An update on psoriasis and metabolic syndrome: A meta-analysis of observational studies

Metabolic syndrome and dermatological diseases: association and treatment

Metabolic syndrome (MetS) is a clinical syndrome associated with cardiovascular disease, diabetes, obesity, and dyslipidemia. Its primary features include dyslipidemia, hypertension, abdominal obesity, and insulin resistance (IR). Recently, research has revealed that MetS is not only a manifestation of internal metabolic disturbances but is also closely associated with various dermatological conditions, including inflammatory skin diseases, autoimmune skin diseases, and skin tumors. These studies have clarified the complex mechanisms underlying the interaction between MetS and these skin diseases, including IR, chronic inflammatory responses, and oxidative stress. This review summarizes the association between MetS and related dermatological conditions and their shared physiological mechanisms. It aims to provide clinicians with new therapeutic strategies and preventive measures to improve the treatment outcomes and quality of life of patients with skin conditions.

Combination therapy of systemic and local metformin improves imiquimod-induced psoriasis-like lesions with type 2 diabetes: the role of AMPK/KGF/STAT3 axis

CONTEXT

Insulin resistance and a disturbed lipid profile are common associations with type 2 diabetes mellitus (T2DM) and different skin diseases, particularly psoriasis (PsO).

OBJECTIVES

We investigated potential therapeutic mechanisms of metformin in a murine animal model of psoriasiform lesions in T2DM.

MATERIALS AND METHODS

Forty-two rats were randomly divided into control, PsO, and type II DM (T2DM) groups. After confirmation of DM, the type II diabetic rats were allocated into T2DM+ PsO, T2DM+ PsO+ systemic metformin (S. met), T2DM+ PsO+ topical metformin (T. met)), and T2DM+ PsO + combined metformin (C. met). PsO was induced by topical imiquimod.

RESULTS

Systemic administration of the cornerstone antidiabetic drug, metformin, was able to improve insulin resistance and lipid profile. At molecular levels, both topical and systemic metformin significantly increased AMP-activated protein kinase (AMPK), and lowered keratinocyte growth factor (KGF) / "Signal transducer and activator of transcription" (STAT)3 protein levels, and the IL-17RA and IL-17RC gene expression.

CONCLUSION

Although its glucose-controlling effect was not optimum, T.met gel served anti-psoriatic and anti-inflammatory effects.

Skin Metabolic Signatures of Psoriasis and Psoriasis Concurrent with Metabolic Syndrome

Purpose

Psoriasis is a complex inflammatory skin disorder that is closely associated with metabolic syndrome (MetS). Limited information is available on skin metabolic changes in psoriasis; the effect of concurrent MetS on psoriatic skin metabolite levels is unknown. We aimed to expand this information through skin metabolomic analysis.

Patients and Methods

Untargeted metabolomics was conducted using skin samples from 38 patients with psoriasis vulgaris with MetS (PVMS), 23 patients with psoriasis vulgaris without MetS (PVNMS), and 10 healthy controls (HC). Data analyses, including multivariate statistical analysis, KEGG pathway enrichment analysis, correlation analysis, and receiver operating characteristic curve analysis, were performed.

Results

Significant discrepancies were found between skin metabolites in the HC and PVNMS groups, particularly those involved in nucleotide and glycerophospholipid metabolism. Fifteen of these metabolites were positively correlated with psoriasis severity. Furthermore, MetS was found to affect the metabolic profiles of patients with psoriasis. There were some metabolites with consistent alterations in both the PVNMS/HC and PVMS/PVNMS comparisons.

Conclusion

This study may provide new insights into the link between skin metabolism and psoriatic inflammation and the mechanism underlying the interaction between psoriasis and MetS.

Immune-Mediated Inflammatory Diseases, Dyslipidemia, and Cardiovascular Risk: A Complex Interplay

Individuals with autoimmune inflammatory diseases, such as systemic lupus erythematosus, rheumatoid arthritis, and psoriasis, are at increased risk for cardiovascular disease. While these diseases share common features of systemic inflammation, the impact of individual autoimmune inflammatory conditions on circulating lipids and lipoproteins varies by specific disease, disease activity, and the immune-suppressing medications used to treat these conditions. A common feature observed in many autoimmune inflammatory diseases is the development of a proatherogenic dyslipidemic state, characterized by dysfunctional HDLs (high-density lipoproteins) and increased oxidation of LDLs (low-density lipoproteins). Various disease-modifying antirheumatic drugs also have complex and variable effects on lipids, and it is critical to take this into consideration when evaluating lipid-related risk in individuals with immune-mediated inflammatory conditions. This review aims to critically evaluate the current understanding of the relationship between immune-mediated inflammatory diseases and dyslipidemia, the underlying mechanisms contributing to atherogenesis, and the impact of various pharmacotherapies on lipid profiles and cardiovascular risk. We also discuss the role of lipid-lowering therapies, particularly statins, in managing residual risk in this high-risk population and explore the potential of emerging therapies with complementary anti-inflammatory and lipid-lowering effects.

Factors Associated with Anxiety, Depression, and Quality of Life in Patients with Psoriasis: A Cross-Sectional Study

BACKGROUND

Psoriasis is a chronic skin disorder affecting 2-3% of the global population, and is associated with several comorbidities, including psychiatric disorders. This study aimed to identify factors influencing anxiety, depression, and quality of life (QoL) in patients with psoriasis.

METHODS

This observational study included 112 patients diagnosed with psoriasis. Dermatological and psychiatric assessments were conducted using Psodisk, the Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HAM-D), Symptom Checklist-90-Revised (SCL-90-R), and 36-Item Short Form Health Survey (SF-36). Descriptive statistics, correlation analyses, and multivariate regression models were employed.

RESULTS

The sample was predominantly middle-aged males (mean age 48.91 years). Females (p < 0.001), patients with arthritis (p < 0.05), and those with a sedentary lifestyle (p < 0.05) showed higher anxiety and depression scores. Psodisk subscales significantly correlated with psychiatric symptoms and QoL measures (p < 0.001). Pain (B: 0.63, p < 0.05; B: -2.03, p < 0.01) and sleep disturbances (B: 0.68, p < 0.01; B: 0.60, p < 0.01; B: -1.46, p < 0.01; B: -1.57, p < 0.05; B: 3.91, p < 0.05) emerged as major predictors of poor mental health and reduced QoL.

CONCLUSIONS

The study underscores the complex relationship between psoriasis, psychiatric comorbidities, and QoL. Key factors exacerbating anxiety and depression include female gender, arthritis, and sedentary lifestyle. Comprehensive management of psoriasis should address both dermatological and psychological aspects, with a focus on pain relief and improving sleep quality to enhance overall patient well-being.

Clinical Implications of Metabolic Syndrome in Psoriasis Management

Psoriasis is an increasingly common chronic immune-mediated skin disease recognized for its systemic effects that extend beyond the skin and include various cardiovascular diseases, neurological diseases, type 2 diabetes, and metabolic syndrome. This study aimed to explore the complex relationship between psoriasis and metabolic syndrome by analyzing clinical, biochemical, and immunological parameters in patients with psoriasis alone and in patients combining psoriasis and metabolic syndrome. A total of 150 patients were enrolled, 76 with psoriasis only (PSO) and 74 with psoriasis and metabolic syndrome (PSO-MS). Data collected included anthropometric measurements, blood tests, and inflammatory markers. Statistical analysis was performed using the independent t-test, Mann-Whitney U test, Kruskal-Wallis test, and chi-square test to compare the two groups. Patients in the PSO-MS group had a significantly higher body weight, abdominal circumference, BMI, and inflammatory markers compared to patients with PSO. In addition, increased levels of IL-17A, cholesterol, triglycerides, and glucose were observed in the PSO-MS group. This study highlights the increased metabolic risk and exacerbated systemic inflammation associated with the coexistence of psoriasis and metabolic syndrome. These findings demonstrate the need for a comprehensive therapeutic approach and early intervention to manage metabolic complications in patients with psoriasis and metabolic syndrome.

