Psoriasis and the risk of pneumonia: a population-based study

Impact of COVID-19 on Influenza and Pneumococcal Vaccination of Psoriatic Patients in Germany: Results from Vac-Pso

BACKGROUND

Suboptimal influenza and pneumococcal vaccination rates have been reported before the COVID-19 pandemics in certain populations at risk for severe infection. The aim of this longitudinal cohort study was to investigate changes in influenza and pneumococcal vaccination rates and patient perceptions in patients with psoriasis (PsO) before and during the pandemic.

METHODS

Data on vaccination, patient and disease characteristics, comorbidity, and patient perceptions were collected with questionnaires before and during the pandemic approximately one year later.

RESULTS

Over the whole cohort who participated in the follow-up visit (n = 287; 59.2% male; mean age: 56.3 years), both influenza and pneumococcal lifetime vaccination prevalences increased significantly from 50.5% to 66.2% and from 16.0% to 41.5%, respectively. A total of 88.5% of PsO patients were interested in a COVID-19 vaccination or had already received it. The reasons for and against vaccinations changed significantly before and during the pandemic.

CONCLUSIONS

Despite a promising increase in the vaccination prevalence in our PsO cohort, it remains important that awareness for vaccinations is encouraged and closely monitored in future research, particularly in populations at risk.

Risk of serious infection and infection mortality in patients with psoriasis: A nationwide cohort study using the Taiwan National Health Insurance claims database

BACKGROUND

The risks of serious infections that lead to hospitalization and mortality in patients with psoriasis in Asia have not been comprehensively studied.

OBJECTIVES

We examined the incidence of serious infection and infection mortality in patients with psoriasis.

METHODS

This population-based retrospective cohort study used the Taiwan National Health Insurance claims database from 2000 to 2017. Adult patients with psoriasis were identified by a relevant International Classification of Diseases (ICD) code and matched to six comparators without psoriasis on age and sex. Psoriasis patients were categorized as having moderate-to-severe disease once exposed to systemic therapies, phototherapy or biologic therapies. The incidence of serious infection and infection mortality were identified by ICD codes from inpatient hospitalization and death registration. Cox proportional hazard models were used to compare the risk, and the results were adjusted for covariates and presented as adjusted hazard ratios (aHR) and 95% confidence interval (95% CI).

RESULTS

Overall, 185,434 psoriasis patients and 1,112,581 comparators were included. A higher rate of serious infection (aHR: 1.21, 95% CI: 1.19-1.22) was found in patients with psoriasis compared to matched comparators without psoriasis, and the risk was enhanced when patients had moderate-to-severe psoriasis (aHR: 1.30, 95% CI: 1.27-1.34). Specifically, there was an increased risk of serious infection due to respiratory infections (aHR: 1.11, 95% CI: 1.09-1.13), skin/soft-tissue infections (aHR: 1.57, 95% CI: 1.52-1.62), sepsis (aHR: 1.23, 95% CI: 1.19-1.27), urinary tract infections (aHR: 1.11, 95% CI: 1.08-1.14), hepatitis B (aHR: 1.18, 95% CI: 1.06-1.30) and hepatitis C (aHR: 1.49, 95% CI: 1.32-1.69). Furthermore, psoriasis patients were associated with a higher risk of infection-related mortality (aHR: 1.15, 95% CI: 1.11-1.18) compared to matched comparators.

CONCLUSION

Patients with psoriasis had a higher risk of serious infection and infection mortality, which was enhanced by moderate-to-severe psoriasis. Practitioners should be aware of the increased risk in patients with psoriasis, but it should not be a barrier to offering effective treatment.

Evaluating the risk of infections under interleukin 23 and interleukin 17 inhibitors relative to tumour necrosis factor inhibitors - A population-based study

BACKGROUND

The risk of infections among patients with psoriasis undergoing interleukin (IL)-23 inhibitors (IL-23i) and IL-17 inhibitors (IL-17i) is yet to be exhaustively determined.

OBJECTIVE

To assess the risk of infectious complications in patients with psoriasis managed by IL-23i and IL-17i with tumour necrosis factor inhibitors (TNFi) as a comparator.

METHODS

A global cohort study comprised two distinct analyses comparing patients with psoriasis under different therapeutic modalities; (i) new users of IL-23i (n = 5272) versus TNFi (n = 5272) and (ii) new users of IL-17i (n = 15,160) versus TNFi (n = 15,160). Study groups were compared regarding the risk of 26 different infections. Propensity score matching was conducted to optimize between-group comparability.

