Prevalence of metabolic syndrome in patients with psoriasis: a population-based study in the United Kingdom. J Invest Dermatol. 2012;132:556-562. [PMID: 22113483 PMCID: PMC3278499 DOI: 10.1038/jid.2011.365]

Cost per responder of biologic drugs used in the treatment of moderate-to-severe plaque psoriasis in France and Germany

OBJECTIVE

The treatment of moderate-to-severe plaque psoriasis has seen significant improvements in recent years with the advent of biologic drugs. The aim of this study was to assess the cost-effectiveness of anti-IL17 drugs and other biologic therapies used to treat moderate-to-severe plaque psoriasis in France and Germany over a one-year time horizon.

METHODS

We developed a cost per responder model for biologic drugs used in psoriasis treatment. The model included anti-IL17s (brodalumab, secukinumab, ixekizumab and bimekizumab), anti-TNFs (adalimumab, etanercept, certolizumab and infliximab), an anti-IL12/23 (ustekinumab), and anti-IL23s (risankizumab, guselkumab and tildrakizumab). Efficacy estimates were collected through a systematic literature review of network meta-analyses on long-term Psoriasis Area and Severity Index (PASI) measures. Dose recommendations and country-specific prices were used to calculate drug costs. Biosimilar drug prices were used when available as a substitute for the originator drugs.

RESULTS

After one year, brodalumab had the lowest cost per PASI100-responder in both France (€20,220) and Germany (€26,807) across all available biologic treatments. Among the anti-IL17s, brodalumab had a 23% lower cost per PASI100-responder vs. the nearest comparator in France (bimekizumab, €26,369), and 30% lower vs. nearest comparator in Germany (ixekizumab, €38,027). Brodalumab also had the lowest cost per PASI75- and PASI90-responder among the anti-IL17s in both France and Germany after one year. Adalimumab had the lowest cost per PASI100-responder among the anti-TNFs in both France (€23,418) and Germany (€38,264). Among the anti-IL-23s, risankizumab had the lowest cost per PASI100-responder in both France (€20,969) and Germany (€26,994).

CONCLUSION

Driven by its lower costs and high response rates, brodalumab was the most cost-effective treatment option for moderate-to-severe plaque psoriasis over a one-year time-horizon within the anti-IL17 class and when compared to all other biologics in France and Germany.

Cardiovascular Screening Practices and Statin Prescription Habits in Patients with Psoriasis among Dermatologists, Rheumatologists and Primary Care Physicians

Patients with psoriasis have a higher prevalence of cardiovascular risk factors. This study evaluated cardiovascular screening practices and statin prescribing habits among dermatologists, rheumatologists and primary care physicians (PCPs) through an online questionnaire, which was distributed through the Spanish scientific societies of the above-mentioned specialties. A total of 299 physicians (103 dermatologists, 94 rheumatologists and 102 PCPs) responded to the questionnaire. Of these, 74.6% reported screening for smoking, 37.8% for hypertension, 80.3% for dyslipidaemia, and 79.6% for diabetes mellitus. Notably, only 28.4% performed global screening, defined as screening for smoking, hypertension, dyslipidaemia, and diabetes mellitus by the same physician, and 24.4% reported calculating 10-year cardiovascular disease (CVD) risk, probably reflecting a lack of comprehensive cardiovascular risk assessment in these patients. This study also identified unmet needs for awareness of cardiovascular comorbidities in psoriasis and corresponding screening and treatment recommendations among PCPs. Of PCPs, 61.2% reported not being aware of the association between psoriasis and CVD and/or not being aware of its screening recommendations, and 67.6% did not consider psoriasis as a risk-enhancing factor when deciding on statin prescription. Thirteen dermatologists (12.6%) and 35 rheumatologists (37.2%) reported prescribing statins. Among those who do not prescribe, 49.7% would be willing to start their prescription. 

Liver fibrosis for the dermatologist: a review

Methotrexate-induced liver fibrosis is not a well-defined pathology, and many of the reported cases can instead be classified as nonalcoholic fatty liver disease by current diagnostic criteria, which is particularly common in the psoriasis cohort. Liver fibrosis usually takes many years to progress; therefore, screening for liver fibrosis should be done no more regularly than annually at the very most in dermatology practice. An algorithm is presented about how to investigate abnormal liver blood tests and screening tools for liver fibrosis are compared.

Advanced Glycation End Products and Psoriasis

Advanced glycation end products (AGEs) are biologically active compounds formed physiologically throughout a sequence of chemical reactions, to generate highly oxidant-reactive aldehydes that combine covalently to proteins. They accumulate slowly in tissues during ageing but also in metabolic and selected inflammatory disorders. Accumulation of AGEs occurs more rapidly and intensely in the skin and serum of patients with type 2 diabetes, obesity, cardiovascular diseases, chronic renal insufficiency, and non-alcoholic fatty liver disease and also in the skin of patients with psoriasis. All of the above conditions are intimately associated with psoriasis. Interaction of AGEs with their receptors (RAGEs) stimulates cellular signaling with the formation of reactive oxygen species and activation of nuclear factor kappa light chain enhancer of activated B (NF-kB), which is a key regulator in the expression of inflammatory mediators and the production of oxidative stress. Thus, AGEs may play an interesting pathogenic role in the intersection of inflammatory and metabolic diseases, may represent a biomarker of inflammation and a potential target for novel therapeutic strategies. This is a narrative review with the objective to summarize current evidence on the role of AGEs in psoriasis.

Dermatology Life Quality Index in Patients with Psoriasis Treated with Biologic Versus Non-biologic Treatment in Malaysia: A Retrospective Cross-Sectional Study

BACKGROUND

Psoriasis imposes a substantial burden on patients' social, emotional, physical, and family life. Although psoriasis has no complete cure, various treatments are available to control its symptoms and improve a patients' quality of life.

OBJECTIVE

We aimed to compare the effectiveness of biologic versus non-biologic treatments on health-related quality of life among patients with psoriasis in Malaysia.

METHODS

This retrospective cross-sectional study evaluated data of adult patients diagnosed with psoriasis during 2007-18 from the Malaysian Psoriasis Registry. Baseline demographics, disease, and treatment characteristics were described. For a subset of patients treated with biologics and non-biologics who had baseline and 6-month follow-up data available, changes in the mean Dermatology Life Quality Index scores and the proportion of patients with a clinically relevant improvement (≥ 4 points) post-treatment were assessed.

RESULTS

Overall, 15,238 adult patients with psoriasis from the Malaysian Psoriasis Registry were included in the analysis. Patients receiving biologics showed a statistically significant reduction in the mean Dermatology Life Quality Index scores after 6 months compared with those receiving non-biologic treatment (- 5.7 vs - 0.8%; p < 0.001). The proportion of patients who achieved a ≥ 4-point improvement in Dermatology Life Quality Index scores was approximately two times greater in the biologic-treated group versus the non-biologic-treated group (56.4 vs 27.7%).

CONCLUSIONS

Biologic treatment showed a greater reduction in the Dermatology Life Quality Index scores of patients with psoriasis versus non-biologic treatment. These results highlight the importance of early treatment with more efficacious treatment options, such as biologic therapies, to improve the overall health-related quality of life of patients with psoriasis.

Association of Apremilast With Vascular Inflammation and Cardiometabolic Function in Patients With Psoriasis: The VIP-A Phase 4, Open-label, Nonrandomized Clinical Trial

Importance

Psoriasis is an inflammatory condition associated with metabolic and cardiovascular disease. Apremilast, a phosphodiesterase 4 inhibitor, is commonly used for psoriasis and can cause weight loss.

Objective

To determine the association between apremilast and aortic vascular inflammation as assessed by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), cardiometabolic markers (primary outcomes at week 16), and abdominal fat composition.

Design, Setting, and Participants

A single-arm, open-label, interventional, nonrandomized clinical trial in which the imaging and laboratory outcomes were measured by an investigator who was blinded to time was conducted between April 11, 2017, and August 17, 2021, at 7 dermatology sites in the United States. A total of 101 patients with moderate to severe psoriasis were screened, 70 enrolled, 60 completed week 16, and 39 completed week 52.

Intervention

Apremilast, 30 mg, twice daily.

