Alcohol misuse in patients with psoriasis: identification and relationship to disease severity and psychological distress

Alcohol consumption and risk of psoriasis: Results from observational and genetic analyses in more than 100,000 individuals from the Danish general population

Background

Psoriasis is associated with high alcohol consumption, but the causality of this relationship is unclear.

Objective

We aimed to use a Mendelian randomization approach to investigate the causal effects of alcohol on incident psoriasis.

Methods

We included 102,655 adults from the prospective Copenhagen studies. All participants filled out a questionnaire on alcohol consumption, were physically examined, and had blood drawn for biochemical and genetic analyses. We created a genetic instrument based on the number of fast-metabolizing alleles in alcohol dehydrogenase 1B and alcohol dehydrogenase 1C, known to be associated with alcohol consumption, to test whether alcohol consumption was causally associated with psoriasis.

Results

Observationally, we found an increased risk of incident psoriasis among individuals with high alcohol consumption compared to those with low alcohol consumption with a hazard ratio of 1.30 (95% confidence interval 1.05-1.60) in the fully adjusted model. Using genetic data to predict alcohol consumption to avoid confounding and reverse causation, we found no association between number of fast-metabolizing alleles and risk of psoriasis.

Limitations

Alcohol consumption was self-reported and psoriasis was defined using the International Classification of Diseases 10th revision and 8th revision codes.

Conclusion

Alcohol consumption is observationally but not causally associated with incident psoriasis.

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.

Risk of liver fibrosis associated with long-term methotrexate therapy may be overestimated

BACKGROUND & AIMS

The risk of significant liver fibrosis from prolonged methotrexate (MTX) exposure has been estimated at around 5%, prompting intensive monitoring strategies. However, the evidence is derived from retrospective studies that under-reported risk factors for liver disease. We evaluated the risk of long-term MTX therapy on liver fibrosis in a longitudinal cohort study using two non-invasive markers.

METHOD

Between 2014-2021, adult patients diagnosed with rheumatoid arthritis (RA) or psoriasis for ≥2 years were recruited prospectively from six UK sites. The MTX group included patients who received MTX for ≥6 months, whereas the unexposed group included those who never received MTX. All patients underwent full liver profiling, with transient elastography (TE) and enhanced liver fibrosis (ELF) marker measurements.

RESULTS

A total of 999 patients (mean age 60.8 ± 12 years, 62.3% females) were included. Of 976 with valid TE values, 149 (15.3%) had liver stiffness ≥7.9 kPa. Of 892 with a valid ELF, 262 (29.4%) had ELF ≥9.8. Age and BMI were independently associated with elevated liver stiffness and ELF. Neither MTX cumulative dose nor duration was associated with elevated liver stiffness. Diabetes was the most significant risk factor associated with liver stiffness ≥7.9 kPa (adjusted odds ratio = 3.19; 95% CI 1.95-5.20; p <0.001). Regular use of non-steroidal anti-inflammatory drugs showed the strongest association with ELF ≥9.8 (odds ratio = 1.76; 95% CI 1.20-2.56; p = 0.003), suggesting the degree of joint inflammation in RA may confound ELF as a non-invasive marker of liver fibrosis.

CONCLUSION

The risk of liver fibrosis attributed to MTX itself might have been previously overestimated; there is a need to consider modifying current monitoring guidelines for MTX.

IMPACT AND IMPLICATIONS

Current guidelines recommend intensive (2-3 monthly) monitoring strategies for patients on long-term methotrexate therapy due to the potential risk of liver fibrosis. Evaluation of the association using two validated non-invasive markers of liver fibrosis, liver stiffness and enhanced liver fibrosis score, in a large cohort of patients with rheumatoid arthritis or psoriasis shows that the reported risk has previously been overestimated. The clinical focus should be to improve patients' metabolic risk factors, diabetes and BMI, that are independently associated with liver stiffness. There is a need to consider modifying current treatment monitoring guidelines for methotrexate.

Prevalence and Odds of Anxiety Disorders and Anxiety Symptoms in Children and Adults with Psoriasis: Systematic Review and Meta-analysi

The magnitude of the association between psoriasis and depression has been evaluated, but not that between psoriasis and anxiety. The aim of this systematic review and meta-analysis was to examine the prevalence and odds of anxiety disorders and symptoms in patients with psoriasis. Five medical databases (Cochrane Database, EMBASE, PubMed, PsychINFO, ScienceDirect) were searched for relevant literature. A total of 101 eligible articles were identified. Meta-analysis revealed different prevalence rates depending on the type of anxiety disorder: 15% [95% confidence interval [CI] 9–21] for social anxiety disorder, 11% [9–14] for generalized anxiety disorder, and 9% [95% CI 8–10] for unspecified anxiety disorder. There were insufficient studies assessing other anxiety disorders to be able to draw any conclusions on their true prevalence. Meta-analysis also showed a high prevalence of anxiety symptoms (34% [95% CI 32–37]). Case-control studies showed a positive association between psoriasis and unspecified anxiety disorder (odds ratio 1.48 [1.18; 1.85]) and between psoriasis and anxiety symptoms (odds ratio 2.51 [2.02; 3.12]). All meta-analyses revealed an important heterogeneity, which could be explained in each case by methodological factors. The results of this study raise the necessity of screening for the presence of anxiety disorders, as previously recommended for depressive disorders, in patients with psoriasis and, if necessary, to refer such patients for evaluation by a mental health professional and appropriate treatment.