RESULTS

Patients under IL-23i had a lower risk of otitis media (HR, 0.66; 95% CI, 0.44-0.97), encephalitis (HR, 0.18; 95% CI, 0.04-0.78), herpes zoster (HZ; HR, 0.58; 95% CI, 0.41-0.82), hepatitis B virus (HBV) reactivation (HR, 0.24; 95% CI, 0.12-0.47), cytomegalovirus (HR, 0.25; 95% CI, 0.07-0.86), influenza (HR, 0.52; 95% CI, 0.38-0.71) and parasitic diseases (HR, 0.78; 95% CI, 0.64-0.95). IL-17i was associated with a decreased risk of pneumonia (HR, 0.76; 95% CI, 0.68-0.85), septicaemia (HR, 0.84; 95% CI, 0.72-0.97), upper respiratory tract infection (HR, 0.84; 95% CI, 0.77-0.92), HZ (HR, 0.79; 95% CI, 0.67-0.92), HBV (HR, 0.59; 95% CI, 0.46-0.76) and hepatitis C virus (HR, 0.71; 95% CI, 0.57-0.88) reactivation, cytomegalovirus (HR, 0.58; 95% CI, 0.36-0.93), Epstein-Barr virus (HR, 0.38; 95% CI, 0.19-0.75), influenza (HR, 0.70; 95% CI, 0.61-0.81) and parasitic diseases (HR, 0.80; 95% CI, 0.72-0.88).

CONCLUSION

Compared with TNFi, IL-23i and IL-17i are associated with decreased risk of several infectious diseases. These agents might be preferred in patients with susceptibility to infections.

Subclinical high-resolution chest CT scan features in psoriasis

BACKGROUND

Although psoriasis is considered a systemic disease, no clear association has been established between psoriasis and lung diseases. This study aims to detect and describe subclinical pulmonary involvement in psoriasis patients with various degrees of cutaneous manifestations.

METHODS

Adult psoriasis patients with no known active pulmonary disease or respiratory symptoms were screened for subclinical pulmonary manifestations and possible parenchymal changes using high-resolution computed tomography (HRCT) scan of the chest. Patients were classified according to the severity of skin manifestations. The clinical characteristics and radiographic findings of these patients were evaluated.

RESULTS

Fifty-nine patients with psoriasis were included, among which 47 (79.7%) had abnormal HRCT scan features. Micronodules were the most common detected lung lesions (66.1%), followed by nonspecific interstitial changes (32.2%), including pleuro-parenchymal band/atelectasis, scarring, and focal ground-glass opacities. Other HRCT findings included emphysematous changes and calcified granulomas. Abnormal HRCT findings correlated with older age and duration of psoriasis but not with the severity of skin manifestations.

CONCLUSIONS

Micronodules and minor focal nonspecific interstitial changes were the most detected lung alterations in patients with psoriasis. These findings of the pilot study highlight a possible pulmonary involvement in patients with psoriasis. Larger multicenter studies are needed to clarify these findings further.

LIMITATIONS

A major limitation of the study, is the lack of a control group with similar radiologic findings of different conditions done in the same geographical region.

Management of Infections in Psoriatic Patients Treated with Systemic Therapies: A Lesson from the Immunopathogenesis of Psoriasis

Modern treatments continue to be developed based on identifying targets within the innate and adaptive immune pathways associated with psoriasis. Whilst there is a sound biologic rationale for increased risk of infection following treatment with immunomodulators, the clinical evidence is confounded by these agents being used in patients affected with several comorbidities. In an era characterized by an ever greater and growing risk of infections, it is necessary to always be updated on this risk. In this mini-review, we will discuss recent updates in psoriasis immunopathogenesis as a rationale for systemic therapy, outline the risk of infections linked to the disease itself and systemic therapy as well, and provide an overview of the prevention and management of infections.

Immunogenicity of three doses of anti-SARS-CoV-2 BNT162b2 vaccine in psoriasis patients treated with biologics

Introduction

Psoriasis has not been directly linked to a poor prognosis for COVID-19, yet immunomodulatory agents used for its management may lead to increased vulnerability to the dangerous complications of SARS-CoV-2 infection, as well as impair the effectiveness of the recently introduced vaccines. The three-dose antibody response trend and the safety of BNT162b2 mRNA vaccine in psoriasis patients treated with biologic drugs have remained under-researched.

Materials and methods

Forty-five psoriatic patients on biologic treatment were enrolled to evaluate their humoral response to three doses of BNT162b2. IgG titers anti-SARS-CoV-2 spike protein were evaluated at baseline (day 0, first dose), after 3 weeks (second dose), four weeks post-second dose, at the time of the third dose administration and 4 weeks post-third dose. Seropositivity was defined as IgG ≥15 antibody-binding units (BAU)/mL. Data on vaccine safety were also collected by interview at each visit.

Results

A statistically significant increase in antibody titers was observed after each dose of vaccine compared with baseline, with no significant differences between patients and controls. Methotrexate used in combination with biologics has been shown to negatively influence the antibody response to the vaccine. On the contrary, increasing body mass index (BMI) positively influenced the antibody response. No adverse effects were reported, and no relapses of psoriasis were observed in the weeks following vaccine administration in our study population.

