Psoriasis and the metabolic syndrome

Galium verum L. extract mitigates cardiovascular events in psoriasis rats

Psoriasis has been considered a systemic immune-mediated disease that can affect function of the heart. However, certain herbal therapy approaches may nullify side effects of psoriasis on the heart. The aim of this study was to investigate the cardioprotective effects of Galium verum extract administration of the heart of psoriatic rats. The study included 24 Wistar albino male rats, divided into 4 groups: control (CTRL), G.verum (GV), psoriasis (PSORI), and psoriasis with G.verum (PSORI + GV). Seven-day topical application of 5% imiquimod cream was used for induction of psoriasis. After induction, animals were received 125 mg/kg G.verum extract for 4 weeks. Isolated hearts were perfused on the Langendorff apparatus and measured: dp/dt max/min, SLVP, DLVP, HR and coronary flow. The oxidative stress biomarkers: TBARS, NO2, O2- and H2O2 were measured in coronary venous effluent. Isolated hearts were fixed and stained with H/E and Picro-sirius red staining. Psoriasis decreased cardiac contractility and relaxation and increased SLVP and DLVP at all perfusion pressure. Treatment with G.verum in psoriasis rats improved contractility and relaxation of the heart and rise SLVP and DLVP. In PSORI + GV group, the decrease of oxidative stress biomarkers were observed in comparison to PSORI group. Diameter and cross-section area of cardiomyocytes were increased in PSORI and PSORI + GV groups compared to the control. Collagen content was increased in PSORI group by 283% and in PSORI + GV group by 188% compared to control. Treatment with G.verum extract exhibited a positive effect on cardiac function, morphometry and redox state of heart of psoriatic rats.

Residual Traditional Risk in Non-Traditional Atherosclerotic Diseases

Individuals with chronic inflammatory and immune disorders are at an increased risk of atherosclerotic events and premature cardiovascular (CV) disease. Despite extensive literature exploring the relationship between "non-traditional" atherosclerotic conditions and CV risk, many aspects remain unresolved, including the underlying mechanisms promoting the "non-traditional CV risk", the development of an innovative and comprehensive CV risk assessment tool, and recommendations for tailored interventions. This review aims to evaluate the available evidence on key "non-traditional" CV risk-enhancer conditions, with a focus on assessing and managing CV risk factors. We conducted a comprehensive review of 412 original articles, narrative and systematic reviews, and meta-analyses addressing the CV risk associated with "non-traditional" atherosclerotic conditions. The analysis examined the underlying mechanisms of these relationships and identified strategies for assessing and mitigating elevated risk. A major challenge highlighted is the difficulty in quantifying the contribution of individual risk factors and disease-specific elements to CV risk. While evidence supports the cardiovascular benefits of statins beyond lipid lowering, such as pleiotropic and endothelial effects, current guidelines lack specific recommendations for the use of statins or other therapies targeting non-traditional CV risk factors. Additionally, the absence of validated cardiovascular risk scores that incorporate non-traditional risk factors hinders accurate CV risk evaluation and management. The growing prevalence of "non-traditional CV risk-enhancer conditions" underscores the need for improved awareness of CV risk assessment and management. A thorough understanding of all contributing factors, including disease-specific elements, is crucial for accurate prediction of cardiovascular disease (CVD) risk. This represents an essential foundation for informed decision-making in primary and secondary prevention. We advocate for future research to focus on developing innovative, disease-specific CV risk assessment tools that incorporate non-traditional risk factors, recognizing this as a promising avenue for translational and clinical outcome research.

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

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

Metabolic comorbidities of psoriasis (Review)

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

Tildrakizumab efficacy, drug survival, and safety are comparable in patients with psoriasis with and without metabolic syndrome: Long-term results from 2 phase 3 randomized controlled studies (reSURFACE 1 and reSURFACE 2)

BACKGROUND

Data for the effect of metabolic syndrome (MetS) on the efficacy and safety of biologic agents for psoriasis treatment are limited.

OBJECTIVE

To evaluate long-term tildrakizumab efficacy, drug survival, and safety in patients with psoriasis by baseline MetS status.

METHODS

Post hoc analyses of up to 3 years of efficacy data and 5 years of safety data from the phase 3, double-blind, randomized controlled reSURFACE 1 and 2 trial (NCT01722331 and NCT01729754) base and extension studies were conducted for patients receiving continuous tildrakizumab 100 or 200 mg.

RESULTS

Of 338 (n = 124/214 in reSURFACE 1/2) and 307 (n = 147/160 in reSURFACE 1/2) patients continuously receiving tildrakizumab 100 and 200 mg, respectively, throughout the studies, 26/44 (21%/21%) and 34/30 (23%/19%) met MetS criteria. Proportions of patients who achieved a 75% improvement in the Psoriasis Area and Severity Index (PASI) in reSURFACE 1/2 were generally comparable among those with versus without MetS at week 52 (tildrakizumab 100 mg, 85%/86% vs 86%/94%; tildrakizumab 200 mg, 76%/87% vs 76%/87%) and through week 148. Results were similar for responders with 90% and 100% improvement in the PASI. Tildrakizumab's safety profile did not vary by MetS status.

LIMITATIONS

Small sample size and post hoc analysis limit interpretation.

CONCLUSION

Long-term tildrakizumab efficacy and safety were comparable between patients with and without MetS.