Alcohol and Psoriasis for the Dermatologist: Know, Screen, Intervene

Psoriasis patients are at increased risk of harmful alcohol use and alcohol dependency with many deleterious effects. Increasing alcohol use is associated with worsening psoriasis severity, is a risk factor for poor response to systemic treatments and may impact on comorbidities such as psoriatic arthritis, cardiovascular disease, cancer and liver disease. Harmful alcohol use and alcohol dependency can be defined by the updated ICD-11 coding system and screening can be completed using many tools including the Cut down, Annoyed, Guilty, Eye-Opener (CAGE), Alcohol Use Disorders Identification Test (AUDIT) and Michigan Alcohol Screening Test (MAST) questionnaires. Dermatologists may be able to complete brief interventions encouraging alcohol reduction in psoriasis patients. Psoriasis patients may respond to messages of gain with reduced psoriasis severity and loss with reduced cardiovascular risk. It is important for dermatologists to discuss alcohol with all psoriasis patients, to be aware of the impact of alcohol in psoriasis and to familiarise themselves with screening tools, brief intervention and local services available to patients who require specialist input for harmful alcohol use or alcohol dependency.

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.

Does the lifestyle of patients with psoriasis affect their illness?

Psoriasis is one of the most common chronic, incurable inflammatory skin diseases, affecting 2–4% of the general population. Etiopathogenesis of this disease remains unclear. It is widely considered to be a multifactorial disorder caused by the interaction between inherited susceptibility alleles and environmental risk factors, such as lifestyle, diet, stimulants, foci of inflammation, and psychological factors. The widespread prevalence of psoriasis is a very significant health and socioeconomic problem. Treatment of psoriasis is based on relieving the acute symptoms of the disease. Despite the implementation of many therapeutic options, including biological treatment, effectiveness of these options is not always sufficient, or in some patients it is not satisfactory. In order to properly control the symptoms of the disease, the patient should be told that the therapeutic effect is achieved not only by pharmacotherapy but also by introducing appropriate healthy habits in everyday life. This article discusses the importance of patient-controlled factors that affect the severity of psoriasis. Theimportance of regular exercise, smoking avoidance, and reduced alcohol consumption is explained, as well as the importance for psoriasis treatment of psychotherapy and spa therapy. Understanding the essence of these factors in the treatment of psoriasis is important in achieving satisfactory therapeutic effects.

High Levels of Psychological Distress, Sleep Disturbance, and Alcohol Use Disorder in Adults With Atopic Dermatitis

BACKGROUND

The burden of illness associated with atopic dermatitis (AD) is significant and multidimensional, especially in those with moderate to severe disease.

OBJECTIVE

Our objective was to evaluate the disease burden of patients with AD in relation to psychological distress, sleep disturbance, and alcohol misuse.

METHODS

Patients with AD, attending 2 tertiary referral centers in Dublin, Ireland, were recruited. A series of validated questionnaires were used including the Patient-Oriented Eczema Measure, Dermatology Life Quality Index (DLQI), Center for Epidemiologic Studies-Depression Scale, Quality of Life in Atopic Dermatitis Questionnaire, Alcohol Use Disorders Identification Test, and Pittsburgh Sleep Quality Index. The Eczema Area and Severity Index was calculated contemporaneously with the questionnaire completion.

RESULTS

One hundred patients completed the questionnaire, of whom 52% were female. Sixty-three percent of patients experienced impaired quality of life as measured by the DLQI. Higher DLQI scores correlated with decreasing age (r = 0.3277, P < 0.0009). Thirty percent were found to be at risk of clinical depression, and higher Center for Epidemiologic Studies-Depression Scale scores correlated with a younger age and eczema severity. Sleep disturbance was greater in those at risk of depression (mean = 10.40 vs 5.79, P < 0.0001). Patients with moderate to severe AD were more likely to score higher on the Alcohol Use Disorders Identification Test, and 25% met the criteria for alcohol use disorder. In relation to sleep, 73% of patients scored higher than 5 on the Pittsburgh Sleep Quality Index, which signifies poor sleep quality.

CONCLUSIONS

Patients with AD endure a significant burden on health with regard to mental well-being, alcohol use, and sleep quality. Clinicians should consider screening patients for these comorbidities.

Alcohol misuse is associated with poor response to systemic therapies for psoriasis: findings from a prospective multicentre cohort study

BACKGROUND

Factors that might influence response to systemic treatment for moderate-to-severe psoriasis are varied, and generally, are poorly understood, aside from high bodyweight, suggesting that other unidentified factors may be relevant in determining response to treatment. The impact of alcohol misuse on treatment response has not been previously investigated.

OBJECTIVES

To investigate whether alcohol misuse is associated with poor response to treatment for psoriasis.

METHODS

This was a prospective cohort study in which response to systemic therapies was assessed using the Psoriasis Area and Severity Index (PASI). The CAGE (Cut down, Annoyed, Guilty, Eye opener) questionnaire was used to screen for alcohol misuse. A multivariable factional polynomial linear regression model was used to examine factors associated with change in PASI between baseline and follow-up.

RESULTS

The cohort comprised 266 patients (biologic cohort, n = 134; conventional systemic cohort, n = 132). For the entire cohort, the median (interquartile range) PASI improved from 13 (10·0-18·3) at baseline to 3 (1·0-7·5) during follow-up. A higher CAGE score [regression coefficient: 1·40, 95% confidence interval (CI) 0·04-2·77]; obesity (1·84, 95% CI 0·48-3·20); and receiving a conventional systemic rather than a biologic therapy (4·39, 95% CI 2·84-5·95) were significantly associated with poor response to treatment; whereas a higher baseline PASI (-0·83, 95% CI -0·92 to -0·74) was associated with a better response to treatment.

CONCLUSIONS

The poor response to therapy associated with alcohol misuse and obesity found in people with psoriasis calls for lifestyle behaviour change interventions and support as part of routine clinical care. Targeting interventions to prevent, detect and manage alcohol misuse among people with psoriasis is needed to minimize adverse health consequences and improve treatment response.

