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Affiliation(s)
- Winifred Badaiki
- 7512 Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Michelle Penney
- 103974 Newlab Clinical Research, St. John's, Newfoundland and Labrador, Canada
| | | | - Kendra Lester
- 7512 The Newfoundland and Labrador Centre for Health Information, St. John's, Newfoundland and Labrador, Canada
| | - Janelle Skeard
- 7512 Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
| | - Janey Shin
- 426218 Janssen Inc., Toronto, ON, Canada
| | | | - Susanne Gulliver
- 103974 Newlab Clinical Research, St. John's, Newfoundland and Labrador, Canada
| | - Wayne Gulliver
- 7512 Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada.,103974 Newlab Clinical Research, St. John's, Newfoundland and Labrador, Canada
| | - Proton Rahman
- 7512 Faculty of Medicine, Memorial University of Newfoundland and Labrador, St. John's, Newfoundland and Labrador, Canada
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Egeberg A, Gisondi P, Carrascosa JM, Warren RB, Mrowietz U. The role of the interleukin-23/Th17 pathway in cardiometabolic comorbidity associated with psoriasis. J Eur Acad Dermatol Venereol 2020; 34:1695-1706. [PMID: 32022950 PMCID: PMC7496750 DOI: 10.1111/jdv.16273] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/21/2020] [Indexed: 12/13/2022]
Abstract
Alterations in the innate and adaptive immunity underpin psoriasis pathophysiology, with the Th17 cells subset now recognized as the fundamental cells in the key controlling pathway involved in its pathogenesis. Since psoriasis is a systemic disease with important comorbidity, further knowledge on the interleukin (IL)‐23/Th17 axis led to the hypothesis that there may be shared pathogenic pathways between primary skin disease and comorbidity. Psoriasis has been identified as a risk factor for cardiovascular and metabolic disease, and increasing evidence gives support to this epidemiological observation from the clinical‐pathologically field. As an example, increased levels of IL‐23 and IL‐23R have been found in human atherosclerotic plaque, and levels correlated with symptom duration and mortality. Also, upregulation of IL‐23/IL‐17 seems to play an important role in both myocardial damage and stroke, with interesting reports on deleterious effect neutralization after administration of related anti‐bodies in both associated conditions. In diabetic patients, increased levels of IL‐23/IL‐17 have also been observed and available data support a synergistic role of IL‐23/IL‐17 in β‐cells damage. In obesity, signs of an expansion of Th17 subset in adipose tissue have been reported, as well as elevated concentrations of IL‐23 in obese patients. In non‐alcoholic fatty liver disease, closely related to metabolic syndrome, but also in other mentioned cardiometabolic disorders, a predominance of IL‐23 and other related pro‐inflammatory factors has been identified as participating in their pathogenesis. Thus, the involvement of the IL‐23/Th17 axis in these shared psoriasis‐cardiometabolic pathogenic mechanisms is reviewed and discussed in the light of the existing preclinical and clinical evidence, including that from comorbid psoriasis patients.
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Affiliation(s)
- A Egeberg
- Department of Dermatology and Allergy, Gentofte Hospital, Hellerup, Denmark
| | - P Gisondi
- Section of Dermatology and Venereology, University of Verona, Verona, Italy
| | - J M Carrascosa
- Department of Dermatology, University Hospital Germans Trias i Pujol, Autonomous University of Barcelona (UAB), Badalona, Spain
| | - R B Warren
- Dermatology Centre, Salford Royal NHS Foundation Trust, Manchester NIHR Biomedical Research Centre, The University of Manchester, Manchester, UK
| | - U Mrowietz
- Psoriasis-Center at the Department of Dermatology, University Medical Center Schleswig-Holstein, Kiel, Germany
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Packer M. Epicardial Adipose Tissue Inflammation Can Cause the Distinctive Pattern of Cardiovascular Disorders Seen in Psoriasis. Am J Med 2020; 133:267-272. [PMID: 31520623 DOI: 10.1016/j.amjmed.2019.08.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 08/27/2019] [Accepted: 08/28/2019] [Indexed: 12/20/2022]
Abstract
Psoriasis is a systemic inflammatory disorder that can target adipose tissue; the resulting adipocyte dysfunction is manifest clinically as the metabolic syndrome, which is present in ≈20%-40% of patients. Epicardial adipose tissue inflammation is likely responsible for a distinctive pattern of cardiovascular disorders consisting of 1) accelerated coronary atherosclerosis leading to myocardial infarction, 2) atrial myopathy leading to atrial fibrillation and thromboembolic stroke, and 3) ventricular myopathy leading to heart failure with a preserved ejection fraction. If cardiovascular inflammation drives these risks, then treatments that focus on blood pressure, lipids, and glucose will not ameliorate the burden of cardiovascular disease in patients with psoriasis, especially in those who are young and have severe inflammation. Instead, interventions that alleviate systemic and adipose tissue inflammation may not only minimize the risks of atrial fibrillation and heart failure but may also have favorable effects on the severity of psoriasis. Viewed from this perspective, the known link between psoriasis and cardiovascular disease is not related to the influence of the individual diagnostic components of the metabolic syndrome.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Tex; Imperial College, London.
