Drug-induced psoriasis from medications, including antimalarials or β-blockers, can be challenging to verify, according to Erik Stratman, MD, a medical dermatologist and chairman of dermatology at Marshfield Clinic Health System and former associate dean for the University of Wisconsin School of Medicine and Public Health—Marshfield Campus, both in Wisconsin. 

Therefore, learning which medications may induce or flare psoriasis can be important for accurate diagnosis and treatment, Stratman said in a presentation at the American Academy of Dermatology Virtual Meeting Experience 2021.

Because no clear, specific phenotype distinguishes drug-induced psoriasis, Stratman pointed to the need to understand the 3 main types of reactions as a first step in determining whether medications provoked psoriasis induction or flare.

The first type of reaction occurs in a person with no history of disease who takes medicine and then experiences an onset of typical psoriasis. “If you are lucky enough to identify the drug and take the drug away, only sometimes will the psoriasis either substantially improve or disappear completely,” Stratman said. “In many cases, the psoriasis will persist.”

A second kind of reaction happens in a person with a history of psoriasis who, because of the drug, has a flare of existing psoriasis, such as worsening plaque or a more severe erythrodermic or pustular variant.

The third type of reaction occurs in a person with no history of psoriasis who takes a medicine, which results in a psoriasis-like reaction without necessarily having all the classic characteristics of psoriasis. “Often, when the drug is stopped, the reaction resolves in the weeks to months ahead,” Stratman said. “The reaction is not truly psoriasis, but rather psoriasiform in nature.”

Medications Most Likely to Impact Psoriasis

The association between drugs and psoriasis onset and/or exacerbation is difficult to attribute and study, according to Stratman. One reason is the frequently long, variable lag time with psoriasis induction or psoriasis flaring. “Usually flaring happens a little quicker than induction of new psoriasis from drug reactions,” he said. The lack of a specific phenotype for drug-related presentations further complicates the difficulties of establishing definite links. 

In his experience, β-blockers are a key concern. “Perhaps we see more of this because of all the metabolic syndrome–related events we see with [patients with] psoriasis,” he said. “These patients are more likely to be prescribed β-blocker therapy.”

Sometimes a break from such treatment is a good starting point. “β-Blockers create not only new psoriasis but may flare existing psoriasis as well,” Stratman said. “In fact, β-blockers are probably the [most common] drug to trigger a new onset of psoriasis. Most of the other drugs cause flares of existing psoriasis.” 

A large US prospective cohort study published in JAMA Dermatology in 2014 concluded that long-term regular β-blocker use for at least 6 years was linked to a 39% increased risk for psoriasis.

On the other hand, lithium predominately exacerbates existing psoriasis, which can take up to 1 year to induce flaring, said Stratman.

Concerning antimalarials, hydroxychloroquine induces psoriasis more often than chloroquine, likely because the former is prescribed much more often and is more often associated with plaque flaring than new disease induction, Stratman added. Average time to flare is 4 to 12 weeks.

For erythrodermic and pustular flares with prednisone therapy, “in our textbooks, we are taught to avoid systemic steroids in [patients with psoriasis] because systemic steroids equal risk of psoriasis flaring,” Stratman said. “But this is counter to my clinical experience and research of others. Systemic corticosteroids are the No. 1 systemic agent prescribed for psoriasis therapy, eclipsing every biologic, methotrexate, and every systemic therapy.” 

A recently published retrospective study in 

 conducted at rural Marshfield Clinic Health System found that the overall flare rate was only 1.42% among adult patients with a solid diagnosis of psoriasis who received at least 1 prescription course of a systemic corticosteroid for any reason and that a severe psoriasis flare occurred in only 0.07% of cases.

The study population consisted of nearly 2000 patients approximately 50 years old (55% female) at the time of their first psoriasis diagnosis, followed by their first steroid prescription roughly 10 years later. Stratman added that 97% of steroid prescribing was done “outside of the field of dermatology” and that the most common steroid prescribed was prednisone.

Patients were seen at the facility at least once during therapy or within 3 months of stopping the medication (most commonly, oral prednisone) between October 2012 and July 2018. 

Slightly more than 50% of patients had 1 steroid course, and 80% of the entire cohort had a total steroid course of less than 60 days. The median steroid dose was 40 mg.

A flare was defined by one of the following: a documented increase in body surface area; a higher Psoriasis Area and Severity Index score; the presence of pustular or erythrodermic skin; patient-subjective reporting of a worsening flare; a physical exam describing a worsening flare compared to a previous exam; or a provider assessment and plan that mentioned flare, rebound, or “objectively worse than before.”

“There was no difference in steroid dose between flaring patients and nonflaring patients,” Stratman noted.