Alcohol in Psoriasis-From Bench to Bedside

Alcohol affects the symptoms, compliance and comorbidities as well as the safety and efficacy of treatments in psoriatic patients. In this review, we aim to summarize and link clinical observations with a molecular background, such as signaling pathways at the cellular level and genetic variations, and to provide an overview of how this knowledge could influence our treatment selection and patient management.

Delphi-based recommendations for the management of cardiovascular comorbidities in patients with psoriatic arthritis and moderate-to-severe psoriasis

The aim of this study was to generate practical recommendations to assist rheumatologists and dermatologists in the management of cardiovascular (CV) comorbidities in patients with moderate-to-severe psoriasis (MS-PSO) and psoriatic arthritis (PsA). A two-round Delphi study was conducted. A panel of experts rated their agreement with a set of statements (n = 52) on a nine-point Likert scale (1 = totally disagree; 9 = totally agree). Statements were classified as inappropriate (median 1-3), irrelevant (median 4-6) or appropriate (median 7-9). Consensus was established when at least two-thirds of the panel responded with a score within any one range. A total of 25 experts, 60% rheumatologists and 40% dermatologists, participated in two consultation rounds. There was overall unanimity on the appropriateness of an initial assessment for CV risk factors in all patients with MS-PSO and PsA. Most panelists (88.0%) also supported the evaluation of patients' psychological and physical status. Additionally, most panelists (72.2%) agreed on a novel sequential approach for the management of CV comorbidities. This sequence starts with the assessment of hypertension, diabetes and dyslipidemia along with the identification of depression and anxiety disorders. Once these factors are under control, smoking cessation programs might be initiated. Finally, if patients have not met weight loss goals with lifestyle modifications, they should receive specialized treatment for obesity. This study has drawn up a set of practical recommendations that will facilitate the management of CV comorbidities in patients with MS-PSO and PsA.

Psychological Distress, Alexithymia and Alcohol Misuse in Patients with Psoriasis: A Cross-Sectional Study

This study investigates (a) the prevalence of psychological distress, alexithymia and alcohol misuse in psoriasis patients; and (b) the relationship between psoriasis severity, alexithymia, alcohol and psychological distress in patients with psoriasis. A cross-sectional study was conducted. Outpatients (n = 184) with moderate to severe psoriasis completed a psychological screening battery. Measures included the Hospital Anxiety and Depression Scale, the Penn State Worry Questionnaire, the twenty-item Toronto Alexithymia Scale, the Dermatology Life Quality Index, the Psoriasis Area and Severity Index, the Self-Administered Psoriasis Area and Severity Index, and the Alcohol Use Disorders Identification Test. Demographic, clinical details and information on knowledge of psychosocial issues, alcohol and confidence on coping with distress and talking to others about psoriasis was also gathered. Alexithymia was associated with anxiety, depression and worry; subjective psoriasis severity was associated with worry. Alcohol misuse was related to anxiety and worry, but not to depression. Appropriate identification and treatment of alcohol difficulties and psychological distress of patients with psoriasis is needed.

A multiple mediation model of trait worry and hazardous drinking among treatment-seeking smokers: the roles of coping and conformity drinking motives

Alcohol use is associated with poorer smoking cessation-related outcomes, and smokers with elevated levels of worry experience greater smoking cessation problems. Yet, little is known about the explanatory mechanisms that may underlie the relationship between trait worry and hazardous drinking among smokers. Therefore, this study explored the explanatory roles of coping and conformity drinking motives in the relationship between trait worry and hazardous drinking outcomes including alcohol consumption, alcohol problems, maximum number of drinks, and the number of prior alcohol quit attempts among treatment-seeking smokers. Participants included 377 treatment-seeking smokers who consumed at least one alcoholic drink in the last year (48% female; 86.2% Caucasian; M _age = 34.83 years, SD = 13.38). Results showed a significant indirect effect of trait worry through coping-related drinking motives in relation to alcohol consumption, alcohol problems, maximum number of drinks, and number of prior drinking quit attempts. These findings were evident after controlling for gender, cigarette dependence, and current psychopathology. These findings suggest that coping drinking motives are one mechanism that may explain the relation between trait worry and hazardous drinking outcomes among treatment-seeking smokers.

The prevalence of ADH1B and OPRM1 alleles predisposing for alcohol consumption are increased in the Hungarian psoriasis population

Alcohol intake affects in great the symptoms and life of  psoriasis patients, although the association of SNPs related to increased alcohol consumption with psoriasis has not been elucidated. Therefore, to investigate the association of psoriasis with established alcohol consumption and dependence-related gene variants we conducted a population-based case-control study including 3743 subjects (776 psoriasis cases and 2967 controls from the general Hungarian population). Genotyping of 23 SNPs at ADH1B, ADH1C, ALDH1A1, ALDH2, SLC6A3, DDC, GABRA2, GABRG1, HTR1B, MAOA, TPH2, CHRM2, GRIN2A, POMC, OPRM1, OPRK1 and BDNF were determined and differences in genotype and allele distributions were investigated. Multiple logistic regression analyses were implemented. Analysis revealed association between C allele of the rs1229984 polymorphism (ADH1B gene) and psoriasis risk (OR_additive = 1.58, 95% CI 1.23-2.03, p < 0.001, OR_recessive = 1.58, 95% CI 1.22-2.04, p = 0.001). Furthermore, the G allele of rs1799971 polymorphism (OPRM1 gene) increased the risk of familial aggregation (OR_additive = 1.99, 95% CI 1.36-2.91, p < 0.001 OR_dominant = 2.01, 95% CI 1.35-3.01, p < 0.001). In subgroups of psoriatic patients with history of early onset and familial aggregation effect allele 'C' of rs1229984 showed association in the additive and recessive models (OR_additive = 2.41, 95% CI 1.26-4.61, p < 0.01, OR_recessive = 2.42, 95% CI 1.26-4.68, p < 0.01). While effect allele 'G' of rs1799971 (OPRM1) also associated with increased risk of early onset and familial aggregation of psoriasis in the additive and dominant models (OR_additive = 1.75, 95% CI 1.27-2.43, p = 0.001, OR_dominant = 1.82, 95% CI 1.26-2.63, p = 0.001). Our results suggest that genetically defined high-risk individuals for alcohol consumption are more common in the psoriasis population.

