Psoriasis is a common chronic inflammatory disease of the skin that is increasingly being recognized as a systemic inflammatory disorder. There are many considerations a provider must take into consideration when treating patients with psoriasis including a number of previously unrecognized comorbidities.
Psoriasis, particularly severe disease, is associated with increased mortality1. This finding applies to men and women. Men with severe psoriasis died 3.5 years younger than men without psoriasis and women died 4.4 years younger. This could be due to a myriad of comorbidities: cardiometabolic disease is prevalent among psoriasis patients especially those with more severe disease. Psoriasis is associated with increased risk of heart attack independent of traditional risk factors like body mass index (BMI), hypertension (HTN), dyslipedemia2 . Longer duration of psoriasis associated with increased risk of cardiovascular disease3,4 .
Pathophysiology of Vascular injury
Chronic systemic, specifically vascular, inflammation may be increased in patients with psoriasis and may contribute to atherogenesis. Shared pathophysiologic pathways including type 1 helper cells (Th1) T cells and Th17 mediated inflammation, increased oxidative stress, endothelial cell dysfunction.
Obesity is an independent risk factor for psoriasis. The risk of psoriasis is found to increase with higher BMI 5. Increases in weight effects efficacy of psoriasis treatment.
Psoriasis patients are more likely to have HTN. Studies of patients with HTN suggest more severe HTN in poorly controlled psoriasis patients versus patients without psoriasis. The likelihood of poorly controlled HTN increases with more severe skin disease, independent of BMI or other risk factors.6
Psoriasis is associated with increased risk of diabetes. Diabetic patients with psoriasis are more likely to require pharmacologic management and suffer from micro and microvascular diabetes complications than diabetic patients without psoriasis.7
Metabolic syndrome: central obesity, hypertension, insulin resistance, and dyslipidemia as well as the individual components of the syndrome as more prevalent in patients with psoriasis.
Psoriasis may be associated with increased incidence of Inflammatory bowel disease, particularly Crohn’s disease as well as nonalcoholic fatty liver disease. Methotrexate, which is used to treat psoriasis can cause liver damage. TNF inhibitors specifically infliximab or adalimumab used to treat Crohn’s disease can induce psoriasis. The reason for this apparently paradoxical effect of the therapy is still unclear. 8
Moderate to severe psoriasis is an independent risk factor for chronic kidney disease (CKD) and end stage renal disease. The odds of CKD increase with psoriasis severity. A U.K. cohort study found severe psoriasis was associated with a fourfold increased risk of death from nephritic or non-hypertensive kidney disease. 9
Disorders of the eye, such as blepharitis, conjunctivitis, xerosis, corneal lesions, and uveitis, may occur with increased frequency in patients with psoriasis. Symptoms of eye involvement include ocular discomfort, flaking or crusting within the eyelashes, swollen eyelids, red eyes, visual changes, and psoriatic lesions on the lids or lid margins. 10
Taking care of a psoriasis patient does not stop with the skin. Joint disease, psoriatic arthritis, is a well-known associated condition but this review of the additional comorbidities will hopefully help these patients get comprehensive care.
See Cynthia Griffith speak at a 2022 Skin, Bones, Hearts & Private Parts CME Conference. Click here to find out where you can see her live and in-person!
1. Gelfand JM, Troxel AB, Lewis JD. et al. The Risk of mortality in patients with psoriasis” results from a population-based study. Arch Dermatol. 2007; 143(12):1493-1499. [Pubmed:18086997]
2. Gelfand JM, Niemand AL, Shin DB, et al. Risk of myocardial infarction in patients with psoriasis. JAMA. 2006. 296 (14):1735-1741. [PubMed: 17032986]
3. Armstrong AW, Harskamp CT, Ledo L, et al. Coronary artery disease in patients with psoriasis referred for coronary angiography. Am J Cardiol. 2012;109(7):976-980. [PubMed:22221950]
4. Li WQ, Han JL, Manson JE, et al. Psoriasis and risk of nonfatal cardiovascular disease in U.S. women: a cohort study. Br J Dermatol. 2012; 166(4):811-818 [PubMed22175820]
5. Kumar S, Han J, Li T, et al. Obesity, waist circumference, weight change and the risk of psoriasis in US women. J Our Acad Dermatology Venerol. 2013;27(10):1293-1298.[PubMed:23057623]
6. Takeshita J, Wang S, Shin DB, et al. Effect of psoriasis severity on hypertension control: a population-based study in the United Kingdom. JAMA Dermatol. 2015;151(2):161-169. [PubMed: 25322196]
7. Azfar RS, Seminara NM, Shin DB, et al. Increased risk of diabetes mellitus and likelihood of receiving diabetes mellitus treatment in patients with psoriasis. Arch Dermatol. 2012;148(9):995-1000. [PubMed:22710320]
8. Li SJ, Perez-Chada LM, Merola JF. TNF Inhibitor-Induced Psoriasis: Proposed Algorithm for Treatment and Management. J Psoriasis Psoriatic Arthritis. 2019;4(2):70-80. doi:10.1177/2475530318810851
9. Abuabara K, Azfar RS, Shin DB, et al. Cause-specific mortality in patients with severe psoriasis: a population-based cohort study in the U.K. Br J Dermatol. 2010; 163(3):586-592. [PubMed:20633008]
10. Ocular psoriasis. AU Rehal B, Modjtahedi BS, Morse LS, Schwab IR, Maibach HI SO J Am Acad Dermatol. 2011 Dec;65(6):1202-12. Epub 2011 May 6.