Genetic causality and metabolite pathway identifying the relationship of blood metabolites and psoriasis

BACKGROUND

Psoriasis is a chronic inflammatory disease that causes significant disability. However, little is known about the underlying metabolic mechanisms of psoriasis. Our study aims to investigate the causality of 975 blood metabolites with the risk of psoriasis.

MATERIALS AND METHODS

We mainly applied genetic analysis to explore the possible associations between 975 blood metabolites and psoriasis. The inverse variance weighted (IVW) method was used as the primary analysis to assess the possible association of blood metabolites with psoriasis. Moreover, generalized summary-data-based Mendelian randomization (GSMR) was used as a supplementary analysis. In addition, linkage disequilibrium score regression (LDSC) was used to investigate their genetic correction further. Metabolic pathway analysis of the most suggested metabolites was also performed using MetaboAnalyst 5.0.

RESULTS

In our primary analysis, 17 metabolites, including unsaturated fatty acids, phospholipids, and triglycerides traits, were selected as potential factors in psoriasis, with odd ratios (OR) ranging from 0.986 to 1.01. The GSMR method confirmed the above results (β = 0.001, p < 0.05). LDSC analysis mainly suggested the genetic correlation of psoriasis with genetic correlations (rg) from 0.088 to 0.155. Based on the selected metabolites, metabolic pathway analysis suggested seven metabolic pathways including ketone body that may be prominent pathways for metabolites in psoriasis.

CONCLUSION

Our study supports the causal role of unsaturated fatty acid properties and lipid traits with psoriasis. These properties may be regulated by the ketone body metabolic pathway.

Metabolic dysfunction associated steatotic liver disease in patients with plaque psoriasis: a case-control study and serological comparison

Background

The relationship between plaque psoriasis and both MASLD and lean MASLD has not been sufficiently explored in the current literature.

Method

This retrospective and observational study was carried out from January 2021 to January 2023 at The First Affiliated Hospital of Zhejiang Chinese Medical University. Patients diagnosed with plaque psoriasis and a control group consisting of individuals undergoing routine physical examinations were enrolled. The incidence of MASLD and lean MASLD among these groups was compared. Additionally, patients with plaque psoriasis were divided into those with MASLD, those with lean MASLD, and a control group with only psoriasis for a serological comparative analysis.

Results

The incidence of MASLD in the observation group and the control group was 43.67% (69/158) and 22.15% (35/158), respectively (p < 0.01). Furthermore, the incidence of lean MASLD within the observation group and the control group was 10.76% (17/158) and 4.43% (7/158), respectively (p < 0.01). After controlling for potential confounding variables, plaque psoriasis was identified as an independent risk factor for MASLD with an odds ratio of 1.88 (95% cl: 1.10-3.21). In terms of serological comparison, compared to the simple psoriasis group, we observed a significant elevation in the tumor marker CYFRA21-1 levels in both groups compared to the control group with simple psoriasis (p < 0.01). Moreover, the MASLD group exhibited elevated levels of inflammatory markers and psoriasis score, whereas these effects were mitigated in the lean MASLD group.

Conclusion

The prevalence of MASLD and lean MASLD is higher among patients with psoriasis. Those suffering from psoriasis along with MASLD show increased psoriasis scores and inflammatory markers compared to those without metabolic disorders. MASLD likely worsens psoriasis conditions, indicating the necessity of targeted health education for affected individuals to reduce the risk of MASLD, this education should include guidelines on exercise and diet. In serological assessments, elevated levels of cytokeratin 19 fragment (CYFRA21-1) were noted in both MASLD and lean MASLD groups, implying a potential synergistic role between psoriasis and MASLD.

Genetic insights into the risk of metabolic syndrome and its components on psoriasis: A bidirectional Mendelian randomization

The role of metabolic syndrome (MetS) on psoriasis has been explored only in observational studies. We conducted this bidirectional Mendelian randomization (MR) to clarify the causal relationship between MetS and its components and psoriasis. The genetic instruments of MetS and its five components (waist circumference [WC], hypertension, fasting blood glucose [FBG], triglycerides [TG], and high-density lipoprotein cholesterol [HDL-C]) were obtained from public genome-wide association studies (GWAS). Outcome datasets for psoriasis were collected from the FinnGen Biobank Analysis Consortium. The main method was inverse variance weighting, complemented by sensitivity approaches to rectify potential pleiotropy. MetS, WC, and hypertension increase the risk of psoriasis (MetS, odd ratios [OR] = 1.17, 95% confidence interval [CI] 1.08-1.27, p = 1.23e-04; WC, OR = 1.65, 95% CI  1.42-1.93, p = 1.06e-10; hypertension, OR = 2.02, 95% CI 1.33-3.07, p = 0.0009). In the reverse analysis, no causal association between psoriasis and MetS and its five components was identified. We provide novel genetic evidence that MetS, WC, and hypertension are risk factors for the development of psoriasis. Early management of MetS and its components may be an effective strategy to decrease the risk of psoriasis.

Higher IL-9 Level is Associated with Psoriasis Vulgaris Complicated by Metabolic Syndrome

Purpose

The underlying pathophysiology linking psoriasis vulgaris (PV) and metabolic syndrome (MetS) is not fully understood. The present study aimed to investigate the serum level of interleukin (IL)-9 and tissue levels of IL-9 and its receptor in PV patients with MetS and analyze the correlation of IL-9 levels with psoriasis disease severity and MetS.

Methods

This study enrolled 75 PV patients with MetS, 57 PV patients without MetS, 20 healthy blood donors, and 7 healthy skin donors. Clinical, socio-demographic, and anthropometric data were obtained from all individuals. Fasting blood glucose, insulin, lipid profile levels, and serum levels of IL-9 and IL-17A were measured. The expression of IL-9 and its receptor in skin specimens in PV patients and healthy controls was determined using immunohistochemistry. Normal human epidermal keratinocytes were stimulated with five pro-inflammatory cytokines (tumor necrosis factor-α, oncostatin M, IL-22, IL-17A, and IL-1α) to establish a psoriatic keratinocyte model and subsequently treated with IL-9. Their mRNA levels of antimicrobial peptides and chemokines were measured using quantitative real-time polymerase chain reaction.

Results

Serum level of IL-9 and tissue levels of IL-9 and its receptor were upregulated in PV patients with MetS. IL-9 level was positively correlated to IL-17A level; however, no significant correlation of IL-9 level with psoriasis area severity index was observed. IL-9 level had a positive correlation with the presence of MetS and its components. Correspondingly, IL-9 level positively correlated with waist circumference, body mass index, homeostasis model assessment-insulin resistance, blood pressure, and triglyceride level and negatively correlated with high-density lipoprotein cholesterol level. Additionally, IL-9 stimulated the expression of antimicrobial peptides and chemokines in a psoriatic keratinocyte model.

Conclusion

Our findings confirmed that higher IL-9 level is associated with PV complicated by MetS, suggesting that IL-9 may be a link between PV and MetS.

Psoriasis and associated risk factors: a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health

OBJECTIVE

This study investigated the association of psoriasis with cardiovascular risk factors and psychological aspects among participants of the Brazilian Longitudinal Study of Adult Health.

METHODS

This is a cross-sectional study from the baseline data of the Brazilian Longitudinal Study of Adult Health cohort, collected between 2008 and 2010 in six state capitals of Brazil (i.e., Belo Horizonte, Porto Alegre, Rio de Janeiro, Salvador, São Paulo, and Vitória). Participants were active and retired civil servants from college and research institutions, aged between 35 and 74 years. Exclusion criteria included the intention to quit working at the institution, pregnancy, severe cognitive impairment, and, if retired, residence outside of a study center's corresponding area. Psoriasis case identification was based on a previous medical diagnosis of psoriasis. Cardiovascular risk profile, psychological aspects, and sociodemographic variables were investigated.

RESULTS

Data from 15,105 participants were analyzed (mean age of 52.3 years, 51.3% women). The prevalence of psoriasis was 1.6% (n=236). Psoriasis was associated with higher education (OR 1.94 [CI 1.07-3.52]), health insurance plan (OR 1.56 [CI 1.08-2.25]), central obesity (OR 1.63 [CI 1.10-2.40]), smoking status (former OR 1.40 [CI 1.03-1.88]; current OR 1.61 [CI 1.08-2.40]), and very bad self-perception of health (OR 7.22 [CI 2.41-21.64]), remaining significant even after multivariate adjustment. Self-reported Black participants were less likely to have psoriasis (OR 0.45 [CI 0.26-0.75]).