The investigators identified a total of 16 flares among 516 manually abstracted patients. “However, 15 of the 16 patients had only worsening plaque-stage psoriasis,” Stratman said. 

Of the 16 flares, 37% indicated flares that commenced prior to corticosteroids, and 18.8% were guttate flares with laboratory evidence of streptococcal pyogenes (strep throat) infection. 

The sole erythrodermic patient was given systemic corticosteroids because of steadily worsening body redness. “I believe the flaring was already in motion rather than [being] caused by the steroid,” Stratman said.

“Our results suggest a very low rate of psoriasis flares [< 1.5%],” Stratman added. “We challenge the teaching/dogma that steroids induced [the] severe psoriasis flares in the general psoriasis population. Strict avoidance of systemic corticosteroids in [patients with psoriasis] may be unnecessary.”

However, Stratman listed some possible limitations of the study including:

its use of only one large Midwest health care system;

no control population of patients with psoriasis with no corticosteroid therapy;

no previous use of criteria defining psoriasis flare;

patient adherence to corticosteroid prescription; and

patients may have received care outside of the system.

Despite the limitations, Stratman recommended that dermatologists consider the possibility of drug-induced psoriasis. “Do not overlook the medication list in [patients with] psoriasis,” he said.

Stratman reported no relevant financial disclosures.

1. Stratman, EJ. Does the use of systemic corticosteroids, antimalarials, or beta-blockers have an impact on patients with psoriasis? Presented at: American Academy of Dermatology Virtual Meeting Experience 2021; April 23-25, 2021. Accessed July 7, 2021.

2. Wu S, Han J, Li WQ, Qureshi AA. Hypertension, antihypertensive medication use, and risk of psoriasis. JAMA Dermatol. 2014;150(9):957-963. doi:10.1001/jamadermatol.2013.9957

3. Gregoire ARF, DeRuyter BK, Stratman. Psoriasis flares following systemic glucocorticoid exposure in patients with a history of psoriasis. JAMA Dermatol. 2021;157(2):198-201. doi:10.1001/jamadermatol.2020.4219

Articles

Lack of specific phenotypes complicates verification.

Find the Difference: Drug-Related Psoriasis

 June 2020, pediatric patients with psoriasis in France frequently missed dermatologic consultations. 

Half the children who were receiving treatment for psoriasis stopped it, and almost 1 in 4 could not adhere to the very measures meant to keep them safe: mask wearing and hand sanitizing. 

More than 27% of study participants canceled in-office dermatologic consultations, over 9% reported that their concerns about going to a doctor kept them from an office visit, and nearly 23% said it was difficult to adhere to hygiene measures because of the need to use irritating hand sanitizers and handwashing routines, as well as mask wearing.

Health care access was also affected during the lockdown. More than 41% of pediatric patients in the study had a dermatologic consultation for psoriasis during lockdown, with about 71% reporting their visits were by teleconsultation. Nearly 40% of those patients said the consultation was because of worsening psoriasis, and about 21% said it was for pandemic-related issues

Additionally, accessing hospitals was difficult during the lockdown in France, according to Emmanuel Mahé, MD, head of dermatology at Argenteuil Hospital Center in Paris. “In our department all consultation activity, except teleconsultation, was stopped for 2½ months,” he said.

Although the study was small, it provided a snapshot of how children who have what can be serious skin diseases suffer during a lockdown. “These ‘invisible’ results...illustrate the difficulties of these children and must be integrated into our care,” Mahé said

Mahé and colleagues found that nearly 72% of the children surveyed had psoriasis lesions during the lockdown. More than 45% were receiving systemic treatments and nearly 19% stopped those treatments, mainly for reasons they linked to the pandemic.

COVID-19–related considerations were not the only reason for the decrease in consultation. 

At the time, doctors and patients had conflicting concerns about the potentially harmful effects of immunosuppressive drugs used to treat chronic diseases such as psoriasis. One concern had to do with a potentially heightened risk of severe COVID-19 that was associated with the use of immunosuppressive drugs. 

Another was the warning that discontinuing systemic treatment or failing to start it could worsen chronic skin disease.

1. Beytout Q, Pepiot J, Maruani A, et al; Association France Psoriasis; Research Group on Psoriasis of the French Society of Dermatology (GrPso); Research Group of the French Society of Pediatric Dermatology (SFPD). Impact of the COVID-19 pandemic on children with psoriasis. Ann Dermatol Venereol. 2021;148(2):106-111. doi:10.1016/j.annder.2021.01.005 

According to a study in Annals of Dermatology and Venerology, pediatric patients with psoriasis in France frequently missed dermatologic consultations. 

French Results Echo Expert Findings

According to a recent Pediatric Dermatology Research Alliance (PeDRA) statement, some systemic medications may have increased risk for patients during the COVID-19 era. The immunosuppressant medications listed below may carry a higher risk of infection than those considered more immunomodulating (eg, low-dose methotrexate, apremilast [Otezla; Amgen]. The risk of infection also varies among the biologic agents.

