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]

High-density lipoprotein cholesterol function improves after successful treatment of psoriasis: a step forward in the right direction

There is epidemiological evidence that high-density lipoprotein (HDL) concentrations, or HDL "levels," exert protection from atherosclerosis, suggesting that HDL plays a role in vascular diseases. More accurate measures of HDL "function" are emerging, such as HDL efflux assays, which measure removal of cholesterol from peripheral tissues. Using this assay, we have demonstrated that psoriasis is associated with decreased HDL "levels" and HDL "function." The study by Holzer et al. in this issue demonstrates in an open-label, uncontrolled study that HDL function is impaired in psoriasis and improves after successful treatment of psoriasis. These findings underscore the notion that treatment of psoriasis likely extends beyond the skin and that a randomized controlled clinical trial is needed to confirm these findings.

Endothelial cell-, platelet-, and monocyte/macrophage-derived microparticles are elevated in psoriasis beyond cardiometabolic risk factors

Background

Psoriasis, especially when severe, is a risk factor for cardiometabolic disease beyond traditional risk factors. The mechanism of atherogenesis in psoriasis remains unknown. Cell membrane vesicles (ie, microparticles), released upon cell activation or apoptosis, have recently been associated with cardiometabolic disease and may play a pathogenic role. Microparticle levels, particularly from endothelial cells and platelets, are elevated in patients with cardiovascular disorders, metabolic syndrome, other inflammatory diseases, autoimmune conditions, and have been shown to be predictive of cardiovascular outcomes.

Methods and Results

Concentrations of microparticles with positive expression for any of 7 cell surface markers (Annexin V, CD3, CD31, CD41a, CD64, CD105, and CD144) were measured in blood samples from psoriasis patients (n=53) and control subjects without psoriasis (n=41). Platelet‐free plasma was separated from whole blood by one‐step centrifugation for microparticle analysis. Microparticles were fluorescently labeled and characterized by flow cytometry. Higher concentrations of CD105 (5.5/μL versus 2.5/μL, P<0.001), CD31 (31/μL versus 18/μL, P=0.002), CD41a (50/μL versus 22/μL, P<0.001), and CD64 (5.0/μL versus 4.1/μL, P=0.02) singly positive microparticles corresponding to endothelial cell‐, platelet‐, and monocyte/macrophage‐derived microparticles, respectively, were found in psoriasis patients compared with controls. These differences persisted after adjustment for traditional cardiometabolic risk factors including body mass index.

Conclusions

Increased microparticle concentrations, independent of cardiometabolic risk factors, in patients with psoriasis suggest that the presence of increased endothelial cell, platelet, and monocyte/macrophage activation with cell turnover may contribute to the heightened atherogenesis associated with psoriasis.

The prevalence of metabolic syndrome in patients with hidradenitis suppurativa

BACKGROUND

Metabolic syndrome is a multifaceted disorder strongly associated with increased risk for development of cardiovascular disease. Chronic inflammatory diseases have been associated with metabolic syndrome. Hidradenitis suppurativa is a chronic inflammatory skin disease with significant physical and emotional sequelae.

OBJECTIVE

We sought to investigate a possible association between hidradenitis suppurativa and metabolic syndrome.

METHODS

A retrospective chart review of all dermatology clinic encounters over an 18-month period identified 366 patients with an appropriate diagnosis of hidradenitis suppurativa. A control population was created from patients seen in the same clinic during the same time period for the diagnoses of either keloids or verruca vulgaris using the matching criteria of age ±5 years, race, and gender. All participants were examined for characteristics of the metabolic syndrome as defined by the National Cholesterol Education Program Adult Treatment Program III guidelines.

RESULTS

The prevalence of metabolic syndrome in patients with hidradenitis suppurativa was 50.6%, which was significantly higher than the control group at 30.2% (P < .001).

LIMITATIONS

This was a retrospective review. Some participants could not be analyzed for metabolic syndrome presence as a result of missing data points.

CONCLUSION

Our results indicate that patients with hidradenitis suppurativa may be at high risk for metabolic syndrome.

