The evolution of psoriasis from skin to heart disease

“While the hypothesis still needs to be proven specifically in a psoriasis population, the data convincingly argues for tighter disease control in patients with psoriasis.”                                  Alexander Egeberg, M.D., Ph.D.

It has become clear in the past two decades that psoriasis has transitioned from being a mere skin condition to a disease with systemic implications, says Alexander Egeberg, M.D., Ph.D., a physician with the University of Copenhagen Herlev and Gentofte Hospital in Denmark.  

Dr. Egeberg

“Patients with psoriasis have an increased incidence and prevalence of cardiovascular risk factors, including obesity, hyperlipidemia, hypertension, diabetes and cardiovascular events, including myocardial infarction and stroke. Moreover, psoriasis significantly impairs patients’ quality of life, and the risk of depression and anxiety disorders is increased in our patients,” Dr. Egeberg said during a presentation on Feb. 16 during the American Academy of Dermatology annual meeting in San Diego.  

PSORIASIS AND DISEASE

Data suggest that plaque psoriasis may be a risk factor for cardiovascular disease and the development of diabetes, he said citing an observational study he published last year on the relationship between psoriasis duration, vascular inflammation and cardiovascular events. Dr. Egeberg and colleagues found that psoriasis duration had detrimental effects on vascular inflammation and major adverse cardiovascular events, suggesting that cumulative duration of exposure to low-grade chronic inflammation might speed vascular disease development and the occurrence of major adverse cardiovascular events. Providers should consider asking psoriasis patients about disease duration in order to determine whether counselling for increased cardiovascular disease risk is needed, they concluded.

In another study, published in February in the Journal of the American Academy of Dermatology, researchers measured psoriasis severity on type 2 diabetes mellitus risk. They found that type 2 diabetes was more likely in patients with severe psoriasis - psoriasis impacting more than 10 percent of their body surface area. Dermatologists and other clinicians who care for psoriasis patients could refer to body surface area measurements to target diabetes prevention efforts among those patients, the authors concluded.

SHARED GENETIC, INFLAMMATORY PATHWAYS

In very recent years, there has been an increased in comorbidities that share genetic and inflammatory pathways; in particular, inflammatory bowel disease, such as Crohn's disease and ulcerative colitis, Dr. Egeberg said.

In their study on the association between psoriasis and inflammatory bowel disease, published in 2016, Dr. Egeberg and colleagues observed that psoriasis is associated with increased risks for Crohn disease and ulcerative colitis, with the association increasing with psoriasis severity. They also observed an increased risk of psoriasis in patients with inflammatory bowel disease, which suggests the need to focus on gastrointestinal symptoms in patients with psoriasis, according to the study.

“Such findings are of particular importance since some drugs may be effective in treating not only psoriasis, but also some of the associated comorbidities, while other drugs may aggravate or induce such comorbidities,” he says.

For example, Dr. Egeberg says recent advances in cardiology have shown that targeted dampening of inflammation - independent of cholesterol levels - significantly reduces the risk of myocardial infarction.

He cites a study published last year in the New England Journal of Medicine in which researchers found that anti-inflammatory therapy targeting the interleukin-1β innate immunity pathway with the drug canakinumab significantly lowered the rate of recurrent cardiovascular events compared to placebo, regardless of lipid-level lowering.

“While the hypothesis still needs to be proven specifically in a psoriasis population, the data convincingly argues for tighter disease control in patients with psoriasis,” Dr. Egeberg says. “For dermatologists, it may be relevant to do an annual screening for traditional cardiovascular risk factors - hypertension, diabetes, high cholesterol, smoking - in patients with psoriasis, and referral to either a general practitioner or a cardiologist may be relevant in those deemed at high risk of cardiovascular disease. Moreover, since inflammatory bowel disease may be present more frequently in patients with psoriasis, gastrointestinal symptoms in these patients may warrant further investigations by a gastroenterologist.”

DISCLOSURES

Dr. Egeberg has received research funding from Pfizer, Eli Lilly, the Danish National Psoriasis Foundation, and the Kgl Hofbundtmager Aage Bang Foundation, and honoraria as consultant and/or speaker from Leo Pharma, Samsung Bioepis Co., Ltd., Pfizer, Eli Lilly, Novartis, Galderma, and Janssen Pharmaceuticals.

REFERENCES

“F012 - Psoriasis and Atopic Dermatitis: Advances in Therapy and Comorbidities,” American Academy of Dermatology 2018 annual meeting. Egeberg, Alexander Egeberg, John Koo, Jonathan I. Silverberg, et al. 9-11 a.m., Friday, February 16.

Egeberg A, Skov L, Joshi AA, et al. “The relationship between duration of psoriasis, vascular inflammation, and cardiovascular events.” JAAD. October 2017. DOI: 10.1016/j.jaad.2017.06.028..

Wan MT, Shin DB, Hubbard RA, Noe MH, Mehta NN, Gelfand JM. “Psoriasis and the risk of diabetes: A prospective population-based cohort study.” JAAD. February 2018. DOIoi: 10.1016/j.jaad.2017.10.050.

Egeberg A, Mallbris L, Warren RB, et al. “Association between psoriasis and inflammatory bowel disease: a Danish nationwide cohort study.” BMJ. September 2016. DOI: 10.1111/bjd.14528.

Ridker PM, Everett BM, Thuren T, et al. “Anti-inflammatory Therapy with Canakinumab for Atherosclerotic Disease.” NEJM. September 2017. DOI: 10.1056/NEJMoa1707914.