Comorbidities as an important component of the disease

Psoriasis is one of the most common inflammatory skin diseases. But it is only in the last thirty years that research in this field has become increasingly intensive. As it turned out, various comorbidities can accompany it and influence not only the course but also the treatment.

The growing knowledge about the pathogenesis of the disease not only led to tremendous progress in the treatment of psoriasis, it also showed that psoriasis is associated with a number of comorbidities that play an important role in the management of the disease,” said Prof. Giampiero Girolomoni, MD, Verona, at the SGDV Congress in Montreux (Tab. 1) [1–4].

Psoriatic Arthritis

Psoriatic arthritis affects approximately 10-40% of psoriatic patients. It usually occurs in the late 20s to 40s, in young patients, and usually after the first skin manifestations. Joint involvement usually begins oligoarticular, but over time can develop into severe polyarticular arthritis. The dermatologist plays a critical role in both the early diagnosis of psoriatic arthritis and the identification of patients with an aggressive form, as well as in identifying patients at increased risk for arthritis. Risk factors for the development of arthritis are: Obesity [5–8], smoking (especially in women) [9], psoriatic scalp involvement and intergluteal/perianal lesions [10], nail dystrophies [10] and subclinical enthesopathies (check quadriceps tendon thickness) [11, 12]. In addition to imaging techniques, various validated questionnaires are available for the diagnosis of arthritis.

Psoriasis and cardiovascular disease

Psoriatic patients have a significantly higher risk of developing metabolic syndrome than the normal population (OR 2.26; 95% CI 1.70-3.01), and the prevalence of metabolic syndrome correlates with the severity of psoriasis [13]. Regarding the risk of cardiovascular disease and stroke, only patients with severe psoriasis have a significantly increased risk (myocardial infarction: RR 3.04; 95% CI 0.65-14.35; cardiovascular mortality RR 1.37; 95% CI 1.17-1.60; stroke RR 1.59; 95% CI 1.34-1.89) [14]. “The question of whether psoriasis treatment can reduce cardiovascular risk is still controversial. However, in my opinion, there is more data in favor than against that the risk can be reduced with proper therapy,” Prof. Girolomoni opined. For example, in the Kaiser cohort, cardiovascular risk was significantly reduced by treatment with TNF inhibitors compared with topical treatment [15]. And in a Danish cohort, significantly fewer cardiovascular events occurred in patients treated with biologics or methotrexate than in those treated with other regimens [16].

Psoriasis and obesity

Obesity is the most important extracutaneous risk factor in psoriasis patients and severely affects treatment. Thus, patients with a high BMI have a poorer short-term response to systemic therapy [17]. Fixed-dose biologics such as etanercept, adalimumab, and ustekinumab may have limited efficacy in obese patients [18, 19]. Furthermore, obesity increases the risk of liver or renal toxicity with methotrexate and cyclosporine [20, 21]. “So could psoriasis patients benefit from weight loss?” the speaker asked. The answer: “Yes,” he said. Weight loss can significantly improve both treatment response and clinical symptoms [22, 23]. For these reasons, weight loss should definitely be targeted therapeutically.

Source: 95th Annual Meeting of the SGDV, September 19-21, 2013, Montreux.

Literature:

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3. Vena GA, et al: Can early treatment with biologicals modify the natural history of comorbidities? Dermatol Ther 2010; 23: 181-193.
4. Menter A, et al: Guidelines of care for the management of psoriasis and psoriatic arthritis: Section 1. Overview of psoriasis and guidelines of care for the treatment of psoriasis with biologics. J Am Acad Dermatol 2008; 58: 826-850.
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20. Rosenberg P, et al: Psoriasis patients with diabetes type 2 are at high risk of developing liver fibrosis during methotrexate treatment. J Hepatol 2007; 46: 1111-1118.
21. Thaçi D, et al.: Body-weight-independent dosing of cyclosporine micro-emulsion and three times weekly maintenance regimen in severe psoriasis. A randomised study. Dermatology 2002; 205: 383-388.
22. Gisondi P, et al: Weight loss improves the response of obese patients with moderate-to-severe chronic plaque psoriasis to low-dose cyclosporine therapy: a randomized, controlled, investigator-blinded clinical trial. Am J Clin Nutr 2008; 88: 1242-1247.
23. Jensen P, et al: Effect of weight loss on the severity of psoriasis: a randomized clinical study. JAMA Dermatol 2013; 149: 795-801.

Dermatology Practice 2013, No. 5