High prevalence of cardiovascular risk factors in patients with moderate or severe psoriasis in northern China

Recent studies suggest that psoriasis is a systemic disorder associated with cardiovascular disease (CVD) risk factors, such as obesity, hypertension and dyslipidemia. However, these risk factors have not been widely recognized across different populations. This cross-sectional study aimed to examine the association of risk factors for CVD with psoriasis by comparing patients with psoriasis and matched controls in northern China. This study identified 291 patients with diagnosed moderate or severe psoriasis as cases and 445 age- and gender-matched subjects as controls. A significant association (P < 0.01) was observed between overall psoriasis incidence and smoking [odds ratio (OR), 2.96; 95 % confidence interval (CI) 2.09-4.09], alcohol consumption (OR, 3.77; 95 % CI 2.381-5.955), diabetes (OR, 2.79; 95 % CI 1.70-4.59), hypertension (OR, 2.19; 95 % CI 1.56-3.06) and hyperlipidemia (OR, 1.76; 95 % CI 1.29-2.40). Furthermore, hypertension correlated with the duration of psoriasis after adjustment for age and sex. Hyperlipidemia, smoking and alcohol consumption were related to the severity of the disease. Moreover, patients with psoriasis had lower levels of apolipoprotein B (ApoB) and lipoprotein (Lip) than did controls (P < 0.05). These data suggest that multiple risk factors for CVD are associated with psoriasis. CVD risk factor screening should be performed, and appropriate measures should be taken accordingly for psoriasis patients.

Psoriasis and Metabolic Syndrome--scientific evidence and therapeutic implications

Psoriasis is a chronic inflammatory disease, predominantly affecting the skin, being included in the group of Immune Mediated Inflammatory Diseases. Growing evidence from the last 10 years suggests that several systemic conditions like metabolic syndrome, cardiovascular disease, diabetes, psychological disorders or inflammatory bowel disease are prevalent in psoriasis patients. The linker might be the chronic secretion of pro-inflammatory cytokines. In this current review, the scientific evidence that explains the relationship between psoriasis and the metabolic syndrome in particular will be addressed, as the metabolic syndrome comprises a group of risk factors for cardiovascular disease, thus offering an overall picture of the systemic involvement in psoriasis. An integrated approach, with an early detection and treatment of the components of the metabolic syndrome, are important steps in psoriasis management. Attention should be paid on influence of psoriasis treatment upon comorbidities and vice-versa.

Mining emerging biomedical literature for understanding disease associations in drug discovery

Systematically evaluating the exponentially growing body of scientific literature has become a critical task that every drug discovery organization must engage in in order to understand emerging trends for scientific investment and strategy development. Developing trends analysis uses the number of publications within a 3-year window to determine concepts derived from well-established disease and gene ontologies to aid in recognizing and predicting emerging areas of scientific discoveries relevant to that space. In this chapter, we describe such a method and use obesity and psoriasis as use-case examples by analyzing the frequency of disease-related MeSH terms in PubMed abstracts over time. We share how our system can be used to predict emerging trends at a relatively early stage and we analyze the literature-identified genes for genetic associations, druggability, and biological pathways to explore any potential biological connections between the two diseases that could be utilized for drug discovery.

Psoriasis: female skin changes in various hormonal stages throughout life--puberty, pregnancy, and menopause

Psoriasis is one of the most prevalent immune mediated skin diseases worldwide. Despite the large prevalence in both men and women, the pathogenesis of this disease has not yet been fully clarified. Nowadays, it is believed that psoriasis is most likely a T helper Th1/Th17 induced inflammatory disease. Stressful life situations are known to cause flare-ups and psoriasis activity may be linked to stress from major life events. We know that stress greatly affects both the hormone and immune systems and that there are many different hormonal phases throughout a woman's lifetime. The severity of psoriasis may fluctuate or be influenced by each phase and this relationship can be seen as disease frequency seems to peak during puberty, postpartum, and menopause when hormone levels fall, while symptoms improve during pregnancy, a state when hormone levels are increased.

Psoriasis severity and the prevalence of major medical comorbidity: a population-based study

IMPORTANCE

Despite the growing literature on comorbidity risks in psoriasis, there remains a critical knowledge gap on the degree to which objectively measured psoriasis severity may affect the prevalence of major medical comorbidity.

OBJECTIVE

To examine the prevalence of major medical comorbidity in patients with mild, moderate, or severe psoriasis, classified objectively based on body surface area involvement, compared with that in patients without psoriasis.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cross-sectional study of patient data from United Kingdom-based electronic medical records; analysis included 9035 patients aged 25 to 64 years with psoriasis and 90,350 age- and practice-matched patients without psoriasis.

MAIN OUTCOMES AND MEASURES

Prevalence of major medical comorbidity included in the Charlson comorbidity index.