CONCLUSION

In a sample of healthy workers, psoriasis was associated with central obesity, smoking, and a very bad self-perception of health, which may contribute to future cardiovascular disease.

Metabolic Syndrome Screening and Nutritional Status of Patients with Psoriasis: A Scoping Review

Background: Patients with plaque psoriasis have an increased risk of metabolic syndrome. However, no studies have assessed the nutritional status or screening methods of this population. Aims: This review aimed to identify and summarise metabolic syndrome screening criteria and the tools/methods used in nutrition assessment in patients with plaque psoriasis. Data synthesis: PubMed, Web of Science, Ovid and Scopus were searched from inception to March 2023, following the Arkensey and O'Malley framework, to identify articles that report nutritional assessment methods/tools and metabolic screening criteria. Twenty-one studies were identified. Overall, these studies used four different screening criteria to define metabolic syndrome. Patients with psoriasis had a high prevalence of metabolic syndrome and had a poor nutritional status compared to controls. However, only anthropometric measures such as weight, height and waist circumference were employed to determine the nutritional status. Only two studies assessed the vitamin D status. Conclusions: Patients with psoriasis have a poor nutritional status, and they are at risk of nutrient deficiencies. However, these health aspects are not routinely assessed and may increase the risk of malnutrition among these patients. Therefore, additional assessments, such as body composition and dietary assessment, are needed to determine the nutritional status to provide a suitable intervention.

Investigating the epidemiological relationship between vitiligo and psoriasis: a population-based study

BACKGROUND

The association of vitiligo with psoriasis is inconsistent in the current literature.

OBJECTIVE

To assess the bidirectional association between vitiligo and psoriasis.

METHODS

A population-based study was performed to compare vitiligo patients (n = 20,851) with age-, sex- and ethnicity-matched control subjects (n = 102,475) regarding the incidence of new-onset and the prevalence of preexisting psoriasis. Adjusted hazard ratios (HRs) and adjusted odds ratios (ORs) were calculated by cox regression and logistic regression, respectively.

RESULTS

The incidence rate of new-onset psoriasis was estimated at 7.9 (95% CI 6.4-9.7) and 4.7 (95% CI 4.1-5.3) cases per 10,000 person-years among patients with vitiligo and controls, respectively. Patients with vitiligo experienced an increased risk of psoriasis (fully-adjusted HR 1.71; 95% CI 1.35-2.17; P < 0.001). On the other hand, the odds of vitiligo were only marginally elevated among patients with preexisting psoriasis (fully-adjusted OR 1.19; 95% CI 1.01-1.40; P = 0.051). Compared to other patients with vitiligo, those with vitiligo and comorbid psoriasis were older at the onset of the disease and had a greater prevalence of metabolic and cardiovascular comorbidities.

CONCLUSIONS

A diagnosis of vitiligo predisposes individuals to develop subsequent psoriasis. Clinicians managing dermatologic patients ought to be aware of this comorbidity. Further research is required to explicate the pathomechanism underlying this epidemiological observation.

Paradoxical Reactions to Anti-TNFα and Anti-IL-17 Treatment in Psoriasis Patients: Are Skin and/or Gut Microbiota Involved?

Psoriasis is a chronic, immune-mediated, inflammatory disease primarily affecting the skin. It is currently coming to light that patients with psoriasis have disrupted intestinal barrier and often suffer from comorbidities associated with the gastrointestinal tract. Moreover, there is growing evidence of both cutaneous and intestinal paradoxical reactions during biologic treatment in patients with psoriasis. This review focuses on barrier defects and changes in immune responses in patients with psoriasis, which play an important role in the development of the disease but are also influenced by modern biological treatments targeting IL-17 and TNFα cytokines. Here, we highlight the relationship between the gut-skin axis, microbiota, psoriasis treatment, and the incidence of paradoxical reactions, such as inflammatory bowel disease in patients with psoriasis. A better understanding of the interconnection of these mechanisms could lead to a more personalized therapy and lower the incidence of treatment side effects, thereby improving the quality of life of the affected patients.

Trajectories of systemic agent use and associated depression- and anxiety-related health care costs among patients with psoriasis

Background

Systemic treatment patterns and related mental health disorders and economic burden among patients with psoriasis are largely unknown.

Objective

To assess systemic treatment patterns and associated depression and anxiety-related health care costs among patients with psoriasis initiating a conventional systemic treatment (CST).

Methods

Using a retrospective cohort design with sequence and cluster analyses, we assessed systemic treatment trajectories (CST and tumor necrosis factor inhibitors or ustekinumab, [TNFi/UST]) over a 2-year period following CST initiation. We compared health care costs between trajectories using 2-part models.

Results

We included 781 patients and identified 8 trajectories: persistent methotrexate users, persistent acitretin users, early CST discontinuation, late methotrexate discontinuation, switch to TNFi/UST, adding TNFi/UST, discontinuation then restart on methotrexate, and discontinuation then restart on acitretin or multiple CST switches. Overall, 165 (21%) patients incurred depression- and anxiety-related health care costs (median annual cost, CAN$56; quartiles, $14-$127). Compared with persistent methotrexate users, adding a TNFi/UST (cost ratio, 3.63; 95% CI, 1.47-5.97) and discontinuation then restart on acitretin or multiple switches between systemic agents (cost ratio, 13.3; 95% CI 5.76-22.47) had higher costs.

Limitations

Trajectory misclassification may have occured. These date represent an association, and causality cannot be inferred, particularly given the risk of confounding.

Conclusion

Depression- and anxiety-related health care costs were high among patients adding TNFi/UST and those discontinuing then restarting on acitretin or experiencing multiple switches between systemic agents.

Psoriatic erythroderma: comparative patient profile and association with psoriatic arthritis

Background: Psoriatic erythroderma is rare and the most severe form of psoriasis characterized by involvement of 80-90% of body surface area. Aims: to compare clinical and demographic characteristics of patients with psoriasis, depending on presence of psoriatic erythroderma in medical history; to assess the association between psoriatic arthritis and a history of psoriatic erythroderma. Materials and methods: patients aged 18 years and older with a duration of psoriasis of 10 years, from the psoriasis patients registry were included. Comparison of continuous quantitative variables was performed using t-test or Mann-Whitney U-test. The 2 test or Fisher's exact test was used to compare qualitative binary variables. The odds ratio of psoriatic arthritis in patients with and without a history of psoriatic erythroderma was calculated, unadjusted and adjusted for other independent variables. Results: The number of patients included in the analysis was 1,870. A history of psoriatic erythroderma (PE) had 227 (12.1%) of them. There were no significant differences in patient age at inclusion to the registry (47.113.1 years vs. 47.713.3 years), and prevalence of PE among men and women (12.6% vs. 11. 4%). Higher prevalence of arterial hypertension (47.9% vs 32.7%), angina pectoris (6.4% vs. 1.9%), myocardial infarction (3. 2% vs. 1.0%), biliary dyskynesia (14.3% vs. 3.9%), fatty liver (12.2% vs. 7.7%), cholelithiasis (8. 6% vs. 3.6%), and toxic liver disease (2.2% vs. 0.5%) among patients with vs without history of PE was found. Psoriatic arthritis was diagnosed in 67.0% patients with a history of psoriatic erythroderma. The odds of having psoriatic arthritis in patients with a history of psoriatic erythroderma were 4 times higher than in patients without erythroderma: 4.043 [2.975-5.493]. When adjusted for sex, age, duration of psoriasis, and body mass index, the odds ratio and statistical significance were maintained: 4.064 [2.939-5.619]. Conclusions: compared to patients without PE those with a history of psoriatic erythroderma have a greater comorbidity burden: a higher prevalence of cardiovascular diseases, diseases of the liver and biliary tract. A significant association between psoriatic arthritis and a history of PE was established.