The Level of FGF 21 as a New Risk Factor for the Occurrence of Cardiometabolic Disorders amongst the Psoriatic Patients

Fibroblast growth factors 21 and 23 are used as markers of cardiometabolic disorders which are common comorbidities in psoriasis. The study aimed to evaluate the serum level of these factors in psoriatic patients and elucidate the possible interplay between disease activity, metabolic or inflammatory parameters, and systemic treatment. A total of 33 patients with active plaque-type psoriasis and 11 healthy controls were enrolled in the study. Patients were divided into subgroups based on their BMI, disease severity, and treatment. Blood samples were collected at the beginning of the study and after 3 months of systemic treatment with acitretin or methotrexate. Serum FGF21 levels in psoriatic patients were higher versus control group (p < 0.05). FGF21 levels regarding psoriasis activity were significantly increased in all three subgroups compared to the controls (p < 0.05). Regarding FGF23, no significant changes were found beside positive correlation with aspartate transferase (p < 0.05). No significant effect of systemic treatment on FGF21 and FGF23 levels was found. Interestingly, a nearly threefold decrease in FGF21 concentration after acitretin-based treatment was observed (p < 0.05). After methotrexate therapy, FGF21 levels remained unchanged. FGF21 levels might be helpful in prediction of the risk of cardiometabolic comorbidities development especially in patients with severe psoriasis and obesity.

Lp-PLA2 as a promising predictor of comorbidities in patients with severe psoriasis

Objective: Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a well- known risk factor of atherosclerotic vascular diseases which are common comorbidities in psoriasis. The aim of this study was to evaluate serum Lp-PLA2 level in psoriatic patients and elucidate possible associations with disease activity, metabolic or inflammatory parameters and systemic treatment.Methods: We enrolled 33 patients with active plaque-type psoriasis and 11 healthy controls. Blood samples were collected before and after 3 months of systemic treatment with acitretin or methotrexate. Serum Lp-PLA2 level were evaluated by enzyme-linked immunosorbent assay.Results: Serum Lp-PLA2 level in patients with psoriasis did not statistically differ comparing to the control group (p = .2). However, in patients with severe psoriasis Lp-PLA2 was significantly higher than in the controls before and after treatment (p = .03, p = .01, respectively). The lipase did not correlate with BMI (p = .22); however, a statistical significance was noted between psoriatics with obesity compared to the controls (p = .03). No significant effect of systemic treatment combined (p = .5) nor separately with acitretin (p = .5) or methotrexate (p = .1) on the Lp-PLA2 level was found, despite clinical improvement.Conclusion: Lp-PLA2 assay might be helpful in assessment of the risk of cardiometabolic comorbidities development especially in patients with severe psoriasis and obesity.

Efficacy and safety of pioglitazone plus phototherapy versus phototherapy in patients with plaque type psoriasis: a Double Blinded Randomized Controlled Trial

Introduction: Thiazolidinediones have shown a good therapeutic effect in psoriasis treatment with no major adverse effects. The purpose of this study was to evaluate and compare the therapeutic effects of the combination of phototherapy and Pioglitazone with the phototherapy alone on plaque psoriasis patients. Methods and Materials: About 60 adults with plaque type psoriasis entered the study. They were randomly divided into two groups; one with pioglitazone and one with placebo and both underwent 30 sessions of phototherapy during 10 weeks. Before and after the treatment Psoriasis Area and Severity Index (PASI) and Dermatology Life Quality Index (DLQI) were assessed. Side effects of the treatment were also investigated. Results: The average PASI of the pioglitazone group was reduced from 20.9 ± 9.8 to 1.8 ± 1.4 (p < .001) versus the placebo group in which the PASI was reduced from 22 ± 8.5 to 4.4 ± 4. In other words, PASI was reduced in the pioglitazone and placebo group by 83.5% and 56.7% respectively (p < .05). The two groups didn't have a significant difference in reducing the DLQI (p = .315). Conclusion: Pioglitazone can vastly enhance the effectiveness of phototherapy in plaque psoriasis patients without causing any important adverse effect and with no success in improving the score of DLQI.

Psoriasis Treatments: A Review of the Current Research Pipeline

Psoriasis treatment is aimed at suppressing skin lesions and preventing relapses. Although in the last decade biological therapies have revolutionized the pharmacologic treatment armamentarium for psoriasis, many patients are still inadequately controlled with currently available therapeutics. An advanced understanding of the immunopathogensis of psoriasis has led to development of new drugs that refine existing treatments or target novel molecular and immunologic pathways. Here we review the most promising topical, oral, and injectable psoriasis treatments in the research pipeline, including agents that target cytokines interleukin (IL)-12/23, tumor necrosis factor-α, IL-20, IL-17, IL-22, inhibitors of calcineurin, phosphodiesterase type 4, protein kinase C, Janus kinase, p38 kinase, purine nucleotide phosphorylase, adenosine receptor agonists, and recombinant chaperonin protein. These targeted therapeutics offer the potential for greater clinical efficacy and less toxicity than traditional agents. As the number of treatment options continues to expand, clinicians will have more diverse opportunities to help patients achieve better psoriasis control.