Position statement for the management of comorbidities in psoriasis

BACKGROUND

The association between psoriasis and some diseases has become relevant in recent years. Providing appropriate management of psoriasis from an early stage requires prompt diagnosis and treatment of concomitant diseases and to prevent any potential comorbidity. This approach should consider the adverse events of the drugs used to treat psoriasis potentially related to the onset of comorbidities.

OBJECTIVE

To provide the dermatologist with an accurate and friendly tool for systematizing the diagnosis of psoriasis-associated comorbidities, which generally escapes the scope of the dermatology setting, and to facilitate decision-making about the referral and treatment of patients with comorbidities.

METHODS

These position statement recommendations were developed by a working group composed of ten experts (four dermatologists, one cardiologist, one rheumatologist, one gastroenterologist, one nephrologist, one endocrinologist and one psychiatrist) and two health services researchers. The expert group selected the psoriasis comorbidities considered according to their relevance in the dermatology setting. The recommendations on diagnostic criteria are based on the current clinical practice guidelines for each of the comorbidities. The information regarding the repercussion of psoriasis medical treatments on associated comorbid diseases was obtained from the summary of product characteristics of each drug.

RESULTS

Recommendations were developed to detect and refer the following psoriasis comorbidities: psoriatic arthritis, cardiovascular risk factors (diabetes, dyslipidaemia, obesity, hypertension and metabolic syndrome), non-alcoholic fatty liver disease, inflammatory bowel disease, kidney disease and psychological disorders (anxiety and depression). In addition, alcohol consumption and tobacco consumption were included. The tables and figures are precise, easy-to-use tools to systematize the diagnosis of comorbidities in patients with psoriasis and facilitate the decision-making process regarding referral and treatment of patients with an associated disease.

CONCLUSION

The application of these position statement recommendations will facilitate the dermatologist practice, and benefit psoriasis patients' health and quality of life.

Does message framing affect changes in behavioural intentions in people with psoriasis? A randomized exploratory study examining health risk communication

Message framing is important in health communication research to encourage behaviour change. Psoriasis, a long-term inflammatory skin condition, has additional comorbidities including high levels of anxiety and cardiovascular disease (CVD), making message framing particularly important. This experimental study aimed to: (1) identify whether health messages about psoriasis presented as either gain- or loss-framed were more effective for prompting changes in behavioural intentions (BI), (2) examine whether BI were driven by a desire to improve psoriasis or reduce CVD risk; (3) examine emotional reactions to message frame; and (4) examine predictors of BI. A two by two experiment examined the effects on BI of message frame (loss vs. gain) and message focus (psoriasis symptom reduction vs. CVD risk reduction). Participants with psoriasis (n = 217) were randomly allocated to one of four evidence-based health messages related to either smoking, alcohol, diet or physical activity, using an online questionnaire. BI was the primary outcome. Analysis of variance tests and hierarchical multiple regression analyses were conducted. A significant frame by focus interaction was found for BI to reduce alcohol intake (p = .023); loss-framed messages were more effective for CVD risk reduction information, whilst gain-framed messages were more effective for psoriasis symptom reduction information. Message framing effects were not found for BI for increased physical activity and improving diet. High CVD risk was a significant predictor  of increased BI for both alcohol reduction (β = .290, p < .01) and increased physical activity (β = -.231, p < .001). Message framing may be an important factor to consider depending on the health benefit emphasised (disease symptom reduction or CVD risk reduction) and patient-stated priorities. Condition-specific health messages in psoriasis populations may increase the likelihood of message effectiveness for alcohol reduction.

Alcohol-Related Mortality in Patients With Psoriasis: A Population-Based Cohort Study

Importance

People diagnosed with psoriasis have an increased risk of premature mortality, but the underlying reasons for this mortality gap are unclear.

Objective

To investigate whether patients with psoriasis have an elevated risk of alcohol-related mortality.

Design, Setting, and Participants

An incident cohort of patients with psoriasis aged 18 years and older was delineated for 1998 through 2014 using the Clinical Practice Research Datalink (CPRD) and linked to Hospital Episode Statistics (HES) and Office for National Statistics (ONS) mortality records. Patients with psoriasis were matched with up to 20 comparison patients without psoriasis on age, sex, and general practice.

Main Outcomes and Measures

Alcohol-related deaths were ascertained via the Office for National Statistics mortality records. A stratified Cox proportional hazard model was used to estimate the cause-specific hazard ratio for alcohol-related death, with adjustment for socioeconomic status.

Results

The cohort included 55 537 with psoriasis and 854 314 patients without psoriasis. Median (interquartile) age at index date was 47 (27) years; 408 230 of total patients (44.9%) were men. During a median (IQR) of 4.4 (6.2) years of follow-up, the alcohol-related mortality rate was 4.8 per 10 000 person-years (95% CI, 4.1-5.6; n = 152) for the psoriasis cohort, vs 2.5 per 10 000 (95% CI, 2.4- 2.7; n = 1118) for the comparison cohort. The hazard ratio for alcohol-related death in patients with psoriasis was 1.58 (95% CI, 1.31-1.91), and the predominant causes of alcohol-related deaths were alcoholic liver disease (65.1%), fibrosis and cirrhosis of the liver (23.7%), and mental and behavioral disorders due to alcohol (7.9%).

