Characterization of Lipoprotein Composition and Function in Pediatric Psoriasis Reveals a More Atherogenic Profile

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

HOMA-IR Index and Pediatric Psoriasis Severity-A Retrospective Observational Study

Psoriasis is a chronic inflammatory disease with specific cutaneous and nail lesions. Recent data has emphasized its systemic nature, highlighting metabolic conditions found in patients. Insulin resistance was identified in adult psoriasis, sometimes related to psoriasis severity. Data regarding this relationship in children are limited. Consequently, we tested the association between the Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) and Psoriasis Area and Severity Index (PASI) using a retrospective dataset of 43 children with various types of psoriasis. First, we attempted to replicate the relationship between the HOMA-IR and PASI. Second, we explored potential associations between these variables and others in the dataset. The results illustrated no association between HOMA-IR and PASI (p-value = 0.512). The exploratory findings hinted at a connection between nail pitting and insulin resistance (p-value = 0.038), yet Bonferroni adjustments suggested the risk of a false-positive finding. Noteworthy associations were found between the HOMA-IR and body mass index (BMI) (p-value = 0.001), the PASI and quality of life impairment (p-value = 0.005), and psoriasis severity and type (p-value = 0.001). The null hypothesis that insulin resistance in children is not positively associated with psoriasis severity cannot be rejected. Pilot estimates of variables and covariates of interest are provided for further confirmatory studies assessing this hypothesis.

The relationship between blood lipid and risk of psoriasis: univariable and multivariable Mendelian randomization analysis

Background

Psoriasis is a chronic inflammatory skin disease. Dyslipidemia may be a risk factor of psoriasis. But the causal relationship between psoriasis and blood lipid still remains uncertain.

Methods

The two data of blood lipid were obtained from UK Biobank (UKBB) and Global Lipid Genetics Consortium Results (GLGC). The primary and secondary database were from large publicly available genome-wide association study (GWAS) with more than 400,000 and 170,000 subjects of European ancestry, respectively. The psoriasis from Finnish biobanks of FinnGen research project for psoriasis, consisting of 6,995 cases and 299,128 controls. The single-variable Mendelian randomization (SVMR) and multivariable Mendelian randomization (MVMR) were used to assess the total and direct effects of blood lipid on psoriasis risk.

Results

SVMR estimates in primary data of blood lipid showed low-density lipoprotein cholesterol (LDL-C) (odds ratio (OR): 1.11, 95%, confidence interval (CI): 0.99-1.25, p = 0.082 in stage 1; OR: 1.15, 95% CI: 1.05-1.26, p = 0.002 in stage 2; OR: 1.15, 95% CI: 1.04-1.26, p = 0.006 in stage 3) and triglycerides (TG) (OR: 1.22, 95% CI: 1.10-1.35, p = 1.17E-04 in stage 1; OR: 1.15, 95% CI: 1.06-1.24, p = 0.001 in stage 2; OR: 1.14, 95% CI: 1.05-1.24, p = 0.002 in stage 3) had a highly robust causal relationship on the risk of psoriasis. However, there were no robust causal associations between HDL-C and psoriasis. The SVMR results in secondary data of blood lipid were consistent with the primary data. Reverse MR analysis showed a causal association between psoriasis and LDL-C (beta: -0.009, 95% CI: -0.016- -0.002, p = 0.009) and HDL-C (beta: -0.011, 95% CI: -0.021- -0.002, p = 0.016). The reverse causation analyses results between psoriasis and TG did not reach significance. In MVMR of primary data of blood lipid, the LDL-C (OR: 1.05, 95% CI: 0.99-1.25, p = 0.396 in stage 1; OR: 1.07, 95% CI: 1.01-1.14, p = 0.017 in stage 2; OR: 1.08, 95% CI: 1.02-1.15, p = 0.012 in stage 3) and TG (OR: 1.11, 95% CI: 1.01-1.22, p = 0.036 in stage 1; OR: 1.09, 95% CI: 1.03-1.15, p = 0.002 in stage 2; OR: 1.07, 95% CI: 1.01-1.13 p = 0.015 in stage 3) positively correlated with psoriasis, and there had no correlation between HDL-C and psoriasis. The results of the secondary analysis were consistent with the results of primary analysis.

