Psoriasis comorbidities 101

"Plaque psoriasis is increasingly recognized as a multisystemic disease whose most common comorbidities include psoriatic arthritis, cardiovascular disease, metabolic syndrome, overweight/obesity, inflammatory bowel disease, and depression. The presence of such comorbidities affects the therapeutic choices for clinicians," researchers write in Seminars in Cutaneous Medicine and Surgery.

Some psoriasis comorbidities share the common ground of systemic inflammation; some are linked to lifestyle choices; still others are related to the very agents used to lessen or clear the cutaneous impact of the disease.

Dermatologists who recognize the many known and potential comorbidities early on can make better treatment choices, potentially slow or prevent disease processes and improve patients’ quality of life, according to an article in a March 2018 supplement in Seminars in Cutaneous Medicine and Surgery.

To do this, dermatologists need a keen sense of what to look for during the history-taking and exam. Dermatologists should consider performing recommended screenings for psoriasis patients and refer patients when needed to primary care or specialists, according to study author Jashin J. Wu, M.D., who is a member of the National Psoriasis Foundation Medical Board, councilor for the International Psoriasis Council, and director of dermatology research for Kaiser Permanente Los Angeles Medical Center.

The dermatologist’s role can be pivotal, even though these comorbidities are typically not in the specialty’s domain, Dr. Wu says.

“Depression and suicidal ideation are much more common in psoriasis. The typical dermatologist will not want to delve into these, but they should at least let patients be aware of resources and refer back to the primary care physician to address these,” Dr. Wu says.

PSORIASIS COMORBIDITIES

Nearly a third of psoriasis patients have psoriatic arthritis. Since psoriatic arthritis typically starts years after plaque psoriasis, dermatologists should understand the importance of evaluating psoriasis patients for joint stiffness and pain.

“Physical examinations should include the fingers (dactylitis) and toes, Achilles tendon (enthesitis), sacroiliac, axial skeleton, and the large joints to identify evidence of swelling, inflammation and nail disease,” they write.

Newer systemic agents can address both cutaneous and joint problems from psoriasis and psoriatic arthritis, the authors write.

Psoriasis is an independent risk factor for heart attack, and the association is more striking for 30-year-olds than for 60-year-olds with severe psoriasis, according to one study. Psoriasis’s link to an increased cardiovascular disease risk is in part related to many of the medications used to treat psoriasis, including acitretin and cyclosporin, which can worsen dyslipidemia. Cyclosporine also can raise blood pressure, according to Dr. Wu.

“In general, patients with severe psoriasis die approximately four years sooner than do patients without psoriasis,” according to the authors.

Several comorbidities have a dose-response relationship with psoriasis, including metabolic syndrome, obesity, and type 2 diabetes.

The good news for today’s patients is that early psoriasis treatment with biological immunomodulating therapy might delay-even prevent-onset of many comorbidities, as well as the risk of premature death, the authors write.  In one study by Wu and colleagues, researchers found the use of tumor necrosis factor (TNF)-alpha inhibitors lowered heart attack risk by 50 percent, for example.

Anxiety, thoughts of suicide and depression are more likely among people who have psoriasis than those who do not. Researchers also have found that treatment of psoriasis in patients with comorbid depression can be more difficult to manage. By the same token, effective psoriasis treatment can lessen comorbid depression and anxiety.

Opportunistic infections can be associated with TNF-alpha inhibitor treatment. In one study, psoriasis patients on systemic agents had an increased risk of Hodgkin lymphoma and cutaneous T-cell lymphoma.

Dermatologists might not consider the impact of pain on these patients, but, according to one, study 42 percent of plaque psoriasis patients reported cutaneous pain, including aching.

Psoriasis is genetically linked to inflammatory bowel disease, and an often overlooked psoriasis comorbidity is hepatic disease. Researchers have found the prevalence of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in psoriasis patients, for example.

Finally, lifestyle choices, including alcohol and tobacco use, can make psoriasis worse and, in the case of smoking, increase psoriasis risk.

To better detect psoriasis comorbidities early, the National Psoriasis Foundation recommends the following, according to Dr. Wu: Psoriasis patients’ blood pressure, pulse and body mass index should be measured every two years. And every five years, dermatologists should check fasting blood glucose and lipid levels-with the caveat that patients with additional risk factors should have blood glucose and lipids checked every two years.

“Outside of these, the dermatologists should refer back to the PCP for further workup as needed,” he says.

To save time, dermatology practices can use preprinted forms to screen for various comorbidities. And if the dermatologist is overwhelmed with lack of time, that provider should refer back to the primary care provider for screening, according to Dr. Wu.

DISCLOSURES

Supported by an educational grant by Ortho Dermatologics. The authors of this study have industry ties, including the one interviewed for this story. Jashin J. Wu, MD, does contracted research for AbbVie Inc., Amgen Inc., Eli Lilly and Company, Janssen Biotech, Inc., Novartis Pharmaceuticals Corporation, Regeneron. Information about disclosures is available at https://www.globalacademycme.com/cme/dermatology-skin-disease-education-foundation/new-treatment-paradigms-psoriasis-understanding/common-and-not-so-common-comorbidities-psoriasis.

REFERENCES

Menter MA, Armstrong AW, Gordon KB, Wu JJ. Common and Not-So-Common Comorbidities of Psoriasis. Semin Cutan Med Surg. 2018 Feb;37(2S):S48-S51. doi: 10.12788/j.sder.2018.011.

Disclosures:

Supported by an educational grant by Ortho Dermatologics. The authors of this study have industry ties, including the one interviewed for this story. Jashin J. Wu, MD, does contracted research for AbbVie Inc., Amgen Inc., Eli Lilly and Company, Janssen Biotech, Inc., Novartis Pharmaceuticals Corporation, Regeneron. Information about disclosures is available at https://www.globalacademycme.com/cme/dermatology-skin-disease-education-foundation/new-treatment-paradigms-psoriasis-understanding/common-and-not-so-common-comorbidities-psoriasis.

References:

Menter MA, Armstrong AW, Gordon KB, Wu JJ. Common and Not-So-Common Comorbidities of Psoriasis. Semin Cutan Med Surg. 2018 Feb;37(2S):S48-S51. doi: 10.12788/j.sder.2018.011.