Conclusions and Relevance

People with psoriasis have approximately a 60% greater risk of dying due to alcohol-related causes compared with peers of the same age and sex in the general population. This appears to be a key contributor to the premature mortality gap. These findings call for routine screening, identification and treatment, using the Alcohol Use Disorders Identification Test (AUDIT-C) in both primary and secondary care to detect alcohol consumption and misuse among people diagnosed with psoriasis.

Addiction: an underestimated problem in psoriasis health care

BACKGROUND

Psoriasis is a disease of enormous socio-economic impact. Despite approval of numerous highly efficient and costly therapies, a minor proportion of severely affected patients actually receives sufficient treatment.

OBJECTIVE

To investigate whether addictions are associated with psoriasis and to develop evidence-based recommendations for dermatologists in their daily clinical practice in order to improve medical assessment of psoriasis and patients' quality of life.

PATIENTS AND METHODS

Psoriasis patients at the University Department of Dermatology were asked to fill out a paper-based self-reported anonymous questionnaire with 92 questions of validated screening tests for the six most common addictions in Germany (alcohol, nicotine, drugs and illegal drugs, gambling, food). Body weight and height as well as current Psoriasis Area and Severity Index (PASI) were documented as well.

RESULTS

Between October 2015 and February 2016, 102 patients (65 males, 37 females; mean age 49.7 years (SD 13.4), range 18-83 years) participated in the study. Fifty-seven of the 102 patients showed addictive behaviour. Of these, 23.8% were high-risk drinkers, 41% regular smokers, 11% at risk of drug abuse, 4.1% at risk of food dependency and 19% compulsive gamblers. Compared with the general population, these results are significantly higher for alcohol abuse (P < 0.005), nicotine (P < 0.001) and gambling (P < 0.001). Body mass index was significantly higher in the study population (P < 0.001).

CONCLUSION

Addictions and gambling are more prevalent in patients with psoriasis compared with the general population. Respective screening measures are recommended in daily practice for doctors treating psoriasis patients, and PeakPASI is suggested as a score to document patients' lifetime highest PASI. Parallel to new drug approvals and even more detailed insights into the pathomechanism of psoriasis, public health strategies and interdisciplinary approaches are essential for a general sustained psoriasis treatment.

The Risk of Cancer in Patients With Psoriasis: A Population-Based Cohort Study in the Health Improvement Network

IMPORTANCE

The risk of cancer in patients with psoriasis remains a cause of special concern due to the chronic inflammatory nature of the disease, the use of immune-suppressive treatments and UV therapies, and the increased prevalence of comorbid, well-established risk factors for cancer, such as smoking and obesity, all of which may increase the risk of carcinogenesis.

OBJECTIVE

To compare the overall risk of cancer, and specific cancers of interest, in patients with psoriasis compared with patients without psoriasis.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cohort study of patients ages 18 to 89 years with no medical history of human immunodeficiency virus, cancer, organ transplants, or hereditary disease (albinism and xeroderma pigmentosum), prior to the start date, conducted using The Health Improvement Network, a primary care medical records database in the United Kingdom. The data analyzed had been collected prospectively from 2002 through January 2014. The analysis was completed in August 2015.

EXPOSURES OF INTEREST

Patients with at least 1 diagnostic code for psoriasis were classified as having moderate-to-severe disease if they had been prescribed psoralen, methotrexate, cyclosporine, acitretin, adalimumab, etanercept, infliximab, or ustekinumab or phototherapy for psoriasis. Patients were classified as having mild disease if they never received treatment with any of these agents.

MAIN OUTCOMES AND MEASURES

Incident cancer diagnosis.

RESULTS

A total of 937,716 control group patients without psoriasis, matched on date and practice visit, and 198,366 patients with psoriasis (186,076 with mild psoriasis and 12,290 with moderate-to-severe disease) were included in the analysis. The adjusted hazard ratios (aHRs) with 95% CIs for any incident cancer excluding nonmelanoma skin cancer (NMSC) were 1.06 (95% CI, 1.02-1.09), 1.06 (95% CI, 1.02-1.09), and 1.08 (95% CI, 0.96-1.22) in the overall, mild, and severe psoriasis group. The aHRs for incident lymphoma were 1.34 (95% CI, 1.18-1.51), 1.31 (95% CI, 1.15-1.49), and 1.89 (95% CI, 1.25-2.86); for NMSC, 1.12 (95% CI, 1.07-1.16), 1.09 (95% CI, 1.05-1.13), and 1.61 (95% CI, 1.42-1.84); and for lung cancer, 1.15 (95% CI, 1.03-1.27), 1.12 (95% CI, 1.01-1.25), and 1.62 (95% CI, 1.16-2.28) in the overall, mild, and severe psoriasis groups, respectively. No significant association was seen with cancer of the breast, colon, prostate, or leukemia.

CONCLUSIONS AND RELEVANCE

The association between psoriasis and cancer, albeit small, was present in our cohort of patients with psoriasis. This association was primarily driven by NMSC, lymphoma, and lung cancer.

Psoriasis as an Independent Risk Factor for Cardiovascular Disease: An Epidemiologic Analysis Using a National Database

BACKGROUND

Psoriasis is known to be associated with metabolic syndrome, a well-established risk factor for ischemic heart disease and stroke. Emerging evidence indicates that psoriasis is an independent risk factor for cardiovascular disease and stroke.

OBJECTIVE

To evaluate whether psoriasis is independently associated with myocardial infarction (MI), ischemic heart disease (MI, angina pectoris, or coronary heart disease), and stroke, we conducted a cross-sectional study using the US National Health and Nutrition Examination Survey (NHANES) database.

