LAS VEGAS – The list of disease states and behaviors that potentially increase morbidity and mortality and lower quality of life for psoriasis patients is well known and includes psoriatic arthritis, Crohn’s disease, depression, alcoholism, and smoking.
Perhaps less well appreciated is the fact that psoriasis is also associated with multiple comorbidities that increase the risk of cardiovascular disease, including hypertension, diabetes, dyslipidemia, and obesity, Dr. Bruce E. Strober said at the SDEF Las Vegas Dermatology Seminar.
Dr. Bruce E. Strober
"The metabolic syndrome, a chronic inflammatory state that is associated with increased cardiovascular mortality, is also common in patients with psoriasis," noted Dr. Strober of the department of dermatology at the University of Connecticut, Farmington. The syndrome is associated with at least three of the following five factors: increased waist circumference or abdominal obesity, hypertension, hypertriglyceridemia, reduced high-density lipoprotein levels, and insulin resistance.
In 2006 German researchers published results from a trial that compared the prevalence of metabolic syndrome in 581 adults hospitalized with plaque-type psoriasis to the prevalence in 1,044 controls who were treated surgically for localized melanoma during the same time period (Arch. Dermatol. Res. 2006;298:321-8). Charts were screened for the presence of concomitant forms of chronic internal diseases.
The researchers discovered that compared with controls, psoriasis patients had a significantly higher prevalence of three components of metabolic syndrome, including diabetes mellitus (odds ratio, 2.48); hyperlipidemia (OR, 2.09); and arterial hypertension (OR, 3.27).
A separate, larger trial conducted in the United Kingdom set out to determine whether the prevalence of major cardiovascular risk factors was higher in mild or severe psoriasis patients, or in patients without psoriasis (J. Am. Acad. Dermatol. 2006;55:829-35). Patients were defined as having severe psoriasis if they received a code for psoriasis as well as systemic therapy used for the treatment of psoriasis, while patients were defined as having mild psoriasis if they ever received a psoriasis code but no systemic therapy.
The population-based study included 127,706 patients with mild psoriasis and 3,854 with severe disease. The researchers found that patients with mild psoriasis had a higher adjusted odds of diabetes (odds ratio, 1.13); hypertension (OR, 1.03); hyperlipidemia (OR, 1.16); obesity (OR, 1.27); and smoking (OR, 1.31), compared with controls, while patients with severe psoriasis had a higher adjusted odds of diabetes (OR, 1.62); obesity (OR, 1.79);and smoking (OR, 1.31) than controls, Dr. Strober reported at the seminar sponsored by Skin Disease Education Foundation (SDEF).
In addition, diabetes (OR, 1.39) and obesity (OR 1.47) were more prevalent in those with severe psoriasis than with mild psoriasis.
According to Dr. Strober, one of the largest studies to evaluate the association between obesity and the risk of psoriasis comes from 78,626 women who participated in the ongoing Nurses’ Health Study (Arch. Intern. Med. 2007;167:1670-5). After adjustment for age, alcohol consumption, and smoking status, the researchers found that the relative risk of developing psoriasis increased with advancing body mass index category: 1.40 for a BMI of 25-29.9 kg/m2, 1.48 for a BMI of 30-34.9 kg/m2, and 2.69 for a BMI of 35 kg/m2 or greater.
A higher waist circumference, hip circumference, and waist-hip ratio were also associated with a higher risk of incident psoriasis.
Myocardial infarction is also associated with psoriasis, according to a population-based study in the United Kingdom that evaluated outcomes in 556,995 controls, 127,139 patients with mild psoriasis, and 3,837 patients with severe psoriasis (JAMA 2006;296:1735-41). The researchers found that the adjusted relative risk of myocardial infarction was 3.58 among controls, 4.04 among those with mild psoriasis, and 5.13 among those with severe psoriasis.
"Possible causes for increased cardiovascular risks in psoriasis include the use of dyslipidemic therapies, such as corticosteroids, acitretin, and cyclosporine; the increased prevalence of obesity and other associated risk factors; and uncontrolled inflammation leading to endothelial dysfunction and dyslipidemia," Dr. Strober said.
He emphasized that many questions remain about the association between psoriasis and cardiovascular risk factors. "Do the associations have any clinical relevance?" he asked. "Do specific comorbidities influence the response to therapy for psoriasis? Does psoriasis influence the response to therapy for any specific comorbidity? Will specific psoriasis therapies reduce the negative health consequences of a comorbidity of psoriasis?"
For now, he said, dermatologists might consider screening patients for the prevalence of cardiovascular risk factors through laboratory evaluations such as a comprehensive metabolic panel and fasting lipids, assessing blood pressure and weight status, and asking patients about their history of smoking, alcohol use, depression, and arthritis.
Dr. Strober disclosed that he is a member of the scientific advisory board for Abbott, Amgen, Janssen, Novartis, and Pfizer. He also disclosed that he is a consultant for Abbott, Amgen, Celgene, Centocor, Galderma, Leo, Maruho, Novartis, and Pfizer, and that he has received honoraria from Abbott.