Conclusions

Our data are largely consistent with the recent literature on this topic confirming the substantial efficacy and safety of BNT162b2 mRNA vaccine on psoriatic patients treated with biologics of different types and support the recommendation to perform additional doses in this specific subgroup of patients.

Low Pneumococcal Vaccination among Patients with Psoriasis in Germany: Results from Vac-Pso

While suboptimal pneumococcal vaccination rates have been reported in immunosuppressed patients with rheumatic diseases, data for patients with psoriasis (PsO) or atopic dermatitis (AD) are scarce. Pneumococcal vaccination in Germany is recommended in patients with certain comorbidities, immunosuppression, and/or aged 60 years or above. The aim of this multicenter cross-sectional study was to investigate the pneumococcal vaccination rate in patients with PsO compared to patients with AD and to evaluate patient perceptions. All patients completed a questionnaire on vaccination status and perceptions, patient and disease characteristics, as well as comorbidity. Medical records and vaccination certificates were reviewed. Over the whole cohort (n = 327 PsO (41.9% female), n = 98 AD (42.9% female)), 83.8% and 42.9% of PsO and AD patients, respectively, had an indication for pneumococcal vaccination due to immunosuppressive treatment. The pneumococcal vaccination rate was 14.4% and 10.2% in PsO and AD patients, respectively. The vaccination rate depended significantly on age, working status and presence of psoriatic arthritis. The most common reason for nonvaccination was lacking recommendation by physicians. Higher awareness, particularly for vaccination indication due to immunosuppression among dermatologists, general physicians, and patients, is warranted.

Role of Fetuin-A in the Pathogenesis of Psoriasis and Its Potential Clinical Applications

Fetuin-A is a plasma glycoprotein exhibiting multifaceted physiological and pathological functions. It has been determined to be involved in various essential biological functions, such as regulation of calcium metabolism, osteogenesis, and insulin signaling pathway. It also plays a crucial role in the pathogenesis of several disorders, including psoriasis. Psoriasis is a chronic systemic inflammatory disorder caused by a constellation of environmental, immunogenic, and genetic factors. It has been shown that dysregulation of cytokines mediated immune response is responsible for the development of psoriasis. Several recent publications suggest that dysregulation of fetuin-A correlates with psoriasis disease activities, revealing its putative role in the development of psoriasis. Furthermore, clinical application of fetuin-A as a diagnostic marker, prognostic predictor, and therapeutic target for different clinical conditions is in progress, and some are showing promising outcomes. This review primarily focuses on the current understanding of the role of fetuin-A in the pathogenesis of psoriasis and its potential clinical applications, with a brief highlight of psoriasis epidemiology and burden. The information was gathered systematically from various journals via electronic searches using various search engines: PubMed, Google Scholar, HINARI, and Cochrane Library from inception to 2022. The studies involved were restricted to English language. Conversely, articles written in other languages, studies done on fetuin B, or studies conducted on other dermatological diseases were excluded from the review article.

A nationwide population-based cohort study of the incidence of severe and rare infections among adults with psoriasis in Denmark

Background

Patients with psoriasis have a high risk for multiple comorbid conditions. However, few studies have examined the association between psoriasis and severe and rare infections. This study reports the incidence of severe and rare infections (considered as rare in Denmark) among Danish patients with psoriasis, compared with the general population.

Objectives

The objectives of this study were to assess the incidence and risk of severe and rare infections in Danish patients with psoriasis and the matched general population, and to compare this risk for patients with severe or mild psoriasis with that of the general population.

Methods

Data for individuals aged ≥18 years who were alive and resident in the source population were collected from the Danish National Patient Register between 1 January 1997 and 31 December 2018. Individuals with any of the investigated chronic infections prior to inclusion were excluded. Patients with psoriasis were matched (1 : 6) for age and sex with general population controls. Severe infections were defined as infections requiring treatment in a hospital setting and rare infections included HIV, hepatitis B and C, and tuberculosis infections. Incidence rates (IRs) were reported per 100 000 person‐years of exposure. Severe psoriasis was defined according to previous or active use of systemic or biological treatment. Patients who never received biological and/or systemic treatment were categorized as having mild psoriasis.

Results

A total of 94 450 patients with psoriasis were matched with 566 700 controls. The respective IRs were higher for patients with any psoriasis compared with controls; IR 3104·9 [95% confidence interval (CI) 3066·6 to 3143·7] and IR 2381·1 (95% CI 2367·6 to 2394·6) for any infection, IR 3080·6 (95% CI 3042·5 to 3119·3) and IR 2364·4 (95% CI 2350·9 to 2377·9) for severe infections, and IR 42·9 (95% CI 38·89 to 47·4) and IR 31·8 (95% CI 30·34 to 33·3) for rare infections, respectively. Patients with severe psoriasis had higher IRs of severe or rare infections (IR 3847·7, 95% CI 3754·3 to 3943·4) compared with patients with mild psoriasis and controls.