Untargeted serum metabonomics study of psoriasis vulgaris based on ultra-performance liquid chromatography coupled to mass spectrometry

Psoriasis is a common, chronic, systemic inflammatory skin disease, the etiology and pathogenesis is unclear. An untargeted high-throughput metabonomics method based on liquid chromatography coupled to mass spectrometry was applied to study the serum metabolic changes in psoriasis vulgaris patients, and to discover serum potential biomarkers for identification, diagnosis and exploring pathogenesis of psoriasis. The serum metabolic profiles from 150 subjects (75 psoriasis patients and 75 healthy controls) were acquired, the raw spectrometric data were processed by multivariate statistical analysis, and 44 potential biomarkers were screened out and identified. The potential biomarkers were mainly involved in glycerophospholipid metabolism, sphingolipid metabolism, arachidonic acid metabolism, bile acid biosynthesis, indicated the pathogenesis of psoriasis may be related to the disturbed metabolic pathways.

Systemic Inflammation, Oxidative Damage to Nucleic Acids, and Metabolic Syndrome in the Pathogenesis of Psoriasis

In the pathogenesis of psoriasis, systemic inflammation and oxidative stress play mutual roles interrelated with metabolic syndrome (MetS). This study aims to map the selected markers of inflammation (C-reactive protein (CRP)), oxidative damage to nucleic acids (DNA/RNA damage; 8-hydroxy-2'-deoxyguanosine, 8-hydroxyguanosine, and 8-hydroxyguanine), and the parameters of MetS (waist circumference, fasting glucose, triglycerides, high-density lipoprotein (HDL) cholesterol, diastolic and systolic blood pressure) in a group of 37 patients with psoriasis (62% of MetS) and in 43 healthy controls (42% of MetS). Levels of CRP, DNA/RNA damage, fasting glucose, and triglycerides were significantly elevated in patients. MetS in conjunction with psoriasis was associated with high levels of CRP, significantly higher than in control subjects without MetS. Patients with MetS exhibited further DNA/RNA damage, which was significantly higher in comparison with the control group. Our study supports the independent role of psoriasis and MetS in the increase of CRP and DNA/RNA damage. The psoriasis contributes to an increase in the levels of both effects more significantly than MetS. The psoriasis also diminished the relationship between CRP and oxidative damage to nucleic acids existent in controls.

Prevalence of metabolic syndrome in patients with psoriasis: a hospital-based cross-sectional study

BACKGROUND:

Emerging epidemiological evidence suggests independent associations between psoriasis and metabolic syndrome. Objectives: The aim of the study was to examine the prevalence of metabolic syndrome and its components in patients with psoriasis, and to assess which factors may predict metabolic syndrome in these patients.

METHODS:

A hospital-based, cross-sectional study with 244 psoriatic patients and 163 control subjects with skin diseases other than psoriasis was conducted at the Clinic of Dermatovenerology, Clinical Center of Serbia, Belgrade, from October 2011 to October 2012. Metabolic syndrome was defined using the revised National Cholesterol Education Program Adult Treatment Panel III. Severity of psoriasis was measured by Psoriasis Area and Severity Index and Body Surface Area.

RESULTS:

The adjusted odds ratios (ORs) and 95% confidence intervals (CI) for psoriasis patients vs. non-psoriasis patients were 2.66 (95% CI, 1.58-4.42) for metabolic syndrome, 3.81 (95% CI, 2.30-6.31) for hypertension, 2.29 (95% CI, 1.39-3.78) for central obesity, 1.92 (95% CI, 1.08-3.41) for hyperglycemia, 1.87 (95% CI 1.18-2.96) for low high-density lipoprotein cholesterol level, and 1.42 (95% CI, 0.87-1.04) for hypertrigliceridemia. We failed to find any statistically significant association between the metabolic syndrome and clinical severity of psoriasis. Later onset and longer duration of psoriasis were predicting factors for metabolic syndrome in our patients. Study limitations: The cross-sectional design of the study does not allow us to draw directional causal inferences concerning the association between psoriasis and metabolic syndrome. Factors such as diet, alcohol consumption or mental health, which have not been evaluated in this study, may be confounders in this relation.

CONCLUSION:

A higher prevalence of metabolic syndrome and its components in patients with psoriasis than in controls, regardless of disease severity, emphasizes the need for early treatment and follow-up of all psoriatic patients with respect to metabolic diseases.

The impact of PASI 75 and PASI 90 on quality of life in moderate to severe psoriasis patients

BACKGROUND

It is well known that psoriasis significantly impacts patients' quality of life (QoL). With the introduction of improved treatment modalities with biologic agents, more patients with moderate to severe psoriasis are able to achieve better results as measured by the Psoriasis Area and Severity Index (PASI). PASI 75 indicates a 75% or greater reduction in PASI scores from baseline and is indicative of excellent disease improvement. With newer biologic agents such as secukinumab, ixekizumab and brodalumab, patients are now capable of achieving PASI 90, introducing additional clinical decisions for physicians when considering treatment options. However, little is known regarding how the difference between achieving PASI-75 versus PASI-90 impacts patients' QoL.

OBJECTIVES

The purpose of this study was to compare how achieving PASI 75 versus PASI 90 impacts QoL for patients with moderate to severe plaque psoriasis by using validated psychometric instruments that have been widely used in both dermatologic and non-dermatologic settings.

METHODS

Two separate open-label clinical trials were conducted to specifically assess QoL in patients with moderate to severe psoriasis on adalimumab or ustekinumab over 24 weeks. In addition to clinical assessments of psoriasis, patients completed two surveys: The Psychological General Well-Being (PGWB) Index and the Dermatology Life Quality Index (DLQI). Changes in total PGWB score and DLQI score at weeks 12 and 24 compared to baseline were compared between groups achieving PASI 75 and PASI 90.