Conclusions

Mendelian randomization (MR) findings provide genetic evidence for causal link between psoriasis and blood lipid. It may be meaningful to monitor and control blood lipid level for a management of psoriasis patients in clinic.

Elevated cholesteryl ester transfer and phospholipid transfer proteins aggravated psoriasis in imiquimod-induced mouse models

Background

Psoriasis is a chronic inflammatory skin disorder related to dyslipidemia, with decreased high-density lipoprotein (HDL). Various cell types express phospholipid transfer protein (PLTP) as well as cholesteryl ester transfer protein (CETP). Their elevated levels among transgenic (Tg) mice led to reduced HDL and a higher risk of atherosclerosis (AS). This study examined whether elevated CETP and PLTP could aggravate psoriasis in a psoriasis vulgaris mouse model.

Methods

The back skins of CETP-Tg, PLTP-Tg, and C57BL/6 male mice, aged six to 8 weeks, were shaved for imiquimod cream (IMQ) (5%) treatment for five consecutive days. The clinical pathological parameters were rated independently using the modified target lesion psoriasis severity score. The skin sections stained with hematoxylin-eosin were scored by the Baker score. Epidermal thickening and differentiation and inflammatory factor infiltration were determined by immunohistochemistry. Inflammatory cytokine levels were measured using quantitative reverse transcription-polymerase chain reaction (RT–PCR) and enzyme-linked immunosorbent assay (ELISA) kits. This work employed SPSS Statistics Version to conduct statistical analyses.

Results

In this study, CETP-Tg and PLTP-Tg mice had higher clinical and histological scores than wild-type (WT) mice. Immunohistochemistry of the epidermis and dermis revealed a high proportion of proliferating cell nuclear antigen (PCNA) positivity within psoriatic skin lesions of CETP-Tg and PLTP-Tg mice compared with WT mice. Interferon-α (IFN-α), interleukin-1β (IL-1β), IL-6, IL-17A, IL-17F, IL-22, and IL-23p19 mRNA levels increased within CETP-Tg and PLTP-Tg mice compared with WT counterparts. In comparison with WT mice, plasma tumor necrosis factor-α (TNF-α) levels, rather than IL-6 levels, were increased in CETP-Tg and PLTP-Tg mice.

Conclusions

Elevated CETP and PLTP aggravate psoriasis in a imiquimod-induced mouse model.

Metabolic Comorbidities and Cardiovascular Disease in Pediatric Psoriasis: A Narrative Review

Psoriasis vulgaris is a common inflammatory, immune mediated, chronic recurrent dermatosis. Psoriasis is also a systemic inflammatory disease, associated with numerous comorbidities, particularly metabolic ones. Here, we summarize and discuss, in a narrative review, the current knowledge about the metabolic comorbidities in psoriatic children. Obesity, insulin resistance, diabetes, cardiovascular disease, and dyslipidemia are identified as the main comorbidities in psoriatic children. In conclusion, dermatologists should be aware of the metabolic comorbidities in children with psoriasis, modulating the therapeutic approach according to the patient’s clinical condition.

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.

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.

Current Understanding of the Immunomodulatory Activities of High-Density Lipoproteins

Lipoproteins interact with immune cells, macrophages and endothelial cells - key players of the innate and adaptive immune system. High-density lipoprotein (HDL) particles seem to have evolved as part of the innate immune system since certain HDL subspecies contain combinations of apolipoproteins with immune regulatory functions. HDL is enriched in anti-inflammatory lipids, such as sphingosine-1-phosphate and certain saturated lysophospholipids. HDL reduces inflammation and protects against infection by modulating immune cell function, vasodilation and endothelial barrier function. HDL suppresses immune cell activation at least in part by modulating the cholesterol content in cholesterol/sphingolipid-rich membrane domains (lipid rafts), which play a critical role in the compartmentalization of signaling pathways. Acute infections, inflammation or autoimmune diseases lower HDL cholesterol levels and significantly alter HDL metabolism, composition and function. Such alterations could have a major impact on disease progression and may affect the risk for infections and cardiovascular disease. This review article aims to provide a comprehensive overview of the immune cell modulatory activities of HDL. We focus on newly discovered activities of HDL-associated apolipoproteins, enzymes, lipids, and HDL mimetic peptides.

