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

Analysis of the Reduction in the Duration of Sick Leave for 32,512 Psoriasis Patients Following the Integration of Targeted Therapies for Psoriatic Disease into the Brazilian Healthcare System: a Retrospective Cohort Study

Purpose

The Brazilian Unified Health System is an interesting model for international healthcare innovation analysis. Covering over 200 million people, this system stands out as one of the largest purchasers of healthcare technologies worldwide. Our goal in this study was to evaluate how targeted therapies reduce the duration of sick leave for psoriasis patients.

Patients and Methods

We conducted a retrospective cohort study within the Brazilian National Institute of Social Security. The primary outcome was the return to work (cessation of sick leave) of patients with psoriasis. Factors such as age, sex, and access to targeted therapies were evaluated using a Cox proportional hazards model.

Results

Over the 25-year period from 1998 to 2023, 32,512 benefits were granted for psoriasis, totalling an expenditure of $577,478,002.15. Public access to psoriatic arthritis (PsA)-targeted therapies decreased the average minimum wage granted to psoriasis patients on sick leave by 22%, and public access to psoriasis-targeted therapies reduced the average wage by 7%. The availability of these therapies was associated with earlier cessation of sick leave in our proportional hazards model (targeted therapies for PsA: hazard ratio (HR) = 1.90, 95% confidence interval (CI) = 1.82-2.00; targeted therapies for psoriasis: HR = 1.63, 95% CI = 1.54-1.70).

Conclusion

This study highlights a remarkable reduction in costs and sick leave duration due to the implementation of therapies for psoriatic disease by the Brazilian Unified Health System, which underscores the importance of considering detailed indirect cost data when evaluating new health technologies for large populations.

Multicomorbidity in Psoriasis Vulgaris: A Retrospective Analysis

Background

The frequencies of comorbidities in patients with psoriasis have been compared to that in the general population in many studies. Moreover, several studies have investigated the risk factors influencing the number of comorbidities in patients with psoriasis. However, a few studies have examined clusters of patients with psoriasis according to their comorbidities. In this study, we aimed to explore the multicomorbidities of psoriasis vulgaris in terms of risk factors and clusters.

Methods

All diagnoses of 452 patients with psoriasis vulgaris were extracted from electronic medical records of a tertiary hospital. Binary association coefficients were calculated for all pairs of comorbidities. Subsequently, a hierarchical cluster analysis was performed.

Results

Among the patients, 30.5% had no comorbidities, 28.8% had a single comorbidity, and 40.7% had multiple comorbidities. The number of comorbidities was positively associated with age and follow-up duration but not with sex. The most striking cluster of comorbidities was composed of diabetes, hepatosteatosis, hyperlipidemia, hypertension, cancer, and cardiovascular disease.

Conclusion

This cluster could be explained by cardiometabolic multimorbidity. Exploring such clusters may provide a more forward-looking perspective for the management of psoriasis patients.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cumulative life course impairment in patients with dermatological diseases, with a focus on psoriasis

The concept of "Cumulative Life Course Impairment" (CLCI) characterizes the set of factors harmful to the lives of patients resulting from the stigma and physical and psychological impairment associated with different chronic diseases, which can accumulate irreversibly over the course of patients lives. The sum of these factors often makes it impossible for these individuals to enjoy their lives fully, intensely and adequately. On the other hand, CLCI also incorporates coping strategies, including external factors and personality characteristics, which may act as modulating or protective factors of vulnerability to the CLCI. Although psoriasis is the most studied dermatological disease in relation to its impact on quality of life and CLCI, several other chronic inflammatory diseases such as atopic dermatitis, hidradenitis suppurativa, and alopecia areata have also been evaluated in relation to the magnitude of the damage to patients lives.

Clinical characterization, physical frailty, and depression in elderly patients with psoriasis from a reference center in Brazil: a cross-sectional study

BACKGROUND

There are few studies dedicated to the characterization of the geriatric population with psoriasis, which has particularities in terms of clinical manifestations and therapeutic limitations. As psoriasis is a chronic disease, presenting a higher prevalence with age, the increase in life expectancy in Brazil demands knowledge about the behavior of the disease among the elderly.

OBJECTIVES

To characterize elderly people with psoriasis from a tertiary service, from the clinical-epidemiological point of view, presence of comorbidities, physical frailty, and affective impact, and to compare these aspects with adults with psoriasis and elderly people without the disease.

METHODS

Cross-sectional study of 64 elderly patients with psoriasis, 64 adults with psoriasis, and 64 elderly patients without the disease. Clinical-demographic aspects, the Beck depression scale, and Skindex-16 were evaluated. Indicators of physical frailty were evaluated in elderly patients: handgrip, sit-to-stand test, fatigue, and weight loss >5%.

RESULTS

In the elderly, the mean age (SD) of psoriasis onset was 44 (10) years, men represented 47% of the sample, the prevalence of arthritis was 22%, and ungual involvement occurred in 72%. Topical corticosteroids were used more often among elderly people with psoriasis (100%) than among adults with the disease (86%), with no difference among other systemic treatments. Diabetes mellitus occurred in 30% of the elderly. Hypertension (59%), dyslipidemia (52%), depression (34%), and fatigue (59%) were more prevalent among the elderly with psoriasis than among the healthy controls.