RESULTS

Among patients with psoriasis, 51.8%, 35.8%, and 12.4%, respectively, had mild, moderate, or severe disease based on body surface area criteria. The mean Charlson comorbidity index was increasingly higher in patients with mild (0.375 vs 0.347), moderate (0.398 vs 0.342), or severe psoriasis (0.450 vs 0.348) (each P < .05). Psoriasis overall was associated with higher prevalence of chronic pulmonary disease (adjusted odds ratio, 1.08; 95% CI, 1.02-1.15), diabetes mellitus (1.22; 1.11-1.35), diabetes with systemic complications (1.34; 1.11-1.62), mild liver disease (1.41; 1.12-1.76), myocardial infarction (1.34; 1.07-1.69), peptic ulcer disease (1.27; 1.03-1.58), peripheral vascular disease (1.38; 1.07-1.77), renal disease (1.28; 1.11-1.48), and rheumatologic disease (2.04; 1.71-2.42). Trend analysis revealed significant associations between psoriasis severity and each of the above comorbid diseases (each P < .05).

CONCLUSIONS AND RELEVANCE

The burdens of overall medical comorbidity and of specific comorbid diseases increase with increasing disease severity among patients with psoriasis. Physicians should be aware of these associations in providing comprehensive care to patients with psoriasis, especially those presenting with more severe disease.

An observational study on the obesity and metabolic status of psoriasis patients

BACKGROUND

Recent studies have suggested that obesity, hyperlipidemia, ischemic heart diseases, metabolic syndrome and hypertension can combine with psoriasis. However, the metabolic comorbidities have not been clearly demonstrated in Korean psoriasis patients.

OBJECTIVE

The purpose of this study was to analyze the association between psoriasis and metabolic abnormalities including obesity, glucose intolerance, hypertension and dyslipidemia in our center. Treatment response of cyclosporine between a high body mass index (BMI) group and normal BMI group was also analyzed to investigate how obesity may affect psoriasis treatment.

METHODS

A retrospective observational study was made on the obesity and metabolic status of psoriasis patients versus normal control group through electronic medical records from January 2008 to April 2009 at Department of Dermatology, Samsung Medical Center, (Seoul, Korea). Medical records, demographics and the Psoriasis Area and Severity Index score before and after cyclosporine treatment were analyzed.

RESULTS

There were no significant differences in the metabolic status between normal control and psoriasis patients. Also, there was no significant difference in the treatment response between high BMI group and normal BMI group, after 4 weeks and 8 weeks of cyclosporine treatment.

CONCLUSION

Our study suggests that in Korean patients, an association between psoriasis and metabolic abnormalities is not obvious. This may reflect a different severity of obesity and metabolic abnormalities between Western and Asian populations.

Initiation of TNF inhibitor therapy and change in physiologic measures in psoriasis

BACKGROUND

Psoriasis may predispose to cardiovascular disease and diabetes. However, the role of tumor necrosis factor (TNF) inhibitor in mediating this risk is controversial.

OBJECTIVE

To assess this relationship, we estimated change in metabolic physiologic measures before and after initiation of TNF inhibitor therapy compared with methotrexate (MTX) therapy among psoriasis patients.

METHODS

We conducted a retrospective cohort study, 2007-2012, using computerized clinical data for 1274 new users of TNF inhibitor and 979 new users of MTX therapy to compare change in blood pressure, lipids, triglycerides, fasting plasma glucose and body mass index (BMI) before and after start of TNF inhibitors or MTX. The study was restricted to new users. We computed within-person change in each measure, so that each patient served as their own control. In addition, we compared TNF inhibitor patients to MTX patients, by computing the adjusted difference in their group means. In secondary analyses, we examined phototherapy as a comparator.

RESULTS

Among starters of TNF inhibitor and MTX therapy, within-person change in physiologic measures at 6 months did not differ significantly. We observed no important or significant changes in any of the physiologic measures with initiation of TNF inhibitor compared with MTX. The same results were found in subgroup analyses focused on men, and on those with hypertension, diabetes mellitus, or obesity. The same results were observed with phototherapy, except that diastolic blood pressure declined by 0.6 mmHg within person during the 6 months after starting phototherapy (P < 0.05).

CONCLUSIONS

The study provides no evidence for improvement of physiologic measures associated with the metabolic syndrome resulting from TNF inhibitor use for psoriasis.

Prevalence of the metabolic syndrome in children with psoriatic disease

Adults with psoriasis have a greater risk of developing metabolic syndrome (MetS) and cardiovascular disease (CVD), but few studies have investigated the prevalence of MetS and other risk factors for CVD in children with psoriasis. In an assessor-blinded study, 20 children ages 9-17 years with a current or previously documented history of psoriasis involving 5% or more of their body surface area or psoriatic arthritis were compared with a cohort of age- and sex-matched controls with benign nevi, warts, or acne. MetS, our primary endpoint, was defined by the presence of abnormal values in at least three of the following measures: triglycerides, high-density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), waist circumference, and blood pressure. Secondary endpoints included high-sensitivity C-reactive protein (hs-CRP), total cholesterol (TC), and low-density lipoprotein cholesterol (LDL-C). Thirty percent (6/20) of children with psoriasis met the criteria for MetS, compared with 5% (1/20) of the control group (p < 0.05). Subjects with psoriasis had higher mean FBG (91.1 mg/dL) than the control group (82.9 mg/dL) (p = 0.01). There were no statistically significant differences in the other four components of MetS, BMI, BMI percentile, hs-CRP, TC, or LDL-C. The results of this trial demonstrate that children with psoriasis have higher rates of MetS than age- and sex-matched controls. It may therefore be important to evaluate children with psoriasis for components of MetS to prevent future CVD morbidity and mortality.