RESULTS

There was no statistically significant difference in PGWB scores between patients achieving PASI 75 and patients achieving PASI 90 in the adalimumab treatment group (week 12 p = .21, but there was at week 24 p = .05). There was a statistically significant difference in DLQI between the patients achieving PASI 75 and the patients achieving PASI 90 in the adalimumab treatment group at week 24 (p = .01), but not week 12 (p = .11). There was no statistically significant difference in PGWB scores between patients achieving PASI 75 and patients achieving PASI 90 in the ustekinumab treatment group (week 12 p = .11, week 24 p = .35). There was no statistically significant difference in DLQI between the patients achieving PASI 75 and the patients achieving PASI 90 in the ustekinumab treatment group at week 24 (week 12 p = .49, week 24 p = .11).

CONCLUSIONS

There has been tremendous attention surrounding newer biologic agents that can achieve PASI 90 and even PASI 100. Although the results are impressive with regard to physical improvement of psoriasis, there may not be a clinically significant difference in QoL when comparing patients who achieve PASI-75 versus PASI 90.

Metabolic Syndrome and Selective Inflammatory Markers in Psoriatic Patients

The presented article studies the role of selected inflammatory and anti-inflammatory serum markers of psoriatic patients in the pathogenesis of metabolic syndrome (MS) and psoriasis. The study is based on the comparison between the group of psoriatic patients (74) and the control group (65). We found significantly higher BMI (p < 0.05) and diastolic blood pressure (p < 0.05) in the psoriatic patients. The values of waist circumference and BMI were significantly higher (p < 0.05) in the male patients compared to the men in the control group. The analysis revealed significantly higher CRP (p < 0.001), Lp-PLA2 (p < 0.001), leptin (p < 0.01), and resistin (p < 0.01) levels in the psoriatic patients. Significantly higher levels of CRP (p < 0.01), Lp-PLA2 (p < 0.001), leptin (p < 0.01), and resistin (p < 0.05) were found in the patients with MS compared to the controls with MS. The level of adiponectin was significantly lower (p < 0.01) in the patients with MS. Finally, we found significantly higher level of Lp-PLA2 (p < 0.001) in the group of patients without MS compared to the controls without MS. In conclusion, observed inflammatory and anti-inflammatory markers (CRP, adiponectin, leptin, resistin, and Lp-PLA2) are involved in both pathogenesis of MS and pathogenesis of psoriasis. The level of Lp-PLA2 indicates the presence of subclinical atherosclerosis (cardiovascular risk) in psoriatic patients.

Age and gender differences in Framingham risk score and metabolic syndrome in psoriasis patients: A cross-sectional study in the Turkish population

Objective:

Psoriasis is associated with an increased frequency of cardiovascular risk factors. Metabolic syndrome (MS) and the Framingham risk score (FRS) are two different algorithms for evaluating cardiovascular risk. They include different features: waist circumference measurement is included in the MS criteria, whereas smoking, age, and gender are questioned in FRS. This study aimed to evaluate the frequency of MS and FRS in psoriasis patients compared with a control group and investigate the differences between MS and FRS.

Methods:

This was a cross-sectional study involving 300 psoriasis patients and 177 controls. MS, FRS, and disease severity were evaluated.

Results:

The frequency of MS was higher in females with psoriasis than in those in the control group (p=0.019). Females in the psoriasis group were more obese than those in the control group (p=0.036). FRS significantly differed between the patients and controls of age >60 years (p=0.006). The risk of hypertension in current and past smokers was higher in the psoriasis patients (OR=2.07 and 2.32–2.48, respectively) than in the control group. There was no statistically significant relationship among MS, FRS, and psoriasis severity (p>0.05).

Conclusion:

The results of this study support the evaluation of cardiovascular risk assessment in female psoriasis patients with MS and in male and elderly psoriasis patients with FRS.

Assessment of adiposity in psoriatic patients by dual energy X-ray absorptiometry compared to conventional methods

BACKGROUND

Obesity is considered a chronic low-grade inflammatory disease that shares mediators of inflammation with psoriasis, such as TNF-α and IL-6. The relationship between these two conditions involves factors such as predisposition and response to therapy, in addition to an association with cardiovascular disease.

OBJECTIVES

The aim of the present study was to investigate the prevalence of adiposity as determined by body mass index (BMI), waist circumference (WC), and dual energy X-ray absorptiometry (DXA) evaluation in patients with psoriasis.

METHODS

BMI, WC and body composition by DXA were measured in 42 psoriatic patients without joint complaints and in 41 control patients using standard procedures. In the comparison between cases and controls, we used Pearson's Χ2 test or Fisher's exact test, and the nonparametric Mann-Whitney test. The difference between the diverse classification methods for obesity was evaluated using McNemar's test. To test the level of agreement between those variables, we used the weighted kappa coefficient.

RESULTS

There was no difference in the prevalence of obesity among cases and controls. Both BMI and WC had low agreement with measures of body fat evaluated by DXA. With the use of DXA scanning, prevalence of overweight and obesity in patients with psoriasis was 83.3%, which constitutes a strong evidence of the need for intervention on this metabolic parameter.

CONCLUSION

Dual energy X-ray absorptiometry was more capable of identifying obesity compared with BMI and WC both in psoriatic and control patients.

