Beyond the plaque

Dermatologists who assess psoriasis patients should look beyond the plaques on the skin and consider not just the increased risk to the joints, but also the heart, mind and more.

"Psoriatic arthritis is the most common and well-known co-morbidity of psoriasis, however, to me, the increased risk for cardiovascular disease, such as heart attack and stroke, is the most important co-morbidity associated with moderate-to severe psoriasis," Andrew Blauvelt, M.D., M.B.A., president and investigator, Oregon Medical Research Center, Portland, Ore.

Cardiovascular and metabolic risk factors among psoriasis patients should be top of mind for dermatologists, according to Joel M. Gelfand, M.D., M.S.C.E., professor of dermatology and epidemiology, vice chair of clinical research, and director of the Psoriasis and Phototherapy Treatment Center University of Pennsylvania Perelman School of Medicine, Philadelphia. Dr. Gelfand has spent much of his career researching psoriasis and presented on the metabolic impact of psoriasis at last January’s Maui Derm for Dermatologists 2016 meeting in Maui, Hawaii.

“We know from dozens, if not more, studies that psoriasis is linked to the metabolic syndrome, as well as its individual components,” says Dr. Gelfand.

For example, as the body surface area affected by psoriasis increases from being very limited, at less than 2 percent, to 3 to 10 percent and to more than 10 percent, patients’ odds of having hyperglycemia and hypertriglyceridemia increase in a dose-response manner, according to a study by Dr. Gelfand and colleagues in the March 2012 Journal of Investigative Dermatology.1

“What we’ve learned in this research is that the severity of skin disease, itself, seems to be related to metabolic problems not driven solely by obesity per se,” Dr. Gelfand says.

When Dr. Gelfand and colleagues looked at the risk of major adverse cardiovascular events among patients with psoriatic arthritis (PsA), rheumatoid arthritis (RA) and psoriasis compared to the general population, they found that people with psoriasis taking disease-modifying antirheumatic drugs (DMARDs) were 42 percent more likely than the general population to have a major adverse cardiovascular event which is very similar to the risk of MACE in patients with RA treated with DMARDs.]

Dr. Blauvelt, who also presented on psoriasis at Maui Derm’s 2016 meeting, cites a recent study in which Dr. Gelfand was among the researchers that suggests a linear correlation with the level of psoriatic skin disease and the level of inflammation documented in the aorta.3

“Aortic inflammation is linked to atherosclerosis, so these data really emphasize the need to discuss the risk of heart disease in patients with extensive skin disease," Dr. Blauvelt says

The knowledge should translate to more vigilance in dermatologic practice, Dr. Gelfand says.

“Dermatologists should educate patients with psoriasis that they are more likely to have risk factors for cardiovascular disease, such as high blood pressure, insulin resistance, abnormal lipids. They should also educate especially those who have more severe psoriasis (the patients you’re considering systemic medications or phototherapy for) that they have a higher risk of cardiovascular events over time,” he says.

Psoriasis patients should be seeing their primary care doctors to make sure they’re up to date on age-appropriate cardiovascular risk screenings. In general, those include a blood pressure check every one to two years; diabetes screening every three years; and a cardiovascular risk assessment for lipid levels every four to six years, according to Dr. Gelfand.

“If they have other risk factors, like they smoke, encourage them to stop smoking. If they are overweight, encourage them to lose weight with a healthy diet-things of that nature,” Dr. Gelfand says. “Many of our psoriasis patients might only be seeing a dermatologist (and not other doctors). In my  practice, I picked up a lot of undiagnosed hypertension and a fair amount of undiagnosed diabetes.”

Having moderate-to-severe psoriasis patients’ comorbidities well controlled is important not only for their overall health, to also to allow for optimal treatment with biologics, according to Dr. Gelfand.

“…some of these conditions can make them more predisposed to complications of biologics. For example, if you have diabetes, that puts you at higher risk of infection,” he says.

NEXT: Other comorbidities

Other comorbidities

In addition to being at higher risk for cardio-metabolic disease and psoriatic arthritis, people with psoriasis are more likely to suffer from mood disorders, inflammatory bowel disease, and, rarely, T cell lymphoma of the skin.

“People with psoriasis are more prone to anxiety and depression, social isolation and even having suicidal ideation,” Dr. Gelfand says. “Generally speaking, in my own interactions with patients, I try to understand if they’re having mental health issues, and, if so, how do they relate to psoriasis? So, if a patient feels their psoriasis is a contributing factor to their anxiety and depression, that’s another reason to treat the disease aggressively and try and control it.”

The link between inflammatory bowel syndrome and psoriasis has long been established.

“More recently, what we’ve learned that there’s probably some shared genetic susceptibility between psoriasis and inflammatory bowel disease,” Dr. Gelfand says.

There is evidence of a cancer-psoriasis link, but isn’t as clear as the other comorbidities, according to Dr. Gelfand.