Main Outcomes and Measures

Aortic vascular inflammation (measured by FDG-PET/CT), 68 cardiometabolic biomarkers, and abdominal fat composition (measured by CT) at week 16 and week 52 compared with baseline.

Results

The mean (SD) age of the 70 patients was 47.5 (14.6) years, 54 were male (77.1%), 4 were Black (5.7%), and 58 were White (82.9%). There was no change in aortic vascular inflammation at week 16 (target to background ratio, -0.02; 95% CI, -0.08 to 0.05; P = .61) or week 52 (target to background ratio, -0.07; 95% CI, -0.15 to 0.01; P = .09) compared with baseline. At week 16, potentially beneficial decreases in interleukin 1b, valine, leucine, isoleucine, fetuin A, and branched-chain amino acids were observed. At week 52 compared with baseline, potentially beneficial decreases in ferritin, β-hydroxybutyrate, acetone, and ketone bodies, with an increase in apolipoprotein A-1, were observed, but there was a reduction in cholesterol efflux. There was an approximately 5% to 6% reduction in subcutaneous and visceral adiposity at week 16 that was maintained at week 52.

Conclusions and Relevance

The findings of this nonrandomized clinical trial suggest that apremilast has a neutral association with aortic vascular inflammation, variable but generally beneficial associations with a subset of cardiometabolic biomarkers, and associations with reductions in visceral and subcutaneous fat, indicating that the drug may have an overall benefit for patients with cardiometabolic disease and psoriasis.

Trial Registration

ClinicalTrials.gov Identifier: NCT03082729.

Clinical Efficacy and Safety of Psoriasis Treatments in Patients with Concomitant Metabolic Syndrome: A Narrative Review

Metabolic syndrome (MetS) is well recognized as a frequent comorbidity of psoriasis with important implications for efficacy and safety of psoriasis treatment. The presence of concomitant MetS is associated with decreased efficacy response to biologic treatment for psoriasis in observational studies. In post hoc analyses of clinical trial data, the anti–IL-23p19 antibody tildrakizumab appears to maintain efficacy in patients compared to those without MetS; no published subgroup analyses by MetS status are yet available for other biologics. However, there is some evidence that obese patients have decreased psoriasis treatment efficacy with biologics with certain mechanisms of action relative to overweight patients. This confounds interpretation of the effect of MetS due to the association between MetS and body weight. Because of the association between MetS and cardiovascular risk, treatment of psoriasis in patients with concomitant MetS requires special consideration for cardiovascular safety and attention to potential for exacerbation of MetS and related conditions, including nonalcoholic fatty liver disease. Additional studies are needed to clarify the risks for treatment failure and cardiovascular safety concerns in patients with psoriasis and concomitant MetS.

Psoriasis and Cardiometabolic Diseases: Shared Genetic and Molecular Pathways

A convincing deal of evidence supports the fact that severe psoriasis is associated with cardiovascular diseases. However, the precise underlying mechanisms linking psoriasis and cardiovascular diseases are not well defined. Psoriasis shares common pathophysiologic mechanisms with atherosclerosis and cardiovascular (CV) risk factors. In particular, polymorphism in the IL-23R and IL-23 genes, as well as other genes involved in lipid and fatty-acid metabolism, renin-angiotensin system and endothelial function, have been described in patients with psoriasis and with cardiovascular risk factors. Moreover, systemic inflammation in patients with psoriasis, including elevated serum proinflammatory cytokines (e.g., TNF-α, IL-17, and IL-23) may contribute to an increased risk of atherosclerosis, hypertension, alteration of serum lipid composition, and insulin resistance. The nonlinear and intricate interplay among various factors, impacting the molecular pathways in different cell types, probably contributes to the development of psoriasis and cardiovascular disease (CVD). Future research should, therefore, aim to fully unravel shared and differential molecular pathways underpinning the association between psoriasis and CVD.

Saliva may predict quality of life in psoriasis as measured by Fourier transform infrared spectroscopy (FTIR) and chemometrics

BACKGROUND

Psoriasis is a chronic skin disease, with several comorbidities, such as psoriatic arthritis, inflammatory bowel disease, metabolic syndrome, and impaired quality of life and work activity. The Dermatology Life Quality Index (DLQI) is the most commonly used quality of life index in psoriatic patients, as it is a marker of severe disease. This study evaluated the association between salivary Fourier transform Infrared Spectroscopy (FTIR) metabolic fingerprints and severity of psoriasis as measured by DLQI, using chemometric algorithms.

MATERIALS AND METHODS

Saliva was collected from 56 (27 with DLQI ≤ 10 [GI]; 29 with DLQI > 10 [GII]) psoriatic patients diagnosed and assessed by DLQI for disease severity by a dermatologist and analyzed by the transflectance technique in mid-infrared. Hierarchic cluster analysis (HCA), principal component analysis (PCA), orthogonal partial least squares discriminant analysis (OPLS-DA) and orthogonal partial least squares (OPLS) algorithms were used to associate salivary FTIR spectra with the respective DLQI scores.

RESULTS

Second derivative (2D) discriminated GI and GII at 2522 cm^-1 (p < 0.0001). HCA and PCA partially discriminated GI from GII at 4000-450 cm^-1 (p = 0.042 and 0.00821, respectively). Data processing with 1^st derivative (1D), 3 latent variables (LV) and 1 orthogonal signal correction (OSC) component at 2550-1801 cm^-1 generated an FTIR/OPLS-DA model with 100% accuracy to classify the severity of psoriasis, and an FTIR/OPLS model to quantify DLQI (range 0-28) with high performance: root mean square error of prediction (RMSEP) < 0.01 and coefficient of determination (R²) > 0.9999.

CONCLUSIONS

Salivary FTIR combined with chemometric algorithms such as OPLS-DA and OPLS can be used as a clinical tool to classify or predict the severity of psoriasis according to DLQI in patients with confirmed psoriasis.

Exploring the Links between Obesity and Psoriasis: A Comprehensive Review

Obesity is a major public health issue worldwide since it is associated with the development of chronic comorbidities such as type 2 diabetes, dyslipidemias, atherosclerosis, some cancer forms and skin diseases, including psoriasis. Scientific evidence has indicated that the possible link between obesity and psoriasis may be multifactorial, highlighting dietary habits, lifestyle, certain genetic factors and the microbiome as leading factors in the progress of both pathologies because they are associated with a chronic pro-inflammatory state. Thus, inflammation management in obesity is a plausible target for psoriasis, not only because of the sick adipose tissue secretome profile but also due to the relationship of obesity with the rest of the immune derangements associated with psoriasis initiation and maintenance. Hence, this review will provide a general and molecular overview of the relationship between both pathologies and present recent therapeutic advances in treating this problem.

Oxidative Stress Induced by High Salt Diet—Possible Implications for Development and Clinical Manifestation of Cutaneous Inflammation and Endothelial Dysfunction in Psoriasis vulgaris

Although oxidative stress is recognized as an important effector mechanism of the immune system, uncontrolled formation of reactive oxygen and nitrogen species promotes excessive tissue damage and leads to disease development. In view of this, increased dietary salt intake has been found to damage redox systems in the vessel wall, resulting in endothelial dysfunction associated with NO uncoupling, inflammation, vascular wall remodeling and, eventually, atherosclerosis. Several studies have reported increased systemic oxidative stress accompanied by reduced antioxidant capacity following a high salt diet. In addition, vigorous ionic effects on the immune mechanisms, such as (trans)differentiation of T lymphocytes are emerging, which together with the evidence of NaCl accumulation in certain tissues warrants a re-examination of the data derived from in vitro research, in which the ionic influence was excluded. Psoriasis vulgaris (PV), as a primarily Th17-driven inflammatory skin disease with proven inflammation-induced accumulation of sodium chloride in the skin, merits our interest in the role of oxidative stress in the pathogenesis of PV, as well as in the possible beneficial effects that could be achieved through modulation of dietary salt intake and antioxidant supplementation.

Cardiometabolic multimorbidity is common among patients with psoriasis and is associated with poorer outcomes compared to those without comorbidity

BACKGROUND

Associations between cardiometabolic multimorbidity and response to therapy in psoriasis are unknown.

OBJECTIVE

Determine the associations of multimorbidity with response to biologic treatment in psoriasis patients.

