New guidelines emphasize comorbidities in psoriasis

February 25, 2019

A decade ago, the list of psoriasis comorbidities didn't go much beyond psoriatic arthritis. Now, new guidelines warn dermatologists that many medical conditions are linked to psoriasis, from cardiovascular disease and metabolic syndrome to cancer, renal and hepatic disease and even the eye condition uveitis.

A decade ago, the list of psoriasis comorbidities didn't go much beyond psoriatic arthritis (PsA). Now, new guidelines warn dermatologists that a wide range of medical conditions are linked to psoriasis, from cardiovascular disease and metabolic syndrome to cancer, renal and hepatic disease and even the eye condition uveitis.

"As we started this new era of psoriasis therapy, it became quite apparent that people with psoriasis had a number of comorbidities. Doctors need to know about these comorbidities so they can make patients aware of them," said University of Alabama at Birmingham professor of dermatology Craig A. Elmets, MD, FAAD, in an interview with Dermatology Times.

Dr. Elmets is co-chair of the work group that developed the joint guidelines for the American Academy of Dermatology and the National Psoriasis Foundation. The guidelines, which provide recommendations about psoriasis care with an emphasis on comorbidities, were published online Feb. 13 in the Journal of the American Academy of Dermatology. (https://doi.org/10.1016/j.jaad.2018.11.058)

In regard to PsA, the guidelines suggest all psoriasis patients should be told about the risk of the disease, and it should be consider in all patients with cutaneous psoriasis (strength of recommendation: B). It adds that "patients with signs and symptoms suspicious for PsA should be fully evaluated for PsA." (strength of recommendation: A)

The guidelines note a link between psoriasis, cardiovascular disease and multiple cardiac risk factors (metabolic syndrome and its components obesity, hypertension, dyslipidemia, and type 2 diabetes). "While the exact mechanism of this association is unclear," they say, "it likely involves humoral and cellular inflammatory mediators."

In some cases, treatment of one condition can help the other, said Dr. Elmets. "One thing we've noticed is that psoriasis patients have a higher BMI than people who don't. It's also been observed that if the obesity is addressed, it can help to improve the psoriatic skin."

According to the guidelines, dermatologists should screen all psoriasis patients for cardiovascular risk and consider earlier, more frequent screening in those "who are candidates for systemic or phototherapy or who have psoriasis involving >10% of the BSA [body surface area]." (strength of recommendation: B)

And all patients with psoriasis should have their blood pressure checked and be referred for treatment if they're at or above 140/90 mmHg. (strength of recommendation: B)

In regard to mental health, the guidelines recommend that dermatologists refer patients who show signs of anxiety, depression, or suicidal ideation (strength of recommendation: A) and both inform and ask patients about anxiety and depression, which are linked to psoriasis. (strength of recommendation: B)

In addition, "psoriasis-specific therapy is recommended as a measure to improve psoriasis-associated anxiety and depression in individuals with psoriasis." (strength of recommendation: B)

The guidelines also provide recommendations about advice to patients regarding alcohol use and smoking. And it offers guidance regarding treatment of patients with inflammatory bowel disease, which is linked to psoriasis.

The guideline authors do not provide recommendations regarding other comorbidities linked to psoriasis, but they do note their existence. These conditions include cancer, renal and hepatic disease, sleep apnea, chronic obstructive pulmonary disease and uveitis.

Disclosures:For the guidelines: no funding is reported

Craig A. Elmets, MD, served as a consultant for Ferndale Laboratories, Inc, receiving honoraria; as a consultant for Vaxin receiving stock and/or stock options; as a consultant/advisory board member for Vertex Pharmaceuticals receiving fees/honoraria; as a principal investigator for the California Association of Winegrape Growers, Kyowa Hakko USA, and Solgenix LLC receiving grants and/or research funding; as an investigator for Elorac, Inc, Idera Pharmaceuticals, Inc, Kyowa Hakko USA, and Solgenix LLC receiving grants and/or research funding; as a data safety monitoring board member for Astellas Pharma US, Inc, and LEO Laboratories, Ltd, receiving fees; as a stockholder for Medgenics, Inc, receiving no fees; and as a stockholder for Aevi Genomic Medicine (receiving stock) and Immunogen (paid to spouse).

Alan Menter, MD, served as a consultant for Abbott Labs, AbbVie, Amgen, Eli Lilly and Company, Galderma USA, Janssen Pharmaceuticals Inc, LEO Pharma US, Menlo Therapeutics, Novartis, Sienna Biopharmaceuticals, and Wyeth Labs receiving honoraria; as a consultant for New Enterprise Associates, Promius Pharma LLC, Spherix Global Insights US, UCB, and Valeant Pharmaceuticals North America receiving fees; as a consultant for Afecta Pharmaceuticals receiving no compensation; as a speaker for Abbott Labs, AbbVie, Amgen, Janssen Biotech, LEO Pharma, US, Pfizer, Inc, Promius Pharma LLC, Sienna Pharmaceuticals, UCB, and Wyeth Labs receiving honoraria; as a principal investigator for AbbVie, Amgen, Boehringer Ingelheim, Celgene Corporation, Eli Lilly and Company, Janssen Pharmaceuticals, Inc, Medimetriks Pharmaceuticals, Inc, Merck & Co, Inc, Novartis Pharmaceutical Corp, and Pfizer, Inc, receiving grant and/or research funding; as an investigator for Eli Lilly and Company and UCB receiving honoraria; investigator for Abbott Labs, Leo Pharma US, and Sienna Biopharmaceutical receiving grants; as an advisory board member for Abbott Labs, AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen Pharmaceuticals, Inc, LEO Pharma US, Medscape, Pfizer, Inc, and Sienna Biopharmaceuticals, receiving honoraria; as an advisory board member for Amgen receiving grant and/or research funding; as an advisory board member for Afecta Pharmaceuticals receiving no compensation; and as an independent contractor for Prime Education receiving fees.

Alan Menter, MD,* served as a consultant for Abbott Labs, AbbVie, Amgen, Eli Lilly and Company, Galderma USA, Janssen Pharmaceuticals Inc, LEO Pharma US, Menlo Therapeutics, Novartis, Sienna Biopharmaceuticals, and Wyeth Labs receiving honoraria; as a consultant for New Enterprise Associates, Promius Pharma LLC, Spherix Global Insights US, UCB, and Valeant Pharmaceuticals North America receiving fees; as a consultant for Afecta Pharmaceuticals receiving no compensation; as a speaker for Abbott Labs, AbbVie, Amgen, Janssen Biotech, LEO Pharma, US, Pfizer, Inc, Promius Pharma LLC, Sienna Pharmaceuticals, UCB, and Wyeth Labs receiving honoraria; as a principal investigator for AbbVie, Amgen, Boehringer Ingelheim, Celgene Corporation, Eli Lilly and Company, Janssen Pharmaceuticals, Inc, Medimetriks Pharmaceuticals, Inc, Merck & Co, Inc, Novartis Pharmaceutical Corp, and Pfizer, Inc, receiving grant and/or research funding; as an investigator for Eli Lilly and Company and UCB receiving honoraria; investigator for Abbott Labs, Leo Pharma US, and Sienna Biopharmaceutical receiving grants; as an advisory board member for Abbott Labs, AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen Pharmaceuticals, Inc, LEO Pharma US, Medscape, Pfizer, Inc, and Sienna Biopharmaceuticals, receiving honoraria; as an advisory board member for Amgen receiving grant and/or research funding; as an advisory board member for Afecta Pharmaceuticals receiving no compensation; and as an independent contractor for Prime Education receiving fees.