Michael L. Shelling

Psoriasis and Vascular Disease—Risk Factors and Outcomes: A Systematic Review of the Literature

BackgroundPsoriasis afflicts 2-3% of the world’s population. Affected patients commonly have risk factors for cardiovascular disease (CVD). In addition, psoriasis is independently associated with CVD and mortality.PurposeTo determine which CVD risk factors are associated with psoriasis independent of confounders, whether psoriasis is associated with CVD independent of CVD risk factors, and whether there is increased mortality among patients with psoriasis.Data SourcesMEDLINE, Embase, and Cochrane Collaborations from inception through October 2009. We reviewed bibliographies of retrieved articles for additional references.Study SelectionCross-sectional, cohort-based, case-control, and randomized controlled trials which involved patients with psoriasis.Data ExtractionTwo investigators independently reviewed studies and resolved any discrepancies by consensus.Data SynthesisOf the 2,303 articles identified by literature search, 90 studies met inclusion criteria for this review; 15 were cohort-based studies, 45 were case-control, and 30 were cross-sectional.LimitationsThe quality of evidence was limited by study heterogeneity and lack of large scale prospective studies with long-term follow-up.ConclusionsPatients with psoriasis demonstrate a higher prevalence of cardiovascular risk factors and appear to be at increased risk for ischemic heart disease, cerebrovascular disease, and peripheral arterial disease. This increase in vascular disease may be independent of shared risk factors and may contribute to the increase in all-cause mortality. Future research should aim to more confidently distinguish between a true causal relationship or merely an association resulting from multiple shared risk factors. Physicians should screen for and aggressively treat modifiable risk factors for CVD in patients with psoriasis.

Psoriasis: An opportunity to identify cardiovascular risk

Psoriasis is highly prevalent and is associated with skin‐associated complaints as well as arthritis, depression and a lower quality of life. Recently, it has been demonstrated that not only do patients with psoriasis have an increased prevalence of cardiovascular risk factors, but an increased risk of myocardial infarction, and for those with severe disease, increased mortality. Dermatologists and other health professionals need to be cognizant of this association and ensure that cardiovascular risk factors are evaluated and treated appropriately in those patients with psoriasis. We review the association between psoriasis, atherosclerosis and inflammation, as well as some treatable cardiovascular risk factors that may prove beneficial in reducing a patient’s cardiovascular risk.

Cytokine Milieu in Psoriasis and Cardiovascular Disease May Explain the Epidemiological Findings Relating These 2 Diseases

Srdjan Prodanovich, MD; Michael L. Shelling, MD; Daniel G. Federman, MD; Robert S. Kirsner, MD, PhD; Departments of Dermatology and Cutaneous Surgery (Drs Prodanovich, Shelling, and Kirsner) and Epidemiology and Public Healing (Dr Kirsner), University of Miami Miller School of Medicine, Miami, Florida; and Department of Medicine, Veterans Administration Medical Center (Dr Federman), and Department of Internal Medicine, Yale University School of Medicine (Dr Federman), West Haven, Connecticut

Psoriasis and vascular disease: an unsolved mystery.

Psoriasis is an immune disease most commonly recognized for its skin and joint manifestations. These produce significant physical, social, and psychological distress in affected patients and resultant reductions in their quality of life. As expected, these concerns are vital in providing symptomatic improvement and in selecting an individualized therapy. Yet, the approach in management of these patients is likely to change given the growing body of evidence linking psoriasis and vascular disease. Stemming from an anecdotally described relationship, the association between psoriasis and vascular disease has become a focus of current research to further elucidate the pathophysiology underlying and connecting these two diseases. This article includes a review of the classical cardiovascular risk factors, the atherothrombotic markers, and the environmental stressors associated with psoriasis, as well as a critical review of the observed vascular diseases, the proposed mechanism of atherosclerosis, and the benefits of treatment of psoriasis.