From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies

BACKGROUND

Many studies have identified cardiovascular risk factors in patients with psoriasis. Some psoriasis therapies may increase cardiovascular disease (CVD) and others may decrease CVD.

OBJECTIVE

We reviewed the literature to define the impact of common psoriasis therapies on cardiovascular measures and outcomes.

RESULTS

Phototherapy has no major cardiovascular impact and may reduce levels of proinflammatory cytokines. Acitretin increases serum lipids and triglycerides, but has not been shown to increase cardiovascular risk. Cyclosporine A increases blood pressure, serum triglycerides, and total cholesterol. Methotrexate is associated with a decreased risk of CVD morbidity and mortality. Among the biologics, data for tumor necrosis factor inhibitors suggest an overall reduction in cardiovascular events. Most data on short-term ustekinumab use suggest no effect on major adverse cardiovascular events, however some authorities remain concerned. Nevertheless, ustekinumab use over a 4-year period shows a decrease in major adverse cardiovascular events when compared both with the general US population and with psoriatics in Great Britain.

LIMITATIONS

Most studies lack the power and randomization of large clinical trials and long-term follow-up periods. In addition, the increased risk of CVD associated with psoriasis itself is a confounding factor.

CONCLUSION

Some therapies for moderate to severe psoriasis, including methotrexate and tumor necrosis factor inhibitors, may reduce cardiovascular events in psoriatic patients. Ustekinumab appears to be neutral but there may be a long-term benefit. Appropriate patient counseling and selection and clinical follow-up are necessary to maximize safety with these agents. Further long-term study is necessary to quantify the benefits and risks associated with biologic therapies.

Epicardial fat thickness is independently associated with psoriasis

BACKGROUND

Several studies have showed an association between psoriasis and cardiovascular (CV) diseases and metabolic syndrome (MS). Assessment of CV risk in patients with psoriasis has become an important issue. Epicardial fat thickness (EFT) is an emerging cardiometabolic risk factor and has been shown to be related to atherosclerosis. EFT has not been studied in the context of psoriasis.

OBJECTIVE

To compare the EFT in psoriasis patients with that in control subjects.

METHODS

31 patients with psoriasis and 32 control subjects were included in this case-control study. EFT was evaluated by two-dimensional transthoracic echocardiography.

RESULTS

EFT was significantly higher in psoriasis patients compared to controls (p = 0.027). Multiple linear regression analysis showed that the association of EFT with psoriasis was independent of MS and age.

CONCLUSION

EFT, which has been suggested as a cardiometabolic risk factor in various diseases, is also independently associated with psoriasis.

Risk of moderate to advanced kidney disease in patients with psoriasis: population based cohort study

OBJECTIVE

To determine the risk of chronic kidney disease in patients with psoriasis.

DESIGN

Population based cohort study and nested cross sectional study.

SETTING

Electronic medical records database based in United Kingdom.

PARTICIPANTS

Cohort study: patients with psoriasis aged 18-90 each matched to up to five patients without psoriasis based on age, practice, and time of visit. Nested study: patients with psoriasis aged 25-64 with confirmed data on psoriasis severity, each matched to up to 10 patients without psoriasis based on age and practice.

MAIN OUTCOME MEASURES

Cohort study: incident moderate to advanced (stage 3 through 5) chronic kidney disease. Nested study: baseline prevalence of chronic kidney disease.

RESULTS

136,529 patients with mild psoriasis and 7354 patients with severe psoriasis based on treatment patterns were matched to 689,702 unaffected patients. The adjusted hazard ratios (95% confidence intervals) for incident chronic kidney disease were 1.05 (1.02 to 1.07), 0.99 (0.97 to 1.02), and 1.93 (1.79 to 2.08) in the overall, mild, and severe psoriasis groups, respectively. Age was a significant effect modifier in the severe psoriasis group, with age specific adjusted hazard ratios (95% confidence intervals) of 3.82 (3.15 to 4.64) and 2.00 (1.86 to 2.17) for patients aged 30 and 60, respectively. In the nested analysis of 8731 patients with psoriasis with measurements of affected body surface area matched to 87,310 patients without psoriasis, the adjusted odds ratios (95% confidence intervals) for chronic kidney disease were 0.89 (0.72 to 1.10), 1.36 (1.06 to 1.74), and 1.58 (1.07 to 2.34) in the mild, moderate, and severe psoriasis groups, respectively.