Altered crosstalk in the dipeptidyl peptidase-4-incretin-immune system in type 1 diabetes: A hypothesis generating pilot study

Both GLP1(7)(-)(36) (via GLP1 receptor) and the dipeptidyl peptidase-4 (DPP4) cleaved form of GLP1 (GLP1(9)(-)(36), independently of GLP1R) may modulate the response of lymphocytes to cytokine stimuli. The incretin axis, CXCR3 (receptor of DPP4 ligand cytokines CXCL9-11) expression on T(reg)s and hematologic parameters were assessed in 34 patients with long standing type 1 diabetes (T1DM) and in 35 healthy controls. Serum DPP4 (sDPP4) activity, plasma total GLP1 and GLP1(7)(-)(36) concentrations were determined. GLP1(9)(-)(36) concentrations were calculated. CXCR3 expression (flow cytometry) was higher on the CD25(-/)(low)Foxp3(+) than on the CD25(+)Foxp3(+) T(reg)s independently from T1DM, suggesting that CD25(-/)(low)Foxp3(+) T(reg)s are possibly waiting for orientational chemotactic stimuli in a "standby mode". The higher sDPP4 activities in T1DM were inversely correlated with GLP1(7)(-)(36) levels and GLP1(9)(-)(36) levels directly with lymphocyte counts in controls. Our results might indicate an altered DPP4-incretin system and altered immunoregulation including a potentially dysfunctional GLP1(9)(-)(36) signaling in T1DM.

Early detection of comorbidity in psoriasis: recommendations of the National Conference on Healthcare in Psoriasis

BACKGROUND

Psoriasis is associated with an increased rate of comorbidities, whose early detection has been adopted into the national healthcare goals. To date, agreed recommendations on early detection in the context of routine dermatological care are missing. The objective of this study was the interdisciplinary development of screening algorithms.

METHODS

The development of the consensus paper was based on a three-step process. First, the National Conference on Healthcare in Psoriasis, convening on behalf of the German Society of Dermatology (DDG) and the Professional Association of German Dermatologists (BVDD), developed a definition of the requirements, areas of application, conception, and methodology of a screening tool. Secondly, based on a literature search, individual working groups compiled evidence for the use of screening parameters. In a third step, an interdisciplinary working group adopted the algorithms in a Delphi consensus process.

RESULTS

The associated working groups evaluated more than 2,000 publications on 15 different comorbidities. A screening algorithm was agreed on for the following twelve indications: arterial hypertension, dyslipidemia, obesity, diabetes mellitus, metabolic syndrome, nonalcoholic steatohepatitis, depression, nicotine abuse, alcohol abuse, chronic inflammatory bowel disease, psoriasis arthritis, and malignant lymphoma. In this context, the requirements of everyday dermatological care were addressed in particular.

CONCLUSIONS

With respect to screening for comorbidities in psoriasis, standardized and consented algorithms are available, which - on national level - may be implemented as a screening tool within the framework of PsoNet - German Psoriasis Networks.

Psoriasis and Diabetes: A Multicenter Study in 222078 Type 2 Diabetes Patients Reveals High Levels of Depression

OBJECTIVE

This study aimed to investigate the association between psoriasis and disease outcome in type 2 diabetes (T2D).

METHODS

222078 T2D patients (≥10 years old) from the prospective, multicenter diabetes patient registry were analyzed. Specific search items were used to identify psoriasis patients. Multiple regression models were fitted and adjusted for demographic confounder.

RESULTS

232 T2D patients had comorbid psoriasis. After adjusting psoriasis patients revealed a higher BMI (31.8 [31.0; 32.6] versus 30.6 [30.5; 30.6] kg/m2, p = 0.004) and HbA1c (64.8 [62.1; 67.6] versus 59.0 [58.9; 59.1] mmol/mol, p < 0.0001). Insulin was used more frequently (62.3 [55.7; 68.5] versus 50.9 [50.7; 51.1] %, p = 0.001), only OAD/GLP-1 was similar, and nonpharmacological treatment was less common (13.3 [9.5; 18.3] versus 21.9 [21.7; 22.1] %, p = 0.002). Severe hypoglycemia (0.31 [0.238; 0.399] versus 0.06 [0.057; 0.060] events per patient-year, p < 0.0001), hypertension (86.1 [81.1; 90.0] versus 68.0 [67.8; 68.2] %, p < 0.0001), and thyroid disease (14.0 [10.1; 19.2] versus 4.6 [4.5; 4.7] %, p < 0.0001) were more prevalent. Depression occurred more often (10.5 [7.1; 15.2] versus 2.8 [2.7; 2.8] %, p < 0.0001).

CONCLUSIONS

Clinical diabetes characteristics in psoriasis T2D patients were clearly worse compared to patients without psoriasis. Comorbid conditions and depression were more prevalent, and more intensive diabetes therapy was required.

Evaluation of body composition parameters in patients with psoriasis

BACKGROUND

Body composition parameters, such as weight, body mass index (BMI), and visceral fat rating, have been found to be associated with psoriasis. However, the associations of these parameters with psoriasis have not been demonstrated clearly.

OBJECTIVES

This study aimed to evaluate body composition parameters in patients with psoriasis.