Association of Metabolic Comorbidities with Pediatric Psoriasis: A Systematic Review and Meta-Analysis

Background

An evident relationship has been shown between psoriasis and metabolic comorbidities. However, the results in pediatric psoriasis vary from study to study, and no meta-analysis exists on the association of metabolic comorbidities with pediatric psoriasis.

Objective

To evaluate the association between psoriasis and metabolic comorbidities in pediatric patients.

Methods

We searched articles published in PubMed, EMBASE, and Cochrane Library databases from inception to April 30, 2019. All observational studies reporting the prevalence of obesity or metabolic comorbidities in pediatric patients with psoriasis were included.

Results

The meta-analysis included 16 unique studies meeting the inclusion criteria. The pooled odds ratios in pediatric patients with psoriasis was 2.40 (95% confidence interval [CI], 1.60~3.59) for obesity (13 studies), 2.73 (95% CI, 1.79~4.17) for hypertension (8 studies), 2.01 (95% CI, 1.09~3.73) for diabetes mellitus (8 studies), 1.67 (95% CI, 1.42~1.97) for dyslipidemia (7 studies), and 7.49 (95% CI, 1.86~30.07) for metabolic syndrome (4 studies).

Conclusion

Pediatric patients with psoriasis showed a significantly higher prevalence of obesity, hypertension, diabetes, dyslipidemia, and metabolic syndrome. Adequate monitoring and timely management of metabolic comorbidities should be considered in these patients.

Pediatric Psoriasis Comorbidities: Screening Recommendations for the Primary Care Provider

Psoriasis, which affects up to 2% of children may be associated with significant comorbidity, including obesity, diabetes, cardiovascular disease, depression, and reduced quality of life. Screening and decision-making require a multidisciplinary approach with the management of potential comorbidities championed by primary care providers and supported by respective specialists and subspecialists. Research into the comorbidities and systemic manifestations has generated significant data culminating in several proposals for a consensus guideline for both pediatric and nonpediatric populations. Our aim is to provide a summary targeted to the pediatric primary care provider from the best available evidence when caring for children with psoriasis.

HDL in Immune-Inflammatory Responses: Implications beyond Cardiovascular Diseases

High density lipoproteins (HDL) are heterogeneous particles composed by a vast array of proteins and lipids, mostly recognized for their cardiovascular (CV) protective effects. However, evidences from basic to clinical research have contributed to depict a role of HDL in the modulation of immune-inflammatory response thus paving the road to investigate their involvement in other diseases beyond those related to the CV system. HDL-C levels and HDL composition are indeed altered in patients with autoimmune diseases and usually associated to disease severity. At molecular levels, HDL have been shown to modulate the anti-inflammatory potential of endothelial cells and, by controlling the amount of cellular cholesterol, to interfere with the signaling through plasma membrane lipid rafts in immune cells. These findings, coupled to observations acquired from subjects carrying mutations in genes related to HDL system, have helped to elucidate the contribution of HDL beyond cholesterol efflux thus posing HDL-based therapies as a compelling interventional approach to limit the inflammatory burden of immune-inflammatory diseases.

Liangxue Jiedu Formula Improves Psoriasis and Dyslipidemia Comorbidity via PI3K/Akt/mTOR Pathway

The pathological mechanism of psoriasis and dyslipidemia comorbidity is unclear, and there are few reports on therapy. By establishing an animal model of ApoE-/- mice induced by imiquimod (IMQ), we explored the effects of Liangxue Jiedu formula (LXJDF), a traditional Chinese herb medicine, on psoriasis and dyslipidemia comorbidity through PI3K/Akt/mTOR pathway. The experiment was divided into a control group, a model group, an LXJDF high-dose group, an LXJDF low-dose group, and a positive drug (atorvastatin) group. Each group of mice was given continuous oral administration once a day. After 3 weeks, the mice dorsal skins were smeared with 62.5 mg of 5% IMQ cream for five consecutive days and continued to be given the corresponding drugs. We observed the effects of LXJDF on skin lesion changes, PASI score, pathological characteristics, blood lipid levels (TC, TG, LDL, HDL, and oxLDL), liver pathology, inflammatory factors in the skin, and the protein expression of PI3K/Akt/mTOR pathway in both the skin and liver. The results showed that LXJDF could significantly improve the psoriasiform skin lesions of IMQ-induced ApoE-/- mice, including the reduction of PASI, thinning of epidermal thickness, inhibition of hyperkeratosis and parakeratosis, and inflammatory infiltration in the dermis, and reduce lipid accumulation in the epidermal. LXJDF could regulate blood lipid levels, reduce liver inflammation, and protect the liver. LXJDF could significantly decrease the gene expressions of inflammatory factors IL-17A, IL-23, IL-6, and TNF-α in the skin. LXJDF showed specific inhibition of PI3K, Akt, mTOR protein, and its phosphorylation expressions. In conclusion, LXJDF exerts an intervention effect on psoriasis and dyslipidemia comorbidity via PI3K/Akt/mTOR and its phosphorylation pathway.