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Merlo G, Cozzani E, Burlando M, Calvieri S, Potenza C, Stingeni L, Filosa G, Pau M, Simonacci M, Caproni M, Parodi A. Effects of TNFα inhibitors in patients with psoriasis and metabolic syndrome: a preliminary study. GIORN ITAL DERMAT V 2020; 155:14-18. [DOI: 10.23736/s0392-0488.17.05621-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
The excellent response of psoriasis to anti-TNF-α(TNF)/IL23/IL17A biologics implies a crucial role for the TNF/IL23/IL17 axis in developing psoriasis. In addition to the TNF/IL23/IL17 axis provided by immune cells, current evidence points to an important contribution of TNF, IL23 and IL17C produced from non-hematopoietic keratinocytes. Therefore, crosstalk between immune cells and keratinocytes forms a multilayered feed-forward loop to accelerate the TNF/IL23/IL17A axis. Many biologics have already been licensed or are under clinical trials. Given that the IL-17 signature is more upregulated in the skin than in synovium in psoriatic arthritis, anti-IL-23/IL-17 agents seem to be superior to anti-TNF-α remedies in the treatment of skin lesions. In this review, we summarize recent topics in psoriasis and the TNF/IL23/IL17 axis.
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Affiliation(s)
- Kazuhisa Furue
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takamichi Ito
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Gaku Tsuji
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takafumi Kadono
- Department of Dermatology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Masutaka Furue
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan -
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Gulliver WP, Randell S, Gulliver S, Macdonald D, Gregory V, Nagle S, Chambenoit O. An Investigation of Comorbid Disease and Health Service Utilization Among Patients With Moderate to Severe Psoriasis in Newfoundland and Labrador. J Cutan Med Surg 2018; 23:29-34. [PMID: 30041544 DOI: 10.1177/1203475418791114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Psoriasis is an inflammatory skin condition affecting 2% to 3% of the population and is associated with several comorbidities, including cardiovascular disease, depression, inflammatory bowel disease, metabolic syndrome, mood disorder, psoriatic arthritis, and weight gain. Psoriasis is treated with a number of topical and systemic therapies, including biologic drugs that directly target proinflammatory cytokines. This cross-sectional retrospective study investigated comorbid conditions reported in the Newfoundland and Labrador psoriasis population, outcomes associated with therapeutic treatment, and use of health care resources. Of the psoriasis comorbidities investigated, psoriatic arthritis was significantly associated with the use of biologic therapy while a failure to respond to biologics was associated with a higher incidence of cardiovascular disease. Patients responsive to biologic treatment had fewer hospital stays than patients treated with other therapies. Our results suggest that biologic therapies have a cardioprotective effect and reduce the number of hospital visits in patients whose symptoms are responsive to treatment.
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Affiliation(s)
- Wayne P Gulliver
- 1 Newlab Clinical Research, St. John's, NL, Canada.,2 Department of Medicine, Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | | | | | - Don Macdonald
- 3 Newfoundland and Labrador Centre for Health Information, St. John's, NL, Canada
| | | | - Sean Nagle
- 5 Novartis Latin America Services, Miami, FL, USA
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Saleem MD, Kesty C, Feldman SR. Relative versus absolute risk of comorbidities in patients with psoriasis. J Am Acad Dermatol 2016; 76:531-537. [PMID: 27986396 DOI: 10.1016/j.jaad.2016.11.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 11/03/2016] [Accepted: 11/13/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Psoriasis is associated with numerous comorbidities, often reported in terms of relative risk. Both doctors and the general population tend to overestimate the effects of exposures when presented in relative terms, leading to anxiety and potentially poor treatment decisions. Absolute risks might provide a better basis for risk assessment. OBJECTIVE To characterize and compare relative and absolute risks of comorbidities in patients with psoriasis. METHODS A systematic review using Medline identified comorbidities associated with psoriasis, their relative risks, and information for calculating absolute risks. RESULTS The comorbidities associated with psoriasis with the highest relative risk were nonmelanoma skin cancer, melanoma, and lymphoma, with relative risks of 7.5, 6.12, and 3.61, respectively; the attributable risk for these 3 conditions were 0.64, 0.05, and 0.17 per 1000 person-years, respectively. To attribute 1 event of these conditions to psoriasis would require seeing 1551; 20,135; and 5823 patients, respectively. LIMITATIONS Database studies might not fully account for confounders, resulting in overestimates of the risk impact of comorbidities. CONCLUSIONS Presenting attributable risk in the form of the number needed to harm provides a clearer picture of the magnitude of risk and a basis for wiser medical decision making and patient education.
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Affiliation(s)
- Mohammed D Saleem
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina.
| | - Chelsea Kesty
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Steven R Feldman
- Center for Dermatology Research, Department of Dermatology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Pathology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Department of Public Health Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
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