METHODS

The relationships between the various body composition parameters and psoriasis were retrospectively examined in 242 patients with plaque psoriasis (119 women, 123 men) over a 2-year period during 2010-2012. In addition, the correlations between body composition parameters and Psoriasis Area and Severity Index (PASI) score were evaluated in treated and untreated patients with psoriasis. Patients were divided into two groups according to whether or not they had received systemic therapy within the previous three months. Body composition values were measured using the Tanita SC-330 Body Composition Analyzer(®).

RESULTS

Statistically significant differences were recorded in terms of weight (kg), body fat percentage, fat mass (kg), total body water (TBW) percentage, metabolic age, visceral fat rating, BMI, and degree of obesity among treated and untreated patients and control subjects. Differences in fat-free mass (FFM) (kg), muscle mass (kg), TBW (kg), and bone mass (kg) were found to be close to the limit for significance. The treated and untreated groups showed no significant differences in any of the parameters evaluated. The correlations between PASI score and the various parameters provided some evidence for such relationships.

CONCLUSIONS

The present study provides evidence of a relationship between some body composition parameters and the occurrence of psoriasis. We suggest that body composition parameters should be analyzed not only in obese psoriasis patients but in all psoriasis patients upon their first diagnosis. Systemic therapy does not appear to cause any changes in body composition parameters.

The efficacy of methotrexate plus pioglitazone vs. methotrexate alone in the management of patients with plaque-type psoriasis: a single-blinded randomized controlled trial

Recently, thiazolidinediones have shown to be efficacious with a favorable safety profile when used in the treatment of chronic plaque-type psoriasis. The aim of this study was to evaluate and compare the efficacy and safety of a combination of methotrexate plus pioglitazone and methotrexate alone in plaque-type psoriasis. A total of 44 adult patients with plaque-type psoriasis were included in the study. Patients were randomized to treatment with methotrexate alone (group A) or methotrexate plus pioglitazone (group B) for 16 weeks. The primary efficacy outcome measure was psoriasis area and severity index (PASI) score change between the study groups at week 16 relative to baseline. The secondary efficacy outcome measure was dermatology life quality index (DLQI) score change between the two groups at week 16 relative to baseline. The PASI 75 score was also measured. After 16 weeks of therapy, the percentage of reduction in the mean PASI score was 70.3% in group B and 60.2% in group A. PASI 75 was achieved in 14 patients (63.6%) in group B compared with two patients (9.1%) in group A within 16 weeks, which was significant (P < 0.001). At 16 weeks from the baseline, a 63.6% decrease in the mean DLQI score of group B was seen, while the decrease for group A was 56.9%. Pioglitazone enhances the therapeutic effect of methotrexate in plaque-type psoriasis, as demonstrated by a reduction in the mean PASI scores. In terms of DLQI, there was no extra benefit by the addition of pioglitazone to methotrexate therapy.

Serum adiponectin and leptin levels in psoriatic patients according to topical treatment

OBJECTIVES

Psoriasis has been considered as a systemic disease associated with obesity, cardiovascular diseases and metabolic syndrome. Adipokines have influence on many metabolic processes. Aim of this study was to evaluate the effect of conventional topical treatment on serum adiponectin and leptin levels in patients with psoriasis.

METHODS

Forty-nine patients with relapse of plaque-type psoriasis and 16 healthy controls were examined. Blood samples were collected before therapy and after 14 days of application. Serum adiponectin and leptin concentrations were examined by enzyme-linked immunosorbent assay for correlations with effectiveness of topical treatment.

RESULTS

Adiponectin and leptin serum levels were significantly decreased in psoriatic patients in comparison to the controls. As a result of the topical treatment, serum adiponectin level did not significantly change. Serum leptin level increased significantly, still remaining lower than in the controls.

CONCLUSIONS

Leptin might be a useful marker in assessing the efficacy of the treatment for psoriasis.

Acitretin in psoriasis: an evolving scenario

Acitretin, an active metabolite of etretinate, is the most widely used systemic retinoid in the treatment of psoriasis. There are several unique characteristics of this drug, which set it apart from other options in the therapeutic armamentarium of psoriasis. It is highly efficacious as monotherapy in some specific clinical subtypes of psoriasis. It has dose-sparing effects when used as combination therapy with conventional systemic drugs as well as the biologics. It is a good option for long-term maintenance therapy. Side effects are common but usually mild and can be managed by its proper dosing and monitoring. With appropriate patient selection, gradual dose escalation, and patient counseling, we can deliver good results in psoriasis with this useful drug. This review gives a comprehensive recount of acitretin use in the present era of biologics in psoriasis.

Future diagnosis, today's treatment - cardiomyopathy in the course of psoriasis: a case report

Psoriasis is a relatively common, chronic skin disease of inflammatory origin. In recent years, public attention has been drawn to a more and more frequently observed relationship between psoriasis and cardiovascular disease. Nowadays, psoriasis is independently held responsible for increased cardiovascular mortality. It seems that the actual significance of the problem, together with a heart-related death risk for these patients is often underestimated. This study presents clinical evidence collected during a long-term observation and treatment of an 80-year-old psoriatic patient with concomitant diabetes, hypertension, and ischemic heart disease, whose overall clinical picture also suggested a congestive, inflammation-related cardiomyopathy with conduction disorders and severe heart failure. Despite the patient's advanced age and associated serious, long-established psoriasis-related problems, he was successfully treated with the use of interventional cardiology methods, as well as cardiac resynchronization therapy.