CONCLUSIONS

Moderate to severe psoriasis is associated with an increased risk of chronic kidney disease independent of traditional risk factors.

The prevalence of obesity is increased in patients with late compared with early onset psoriasis

PURPOSE

We compared the clinical and epidemiologic characteristics of early and late onset psoriasis with an emphasis on potential differences in the comorbidities associated with each subtype.

METHODS

An observational, multicenter study was performed, and associations between the age at the time of diagnosis and binary comorbidity outcomes were evaluated using multiple logistic regression analysis adjusted for age and other relevant confounders.

RESULTS

An increased prevalence of positive family history, psoriatic arthritis, and depression was observed in patients with early onset psoriasis. On the other hand, late onset psoriasis was more frequently associated with obesity and elevated waist circumference compared with early onset form. Elderly psoriatic patients (at the age of 75 years) with late onset psoriasis are at an especially high risk for obesity compared with individuals at the same age with an early onset disease.

CONCLUSIONS

The increased frequency of psoriasis in the family of early onset patients may suggest that manifestation of psoriasis at younger age is driven by strong genetic influence. However, such a remarkable association of abdominal obesity with late onset psoriasis may suggest that obesity can be one of the acquired factors that may predispose for the development of psoriasis in the elderly.

Risk factors for comorbidities in Czech psoriatic patients: results of a hospital-based case-control study

BACKGROUND

Psoriasis is now known to be associated with multiple other diseases/comorbidities - including the metabolic syndrome, atherosclerosis and gastrointestinal diseases which are all significantly higher in psoriasis patients. Research results however are highly variable and the conclusions are ambiguous. As no similar study has been performed to date in Czech psoriatic patients, this study aimed at identifying risk factors and early stages of selected diseases/comorbidities in the patients.

METHODS AND RESULTS

The study was designed as a hospital-based case-control study. 131 patients with chronic plaque psoriasis formed the cases and 267 patients with other skin disorders formed the controls. A comparison was made of basic demographic and anthropometric indicators, metabolic parameters, the presence of specific antibodies (ASCA, AEP, p-ANCA, AGC, EMA, ARA, t-TG, AGA) and non-specific signs of gastrointestinal diseases. The chi squared, MWU tests and binary logistical model were used to evaluate the data. The results showed significant differences (P<0.05) for the following parameters: blood pressure, waist circumference, weight, BMI values, leucocytes values, HDL cholesterol level, glycemia and gliadine antibody IgA level. All differences were to the detriment of psoriasis patients. In the binary logistical model the following parameters were associated with psoriasis: diastolic blood pressure, leucocyte value and glycemia. For all variables included in the logistical model P≤0.001.

CONCLUSIONS

The results were coherent and consistent with existing data. They indicate that psoriasis is interconnected with hypertension, higher BMI and a decreased level of HDL cholesterol. These parameters have been clearly demonstrated as risk factors for the development of cardiovascular diseases. Higher levels of gliadine IgA antibodies are one of the diagnostic markers of celiac disease. Higher values of leukocytes may be interpreted as a nonspecific indicator of gastrointestinal inflammatory diseases. The associations between psoriasis and diastolic blood pressure, BMI value and glycemia are statistically significant in the binary logistic regression model. Care for psoriatic patients should focus especially on secondary prevention of predisposing diseases.

The gut-liver axis

PURPOSE OF REVIEW

The liver adaptively responds to extra-intestinal and intestinal inflammation. In recent years, the role of the autonomic nervous system, intestinal failure and gut microbiota has been investigated in the development of hepatic, intestinal and extra-intestinal disease.

RECENT FINDINGS

The autonomic nervous system can be stimulated via enteral fat leading to cholecystokinin release, stimulating receptors in the gut and in the brain. This promotes bowel integrity, dampening the inflammatory response to food antigens. Consensus exists that intravenously administered long-chain fatty acids can cause liver damage but randomized-controlled trials are lacking. Disruption of the enterohepatic circulation of bile salts can give rise to cholestasis and nonalcoholic fatty liver disease, which may progress to fibrosis and cirrhosis. Reduced intestinal availability of bile salts reduces stimulation of the farnesoid X receptor. This may induce hepatic bile salt overload and associated hepatotoxicity through reduced action of intestinal fibroblast growth factor 19. Evidence is put forward to suggest that the intestinal microbiota is associated with liver abnormalities.