Clinical Approach to Atypical Wounds With a New Model for Understanding Hypertensive Ulcers

I N 2004, THE AMERICAN ACADEMY OF DERMATOLogy, in concert with the Society of Investigative Dermatology, reported on the burden of skin disease in the United States. Examining both direct and indirect costs, they found wounds to be the most financially costly of all skin disease. In fact, recent estimates suggest that nearly 6.5 million patients in the United States are affected with chronic wounds, with an annual expenditure of nearly

Failure to counsel patients with psoriasis to decrease alcohol consumption (and smoking)

25 billion for treatment alone. More importantly, the burden of disease appears to be on the rise owing, at least in part, to the increasing prevalence of diabetes, obesity, and an aging population. These numbers do not include the numerous skin diseases ranging from a primary syphilitic chancre to pemphigus vulgaris, with resultant wounds as one of their manifestations. In addition, dermatologists create more surgical wounds than any other specialty. Collectively, wounds are responsible for significant personal distress and discomfort, economic burden, morbidity, and even mortality.

N-of-1 trials: not just for academics.

Most dermatologists appreciate that psoriasis is a chronic, systemic, inflammatory disorder, multifactorial in etiology, with a complex interplaybetweengeneticpredispositionandenvironmental and behavioral factors (such as alcohol intake, obesity, and smoking). Behavioral factors appear to play a role in the development of psoriasis as well as affect the clinical severity of disease. 1,2 As such, the awareness and ascertainment of these risk factors would be an importantaspectofpsoriasismanagement.Hereinliesthepractice gap for most dermatologists: Inattention to alcohol andsmokingbehaviorsprecludestheopportunityfortheir modification (by reduction or even cessation). To better understand the barriers to changing clinical practice, let us briefly examine the impact of these factors on psoriasis. Qureshi et al provide evidence suggesting that alcohol is a risk factor for the development of psoriasis, with a particular increase in risk for those with the greatest intensity and severity of use. Patients with a genetic predisposition (HLA-Cw6 and HLA-B57) to developing psoriasis have this risk compounded by smoking,stressfullifeevents,andevenobesity. 1 Datafor HLA types and alcohol does not yet exist, but a similar relationship seems plausible. This increased risk of developing psoriasis from smoking was normalized for individualswhohadquitsmokingforatleast20years,suggesting that modification of behavioral factors may play aroleinprimarypreventionofpsoriasis.Withthisknowledge, does reduction in alcohol and smoking lead to an improvementinpsoriasis?Abstinencefromalcoholseems to lead to a reduction in disease severity 2 (and similarly for smoking cessation) and an improvement of palmopustular psoriasis. Barriers to incorporating and applying this knowledge into clinical practice remain. Many dermatologists do not routinely ask about smoking and drinking behaviors. In part, dermatologists may be reticent to discuss smoking and alcohol modification because they are not familiar with current practices and treatment options to aid in cessation. By having patients in the waiting room complete a psoriasis questionnaire designed to identify these health risk factors or by using a template of a set ofquestionswhentakinghistoriesfrompatientswithpsoriasis,collectionofinformationcanbestreamlined.With basic education, dermatologists may be able to develop their skills in counseling these patients regarding behavior modification. Regardless, it is essential for dermatologists to address this issue, since this provides an opportunity for patient education. Educational materials such as pamphlets and brochures can be provided, and patients can be directed to experts in lifestyle modification. Current patient education materials, such as those from the American Academy of Dermatology, can be modified to include information related to alcohol intake and smoking. Other lifestyle factors such as weight loss can be promoted and monitored as methods of risk reduction. Simply educating patients on these benefits may encourage them to make changes. While targeted therapeutics are honed, opportunity exists to intercede on modifiable risk factors and comorbidities that are commonly encountered. Patients with psoriasis should be educated regarding the impact of behavioral factors on their disease and the purported benefitsfrommodificationofthesefactors.Collaborationwith primary care physicians may allow for further reinforcement and greater modifications of these factors.