METHODS

CorEvitas Psoriasis Registry participants who initiated biologic therapy and had 6-months follow-up were stratified by 0, 1, 2+ comorbidities (diabetes, hypertension, hyperlipidemia). Adjusted odds ratios (95% CIs) were calculated overall and separately by biologic class (TNFi, IL-17i, IL-12/23i + IL-23i), to assess the likelihood of achieving response for the 1 and 2+ groups vs. 0.

RESULTS

Of 2,923 patients, 49.5%, 24.7% and 25.8% reported 0, 1 and 2+ comorbidities, respectively. Overall, likelihood of PASI75 was 18% (OR =0.82; 95%CI: 0.67, 1.00) and 23% (OR =0.77; 95%CI: 0.63, 0.96) lower in those with 1 and 2+ comorbidities, respectively, vs. 0. In those who initiated IL-17i, odds of PASI75 and PAS90 were 34% (OR =0.66; 95%CI: 0.48-0.91) and 35% (OR =0.65; 95%CI: 0.47-0.91) lower in the 2+ multimorbidity cohort. No significant associations were found among users of TNFi or IL-12/23i + IL-23i groups in the multimorbidity group.

LIMITATIONS

Patients may not be representative of all psoriasis patients.

CONCLUSION

Multimorbidity in psoriasis may decrease the likelihood of achieving treatment response to biologic therapy and should be considered when discussing treatment expectations with patients.

Metabolic Syndrome in Psoriasis Is Associated With Upregulation of CXCL16 on Monocytes and a Dysbalance in Innate Lymphoid Cells

Psoriasis is frequently associated with the metabolic syndrome and occurs more often in obese individuals. In order to understand innate immune mechanisms mediating this inflammatory pattern we investigated expression of the chemokine and lipid scavenger receptor CXCL16 in patients with psoriasis and associated comorbidities. CXCL16 expression was enhanced on all monocyte subsets in psoriatic patients compared with healthy controls and positively correlated with psoriasis activity and severity index, body mass index and the risk for cardiovascular disease indicated by PROCAM score. The intensity of CXCL16 expression on monocytes further correlated with their capability to phagocytose oxidized LDL indicating the possibility to transform into foam cells in atherosclerotic plaques. Patients with psoriasis and atherosclerosis or obesity displayed elevated numbers of innate lymphoid cells in blood with specific increase of the IFN-γ or IL-17 producing ILC1 and ILC3 subpopulations. The expression of the CXCL16 receptor, CXCR6, was increased in ILCs and co-expressed with CCR6 but not CCR7 indicating their migratory potential to psoriatic skin or adipose tissue that is characterized by strong CXCL16 and CCL20 expression. This hypothesis was supported by the finding that the percentage of CXCR6 expressing ILCs was alleviated in blood of psoriatic patients. Together these data link a strong expression of CXCL16 to metabolic syndrome in psoriasis and indicate a possible link to ILC activation and tissue distribution in obese psoriatic patients. These data contribute to the understanding of the complex interaction of innate immunity and metabolic state in psoriasis.

Psoriasis and Cardiovascular Diseases: An Immune-Mediated Cross Talk?

Psoriasis is a chronic immune-mediated inflammatory skin disease, characterized by well-demarcated scaly, erythematous, infiltrated plaques. The cutaneous-to-systemic expansion of the inflammation in psoriasis leads to the concept of “psoriatic march” or “inflammatory skin march”. Accordingly, psoriasis is thought to be a systemic inflammatory disease associated with numerous comorbidities. Indeed, it’s currently considered an independent risk factor for cardiovascular diseases. Here, we discuss the current knowledge on TNF-α and IL-23/IL-17 mediated pathways linking the psoriatic plaque to the cardiovascular compartment. We further argue the possible involvement of the endothelial compartment in the psoriatic plaque- cardiovascular system crosstalk.

Comorbidity in Adult Psoriasis: Considerations for the Clinician

Psoriasis is associated with several comorbidities ranging from cardiovascular comorbidity and mental disorders to other immune mediated inflammatory diseases. However, most of these co-morbidities are often overlooked or diagnosed late. Furthermore, evidence suggests that comorbidities are undertreated. Here, we provide an overview of comorbidities in psoriasis and present a simple rundown of considerations of relevance to the clinician. We hope that this review may raise clinicians' awareness of comorbidities in psoriasis and provide simple guidance regarding screening tools and treatment decisions in psoriasis with comorbidities.

Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases

An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.

Global prevalence of metabolic syndrome in patients with psoriasis in the past two decades: current evidence

Patients with psoriasis are at an increased risk of metabolic syndrome (MetS); however, a systematic analysis of its global prevalence has not been performed to date. Here, we performed a systematic review and meta-analysis to assess the prevalence of MetS among patients with psoriasis. We searched five databases from inception through September 2021 and used the Agency for Healthcare Research and Quality (AHRQ) and Newcastle-Ottawa Scale (NOS) tools to assess observational study quality. Stata SE 15.1 was used to perform the data analysis. Subgroup, meta-regression and sensitivity analyses were used to evaluate interstudy heterogeneity. Publication bias was evaluated using Egger's and Begg's linear tests. The global prevalence of MetS in patients with psoriasis was 32% (95% confidence interval [CI], 0.26-0.38). The prevalence in adults was 32% (95% CI, 0.29-0.36), while that in children and adolescents was 9% (95% CI, 0.00-0.18). Latin America had the highest prevalence of 47% (95% CI, 0.43-0.51), whereas North America had the lowest prevalence of 26% (95% CI, 0.16-0.37). Patients with psoriasis vulgaris (29%; 95% CI, 0.23-0.35) or severe psoriasis (37%; 95% CI, 0.27-0.46) had a higher prevalence of MetS than those with other psoriasis types. These findings suggest that MetS should be appropriately recognized and managed in patients with psoriasis. More population-based prospective observational studies are required to elucidate the mechanisms underlying the coexistence of MetS in patients with psoriasis.

Prevalence of cardiovascular risk factors in patients with psoriasis

OBJECTIVES

The main goal of the study was to describe the demographic, epidemiological, clinical and laboratory characteristics of a monitored group of patients with psoriasis to assess the prevalence of cardiovascular comorbidities and to define the cardiovascular risk profile.

METHODS

One hundred and ninety outpatients aged over 18 were included in the prospective observational cross-sectional study. Demographic and clinical data were obtained from patients. The severity of psoriasis was evaluated using the Psoriasis Area and Severity Index (PASI) and the Dermatology Life Quality Index (DLQI). The results of laboratory testing were identified based on patient health records.

RESULTS

Based on an evaluation of psoriasis phenotypes, 150 patients (78.95%) suffered from plaque psoriasis, 18 (9.5%) from palmoplantar psoriasis, 11 (5.8%) from guttate psoriasis, 6 (3.2%) from generalized pustular psoriasis, and 5 (2.6%) from erythrodermic psoriasis. The personal medical history discovered the occurrence of arterial hypertension in 83 patients (43.7%), the occurrence of depression in 49 patients (25.8%), type 2 diabetes in 29 patients (15.3%), and dyslipidaemia in 48 patients (25.3%).

CONCLUSION

It is noteworthy that psoriasis may be demonstrated as a multi-system disease which does not only affect the skin and its adnexa. The association of psoriasis with comorbidities may significantly increase morbidity and total mortality as well as the demands for health care provision.

Systemic pharmacological treatments for chronic plaque psoriasis: a network meta-analysis

BACKGROUND

Psoriasis is an immune-mediated disease with either skin or joints manifestations, or both, and it has a major impact on quality of life. Although there is currently no cure for psoriasis, various treatment strategies allow sustained control of disease signs and symptoms. The relative benefit of these treatments remains unclear due to the limited number of trials comparing them directly head-to-head, which is why we chose to conduct a network meta-analysis.

OBJECTIVES

To compare the efficacy and safety of non-biological systemic agents, small molecules, and biologics for people with moderate-to-severe psoriasis using a network meta-analysis, and to provide a ranking of these treatments according to their efficacy and safety.

SEARCH METHODS

For this update of the living systematic review, we updated our searches of the following databases monthly to October 2021: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of systemic treatments in adults over 18 years with moderate-to-severe plaque psoriasis, at any stage of treatment, compared to placebo or another active agent. The primary outcomes were: proportion of participants who achieved clear or almost clear skin, that is, at least Psoriasis Area and Severity Index (PASI) 90; proportion of participants with serious adverse events (SAEs) at induction phase (8 to 24 weeks after randomisation).