SUMMARY

Enteral lipids reduce inflammation and liver damage during stress or systemic inflammation, whereas parenteral lipid is associated with liver damage. Maintaining the enterohepatic circulation of bile salts limits hepatic cholestasis through an farnesoid X receptor feedback pathway. Changes in gut microbiota composition may induce liver disease.

Treatment and referral patterns for psoriasis in United Kingdom primary care: a retrospective cohort study

BACKGROUND

In the UK, referrals to specialists are initiated by general practitioners (GPs). Study objectives were to estimate the incidence of diagnosed psoriasis in the UK and identify factors associated with GP referrals to dermatologists.

METHODS

Newly diagnosed patients with psoriasis were identified in The Health Improvement Network (THIN) database between 01 July 2007-31 Oct 2009. Incidence of diagnosed psoriasis was calculated using the number of new psoriasis patients in 2008 and the mid-year total patient count for THIN in 2008. A nested case-control design and conditional logistic regression were used to identify factors associated with referral.

RESULTS

Incidence rate of diagnosed adult psoriasis in 2008 was 28/10,000 person-years. Referral rate to dermatologists was 18.1 (17.3-18.9) per 100 person-years. In the referred cohort (N=1,950), 61% were referred within 30 days of diagnosis and their median time to referral was 0 days from diagnosis. For those referred after 30 days (39%, median time to referral: 5.6 months), an increase in the number of GP visits prior to referral increased the likelihood of referral (OR=1.87 95% CI:1.73-2.01). A prescription of topical agents such as vitamin D3 analogues 30 days before referral increased the likelihood of being referred (OR=4.67 95% CI: 2.78-7.84), as did corticosteroids (OR=2.45 95% CI: 1.45-4.07) and tar products (OR=1.95 95% CI: 1.02-3.75).

CONCLUSIONS

Estimates of the incidence of diagnosed adult psoriasis, referral rates to dermatologists, and characteristics of referred patients may assist in understanding the burden on the UK healthcare system and managing this population in primary and secondary care.

Cardiovascular Comorbidities of Psoriasis and Psoriatic Arthritis: A Report from the GRAPPA 2012 Annual Meeting

At the 2012 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) in Stockholm, Sweden, several GRAPPA members led a panel discussion on cardiovascular (CV) comorbidities of psoriasis and psoriatic arthritis (PsA). The panelists discussed the role of insulin resistance in the pathophysiology of psoriasis, the possible effect of tumor necrosis factor inhibitors on CV comorbidities, and the effect of 12/23 monoclonal antibodies on CV outcomes. The panelists also addressed how lessons from CV comorbidity research could be applied to other areas of comorbidity research in psoriasis and PsA and identified future research directions in this area.

Obstacles and solutions to screening psoriasis patients for cardiovascular risk factors

BACKGROUND

Psoriasis has been linked with cardiovascular risk factors (CVRFs), including the metabolic syndrome, yet many patients with psoriasis remain unscreened.

OBJECTIVE

To assess the reasons for lack of screening for CVRFs in psoriasis patients, and the impact of an education programme targeting these deficiencies.

METHODS

All patients with psoriasis, regardless of severity, and all dermatologists working at the National Skin Centre (NSC) in Singapore were surveyed over a 2-month period on their attitudes and knowledge regarding psoriasis and cardiovascular risk. This was followed by a targeted programme which was implemented over 2 months to address these identified deficiencies. Patients and doctors were surveyed a second time to assess the effects of the intervention.

RESULTS

Obstacles to screening included lack of patient knowledge, patients not considering screening important, and lack of time during the clinic consultation. After the intervention, there was a significant increase in the proportion of patients who were aware of increased cardiovascular risk in psoriasis (33.0% to 62%), with more patients attending screening (39.1% to 63.2%). While the level of doctors' knowledge did not significantly increase, there was an increase in the proportion of patients who were screened post-intervention (37.1% to 66.2%), and more doctors reported that they were more likely to screen psoriatic patients from an earlier age (30.2% to 58.1%).

CONCLUSIONS

The obstacles in implementing universal screening for CVRFs in psoriasis patients stem from patient, doctor and system factors. A comprehensive programme targeting all aspects of this ecosystem helps to achieve holistic care for patients with psoriasis.