STUDY LIMITATIONS

The study was carried out in a public reference service for patients with psoriasis, all of which were undergoing treatment.

CONCLUSIONS

Elderly people with psoriasis from a tertiary service showed greater affective impairment, metabolic comorbidities, and physical frailty than elderly controls.

Telmisartan Lowers Elevated Blood Pressure in Psoriatic Mice without Attenuating Vascular Dysfunction and Inflammation

BACKGROUND

Psoriasis is hallmarked by vascular dysfunction, arterial hypertension, and an increased risk for cardiovascular diseases. We have shown recently that skin-driven interleukin (IL)-17A expression promotes psoriasis-like disease in mice, and this is associated with vascular inflammation, vascular dysfunction, and hypertension. As an intensive risk-factor reduction is recommended for psoriasis patients, we aimed to elucidate the impact of the angiotensin II receptor type 1 (AT1) antagonist telmisartan in a mouse model of severe psoriasis-like skin disease.

METHODS AND RESULTS

Elevated blood pressure measured by tail-cuff plethysmography in mice with keratinocyte-specific IL-17A overexpression (K14-IL-17A^ind/+ mice) was significantly reduced in response to telmisartan. Importantly, vascular dysfunction, as assessed by isometric tension studies of isolated aortic rings, vascular inflammation measured by flow cytometry analysis of CD45⁺CD11b⁺ immune cells, as well as the increased peripheral oxidative stress levels assessed by L-012-enhanced chemiluminescence were not attenuated by telmisartan treatment of K14-IL-17A^ind/+ mice, nor was the persisting skin inflammation.

CONCLUSION

We provide first evidence for an effective antihypertensive treatment in experimental psoriasis by AT1 blockade, but without any impact on vascular inflammation and dysfunction in our mouse model of severe psoriasis-like skin disease. This suggests that vascular function and inflammation in psoriasis might not be attenuated as long as skin inflammation persists.

A multidimensional assessment of the burden of psoriasis: results from a multinational dermatologist and patient survey

BACKGROUND

Psoriasis is a chronic, immune-mediated disease, characterized by symptoms that include itching and skin pain and is often associated with comorbidities. Patients have a substantial detriment to quality of life (QoL) and work productivity with associated cost burden.

OBJECTIVES

To investigate the incremental burden of comorbidities, itch and affected body areas among systemic eligible patients with psoriasis, using a multinational survey of dermatologists and their patients with psoriasis.

METHODS

Multinational data from the Growth from Knowledge (GfK) Disease Atlas Global Real-World Evidence program were used. Eligible patients were identified as those who were currently having or had ever had moderate-to-severe psoriasis, and must have been receiving prescription treatments at the time of the survey. Multivariable regression analyses were conducted to assess the incremental burden among psoriasis patients with physical and psychological comorbidities, itch and affected visible and sensitive body areas vs. psoriasis patients without these conditions, respectively.

RESULTS

The study enrolled 3821 patients with psoriasis, from nine countries, with an average Psoriasis Area and Severity Index score of 6·4. The presence of comorbidities was associated with a significant increase in the likelihood of skin pain, lower QoL, greater work impairment and increased usage of medical resources (except in psoriasis patients with obesity and type 2 diabetes). Psoriasis patients suffering from itch and those with visible and sensitive affected body areas also had impaired QoL vs. those without these conditions.

CONCLUSIONS

Psoriasis patients with physical and psychological comorbidities, itch and affected visible and sensitive body areas had lower QoL and greater work impairment compared to those without these conditions.

No Relation between Psoriasis and Renal Abnormalities: A Case-Control Study

Multiple observational studies have demonstrated that psoriasis is associated with nephropathy; however, the renal involvement in psoriasis remains largely a matter of debate. The current study was designed to investigate if psoriatic patients are at increased risk of renal abnormalities, in absence of any other comorbidities. Forty patients (11 women, 29 men, mean age 44.9 ± 15.45 years) with moderate to severe chronic plaque type psoriasis who were not under systemic therapy and 40 age- and gender-matched control subjects were enrolled in the study. Patients and controls with history of diabetes, hypertension, and chronic renal disease were excluded. Urinalysis by dipstick and microscopic evaluation and 24 h proteinuria and albuminuria were measured in all patients and controls. Patients with psoriasis and controls were not significantly different with respect to the prevalence of abnormal urinalysis (7.5% versus 5%, P = 1.0), mean 24 h proteinuria (70.40 ± 24.38 mg/24 h versus 89.40 ± 26.78 mg/24 h, P = 0.30), and albuminuria (14.15 ± 8.12 mg/24 h versus 16.62 ± 8.21 mg/24 h, P = 0.18). The presence of abnormal urinalysis was not more common in patients with psoriasis than in controls. Our study demonstrated that psoriatic patients without any other comorbidities are not at increased risk of kidney disease.