The link between psoriasis and other medical conditions such as psoriatic arthritis (PsA), cardiovascular disease, metabolic disorder, inflammatory bowel disease, psychiatric disorders, lymphoma and ocular disease is being recognized by a growing body of peer review literature. Adults and children with severe psoriasis appear to have a higher likelihood of such comorbidities and an increased risk of mortality.1-9
Experts contend that psoriasis care should be more comprehensive. “It’s time to stop looking at psoriasis as just a skin disease. It’s a systemic disease as much as anything else,” explains Gary Goldenberg, MD, assistant professor of dermatology and pathology in the departments of dermatology and pathology at the Icahn School of Medicine at Mount Sinai in New York, NY. When considering treatment options of psoriasis with biologics and other drugs, dermatologists must consider a patient’s overall health situation. For example, clinicians also need to factor in “patient comorbidities, such as heart failure or multiple sclerosis, and determine if biologic therapy will improve or worsen these comorbidities,” says Mark Lebwohl, MD, chair of department of dermatology at the Icahn School of Medicine at Mount Sinai and chairman emeritus of the National Psoriasis Foundation (NPF) Medical Board. (For more on Drs. Goldenberg and Lebwohl’s perspective on psoriasis see The Dermatologist’s Biologics & Beyond supplement.)
Incidence
Psoriasis is a chronic inflammatory skin disease that affects approximately 2% to 3% of the adult population in the United States.9 Studies show that psoriasis primarily peaks in the second and fifth decades of life. Presentation ranges from mild and limited to one area of the body to more severe and generalized.9,10 The etiology of psoriasis is still being elucidated, and researchers are looking at a combination of genetic and environmental factors.10-12
Psoriatic Arthritis
PsA, a chronic, inflammatory arthritis that causes pain, swelling and stiffness of the joints and tendons, is considered the most common extracutaneous manifestation of psoriasis.13 It is estimated that at least 11% of Americans with psoriasis have been diagnosed with PsA. NPF estimates that up to 30% of the 7.5 million Americans with psoriasis will eventually develop PsA.
“In 85% of individuals, skin disease of psoriasis precedes joint disease,” notes Andrew Robertson, PhD, chief scientific and medical officer of the NPF, in his Voices guest commentary in the May 2014 The Dermatologist.
“Despite the prevalence and seriousness of PsA, it remains underdiagnosed and undertreated. According to NPF research from 2011, nearly 1 in 4 people with psoriasis may have undiagnosed PsA,” he says, adding that dermatologists should be on the look out for PsA with their psoriasis patients.
Other Comorbidities
A recent study by Yeung et al6 published in JAMA Dermatology demonstrates that psoriasis is linked to an increased presence of other diseases that affect the lungs, heart, kidneys, liver and pancreas. University of Pennsylvania researchers conducted a population-based, cross-sectional study using data from The Health Improvement Network (THIN), an electronic medical records database in the United Kingdom to determine the prevalence of major medical comorbidity in patients with psoriasis. The version of THIN used in this study included longitudinal data on 7.5 million patients from 415 general practices. The researchers analyzed data from 9,035 psoriasis patients, age 25 to 64, and 90,350 age- and practice-matched patients without psoriasis. The researchers mailed questionnaires to each patient’s general practitioner to verify psoriasis status. The practitioners rated the severity of psoriasis for each patient as mild, moderate or severe considering the amount of body surface area affected. The primary endpoint was the prevalence of major medical comorbidity included in the Charlson comorbidity index.
Among the patients with psoriasis, 51.8%, 35.8% and 12.4%, respectively, had mild, moderate or severe disease. Systemic therapy and/or phototherapy use was recorded before assessment of disease severity in 137 of the patients with mild, 278 with moderate and 322 with severe psoriasis. The mean Charlson comorbidity index was increasingly higher in the psoriasis group versus the control group across all categories of psoriasis severity. A Charlson index scores trend analysis by disease severity showed significant associations. After adjustment for age, sex and follow-up duration, patients with mild, moderate or severe psoriasis had higher odds of having at least 1 major comorbid disease than patients without psoriasis.
Psoriasis was associated with a higher prevalence of chronic pulmonary disease, diabetes, diabetes with systemic complications, mild liver disease, myocardial infarction, peptic ulcer disease, peripheral vascular disease, renal disease and rheumatic disease.