High-Density Lipoprotein (HDL) in Allergy and Skin Diseases: Focus on Immunomodulating Functions

From an evolutionary perspective, lipoproteins are not only lipid transporters, but they also have important functions in many aspects of immunity. High-density lipoprotein (HDL) particles are the most abundant lipoproteins and the most heterogeneous in terms of their composition, structure, and biological functions. Despite strong evidence that HDL potently influences the activity of several immune cells, the role of HDL in allergies and skin diseases is poorly understood. Alterations in HDL-cholesterol levels have been observed in allergic asthma, allergic rhinitis, atopic dermatitis (eczema), psoriasis, urticaria, and angioedema. HDL-associated apolipoprotein (apo) A-I, apoA-IV, and apoC-III, and lyso-phosphatidylcholines potently suppress immune cell effector responses. Interestingly, recent studies provided evidence that allergies and skin diseases significantly affect HDL composition, metabolism, and function, which, in turn, could have a significant impact on disease progression, but may also affect the risk of cardiovascular disease and infections. Interestingly, not only a loss in function, but also, sometimes, a gain in function of certain HDL properties is observed. The objective of this review article is to summarize the newly identified changes in the metabolism, composition, and function of HDL in allergies and skin diseases. We aim to highlight the possible pathophysiological consequences with a focus on HDL-mediated immunomodulatory activities.

Pediatric psoriasis and association with cardiovascular and metabolic comorbidities: Systematic review and meta-analysis

BACKGROUND/OBJECTIVES

There is an increasing volume of evidence which supports the link between psoriasis and cardiometabolic risk including obesity, metabolic syndrome, diabetes, hyperlipidemia, and myocardial infarction. Although one-third to one-half of psoriasis cases start during childhood, it is unclear whether childhood psoriasis is similarly associated with a cardiometabolic risk profile.

METHODS

Electronic database searches were performed to identify studies comparing the proportion of pediatric psoriasis cases with controls in terms of dichotomous outcomes including the proportion of patients with overweight BMI, obese BMI, metabolic syndrome, diabetes, hypertension, hyperlipidemia, ischemic heart disease, or heart failure; continuous outcomes recorded include BMI, systolic blood pressure, diastolic blood pressure, HDL, LDL, triglycerides, and total cholesterol.

RESULTS

A statistically significant association was found between pediatric psoriasis and overweight/obesity as well as waist:height ratio >0.5, in addition to metabolic syndrome, diabetes, hyperlipidemia, hypertension, and cardiac ischemia and failure. The association with obesity is dependent on the severity of disease, where moderate-severe psoriasis patients have higher odds of obesity compared to mild psoriasis.

CONCLUSIONS

Our systematic review and pooled meta-analysis demonstrate a significant association between childhood psoriasis and obesity, central adiposity, and other cardiometabolic comorbidities. Clinicians should consider the assessment of comorbidities in children with psoriasis, which may allow for early lifestyle interventions and education.