IL-17 in psoriasis: implications for therapy and cardiovascular co-morbidities

Psoriasis is a prevalent, chronic inflammatory disease of the skin mediated by cross-talk occurring between epidermal keratinocytes, dermal vascular cells and immunocytes, including activated antigen presenting cells (APCs), monocytes/macrophages, and Th1 and Th17 cells. Increased proliferation of keratinocytes and endothelial cells in conjunction with immune cell infiltration leads to the distinct epidermal and vascular hyperplasia that is characteristic of lesional psoriatic skin. Interaction of activated T cells with monocytes/macrophages occurs via the Th17/IL-23 axis and is crucial for maintaining the chronic inflammation. Recent epidemiological evidence has demonstrated that psoriasis patients have an increased risk of developing and dying of cardiovascular disease. Similar pathology between psoriasis and cardiovascular disease, including involvement of key immunologic cell populations together with release of common inflammatory mediators such as IL-17A suggest a mechanistic link between the two diseases. This review will focus on concepts critical to psoriasis pathogenesis, systemic manifestations of psoriasis, the role of IL-17 in psoriasis and cardiovascular disease and the potential role for IL-17 in mediating cardiovascular co-morbidities in psoriasis patients.

Systematic review of UV-based therapy for psoriasis

BACKGROUND

UV-based therapies, which include narrow-band (NB) UVB, broad-band (BB) UVB, and psoralen and UVA (PUVA), are well known treatment options for moderate to severe plaque psoriasis. However, there are limited evidence-based reviews on their efficacy, short-term safety, and tolerability.

AIM

The aim of the study was to evaluate the efficacy, short-term safety, and tolerability of UV-based therapy in the treatment of adults with moderate to severe plaque psoriasis.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating NB-UVB, BB-UVB, and PUVA in adults with moderate to severe plaque-type psoriasis. Our efficacy outcomes were ≥ Psoriasis Area and Severity Index (PASI)-75 and clearance. We evaluated the short-term safety and tolerability from the percentage of adverse effects and withdrawal due to adverse effects, respectively.

RESULTS

Forty-one RCTs, with a total of 2,416 patients, met the eligibility criteria and were included in the analysis. In regard to PASI-75 in monotherapy trials, PUVA (mean: 73 %, 95 % CI 56-88) was the most effective modality. Trials with BB-UVB also showed a high PASI-75 (73 %) but with a wide CI (18-98) due to heterogeneity of the total available three studies. This was followed by NB-UVB (mean: 62 %, 95 % CI 45-79) then bath PUVA (mean: 47 %, 95 % CI 30-65). In regard to clearance in the monotherapy trials, PUVA (mean: 79 %, 95 % CI 69-88) was superior to NB-UVB (mean: 68 %, 95 % CI 57-78), BB-UVB (mean: 59 %, 95 % CI 44-72), and bath PUVA (mean: 58 %, 95 % CI 44-72). The percentages of asymptomatic erythema development in monotherapy trials were 64 % for BB-UVB, 57 % for NB-UVB, 45 % for PUVA, and 34 % for bath PUVA. Symptomatic erythema or blistering percentages for the monotherapy trials were as follows: 7.8 % for NB-UVB, 2 % for BB-UVB, 17 % for PUVA, and 21 % for bath PUVA. The percentages of withdrawal due to adverse effects were 2 % for NB-UVB, 4.6 % for BB-UVB, 5 % for PUVA, and 0.7 % for bath PUVA monotherapy trials.

CONCLUSIONS

As a monotherapy, PUVA was more effective than NB-UVB, and NB-UVB was more effective than BB-UVB and bath PUVA in the treatment of adults with moderate to severe plaque-type psoriasis, based on clearance as an end point. Based on PASI-75, the results were similar except for BB-UVB, which showed a high mean PASI-75 (73 %) that was similar to PUVA, but with a wide CI (18-98). The short-term adverse effects were mild as shown by the low rate of withdrawal due to adverse effects.

Psoriasis and metabolic syndrome: a systematic review and meta-analysis of observational studies

BACKGROUND

Increasing population-based studies have suggested a relationship between psoriasis and metabolic syndrome.

OBJECTIVE

The objective of this study was to perform a systematic review and meta-analysis that synthesizes the epidemiologic associations between psoriasis and metabolic syndrome.

METHODS

We searched for observational studies from MEDLINE, EMBASE, and Cochrane Central Register from Jan 1, 1980 to Jan 1, 2012. We applied the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines in the conduct of this study.

RESULTS

We identified 12 observational studies with a total of 1.4 million study participants fulfilling the inclusion criteria, among whom 41,853 were patients with psoriasis. Based on random-effects modeling of cross-sectional and case-controlled studies, the pooled odds ratio (OR) for metabolic syndrome among patients with psoriasis was 2.26 (95% confidence interval [CI] 1.70-3.01) compared with the general population. Visual inspection of a funnel plot and formal analysis with the Egger test suggested publication bias and absence of small studies in the published literature (P = .03). A dose-response relationship was also observed between psoriasis severity and prevalence of metabolic syndrome.