Decreased plasma levels of clusterin in patients with psoriasis

INTRODUCTION AND OBJECTIVES

Psoriasis is a chronic inflammatory disease that has been linked to increased cardiovascular risk. The glycoprotein clusterin (apolipoprotein J) is a component of high-density lipoproteins and has a protective role in atherosclerosis. The aim of the present study was to evaluate the plasma levels of clusterin and the proinflammatory cytokine macrophage migration inhibitory factor (MIF) in patients with severe psoriasis, comparing groups of patients with different risks of cardiovascular disease.

MATERIAL AND METHODS

Twenty-one patients with severe psoriasis (psoriasis area severity index and body surface area>10) and 11 healthy controls with no dermatologic disease were studied. Cardiovascular risk factors were assessed according to the Adult Treatment Panel (ATP) III criteria. Subclinical carotid atheromatosis was assessed by Doppler ultrasonography of the carotid arteries. Plasma clusterin and MIF levels were measured by enzyme-linked immunosorbent assay.

RESULTS

ATP-III criteria for metabolic syndrome were met by 47% of the patients, and 33% had carotid atheromatous plaque. Mean (SD) clusterin plasma levels were significantly lower in patients with psoriasis compared with controls (81.39 [27.30] μg/mL for the 21 patients vs 117 [21.6] μg/mL for the 11 controls; P=.0017). MIF plasma levels (ng/ml) were significantly higher in patients with atheromatous plaque compared with controls (53.22 [29.02] for the 6 patients with plaque vs 34.21 [9.65] for the 11 controls; P=.0394).

CONCLUSIONS

The decreased plasma levels of clusterin in psoriatic patients suggested an association with the disease and might be an indicator of systemic inflammatory activity. Increased levels of MIF appear to be associated with cardiovascular risk factors and carotid atheromatous plaque.

Cardiovascular comorbiditiy in psoriasis

The chronic inflammatory nature of psoriasis is also thought to predispose patients to other diseases with an inflammatory component, the most notable being cardiovascular and metabolic (cardiometabolite) disorders. This concept is supported by studies showing that psoriasis is associated with cardiovascular risk factors like diabetes, obesity, hypertension, dyslipidemia, smoking and diseases including MI. Given the increased prevalence of cardiovascular co morbidities in patients, dermatologists treating psoriasis need to approach the disease as a potentially multisystem disorder and must alert these patients to the potentially negative effects of their disease.

Psoriasis, a model of dermatologic psychosomatic disease: psychiatric implications and treatments

Psoriasis is a common dermatologic disorder with psychiatric comorbidity that often goes undetected and untreated. Psoriasis has higher associations with psychiatric illness than do other dermatologic conditions. We conducted a comprehensive qualitative review of all published medical literature on psoriasis and psychiatric comorbidities since 2005. We found that psoriasis patients suffer psychiatric and psychosocial morbidity that is not commensurate with the extent of cutaneous lesions. Biologic therapies and nonpharmacologic psychosocial interventions show promise in treating comorbid psychiatric illness. The main limitations of this review are the low quality of published studies and the infrequent use of basic science endpoints in reporting treatment outcomes. The literature examining the psychiatric comorbidity of psoriasis is expanding but remains of variable quality. Stronger studies will be necessary to more accurately estimate comorbidities and help identify and comprehensively treat suffering patients.

Iatrogenic effects of biologics for psoriasis

Use of the biologic agents in moderate to severe chronic plaque psoriasis has provided novel and highly efficacious treatment options. Generally less systemically toxic than more traditional agents, the risks and benefits for these agents must also be considered. We present a review of the iatrogenic effects associated with use of the biologic agents in psoriasis. Focus is placed on antitumor necrosis factor agents, because they are the most studied and commonly used agents, as well as T-cell modulators and interleukin inhibitors.

Obesity and the skin

Obesity is a serious global health problem, perhaps the biggest public health issue of our times. Excess body weight may be a factor in carcinogenesis in general, as well as contributing to the pathogenesis of metabolic, cardiovascular and musculoskeletal disorders. Obesity also has many cutaneous features, which form the basis for this review article. Many of these clinical entities are common to the majority of obese patients, e.g. striae distensae, plantar hyperkeratosis and an increased risk of skin infections. However, it may also be associated with poor wound healing, malignant melanoma and an increased risk of inflammatory dermatoses, such as psoriasis, as well as some rarer disorders. Therapeutic interventions for obesity, whether over-the-counter, prescription medicines or surgical interventions, are increasingly commonplace. All of these treatment modalities potentially have dermatological side-effects too.

Psoriasis in patients older than 65 years. A comparative study with younger adult psoriatic patients

OBJECTIVES

To examine the clinical characteristics of psoriasis, prevalence of comorbidities and quality of life in psoriasis patients older than 65 years and to compare them with younger adult psoriatic patients.

DESIGN

Prospective observational study of prevalence.

SETTING AND PARTICIPANTS

Patients older than 18 years with diagnosis of psoriasis attended at the Dermatology Department of the University Hospital of A Coruña (Galicia, Spain). A total of 371 patients were included (218 males and 153 females) with ages ranging from 18 to 85 years, of whom 70 were older than 65 years.

MEASUREMENTS

Demographic data, clinical characteristics and psoriasis treatment, history of hypertension, diabetes mellitus, smoking and alcohol consumption and quality of life impairment were registered. Body mass index, waist-hip ratio, left ventricular hypertrophy, average value of systolic and diastolic blood pressure, cholesterol, triglycerides and glucose blood levels were also measured.

