Joel M. Gelfand

Patients with severe psoriasis are at increased risk of cardiovascular mortality: cohort study using the General Practice Research Database

AIMS Psoriasis is a common chronic inflammatory T-helper cell-1/17 mediated skin disease. Recent studies suggest that psoriasis, particularly if severe, may be an independent risk factor for atherosclerosis, myocardial infarction (MI), and stroke. We conducted a cohort study using the General Practice Research Database to determine if severe psoriasis patients have an increased risk of cardiovascular (CV) mortality. METHODS AND RESULTS Severe psoriasis was defined as patients who received a psoriasis diagnosis and systemic therapy consistent with severe psoriasis (n = 3603). Up to four unexposed patients without psoriasis were selected from the same practices and start dates for each psoriasis patient (n = 14 330). For every death, the cause was determined by review of the electronic medical record. Severe psoriasis was an independent risk factor for CV mortality (HR 1.57; 95% CI 1.26, 1.96) when adjusting for age, sex, smoking, diabetes, hypertension, and hyperlipidaemia. Overall, severe psoriasis patients experienced one extra CV death per 283 patients per year, even when adjusting for major CV risk factors. The relative risk of CV mortality was modified by age. For example, the RR of CV death for a 40-year-old and 60-year-old with severe psoriasis was 2.69 (1.45, 4.99) and 1.92 (1.41, 2.62), respectively. The findings were robust to multiple sensitivity analyses. CONCLUSION Patients with severe psoriasis have an increased risk of CV mortality that is independent of traditional CV risk factors. Additional studies are needed to determine the mechanism of this association and the impact that control of psoriasis has on CV risk.

The risk of depression, anxiety and suicidality in patients with psoriasis: A population-based cohort study

OBJECTIVE To determine the incidence of depression, anxiety, and suicidality in patients with psoriasis compared with the general population. DESIGN A population-based cohort study using data collected as part of patients electronic medical record from 1987 to 2002. SETTING General Practice Research Database. PATIENTS Analyses included 146 042 patients with mild psoriasis, 3956 patients with severe psoriasis, and 766 950 patients without psoriasis. Five controls without psoriasis were selected from the same practices and similar cohort entry dates as patients with psoriasis. MAIN OUTCOME MEASURE Clinical diagnoses of depression, anxiety, and suicidality among patients. RESULTS The adjusted hazard ratios (HRs) for receiving a diagnosis of depression, anxiety, and suicidality in patients with psoriasis compared with controls were 1.39 (95% confidence interval [CI], 1.37-1.41), 1.31 (95% CI, 1.29-1.34), and 1.44 (95% CI, 1.32-1.57), respectively. The adjusted HR of depression was higher in severe (HR, 1.72; 95% CI, 1.57-1.88) compared with mild psoriasis (HR, 1.38; 95% CI, 1.35-1.40). Younger patients with psoriasis had elevated HRs of outcomes compared with older patients with psoriasis. CONCLUSIONS Patients with psoriasis have an increased risk of depression, anxiety, and suicidality. We estimate that in the United Kingdom, in excess of 10 400 diagnoses of depression, 7100 diagnoses of anxiety, and 350 diagnoses of suicidality are attributable to psoriasis annually. It is important for clinicians to evaluate patients with psoriasis for these conditions to improve outcomes. Future investigation should determine the mechanisms by which psoriasis is associated with psychiatric outcomes as well as approaches for prevention.

National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening

There have been several articles and reports in recent months about comorbidities and risks that affect psoriasis patients in addition to their underlying disease. This piece reviews the current literature and begins to address what should be done with this new information by updating the clinician about what health screening tests, preventative exams, and referrals should be considered in this population.

The prevalence of previously diagnosed and undiagnosed psoriasis in US adults: Results from NHANES 2003-2004