DATA COLLECTION AND ANALYSIS

We conducted duplicate study selection, data extraction, risk of bias assessment and analyses. We synthesised data using pairwise and network meta-analysis (NMA) to compare treatments and rank them according to effectiveness (PASI 90 score) and acceptability (inverse of SAEs). We assessed the certainty of NMA evidence for the two primary outcomes and all comparisons using CINeMA, as very low, low, moderate, or high. We contacted study authors when data were unclear or missing. We used the surface under the cumulative ranking curve (SUCRA) to infer treatment hierarchy, from 0% (worst for effectiveness or safety) to 100% (best for effectiveness or safety).

MAIN RESULTS

This update includes an additional 19 studies, taking the total number of included studies to 167, and randomised participants to 58,912, 67.2% men, mainly recruited from hospitals. Average age was 44.5 years, mean PASI score at baseline was 20.4 (range: 9.5 to 39). Most studies were placebo-controlled (57%). We assessed a total of 20 treatments. Most (140) trials were multicentric (two to 231 centres). One-third of the studies (57/167) had high risk of bias; 23 unclear risk, and most (87) low risk. Most studies (127/167) declared funding by a pharmaceutical company, and 24 studies did not report a funding source. Network meta-analysis at class level showed that all interventions (non-biological systemic agents, small molecules, and biological treatments) showed a higher proportion of patients reaching PASI 90 than placebo. Anti-IL17 treatment showed a higher proportion of patients reaching PASI 90 compared to all the interventions, except anti-IL23. Biologic treatments anti-IL17, anti-IL12/23, anti-IL23 and anti-TNF alpha showed a higher proportion of patients reaching PASI 90 than the non-biological systemic agents. For reaching PASI 90, the most effective drugs when compared to placebo were (SUCRA rank order, all high-certainty evidence): infliximab (risk ratio (RR) 50.19, 95% CI 20.92 to 120.45), bimekizumab (RR 30.27, 95% CI 25.45 to 36.01), ixekizumab (RR 30.19, 95% CI 25.38 to 35.93), risankizumab (RR 28.75, 95% CI 24.03 to 34.39). Clinical effectiveness of these drugs was similar when compared against each other. Bimekizumab, ixekizumab and risankizumab showed a higher proportion of patients reaching PASI 90 than other anti-IL17 drugs (secukinumab and brodalumab) and guselkumab. Infliximab, anti-IL17 drugs (bimekizumab, ixekizumab, secukinumab and brodalumab) and anti-IL23 drugs (risankizumab and guselkumab) except tildrakizumab showed a higher proportion of patients reaching PASI 90 than ustekinumab and three anti-TNF alpha agents (adalimumab, certolizumab and etanercept). Ustekinumab was superior to certolizumab; adalimumab and ustekinumab were superior to etanercept. No significant difference was shown between apremilast and two non-biological drugs: ciclosporin and methotrexate. We found no significant difference between any of the interventions and the placebo for the risk of SAEs. The risk of SAEs was significantly lower for participants on methotrexate compared with most of the interventions. Nevertheless, the SAE analyses were based on a very low number of events with low- to moderate-certainty for all the comparisons (except methotrexate versus placebo, which was high-certainty). The findings therefore have to be viewed with caution. For other efficacy outcomes (PASI 75 and Physician Global Assessment (PGA) 0/1), the results were similar to the results for PASI 90. Information on quality of life was often poorly reported and was absent for several of the interventions.

AUTHORS' CONCLUSIONS

Our review shows that, compared to placebo, the biologics infliximab, bimekizumab, ixekizumab, and risankizumab were the most effective treatments for achieving PASI 90 in people with moderate-to-severe psoriasis on the basis of high-certainty evidence. This NMA evidence is limited to induction therapy (outcomes measured from 8 to 24 weeks after randomisation), and is not sufficient for evaluating longer-term outcomes in this chronic disease. Moreover, we found low numbers of studies for some of the interventions, and the young age (mean 44.5 years) and high level of disease severity (PASI 20.4 at baseline) may not be typical of patients seen in daily clinical practice. We found no significant difference in the assessed interventions and placebo in terms of SAEs, and the safety evidence for most interventions was low to moderate quality. More randomised trials directly comparing active agents are needed, and these should include systematic subgroup analyses (sex, age, ethnicity, comorbidities, psoriatic arthritis). To provide long-term information on the safety of treatments included in this review, an evaluation of non-randomised studies and postmarketing reports from regulatory agencies is needed. Editorial note: This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Tildrakizumab efficacy and safety in patients with psoriasis and concomitant metabolic syndrome: post hoc analysis of 5-year data from reSURFACE 1 and reSURFACE 2

BACKGROUND

Limited data are available on long-term efficacy and safety of biologics in patients with psoriasis and metabolic syndrome (MetS), a common comorbidity.

OBJECTIVES

This analysis updates tildrakizumab efficacy and safety for up to 5 years in patients with and without MetS.

METHODS

This was a post hoc analysis of the double-blind, randomized, placebo-controlled, phase 3 reSURFACE 1 (NCT01722331) and reSURFACE 2 (NCT01729754) trials in adult patients with moderate to severe chronic plaque psoriasis. Analyses included data through Week 244 from patients who continuously received tildrakizumab 100 (TIL100) or 200 mg (TIL200) and entered the extension studies, stratified by baseline MetS status. Efficacy was assessed via Psoriasis Area and Severity Index (PASI) scores. Safety was evaluated from exposure-adjusted incidence rates (EAIRs) of treatment-emergent adverse events (TEAEs).

RESULTS

reSURFACE 1 and reSURFACE 2 analyses included 26 and 44 TIL100-treated patients with MetS, 98 and 167 TIL100-treated patients without MetS, 34 and 30 TIL200-treated patients with MetS, and 111 and 130 TIL200-treated patients without MetS, respectively. There were no clinically relevant differences in PASI 75/90/100 response rates at Week 244 between patients with vs without MetS. The proportion of patients with vs without MetS achieving absolute PASI score <3 at Week 244 was 53.8% vs 69.4% and 77.3% vs 80.8% in reSURFACE 1 and 2, respectively, for TIL100-treated patients and 58.8% vs 72.1% and 63.3% vs 72.3%, respectively, for TIL200-treated patients. In both studies, median reduction from baseline PASI score at all time points in patients with vs without MetS was >83% vs >89% for TIL100 and >85% vs >90% for TIL200. Pooled EAIRs of TEAEs, serious TEAEs, and TEAEs of special interest were similar in patients with and without MetS.

CONCLUSIONS

Tildrakizumab maintains efficacy and a favorable safety profile over 5 years in patients with psoriasis regardless of MetS status.

Can Biological Drugs Diminish the Risk of Sarcopenia in Psoriatic Patients?

Sarcopenia and psoriasis are different inflammatory diseases that share common comorbidities (e.g., cardiovascular diseases, metabolic syndrome, obesity, autoimmune diseases, depression). Psoriasis is a dermatosis involving the skin, joints, and nails. Its estimated prevalence is 2–4%, and the possibility of progression to psoriatic arthritis reaches 6–42%. Sarcopenia is defined as reduced muscle strength, muscle quantity, and physical performance due to non-ageing related causes. It affects up to 10% of the general population. We conducted a review of the literature to provide up-to-date information about the risk of sarcopenia in psoriasis and to identify risk factors that increase this risk. The search of the literature allowed us to include 51 publications, but only five cross-sectional studies provided quantitative results on the rates of sarcopenia in psoriasis. The prevalence of sarcopenia in psoriasis varied from 9.1% to 61.7%. This wide range was caused by different definitions of sarcopenia and different cut-off values across studies. Prognostic factors include lean mass and fat mass. Further research based on the European Working Group on Sarcopenia in Older People guidelines is required. Such studies should include not only muscle mass and strength but also other factors that may influence the occurrence of sarcopenia and inflammatory markers.