Corticosteroids (eg, prednisone, prednisolone, methylprednisolone)

Anti-CD20 (pan–B cell) rituximab [Rituxan; Genetech]

Tumor necrosis factor inhibitors (eg, etanercept [Enbrel; Amgen], adalimumab, infliximab [Avsola; Amgen]

IL-17 inhibitors (eg, secukinumab [Cosentyx; Novartis], ixeki-zumab [Taltz; Eli Lilly and Company]

IL-12/IL-23 inhibitor ustekinumab [Stelara; Janssen Pharmaceuticals]

It may be safer to continue rather than discontinue these or other medicines for children with moderate to severe skin disease, according to PeDRA. Providers should weigh whether the risk of a worsening skin condition when off the medicine is greater than the risk of COVID-19 infection and severe health consequences of an infection.

 PeDRA. General information for patients and caregivers about COVID-19. Updated May 11, 2020. Accessed June 24, 2021. General Information for Patients and Caregivers about COVID-19 (pedraresearch.org). 

by Elaine Siegfried, MD, professor of pediatrics and dermatology at Saint Louis University Doisy College of Health Sciences and director of pediatric dermatology at Cardinal Glennon Children’s Hospital in St Louis, Missouri.

Some systemic medications may have increased risk for patients during the COVID-19 era, according to a recent Pediatric Dermatology Research Alliance (PeDRA) statement.

PeDRA Lists Systemics With Higher COVID-19 Risk

“The following supplements are what I hear about from patients most commonly. Further studies are needed to better understand any role for these supplements, and patients are encouraged to engage in conversation with their dermatology providers,” says Theresa Vavra, PharmD, BCPS, a clinical pharmacy specialist in dermatology at the University of Iowa Health Care.

1. Fish oil may be helpful in psoriasis as an adjunctive therapy due to its anti-inflammatory effects, with little concern for patient harm. However, additional studies are needed to confirm this before specific treatment recommendations can be made regarding its use.

Chen Xi, Hong S, Sun X, et al. Efficacy of fish oil and its components in the   management of psoriasis: a systematic review of 18 randomized controlled trials. Nutr Rev. 2020;78(10):827-840.

Clark CCT, Taghizadeh M, Nahavandi M, et al. Efficacy of w-3 supplementation in patients with psoriasis: a meta-analysis of randomized controlled trials. Clin Rheumatol. 2019;38(4):977-988.

Elmets CA, Korman NJ, Farley Prater E, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol. 2021;84(2):432-470.

2. Patients acknowledge vitamin D from sunlight as being beneficial for psoriasis. Although topical vitamin D and sunlight have been beneficial for improving psoriasis, oral supplementation has not been helpful. Patient harm may be associated with excess vitamin D supplementation, including higher calcium levels and bone demineralization. 

Theodoridis X, Grammatikopoulou MG, Stamouli EM, et al. Effectiveness of oral vitamin D supplementation in lessening disease severity among patients with psoriasis: a systematic review and meta-analysis of randomized controlled trials. Nutrition. 2021;82:111024.

Elmets CA, Korman NJ, Farley Prater E, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with topical therapy and alternative medicine modalities for psoriasis severity measures. J Am Acad Dermatol. 2021; 84(2):432-470.

3. Patients explain that they take curcumin or turmeric because they believe it to be good for decreasing inflammation. It may be beneficial for patients with psoriasis as adjunctive therapy, but it is poorly absorbed. Insufficient scientific evidence exists to support its use and further studies are needed.

Gamret AC, Price A, Fertig RM, et al. Complementary and alternative medicine therapies for psoriasis: a systematic review. JAMA Dermatol. 2018;154(11):1330-1337.

Theresa Vavra, PharmD, BCPS, provides studies for some of the most commonly used supplements by patients with psoriasis.

Studies of Commonly Used Supplements for Psoriasis

Whitney Linsenmeyer, PhD, RD, LD, an assistant professor of nutrition at Saint Louis University Doisy College of Health Sciences and spokesperson for the Academy of Nutrition and Dietetics, says:

1. An anti-inflammatory diet may be a useful strategy in managing psoriasis. 

The Mediterranean diet is a sound place to start; this approach is endorsed by leading health organizations, including the World Health Organization and Harvard T.H. Chan School of Public Health. The Mediterranean diet is rich in vegetables, fruits, nuts and seeds, whole grains, fish, and healthy oils. Dietary recommendations include 1) core foods to enjoy daily, such as whole grains, fruits, vegetables, beans, herbs, spices, and nuts, and healthy fats such as olive oil; 2) fish and seafood at least twice weekly; 3) moderate portions of dairy, eggs, and occasional poultry; and 4) infrequent servings of red meat and sweets. 