“These patients seem to have a mildly increased risk of lymphoma and much of that is driven by T cell lymphoma of the skin,” Dr. Gelfand says. “It’s hard to know how much of that is driven by misdiagnosis, because, early on, T cell lymphoma of the skin can look a lot like psoriasis. Or maybe, if you’re living with chronic T cell proliferation on your skin, it could eventually transform into lymphoma of the skin.”

It’s important that make the right diagnosis because some psoriasis treatments could aggravate and even result in progression of T cell lymphoma of the skin. As a result, skin biopsies are key in evaluating patients who have atypical features of psoriasis and for patients who  are not responding appropriately to treatment, Dr. Gelfand says.

Make note

It has been known for many years that strep infections can results in psoriasis flairs-particularly the guttate version of psoriasis.

“When a patient comes with a psoriasis flair, we should ask have you had symptoms of sore throat or fever and look in the oral pharynx,” Dr. Gelfand says. “If we are going to be using immunologically modifying therapies that may predispose people to infection, one strategy to lower the risk of infection is to use vaccinations. Doctors should know that they should not use a live vaccine when someone is on one of these treatments. For example, the common live vaccines are the Zoster vaccine, as well as the inhaled flu vaccine. You wouldn’t want to use the inhaled version; you’d want to use the shot.”

While dermatologists are generally aware of the high risk of psoriatic arthritis among psoriasis patients, recent evidence suggests that even dermatologists frequently miss the diagnosis, according to Dr. Gelfand.

“Studies have been done where rheumatologists evaluate patients who have been seen by dermatologists for their psoriasis, and the rheumatologists have found a fair number of patients with psoriatic arthritis not identified by their dermatologists. So, this can be a very tricky disease to identify and diagnose,” he says.

NEXT: Emerging evidence

Emerging evidence

There is new research in psoriasis comorbidities, including in the areas of sleep disturbance and sleep apnea, COPD and peptic ulcer disease, which show potential links to psoriasis.

“Time will tell if these are truly related to psoriasis, or if it’s by chance. There’s not enough data yet to know for certain,” he says.

Dr. Blauvelt says the most interesting science going on related to co-morbidities are the studies that are looking at how effective treatments for psoriasis may decrease the risk for cardiovascular disease.

“If these studies show that clearing skin leads to improvements in systemic inflammation and fewer heart attacks and strokes, then this will represent a major clinical turning point in how we approach and manage our patients with extensive psoriasis," Dr. Blauvelt says. 

The bottom line, according to Dr. Gelfand, is for dermatologists to think holistically about psoriasis patients.

“By doing that, we hope to have better outcomes not only in the skin but also for their long-term health and wellbeing,” he says. “I think one of the major things colleagues should know about is work that we’ve done showing that people with psoriasis who go on systemic therapies have the same increased rates of mortality and cardiovascular disease as people who have rheumatoid arthritis. That’s a striking finding. And the only way we can help reverse the comorbidity curve is by educating our patients and by advocating for appropriate preventive care.”

References:

Gelfand JM. Prevalence of metabolic syndrome in patients with psoriasis: a population-based study in the United Kingdom. J Invest Dermatol. 2012 Mar;132(3 Pt 1):556-62. http://www.ncbi.nlm.nih.gov/pubmed/22113483.

Ogdie A, Yu Y, Haynes K, Love TJ, Maliha S, Jiang Y, Troxel AB, Hennessy S, Kimmel SE, Margolis DJ, Choi H, Mehta NN, Gelfand JM. Risk of major cardiovascular events in patients with psoriatic arthritis, psoriasis and rheumatoid arthritis: a population-based cohort study. Ann Rheum Dis. 2015 Feb;74(2):326-32. http://www.ncbi.nlm.nih.gov/pubmed/25351522

Naik HB, Natarajan B, Stansky E, Ahlman MA, Teague H, Salahuddin T, Ng Q, Joshi AA, Krishnamoorthy P, Dave J, Rose SM, Doveikis J, Playford MP, Prussick RB, Ehrlich A, Kaplan MJ, Lockshin BN, Gelfand JM, Mehta NN. Severity of Psoriasis Associates With Aortic Vascular Inflammation Detected by FDG PET/CT and Neutrophil Activation in a Prospective Observational Study. Arterioscler Thromb Vasc Biol. 2015 Dec;35(12):2667-76.http://www.ncbi.nlm.nih.gov/pubmed/26449753

Disclosures:

Dr. Blauvelt has served as a scientific adviser and clinical study investigator for AbbVie, Amgen, AstraZeneca, Boehringer Ingelheim, Celgene, Dermira, Genentech, GSK, Janssen, Lilly, MedImmune, Merck, Novartis, Pfizer, Regeneron, Sandoz, Sanofi, Sun, UCB, and Valeant, and as a paid speaker for Lilly.

Dr. Gelfand has relationships (such as financial, consulting or research) with Amgen, Coherus, Janssen, Celgene, Astrazenec, Novartis, Pfizer, Sanofi, Valeant and various CME entities.