Dermatological manifestations of cardiac conditions

Various cardiac disorders seen in general and acute medicine have dermatological manifestations that may provide critical clues to the underlying disease. This review will discuss the important dermatological signs seen in cardiac conditions. We believe greater interdisciplinary liaison will improve our understanding of the link between the dermatological and cardiovascular systems and the underlying disease processes.

Psoriasis and metabolic syndrome: implications for the management and treatment of psoriasis

Psoriasis is a chronic systemic inflammatory disorder associated with several comorbidities in addition to the characteristic skin lesions. Metabolic syndrome (MetS) is the most frequent comorbidity in psoriasis and a risk factor for cardiovascular disease, a major cause of death among patients with psoriasis. Although the exact causal relationship between these two disorders is not fully established, the underlying pathophysiology linking psoriasis and MetS seems to involve overlapping genetic predispositions and inflammatory pathways. Dysregulation of the IL‐23/Th‐17 immune signalling pathway is central to both pathologies and may be key to promoting susceptibility to metabolic and cardiovascular diseases in individuals with and without psoriasis. Thus, biological treatments for psoriasis that interrupt these signals could both reduce the psoriatic inflammatory burden and also lessen the risk of developing atherosclerosis and cardiometabolic diseases. In support of this hypothesis, improvement of skin lesions was associated with improvement in vascular inflammation in recent imaging studies, demonstrating that the beneficial effect of biological agents goes beyond the skin and could help to prevent cardiovascular disease. This review will summarize current knowledge on underlying inflammatory mechanisms shared between psoriasis and MetS and discuss the most recent clinical evidence for the potential for psoriasis treatment to reduce cardiovascular risk.

Identifying and managing psoriasis-associated comorbidities: the IMPACT research programme

Background

Psoriasis is a common, lifelong inflammatory skin disease, the severity of which can range from limited disease involving a small body surface area to extensive skin involvement. It is associated with high levels of physical and psychosocial disability and a range of comorbidities, including cardiovascular disease, and it is currently incurable.

Objectives

To (1) confirm which patients with psoriasis are at highest risk of developing additional long-term conditions and identify service use and costs to patient, (2) apply knowledge about risk of comorbid disease to the development of targeted screening services to reduce risk of further disease, (3) learn how patients with psoriasis cope with their condition and about their views of service provision, (4) identify the barriers to provision of best care for patients with psoriasis and (5) develop patient self-management resources and staff training packages to improve the lives of people with psoriasis.

Design

Mixed methods including two systematic reviews, one population cohort study, one primary care screening study, one discrete choice study, four qualitative studies and three mixed-methodology studies.

Setting

Primary care, secondary care and online surveys.

Participants

People with psoriasis and health-care professionals who manage patients with psoriasis.

Results

Prevalence rates for psoriasis vary by geographical location. Incidence in the UK was estimated to be between 1.30% and 2.60%. Knowledge about the cost-effectiveness of therapies is limited because high-quality clinical comparisons of interventions have not been done or involve short-term follow-up. After adjusting for known cardiovascular risk factors, psoriasis (including severe forms) was not found to be an independent risk factor for major cardiovascular events; however, co-occurrence of inflammatory arthritis was a risk factor. Traditional risk factors were high in patients with psoriasis. Large numbers of patients with suboptimal management of known risk factors were found by screening patients in primary care. Risk information was seldom discussed with patients as part of screening consultations, meaning that a traditional screening approach may not be effective in reducing comorbidities associated with psoriasis. Gaps in training of health-care practitioners to manage psoriasis effectively were identified, including knowledge about risk factors for comorbidities and methods of facilitating behavioural change. Theory-based, high-design-quality patient materials broadened patient understanding of psoriasis and self-management. A 1-day training course based on motivational interviewing principles was effective in increasing practitioner knowledge and changing consultation styles. The primary economic analysis indicated a high level of uncertainty. Sensitivity analysis indicated some situations when the interventions may be cost-effective. The interventions need to be assessed for long-term (cost-)effectiveness.

Limitations

The duration of patient follow-up in the study of cardiovascular disease was relatively short; as a result, future studies with longer follow-up are recommended.

Conclusions

Recognition of the nature of the psoriasis and its impact, knowledge of best practice and guideline use are all limited in those most likely to provide care for the majority of patients. Patients and practitioners are likely to benefit from the provision of appropriate support and/or training that broadens understanding of psoriasis as a complex condition and incorporates support for appropriate health behaviour change. Both interventions were feasible and acceptable to patients and practitioners. Cost-effectiveness remains to be explored.

Future work

Patient support materials have been created for patients and NHS providers. A 1-day training programme with training materials for dermatologists, specialist nurses and primary care practitioners has been designed. Spin-off research projects include a national study of responses to psoriasis therapy and a global study of the prevalence and incidence of psoriasis. A new clinical service is being developed locally based on the key findings of the Identification and Management of Psoriasis Associated ComorbidiTy (IMPACT) programme.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 3. See the NIHR Journals Library website for further project information.

The Effects of Modified Intermittent Fasting in Psoriasis (MANGO): Protocol for a Two-Arm Pilot Randomized Controlled Open Cross-over Study

BACKGROUND

Psoriasis is a complex disease associated with multiple comorbidities, including metabolic syndrome and leaky gut syndrome. Dietary lifestyle interventions have been reported to affect the disease in terms of lesional severity. It remains unclear how diets affect these comorbidities and the general health in psoriasis patients. Modified intermittent fasting (MIF) on 2 nonconsecutive days has shown beneficial effects on metabolic parameters. A significant advantage of MIF over the currently investigated dietary changes is its feasibility.

OBJECTIVE

Here, we aim to study the effects of MIF on skin, gut, and metabolic health in psoriasis patients.

METHODS

A 2-arm pilot randomized controlled open cross-over study will be performed in 24 patients with psoriasis. Patients will be randomized 1:1 to either start with 12 weeks of MIF and go on a subsequent regular diet for another 12 weeks or start with 12 weeks of regular diet and do subsequent MIF for 12 weeks. The following parameters will be assessed: demographics, disease phenotype, medical and familial history, psoriasis severity, dermatology-specific and general quality of life, nutritional and physical habits, mental and intestinal health, intestinal and cutaneous integrity, inflammatory and metabolic markers, and satisfaction.

RESULTS

A total of 24 participants have been enrolled in the study. The final visit is foreseen for June 2021.

CONCLUSIONS

The aim is to uncover the effects of MIF on psoriasis severity and gut health integrity through clinical and molecular investigation. More precisely, we want to map the evolution of the different markers, such as psoriasis severity, permeability, and inflammation, in response to MIF as compared to a regular diet,. Understanding how dietary lifestyles can affect epithelial lineages, such as the skin and gut, will greatly improve our understanding of the development of psoriasis and may offer a nonpharmacological venue for treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04418791; https://clinicaltrials.gov/ct2/show/NCT04418791.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/26405.

A Multivariate Analysis of Depression Prevalence in Psoriasis Patients: A Cohort Study

The literature reported higher depression rates in psoriasis patients compared to the general population. Our study aimed to verify whether variability in depression prevalence was due to using different diagnostic tools. We also aimed to determine whether dysfunctional coping strategies might increase the depression burden. We assessed psoriasis severity by the Psoriasis Area Severity Index (PASI) and PSOdisk. We analyzed mental alterations of 120 outpatients by Hamilton Depression and Anxiety Rating Scales (HAM-D and HAM-A), Symptom Checklist-90-Revised (SCL-90-R), plus coping strategies and quality of life by Coping Orientation to Problems Experienced (COPE) Inventory and 36-Item Short Form Health Survey (SF-36). We divided our cohort into five subgroups from minimal to severe psoriasis using the PSOdisk total score. Depression prevalence varied according to the assessment criteria for specificity, frequency, and severity. Different mood disorders other than major depression emerged when we used DSM-IV-TR criteria. Correlation analysis of the criteria we used to diagnose depression or depressed mood indicated that a dysfunctional coping strategy was highly and positively correlated only in patients of the severe subgroup. Differently, a negative correlation emerged between the SF-36 Mental Summary Component (MSC) and behavioral disengagement, thus suggesting that psychopathological distress might induce patients with a marked/severe psoriasis to adopt dysfunctional coping strategies. Dermatologists are fundamental in detecting comorbid depression, referring psoriasis patients to mental health specialists to achieve adequate treatments, and preventing suicide risk.