2. Specific anti-inflammatory foods include:

Green leafy vegetables, such as spinach, kale, and collards 

Fruit, including strawberries, blueberries, raspberries, cherries, oranges, and apples

Nuts, such as almonds, walnuts, and pistachios 

Fatty fish, including salmon, mackerel, tuna, and sardines 

3. For those managing psoriasis, avoiding specific foods that are known triggers or may worsen symptoms (ie, gluten in wheat, rye, barley) is vital. 

Whitney Linsenmeyer, PhD, RD, LD, provides 3 dietary considerations for patients with psoriasis.

 3 Dietary Considerations for Psoriasis 

Children and adolescents aged 12 to 15 years are now eligible to receive COVID-19 vaccinations and additional trials are underway to evaluate vaccines’ efficacy and safety for those under 12. However, coronavirus is not in the rearview mirror for the pediatric population. Dermatologists and investigators are just beginning to assess the pandemic’s full physical and psychological burden on pediatric patients with psoriasis.

New study data, along with guideline updates from organizations such as the National Psoriasis Foundation and regulatory guidance from relevant government agencies, are helping to build a new framework for developing more effective treatment plans for pediatric patients with psoriasis within the context of COVID-19.

The first step for most practices is reestablishing regular consultations with pediatric patients and their families.

Gaps in care negatively affected US children and teens with psoriasis during the pandemic, according to Lawrence Eichenfield, MD, vice chair of the Department of Dermatology, professor of dermatology and pediatrics at the University of San Diego School of Medicine and chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego. Eichenfield said he and colleagues saw patients with significant disease and delayed diagnoses because families were hesitant to visit the medical center during lockdown. 

“Many patients missed visits, even virtual visits, as the pandemic started,” Eichenfield told 

. “We reached out to some patients on biologics or responded to queries…about whether they should continue on with their medications and how they might communicate with us about infections or concerns about infections. Reflecting several position statements from relevant organizations, our policy called for continuation of systemic therapies with pediatric psoriasis, along with reasonable, and fairly aggressive, consideration about exposure situations and masking.”

COVID-19–related stresses affected some pediatric patients with psoriasis not only physically, but mentally, according to Eichenfield. He and his colleagues saw the pandemic’s toll on physical conditions such as skin flaring, but they also noted its impact on many patients’ mood, anxiety, and, in some cases, depression. Independently of psoriasis, all patients in his practice get screening for depression. Adolescent patients had markedly increased mental health issues during the pandemic, he added.

“The good news is none of our patients had complicated COVID-19 infection, and none interrupted systemic therapy,” Eichenfield said.

One of the great pandemic-related advances in France was the technical and regulatory deployment of telemedicine within days of the start of the lockdown. “This allowed us to move forward quickly, to answer questions for many children and adults,” Mahé said. “The children love it. They are in their family [environment] and are very relaxed.”

Telemedicine is not the only solution but it has been indispensable during the pandemic, he added. “There is currently work being done to standardize the follow-up of these children, not only in the event of another confinement but in general. For example, parents often have to take half a day off work to bring their children to hospital,” he pointed out.

Teledermatology remains useful for follow-ups and as a screening tool for new visits, according to Eichenfield. “We prefer in-person visits for new evaluations for possible psoriasis, given there has often been misdiagnosis or delays in diagnosis,” he said. “And there is much counseling about how we manage the disease, screen for comorbidities, and select our therapies together.”

Widespread adoption of telemedicine and understanding how to incorporate it in evaluating children who have moderate to severe inflammatory skin disease has taken a leap forward in the United States. It will likely remain an option, according to Elaine Siegfried, MD, a professor of pediatrics and dermatology at Saint Louis University Doisy College of Health Sciences and director of pediatric dermatology at Cardinal Glennon Children’s Hospital, in St Louis, Missouri. “I think there are challenges to doing telemedicine, especially for kids who have total body inflammatory skin diseases like psoriasis or eczema, but I am learning to appreciate what can and can’t be assessed by video and patient-submitted [images],” she said.

Dermatologists have learned a lot about how COVID-19 and lockdown measures affect children with skin diseases, including psoriasis and eczema, according to Siegfried. She strongly believes that taking a biologic is not a contraindication for getting the vaccine. However, she is not as confident about which systemic treatments are safest at this time because some may be more immunosuppressant than others. Siegfried is also concerned that the number of children participating in clinical psoriasis and eczema trials is always less than that in the corresponding adult trials, and that the pediatric trials generally start later. So long-term safety information is comparatively delayed. 