“The burdens of overall medical comorbidity and of specific comorbid diseases increases with increasing disease severity among patients with psoriasis,” the researchers conclude. “Physicians should be aware of these associations in providing comprehensive care to patients with psoriasis, especially those presenting with more severe disease.”6
Results from a study of 88 patients by Orgaz-Molina et al14 confirmed previous research that demonstrates vitamin D insufficiency is linked to higher cardiovascular risk factors in psoriatic patients. The researchers examined the association between vitamin D serum levels and subclinical carotid atherosclerosis (maximal intima-media thickness) in psoriatic patients against a control group. The study findings demonstrated that vitamin D levels were significantly lower in psoriatic patients compared with the control group, despite adjusting for selected confounding factors. A negative association between vitamin D levels and maximal intima-media thickness was also shown. The study also revealed that psoriatic patients with a longer history of disease had significantly higher maximal intima-media thickness versus the control group.14
Elevated Cholesterol
Wu et al15 examined the association between hypercholesterolemia and psoriasis and PsA in a large database of nearly 100,000 females in the United States. The team evaluated whether the level of association was affected by duration of elevated cholesterol and use of cholesterol-lowering treatments. From the Nurses’ Health Study II database, 646 women with psoriasis and 165 of them with PsA were identified. Individuals with psoriasis and hypercholesterolemia usually had a higher body mass index and increased incidence of cardiovascular disease, type 2 diabetes, hypertension and a history of smoking than those without elevated cholesterol.
The research team confirmed that hypercholesterolemia is associated with an elevated risk of psoriasis and psoriasis with PsA. Individuals with a longer history of hypercholesterolemia, (>7 years), were at a higher risk of developing either systemic inflammatory condition. The use of cholesterol-lowering drugs did not affect the level of risk.15
Detecting Psoriasis Comorbidities
A study in Archives of Dermatological Research7 provides suggestions for detecting individual risk factors for comorbidities in patients with psoriasis. The study, conducted by a group of researchers from various institutions in Germany, included 3 broad categories of comorbidities that may occur in psoriasis patients: cardiovascular risk, metabolic syndrome and psychosocial stress and mental illness.
Related to cardiovascular risk, the authors looked at 10 specific risk factors and conclude that 5 are particularly relevant: age, sex, chronic nicotine abuse, dyslipidemia and arterial hypertension. The group examined 2 risk factors (insulin resistance and being overweight/obese) of metabolic syndrome and concluded that both are relevant as individual risk factors for metabolic syndrome in patients with psoriasis.
In an examination of psychosocial stress and mental illness, the researchers note the prevalence of diseases such as depression in psoriasis patients and the increased likelihood of patients who suffer from alcohol and other addictions. The issues are most prominent in patients with severe disease and may affect up to a third of all psoriasis patients. They recommend all psoriasis patients be evaluated and monitored for signs of psychosocial stress and mental illness.
The study includes a checklist of recommendations for detecting individual risk factors for comorbidities in psoriasis patients based on when the investigation was developed. They also note patients should be reassessed yearly.7
References
1. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296(14):1735-1741.
2. Cohen AD, Weitzman D, Dreiher J. Psoriasis and hypertension: a case–control study. Acta Derm Venereol. 2010;90(1):23-26.
3. Christophers E. Comorbidities in psoriasis. Clin Dermatol. 2007;25(6):529-534.
4. Sommer DM, Jenisch S, Suchan M, Christophers E, Weichenthal M. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res. 2006;298(7):321-328.
5. Gelfand JM, Troxel AB, Lewis JD, et al. The risk of mortality in patients with psoriasis: Results from a population-based study. Arch Dermatol. 2007;143(12):1493-1499.
6. Yeung H, Takeshita J, Mehta NN, et al. Psoriasis severity and prevalence of major medical comorbidity: A population-based study. JAMA Dermatol. 2013;149(10):1173-1179.
7. Wohlrab J, Fiedler G, Gerdes S, et al. Recommendations for detection of individual risk for comorbidities in patients with psoriasis. Arch Dermatol Res. 2013;305(2):91-98.
8. Wootton CI, Murphy R. Psoriasis in children: Should we be worried? Br J Dermatol. 2013;168(3):661-663.
9. Haddican, M, and Goldenberg, G. Examining the link: systemic manifestations associated with psoriasis. The Dermatologist. 2012;20(11):26-29.