S2k guidelines for the treatment of psoriasis in children and adolescents - Short version part 1

The present guidelines are aimed at residents and board-certified physicians in the fields of dermatology, pediatrics, pediatric dermatology and pediatric rheumatology as well as policymakers and insurance funds. They were developed by dermatologists and pediatric dermatologists in collaboration with pediatric rheumatologists using a formal consensus process (S2k). The guidelines highlight topics such as disease severity, quality of life, treatment goals as well as problems associated with off-label drug therapy in children. Trigger factors and diagnostic aspects are discussed. The primary focus is on the various topical, systemic and UV-based treatment options available and includes recommendations for use and treatment algorithms. Other aspects addressed herein include vaccinations in children and adolescents with psoriasis as well as various disease subtypes such as guttate psoriasis, diaper psoriasis, pustular psoriasis and psoriatic arthritis. Finally, we also provide recommendations for imaging studies and the diagnostic workup to rule out tuberculosis prior to initiating systemic treatment. Note: This article constitutes part 1 of the Sk2 guidelines for the treatment of psoriasis in children and adolescents. Part 2 will be published in the next issue. It contains chapters on UV therapy, systemic treatment, tonsillectomy and antibiotics, vaccinations, guttate psoriasis, psoriatic arthritis, complementary medicine, as well as imaging studies and diagnostic workup to rule out tuberculosis prior to systemic treatment.

Clinical characteristics including cardiovascular and metabolic risk factors in adolescents with psoriasis

BACKGROUND

Clinical studies on psoriasis in adolescents have mainly been performed in patients with severe psoriasis. Population-based studies of clinical characteristics and risk factors for later cardiovascular and metabolic disease in children and adolescents are lacking.

OBJECTIVES

To examine the clinical characteristics of adolescents with psoriasis nested in a general population cohort. Furthermore, to investigate cardiovascular and metabolic risk factors in the adolescents with psoriasis compared to parentally predisposed and non-predisposed adolescents without psoriasis from the same birth cohort.

METHODS

We identified adolescents with and without psoriasis using a nationwide general population birth cohort in Denmark. A clinical examination included skin inspection and scoring of psoriasis severity, completion of a questionnaire on psoriasis and comorbidities, physical measurements, and blood sampling. Participants also completed self-administered questionnaires on quality of life and mental health.

RESULTS

We included 81 adolescents with psoriasis and 234 controls (110 with genetic predisposition for psoriasis and 124 without predisposition). Median age was 15.6 (13.5-18.5) years, and in those with active psoriasis, median Psoriasis Area and Severity Index score was 1.2 (0.1-11.4). The scalp was the most common site of psoriasis, both at debut and at time of examination. Diaper rash in infancy was more frequent in the psoriasis group. No significant differences regarding quality of life, anxiety and depression were found. More adolescents with psoriasis were obese (8.6% vs. 1.7%, P = 0.008), and physical measures of abdominal obesity were also significantly higher. HbA1c was significantly higher (31.55 vs. 30.81 mmol/mol, P = 0.048), while no differences were found for blood pressure, lipids or high-sensitivity C-reactive protein. In a subgroup analysis, this was evident in the non-predisposed psoriasis-free controls only.

CONCLUSIONS

Overall, adolescents with psoriasis from this general population had mild disease. Still, early markers of cardiovascular and metabolic disease were elevated.

Cohort profile: the clinical 'Psoriasis in Adolescents' (PIA) cohort in Denmark

PURPOSE

Psoriasis is a chronic inflammatory skin disease that frequently debuts in childhood and adolescence. We wished to determine environmental and genetic risk factors for the development of psoriasis in children and adolescents, as well as to investigate debut type, trigger factors, course of disease, nature and influence of stress related to both child and family and risk factors for comorbidity. The 'Psoriasis in Adolescents' (PIA) cohort will provide data on the relationship between psoriasis and, respectively, genetic disposition, early-life exposures, quality of life and comorbidity.

PARTICIPANTS

The PIA cohort is nested in the large general population Danish National Birth Cohort (DNBC). We invited 390 adolescents with psoriasis and corresponding maternally predisposed and non-predisposed controls. Participants underwent an interview and a clinical examination consisting of a skin inspection and physical measurements including blood sampling and microbiological swabs. Additionally, four self-administered questionnaires on physical and mental health were completed.

FINDINGS TO DATE

The final PIA cohort consists of 81 adolescents with psoriasis, 110 parentally predisposed and 124 non-predisposed psoriasis-free adolescents. The validity of the maternally reported psoriasis status from the DNBC was found to be low on clinical examination (47.5%). In contrast, the self-reported psoriasis status of the DNBC mothers was clinically confirmed in 80.8% of the cases.