RESULTS

Patients older than 65 years have statistically significant higher prevalence of hypertension, left ventricular hypertrophy, waist-hip ratio, diabetes mellitus and raised blood glucose levels. There was also association between clinical severity of psoriasis and smoking and alcohol intake as well as between quality of life and type of psoriasis treatment.

CONCLUSIONS

Psoriasis in patients older than 65 years represents a significant proportion of cases and its prevalence is expected to increase. Because these patients are more prone to suffer comorbidities and to develop adverse effects due to psoriasis treatment, attention to pharmacologic interactions and correction of cardiovascular risk factors and toxic habits should be especially taken in mind in this age group.

Do eating disorders accompany metabolic syndrome in psoriasis patients? Results of a preliminary study

BACKGROUND

Metabolic syndrome (MBS) has been reported as a frequent comorbidity in psoriatic patients. The main pathogenesis is considered to be inflammation in this association. MBS has been investigated in eating disorders as well. While psoriasis has some psychiatric comorbidities, the link between psoriasis, MBS, and eating disorders (EDs) is unknown.

METHODS

The study was designed as a cross-sectional, randomized, and controlled trial. A total of 100 patients with psoriasis were included in the study. Sociodemographic data, clinical subtype of psoriasis, Psoriasis Area and Severity Index (PASI) scores, and associated diseases were registered for each patient. The criteria for diagnosis of MBS developed by the International Diabetes Foundation (IDF) was used. These are central obesity (waist circumference ≥94 cm in men or ≥80 cm in women), plus two of the following: elevated triglycerides (≥150 mg/dL), reduced high-desity lipoprotein cholesterol (>40 mg/dL for men; >50 mg/dL for women), elevated blood pressure (≥130 mmHg systolic or ≥85 mmHg diastolic), and elevated fasting blood glucose (≥100 mg/dL). Additionally, the Eating Attitude Test (EAT), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI), and psychiatric interview were performed for all patients.

RESULTS

There were 45 female and 55 male patients, aged between 18 and 85 years old (median 41.12 ± 16.01). MBS was present in 31% of the patients with psoriasis. There was no correlation between the severity of psoriasis and MBS. EAT scores were ≥30 in 7/100 patients. Four out of 31 patients with MBS (12.9%) had ED and 3/69 patients were without MBS (4.3%). Mean ED scores were compared statistically and the difference was significant (EAT = 17.9 ± 9.558 and 11.5 ± 7.204, P < 0.001).

CONCLUSION

Defining risk factors leading to comorbidities is important in psoriasis. EDs seem to have an impact on the development of MBS in psoriasis. Establishment and treatment of EDs in patients with psoriasis may prevent the onset of MBS and other comorbidities due to MBS.

Epidemiology and comorbidities of psoriasis patients in a national database in Taiwan

BACKGROUND

Recent findings in psoriasis research have shown that psoriasis is frequently associated with systemic comorbidities.

OBJECTIVES

This study aims to describe the epidemiology of psoriasis and the prevalence of comorbidities in patients with psoriasis in Taiwan.

METHODS

Patients who had at least one outpatient visit or admission with ICD-9-CM diagnosis code 696.0-1 in the Taiwan National Health Insurance (NHI) claims database during 2006 were identified as psoriasis cases. The cases were further classified into moderate to severe psoriasis (sPsO) for those who had previously received systemic therapy during the study period and mild psoriasis (mPsO) for those who had not. The cases were matched in a 1:4 ratio with controls from a sample cohort of 997,771 enrolees representative of the Taiwan population. Matching variables included age, gender and residential area. Prevalence of comorbidities was assessed using prevalence relative risk (RR) based upon a Cox proportional regression model.

RESULTS

51,800 psoriasis cases were identified (prevalence=0.235%; mean age=46.4±18.6; male:female=1.6:1) and 17.5% of cases were sPsO type. Psoriasis was associated with a significantly increased prevalence ratio (RR; [95% confidence interval]) for hypertension (1.51; [1.47, 1.56]), diabetes (1.64; [1.58, 1.70]), hyperglyceridaemia (1.61; [1.54, 1.68]), heart disease (1.32; [1.26, 1.37]), hepatitis B viral infection (1.73; [1.47, 2.04]), hepatitis C viral infection (2.02; [1.67, 2.44]), rheumatoid arthritis (3.02; [2.68, 3.41]), systemic lupus erythematosus (6.16; [4.70, 8.09]), vitiligo (5.94; [3.79, 9.31]), pemphigoid (14.75; [5.00, 43.50]), pemphigus (41.81; [12.41, 140.90]), alopecia areata (4.71; [2.98, 7.45]), lip, oral cavity and pharynx cancer (1.49; [1.22, 1.80]), digestive organs and peritoneum cancer (1.57; [1.41, 1.74]), depression (1.50; [1.39, 1.61]), fatty liver (2.27; [1.90, 2.71]), chronic airways obstruction (1.47; [1.34, 1.61]), sleep disorder (3.89; [2.26, 6.71]), asthma (1.29; [1.18, 1.40]), and allergic rhinitis (1.25; [1.18, 1.33]). Conversely, psoriasis was not associated with an increased risk of Crohn's disease.

CONCLUSIONS

Psoriasis was associated with a significantly increased risk of comorbidities, especially for those patients with moderate to severe disease. These health associations should be taken into consideration when evaluating the burdens of psoriasis and designing effective treatment plans.