10. Langley RG, Krueger GG, Griffiths CE. Psoriasis: epidemiology, clinical features, and quality of life. Ann Rheum Dis. 2005;64(suppl 2):ii18-23.
11. Griffiths C, Camp R, Barker J. Psoriasis. In: Champion RH, Burton JL, Burn DA, Breathnach SM, eds. Textbook of Dermatology, 7th ed, Vol. 2. Oxford, United Kingdom: Blackwell Science Publications; 2004:35.1-35.69.
12. Christophers E, Mrowietz U. Psoriasis. In: Freedberg IM, Eisen AZ, Wolf K, Austen KF, Goldsmith LA, Katz SI, eds. Fitzpatrick’s Dermatology in General Medicine, 6th ed. New York, NY: McGraw Hill; 2003:407-435.
13. Onumah N, Kircik LH. Psoriasis and its comorbidities. J Drugs Dermatol. 2012;11(5 suppl):s5-s10.
14. Orgaz-Molina J, Magro-Checa C, Rosales-Alexander JL, et al. Vitamin D insufficiency is associated with higher carotid intima-media thickness in psoriatic patients. Eur J Dermatol. P2014;24(1):53-62.
15. Wu S, Li WQ, Han J, Sun Q, Qureshi AA. Hypercholesterolemia and risk of incident psoriasis and psoriatic arthritis in US women. Arthritis Rheumatol. 2014;66(2):304-310.
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The link between psoriasis and other medical conditions such as psoriatic arthritis (PsA), cardiovascular disease, metabolic disorder, inflammatory bowel disease, psychiatric disorders, lymphoma and ocular disease is being recognized by a growing body of peer review literature. Adults and children with severe psoriasis appear to have a higher likelihood of such comorbidities and an increased risk of mortality.1-9
Experts contend that psoriasis care should be more comprehensive. “It’s time to stop looking at psoriasis as just a skin disease. It’s a systemic disease as much as anything else,” explains Gary Goldenberg, MD, assistant professor of dermatology and pathology in the departments of dermatology and pathology at the Icahn School of Medicine at Mount Sinai in New York, NY. When considering treatment options of psoriasis with biologics and other drugs, dermatologists must consider a patient’s overall health situation. For example, clinicians also need to factor in “patient comorbidities, such as heart failure or multiple sclerosis, and determine if biologic therapy will improve or worsen these comorbidities,” says Mark Lebwohl, MD, chair of department of dermatology at the Icahn School of Medicine at Mount Sinai and chairman emeritus of the National Psoriasis Foundation (NPF) Medical Board. (For more on Drs. Goldenberg and Lebwohl’s perspective on psoriasis see The Dermatologist’s Biologics & Beyond supplement.)
Incidence
Psoriasis is a chronic inflammatory skin disease that affects approximately 2% to 3% of the adult population in the United States.9 Studies show that psoriasis primarily peaks in the second and fifth decades of life. Presentation ranges from mild and limited to one area of the body to more severe and generalized.9,10 The etiology of psoriasis is still being elucidated, and researchers are looking at a combination of genetic and environmental factors.10-12
Psoriatic Arthritis
PsA, a chronic, inflammatory arthritis that causes pain, swelling and stiffness of the joints and tendons, is considered the most common extracutaneous manifestation of psoriasis.13 It is estimated that at least 11% of Americans with psoriasis have been diagnosed with PsA. NPF estimates that up to 30% of the 7.5 million Americans with psoriasis will eventually develop PsA.
“In 85% of individuals, skin disease of psoriasis precedes joint disease,” notes Andrew Robertson, PhD, chief scientific and medical officer of the NPF, in his Voices guest commentary in the May 2014 The Dermatologist.
“Despite the prevalence and seriousness of PsA, it remains underdiagnosed and undertreated. According to NPF research from 2011, nearly 1 in 4 people with psoriasis may have undiagnosed PsA,” he says, adding that dermatologists should be on the look out for PsA with their psoriasis patients.