Conclusions

As the severity of psoriasis increases, so does the risk of severe and rare infections. Therefore, clinicians should be aware of the increased risk of severe and rare infections in patients with severe psoriasis so that early investigation and treatment can be initiated.

What is already known about this topic?

Few studies have looked at the incidence and prevalence of serious infections (associated with hospitalization) and rare infections including tuberculosis, hepatitis B and C, and HIV among patients with different severities of psoriasis.

What does this study add?

Patients with psoriasis have an increased risk of severe and rare infections.

Clinicians should be aware of the increased risk of severe and rare infections in patients with severe psoriasis so that early investigation and treatment can be initiated.

The length of stay and inpatient burden in inpatients with different psoriasis subtypes

Background: Heavy disease burden of psoriasis has been indicated by previous studies. However, the cost of care and length of stay (LOS) in inpatients with different psoriasis subtypes were rarely addressed. This study aimed to investigate the cost of care and LOS in Chinese patients with different psoriasis types and to clarify the independent factors affecting LOS. Methods: We conducted a cross-sectional study by enrolling patients with psoriasis who were hospitalized between 13 Feb 2017 and 29 Mar 2021. Demographic and clinical characteristics of the patients were collected by reviewing their Electronic Medical Records. Multivariate linear regression was used to estimate the associations with adjustments. Results: A total of 310 adult patients with psoriasis were included (mean cost of care: 13.0±22.3 kCNY; mean LOS: 7.9±4.3 days). Statistically significant differences were found among patients with different psoriasis subtypes in LOS (P<0.001) but not in the cost of care (P=0.530). Relative to psoriasis vulgaris, pustular psoriasis (Adjusted coefficient: 2.37, 95% confidence interval (CI): 0.87-3.87) and erythrodermic psoriasis (Adjusted coefficient: 2.92, 95%CI: 1.38-4.47) were significantly associated with an increased LOS. Meanwhile, respiratory tract infections (Adjusted coefficient: 1.60, 95%CI: 0.11-3.10) also significantly increased the LOS. On the contrary, a decreased LOS was found in psoriatic arthritis patients treated with TNF-alpha inhibitors (Adjusted coefficient: -2.21, 95%CI: -4.37 to -0.05). Conclusions: LOS differed significantly among different psoriasis subtypes while the inpatient burden for a single hospitalization was alike. Infection is an important factor associated with a longer LOS. TNF-alpha inhibitors evidently reduced the total hospital stay period for patients with psoriatic arthritis.

Risk of infections in psoriasis: assessment and challenges in daily management

INTRODUCTION

In daily practice management of psoriasis, evaluation of risk factors for infections is having a growing influence. Indeed, in psoriatic patients, risk of infections may be due to psoriasis itself, immunomodulatory therapy, and comorbidities that may increase this risk and patient hospitalization.

AREAS COVERED

Given the greater understanding of psoriasis pathogenesis and the increasing number of treatment options, it is particularly important to customize therapy according to each, single patient; psoriasis features and comorbidities are also essential to tailor treatment goals.

EXPERT OPINION

In this perspective, the current knowledge on the infectious risk in psoriatic patient, related to comorbidities, such as diabetes mellitus, cardiovascular disease, and chronic obstructive pulmonary, to 'special populations,' to chronic infections, such as latent tuberculosis, chronic hepatitis B and C, and HIV, and to the most recent Covid-19 pandemic scenario, is reviewed and discussed in order to suggest the most appropriate approach and achieve the best available therapeutic option.

Influenza Vaccination in Psoriatic Patients-Epidemiology and Patient Perceptions: A German Multicenter Study (Vac-Pso)

The risk of developing severe complications from an influenza virus infection is increased in patients with chronic inflammatory diseases such as psoriasis (PsO) and atopic dermatitis (AD). However, low influenza vaccination rates have been reported. The aim of this study was to determine vaccination rates in PsO compared to AD patients and explore patient perceptions of vaccination. A multicenter cross-sectional study was performed in 327 and 98 adult patients with PsO and AD, respectively. Data on vaccination, patient and disease characteristics, comorbidity, and patient perceptions was collected with a questionnaire. Medical records and vaccination certificates were reviewed. A total of 49.8% of PsO and 32.7% of AD patients were vaccinated at some point, while in season 2018/2019, 30.9% and 13.3% received an influenza vaccination, respectively. There were 96.6% and 77.6% of PsO and AD patients who had an indication for influenza vaccination due to age, immunosuppressive therapy, comorbidity, occupation, and/or pregnancy. Multivariate regression analysis revealed higher age (p < 0.001) and a history of bronchitis (p = 0.023) as significant predictors of influenza vaccination in PsO patients. Considering that most patients had an indication for influenza vaccination, the rate of vaccinated patients was inadequately low.