Prevalence and correlates of skin cancer screening among middle-aged and older white adults in the United States

To the Editors:—It was with great interest that we read the study by Scuffham et al.1 and the accompanying editorial by Larson2 about the use of n-of-1 trials. Traditional medical training often emphasizes large, randomized, controlled trials as being perched on the highest tier in the hierarchy of research, but as the authors clearly state, these studies’ findings may not be applicable to specific individuals. After reading these two articles, we came away both extremely impressed by their contents and this heretofore little known process, but extremely daunted by the prospect of employing it in most practitioners’ daily practice, especially with Scuffham’s definition of it being “multi-cycle within-patient, randomized, double-blind, cross-over comparisons of a drug and placebo (or another drug) using standardized measures of effect.” However, with additional reflection, we realize that busy general medicine clinicians geographically or psychologically far from academic centers have the opportunity to employ similar concepts, just as many dermatologists have been doing for years. This practical approach demonstrates particular utility in the setting of chronic inflammatory skin conditions, such as psoriasis or atopic dermatitis. For diffuse and often bilateral disease, one half of a patient’s body can serve as the control for the other half. In this way, patients can determine the relative efficacy of certain topical agents and individualize the long-term approach to their condition. In the case of psoriasis, patients may use a single agent (topical corticosteroids, vitamin D analogues, retinoids or even coal tar) on one side with comparison to another single agent or even combination therapy on the other side. Similarly, patients with atopic dermatitis often experience a chronic course of their disease with periods of variable severity. This approach may be utilized to determine individual patient response to treatment with topical steroids (which vary by medication, strength and vehicle) and/or the non-steroidal topical immunomodulators. For these patients, the efficacy of topical therapy is determined by a combination of the efficacy intrinsic to the medications, their individual response to therapy, and even more important the patients’ preference and subsequent adherence to regular application. These slightly inelegant, less than formal studies have proven invaluable in our own personal experience, and we encourage practitioners to consider this in some of their patients.

Gaining insights into the relationship of obesity, weight loss, and psoriasis

It is with great interest that we read the study of Coups t al demonstrating low rates of skin cancer screening in a arge, national sample. Previously we, too, have shown low ates of skin cancer screening using differing methodoloies, eg, chart review and surveys administered to paients, dermatologists, or primary care clinicians. We are not entirely surprised by their additional finding hat patients who did not report undergoing total body skin xamination also reported low rates of screening for other alignancies, such as colon, breast, and prostate cancer. pproximately 1 in 9 study subjects were at least 80 years ld, and cancer screening in the very elderly may not be arranted. We hope that the authors can examine the findngs for those between the ages of 50 and 75 years old, here these particular cancer screenings are more widely ccepted. Furthermore, while the authors appropriately acknowldge that the patients’ report of having undergone a total ody skin examination may not accurately reflect actual ractice, they fail to acknowledge that their report of unergoing prostate-specific antigen (PSA) testing also may ot reflect actual practice. Nearly one-third of patients who ad undergone PSA testing were unaware that they had had he test. While we have no data to support our assertion, ue to the nature of these cancer screening tests, we do

Laser Applications in Children

Dermatologists now recognize that patients with psoriasis have an associated increased risk for and prevalence of hypertension, diabetes, dyslipidemia, obesity, and vascular disease. However, changes in management of patients with psoriasis have lagged behind advances in knowledge. Specifically, the complex relationship between psoriasis and obesity has become a focus of study. Patients with a higher body mass index (BMI) have an increased risk for new-onset psoriasis, and the higher the BMI (obesity), the higher the Psoriasis Area Severity Index at disease onset.1 In some patients, obesity follows the onset of psoriasis,2 possibly because of the particular inflammatory cytokine milieu. In this issue, Jensen et al3 identify the benefits of a low-energy diet in patients with psoriasis, with a trend toward reduced disease severity and significant improvement in quality of life. These findings may help us embrace a more comprehensive approach to patients with psoriasis.