Other Comorbidities
A recent study by Yeung et al6 published in JAMA Dermatology demonstrates that psoriasis is linked to an increased presence of other diseases that affect the lungs, heart, kidneys, liver and pancreas. University of Pennsylvania researchers conducted a population-based, cross-sectional study using data from The Health Improvement Network (THIN), an electronic medical records database in the United Kingdom to determine the prevalence of major medical comorbidity in patients with psoriasis. The version of THIN used in this study included longitudinal data on 7.5 million patients from 415 general practices. The researchers analyzed data from 9,035 psoriasis patients, age 25 to 64, and 90,350 age- and practice-matched patients without psoriasis. The researchers mailed questionnaires to each patient’s general practitioner to verify psoriasis status. The practitioners rated the severity of psoriasis for each patient as mild, moderate or severe considering the amount of body surface area affected. The primary endpoint was the prevalence of major medical comorbidity included in the Charlson comorbidity index.
Among the patients with psoriasis, 51.8%, 35.8% and 12.4%, respectively, had mild, moderate or severe disease. Systemic therapy and/or phototherapy use was recorded before assessment of disease severity in 137 of the patients with mild, 278 with moderate and 322 with severe psoriasis. The mean Charlson comorbidity index was increasingly higher in the psoriasis group versus the control group across all categories of psoriasis severity. A Charlson index scores trend analysis by disease severity showed significant associations. After adjustment for age, sex and follow-up duration, patients with mild, moderate or severe psoriasis had higher odds of having at least 1 major comorbid disease than patients without psoriasis.
Psoriasis was associated with a higher prevalence of chronic pulmonary disease, diabetes, diabetes with systemic complications, mild liver disease, myocardial infarction, peptic ulcer disease, peripheral vascular disease, renal disease and rheumatic disease.
“The burdens of overall medical comorbidity and of specific comorbid diseases increases with increasing disease severity among patients with psoriasis,” the researchers conclude. “Physicians should be aware of these associations in providing comprehensive care to patients with psoriasis, especially those presenting with more severe disease.”6
Results from a study of 88 patients by Orgaz-Molina et al14 confirmed previous research that demonstrates vitamin D insufficiency is linked to higher cardiovascular risk factors in psoriatic patients. The researchers examined the association between vitamin D serum levels and subclinical carotid atherosclerosis (maximal intima-media thickness) in psoriatic patients against a control group. The study findings demonstrated that vitamin D levels were significantly lower in psoriatic patients compared with the control group, despite adjusting for selected confounding factors. A negative association between vitamin D levels and maximal intima-media thickness was also shown. The study also revealed that psoriatic patients with a longer history of disease had significantly higher maximal intima-media thickness versus the control group.14
Elevated Cholesterol
Wu et al15 examined the association between hypercholesterolemia and psoriasis and PsA in a large database of nearly 100,000 females in the United States. The team evaluated whether the level of association was affected by duration of elevated cholesterol and use of cholesterol-lowering treatments. From the Nurses’ Health Study II database, 646 women with psoriasis and 165 of them with PsA were identified. Individuals with psoriasis and hypercholesterolemia usually had a higher body mass index and increased incidence of cardiovascular disease, type 2 diabetes, hypertension and a history of smoking than those without elevated cholesterol.
The research team confirmed that hypercholesterolemia is associated with an elevated risk of psoriasis and psoriasis with PsA. Individuals with a longer history of hypercholesterolemia, (>7 years), were at a higher risk of developing either systemic inflammatory condition. The use of cholesterol-lowering drugs did not affect the level of risk.15
Detecting Psoriasis Comorbidities
A study in Archives of Dermatological Research7 provides suggestions for detecting individual risk factors for comorbidities in patients with psoriasis. The study, conducted by a group of researchers from various institutions in Germany, included 3 broad categories of comorbidities that may occur in psoriasis patients: cardiovascular risk, metabolic syndrome and psychosocial stress and mental illness.
Related to cardiovascular risk, the authors looked at 10 specific risk factors and conclude that 5 are particularly relevant: age, sex, chronic nicotine abuse, dyslipidemia and arterial hypertension. The group examined 2 risk factors (insulin resistance and being overweight/obese) of metabolic syndrome and concluded that both are relevant as individual risk factors for metabolic syndrome in patients with psoriasis.
In an examination of psychosocial stress and mental illness, the researchers note the prevalence of diseases such as depression in psoriasis patients and the increased likelihood of patients who suffer from alcohol and other addictions. The issues are most prominent in patients with severe disease and may affect up to a third of all psoriasis patients. They recommend all psoriasis patients be evaluated and monitored for signs of psychosocial stress and mental illness.