Pediatric-specific data are limited regarding the impact of recently approved biologics for pediatric psoriasis, such as secukinumab (Cosentyx; Novartis) and ixekizumab (Taltz; Eli Lilly and Company), on vaccine safety and efficacy as well as on immune maturation. Experience with the interleukin (IL)-12/IL-23 inhibitor ustekinumab (Stelara; Janssen Biotech) is a little greater because it has been approved for other indications at much higher doses than those used for psoriasis.

“I’m not wary about the IL-4 and IL-13 inhibitor dupilumab [Dupixent; Regeneron Pharmaceuticals/Sanofi-Aventis], because blocking T helper type 2 (Th2)-driven immune responses upregulates Th1 responses, supporting better antibody production,” Siegfried said.

Joel M. Gelfand, MD, MSCE, coauthor of a recent article on National Psoriasis Foundation (NPF) COVID-19 Task Force guidance on managing psoriatic disease during the pandemic,

 said the task force updates its guidance as new data emerge.

. The most recent focus on COVID-19 vaccines,” said Gelfand, vice chair of clinical research and medical director, Dermatology Clinical Studies Unit, director at the Psoriasis and Phototherapy Treatment Center, and a professor of dermatology, epidemiology in biostatistics, and epidemiology at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

NPF guidelines now recommend that patients, including children, should take the first COVID-19 vaccine currently approved under the FDA’s emergency use authorization for which they are eligible. This aligns with similar guidance from the Centers for Disease Control and Prevention

 “We generally recommend patients stay on systemic therapies when receiving a COVID-19 vaccine,” Gelfand added.

However, out of what Gelfand described as an abundance of caution and until more data emerge, the NPF task force recommends that patients with psoriatic disease who are taking abatacept, cyclosporine, leflunomide, glucocorticoids (eg, prednisone), methotrexate, or tofacitinib continue to take masking and social distancing precautions, even if they have been vaccinated against COVID-19, when they are in contact with people who have not been vaccinated or whose vaccination status is not verifiable. “It is critically important that dermatologists be aware that the task force recommends the use of antibody ‘cocktails’ for patients who develop COVID-19 and are at high risk for progressing to severe COVID-19 and/or hospitalization,” he said.

He also pointed out 2 main differences in approaching treatment for children vs adults with psoriasis. “First, due to their young age they are generally at low risk for a severe course of COVID-19 illness,” he said. “However, children with psoriasis may have comorbidities such as obesity that increase their risk. Second, social distancing may be more challenging for children than for adults. The task force recommends that children with psoriasis mask and distance when at school. If the school environment is unable to ensure these prevention measures or families believe their child may not be able to adhere to these practices, we encourage discussion with the patient, caregivers, and [their] clinician to collectively develop a learning plan [that is] in the best interest and safety of the child.”

The most important message is that children with psoriasis should continue their systemic therapies during the pandemic, he continued. “While some uncertainty remains, it is clear that stopping systemic treatment has led to psoriasis flares in many cases, which can only worsen the emotional burden of coping with the disruptions caused by the pandemic,” Gelfand said.

Pandemic challenges continue, despite the rollout of major programs related to COVID-19 and particularly on the vaccine front, according to Gelfand. “While the risk of hospitalization or death from COVID-19 in children is very low, the risk of long-term effects of having COVID-19 in childhood is only starting to emerge, as [is] the development of new variants which pose new threats, particularly to those who are not vaccinated,” he said.

Mahé is a consultant, advisor, or speaker for AbbVie, Amgen, Celgene (Bristol Myers Squibb), Eli Lilly and Company, Janssen Cilag, LEO Pharma, Novartis, and Sanofi. 

Gelfand served as a consultant for Abcentra, AbbVie, Bristol Myers Squibb, Boehringer Ingelheim, Eli Lilly and Company (DMC), GlaxoSmithKline, Janssen Biologics, Mindera Dx, NeuroDerm (DSMB), Novartis Corp, UCB (DSMB), and Trevi Therapeutics, and received honoraria. He receives research grants (given to the trustees of the University of Pennsylvania) from Boehringer Ingelheim and Pfizer Inc and received payment for continuing medical education work related to psoriasis that was supported indirectly by pharmaceutical sponsors. He is a co-holder of a patent of resiquimod (Galderma) for the treatment of cutaneous T-cell lymphoma. He is a deputy editor for the Journal of Investigative Dermatology, receiving honoraria from the Society for Investigative Dermatology; chief medical editor for Healio Psoriatic Disease, receiving honoraria; and a member of the board of directors for the International Psoriasis Council, receiving no honoraria.

Siegfried receives honoraria or consulting fees from, or she/her institution has research ties to, AbbVie, Eli Lilly and Company, Janssen Pharmaceuticals, LEO Pharma, Novartis, Pfizer Inc– DSMB, Regeneron, Sanofi Genzyme, and UCB–DSMB. 