Association Between Chronic Inflammatory Diseases and Stroke-Associated Pneumonia - An Epidemiological Study

BACKGROUND

Pneumonia, the most common post-acute ischemic stroke (AIS) infection, accounts for up to 30% of deaths after a stroke. Multiple chronic inflammatory diseases, such as rheumatoid arthritis, psoriasis, and inflammatory bowel disease, are associated with increased risk of stroke and stroke morbidity. This study assessed the relationship between chronic inflammatory diseases and stroke-associated pneumonia (SAP).

METHODS

Using data from the 2015-2017 National Inpatient Sample, we classified hospital discharges with a diagnosis of AIS as having ulcerative colitis, Crohn's disease, rheumatoid arthritis, psoriasis, systemic lupus erythematosus, other chronic inflammatory diseases, multiple chronic inflammatory diseases, or none. With multivariable logistic regression, we assessed for associations between chronic inflammatory disease and in-hospital SAP or death.

RESULTS

Among AIS discharges, there was a decreased risk of SAP among those with psoriasis or other chronic inflammatory diseases (adjusted odds ratio (aOR) 0.70, 95%CI 0.63-0.99; aOR 0.64, 95%CI, 0.46-0.89, respectively), compared to those without psoriasis and without other chronic inflammatory disease, respectively. Rheumatoid arthritis, psoriasis, and other chronic inflammatory diseases were associated with reduced in-hospital mortality (aOR 0.89, 95%CI 0.78-1.00; aOR 0.77, 95%CI 0.59-1.00; aOR 0.69, 95%CI 0.50-0.94, respectively).

CONCLUSIONS

The risk of SAP and in-hospital mortality varies by chronic inflammatory disease - psoriasis and other chronic inflammatory diseases are associate with reduced rates of SAP, whereas rheumatoid arthritis, psoriasis and other chronic inflammatory disease were associated with reduced in-hospital mortality. Further investigations are needed to determine a relationship between the potential role of immunomodulation and the reduction in SAP and mortality in chronic inflammatory diseases.

Treatment of psoriasis in end-stage renal disease patients is associated with decreased mortality: A retrospective cohort study

BACKGROUND

Psoriasis impairs the quality of life of approximately 7.5 million Americans and is associated with serious comorbidities. Because of chronic vascular access and epidermal dysfunction, end-stage renal disease (ESRD) patients with psoriasis may be at greater risk for infection, and psoriasis treatment could affect this risk.

METHODS

A retrospective cohort analysis was performed using the United States Renal Data System from 2004-2011 to investigate the association of psoriasis with infections common to ESRD patients, as well as the effect of psoriasis treatment on infection risk as well as mortality.

RESULTS

A total of 8,911 psoriasis patients were identified. Psoriasis was associated with a significantly increased risk for all queried infections, especially cellulitis (adjusted relative risk = 1.55), conjunctivitis (1.47), and onychomycosis (1.36). Psoriasis treatment (systemic, local, and light) was associated with a significantly decreased risk of some infections. Psoriasis treatment was also correlated with a significantly decreased risk of mortality, with systemic therapies (biologics and other immunosuppressants) showing the greatest reduction (adjusted hazard ratio = 0.55).

CONCLUSIONS

These results suggest that psoriasis-ESRD patients may have an increased risk of infection and treatment of psoriasis is associated with a reduced risk of some infections and improved survival.

Associations between COVID-19 and skin conditions identified through epidemiology and genomic studies

BACKGROUND

Coronavirus disease 2019 (COVID-19) is commonly associated with skin manifestations, and may also exacerbate existing skin diseases, yet the relationship between COVID-19 and skin diseases remains unclear.

OBJECTIVE

By investigating this relationship through a multiomics approach, we sought to ascertain whether patients with skin conditions are more susceptible to COVID-19.

METHODS

We conducted an epidemiological study and then compared gene expression across 9 different inflammatory skin conditions and severe acute respiratory syndrome coronavirus 2-infected bronchial epithelial cell lines, and then performed a genome-wide association study transdisease meta-analysis between COVID-19 susceptibility and 2 skin diseases (psoriasis and atopic dermatitis).

RESULTS

Skin conditions, including psoriasis and atopic dermatitis, increase the risk of COVID-19 (odds ratio, 1.55; P = 1.4 × 10-9) but decrease the risk of mechanical ventilation (odds ratio, 0.22; P = 8.5 × 10-5). We observed significant overlap in gene expression between the infected normal bronchial epithelial cells and inflammatory skin diseases, such as psoriasis and atopic dermatitis. For genes that are commonly induced in both the severe acute respiratory syndrome coronavirus 2 infection and skin diseases, there are 4 S100 family members located in the epidermal differentiation complex, and we also identified the "IL-17 signaling pathway" (P = 4.9 × 10-77) as one of the most significantly enriched pathways. Furthermore, a shared genome-wide significant locus in the epidermal differentiation complex was identified between psoriasis and severe acute respiratory syndrome coronavirus 2 infection, with the lead marker being a significant expression quantitative trait locus for S100A12 (P = 3.3 × 10-7).

