Rita V. Patel

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.

The Role of Cardiovascular Disease in the Patient with Psoriasis

Psoriasis is an immune-mediated disease that affects up to 3% of the general population. Cardiovascular disease types like coronary artery disease, cerebrovascular disease, and peripheral vascular disease occur independently in the patient with psoriasis when controlling for confounding factors. Additionally, population-based studies report that cardiovascular disease risk factors like hypertension, obesity, diabetes, smoking, and metabolic syndrome occur with a higher prevalence in the psoriasis patient population. This review article highlights those studies detailing the cardiovascular disease types and risk factors that arise with increased prevalence in patients with psoriasis. Additionally, this article reviews those trials that investigated the disease-specific inflammatory markers (i.e., hyperhomocysteinemia, C-reactive protein, and tumor necrosis factor-α) and comorbid risk factors (i.e., insulin resistance and metabolic syndrome) that might be impacted when systemic therapies are implemented in the patient with psoriasis.

Evaluating Psoriasis: A Review of the Assessments Most Commonly Used in Clinical Trials

Psoriasis is a chronic autoimmune inflammatory skin disease that affects 1% to 3% of the global population. Because no psoriasis biomarkers are available to assess disease severity, clinical measures are used in daily practice and in research to measure both severity and treatment response. In the clinic, psoriasis may be graded by the dermatologist as mild to severe and improvement measured as worse, unchanged, better, much better, or clear. However, these scales are insufficient for clinical trials, where objective tools that are reliable, valid, and consistent from investigator to investigator are needed to quantify disease activity more precisely. The aim of this research is to update the reader on how to assess the major evaluation components of psoriasis severity and to review the most common global and local psoriasis scales used by the clinical trial physician (Psoriasis Area and Severity Index, Physicians Global Assessment, Target Lesion Psoriasis Severity Scale, Lattice System Physicians Global Assessment).

Treatment of Erythrodermic Psoriasis: Practical Application of the National Psoriasis Foundation Consensus Statement

The management of erythrodermic psoriasis often presents a dermatologic challenge because of the lack of adequate high-quality medical literature concerning treatment options, side effect profiles associated with available therapies, and the development of concomitant comorbidities during treatment that further limit therapeutic options. After reviewing the literature published on erythrodermic psoriasis, taking into account the quality of the evidence-based medicine, in April 2010 the medical board at the National Psoriasis Foundation released a consensus algorithm for treating the patient with erythrodermic psoriasis. We present a case of a 53-year-old man with a 20-year history of plaque psoriasis who developed an erythrodermic exacerbation involving 100% body surface area. The patient was eventually administered cyclosporine 5 mg/kg/day divided into two equal doses, and the results of this treatment were excellent. He was eventually changed to a maintenance regimen involving cyclosporine 3.5 mg/kg/day divided into two equal doses along with methotrexate 15 mg weekly given for a 1-month period followed by a 1-month drug holiday. The patient has been successfully maintained on this intermittent regimen for the past 3 years with no evidence of toxicity.

The Appearance of a Cutaneous Anaplastic Lymphoma in a Psoriasis Patient Taking Methotrexate

The use of immunosuppressive therapies, including methotrexate (MTX) in the psoriasis population has been associated with the formation of lymphoproliferative disorders. We present a case of a 78-year-old patient with long-standing psoriasis who developed an anaplastic cutaneous lymphoma after approximately 16 months of treatment with 15 mg per week of MTX. Within a month of diagnosis, the MTX was tapered and acitretin was started. Ten weeks later, the patients lymphoma was clinically resolved, and his psoriasis was well controlled with acitretin and topical therapy as needed. Until further investigation in the form of large prospective clinical trials are completed to substantiate the carcinogenic risk of this antipsoriatic therapy, physicians should be made aware of this plausible association and, along with regular blood work for hepatotoxicity, careful skin screening should be conducted regularly.

Synergy of Light and Radiofrequency Energy for Hair Removal

Publisher Summary This chapter discusses the synergy of light and radiofrequency energy for hair removal. Hair removal using lasers and light-based methodologies are limited by the chromophore dependence on melanin located in the hair shaft, creating a small window of efficacy and safety for the treatment of light hair hues and darker skin phenotypes. More recently, using an alternative source of energy, RF, and synthesizing its use with current light and laser modalities have eliminated this dependence on the melanin chromophore. The combination of optical and RF has proven to be a safe and effective method for the permanent removal of unwanted hair, and has shown promising effects in both those individuals with darker skin types as well as in those with blond or white hair, while also creating a high safety profile with minimal patient discomfort. Further investigation with more long-term studies and comparison trials are needed to further elucidate the integrated RF and optical energy technology, especially in the earlier refractory group of photoepilatory individuals.