Eichenfield has consulting and/or research ties to AbbVie, Allergan, Almirall, Dermira, Eli Lilly and Company, Galderma, Glenmark, Incyte, LEO Pharma, Novartis, Ortho Dermatologics/Valeant, Otsuka Pharmaceutical Co, Pfizer Inc, and Sanofi-Regeneron.

Gelfand JM, Armstrong AW, Bell S, et al. National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease during the pandemic: version 2–advances in psoriatic disease management, COVID-19 vaccines, and COVID-19 treatments. J Am Acad Dermatol. 2021;84(5):1254-1268. doi:10.1016/j.jaad.2020.12.058

COVID-19 Task Force guidance statements. NPF. Updated June 1, 2021. Accessed June 28, 2021. https://www.psoriasis.org/covid-19-task-force-guidance-statements/

Beytout Q, Pepiot J, Maruani A, et al; Association France Psoriasis; Research Group on Psoriasis of the French Society of Dermatology (GrPso); Research Group of the French Society of Pediatric Dermatology (SFPD). Impact of the COVID-19 pandemic on children with psoriasis. Ann Dermatol Venereol. 2021;148(2):106-111. doi:10.1016/j.annder.2021.01.005 

Covid-19 vaccines for children and teens. Centers for Disease Control and Prevention. Updated May 27, 2021. Accessed June 30, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/adolescents.html

Committee on Infectious Diseases. COVID-19 vaccines in children and adolescents. Pediatrics. Published online May 12, 2021. doi:10.1542/peds.2021-052336 

COVID-19 advice for the public: getting vaccinated. World Health Organization. Updated June 14, 2021. Accessed July 1, 2021. 

https://www.who.int/emergencies/diseases/novel-coronavirus-2019/covid-19-vaccines/advice

COVID-19’s lingering impact brings new considerations for treatment regimens for pediatric patients with psoriasis. 

Transform Pandemic Lessons Into Actionable Care Plans

 In results from a survey of 270 patients with psoriasis, more than half had tried 1 to 4 dietary interventions or supplements to treat symptoms. Many found that specific diets, such as the ketogenic diet, and supplements, including probiotics, helped, according to data presented at the 2021 Society for Investigative Dermatology (SID) Virtual Annual Meeting in May.

“We often field questions about diet and supplements in our clinic, not just related to psoriasis but related to a lot of dermatologic entities,” said senior study author Jennifer G. Powers, MD, a clinical associate professor of dermatology at the University of Iowa Hospitals and Clinics in Iowa City.

Understanding patients’ dietary habits is particularly important when treating patients with psoriasis because they are known to have a higher body mass index (BMI) and are more likely to have metabolic syndrome than the general population.

“We thought it would be particularly interesting to understand what [patients with] psoriasis are doing to work on their psoriasis from a nutritional standpoint, and what they feel has actually helped them,” Powers said.

Powers and her colleagues from Saint Louis University School of Medicine reported on patients’ responses to a 30-question survey assessing the popularity of specific dietary regimens and common supplements. 

The investigators found that of the 270 patients responding, approximately 30% had tried to lose weight. Additionally, more than one-third of those attempting to lose weight said it had a positive impact on psoriasis severity. 

Powers said this finding corresponds to what she sees anecdotally in the clinic. Patients with psoriasis who lose weight or make certain dietary adjustments sometimes see changes in their skin. But without a study to confirm that weight loss is the cause of skin improvement, it is hard to draw any conclusions. 

See our interview with Powers about this study here.

“What is nice about this study is we were powered enough to make some summary statements about what happens more globally,” she said. “At least we were able to dip our toes in and try to understand what patients are doing and what they actually feel is helping.”

Among those who endorsed weight loss interventions, 50% said their psoriasis improved with a ketogenic diet. Forty-six percent reported benefiting from the Mediterranean diet, 40% from a vegetarian diet, and 36% from a gluten-free diet.

Thirty-two percent of respondents had tried supplementing with oral vitamin D, making it the most tried supplement in the study. More than a quarter of patients with psoriasis had tried oral fish oil, followed by 21% who had tried probiotics. 

The largest percentage of patients endorsed the least tried supplement, probiotics, with 29% reporting that it had helped their psoriasis. Nearly 28% of those taking vitamin D said it helped and nearly 26% of patients taking fish oil gave it a thumbs-up.

Which Patients Were More Likely to Try These Interventions?

The investigators found that patients with psoriasis who were 55 years and younger were more likely to try diets and supplements than older patients. The survey also revealed that patients with 2 or more psoriasis subtypes, including plaque, guttate, flexural, scalp, or nail, tried more diets or supplements.