LIMITATIONS

No studies to date have assessed incidence of metabolic syndrome among patients with psoriasis.

CONCLUSIONS

Compared with the general population, psoriasis patients have higher prevalence of metabolic syndrome, and patients with more severe psoriasis have greater odds of metabolic syndrome than those with milder psoriasis.

The association between psoriasis and obesity: a systematic review and meta-analysis of observational studies

Objective:

Psoriasis is an inflammatory skin disease affecting 2–4% of the world population. The objective of this study was to perform a systematic review and meta-analysis synthesizing the epidemiological associations between psoriasis and obesity.

Data sources:

We searched for observational studies from MEDLINE, EMBASE and Cochrane Central Register from 1 January 1980 to 1 January 2012. We applied the Meta-Analysis of Observational Studies in Epidemiology guidelines in the conduct of this study.

Study selection:

We identified 16 observational studies with a total of 2.1 million study participants (201 831 psoriasis patients) fulfilling the inclusion criteria.

Results:

Using random-effects meta-analysis, the pooled odds ratio (OR) for obesity among patients with psoriasis was 1.66 (95% confidence interval (CI) 1.46–1.89) compared with those without psoriasis. From the studies that reported psoriasis severity, the pooled OR for obesity among patients with mild psoriasis was 1.46 (95% CI 1.17–1.82) and the pooled OR for patients with severe psoriasis was 2.23 (95% CI 1.63–3.05). One incidence study found that psoriasis patients have a hazard ratio of 1.18 (95% CI 1.14–1.23) for new-onset obesity.

Conclusions:

Overall, compared with the general population, psoriasis patients have higher prevalence and incidence of obesity. Patients with severe psoriasis have greater odds of obesity than those with mild psoriasis.

Metabolic syndrome in patients with psoriatic disease

Psoriasis is a common Th-1 and Th-17-mediated chronic inflammatory disease that has been associated with metabolic syndrome, a constellation of cardiovascular risk factors including obesity, hypertension, dyslipidemia, and insulin resistance. Overlapping inflammatory pathways and genetic susceptibility may be potential biologic links underlying this association. Multiple epidemiologic studies have consistently demonstrated higher prevalence of metabolic syndrome in patients with psoriasis. Dose-response relationships between more severe psoriasis and higher prevalence of metabolic syndrome components were recently established. This association has important clinical implications for the comprehensive management of psoriasis: Patients with psoriasis should be routinely screened for metabolic syndrome and treated accordingly to manage cardiometabolic risk, while clinicians should monitor potential effects on treatment efficacy and safety in patients with comorbid psoriasis and metabolic syndrome. Further research will be necessary to establish the directionality of this association and to explore the effect of treatment on these comorbid diseases.

Abnormal lipoprotein particles and cholesterol efflux capacity in patients with psoriasis

OBJECTIVES

Psoriasis is a Th-1/17 mediated inflammatory disease associated with increased risk of cardiovascular disease (CVD). Inflammation may modulate lipoprotein particle number and directly impair HDL functions, in particular reverse cholesterol transport (RCT). We sought to study how chronic in vivo inflammation modulates lipoprotein particle composition using nuclear magnetic resonance spectroscopy (NMR) and HDL efflux in psoriasis.

METHODS AND RESULTS

We prospectively enrolled a consecutive sample of patients with psoriasis (n = 122) and compared lipoprotein and metabolic risk factors to patients without psoriasis (n = 134). Fasting lipids, insulin, glucose were measured by standard assays, and lipoprotein concentration and size were measured by NMR. In a random subset (n = 100 each group), HDL efflux capacity was quantified using a validated ex vivo system involving the incubation of macrophages with apolipoprotein B-depleted serum from patients. Traditional lipid concentrations were similar in both groups except for HDL concentration which was lower in psoriasis (43 mg/dl (36-58) vs 50 (42-62), p < 0.01). However, NMR showed an atherogenic profile in psoriasis similar to that observed in diabetes, with significant increase in LDL particle concentration [1210.5 (1002-1498) vs 1115 (935-1291), p = 0.02] with decrease in LDL size [20.6 (20.3-21.1) vs 21.3 (20.6-21.1), p < 0.001] beyond CV risk factors and HOMA-IR (p = 0.001). Finally, HDL efflux capacity was lower in psoriasis compared to controls in fully adjusted models (beta -0.14, p = 0.001).

CONCLUSIONS

These data support a more atherogenic lipoprotein profile by NMR and decreased HDL efflux capacity in psoriasis patients compared to controls beyond CVD risk factors. The abnormal lipoprotein particle composition and HDL efflux capacity in psoriasis may provide a link between psoriasis and CVD.