Psoriasis Guidelines From AAD, NPF Spotlight Comorbidities

The American Academy of Dermatology and the National Psoriasis Foundation released care management guidelines for dermatologists who treat patients with psoriasis, who are at increased risk for several inflammatory, cardiovascular, and metabolic conditions.

Published recently in the Journal of the American Academy of Dermatology, the authors noted that psoriasis affects up to 3.2% of adults in the United States and patients are frequently undiagnosed, undertreated, or untreated.

Although skin inflammation is the most prominent and most recognizable symptom, “recognition of the condition as a chronic, multisystem inflammatory disorder is imperative to optimize management,” they wrote.

Increased Risk for Psoriatic Arthritis

Patients with psoriasis are associated with a higher risk of developing psoriatic arthritis (PsA) and inflammatory arthritis. The prevalence of PsA in patients with psoriasis between 30% and 33%, with an onset time of 10-11 years.

PsA is heavily associated with inflammatory arthritis and can cause significant morbidity. It can appear similar to rheumatoid arthritis (RA) and ankylosing spondylitis. Patients can experience arthritis in the small joints of the feet and hands, knees, wrists, elbows, as with RA, or inflammatory arthritis of the spine, similar to AS.

PsA screening tools may include the Psoriasis Epidemiology Screening Tool, the Toronto Psoriatic Arthritis Screen, the Psoriatic Arthritis Screening and Evaluation, and the Early Arthritis for Psoriatic Patients questionnaire; the authors said they are “moderately reliable” but their utility in practice is debated, since their performance is variable when used in groups other than for which they were originally developed.

“Because screening and early detection of inflammatory arthritis are essential to optimize patient QoL and reduce morbidity, providers may consider using a formal screening tool of their choice,” the authors suggested.

Patients with psoriasis should notify their dermatologists or primary care providers if a musculoskeletal concern such as morning joint stiffness or swelling exists; they may be asked to consult with a rheumatologist.

Increased Risk of Cardiovascular Disease

Cardiovascular disease (CVD) is a common cause of morbidity and death worldwide and is a serious concern for patients with psoriasis, who are at different levels of risk depending on the severity of their psoriasis. In 1 study, the authors said, heart attacks ranged from 1.8% for those with mild cases of psoriasis to 2.9% for those with severe forms.

Another study found that strokes occur in 1 in 4115 of patients with mild psoriasis and 1 in 530 of patients with severe cases per year. Other researchers have concluded that psoriasis accounts for 11,000 additional major adverse cardiovascular events (MACEs) in the United States each year.

Additionally, patients who are treated with tumor necrosis factor alpha (TNF-𝛼) inhibitors experience fewer cardiovascular events and a lower risk of MACEs compared with those treated with methotrexate, cyclosporine, retinoids, and other therapies.

However, authors noted that use of TNF-𝛼 inhibitors is relatively contraindicated in patients with psoriasis as some studies have shown that TNF inhibitors may contribute to increased mortality in patients with congestive heart failure.

“Consultation with cardiologists and other specialists should be performed as deemed necessary by the dermatologist or primary care provider to confirm diagnoses and establish a treatment plan,” investigators suggested.

Increased Risk of Metabolic Syndrome

Patients with psoriasis have an increased of developing metabolic syndrome, which is a collective term used to describe cardiovascular risk factors including obesity, hypertension, dyslipidemia, and insulin resistance.

In 1 study, 34% of psoriasis patients met the criteria for metabolic syndrome compared with 26% of people in the control group. Age, sex, follow-up, smoking, and social class did not alter these values significantly.

Individual disorders that were significantly more common in patients with psoriasis than controls included obesity (38% vs 31%; odds ratio [OR] 1.38; 95% CI, 1.29-1.48), elevated triglycerides (36% vs 28%; OR 1.49; 95% CI, 1.39-1.60), hypertension (31% vs 28%; OR 1.20; 95% CI, 1.11-12.9), and elevated glucose levels (22% vs 16%; OR 1.44; 95% CI, 1.33-1.56.

Recommendations for care management include the suggestion of an appropriate diet, regular exercise, smoking cessation, and mental wellness. Gastric bypass surgery should be considered for patients with psoriasis who have a body mass index (BMI) of >40 kg/m² when standard weight loss strategies fail.

The researchers suggested that “it is prudent that dermatologists inform their patients regarding this association and ensure that the patient is engaged with his or her primary care provider for appropriate screening,” such as for blood pressure, heart rate, height, weight, BMI, abdominal circumference, fasting blood glucose, hemoglobin A1C, fasting cholesterol, and triglycerides.

Reference

Elmets CA, Leonardi CI, Davis DMR, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. JAAD. April 2019; 80(4):1073-1113. doi:10.1016/j.jaad.2018.11.058.