CONCLUSIONS

Together our findings suggest association between inflammatory skin conditions and higher risk of COVID-19, but with less severe course, and highlight shared components involved in anti-COVID-19 immune response.

In the Real World: Infections Associated with Biologic and Small Molecule Therapies in Psoriatic Arthritis and Psoriasis

PURPOSE OF REVIEW

To summarize our most current understanding of the real world risk of infections associated with biologic and small molecule therapies in the setting of psoriatic disease.

RECENT FINDINGS

Patients with psoriasis or psoriatic arthritis are at increased risk for infection from both their disease and some of their therapies. There is little real world data for biologic and small molecule therapies; however, ustekinumab and biologics inhibiting IL-17 or IL-23 appear to have reduced risk estimates compared to anti-TNF therapies. Apremilast seems to have little infectious signal with limited real world data, and for JAK inhibitors, limited real world data suggest a higher risk of herpes zoster. Recently approved targeted and small molecule therapies for psoriasis carry infectious risks for patients, although they appear to vary across mechanism of action. As these treatments become more widespread, and additional therapies are approved, it will be imperative to evaluate their safety in the context of real world data.

All-cause and cause-specific mortality in psoriasis: A systematic review and meta-analysis

BACKGROUND

An overview of mortality risk associated with psoriasis is lacking.

OBJECTIVE

To perform a systematic review and meta-analysis of mortality risk in psoriasis.

METHODS

We included studies reporting all-cause or cause-specific mortality risk estimates in psoriasis patients compared with general population or subjects free of psoriasis. We calculated pooled relative risks (RRs) and 95% confidence intervals (CIs).

RESULTS

We included 12 studies. The pooled RRs for all-cause mortality were 1.21 (95% CI 1.14-1.28) in psoriasis, 1.13 (95% CI 1.09-1.16) in mild psoriasis, and 1.52 (95% CI 1.35-1.71) in severe psoriasis. The pooled RRs for cardiovascular mortality were 1.15 (95% CI 1.09-1.21) in psoriasis, 1.05 (95% CI 0.92-1.20) in mild psoriasis, and 1.38 (95% CI 1.09-1.74) in severe psoriasis. For noncardiovascular causes, mortality risk from liver disease, kidney disease, and infection was significantly increased in psoriasis, regardless of disease severity. The mortality risk in liver and kidney disease was the highest. There was also a significantly increased mortality risk associated with neoplasms in severe psoriasis patients and chronic lower respiratory disease in all and mild psoriasis patients.

LIMITATIONS

Although associations were consistent, their magnitude was heterogenous.

CONCLUSION

Psoriasis is associated with an increased risk for mortality from all causes (in a dose-response manner with disease severity) and from several specific causes.

Psoriasis and Respiratory Comorbidities: The Added Value of Fraction of Exhaled Nitric Oxide as a New Method to Detect, Evaluate, and Monitor Psoriatic Systemic Involvement and Therapeutic Efficacy

Psoriasis is a chronic inflammatory systemic disease characterized by a wide range of comorbidities. Respiratory comorbidities are currently poorly characterized and with discordant results. The systemic state of inflammation caused by psoriasis acts de novo on respiratory tissues and amplifies preexisting inflammation from asthma or chronic obstructive pulmonary disease. Because the lungs act as a gas exchanger between the internal and external environment, the impact of chronic psoriasis inflammation may be easily assessed through the analysis of exhaled breath. The fraction of exhaled nitric oxide test (FeNO) is a potential noninvasive solution that can provide quantitative and qualitative indices of respiratory airway inflammation. FeNO is routinely used to screen and manage asthmatic patients. Recent pilot studies contain encouraging data that underscore its possible use with systemic inflammatory nonpulmonary diseases, such as psoriasis. FeNO may therefore be a useful tool to evaluate underestimated airway inflammation and at the same time globally evaluate the impact of systemically antipsoriatic therapies.

Interstitial Pneumonia in Psoriasis

Objective

To investigate the relationship between psoriasis and interstitial pneumonia (IP).

Patients and Methods

We analyzed the clinical data of patients with psoriasis treated with biologic agents from June 1, 2008, to June 30, 2017, retrospectively. Chest computed tomography was performed in 392 patients before treatment. The clinical characteristics and radiographic findings of these patients were evaluated.

Results

Of the 392 patients with psoriasis, IP was detected in 8 patients (2%). Bilateral ground-glass and/or irregular linear (reticular) opacity in the lower lung zone was the most common chest computed tomography finding. Five of the 8 patients with IP were treated with anti–interleukin (IL) 12/IL-23 or IL-17 antibodies, leading to decreased or stable IP activity.

Conclusion

Interstitial pneumonia was detected in 2% of patients with psoriasis who needed systemic treatments. Ground-glass and/or irregular linear (reticular) opacity in the bilateral lower lobes was characteristic of IP with psoriasis. The IL-23/IL-17 axis may play important roles in the pathogenesis of IP in psoriasis.