BACKGROUND Psoriasis is a predictor of morbidity. It is important to determine the extent to which psoriasis remains undiagnosed. OBJECTIVE To determine the prevalence of psoriasis. METHODS We conducted a cross-sectional study using the National Health and Nutrition Examination Survey 2003-2004. RESULTS The prevalence of diagnosed psoriasis was 3.15% (95% confidence interval [CI], 2.18-4.53), corresponding to 5 million adults. Approximately 17% of these patients have moderate to severe psoriasis based on body surface area report and 25% rate psoriasis a large problem in everyday life. The prevalence of undiagnosed active psoriasis by conservative estimate was 0.4% (95% CI, 0.19-0.82), corresponding to approximately 600,000 US adults, and 2.28% (95% CI, 1.47-3.50) by a broader definition, corresponding to 3.6 million US adults. Undiagnosed patients had a trend toward being more likely to be male, nonwhite, less educated, and unmarried compared with patients who had received a diagnosis. LIMITATIONS The method for determining the presence of psoriasis had limited ability to detect mild disease and only fair interrater agreement. CONCLUSION More than 5 million adults have been diagnosed with psoriasis. A large number have undiagnosed psoriasis and there are important disparities which may be associated with not receiving medical attention.

The risk of stroke in patients with psoriasis.

Psoriasis is a chronic Th-1 and Th-17 inflammatory disease. Chronic inflammation has also been associated with atherosclerosis and thrombosis. The purpose of this study was to determine the risk of stroke in patients with psoriasis. We conducted a population-based cohort study of patients seen by general practitioners participating in the General Practice Research Database in the United Kingdom, 1987-2002. Mild psoriasis was defined as any patient with a diagnostic code of psoriasis, but no history of systemic therapy. Severe psoriasis was defined as any patient with a diagnostic code of psoriasis and a history of systemic therapy consistent with severe psoriasis. The unexposed (control) population was composed of patients with no history of a psoriasis diagnostic code. When adjusting for major risk factors for stroke, both mild (hazard ratio (HR) 1.06, 95% confidence interval (CI) 1.0-1.1) and severe (1.43, 95% CI 1.1-1.9) psoriasis were independent risk factors for stroke. The excess risk of stroke attributable to psoriasis in patients with mild and severe disease was 1 in 4,115 per year and 1 in 530 per year, respectively. Patients with psoriasis, particularly if severe, have an increased risk of stroke that is not explained by major stroke risk factors identified in routine medical care.

Prevalence of Metabolic Syndrome in Patients with Psoriasis: A Population-Based Study in the United Kingdom

Increasing epidemiological evidence suggests independent associations between psoriasis and cardiovascular and metabolic disease. Our objective was to test the hypothesis that directly-assessed psoriasis severity relates to the prevalence of metabolic syndrome and its components. Population-based, cross-sectional study using computerized medical records from The Health Improvement Network Study population included individuals aged 45-65 years with psoriasis and practice-matched controls. Psoriasis diagnosis and extent were determined using provider-based questionnaires. Metabolic syndrome was defined using National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP) III criteria. 44,715 individuals were included: 4,065 with psoriasis and 40,650 controls. 2,044 participants had mild psoriasis (≤2% body surface area (BSA)), 1,377 had moderate (3-10% BSA), and 475 had severe psoriasis (>10% BSA). Psoriasis was associated with metabolic syndrome, adjusted odds ratio (OR) 1.41 (95% CI 1.31-1.51), varying in a “dose-response” manner, from mild (adj. OR 1.22, 95% CI 1.11-1.35) to severe psoriasis (adj. OR 1.98, 95% CI 1.62-2.43). Psoriasis is associated with metabolic syndrome and the association increases with increasing disease severity. Furthermore, associations with obesity, hypertriglyceridemia and hyperglycemia increase with increasing disease severity independent of other metabolic syndrome components. These findings suggest that screening for metabolic disease should be considered for psoriasis, especially when extensive.

Cause-specific mortality in patients with severe psoriasis: a population-based cohort study in the U.K.

Background  Severe psoriasis is associated with excess mortality and increased risk of cardiovascular death. Population‐based data evaluating cause‐specific mortality in patients with psoriasis are limited.

Attributable Risk Estimate of Severe Psoriasis on Major Cardiovascular Events

BACKGROUND Recent studies suggest that psoriasis, particularly if severe, may be a risk factor for major adverse cardiac events, such as myocardial infarction, stroke, and mortality from cardiovascular disease. We compared the risk of major adverse cardiac events between patients with psoriasis and the general population and estimated the attributable risk of severe psoriasis. METHODS We performed a cohort study in the General Practice Research Database. Severe psoriasis was defined as receiving a psoriasis diagnosis and systemic therapy (N=3603). Up to 4 patients without psoriasis were selected from the same practices and start dates for each patient with psoriasis (N=14,330). RESULTS Severe psoriasis was a risk factor for major adverse cardiac events (hazard ratio 1.53; 95% confidence interval, 1.26-1.85) after adjusting for age, gender, diabetes, hypertension, tobacco use, and hyperlipidemia. After fully adjusted analysis, severe psoriasis conferred an additional 6.2% absolute risk of 10-year major adverse cardiac events. CONCLUSION Severe psoriasis confers an additional 6.2% absolute risk of a 10-year rate of major adverse cardiac events compared with the general population. This potentially has important therapeutic implications for cardiovascular risk stratification and prevention in patients with severe psoriasis. Future prospective studies are needed to validate these findings.