FUTURE PLANS

The PIA cohort offers the possibility of assessing the clinical characteristics, course of psoriasis and development of comorbidities in adolescents with clinically confirmed disease from a general population. Comparison with predisposed and non-predisposed controls is possible and genetic analyses are scheduled. We plan to invite the participants for a follow-up in 5-10 years. Furthermore, we plan to include newly diagnosed adolescents with psoriasis from the 18-year DNBC follow-up. All information is linkable on the individual level with data from the DNBC and nationwide registries in Denmark.

Psoriasis and metabolic and cardiovascular comorbidities in children: A systematic review

INTRODUCTION

Psoriasis is associated with a higher risk of cardiovascular and/or metabolic comorbidity in adults, but discordant data have been reported in children.

OBJECTIVE

To evaluate the frequency of metabolic and cardiovascular comorbidity in children with psoriasis and to establish whether age at onset of psoriasis correlates with metabolic and cardiovascular comorbidity in adulthood.

MATERIAL AND METHODS

We conducted a systematic review on MEDLINE, using PubMed and Ovid. The search was limited to children (<18 years). The following key words were used: "psoriasis" with "children or childhood or adolescent" and "obesity" or "hypertension" or "diabetes" or "dyslipidemia" or "cardiovascular risk factor" or "myocardial infarction" or "stroke" or "coronaropathy" or "comorbidity". The reference lists of the articles retrieved were checked for additional relevant studies.

RESULTS

A total of 377 potential citations were analyzed. After removing duplicate articles and reviewing eligibility in titles and abstracts, 16 articles remained. The studies analyzed revealed significantly higher risk of overweight and obesity in children with psoriasis, despite the numerous definitions used. Four studies reported higher risk of abdominal obesity in children with psoriasis. Data on hypertension, diabetes, dyslipidemia, metabolic syndrome, and major cardiovascular events suggested there was no higher risk of these comorbidities in children with psoriasis. Two studies suggested that age at onset of psoriasis did not increase the frequency of comorbidity in adulthood.

CONCLUSION

This systematic review suggests that psoriasis in children is not associated with metabolic and cardiovascular comorbidities, except overweight and obesity, for which higher prevalence is clearly demonstrated in the literature.

Pediatric psoriasis: Evolving perspectives

BACKGROUND/OBJECTIVES

Childhood-onset psoriasis is a common skin disorder that has recently received increasing attention, particularly because of its significant medical, social, financial, and psychological burdens and its associated comorbidities. With limited data available and lack of standardized management guidelines for pediatric psoriasis, an expert panel desired to provide an updated critical overview and practical guidance for management of the affected population.

METHODS

A panel of pediatric dermatologists with extensive experience in pediatric psoriasis defined and prioritized a core set of topics, performed an English-language literature review, prepared critical evaluations and presentations of topic areas, and carried out a consensus meeting and follow-up consensus manuscript.

RESULTS

The summation of evolving perspectives in pediatric psoriasis includes epidemiology and natural history of the disease, precipitating factors and comorbidities, quality of life and burden of disease, clinical features and disease presentation, differential diagnosis, pathogenesis and treatment, including topical, photo, and systemic therapies.

CONCLUSION

Pediatric psoriasis is an important immune-mediated inflammatory skin disease with potential for significant impact on affected individuals and their caregivers. Current state-of-the-art care is based primarily on experience and expert consensus, but pediatric data are accumulating and therapeutic options are rapidly evolving.

[What's new in pediatric dermatology?]