Comorbid obesity and history of diabetes are independently associated with poorer treatment response to biologics at 6 months: A prospective analysis in Corrona Psoriasis Registry

BACKGROUND

Psoriasis is associated with comorbid systemic metabolic disease.

OBJECTIVE

To assess possible associations of comorbid obesity, history of diabetes, hypertension, and hyperlipidemia with response to biologic treatment at 6 months among patients in CorEvitas' Psoriasis Registry.

METHODS

Participants included 2924 patients initiating biologic therapy (tumour necrosis factor inhibitors [TNFi], interleukin [IL]-17i, IL-12/23i, or IL-23i) with baseline and 6-month follow-up visits available. Logistic regressions resulted in adjusted odd ratios (OR) and 95% confidence intervals (CI) for achievement of response in select outcomes for those with obesity and history of diabetes, hypertension, and hyperlipidemia relative to those without each.

RESULTS

Overall, obesity reduced by 25% to 30% odds of achieving PASI75 (OR, 0.75; 95% CI, 0.64-0.88) and PASI90 (OR, 0.70; 95% CI, 0.59-0.81). History of diabetes reduced odds of achieving PASI75 by 31% (OR, 0.69; 95% CI, 0.56-0.85) and PASI90 by 21% (OR, 0.79; 95% CI, 0.63-0.98). Obesity was associated with lower response to TNFi and IL-17i classes. Independent of obesity, diabetes was associated with poorer outcomes when on IL-17i therapy and hypertension, to a lesser extent, when on the TNFi class. No significant associations were found in the hyperlipidemia group.

LIMITATIONS

The study assessed only short-term effectiveness and small sample sizes limited the power to detect differences.

CONCLUSION

Assessment of comorbid disease burden is important for improved likelihoods of achieving treatment response with biologics.

Effect of diet and weight loss on the severity of psoriasis

Psoriasis is one of the most common chronic inflammatory skin diseases, constituting a significant health and socioeconomic problem. Despite numerous therapeutic options, the results of treatment often remain insufficient. This may be due to the lack of compliance with medical prescriptions and patients’ limited knowledge of their disease. Psoriatic patient's skin well-being is affected by many factors, including lifestyle. The course of the disease is affected by obesity, improper diet, and stimulants. Often these factors coexist. Excessive weight gain in psoriasis can be caused by a decrease in physical activity, caused by feelings of social stigma, coexistence of psoriatic arthritis, depression, and increased alcohol consumption. Several studies have confirmed that the average fat, protein, and calorie content in the diet of a patient with psoriasis are above the recommended norms. On the other hand, adhering to a low calorie, reducing diet results in a clinically significant improvement in the Psoriasis Area Severity Index (PASI) and patients’ quality of life (i.e., reduction of Dermatology Life Quality Index [DLQI]). Weight reduction caused by diet and exercise reduces the severity of skin lesions, even in people who have not achieved improvement after general treatment. Therefore, it is important to educate the patient about the nature of the disease at the very beginning of treatment. Patients with moderate to severe forms of the disease are predisposed to the development of cardiovascular diseases, obesity, diabetes, and anxiety. That is why plaque psoriasis requires a comprehensive treatment and a holistic approach to the patient.

A Cross-Sectional Study to Assess Sub-clinical Atherosclerosis in Patients of Psoriasis Independent of Metabolic Syndrome

Background

A sustained inflammatory state of psoriasis causes comorbidities such as psoriatic arthritis, metabolic syndrome (MetS), and cardiovascular disease.

Aims

To note the duration and severity of psoriasis, assess prevalence of MetS, and correlate these with indicators of sub-clinical atherosclerosis.

Methodology

Thirty-two patients of chronic plaque psoriasis were enrolled in the study. Their demographic particulars, clinical details, results of investigations to assess MetS, and indicators of sub-clinical atherosclerosis, namely, carotid intimal media thickness (CIMT) measured using B-mode USG and epicardial fat thickness (EFT) using 2-D ECHO, were recorded.

Results

The study participants were predominantly male (2.5:1); their mean age was 40.45 ± 12.42 years, the median disease duration (DD) was 2 years, and the mean psoriatic area severity index (PASI) score was 8.62 ± 7.49. Mild disease (PASI <5) was present in 12 participants (37.5%), and shorter DD (<5 years) was present in 16 (50%) participants. MetS, detected in 11 (37.5%) study participants, was not significantly associated with CIMT, EFT, DD, and PASI. CIMT and EFT too did not correlate significantly with DD, PASI, or measures of MetS. Neither did there exist any significant correlation between CIMT and EFT.

Conclusion

Sub-clinical atherosclerosis in our study participants was not significantly associated with either measures of MetS or duration/severity of psoriasis.

Metabolic comorbidities of psoriasis (Review)

Psoriasis is a chronic inflammatory and immune-mediated condition, which is no longer considered as being limited to the skin, but may affect the entire body. Epidemiological studies have shown that certain disorders, including obesity, diabetes, liver abnormalities, elevated lipid levels in the blood and metabolic syndrome, may occur more frequently in patients with psoriasis compared with the general population. As psoriasis is a chronic disease, the frequently associated comorbidities must be identified early to ensure timely treatment and, possibly, their prevention. Comorbidities often manifest clinically 1-2 years after the onset of psoriasis and are commonly seen in patients with severe forms of the disease. The association between psoriasis and its comorbidities is not coincidental, but rather based on common pathophysiological mechanisms and risk factors that underlie the increased frequency of comorbidities in patients with psoriasis. The aim of the present review was to emphasize the important role of dermatologists in the early recognition of comorbidities in patients with psoriasis, with a focus on metabolic comorbidities, precisely because the dermatologists are usually the first medical contact due to the predominance of skin lesions. Therefore, these specialists have the responsibility to inform patients on the association between psoriasis and possible multiple comorbidities, devise prevention and treatment plans, or even redirect patients to other specialists.

Nutritional Therapy in Persons Suffering from Psoriasis

Psoriasis is a chronic inflammatory skin disease. Immunological, genetic, and environmental factors, including diet, play a part in the pathogenesis of psoriasis. Metabolic syndrome or its components are frequent co-morbidities in persons with psoriasis. A change of eating habits can improve the quality of life of patients by relieving skin lesions and by reducing the risk of other diseases. A low-energy diet is recommended for patients with excess body weight. Persons suffering from psoriasis should limit the intake of saturated fatty acids and replace them with polyunsaturated fatty acids from the omega-3 family, which have an anti-inflammatory effect. In diet therapy for persons with psoriasis, the introduction of antioxidants such as vitamin A, vitamin C, vitamin E, carotenoids, flavonoids, and selenium is extremely important. Vitamin D supplementation is also recommended. Some authors suggest that alternative diets have a positive effect on the course of psoriasis. These diets include: a gluten-free diet, a vegetarian diet, and a Mediterranean diet. Diet therapy for patients with psoriasis should also be tailored to pharmacological treatment. For instance, folic acid supplementation is introduced in persons taking methotrexate. The purpose of this paper is to discuss in detail the nutritional recommendations for persons with psoriasis.

Changes in metabolic syndrome and risk of psoriasis: a nationwide population-based study

Metabolic syndrome (MetS) is associated with psoriasis, but it remains unclear whether risk of psoriasis remains in patients whose MetS diagnosis changes. To assess the relationship between risk of psoriasis and changes in MetS components. We obtained data from the National Health Insurance Service of Korea and divided the participants into four groups: individuals without MetS (control); individuals with MetS in 2009, but without MetS in 2012 (pre-MetS); individuals without MetS in 2009, but with newly diagnosed MetS in 2012 (post-MetS); and individuals with MetS during the 2009-2012, period (continuous-MetS). We calculated the risk of psoriasis for each group. Risk of psoriasis was similar in the control and pre-MetS groups but was significantly higher in the post-MetS group (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.04-1.12) and in the continuous-MetS group (HR, 1.11; 95% CI, 1.07-1.15) than in the control group. Among MetS components, waist circumference showed the strongest association with psoriasis, followed by high-density lipoprotein and triglyceride levels. Risk of psoriasis was higher in patients with continuous- or post-MetS than in those with pre-MetS (regardless of prior MetS status).