Prevalence of the Metabolic Syndrome in Psoriasis: Results From the National Health and Nutrition Examination Survey 2003–2006

OBJECTIVES To estimate the prevalence of the metabolic syndrome among individuals with psoriasis and to examine the association between these 2 conditions in the general US population. DESIGN Cross-sectional health survey of a nationally representative random sample of the noninstitutionalized civilian US population. SETTING The National Health and Nutrition Examination Survey, 2003-2006. PARTICIPANTS The study included 6549 participants aged 20 to 59 years. MAIN OUTCOME MEASURES Prevalence of the metabolic syndrome defined by the revised National Cholesterol Education Program Adult Treatment Panel III definition and odds ratios for associations after adjustment for age, sex, race/ethnicity, smoking status, and C-reactive protein levels. RESULTS The prevalence of the metabolic syndrome was 40% among psoriasis cases and 23% among controls. According to 2008 US census data, the projected number of patients with psoriasis aged 20 to 59 years with the metabolic syndrome was 2.7 million. The univariate and multivariate odds ratios for patients with psoriasis and the metabolic syndrome were 2.16 (95% confidence interval, 1.16 to 4.03) and 1.96 (1.01 to 3.77), respectively. The most common feature of the metabolic syndrome among patients with psoriasis was abdominal obesity, followed by hypertriglyceridemia and low levels of high-density lipoprotein cholesterol. CONCLUSIONS The prevalence of the metabolic syndrome is high among individuals with psoriasis. Given the serious complications associated with the metabolic syndrome, this frequent comorbidity should be recognized and taken into account in the long-term treatment of individuals with psoriasis.

Psoriasis Severity and the Prevalence of Major Medical Comorbidity: A Population-Based Study

IMPORTANCE Despite the growing literature on comorbidity risks in psoriasis, there remains a critical knowledge gap on the degree to which objectively measured psoriasis severity may affect the prevalence of major medical comorbidity. OBJECTIVE To examine the prevalence of major medical comorbidity in patients with mild, moderate, or severe psoriasis, classified objectively based on body surface area involvement, compared with that in patients without psoriasis. DESIGN, SETTING, AND PARTICIPANTS Population-based cross-sectional study of patient data from United Kingdom-based electronic medical records; analysis included 9035 patients aged 25 to 64 years with psoriasis and 90,350 age- and practice-matched patients without psoriasis. MAIN OUTCOMES AND MEASURES Prevalence of major medical comorbidity included in the Charlson comorbidity index. RESULTS Among patients with psoriasis, 51.8%, 35.8%, and 12.4%, respectively, had mild, moderate, or severe disease based on body surface area criteria. The mean Charlson comorbidity index was increasingly higher in patients with mild (0.375 vs 0.347), moderate (0.398 vs 0.342), or severe psoriasis (0.450 vs 0.348) (each P < .05). Psoriasis overall was associated with higher prevalence of chronic pulmonary disease (adjusted odds ratio, 1.08; 95% CI, 1.02-1.15), diabetes mellitus (1.22; 1.11-1.35), diabetes with systemic complications (1.34; 1.11-1.62), mild liver disease (1.41; 1.12-1.76), myocardial infarction (1.34; 1.07-1.69), peptic ulcer disease (1.27; 1.03-1.58), peripheral vascular disease (1.38; 1.07-1.77), renal disease (1.28; 1.11-1.48), and rheumatologic disease (2.04; 1.71-2.42). Trend analysis revealed significant associations between psoriasis severity and each of the above comorbid diseases (each P < .05). CONCLUSIONS AND RELEVANCE The burdens of overall medical comorbidity and of specific comorbid diseases increase with increasing disease severity among patients with psoriasis. Physicians should be aware of these associations in providing comprehensive care to patients with psoriasis, especially those presenting with more severe disease.