Psoriasis and infection. A clinical practice narrative

The Australasian Psoriasis Collaboration has developed a clinical practice narrative with respect to the relationship between psoriasis, its treatment and infection. The cutaneous microbiome of patients with psoriasis is different to those without psoriasis, although the significance of this is unclear. Whilst a wide range of microorganisms has been associated with psoriasis (including β-haemolytic streptococci, Staphylococcus aureus, Porphyromonas gingivalis, Candida albicans, Chlamydia psittaci, human immunodeficiency virus and hepatitis C virus), there is limited evidence that antimicrobial therapy is of direct benefit in preventing flares of psoriasis. Psoriasis is independently associated with an increased risk of serious infection, but the absolute risk is low. The risk of serious infections is further increased with immune-modulatory treatments. The decision whether to, and when to, stop or resume immune-modulatory treatment after a serious infection has occurred depends on risk assessment for that patient, taking into account the infection being treated, the risk of recurrent infection, any interventions that can modify the risk and the need for psoriasis control. Live vaccines (e.g. MMR, varicella, zoster and yellow fever) are generally contraindicated in patients with psoriasis on immune-modulatory agents, but this depends on the degree of immune suppression and individual risk factors. Wound healing in psoriasis is normal. Treatment with infliximab, adalimumab, etanercept, methotrexate and ciclosporin can safely be continued through low-risk surgical procedures. For moderate- and high-risk surgeries, a case-by-case approach should be taken based on the patient's individual risk factors and comorbidities.

Risk of Serious Infection, Opportunistic Infection, and Herpes Zoster among Patients with Psoriasis in the United Kingdom

The risk of infection among patients with psoriasis of varying severity in a broadly representative population remains poorly understood. Using The Health Improvement Network (THIN), an electronic medical records database representative of the general UK population, we performed a cohort study to determine the risks of serious infection, opportunistic infection, and herpes zoster among patients with versus without psoriasis and according to psoriasis severity. We identified 187,258 patients with mild and 12,442 patients with moderate to severe psoriasis based on treatment patterns. Using Cox proportional hazards regression, the adjusted hazard ratios (95% confidence intervals) for serious infection were 1.18 (1.16-1.21) and 1.63 (1.52-1.75) for the mild and moderate to severe psoriasis groups, respectively. Among a nested cohort of 8,569 psoriasis patients with disease severity classified by body surface area involvement, similar results were obtained with the exception of an attenuated but significantly increased risk of serious infection among the moderate to severe psoriasis group (1.27 [1.10-1.47]). Overall, the risks of opportunistic infection and herpes zoster were significantly increased only among the moderate to severe psoriasis group and were associated with immunosuppressive therapy. Our analyses suggest that psoriasis is associated with an increased risk of serious infection, and psoriasis severity is a predictor of serious infection risk.

Increased Incidence of Critical Illness in Psoriasis

BACKGROUND

Psoriasis is associated with an increased risk of comorbid disease. Despite the recognition of increased morbidity in psoriasis, the effects on health care utilisation remain incompletely understood. Little is known about the risk of intensive care unit (ICU) admission in persons with psoriasis.

OBJECTIVE

To compare the incidence of ICU admission and post-ICU mortality rates in a psoriasis population compared with a matched population without psoriasis.

METHODS

Using population-based administrative data from Manitoba, Canada, we identified 40 930 prevalent cases of psoriasis and an age-, sex-, and geographically matched cohort from the general population (n = 150 210). We compared the incidence of ICU admission between populations using incidence rates and Cox regression models adjusted for age, sex, socioeconomic status, and comorbidity and compared mortality after ICU admission.

RESULTS

Among incident psoriasis cases (n = 30 150), the cumulative 10-year incidence of ICU admission was 5.6% (95% confidence interval [CI], 5.3%-5.8%), 21% higher than in the matched cohort (incidence rate ratio, 1.21; 95% CI, 1.15-1.27). In the prevalent psoriasis cohort, crude mortality in the ICU was 11.5% (95% CI, 9.9%-13.0%), 32% higher than observed in the matched population admitted to the ICU (8.7%; 95% CI, 8.3%-9.1%). Mortality rates after ICU admission remained elevated at all time points in the psoriasis cohort compared with the matched cohort.

CONCLUSION

Psoriasis is associated with an increased risk for ICU admission and with an increased risk of mortality post-ICU admission.

Psoriasis and comorbid diseases: Epidemiology

Psoriasis is a common chronic inflammatory disease of the skin that is increasingly being recognized as a systemic inflammatory disorder. Psoriatic arthritis is a well-known comorbidity of psoriasis. A rapidly expanding body of literature in various populations and settings supports additional associations between psoriasis and cardiometabolic diseases, gastrointestinal diseases, kidney disease, malignancy, infection, and mood disorders. The pathogenesis of comorbid disease in patients with psoriasis remains unknown; however, shared inflammatory pathways, cellular mediators, genetic susceptibility, and common risk factors are hypothesized to be contributing elements. As additional psoriasis comorbidities continue to emerge, education of health care providers is essential to ensuring comprehensive medical care for patients with psoriasis.