Assessment of Vitamin D Level in Patients with Psoriasis and Its Correlation with Disease Severity: A Case–Control Study

Background

Chronic plaque psoriasis is a chronic inflammatory skin disorder. Vitamin D has been shown to have effects on keratinocyte differentiation as well as immune regulation in the skin.

Objective

The main objective of this study was to assess the 25hydroxyvitamin D [25 (OH) D] level in patients with psoriasis in comparison with healthy control subjects.

Materials and Methods

This case–control study included 180 persons (120 cases and 60 age- and sex-matched control subjects) from outpatient department of BPKIHS, a tertiary care hospital in eastern Nepal. Severity of psoriatic skin lesions was assessed using psoriasis area severity index (PASI) scoring. Serum vitamin D level was assessed by chemiluminescent immunoassay.

Results

The mean serum 25(OH) D levels in psoriatic patients and controls were 19.57 ± 6.85 ng/mL and 23.63 ± 6.40 ng/mL, respectively. The difference was statistically significant even after adjusting for confounding factors in a multivariate analysis (aOR 2.929, 95% CI 1.376–6.230). Low serum 25(OH) D levels were negatively associated with the severity of disease (r= −0.628, P= 0.01).

Conclusion

Serum 25(OH) D levels are significantly lower in psoriatic patients than in healthy control subjects. Deficiency of serum 25(OH) D was associated with severity of disease with an inverse relationship with PASI score.

Inflammatory Bowel Disease-associated Fatty Liver Disease: the Potential Effect of Biologic Agents

Inflammatory bowel diseases [IBD] exhibit intestinal and systemic manifestations. Nonalcoholic fatty liver disease [NAFLD] is a common co-existing condition, possibly contributing to the cardio-metabolic burden and overall morbidity. Εmerging therapeutic choices of biologic agents have modified the clinical course of IBD; however, their impact on IBD-associated NAFLD has not been extensively evaluated. The prevalence of NAFLD varies among IBD patients, but it appears higher than in the general population in the majority of quality studies. In terms of pathogenetic and risk factors of NAFLD, they may vary with IBD activity. Dysbiosis, mucosal damage, and cytokine release have been implicated in the pathogenesis during the relapses, whereas metabolic risk factors seem to play a dominant role during the remissions of IBD. Considering biologics, although quality data are scarce, agents suppressing tumour necrosis factor may offer potential benefits in IBD-associated NAFLD, whereas anti-integrins do not appear to confer any therapeutic advantage. In conclusion, IBD-associated NAFLD possibly follows two different patterns, one manifested during the relapses and one during the remissions of IBD. Some, but not all, biologics may benefit NAFLD in patients with IBD. Further mechanistic and prospective cohort studies are warranted to illuminate the effects of various biologics on NAFLD.

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

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

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

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

Serum Intestinal Metabolites are Raised in Patients with Psoriasis and Metabolic Syndrome

Purpose

Psoriasis is an immune-mediated chronic inflammatory disease. Metabolic syndrome (MetS) is characterized by central obesity, hypertension, dyslipidemia, diabetes and insulin resistance (IR). Increasing evidence indicates that psoriasis is associated with MetS. This study aimed to explore some metabolite indexes which could evaluate the severity or predict the risk of psoriasis patients associated with MetS.

Patients and methods

It was a case-control study conducted in Beijing Hospital of Traditional Chinese Medicine. Sixty healthy volunteers (HC), 100 patients with psoriasis (Ps), 100 patients with MetS (MetS) and 80 patients with both psoriasis and MetS (Ps+MetS) were entered between January 2016 and December 2018. Blood samples were taken after at least 12 hours fasting and the contents of trimethylamine N-oxide (TMAO), carnitine, choline and betaine in serum were measured by Liquid Chromatography Mass Spectrometry (LC-MS/MS). Besides, the serum levels of low-density lipoprotein (LDL), high-density lipoprotein (HDL), cholesterol (CHO), triglyceride (TG), blood glucose (BG), creatinine (Cr), urea nitrogen (BUN), uric acid (UA) were determined.

Results

The non-healthy groups had different degrees of dyslipidemia, Ps-MetS> Ps >MetS. Compared with HC, the Ps had a higher level of TG; The MetS had the lowest level of HDL; The Ps+Mets had the highest level of TG and CHO. The Ps and Ps+MetS both had high level of UA, but there was no difference between the two groups. As for intestinal metabolites, the Ps had significant differences in TMAO, carnitine, and betaine in comparison with HC. The MetS had the highest level of TMAO. There was positive correlation between PASI and TMAO and betaine.

Conclusions

TMAO and betaine could serve as indexes reflecting the severity of psoriasis. TG, CHO, LDL and UA could serve as risk factors of MetS in psoriatic patients.

Whether Screening for Non-alcoholic Fatty Liver Disease in Patients With Psoriasis Is Necessary: A Pilot Quality Improvement Project

Background

Psoriasis is a chronic inflammatory skin disease that is strongly associated with non-alcoholic fatty liver disease (NAFLD). Both conditions are associated with excess cardiovascular and liver-related morbidity and mortality. The severity of psoriasis correlates with the degree of liver inflammation and scarring, which can be further exacerbated by systemic immunomodulators such as methotrexate.

Currently, no clinical pathway exists to screen psoriasis patients for NAFLD in our Trust. We aimed to develop a shared clinical pathway between our hepatology and dermatology departments to allow early identification and management of NAFLD in this patient group.

Methods

A multidisciplinary team was assembled to identify patient priorities, management goals, and screening criteria. We identified gaps in our service and reviewed current clinical best practice guidelines. A clinical pathway was developed using a process map and revised according to feedback received. We piloted this pathway on a prospective cohort of psoriasis patients identified by our dermatology department. Patients were invited for transient elastography if fatty liver was identified on an ultrasound scan. Baseline demographics, biochemistry and imaging results were collected and analysed.

Results

Of 57 psoriasis patients, 30 (52.6%) had sonographic evidence of hepatic steatosis. The median age was comparable between groups with 56 and 55 years in the psoriasis-NAFLD (Ps-NAFLD) and no-NAFLD groups respectively. There were more males in the Ps-NAFLDgroup (56.7%) compared to the no-NAFLD group (37%). Fifteen out of 30 patients were eligible for transient elastography (two were excluded due to body habitus). Seven (53.8%) patients had no-to-mild fibrosis indicated by liver stiffness measurement (LSM) ≤7kPa, while six (46.1%) had moderate-to-severe fibrosis. Three (23.0%) patients had scores suggestive of cirrhosis (LSM>13kPa).

Conclusions

The introduction of a new shared-care pathway at our Trust has resulted in a streamlined way in which psoriasis patients can be screened and treated for NAFLD.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Tildrakizumab for treatment of moderate to severe psoriasis: an expert opinion of efficacy, safety, and use in special populations

INTRODUCTION

Tildrakizumab is a monoclonal antibody that targets the p19 subunit of IL-23, a crucial cytokine for Th17 cells. Tildrakizumab has been assessed in several Phase I, II, and III clinical trials and is approved for treatment of adults with moderate to severe plaque psoriasis who are indicated for systemic therapy.

AREAS COVERED

The available evidence on the efficacy, safety, and use of tildrakizumab in special populations was evaluated by 14 experts who critically reviewed the current literature.

EXPERT OPINION

Tildrakizumab has good efficacy that lasts for at least 5 years in patients with moderate to severe psoriasis, and appears to be safe and well tolerated in the long-term with no apparent dose-related differences in adverse events, a low incidence of discontinuation due to adverse events, and no evidence of increased risk of malignancies. The safety and the efficacy of tildrakizumab has also been confirmed in special populations such as those with inflammatory bowel disease, cardiovascular disease, metabolic syndrome, and advanced age. Early intervention with IL-23-inhibitors, such as tildrakizumab, may help to control symptoms and change the long-term course of the disease in patients affected by plaque psoriasis, while improving the quality of life and potentially minimizing the risk of developing comorbidities.