The association of a birth defect and a segmental hemangioma is well established, a consensus concerning evaluation and monitoring of infants with PHACE or LUMBAR syndromes has been published. The efficacy of propranolol in infantile hemangioma is proven; however there were still unresolved issues concerning the safety in children; after 8 years of use on thousands of children safety data collection did not show any unexpected side effects. Topical treatment of infantile hemangiomas with beta-blockers, such as timolol, is very popular, but recent publications revealed a significant systemic absorption that could be responsible for severe side effects, such as bradycardia, in low birthweight infants. As a consequence, this therapeutic option should be considered with caution. In the last 2 years mTOR inhibitors have been tested in low-flow vascular malformations with varying success, but progress remains to be done in the treatment of vascular abnormalities. Today, genetics has led to advances in the understanding of the pathophysiology and in the future targeted therapies could probably be feasible. Skin barrier deficiency is responsible for the development of allergic phenomena in atopic patients, since it has been shown that sensibilisation, even to food, could probably be induced by skin contact. Unfortunately, the topical treatment with crisaborole, a phosphodiesterase 4 inhibitor, does not look like a revolution in children atopic dermatitis, its efficacy seems equivalent to emollient application. In the field of infectious diseases, changes in viral outbreaks are the most reported. Furthermore epidemic Zika virus, enteroviruses are responsible for expanded dermatological manifestations and also severe meningoencephalitis. Paraviral character of various eruptions, such as gloves and socks syndrome or eruptive pseudoangiomatosis is challenged.

Chronic skin inflammation accelerates macrophage cholesterol crystal formation and atherosclerosis

Inflammation is critical to atherogenesis. Psoriasis is a chronic inflammatory skin disease that accelerates atherosclerosis in humans and provides a compelling model to understand potential pathways linking these diseases. A murine model capturing the vascular and metabolic diseases in psoriasis would accelerate our understanding and provide a platform to test emerging therapies. We aimed to characterize a new murine model of skin inflammation (Rac1V12) from a cardiovascular standpoint to identify novel atherosclerotic signaling pathways modulated in chronic skin inflammation. The RacV12 psoriasis mouse resembled the human disease state, including presence of systemic inflammation, dyslipidemia, and cardiometabolic dysfunction. Psoriasis macrophages had a proatherosclerotic phenotype with increased lipid uptake and foam cell formation, and also showed a 6-fold increase in cholesterol crystal formation. We generated a triple-genetic K14-RacV12-/+/Srb1-/-/ApoER61H/H mouse and confirmed psoriasis accelerates atherogenesis (~7-fold increase). Finally, we noted a 60% reduction in superoxide dismutase 2 (SOD2) expression in human psoriasis macrophages. When SOD2 activity was restored in macrophages, their proatherogenic phenotype reversed. We demonstrate that the K14-RacV12 murine model captures the cardiometabolic dysfunction and accelerates vascular disease observed in chronic inflammation and that skin inflammation induces a proatherosclerotic macrophage phenotype with impaired SOD2 function, which associated with accelerated atherogenesis.

Psoriasis and Cardiovascular Comorbidities: Focusing on Severe Vascular Events, Cardiovascular Risk Factors and Implications for Treatment

Psoriasis is a common and chronic inflammatory disease of the skin. It may impair the physical and psychosocial function of patients and lead to decreased quality of life. Traditionally, psoriasis has been regarded as a disease affecting only the skin and joints. More recently, studies have shown that psoriasis is a systemic inflammatory disorder which can be associated with various comorbidities. In particular, psoriasis is associated with an increased risk of developing severe vascular events such as myocardial infarction and stroke. In addition, the prevalence rates of cardiovascular risk factors are increased, including hypertension, diabetes mellitus, dyslipidemia, obesity, and metabolic syndrome. Consequently, mortality rates have been found to be increased and life expectancy decreased in patients with psoriasis, as compared to the general population. Various studies have also shown that systemic treatments for psoriasis, including methotrexate and tumor necrosis factor-α inhibitors, may significantly decrease cardiovascular risk. Mechanistically, the presence of common inflammatory pathways, secretion of adipokines, insulin resistance, angiogenesis, oxidative stress, microparticles, and hypercoagulability may explain the association between psoriasis and cardiometabolic disorders. In this article, we review the evidence regarding the association between psoriasis and cardiovascular comorbidities, focusing on severe vascular events, cardiovascular risk factors and implications for treatment.

Psoriasis-associated vascular disease: the role of HDL

Psoriasis is a chronic inflammatory systemic disease with a prevalence of 2-3%. Overwhelming evidence show an epidemiological association between psoriasis, cardiovascular disease and atherosclerosis. Cardiovascular disease is the most frequent cause of death in patients with severe psoriasis. Several cardiovascular disease classical risk factors are also increased in psoriasis but the psoriasis-associated risk persists after adjusting for other risk factors.Investigation has focused on finding explanations for these epidemiological data. Several studies have demonstrated significant lipid metabolism and HDL composition and function alterations in psoriatic patients. Altered HDL function is clearly one of the mechanisms involved, as these particles are of the utmost importance in atherosclerosis defense. Recent data indicate that biologic therapy can reverse both structural and functional HDL alterations in psoriasis, reinforcing their therapeutic potential.