Psoriasis and comorbid diseases: Implications for management

As summarized in the first article in this continuing medical education series, the currently available epidemiologic data suggest that psoriasis may be a risk factor for cardiometabolic disease. Emerging data also suggest associations between psoriasis and other comorbidities beyond psoriatic arthritis, including chronic kidney disease, inflammatory bowel disease, hepatic disease, certain malignancies, infections, and mood disorders. Recognizing the comorbid disease burden of psoriasis is essential for ensuring comprehensive care of patients with psoriasis. The clinical implications of the comorbid diseases that are associated with psoriasis and recommendations for clinical management are reviewed in this article.

Psoriatic inflammation enhances allergic airway inflammation through IL-23/STAT3 signaling in a murine model

Psoriasis is an autoimmune inflammatory skin disease characterized by activated IL-23/STAT3/Th17 axis. Recently psoriatic inflammation has been shown to be associated with asthma. However, no study has previously explored how psoriatic inflammation affects airway inflammation. Therefore, this study investigated the effect of imiquimod (IMQ)-induced psoriatic inflammation on cockroach extract (CE)-induced airway inflammation in murine models. Mice were subjected to topical and intranasal administration of IMQ and CE to develop psoriatic and airway inflammation respectively. Various analyses in lung/spleen related to inflammation, Th17/Th2/Th1 cell immune responses, and their signature cytokines/transcription factors were carried out. Psoriatic inflammation in allergic mice was associated with increased airway inflammation with concurrent increase in Th2/Th17 cells/signature cytokines/transcription factors. Splenic CD4+ T and CD11c+ dendritic cells in psoriatic mice had increased STAT3/RORC and IL-23 mRNA expression respectively. This led us to explore the effect of systemic IL-23/STAT3 signaling on airway inflammation. Topical application of STA-21, a small molecule STAT3 inhibitor significantly reduced airway inflammation in allergic mice having psoriatic inflammation. On the other hand, adoptive transfer of IL-23-treated splenic CD4+ T cells from allergic mice into naive recipient mice produced mixed neutrophilic/eosinophilic airway inflammation similar to allergic mice with psoriatic inflammation. Our data suggest that systemic IL-23/STAT3 axis is responsible for enhanced airway inflammation during psoriasis. The current study also suggests that only anti-asthma therapy may not be sufficient to alleviate airway inflammatory burden in asthmatics with psoriasis.

Incidence of autoimmune diseases in a nationwide HIV/AIDS patient cohort in Taiwan, 2000-2012

OBJECTIVES

It is not known if the incidences of autoimmune diseases are higher in individuals living with HIV infection or AIDS. Our study investigated the incidences of autoimmune diseases among people living with HIV/AIDS (PLWHA) in Taiwan during 2000-2012.

METHODS

The Taiwan National Health Insurance Research Database was used to identify PLWHA. The incidence densities of systemic and organ-specific autoimmune diseases were calculated, and age-adjusted, sex-adjusted and period-adjusted standardised incidence rates (SIRs) were obtained by using two million people from the general population as controls. To examine the effects of highly active antiretroviral therapy (HAART) on the incidence of autoimmune diseases, the incidence densities and SIRs of autoimmune diseases were calculated after stratifying PLWHA by HAART status.

RESULTS

Of the 20 444 PLWHA identified, the overall mean (SD) age was 30.1 (11.0) years; 67.2% of the subjects received HAART. As compared with the general population, SIRs were higher for incident Sjögren syndrome (SIR=1.64; 95% CI 1.24 to 2.13), psoriasis (SIR=2.05; 95% CI 1.67 to 2.48), systemic lupus erythematosus (SLE) (SIR=2.59; 95% CI 1.53 to 4.09), autoimmune haemolytic anaemia (SIR=35.06; 95% CI 23.1 to 51.02) and uveitis (SIR=2.50; 95% CI 2.05 to 3.02), but were lower for incident ankylosing spondyloarthritis (SIR=0.70; 95% CI 0.48 to 0.99). When the effect of HAART on incident autoimmune diseases was considered, PLWHA who received HAART had higher SIRs for psoriasis, autoimmune haemolytic anaemia and uveitis, but had lower risks of rheumatoid arthritis (RA) and ankylosing spondyloarthritis. In contrast, PLWHA who did not receive HAART had higher SIRs for Sjögren syndrome, psoriasis, RA, SLE, scleroderma, polymyositis, autoimmune haemolytic anaemia and Hashimoto's thyroiditis.

CONCLUSIONS

PLWHA had higher risks of incident Sjögren syndrome, psoriasis, SLE, autoimmune haemolytic anaemia and uveitis.