Leptin Receptor (rs1137101) and Brain-Derived Neurotrophic Factor (rs925946) Gene Variants Are Associated with Obesity in the Early- but Not in the Late-Onset Population of Hungarian Psoriatic Patients

Background: Psoriatic patients have considerably higher odds of being obese compared with the general population; however, the exact pathophysiological link between psoriasis and obesity needs to be elucidated. Methods: To investigate the association of psoriasis with established obesity-related gene variants, we conducted a population-based case-control study including 3541 subjects (574 psoriasis cases and 2967 controls from the general Hungarian population). Genotyping of 20 SNPs at ADIPOQ, BDNF, FTO, GNPDA2, LEPR, MC4R, NEGR1, NPY, PPARG, TMEM18, and UCP2 were determined, and differences in genotype and allele distributions were investigated. Multiple logistic regression analyses were implemented. Results: Analysis revealed an association between the G allele of the rs1137101 polymorphism (LEPR gene) and obesity risk (OR: 3.30 (1.45; 7.50), p = 0.004) in the early-onset group of psoriatic patients. Furthermore, the T allele of rs925946 polymorphism (BDNF gene) was also associated with increased risk of obesity in early-onset psoriasis (OR: 2.26 (1.24; 4.14), p = 0.008). Conclusions: Our results suggest that in psoriatic patients, there are prominent differences in the causes of obesity that should be accounted for, including not only environmental factors but also patient characteristics, such as the time of disease onset as well as genetic factors.

Psoriasis and its management in women of childbearing age: tools to increase awareness in dermatologists and patients

Psoriasis is a common, chronic inflammatory disease with a multifactorial pathogenesis. Mean age at presentation of psoriasis is 28 years in women, which is almost the height of fertility age. Since women of childbearing potential represent a significant proportion of psoriatic patients, the impact of psoriasis and its treatment on fertility, pregnancy, and breastfeeding should be highlighted for a proper management. Therefore, when approaching to a psoriatic woman of childbearing age, Healthcare Providers should be adequately informed and ready to provide the patients with answers to the most frequently asked questions. The Italian Society of Dermatology and Venereology (SIDeMaST) has fostered a Task Force named "Psoriasis in Women of Childbearing Age" which is composed by a group of Italian female dermatologists with a high expertise in psoriasis treatment. The aims of the Task Force are to increase awareness of the disease and its treatment in patients of childbearing age among both dermatologists and women affected by psoriasis and to encourage counselling on family planning. With the aim of providing a real support for the proper management of the delicate journey to motherhood, the Italian Task Force has published two different informative booklets addressed to patients and dermatologists which focus on the main issues regarding psoriasis in women of childbearing age.

L-Theanine Alleviates IMQ-Induced Psoriasis Like Skin Inflammation by Downregulating the Production of IL-23 and Chemokines

Psoriasis, the most common skin inflammatory disease, is characterized by massive keratinocyte proliferation and immune cell infiltration into epidermis. L-Theanine (L-THE), a nonproteinogenic amino acid derived from green tea (Camellia sinensis), has been proved to possess the properties of anti-inflammatory, antidepressants and neuroprotective. However, whether L-THE has a therapeutic effect on psoriasis is still unknown. In this study, we found that the epidermal thickness and inflammatory response were significantly reduced in Imiquimod (IMQ)-induced psoriasis mice by applying with L-THE on mice skin. The expression of proliferation and inflammation associated genes such as keratin 17, IL-23 and CXCL1-3 was also downregulated by L-THE. Furthermore, L-THE inhibited the production of IL-23 in dendritic cells (DCs) after IMQ treatment, and decreased the levels of chemokines in keratinocytes treated with IL-17A by downregulating the expression of IL-17RA. RNA-seq and KEGG analysis revealed that L-THE significantly regulated the expression of IL-17A and NF-κB signaling pathway-associated genes. Metabolomics analysis displayed that L-THE promoted propanoate metabolism which has been reported to inhibit the activity of TH17 cells. Therefore, our results demonstrated that L-THE significantly decreases the levels of IL-23 and chemokines, and attenuates IMQ-induced psoriasis like skin inflammation by inhibiting the activation of NF-κB and IL-17A signaling pathways, and promoting the propanoate metabolism. Our findings suggest that topical applied L-THE can be used as a topical drug candidate for the treatment of psoriasis or as an adjuvant treatment of ustekinumab or secukinumab to prevent the relapse of psoriasis.

Serum lactate dehydrogenase level as a possible predictor of treatment preference in psoriasis

BACKGROUND

The efficacy of small molecule inhibitors for intracellular signal mediators varies among the individuals, and their mechanism of action is broad. A phosphodiesterase 4 inhibitor apremilast shows a dramatic effect on a certain proportion of psoriatic patients by modulating the cellular metabolism and regulating the production of pro-inflammatory molecules. However, it is unclear to which disease subtype this drug benefits. While psoriasis is a Th17-mediated disease, how immune cells are affected by the modulation of cellular metabolism is not fully evaluated, either.

OBJECTIVE

This study aims to identify the indices which predict the efficacy of apremilast in psoriasis, and to investigate the impact of metabolic activity in immune cells on the psoriatic pathogenesis.

METHODS

The association of treatment efficacy with clinical and laboratory data of the 58 psoriatic patients was evaluated. The reflector of the associated index was also sought among the indices of cellular metabolic pathways by use of an extracellular flux analyzer.

RESULTS

There was a correlation between clinical improvement and the serum lactate dehydrogenase (LDH) level in the patients treated with apremilast but not in those with biologics. Serum LDH level did not correlate with the cutaneous disease severity but correlated with the oxygen consumption rate of blood T cells.

CONCLUSION

Psoriatic patients with high serum LDH level can be benefitted by apremilast. The serum LDH level reflects the augmented respiratory activity of T cells in psoriasis. Our results would highlight the importance of regarding metabolic skew in immune cells as a treatment target in psoriasis.

Associations Between Safety of Certolizumab Pegol, Disease Activity, and Patient Characteristics, Including Corticosteroid Use and Body Mass Index

Objective

To investigate the impact of baseline and time‐varying factors on the risk of serious adverse events (SAEs) in patients during long‐term certolizumab pegol (CZP) treatment.

Methods

Safety data were pooled across 34 CZP clinical trials in rheumatoid arthritis (RA), axial spondyloarthritis (axSpA), psoriatic arthritis (PsA), and plaque psoriasis (PSO). Cox proportional hazards modeling was used to investigate the association of baseline patient characteristics with risk of serious infectious events (SIEs), malignancies, and major adverse cardiac events (MACEs). Cox modeling for recurrent events assessed the impact of time‐varying body mass index (BMI), systemic corticosteroid (CS) use, and disease activity on SIE risk in RA and SAE risk in PSO.

Results

Data were pooled from 8747 CZP‐treated patients across indications. Cox models reported a 44% increase in SIE risk associated with a baseline BMI of 35 kg/m² or more versus a baseline BMI of 18.5 kg/m² to less than 25 kg/m². Baseline systemic CS use, age of 65 years or more, and disease duration of 10 years or longer also increased SIE risk. Older age was the only identified risk factor for malignancies. The risk of MACEs increased 107% for BMI of 35 kg/m² or more versus BMI of 18.5 kg/m² to less than 25 kg/m² and increased 51% for men versus women. Higher disease activity, older age, systemic CS use, BMI of 35 kg/m² or more, and baseline comorbidities were SIE risk factors in RA. Age and systemic CS use were risk factors for SAEs in PSO.

Conclusion

Age, BMI, systemic CS use, and disease activity were identified as SIE risk factors in CZP‐treated patients. Risk of malignancies was greater in older patients, whereas obesity and male sex were MACE risk factors.

Serum fatty acid binding protein 5 (FABP5) as a potential biomarker of inflammation in psoriasis

Fatty acid binding protein 5 (FABP5) is elevated in psoriatic keratinocytes and could be involved in systemic metabolic disturbances in psoriasis. The aim of the study was to evaluate serum FABP5 in obese and non-obese psoriatic patients, to assess the relationship between FABP5 and the duration, severity of the disease, inflammatory and metabolic markers and influence of treatment with narrowband-ultraviolet B (NB-UVB). Seventy-four patients (30 treated with NB-UVB) with psoriasis were enrolled in the study. The serum concentrations of FABP5 were measured using Human FABP5 Enzyme-Linked Immunosorbent Assay kit. Serum fatty acids were measured by gas-liquid chromatography. Serum FABP5 levels in psoriatic patients were higher versus control group (P < 0.001). FABP5 in patients with PASI > 20 was higher compared to the mild group (PASI < 10) (P < 0.001) and serum FABP5 correlated positively with PASI score (r = 0.41, P < 0.001). There was also positive correlation between FABP5 and basic inflammation indices. Decrease of PASI after NB-UVB treatment (P < 0.001) was observed and accompanied by decrease of the serum FABP5 (P = 0.007). FABP5 is a potential marker of psoriasis, its severity and clinical outcome after therapy with NB-UVB. FABP5 may reflect metabolic disturbances in psoriatic patients.