Pediatric psoriasis: Should we be concerned with comorbidity? Cross-sectional study

BACKGROUND

Similarly to psoriasis in adults, recent research has linked psoriasis to several comorbidities in children. The aim of this study was therefore to describe comorbidities associated with pediatric psoriasis, to investigate their relationship with psoriasis characteristics and severity, and to perform a review of the literature.

METHODS

A cross-sectional study was performed on a sample of Moroccan children with psoriasis, in 2014-2016.

RESULTS

A total of 64 pediatric psoriasis patients had metabolic comorbidities in association with psoriasis; 20 children had non-metabolic comorbidities; and 76 children had no comorbidity. The metabolic comorbidities were as follows: abdominal obesity, 40% (n = 64); overweight, 12.5% (n = 20); metabolic syndrome, 3.7% (n = 6); and dyslipidemia, 3.1% (n = 5); the non-metabolic comorbidities were atopy, 4.3% (n = 7); epilepsy, 3.1% (n = 5); celiac disease, 1.8% (n = 3); vitiligo, 1.8% (n = 3); alopecia ariata, 0.6% (n = 1); and valvular cardiopathy, 0.6% (n = 1). No cases of diabetes mellitus, obesity, or high blood pressure were recorded. Significant factors associated with metabolic comorbidity were extended psoriasis vulgaris >10% (P = 0.01; OR, 2.19), severe psoriasis especially pustular and erythroderma (P = 0.018; OR, 2), nail involvement (P = 0.016; OR, 1.5), face involvement (P = 0.01; OR, 1,59), resistance to topical treatment (P = 0.003; OR, 2.5) and alteration of quality of life (P = 0.02; OR, 1,7). There was no significant risk factor associated with non-metabolic comorbidity.

CONCLUSIONS

Given the frequent association of pediatric psoriasis with many disorders, these comorbidities should be investigated and identified so that they can be taken into account in the management of psoriasis in order to avoid treatment failure. Regular follow up should be carried out in patients at risk of metabolic comorbidity.

Pediatric Psoriasis Comorbidity Screening Guidelines

Importance

Psoriasis is a complex inflammatory skin condition associated with serious medical comorbidities in adults, including obesity, hypertension, dyslipidemia, type 2 diabetes mellitus, psoriatic arthritis, nonalcoholic fatty liver disease, depression, anxiety, and decreased quality of life. Because psoriasis begins in childhood in almost one-third of patients, early identification of risk may be critical to minimizing effects on future health.

Objective

To develop the first set of guidelines for comorbidity screening for patients with pediatric psoriasis based on current evidence.

Evidence Review

A literature review was performed using PubMed from January 1999 through December 2015. Limiting the search to human studies published in English and removing reviews and editorials produced 153 relevant manuscripts. An expert panel in psoriasis, pediatric dermatology, pediatric rheumatology, pediatric gastroenterology, pediatric endocrinology, and adult and pediatric cardiology used the patient-centered Strength of Recommendation Taxonomy (SORT) method to evaluate and grade the quality of evidence.

Findings

Because of the limited number of pediatric studies published on these topics, the strength of the panel's recommendations is classified as SORT level C expert consensus recommendations. The majority of recommendations coincide with those endorsed by the American Academy of Pediatrics for the general pediatric patient but with added attention to signs and symptoms of arthritis, depression, and anxiety. The panel also identified key areas for further investigation.

Conclusions and Relevance

Patients with pediatric psoriasis should receive routine screening and identification of risk factors for associated comorbidities. These guidelines are relevant for all health care providers caring for patients with pediatric psoriasis, including primary care clinicians, dermatologists, and pediatric specialists. Because these are the first pediatric guidelines, re-review and refinement will be necessary as studies further detail, and possibly stratify, risk in affected children.

Psoriasis and comorbid diseases: Epidemiology

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