The study includes a checklist of recommendations for detecting individual risk factors for comorbidities in psoriasis patients based on when the investigation was developed. They also note patients should be reassessed yearly.7
References
1. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296(14):1735-1741.
2. Cohen AD, Weitzman D, Dreiher J. Psoriasis and hypertension: a case–control study. Acta Derm Venereol. 2010;90(1):23-26.
3. Christophers E. Comorbidities in psoriasis. Clin Dermatol. 2007;25(6):529-534.
4. Sommer DM, Jenisch S, Suchan M, Christophers E, Weichenthal M. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res. 2006;298(7):321-328.
5. Gelfand JM, Troxel AB, Lewis JD, et al. The risk of mortality in patients with psoriasis: Results from a population-based study. Arch Dermatol. 2007;143(12):1493-1499.
6. Yeung H, Takeshita J, Mehta NN, et al. Psoriasis severity and prevalence of major medical comorbidity: A population-based study. JAMA Dermatol. 2013;149(10):1173-1179.
7. Wohlrab J, Fiedler G, Gerdes S, et al. Recommendations for detection of individual risk for comorbidities in patients with psoriasis. Arch Dermatol Res. 2013;305(2):91-98.
8. Wootton CI, Murphy R. Psoriasis in children: Should we be worried? Br J Dermatol. 2013;168(3):661-663.
9. Haddican, M, and Goldenberg, G. Examining the link: systemic manifestations associated with psoriasis. The Dermatologist. 2012;20(11):26-29.
10. Langley RG, Krueger GG, Griffiths CE. Psoriasis: epidemiology, clinical features, and quality of life. Ann Rheum Dis. 2005;64(suppl 2):ii18-23.
11. Griffiths C, Camp R, Barker J. Psoriasis. In: Champion RH, Burton JL, Burn DA, Breathnach SM, eds. Textbook of Dermatology, 7th ed, Vol. 2. Oxford, United Kingdom: Blackwell Science Publications; 2004:35.1-35.69.
12. Christophers E, Mrowietz U. Psoriasis. In: Freedberg IM, Eisen AZ, Wolf K, Austen KF, Goldsmith LA, Katz SI, eds. Fitzpatrick’s Dermatology in General Medicine, 6th ed. New York, NY: McGraw Hill; 2003:407-435.
13. Onumah N, Kircik LH. Psoriasis and its comorbidities. J Drugs Dermatol. 2012;11(5 suppl):s5-s10.
14. Orgaz-Molina J, Magro-Checa C, Rosales-Alexander JL, et al. Vitamin D insufficiency is associated with higher carotid intima-media thickness in psoriatic patients. Eur J Dermatol. P2014;24(1):53-62.
15. Wu S, Li WQ, Han J, Sun Q, Qureshi AA. Hypercholesterolemia and risk of incident psoriasis and psoriatic arthritis in US women. Arthritis Rheumatol. 2014;66(2):304-310.
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The link between psoriasis and other medical conditions such as psoriatic arthritis (PsA), cardiovascular disease, metabolic disorder, inflammatory bowel disease, psychiatric disorders, lymphoma and ocular disease is being recognized by a growing body of peer review literature. Adults and children with severe psoriasis appear to have a higher likelihood of such comorbidities and an increased risk of mortality.1-9
Experts contend that psoriasis care should be more comprehensive. “It’s time to stop looking at psoriasis as just a skin disease. It’s a systemic disease as much as anything else,” explains Gary Goldenberg, MD, assistant professor of dermatology and pathology in the departments of dermatology and pathology at the Icahn School of Medicine at Mount Sinai in New York, NY. When considering treatment options of psoriasis with biologics and other drugs, dermatologists must consider a patient’s overall health situation. For example, clinicians also need to factor in “patient comorbidities, such as heart failure or multiple sclerosis, and determine if biologic therapy will improve or worsen these comorbidities,” says Mark Lebwohl, MD, chair of department of dermatology at the Icahn School of Medicine at Mount Sinai and chairman emeritus of the National Psoriasis Foundation (NPF) Medical Board. (For more on Drs. Goldenberg and Lebwohl’s perspective on psoriasis see The Dermatologist’s Biologics & Beyond supplement.)
