The New Thinking on Psoriasis

Agrowing and convincing body of evidence links psoriasis to a host of emotional, psychiatric, and systemic comorbidities that can affect patients of all ages throughout their lifespan, often regardless of disease severity.

It’s time to change how we think about and treat this disease. The burden on our patients is severe, but it can be dramatically lessened with coordinated care and aggressive treatment.

Consider the 16-year-old girl who goes to her local swimming pool with her best friends. The lifeguard takes one look at the scaly, red and flaky patches on her hands and legs and says she can’t swim without a doctor’s note. This scenario illustrates how psoriasis can damage self-esteem during the formative years.

And this trauma worsens with advancing age leading to intimacy issues, absenteeism at work, increased risk of depression, and suicidal ideation. Some psoriasis patients will avoid dating altogether due to poor body image, and genital psoriasis can also have a profoundly negative impact on sex and intimacy. And one-quarter of psoriasis patents don’t want children for fear of passing the disease on to their offspring.

Regardless of psoriasis severity, nearly 60 percent of patients consider psoriasis to have a major effect on quality of life.¹ The good news here is that treatment can mitigate these effects. In one study of patients with moderate-to-severe psoriasis who were randomized 1:1:1 to ustekinumab (45 or 90 mg) or placebo, individuals in in active treatment groups showed greater improvements in anxiety, depression, and Dermatology Life Quality Index.² Greater Psoriasis Area Severity Index (PASI) reduction correlates to greater improvement in DLQI.³

The Heart of the Matter

Psoriasis is also associated with multiple factors that increase the risk of cardiovascular disease namely hypertension, diabetes, dyslipidemia, obesity, metabolic syndrome, smoking, and atheroscleoris. What’s more, psoriasis is independently associated with myocardial infarction. By some estimates, psoriasis confers a four- to five-fold increase of heart attack and stroke.

The common denominator is likely inflammation as all of these risk factors augment the inflammatory load, which, in turn, sets the stage for heart attack and stroke. We know that vascular inflammation in psoriasis localizes to the arterial wall, which is the site where early atherosclerosis begins.⁴ Severe psoriasis patients lose about five years of their life due to their disease, according to multiple studies.

The big question has been whether aggressively treating inflammation with disease-modifying and biologic drugs lowers these risks. In research presented at the 2016 American Academy of Dermatology meeting in Washington, DC, patients being treated with biologics showed a significantly lower risk for a cardiovascular event than their counterparts who received phototherapy after about four months of treatment.

Other systemic diseases that travel with psoriasis include psoriatic arthritis, dactylitis, certain types of cancer, such as lymphoma and nonmelanoma skin cancer, inflammatory bowel disease, nail changes, and osteoporosis.

Psoriasis and Pregnancy

Psoriasis can also has a negative affect on pregnancy and delivery. Studies have shown that it increases the risk for spontaneous abortion, preterm birth, severe pre-eclampsia or eclampsia, placenta previa with and without hemorrhage, and ectopic pregnancy. Women with psoriasis are also more like to deliver babies with low birth weight. Psoriasis does not increase risk of Cesearean section delivery. This is largely because obstetricians do not want to cut through psoriatic skin.

Embracing a Team Approach to Treatment

Given the growing list of comorbidities associated with psoriasis, the onus is on dermatologists to collaborate and coordinate care with primary care physicians and other specialists namely psychiatrists, cardiologists, and obstetrician/gynecologists. Treating psoriasis and its associated complications and comorbidities takes a team effort. Ultimately, this approach will improve quality of life as well as skin, joint and overall health for our patients. n

Jerry Bagel, MD is Director of the Psoriasis Treatment Center of Central New Jersey. He originally presented these findings at the March 2016 American Osteopathic College of Dermatology (AOCD) meeting in New York City.

1. Armstrong AW, et al. “Quality of Life and Work Productivity Impairment among Psoriasis Patients: Findings from the National Psoriasis Foundation Survey Data 2003–2011.” PLOS One. 2012;7:e52935

2. Langley RG, et al. “Ustekinumab significantly improves symptoms of anxiety, depression, and skin-related quality of life in patients with moderate-to-severe psoriasis: Results from a randomized, double-blind, placebo-controlled phase III trial.” J Am Acad Dermatol. 2010;63:457–65

3. Revicki DA, et al. “Impact of adalimumab treatment on patient-reported outcomes: results from a Phase III clinical trial in patients with moderate to severe plaque psoriasis.” J Dermatolog Treat. 2007;18:341–5.

4. Dave J, et al. “Vascular inflammation in psoriasis localizes to the arterial wall using a novel imaging technique.” JAAD 2014;ePub ahead of print

5. Wu J. “Cardiovascular (CV) Event Risk Assessment in Psoriasis (Ps) Patients Treated with Tumor Necrosis Factor-alpha Inhibitors (TNFi) versus Phototherapy.” Presented at AAD 2016, Washington DC/