Assessment of the Toronto Psoriatic Arthritis Screen 2 as a Screening Tool for Psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease affecting multiple organ systems and resulting in reduced quality of life for many patients. A screening tool would be useful, particularly in underserviced or research settings with limited access to dermatologists. The Toronto Psoriatic Arthritis Screen, version 2 (ToPAS 2) is a validated screening tool for psoriatic arthritis containing questions specific for psoriasis.

OBJECTIVES

To evaluate the performance of skin-specific questions from ToPAS 2 for the diagnosis of psoriasis.

METHODS

Participants aged >18 were recruited from Dermatology and Family Medicine clinics and completed the ToPAS 2 questionnaire prior to being examined by a dermatologist for psoriasis. Two scoring indexes were derived from the ToPAS 2 skin-related questions using backward selection regression models. Statistical analysis was performed using receiver operating characteristic (ROC) curves to measure their performances.

RESULTS

Two hundred and fifty eight participants were recruited. 32 (12%) were diagnosed with psoriasis by dermatologist assessment. Index 1 includes all 5 skin-related questions from ToPAS 2, while Index 2 includes three of the five questions. Both indexes demonstrate high specificity (82% to 92%), sensitivity (69% to 84%), and excellent negative predictive value (NPV) (>95%) for a diagnosis of psoriasis. The overall discriminatory power of these models is 0.823 (Index 1) and 0.875 (Index 2).

CONCLUSIONS

Skin-related questions from ToPAS 2 have discriminatory value in detecting psoriasis, specifically questions relating to a family history, a prior physician diagnosis of psoriasis or a rash consistent with images of plaque psoriasis. This study is a valuable step in developing a screening tool for psoriasis.

Cutaneous and Systemic Psoriasis: Classifications and Classification for the Distinction

Psoriasis is a chronic multisystem inflammatory disease that affects ~0.1–1.5% of the world population. The classic cutaneous manifestation of psoriasis is scaly erythematous plaques, limited or widely distributed. Moreover, psoriasis could be associated with comorbidities like psoriatic arthritis, metabolic syndrome, diabetes, cardiovascular disease, nephropathy, bowel disease, and brain diseases. In this review, we suggest that psoriasis should be classified as cutaneous psoriasis or systemic psoriasis and propose the classification for distinction. This would help to better understand and manage psoriasis.

Nutrition and psoriasis

Nutrition and dietary supplements are commonly used in the management of psoriasis; however, evidence of their efficacy is inconsistent. Although some dietary interventions have been shown to improve psoriasis consistently, others have little evidence supporting their use. We review common dietary interventions for the management of psoriasis and the evidence behind them. Caloric restriction, especially in overweight and obese individuals, has been shown to consistently diminish psoriatic activity. Evidence about other supplements and dietary interventions is inconsistent. Given the cost and side effects of pharmaceutical treatments for psoriasis, larger, long-term studies on the use of nutrition for the management of psoriasis are necessary.

Psoriasis and Atherosclerosis-Skin, Joints, and Cardiovascular Story of Two Plaques in Relation to the Treatment with Biologics

It is known that both psoriasis (PSO) limited to the skin and psoriatic arthritis (PSA) increase the risk of cardiovascular complications and atherosclerosis progression by inducing systemic inflammatory response. In recent decades, the introduction of biological medications directed initially against TNF-α and, later, different targets in the inflammatory cascade brought a significant breakthrough in the efficacy of PSO/PSA treatment. In this review, we present and discuss the most recent findings related to the interplay between the genetics and immunology mechanisms involved in PSO and PSA, atherosclerosis and the development of cardiac dysfunction, as well as the current PSO/PSA treatment in view of cardiovascular safety and prognosis.

Psoriasis Severity and Cardiometabolic Risk Factors in a Representative US National Study

BACKGROUND

Psoriasis is associated with metabolic syndrome; however, the relationship of psoriasis severity with individual cardiometabolic risk factors is not clear. There is a reporting gap between the cardiometabolic risks among patients with psoriasis and what has been reported in the literature using US samples.

OBJECTIVES

The objective of this study was to examine the disease burden of psoriasis and assess the associations of psoriasis severity and cardiometabolic risk factors in a nationally representative sample.

METHODS

We conducted a cross-sectional study using the weighted pooled data from the National Ambulatory Medical Care Survey (NAMCS) 2007 through 2016. The NAMCS data were collected from US office-based physicians. Each physician was randomly assigned a specific week to report a sample of their cases. Patients were categorized as severe psoriasis if they were prescribed at least one systemic therapy. We used logistic regression models adjusting for potential confounders to estimate the associations of psoriasis severity with individual cardiometabolic factors.

RESULTS

There were about 3.3 million office-based psoriasis visits per year with a mean age of 50 years, a female-to-male ratio of 1:1, and severe disease in 23%. We observed greater values of blood pressure, lipid profiles, and higher body mass index among patients with psoriasis, compared with patients without psoriasis. A higher proportion of the psoriasis patient group were overweight and obese (73.6% vs 62.9% in the non-psoriasis patient group). Compared to mild case groups, severe case groups tended to have a higher proportion of overweight/obese with a body mass index ≥  25 kg/m² (77% vs 73%). Obesity was weakly associated with psoriasis severity (adjusted odds ratio = 1.37, 95% confidence interval 0.98-1.91 for mild disease and adjusted odds ratio = 1.42, 95% confidence interval 0.80-2.52 for severe cases).

CONCLUSIONS

Cardiometabolic factors are related health issues in psoriasis, and obesity is associated with greater psoriasis severity.

Skin and Metabolic Syndrome: An Evidence Based Comprehensive Review

Metabolic syndrome is currently considered to be a global epidemic, causing a significant increase in the cost of health care, apart from deteriorating the quality of life. Skin serves as a mirror of underlying metabolic sinister. Various dermatological conditions like psoriasis, acanthosis nigricans, lichen planus, acne vulgaris, acrochordons, atopic dermatitis, etc. have been reported to be associated with metabolic syndrome. We hereby present an evidence-based review of the various dermatological conditions and their association with the development of metabolic syndrome.

Role of psoriatic keratinocytes in the metabolic reprogramming of dermal mesenchymal stem cells

BACKGROUND

Psoriasis is an immune-mediated inflammatory skin disease, featured by epidermal hyperproliferation. Psoriasis exhibits metabolic abnormalities, which can further aggravate the condition of psoriasis. The present study aimed to investigate the role of psoriatic keratinocytes (KCs) in the metabolic reprogramming of dermal mesenchymal stem cells (DMSCs).

METHODS

Dermal mesenchymal stem cells were cocultured with primary KCs either from psoriatic lesions or from normal subjects using Transwell plate. Glycolysis and mitochondrial metabolism of DMSCs were detected by Seahorse Metabolic Analyzer. Expression levels of proteins were analyzed by Western blotting. DMSCs proliferation was assessed using 5-ethynyl-2'-deoxyuridine assay and Cell Counting Kit-8.

RESULTS

In comparison with normal KCs, coculture of psoriatic KCs with DMSCs dramatically increased glycolytic and mitochondrial metabolism, and expression levels of stem cell factor, epidermal growth factor, glucose transporter 1, and c-Myc. Moreover, psoriatic KCs were more potent than normal KCs in the stimulation of DMSC proliferation.

CONCLUSIONS

In conclusion, psoriatic KCs display a higher potency in metabolic reprogramming and stimulation of DMSC proliferation, possibly contributing to the pathogenesis of psoriasis. However, whether the intervention of metabolic reprogramming of DMSCs can alleviate psoriasis remains to be determined.

Visceral adiposity in patients with psoriatic arthritis and psoriasis alone and its relationship with metabolic and cardiovascular risk

BACKGROUND

Fat mass distribution, especially in the abdominal visceral region, has been rarely evaluated in patients with PsA or psoriasis (PsO).

METHODS

Patients with PsA and patients with PsO alone were evaluated and compared with control subjects (1:1 ratio in each patient group) matched for age, sex and BMI category. Body composition and fat distribution (android and visceral fat) were evaluated by DXA. Anthropometric measurements, disease activity and the systematic coronary risk evaluation (SCORE) cardiovascular risk were assessed. Metabolic parameters (insulin, homeostasis model assessment for insulin resistance), serum adipokines [total and high-molecular-weight adiponectin, leptin, resistin and retinol-binding protein-4 (RBP4)] were measured.