METHODS

Data on clinical history of psoriasis, MI, angina pectoris, coronary heart disease, and stroke from the questionnaire as well as laboratory parameters on serum lipid and uric acid levels in the cycle years 2003-2006 and 2009-2012 were analyzed. Multivariate analysis with logistic regression modelling was performed with the aforementioned cardiovascular events or stroke as the dependent variables and with risk factors such as age, gender, ethnic group, current smoking status, alcohol consumption, metabolic syndrome, hyperuricemia, and psoriasis as independent variables.

RESULTS

There were 520 cases of psoriasis, and 108 of them had metabolic syndrome (20.8%). Well-established cardiovascular risk factors such as age, gender, ethnic group, smoking, alcohol consumption, metabolic syndrome, and hyperuricemia were also found to have significant associations with MI and ischemic heart disease (all P values <.001). Psoriatic patients were at significantly higher risks of developing MI (odds ratio [OR] 2.24; 95% CI: 1.27-3.95; P = .005) and ischemic heart disease (OR 1.90; 95% CI: 1.18-3.05; P = .008), but not stroke (OR 1.01; 95% CI: 0.48-2.16; P = .744), after adjustment was made for major cardiovascular risk factors.

CONCLUSION

This study provides epidemiological evidence that psoriasis may be independently associated with the development of MI and ischemic heart disease. Physicians should be cognizant of any underlying cardiovascular risk factors, especially among psoriatic patients with metabolic syndrome, and manage them according to national guidelines.

Improving patient outcomes in psoriasis: strategies to ensure treatment adherence

Psoriasis is a frequent inflammatory disease with a chronic and relapsing course. Therefore, patients with psoriasis are likely to undergo different treatments for long periods of time. Traditionally, therapies used in psoriasis have been associated with poor levels of adherence due to the complexity of the regimens and the poor results obtained with the topical therapies. These poor outcomes are associated with high levels of frustration and anxiety, which decrease adherence and worsen the disease. With the recent introduction of highly efficacious biologic therapies, patients can achieve very good and prolonged responses. However, most patients with psoriasis have mild disease and may be treated with skin-directed therapies. Therefore, it is important to develop strategies to improve adherence in order to achieve better outcomes, and to improve the overall quality of life. Hence, acknowledging the causes of nonadherence is crucial for implementing these strategies. In this summary, we review the causes of nonadherence, and we provide behavioral strategies in order to improve adherence and, ultimately, the outcome of patients with psoriasis.

Psoriasis is a systemic disease with multiple cardiovascular and metabolic comorbidities

There is evidence that patients with moderate to severe psoriasis have an increased risk of conditions such as cardiovascular disease, obesity, diabetes mellitus, and metabolic syndrome. The precise mechanisms underlying the observed increase in cardiovascular disease in psoriasis remain to be defined but inflammatory pathways mutual to both conditions are probably involved. Suppression of systemic inflammation in psoriasis could help reduce cardiovascular inflammation but robust evidence is still lacking evidence is lacking. This article summarizes the current literature on cardiovascular and metabolic comorbidities in psoriasis, identifies research gaps, and suggests management strategies to reduce cardiovascular risk in patients with moderate to severe psoriasis.

Biomolecules and Biomarkers Used in Diagnosis of Alcohol Drinking and in Monitoring Therapeutic Interventions

BACKGROUND

The quantitative, measurable detection of drinking is important for the successful treatment of alcohol misuse in transplantation of patients with alcohol disorders, people living with human immunodeficiency virus that need to adhere to medication, and special occupational hazard offenders, many of whom continually deny drinking. Their initial misconduct usually leads to medical problems associated with drinking, impulsive social behavior, and drunk driving. The accurate identification of alcohol consumption via biochemical tests contributes significantly to the monitoring of drinking behavior.

METHODS

A systematic review of the current methods used to measure biomarkers of alcohol consumption was conducted using PubMed and Google Scholar databases (2010-2015). The names of the tests have been identified. The methods and publications that correlate between the social instruments and the biochemical tests were further investigated. There is a clear need for assays standardization to ensure the use of these biochemical tests as routine biomarkers.

FINDINGS

Alcohol ingestion can be measured using a breath test. Because alcohol is rapidly eliminated from the circulation, the time for detection by this analysis is in the range of hours. Alcohol consumption can alternatively be detected by direct measurement of ethanol concentration in blood or urine. Several markers have been proposed to extend the interval and sensitivities of detection, including ethyl glucuronide and ethyl sulfate in urine, phosphatidylethanol in blood, and ethyl glucuronide and fatty acid ethyl esters in hair, among others. Moreover, there is a need to correlate the indirect biomarker carbohydrate deficient transferrin, which reflects longer lasting consumption of higher amounts of alcohol, with serum γ-glutamyl transpeptidase, another long term indirect biomarker that is routinely used and standardized in laboratory medicine.

Alcohol intake measured by phosphatidylethanol in blood and the lifetime drinking history interview are correlated with the extent of psoriasis

BACKGROUND

Psoriasis has been reported to be associated with alcohol consumption.

OBJECTIVE

To investigate the level of alcohol intake in individuals with psoriasis and correlate intake with the extent of disease and pruritus.

METHODS

Twenty-nine outpatients (15 females and 14 males) with stable chronic plaque psoriasis of moderate severity were recruited. The Psoriasis Area and Severity Index (PASI) and the degree of pruritus (visual analogue scale) were compared with measures of drinking habits as determined by the Lifetime Drinking History (LDH), the Alcohol Use Disorders Identification Test and whole-blood phosphatidylethanol (PEth), an alcohol-specific biomarker.

RESULTS

The majority of patients were social drinkers with moderate alcohol consumption as determined by PEth and LDH. Alcohol consumption correlated significantly with the PASI score. There was no correlation between alcohol use and pruritus.