Additionally, as other studies have shown, patients with a BMI above 30 were more likely to have moderate to severe disease. Although 5.9% of patients (16) had tried 5 or more diets or supplements, approximately 42% of those surveyed had not tried any diets or supplements.

A supplement or a dietary intervention rarely offers the efficacy of a drug such as adalimumab (Humira; AbbVie), Powers said. However, patients tend to find the adverse effect profile of a diet or supplement more favorable than that of a biologic or other prescription medication, she noted.

“We have a lot of great drugs, so we don’t necessarily need these types of interventions most of the time, but if a patient has very mild disease or if they are looking to improve a little bit we wonder if these could contribute to the overall improvement,” Powers said.

As the majority of patients studied had tried at least 1 diet or supplement—and many had tried several—dermatologists should consider a patient’s willingness to use these types of treatment options.

“Our research gives dermatologists a jumping off point for discussing these other interventions. Now dermatologists know which supplements and dietary interventions might be on patients’ radar,” Powers said, “but we need more data about whether or not these dietary interventions and supplements could be used in the future as part of treatment.”

Powers reported no financial interest or conflicts of interest.

1. Dhinsa H, Wu N, Chaudhry S, Powers JG. Diet and nutritional behaviors of patients with Psoriasis. Abstract presented at: 2021 SID Virtual Annual Meeting; May 3-8, 2021. July 15, 2021. Abstract LB741. 

https://www.sidannualmeeting.org/wp-content/uploads/2021/05/SID-2021-Virtual-Meeting-LB-Abstract-Booklet-FINAL.pdf

2. Gisondi P, Fostini AC, Fossà I, Girolomoni G, Targher G. Psoriasis and the metabolic syndrome. Clin Dermatol. 2018;36(1):21-28. doi:10.1016/j.clindermatol.2017.09

Holistic options for disease management show improvement in mild psoriasis.

Patients Share Experience with Dietary Interventions, Supplement Use 

A growing body of research adds to evidence that psoriasis’ comorbidities are much further reaching than previously thought. As a result, clinicians need to address this expanding list of possible comorbidities in their approach to patient care, said Tiago Torres, MD, PhD, professor of dermatology at the Instituto de Ciências Biomédicas Abel Salazar at the University of Porto in Portugal, who recently spoke at the European Academy of Dermatology and Venereology (EADV) Spring Symposium 2021.

Torres said the most common form of psoriasis vulgaris is plaque psoriasis, typically characterized by the presentation of erythematous-raised plaques and thick silvery scales on the skin. Other forms of the disease include pustular, palmoplantar, nail, guttate, inverse, and erythrodermic psoriasis. One in 3 patients with psoriasis may also develop psoriatic arthritis (PsA) and present with signs of swelling, stiffness, and pain in the joints and areas surrounding the joints.

Beyond the characteristic cutaneous signs and symptoms of the disease as well as joint manifestations in the case of PsA, patients with psoriasis also may suffer from ocular inflammation (conjunctivitis, blepharitis, and uveitis), inflammatory bowel disease (ie, Crohn disease and ulcerative colitis), renal disease, chronic obstructive pulmonary disease, and obstructive sleep apnea.

Cardiometabolic diseases now have a place on the list of possible comorbidities. This includes cardiovascular disease, obesity, hypertension, diabetes, hyperlipidemia, and nonalcoholic hepatic steatosis. One or more of these manifestations and symptoms can often lead to anxiety, reactive depression, and suicide ideation in patients, underscoring the need for clinicians to monitor and screen this patient population for any of these comorbidities.

“Fortunately, our collective knowledge of psoriasis and the systemic impact that the disease can have on other tissues and organ systems has grown over the [past few] years, with particular focus on cardiometabolic comorbidities,” Torres said. “[Patients with psoriasis] have an increased morbidity and mortality as well as a decreased quality of life due to the multimorbid nature of the disease. As such, it has become paramount that clinicians screen, monitor, and aggressively treat the associated comorbidities of the disease, particularly obesity.”

The physiological explanation for the association between psoriasis and cardiometabolic and cardiovascular disease is slowly becoming better understood. According to Torres, significant systemic inflammation is associated with psoriasis, and this inflammation appears to be at least one of the root causes of the disease. 

“The common denominator appears to be systemic inflammation, and there are many similar aspects in terms of the atherosclerotic inflammation, linking psoriasis and cardiovascular disease through systemic inflammation, which perpetuates the cycle of disease,” Torres said. 

One of the key comorbidities of psoriasis is obesity, which influences psoriasis and cardiovascular disease. The increased prevalence of cardiovascular comorbidities, especially obesity, is particularly important in psoriasis because of the systemic inflammation produced. Obesity is associated with a constant low-grade chronic inflammatory state, Torres said, and patients with a body mass index higher than 30 have demonstrated a 2-fold risk of developing the disease. According to Torres, the current evidence indicates that weight loss is associated with improvement in psoriasis and PsA severity—likely due to decrease in inflammatory load—improvement in patients’ metabolic profile, and improvement of the response to psoriatic treatments with fewer adverse events.