RESULTS

Data for 52 patients with PsA and 52 patients with PsO and their respective paired controls were analysed. Android fat and visceral fat were found to be significantly higher in patients with PsO compared with their controls, while these measurements did not differ between patients with PsA and their controls. By multivariate analysis, after adjusting for age, sex and BMI, visceral fat was higher in PsO patients compared with PsA patients (P = 0.0004) and the whole group of controls (P = 0.0013). Insulin levels and HOMA-IR were increased in both PsA and PsO groups. High-molecular-weight/total adiponectin ratio was decreased in patients with PsO. RBP4 was significantly higher in both PsA and PsO patients. In patients with PsO, visceral fat strongly correlated with SCORE (r = 0.61).

CONCLUSION

Visceral fat accumulates more in PsO alone than in PsA. Visceral adiposity may be a more pressing concern in PsO relative to PsA.

TRIAL REGISTRATION

The ADIPSO study (Évaluation du tissu ADIpeux et des adipokines dans le PSOriasis et le rhumatisme psoriasique et analyse de ses relations avec le risque cardiovasculaire) is a case-control study conducted in Besançon, France, and is registered on ClinicalTrials.gov under the number NCT02849795.

Psoriasis and Cardiometabolic Diseases: The Impact of Inflammation on Vascular Health

Psoriasis is a common chronic inflammatory condition associated with a higher risk of cardiovascular disease. Psoriasis confers a dose-dependent increase in risk for the metabolic syndrome and its components. The metabolic syndrome and its components have been associated with higher coronary atherosclerosis in psoriasis and cardiovascular events in the general population. In this review, we discuss the role of inflammation and psoriasis in cardiometabolic diseases with a focus on the metabolic syndrome and its components. We highlight the relationship between psoriasis and important cardiovascular risk factors encompassed by obesity, dyslipidemia, insulin resistance and hypertension. Furthermore, we briefly highlight literature on anti-inflammatory therapies and their impact on the components of the metabolic syndrome as well as directly quantified coronary atherosclerosis burden.

Thrombosis in Psoriasis: Cutaneous Cytokine Production as a Potential Driving Force of Haemostatic Dysregulation and Subsequent Cardiovascular Risk

Psoriasis (PsO) is a common T cell-mediated inflammatory disorder of the skin with an estimated prevalence of 2%. The condition manifests most commonly as erythematous plaques covered with scales. The aetiology of PsO is multifactorial and disease initiation involves interactions between environmental factors, susceptibility genes, and innate and adaptive immune responses. The underlying pathology is mainly driven by interleukin-17. In addition, various inflammatory mediators from specific T helper (T_H) cell subsets, namely T_H1, T_H17, and T_H22, are overexpressed in cutaneous lesions and may also be detected in the peripheral blood of psoriatic patients. Moreover, these individuals are also at greater risk, compared to the general population, of developing multiple comorbid conditions. Cardiovascular disease (CVD) has been recognised as a prominent comorbidity of PsO. A potential mechanism contributing to this association may be the presence of a hypercoagulable state in these individuals. Inflammation and coagulation are closely related. The presence of chronic, low-grade systemic inflammation may promote thrombosis – one of the major determinants of CVD. A pro-inflammatory milieu may induce the expression of tissue factor, augment platelet activity, and perturb the vascular endothelium. Altogether, these changes will result in a prothrombotic state. In this review, we describe the aetiology of PsO, as well as the pathophysiology of the condition. We also consider its relationship to CVD. Given the systemic inflammatory nature of PsO, we evaluate the potential contribution of prominent inflammatory mediators (implicated in PsO pathogenesis) to establishing a prothrombotic state in psoriatic patients.

Gout Augments the Risk of Cardiovascular Disease in Patients With Psoriasis: A Population-Based Cohort Study

Objective

Patients with psoriasis (PsO) have a high frequency of concomitant gout and increased risk of cardiovascular diseases (CVD). We aimed to estimate the synergistic impact of gout on the risk of CVD in patients with PsO.

Methods

A population-based cohort of patients registered in the National Health Insurance Research Database of Taiwan between 2000 and 2013 was stratified according to the presence of PsO and gout. Propensity score analysis was used to match age and gender at a ratio of 1:4. Cox proportional hazard models and subgroup analyses were used to estimate the hazard ratios (HRs) for CVD adjusted for traditional risk factors. The Kaplan–Meier method was used to plot the cumulative incidence curves.

Results

Patients with combined PsO and gout (n = 97), PsO alone (n = 388), gout alone (matched, n = 388) and matched controls (n = 388) were identified. Compared with the patients with PsO alone, the patients with combined PsO and gout had a significantly higher risk of CVD (relative risk 2.39, 95% CI 1.56 to 3.65). After adjustment for traditional risk factors, the risk of CVD was higher in patients with gout alone (HR 2.16, 95% CI 1.54 to 3.04) and in patients with combined PsO and gout (HR 2.72, 95% CI 1.73 to 4.28).

Conclusions

Gout augments the risk of CVD independently of traditional risk factors in patients with PsO.

Arterial stiffness, the hidden face of cardiovascular risk in autoimmune and chronic inflammatory rheumatic diseases

BACKGROUND AND OBJECTIVE

Cardiovascular diseases (CVD) are the leading causes of death in chronic inflammatory rheumatic diseases and are not solely explained by the increased prevalence of cardiovascular (CV) risk factors in this population. Arterial stiffness, assessed primarily by pulse wave velocity (PWV) and more indirectly by augmentation index (AIx), is a surrogate marker of CVD that should be considered. The objective of this review was to investigate the relationship between arterial stiffness and chronic inflammatory and/or autoimmune diseases.

METHODS

We performed a systemic literature review of articles published in Medline from January 2012 to April 2020 restricted to English languages and to human adults. We selected relevant articles about the relationship between arterial stiffness and rheumatoid arthritis, systemic lupus erythematosus, psoriasis, Sjogren's syndrome and ankylosing spondylitis. For each selected article, data on PWV and AIx were extracted and factors that may have an impact on arterial stiffness were identified.

RESULTS

A total of 214 references were identified through database searching and 82 of them were retained for analysis. Arterial stiffness is increased in chronic inflammatory and autoimmune diseases. Traditional CV risk factors such as hypertension and dyslipidemia accentuate this relationship. Current data are insufficient to determine whether disease activity significantly influences arterial stiffness, whereas disease duration seems rather critical. TNF-alpha inhibitors and cardiorespiratory fitness tend to decrease arterial stiffness. Finally, increased arterial stiffness leads to diastolic dysfunction, which is the main mechanism of heart failure in chronic inflammatory rheumatic diseases.

CONCLUSION

CV risk assessment in chronic inflammatory and autoimmune diseases should also rely on PWV and AIx.

Triglyceride-lowering and anti-inflammatory mechanisms of omega-3 polyunsaturated fatty acids for atherosclerotic cardiovascular risk reduction

Atherosclerotic cardiovascular disease (ASCVD) is the leading cause of death globally. Omega-3 polyunsaturated fatty acids (PUFAs) including eicosapentaenoic acid and docosahexaenoic acid have been extensively studied as both dietary supplement and pharmaceutical agent for the prevention of ASCVD. Epidemiological and retrospective studies have long shown the inverse relationship of omega-3 PUFA consumption and ASCVD event but results of previous large randomized controlled trials have not consistently shown the same effect. Meta-analysis and a recent clinical trial using a high dose of eicosapentaenoic acid showed convincing protective effects of omega-3 PUFAs on ASCVD. Emerging evidence shows that both chronic inflammation and hypertriglyceridemia increase the risk of atherosclerosis. Amelioration of the inflammatory process and reduction of hypertriglyceridemia provide two mechanisms on the prevention and management of ASCVD, and agents with both of these effects are more potent and desirable. Omega-3 PUFAs exert anti-hypertriglyceridemia effect, ameliorate inflammation, and maintain the resolution of inflammation homeostasis pleiotropically through multiple molecular and cellular mechanisms. This review presents the pathophysiology of atherosclerosis, the mechanisms of omega-3 PUFAs on the reduction of the atherosclerotic risk, and the current clinical utilities of omega-3 PUFAs on the prevention of ASCVD.