CONCLUSION

The level of alcohol consumption is correlated with the extent of psoriasis.

Diet in dermatology: Part II. Melanoma, chronic urticaria, and psoriasis

The roles of dietary factors in aggravating, preventing, or treating skin diseases are common questions encountered in dermatology practice. Part II of this two-part series reviews dietary modifications that can potentially be utilized in the management of melanoma, chronic urticaria, and psoriasis patients. Specifically, we examine the effect of alcohol consumption and supplementation with vitamins D and E, polyunsaturated fatty acids, selenium, green tea, resveratrol, and lycopene on melanoma risk. The relationships between chronic urticaria symptoms and dietary pseudoallergens, gluten, and vitamin D are analyzed. We explore weight loss, reduced alcohol consumption, and gluten avoidance as means of reducing psoriasis-associated morbidity, as well as the possible utility of supplementation with polyunsaturated fatty acids, folic acid, vitamin D, and antioxidants. With proper knowledge of the role of diet in these cutaneous disease processes, dermatologists can better answer patient inquiries and consider implementation of dietary modifications as adjuncts to other treatments and preventative measures.

Psoriasis: Biologic treatment and liver disease

Patients with moderate or severe psoriasis have a high prevalence of chronic liver disease. Chronic liver disease in these patients is related to metabolic syndrome, alcohol abuse or viral infections. Therefore, treatment of these patients is challenging. Classic systemic treatments may be contraindicated because of their immunosuppressive and hepatotoxic potential. First-line therapy in this setting is generally ultraviolet B phototherapy combined with topical treatment, but its feasibility and efficacy are sometimes limited. The therapeutic options are further restricted by concomitant psoriatic arthritis. Biologic treatments have shown to be effective in psoriasis and psoriatic arthritis, and they are largely devoid of liver toxicity. Anti-tumor necrosis factor-alpha (TNF-α) treatments have proven to be effective and safe in patients with chronic hepatitis C virus (HCV) infections and other non-infectious chronic liver disorders, including alcoholic and non-alcoholic liver diseases. However, in chronic hepatitis B virus (HBV), anti-TNF-α treatments carry a potential risk of HBV reactivation. Anti-interleukin-12/23 treatments are also effective in patients with psoriasis, but data regarding their safety in chronic hepatitis infections are still limited. Safety reports in patients with psoriasis and chronic HCV infection are contradictory, and in chronic HBV evidence indicate a high risk of viral reactivation. Moreover, concerns remain about the long-term safety of both TNF-α antagonists and ustekinumab. Non-viral liver diseases such as alcoholic and non-alcoholic liver diseases are more prevalent in patients with psoriasis than in the general population. TNF-α antagonists have also been prescribed in these patients. Although data are still scarce in this setting, results suggest a favorable profile in patients with psoriasis and non-alcoholic liver diseases. We review the literature regarding all these aspects.

Drug survival of fumaric acid esters for psoriasis: a retrospective study

BACKGROUND

Fumaric acid esters (FAEs) have been used for over 30 years in the management of psoriasis.

OBJECTIVES

To determine drug survival of FAEs in patients with psoriasis, treatment-limiting adverse drug events and the range of effective drug doses.

METHODS

A retrospective, single-centre study assessing all patients commenced on FAEs between October 2003 and July 2012. Demographic data, length of treatment, reasons for discontinuation of FAEs, side-effects and range of doses were recorded.

RESULTS

Two hundred and forty-nine patients [160 (64%) male] were included. The mean age at which FAEs were commenced was 44·5 years (range 17-82 years). The mean length of treatment was 28 months (range 1 week to 106 months). In patients who were commenced on FAEs ≥ 4 years before inclusion in this study, the 4-year drug survival was 60% (64/107). FAEs were discontinued in 146/249 patients (59%); this was due to lack of efficacy in 59/146 (40%) and gastrointestinal upset in 39/146 (27%). A very low dose of FAEs (< 240 mg daily) was successful in maintaining control of psoriasis in 26 (10%) patients. The mean treatment duration of these patients was 64 months (range 32-106 months).

CONCLUSIONS

Fumaric acid esters have a 4-year drug survival rate of 60%, which compares favourably with reported 4-year survival rates of 40% for etanercept and adalimumab and 70% for infliximab. Longer drug survival is more likely in the significant subgroup of patients in whom a very low dose of FAEs is sufficient to control disease. The reasons for this are unclear.

Psoriasis beyond the skin: an expert group consensus on the management of psoriatic arthritis and common co-morbidities in patients with moderate-to-severe psoriasis

BACKGROUND

Psoriatic arthritis (PsA) and co-morbidities of psoriasis represent a significant clinical and economic burden for patients with moderate-to-severe psoriasis. Often these co-morbidities may go unrecognized or undertreated. While published data are available on the incidence and impact of some of them, practical guidance for dermatologists on detection and management of these co-morbidities is lacking.

OBJECTIVE

To prepare expert recommendations to improve the detection and management of common co-morbidities in patients with moderate-to-severe psoriasis.

METHODS

A systematic literature review was conducted on some common co-morbidities of psoriasis-cardiovascular (CV) diseases (including obesity, hypertension, hyperglycaemia and dyslipidaemia), psychological co-morbidities (including depression, alcohol abuse and smoking) and PsA-to establish the incidence and impact of each. Data gaps were identified and a Delphi survey was carried out to obtain consensus on the detection and management of each co-morbidity. The expert panel members for the Delphi survey comprised 10 dermatologists with substantial clinical expertise in managing moderate-to-severe psoriasis patients, as well as a cardiologist and a psychologist (see appendix) with an interest in dermatology. Agreement was defined using a Likert scale of 1-7. Consensus regarding agreement for each statement was defined as ≥75% of respondents scoring either 1 (strongly agree) or 2 (agree).