Incidence
Psoriasis is a chronic inflammatory skin disease that affects approximately 2% to 3% of the adult population in the United States.9 Studies show that psoriasis primarily peaks in the second and fifth decades of life. Presentation ranges from mild and limited to one area of the body to more severe and generalized.9,10 The etiology of psoriasis is still being elucidated, and researchers are looking at a combination of genetic and environmental factors.10-12
Psoriatic Arthritis
PsA, a chronic, inflammatory arthritis that causes pain, swelling and stiffness of the joints and tendons, is considered the most common extracutaneous manifestation of psoriasis.13 It is estimated that at least 11% of Americans with psoriasis have been diagnosed with PsA. NPF estimates that up to 30% of the 7.5 million Americans with psoriasis will eventually develop PsA.
“In 85% of individuals, skin disease of psoriasis precedes joint disease,” notes Andrew Robertson, PhD, chief scientific and medical officer of the NPF, in his Voices guest commentary in the May 2014 The Dermatologist.
“Despite the prevalence and seriousness of PsA, it remains underdiagnosed and undertreated. According to NPF research from 2011, nearly 1 in 4 people with psoriasis may have undiagnosed PsA,” he says, adding that dermatologists should be on the look out for PsA with their psoriasis patients.
Other Comorbidities
A recent study by Yeung et al6 published in JAMA Dermatology demonstrates that psoriasis is linked to an increased presence of other diseases that affect the lungs, heart, kidneys, liver and pancreas. University of Pennsylvania researchers conducted a population-based, cross-sectional study using data from The Health Improvement Network (THIN), an electronic medical records database in the United Kingdom to determine the prevalence of major medical comorbidity in patients with psoriasis. The version of THIN used in this study included longitudinal data on 7.5 million patients from 415 general practices. The researchers analyzed data from 9,035 psoriasis patients, age 25 to 64, and 90,350 age- and practice-matched patients without psoriasis. The researchers mailed questionnaires to each patient’s general practitioner to verify psoriasis status. The practitioners rated the severity of psoriasis for each patient as mild, moderate or severe considering the amount of body surface area affected. The primary endpoint was the prevalence of major medical comorbidity included in the Charlson comorbidity index.
Among the patients with psoriasis, 51.8%, 35.8% and 12.4%, respectively, had mild, moderate or severe disease. Systemic therapy and/or phototherapy use was recorded before assessment of disease severity in 137 of the patients with mild, 278 with moderate and 322 with severe psoriasis. The mean Charlson comorbidity index was increasingly higher in the psoriasis group versus the control group across all categories of psoriasis severity. A Charlson index scores trend analysis by disease severity showed significant associations. After adjustment for age, sex and follow-up duration, patients with mild, moderate or severe psoriasis had higher odds of having at least 1 major comorbid disease than patients without psoriasis.
Psoriasis was associated with a higher prevalence of chronic pulmonary disease, diabetes, diabetes with systemic complications, mild liver disease, myocardial infarction, peptic ulcer disease, peripheral vascular disease, renal disease and rheumatic disease.
“The burdens of overall medical comorbidity and of specific comorbid diseases increases with increasing disease severity among patients with psoriasis,” the researchers conclude. “Physicians should be aware of these associations in providing comprehensive care to patients with psoriasis, especially those presenting with more severe disease.”6
Results from a study of 88 patients by Orgaz-Molina et al14 confirmed previous research that demonstrates vitamin D insufficiency is linked to higher cardiovascular risk factors in psoriatic patients. The researchers examined the association between vitamin D serum levels and subclinical carotid atherosclerosis (maximal intima-media thickness) in psoriatic patients against a control group. The study findings demonstrated that vitamin D levels were significantly lower in psoriatic patients compared with the control group, despite adjusting for selected confounding factors. A negative association between vitamin D levels and maximal intima-media thickness was also shown. The study also revealed that psoriatic patients with a longer history of disease had significantly higher maximal intima-media thickness versus the control group.14
Elevated Cholesterol
Wu et al15 examined the association between hypercholesterolemia and psoriasis and PsA in a large database of nearly 100,000 females in the United States. The team evaluated whether the level of association was affected by duration of elevated cholesterol and use of cholesterol-lowering treatments. From the Nurses’ Health Study II database, 646 women with psoriasis and 165 of them with PsA were identified. Individuals with psoriasis and hypercholesterolemia usually had a higher body mass index and increased incidence of cardiovascular disease, type 2 diabetes, hypertension and a history of smoking than those without elevated cholesterol.