Torres noted a high prevalence of underdiagnosed and undertreatment of cardiovascular diseases in patients with psoriasis. In a recent nationwide study evaluating the awareness and management of cardiovascular risk of psoriasis among Portuguese dermatologists, Torres found that 40% of physicians did not contribute to cardiovascular risk–factor management, 12% had no knowledge of the association, 15% passed cardiovascular risk–factor management to general practitioners, and 45% actively screened and monitored patients, although mainly for moderate to severe disease.

“I believe that it is very important to not only increase the awareness of this subject to clinicians and to actively screen and monitor [patients with] psoriasis for these comorbidities, but also to advise patients to lead a healthy lifestyle, including losing excess weight, stopping smoking, and [conducting] regular physical activity,” Torres said. 

Interestingly, the group of metabolic abnormalities that define metabolic syndrome also appear to occur more frequently in patients with PsA vs patients with psoriasis or rheumatoid arthritis (RA). In a recent study, Loganathan et al performed a systematic review and meta-analysis to determine the prevalence of metabolic syndrome among patients with PsA, psoriasis, and RA. The investigators searched Medline, PubMed, Embase, Google Scholar, ProQuest, Ebsco Cinahl, Scopus, ScienceDirect, Web of Science, and Cochrane Library for all relevant studies published between January 1990 and August 2019 and included 24, 89, and 53 studies for PsA, psoriasis, and RA, respectively, in the final analysis.

They found that patients with PsA had a significantly higher prevalence of metabolic syndrome compared to patients with psoriasis or RA. Data showed that the pooled prevalence of metabolic syndrome in PsA populations was 0.46 ± 0.06 vs 0.34 ± 0.03 and 0.31 ± 0.04 in the psoriasis and RA patient populations, respectively. Also, patients with PsA were 1.62 ± 0.036 and 1.66 ± 0.038 times more likely to have metabolic syndrome compared with psoriasis and RA populations.

The percentages of patients with PsA and metabolic syndrome in the European, Asian, North American, and Middle Eastern groups were 47.2%, 45.78%, 34.88%, and 48.4 %, respectively. In PsA populations, data showed that patients from countries with a lower gross national income (GNI) tended to have a higher prevalence of metabolic syndrome, and the prevalence of PsA was also higher when matched to RA and psoriasis populations from matched GNI groups.

According to the study authors, rheumatologists often do not assess for metabolic syndrome as part of routine evaluations in patients with inflammatory arthritis.

“Metabolic syndrome is underappreciated in psoriatic disease, especially in psoriatic arthritis. More research needs to be done in determining whether effective management of metabolic syndrome can lead to improved disease control and cardiovascular outcomes,” wrote the study authors.

After addressing the cutaneous manifestations of psoriasis in his patients to improve the skin disease, Torres focuses on decreasing the systemic inflammation in patients, which is crucial to lessening the impact of cardiovascular disease. In addition, screening and treating cardiovascular and cardiometabolic symptoms such as obesity are paramount.

“If we treat the obesity or overweight patients, we are decreasing the risk of the other comorbidities, which will have a positive impact on the global health of the patient,” Torres said.

A multidisciplinary approach is also crucial in the patients with psoriasis who more than likely will have 1 or more comorbidities associated with the skin disease. 

“In more complex cases, it would behoove dermatologists to consult with rheumatologists, internists, cardiologists, and endocrinologists as well as general practitioners for a more complete care of the [patient with] psoriasis and [the] associated cardiometabolic diseases,” Torres said.

Torres T. Is there a need to look for comorbidities in psoriasis? Presented at: European Academy of Dermatology and Venerology Spring Symposium 2021; May 6-7, 2021; virtual. Accessed June 30, 2021.

Raposo I, Bettencourt A, Selores M, Torres T. Awareness and screening attitudes of Portuguese dermatologists on cardiovascular risk factors in psoriatic patients. Eur J Dermatol. 2017;27(4):443-445. doi:10.1684/ejd.2017.3053

Loganathan A, Kamalaraj N, El-Haddad C, Pile K. Systemic review and meta-analysis
on prevalence of metabolic syndrome in psoriatic arthritis, rheumatoid arthritis and psoriasis. Int J Rheum Dis. 2021 Published online June 2, 2021. doi:10.1111/1756-185X.14147

Due to the multimorbid nature of the disease, clinicians must screen, monitor, and aggressively treat the associated comorbidities.

Dermatology Times, Psoriasis Supplement, August 2021 (Vol. 42, Supp. 02)