Deterioration of Health-Related Quality of Life After Withdrawal of Risankizumab Treatment in Patients with Moderate-to-Severe Plaque Psoriasis: A Machine Learning Predictive Model

INTRODUCTION

Risankizumab has demonstrated efficacy in treating moderate-to-severe psoriasis. The phase-3 IMMhance trial (NCT02672852) examined the effect of continuing versus withdrawing from risankizumab treatment on psoriasis severity, including the Psoriasis Area and Severity Index (PASI) and static Physician Global Assessment (sPGA). However, the effect of withdrawal on health-related quality of life (HRQL) was not assessed. Therefore, this study was conducted to evaluate the impact of risankizumab withdrawal on HRQL measured by the Dermatology Life Quality Index (DLQI). Because DLQI was not measured beyond week 16 in IMMhance, a machine learning predictive model for DLQI was developed.

METHODS

A machine learning model for DLQI was fitted using repeated measures data from three phase-3 trials (NCT02684370, NCT02684357, NCT02694523) (pooled N = 1602). An elastic-net algorithm performed automated variable selection among candidate predictors including concurrent PASI and sPGA, demographics, and interaction terms. The machine learning model was used to predict DLQI at weeks 28-104 of IMMhance among patients re-randomized to continue (N = 111) or withdraw from (N = 225) risankizumab after achieving response (sPGA = 0/1) at week 28.

RESULTS

The machine learning predictive model demonstrated good statistical fit during tenfold cross-validation and external validation against observed DLQI at weeks 0-16 of IMMhance (N = 507). Predicted improvements in DLQI from baseline were lower in the withdrawal versus the continuation cohort (mean DLQI change at week 104, -5.9 versus -11.5, difference [95% CI] = 5.6 [4.1, 7.3]). Predicted DLQI deteriorated more extensively than PASI (49.7% versus 36.4%) after treatment withdrawal.

CONCLUSIONS

The predicted DLQI score deteriorated more rapidly after risankizumab withdrawal than the PASI score, an objective measure of disease. These findings suggest that the deterioration in HRQL reflects more substantial impacts after risankizumab discontinuation than those measured by PASI only.

Prevalence of Metabolic Syndrome and Its Parameters and Their Correlations With Psoriasis Duration, Severity, and Sleep Quality In Psoriasis Patients: A Cross-Sectional Study

Background

Psoriasis is an inflammatory skin disease that may lead to comorbidities, including metabolic syndrome (MS).

Objective

We determined the prevalence of MS and its correlation with psoriasis duration, severity, and sleep quality in psoriasis patients.

Methods

A total of 112 subjects with chronic plaque psoriasis were studied. Demographics, MS parameters, disease duration, severity, and sleep quality were examined. The Psoriasis Area and Severity Index (PASI) and the Pittsburgh Sleep Quality Index (PSQI) were used to assess psoriasis severity and sleep quality, respectively. Presence of MS and its correlations with psoriasis duration, severity and sleep quality were investigated.

Results

Of 112 patients, 76 (67.8%) were diagnosed with MS. Of all patients, 74.1% had a high PASI, and 84.8% had a high PSQI. The mean values of psoriasis duration, body mass index, waist circumference, fasting glucose, HOMA-IR, triglyceride levels, blood pressure, PSQI, sleep latency, and daytime sleep dysfunction were significantly higher in the MS group than non-MS group, whereas the mean HDL level was lower. The prevalences of MS, high fasting glucose, and low HDL were significantly higher among female, but not male, patients with severe psoriasis (PASI >10) than those without severe psoriasis. Disease duration, high body mass index, waist circumference, blood pressure, fasting glucose, HOMA-IR, triglyceride levels, low HDL, and poor sleep quality were significantly correlated with the presence of MS. However, only waist circumference, fasting glucose, blood pressure, and low HDL were predictive of the development of MS.

Conclusions

MS is common among psoriasis patients, and especially in females with advanced psoriasis, high fasting glucose, and low HDL levels. Besides diagnostic criteria of MS, a long duration of psoriasis, poor sleep quality and high-HOMA-IR correlate with the development of MS. High fasting glucose and low HDL levels may facilitate MS development in association with psoriasis severity in females.

Interleukin-17 and Interleukin-23: A Narrative Review of Mechanisms of Action in Psoriasis and Associated Comorbidities

Psoriasis is an immune-mediated inflammatory skin disease associated with numerous inflammatory comorbidities, including increased cardiovascular risk. The interleukin (IL)-23/IL-17 axis plays a central role in the immunopathogenesis of psoriasis and related comorbidities by acting to stimulate keratinocyte hyperproliferation and feed-forwarding circuits of perpetual T cell-mediated inflammation. IL-17 plays an important role in the downstream portion of the psoriatic inflammatory cascade. This review discusses the distinct mechanisms of action of IL-17 and IL-23 in the immunopathogenesis of psoriasis and related comorbidities plus the significant therapeutic benefits of selectively inhibiting these cytokines in patients with moderate to severe plaque psoriasis.

Psoriasis: Comorbidities

Psoriasis has long been known as a disease with many complications, but was attributed to diet and obesity. However, in recent years, psoriasis itself has been recognized as a series of systemic inflammatory diseases, and that the cytokines involved can induce a variety of other diseases. Individuals with psoriasis were also found to have higher incidences of cerebral and cardiovascular diseases and a younger age at death compared to healthy individuals. However, no clear guidelines have been defined regarding how much vascular lesion testing should be performed in patients with psoriasis. In this report, I attempt to unravel the objective data on psoriasis and its complications from various reviews and reports, and introduce the impact of biologics, which are currently the main treatment for psoriasis, on cardiac vascular disease.

Metabolic Syndrome and Psoriasis: A Case-Control Study in Kabul, Afghanistan

BACKGROUND

Psoriasis is a chronic inflammatory disease that is not limited to the skin. Recently, numerous studies have shown a positive association between metabolic syndrome and psoriasis.

OBJECTIVE

The current study aimed to examine the association of metabolic syndrome with psoriasis in an Afghan population.

METHODS

This was a case- control study including 114 patients with psoriasis and 114 controls aged ≥18 years admitted to the dermatology department of Maiwand Teaching Hospital in Kabul, Afghanistan. Height, weight, blood pressure, and waist circumference were measured in all subjects. Blood glucose, triglyceride, cholesterol, and high-density lipoprotein cholesterol levels were tested following overnight fasting. The modified National Cholesterol Education Program - Adult Treatment Panel III criteria were used for the diagnosis of metabolic syndrome.

RESULTS

In total, 51.8% of the cases and 44.7% of the controls were male. The average age of participants was 33.4±13.1 years in the case group and 41.1±15.4 years in the control group. The average duration of disease for psoriasis was 4.2 years with 5.6 years SD. The average PASI was 10.8 with 5.1 SD. More than half of the cases (62.3%) had moderate to severe psoriasis and 37.7% had mild psoriasis. The prevalence of metabolic syndrome was higher among patients with psoriasis compared to controls (36.8% vs 21.1%) with OR of 2.18 (p=0.009). In addition, overweight/obesity was more prevalent among cases compared to controls (65.8% vs 41.2%) with OR of 2.74 (p<0.001), whereas the waist circumference was not significantly different between the two groups. Furthermore, the mean levels of total cholesterol, triglyceride, and fasting blood glucose were also higher among patients with psoriasis compared to controls.

CONCLUSION

The results of the study confirm the association between psoriasis and metabolic syndrome. Hence, screening psoriatic patients for metabolic syndrome should be considered.