The research team confirmed that hypercholesterolemia is associated with an elevated risk of psoriasis and psoriasis with PsA. Individuals with a longer history of hypercholesterolemia, (>7 years), were at a higher risk of developing either systemic inflammatory condition. The use of cholesterol-lowering drugs did not affect the level of risk.15
Detecting Psoriasis Comorbidities
A study in Archives of Dermatological Research7 provides suggestions for detecting individual risk factors for comorbidities in patients with psoriasis. The study, conducted by a group of researchers from various institutions in Germany, included 3 broad categories of comorbidities that may occur in psoriasis patients: cardiovascular risk, metabolic syndrome and psychosocial stress and mental illness.
Related to cardiovascular risk, the authors looked at 10 specific risk factors and conclude that 5 are particularly relevant: age, sex, chronic nicotine abuse, dyslipidemia and arterial hypertension. The group examined 2 risk factors (insulin resistance and being overweight/obese) of metabolic syndrome and concluded that both are relevant as individual risk factors for metabolic syndrome in patients with psoriasis.
In an examination of psychosocial stress and mental illness, the researchers note the prevalence of diseases such as depression in psoriasis patients and the increased likelihood of patients who suffer from alcohol and other addictions. The issues are most prominent in patients with severe disease and may affect up to a third of all psoriasis patients. They recommend all psoriasis patients be evaluated and monitored for signs of psychosocial stress and mental illness.
The study includes a checklist of recommendations for detecting individual risk factors for comorbidities in psoriasis patients based on when the investigation was developed. They also note patients should be reassessed yearly.7
References
1. Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006;296(14):1735-1741.
2. Cohen AD, Weitzman D, Dreiher J. Psoriasis and hypertension: a case–control study. Acta Derm Venereol. 2010;90(1):23-26.
3. Christophers E. Comorbidities in psoriasis. Clin Dermatol. 2007;25(6):529-534.
4. Sommer DM, Jenisch S, Suchan M, Christophers E, Weichenthal M. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res. 2006;298(7):321-328.
5. Gelfand JM, Troxel AB, Lewis JD, et al. The risk of mortality in patients with psoriasis: Results from a population-based study. Arch Dermatol. 2007;143(12):1493-1499.
6. Yeung H, Takeshita J, Mehta NN, et al. Psoriasis severity and prevalence of major medical comorbidity: A population-based study. JAMA Dermatol. 2013;149(10):1173-1179.
7. Wohlrab J, Fiedler G, Gerdes S, et al. Recommendations for detection of individual risk for comorbidities in patients with psoriasis. Arch Dermatol Res. 2013;305(2):91-98.
8. Wootton CI, Murphy R. Psoriasis in children: Should we be worried? Br J Dermatol. 2013;168(3):661-663.
9. Haddican, M, and Goldenberg, G. Examining the link: systemic manifestations associated with psoriasis. The Dermatologist. 2012;20(11):26-29.
10. Langley RG, Krueger GG, Griffiths CE. Psoriasis: epidemiology, clinical features, and quality of life. Ann Rheum Dis. 2005;64(suppl 2):ii18-23.
11. Griffiths C, Camp R, Barker J. Psoriasis. In: Champion RH, Burton JL, Burn DA, Breathnach SM, eds. Textbook of Dermatology, 7th ed, Vol. 2. Oxford, United Kingdom: Blackwell Science Publications; 2004:35.1-35.69.
12. Christophers E, Mrowietz U. Psoriasis. In: Freedberg IM, Eisen AZ, Wolf K, Austen KF, Goldsmith LA, Katz SI, eds. Fitzpatrick’s Dermatology in General Medicine, 6th ed. New York, NY: McGraw Hill; 2003:407-435.
13. Onumah N, Kircik LH. Psoriasis and its comorbidities. J Drugs Dermatol. 2012;11(5 suppl):s5-s10.
14. Orgaz-Molina J, Magro-Checa C, Rosales-Alexander JL, et al. Vitamin D insufficiency is associated with higher carotid intima-media thickness in psoriatic patients. Eur J Dermatol. P2014;24(1):53-62.
15. Wu S, Li WQ, Han J, Sun Q, Qureshi AA. Hypercholesterolemia and risk of incident psoriasis and psoriatic arthritis in US women. Arthritis Rheumatol. 2014;66(2):304-310.
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