RESULTS

The expert panel members addressed several topics including screening, intervention, monitoring frequency, and the effects of anti-psoriatic treatment on each co-morbidity. Consensus was achieved on 12 statements out of 22 (3 relating to PsA, 4 relating to psychological factors, 5 relating to CV factors). The panel members felt that dermatologists have an important role in screening their psoriasis patients for PsA and in assessing them for psychological and CV co-morbidities. In most cases, however, patients should be referred for specialist management if other co-morbidities are detected.

CONCLUSION

This article provides useful and practical guidance for the detection and management of common co-morbidities in patients with moderate-to-severe psoriasis.

Alcohol consumption and psoriasis: a systematic literature review

The association between alcohol consumption and psoriasis has been frequently discussed since the 1980s, but no systematic review has been elaborated on the subject so far. The aim of this systematic literature review was to assess whether alcohol consumption is more prevalent in psoriasis patients than in the general population and whether alcohol consumption is a risk factor of psoriasis. A systematic literature search was carried out in the Medline, Embase and Cochrane databases using the keywords 'psoriasis' AND 'alcohol drinking' OR 'alcohol-related disorders'. The search was then enlarged with the keywords 'psoriasis' AND 'risk factor' OR 'comorbidity'. Altogether 911 references in English and French were found. Out of these, 837 articles were excluded by reading the abstract and 46 by reading the article. A total of 28 articles were selected. Alcohol consumption in psoriasis patients versus the general population: 23 studies were selected; 18 concluded that alcohol consumption was more prevalent in psoriasis patients, and 5 did not. Three studies compared the prevalence of excessive drinking using a questionnaire on alcohol dependence (CAGE or Self-administered alcohol screening test (SAAST)) or with quantitative criteria for excessive drinking. In these studies, excessive drinking was more prevalent among psoriasis patients than in the general population. Other articles studied the quantity and type of alcohol consumed. In 11 studies, psoriasis patients consumed more alcohol than the controls. Four other studies showed excessive alcohol consumption in psoriasis patients without control group comparison. Conversely, five studies identified no difference in alcohol consumption between psoriasis patients and the general population. The heterogeneity in the measurement of alcohol consumption did not allow performing meta-analysis. Alcohol as a risk factor for psoriasis: only five studies were selected. In four of these studies alcohol was found to be a risk factor for psoriasis. Alcohol consumption seems to be greater in psoriasis patients than in the general population. However, there is not enough evidence to establish whether alcohol consumption is indeed a risk factor for psoriasis.

Psoriasis and psycho-dermatology

Introduction

Psoriasis is a common, long-term skin condition associated with high levels of psychological distress and considerable life impact. The impact of psoriasis, beyond the skin, is often not recognised and under-treated.

Methods

This paper explores the relationship between psychological distress and psoriasis including reference to the ‘brain–skin access’. The life impact of psoriasis is discussed and pharmacological interventions which affect distress associated with psoriasis and psychological interventions are reviewed. Evidence from peer-reviewed journals and controlled trials inform the text.

Results

Psoriasis has a profound impact on mental health and well-being which is under-recognised by clinicians. The sympathetic adrenal medullary axis and hypothalamic pituitary adrenal axis are likely to be involved in the onset of psoriasis and there may also be an effect from inflammation in the skin on the central release of corticotrophin-releasing hormone. Psoriasis can be stigmatising and may affect all aspects of life including relationships, employment, social life and leisure activities. There is some evidence for psychological interventions being effective in the management of distress associated with psoriasis and psoriasis itself. Studies, however, have used disparate outcomes and methods and largely involve low numbers of patients. There is very limited access to psychological support for the patients with psoriasis despite evidence of high levels of psychological distress and considerable life impact.

Conclusions

Psoriasis is a long-term skin condition associated with high levels of distress and considerable life impact, both of which are under-recognised. Routine screening for distress with access to effective treatment is required. There is a need for high-quality studies to assess the effect of psychological intervention in patients with psoriasis both to inform guidance and facilitate the provision of effective psychological support services.

Smoking and risk of incident psoriasis among women and men in the United States: a combined analysis

The authors evaluated the association between smoking and the incidence of psoriasis among 185,836 participants from a cohort of older women (the Nurses' Health Study, 1996-2008), a cohort of younger women (the Nurses' Health Study II, 1991-2005), and a cohort of men (Health Professionals' Follow-up Study, 1986-2006). Information on smoking was collected biennially during follow-up. The authors identified a total of 2,410 participants with incident psoriasis. Compared with never smokers, past smokers had a relative risk of incident psoriasis of 1.39 (95% confidence interval (CI): 1.27, 1.52) and current smokers had a relative risk of 1.94 (95% CI: 1.64, 2.28). For current smokers who smoked 1-14 cigarettes/day, the relative risk was 1.81 (95% CI: 1.38, 2.36); for those who smoked 15-24 cigarettes/day, the relative risk was 2.04 (95% CI: 1.68, 2.47); and for those who smoked 25 or more cigarettes/day, the relative risk was 2.29 (95% CI: 1.74, 3.01). There was a trend toward an increased risk of psoriasis with increasing pack-years or duration of smoking (P(trend) < 0.0001). The risk was highest among smokers who had 65 or more pack-years of smoking (relative risk = 2.72, 95% CI: 2.05, 3.60) and among those with a smoking duration of 30 or more years (relative risk = 1.99, 95% CI: 1.75, 2.25). The authors observed a graded reduction of risk with an increase in time since smoking cessation (P(trend) <0.0001). In this study, smoking was found to be an independent risk factor for psoriasis in both women and men. Psoriasis risk was particularly augmented for heavy smokers and persons with longer durations of smoking.