Deep learning based classification of facial dermatological disorders

Common properties of dermatological diseases are mostly lesions with abnormal pattern and skin color (usually redness). Therefore, dermatology is one of the most appropriate areas in medicine for automated diagnosis from images using pattern recognition techniques to provide accurate, objective, early diagnosis and interventions. Also, automated techniques provide diagnosis without depending on location and time. In addition, the number of patients in dermatology departments and costs of dermatologist visits can be reduced. Therefore, in this work, an automated method is proposed to classify dermatological diseases from color digital photographs. Efficiency of the proposed approach is provided by 2 stages. In the 1st stage, lesions are detected and extracted by using a variational level set technique after noise reduction and intensity normalization steps. In the 2nd stage, lesions are classified using a pre-trained DenseNet201 architecture with an efficient loss function. In this study, five common facial dermatological diseases are handled since they also cause anxiety, depression and even suicide death. The main contributions provided by this work can be identified as follows: (i) A comprehensive survey about the state-of-the-art works on classifications of dermatological diseases using deep learning; (ii) A new fully automated lesion detection and segmentation based on level sets; (iii) A new adaptive, hybrid and non-symmetric loss function; (iv) Using a pre-trained DenseNet201 structure with the new loss function to classify skin lesions; (v) Comparative evaluations of ten convolutional networks for skin lesion classification. Experimental results indicate that the proposed approach can classify lesions with high performance (95.24% accuracy).

Correlation of metabolic syndrome with serum omentin-1 and visfatin levels and disease severity in psoriasis and psoriatic arthritis

Psoriasis and psoriatic arthritis (PsA) have been linked to metabolic syndrome (MS). The impact of adipokines on psoriasis, PsA, and MS pathogenesis has recently received investigative attention. A total of 80 subjects with psoriasis, 40 subjects with PsA, and 60 healthy controls were enrolled. Serum omentin and visfatin levels were measured, and MS presence was determined. PASI and DAS28 were used to measure disease severity for psoriasis and PsA, respectively. The prevalence of MS was determined to be 49% in psoriasis, 48% in PsA, and 28% in control groups. Rates were similar in psoriasis and PsA groups and was significantly greater when compared to control (P = .028). Diastolic blood pressure and waist circumference were significantly greater in the psoriasis group. Although the presence of MS positively correlated with age and disease duration in the psoriasis group, no significant relationships with PASI and DAS28 were found. Among all groups combined, there was no significant relationship with omentin and visfatin levels. In the psoriasis group, omentin and visfatin levels were greater in those with MS compared to those without MS. The relationships between omentin and visfatin levels with MS in patients with psoriasis and PsA has not yet been fully elucidated. These results suggest that elevated omentin and visfatin levels seen in psoriasis may be linked to MS rather than psoriasis itself. Additional research is needed to investigate the utility of these measurements as indicators of MS in patients with psoriasis.

The Risk of Systemic Diseases in Those with Psoriasis and Psoriatic Arthritis: From Mechanisms to Clinic

Psoriasis and psoriatic arthritis (PsA) have been recently considered as chronic systemic inflammatory disorders. Over the past decades, enormous evidence indicates that patients with psoriasis and PsA have a higher risk of developing various comorbidities including cardiovascular disease, metabolic disease, cancers, infections, autoimmune disease, and psychiatric diseases. However, reported risks of some comorbidities in those with psoriasis and PsA are somewhat different according to the research design. Moreover, pathomechanisms underlying comorbidities of those with psoriasis and PsA remain poorly elucidated. The purpose of this review is to provide the most updated comprehensive view of the risk of systemic comorbidities in those with psoriasis and PsA. Molecular mechanisms associated with the development of various comorbidities in those with psoriasis and PsA are also reviewed based on recent laboratory and clinical investigations. Identifying the risk of systemic comorbidities and its associated pathomechanisms in those with psoriasis and PsA could provide a sufficient basis to use a multi-disciplinary approach for treating patients with psoriasis and PsA.

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 Bidirectional Association Between Bullous Pemphigoid and Psoriasis: A Population-Based Cohort Study

The risk of developing psoriasis during the course of bullous pemphigoid (BP) is yet to be investigated. We aimed to assess the risk of psoriasis among patients with BP and the risk of BP in individuals with a history of psoriasis. A population-based retrospective cohort study was conducted comparing BP patients (n = 3,924) with age-, sex-, and ethnicity-matched control subjects (n = 19,280) with regard to incident cases of psoriasis. A case-control design was additionally followed to estimate the risk of BP in those with a preceding diagnosis of psoriasis. Adjusted hazard ratios (HRs) and adjusted odds ratios (ORs) were estimated by Cox regression and logistic regression, respectively. The incidence of psoriasis was 1.78 (95% CI, 1.25–2.48) and 0.67 (95%CI, 0.53–0.83) per 1,000 person-years among patients with BP and controls, respectively. Patients with BP were 2.6-fold more likely to develop psoriasis (HR, 2.60; 95%CI, 1.59–4.27) compared to controls. Furthermore, the prevalence of preexisting psoriasis was higher in patients with BP than in control subjects (1.7 vs. 1.1%, respectively; P < 0.001). A history of psoriasis was associated with a 50% increase in the risk of BP (OR, 1.53; 95%CI, 1.17–2.02). Patients with a dual diagnosis of BP and psoriasis were younger, had higher prevalence of smoking and hypertension, and were treated more frequently with prolonged systemic and topical corticosteroids when compared to the remaining patients with BP. To conclude, a bidirectional association exists between BP and psoriasis. Awareness of this association may be of great importance for physicians managing patients with BP and psoriasis.

Metabolic Syndrome Negatively Impacts Stone-Specific Quality of Life

Purpose: Metabolic syndrome (MetS) is a cluster of metabolic diseases that is linked to atherosclerotic cardiovascular disease. MetS has also been linked to increased nephrolithiasis. However, limited research has been conducted on MetS and its impact on stone-specific health-related quality of life (HRQOL). This study aims to examine the hypothesis that the presence of MetS is associated with decreased HRQOL. Materials and Methods: The Wisconsin Stone Quality of Life Questionnaire, a stone-specific HRQOL questionnaire, was used to survey 3051 patients with kidney stones. Medical history was collected from patients. These data were used to distinguish MetS patients from non-MetS patients. Among patients with current stones, a Wilcoxon rank sum test was used to compare HRQOL scores from MetS patients and non-MetS patients. HRQOL from patients with and without individual MetS components were also compared, and a multivariate analysis was conducted. Results: Statistical comparison between MetS patients (median score 102/140) and non-MetS patients (median score 106/140) demonstrated a lower stone-specific HRQOL in patients with MetS (p = 0.049). Among individual MetS components, patients with diabetes mellitus (DM) or body mass index (BMI) >30 had significantly lower HRQOL than patients without DM or BMI <30 (p = 0.028 and p < 0.001, respectively). The multivariate analysis supported this trend as MetS remained a significant predictor of decreased HRQOL (p = 0.002) after controlling for other variables assessed. Conclusions: This study indicates an association between MetS and a lower stone-specific QOL. This has important implications for stone prevention strategies in patients with MetS. Clinical Trial Registration number: H14-01143.

HLA Correlations with Clinical Phenotypes and Risk of Metabolic Comorbidities in Singapore Chinese Psoriasis Patients

INTRODUCTION

Psoriasis is a systemic, chronic inflammatory disease that not only afflicts the skin but is also associated with cardiovascular disease and metabolic syndrome. The strongest susceptibility loci for the disease is within the human leukocyte antigen (HLA) complex, though specific HLA allelic associations vary between populations.

OBJECTIVE

Our objective was to investigate HLA associations with clinical phenotypes of psoriasis and metabolic syndrome in Chinese psoriasis cases.

METHODS

We conducted an observational case-control study in Singapore with a cohort of psoriasis cases consecutively recruited from an outpatient specialist dermatological center (n = 120) compared with 130 healthy controls.

RESULTS

Significant HLA associations with psoriasis were observed with HLA-A*02:07, B*46:01, C*01:02, and C*06:02. The three-locus haplotype of A*02:07-C*01:02-B*46:01 was also significant (odds ratio [OR] 3.07; p = 9.47 × 10^-5). We also observed an association between nail psoriasis and HLA-A*02:07 carriers (OR 4.50; p = 0.002), whereas C*06:02 carriers were less prone to have nail involvement (OR 0.16; p = 0.004). HLA-A*02:07 was also identified as a possible risk allele for hypertension (OR 2.90; p < 0.05), and C*01:02 was a possible risk allele for dyslipidemia (OR 3.36; p < 0.05), both known to be common comorbidities in patients with psoriasis.

CONCLUSION

Our results demonstrate the growing importance of discerning population-specific clinical phenotypes and their association with certain HLA alleles in psoriasis.

Immunometabolism: an overview and therapeutic prospects in autoimmune diseases

Metabolism is a critical immune regulator under physiologic and pathologic conditions. Culminating evidence has disentangled the contribution of distinct metabolic pathways, namely glucolysis, pentose phosphate, fatty acid oxidation, glutaminolysis, Krebs cycle and oxidative phosphorylation, in modulating innate and adaptive immune cells based on their activation/differentiation state. Metabolic aberrations and changes in the intracellular levels of specific metabolites are linked to the inflammatory phenotype of immune cells implicated in autoimmune disorders such as systemic lupus erythematosus, rheumatoid arthritis, multiple sclerosis and diabetes. Notably, targeting metabolism such as the mTOR by rapamycin, hexokinase by 2-deoxy-D-glucose, AMP-activated protein kinase by metformin, may be used to ameliorate autoimmune inflammation. Accordingly, research in immunometabolism is expected to offer novel opportunities for monitoring and treating immune-mediated diseases.

Cell adhesion molecules, plasminogen activator inhibitor type 1, and metabolic syndrome in patients with psoriasis

The objective of this study is to delineate the cellular adhesion molecule (CAM) profile and plasminogen activator inhibitor type 1 (PAI-1), and their association with metabolic syndrome (MetS) and carbohydrate metabolism biomarkers in psoriasis patients with mild and moderate severity. Sixty-seven patients with psoriasis as well as 102 healthy subjects were recruited. Insulin and Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), but not glucose, were significantly higher in psoriasis than in controls. Psoriasis was characterized by increased plasma levels of platelet endothelial cell adhesion molecule 1 (PECAM-1), vascular cell adhesion molecule 1 (VCAM-1), intercellular adhesion molecule 1 (ICAM-1), E-selectin, and PAI-1 as compared with controls. Psoriasis diagnosis could explain 59.0% of CAM and PAI-1 variance, with a particularly strong impact on E-selectin (45.6%), VCAM-1 (32.7%), and PAI-1 (24.8%). Subjects with MetS showed significantly higher E-selectin and PAI-1 than those without MetS. Using VCAM-1, E-selectin, PAI-1 (all positively), and P-selectin (inversely) in a binary regression equation, it was found that 87.6% of all patients were correctly classified with a sensitivity of 92.5% and a specificity of 84.3%. CAM and PAI-1 were correlated with carbohydrate metabolism biomarkers (glucose, insulin, and HOMA-IR). In conclusion, CAM levels are associated with psoriasis diagnosis and MetS may influence E-selectin and PAI-1 concentrations. More studies are needed to verify the causality among these factors, as well as their relation to the different degrees of disease severity.

Prevalence of Metabolic Syndrome Among Patients with Psoriasis Treated with TNF Inhibitors and the Effects of Anti-TNF Therapy on Their Lipid Profile: A Prospective Cohort Study

Background: Tumor necrosis factor (TNF) is an important inflammatory cytokine in the pathogenesis of psoriasis and metabolic syndrome (MS). Patients with psoriasis have higher rates of MS; therefore, some authors suggest an MS screening within this population. In addition, TNF inhibitor treatment often modifies the metabolic profiles of these patients. This study describes the epidemiological, clinical, and laboratory characteristics of patients with psoriasis undergoing anti-TNF treatment and evaluates whether anti-TNF treatments influence changes in their metabolic parameters. Methods: A prospective 6-month cohort study followed patients who underwent three consecutive consultations at 0, 3, and 6 months. The sample composed of 83 patients with psoriasis using anti-TNF. Results: The mean age and disease duration of the patients were 48 ± 11 and 16 ± 9 years, respectively. Most patients were men (61.5%). The prevalence of MS was 36%, and high rates of abdominal obesity (59%) and overweight (82%) were observed. Anti-TNF treatment significantly altered total cholesterol levels (195.5 ± 36.17 vs. 183.5 ± 41.23, P = 0.04) and low-density lipoprotein (LDL) cholesterol levels (128.5 ± 31.26 vs. 113 ± 36.31, P = 0.04). This study has some limitations, such as small sample size, brief follow-up period (6 months), patient recruitment from a tertiary-level referral center, and no control group. Conclusions: Patients with psoriasis have high rates of MS, overweight, and obesity, but anti-TNF treatment seems to improve the metabolic profile of these patients by decreasing their total and LDL cholesterol levels.

The burden of metabolic syndrome on osteoarthritic joints

Background

The prevalence of osteoarthritis (OA) increases with obesity, with up to two thirds of the elderly obese population affected by OA of the knee. The metabolic syndrome (MetS), frequently associated with central obesity and characterised by elevated waist circumference, raised fasting plasma glucose concentration, raised triglycerides, reduced high-density lipoproteins, and/or hypertension, is implicated in the pathogenesis of OA. This narrative review discusses the mechanisms involved in the influence of MetS on OA, with a focus on the effects on macrophages and chondrocytes.

Main text

A skewing of macrophages towards a pro-inflammatory M1 phenotype within synovial and adipose tissues is thought to play a role in OA pathogenesis. The metabolic perturbations typical of MetS are important drivers of pro-inflammatory macrophage polarisation and activity. This is mediated via alterations in the levels and activities of the cellular nutrient sensors 5′ adenosine monophosphate-activated protein kinase (AMPK) and mammalian target of rapamycin complex 1 (mTORC1), intracellular accumulation of metabolic intermediates such as succinate and citrate, and increases in free fatty acids (FFAs) and hyperglycaemia-induced advanced glycation end-products (AGEs) that bind to receptors on the macrophage surface. Altered levels of adipokines, including leptin and adiponectin, further influence macrophage polarisation. The metabolic alterations in MetS also affect the cartilage through direct effects on chondrocytes by stimulating the production of pro-inflammatory and catabolic factors and possibly by suppressing autophagy and promoting cellular senescence.

Conclusions

The influence of MetS on OA pathogenesis involves a wide range of metabolic alterations that directly affect macrophages and chondrocytes. The relative burden of intra-articular versus systemic adipose tissue in the MetS-associated OA remains to be clarified. Understanding how altered metabolism interacts with joints affected by OA is crucial for the development of further strategies for treating this debilitating condition, such as supplementing existing therapies with metformin and utilising ω-3 fatty acid derivatives to restore imbalances in ω-3 and ω-6 fatty acids.

P-Value Demystified

Biomedical research relies on proving (or disproving) a research hypothesis, and P value becomes a cornerstone of "null hypothesis significance testing." P value is the maximum probability of getting the observed outcome by chance. For a statistical test to achieve significance, the error by chance must be less than 5%. The pros are the P value that gives the strength of evidence against the null hypothesis. We can reject a null hypothesis depending on a small P value. However, the value of P is a function of sample size. When the sample size is large, the P value is destined to be small or "significant." P value is condemned by one school of thought who claims that focusing more on P value undermines the generalizability and reproducibility of research. For such a situation, presently, the scientific world is inclined in knowing the effect size, confidence interval, and the descriptive statistics; thus, researchers need to highlight them along with the P value. In spite of all the criticism, it needs to be understood that P value carries paramount importance in "precise" understanding of the estimation of the difference calculated by "null hypothesis significance testing." Choosing the correct test for assessing the significance of the difference is profoundly important. The choice can be arrived by asking oneself three questions, namely, the type of data, whether the data is paired or not, and on the number of study groups (two or more). It is worth mentioning that association between variables, agreement between assessments, time-trend cannot be arrived by calculating the P value alone but needs to highlight the correlation and regression coefficients, odds ratio, relative risk, etc.