SDEF: Psoriasis Comorbidities Carry Implications for Disease Management

Studies show that severe psoriasis is associated with a 50% increased risk of mortality and up to 5 years of life lost, according to Dr. Joel M. Gelfand.

The leading causes of death in psoriasis patients are cardiovascular disease, infection, and cancer, which account for 34%, 22%, and 21% of deaths, respectively (Br. J. Dermatol. 2010;163:586-92), Dr. Gelfand said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Although there are not yet enough data to confirm a causal effect between psoriasis and these leading causes of death, the findings do have implications for managing patients with psoriasis, he said. Data have consistently demonstrated an association between psoriasis and cardiovascular disease, with numerous published studies linking the two conditions.

Taken together, findings from several of these studies suggest that patients with psoriasis are at increased risk of myocardial infarction, stroke, and cardiovascular death, and that those with severe psoriasis have the greatest risks, said Dr. Gelfand of the department of dermatology at the University of Pennsylvania in Philadelphia.

The clinical significance of these findings is striking; patients with severe psoriasis, for example, are 15 times more likely to die prematurely as a result of cardiovascular disease attributable to psoriasis than they are to develop a melanoma, he said.

One study demonstrated a link between psoriasis and several cardiovascular risk factors, including smoking, obesity, dyslipidemia, hypertension, and diabetes, said Dr. Gelfand, who was one of the authors of the study (J. Am. Acad. Dermatol. 2006;55;829-35).

Furthermore, a population-based cohort study involving more than 130,000 psoriasis patients – including more than 3,800 with severe psoriasis - and up to 5 controls per patient, suggested that psoriasis confers an independent risk for myocardial infarction, particularly in young patients with severe psoriasis. The adjusted relative risk of MI in a 30-year-old patient with mild psoriasis was 1.29, and in a 30-year-old with severe psoriasis was 3.01. The adjusted relative risk of MI in a 60-year old with mild psoriasis was 1.08, and in a 60-year-old with severe psoriasis was 1.36, Dr. Gelfand and his colleagues reported (JAMA 2006;296:1735-41).

That study was conducted using the General Practice Research Database of medical records in the United Kingdom, which includes more than 9 million patients and more than 40 million person-years of follow-up data from 1987 to 2002, he said, adding that at least 12 papers have confirmed an association between psoriasis and cardiovascular disease independent of traditional risk factors for cardiovascular disease.

Although the available data on psoriasis and cardiovascular disease demonstrate the biologic credibility of an association, as well as a plausible time sequence suggesting causation, dose response has been demonstrated in only a few studies, and the strength of the study design has been variable, Dr. Gelfand said.

Although most studies have found an effect – along with a modest but clinically important strength of association similar to the association seen in heart disease, hypertension, and diabetes – data from a randomized controlled trial are needed before a causal relationship between psoriasis and cardiovascular disease can be confirmed, and before a link between aggressive treatment of psoriasis and a reduced risk of cardiovascular disease can be demonstrated, he said in an interview, adding that it currently remains unclear whether aggressive treatment will lower cardiovascular disease risk.

However, the U.S. Preventive Services Task Force, the American Diabetes Association, and the National Cholesterol Education Program recommend that severe psoriasis patients over age 21 years undergo blood pressure screening at each office visit; that those aged 45 years and older undergo fasting blood glucose testing every 3 years (unless they have diabetes risk factors, in which case they should undergo screening earlier and more often); and that those aged 20 years and older undergo cholesterol screening every 5 years.

Existing data also support recommendations for addressing concerns about infection and cancer risk in patients with psoriasis, Dr. Gelfand said.

Patients with severe psoriasis are 65% more likely to die of an infection than are those without psoriasis (Br. J. Dermatol. 2010;163:586-92). Specifically, studies have shown that streptococcal pharyngitis is a risk factor for guttate psoriasis, and that HIV is a risk factor for severe psoriasis, he said, noting that it is recommended that patients be screened for streptococcal infection with guttate flares, and that they be screened for HIV if they have severe psoriasis.

It is also important that patients with psoriasis be routinely vaccinated – prior to initiation of immunosuppressive therapy – against influenza and pneumonia. Vaccination against hepatitis B in patients at risk for infection should also be considered, as well as vaccination against zoster in patients aged 60 and older.

As for cancer, it is a concern in psoriasis patients because of the chronic use of immunosuppressive therapies, comorbid behaviors, and chronic inflammation, Dr. Gelfand said. Patients with severe psoriasis are 41% more likely to die of cancer than are those without psoriasis.

Studies have shown – although not consistently – that psoriasis may be linked with lung, liver, pancreatic, breast, colon, bladder, and kidney cancer. Lymphoma is also a particular concern, with cutaneous T-cell lymphoma having the strongest association.

As with cardiovascular disease, however, findings are not strong or consistent enough to confirm a causal effect of psoriasis on cancer risk, or to clarify whether any association is a disease effect or treatment effect.

Still, the available findings are concerning enough that biopsy should be considered in severe disease, especially if clinical features are not classic, and in those who fail to respond to treatment, because cutaneous T-cell lymphoma may progress rapidly in those on immunosuppressive therapy.

"Always consider a skin biopsy in patients with atypical features of psoriasis and those not responding to treatment," Dr. Gelfand said.

Also, encourage patients to stay up to date on age-appropriate cancer screening. According to Centers for Disease Control guidelines, women aged 21-70 years should undergo cervical cancer screening every 2-3 years, women aged 50-74 years should undergo screening for breast cancer by mammography every 2 years, and men and women aged 50-75 years should undergo screening for colon cancer by fecal occult blood testing every year, by flexible sigmoidoscopy every 5 years, and by colonoscopy every 10 years, he said.

Dr. Gelfand has been an investigator and/or consultant for Amgen, Abbott, Centocor, Pfizer, Celgene, Novartis, and Genentech. He reported having no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

Studies show that severe psoriasis is associated with a 50% increased risk of mortality and up to 5 years of life lost, according to Dr. Joel M. Gelfand.

The leading causes of death in psoriasis patients are cardiovascular disease, infection, and cancer, which account for 34%, 22%, and 21% of deaths, respectively (Br. J. Dermatol. 2010;163:586-92), Dr. Gelfand said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Although there are not yet enough data to confirm a causal effect between psoriasis and these leading causes of death, the findings do have implications for managing patients with psoriasis, he said. Data have consistently demonstrated an association between psoriasis and cardiovascular disease, with numerous published studies linking the two conditions.

Taken together, findings from several of these studies suggest that patients with psoriasis are at increased risk of myocardial infarction, stroke, and cardiovascular death, and that those with severe psoriasis have the greatest risks, said Dr. Gelfand of the department of dermatology at the University of Pennsylvania in Philadelphia.

The clinical significance of these findings is striking; patients with severe psoriasis, for example, are 15 times more likely to die prematurely as a result of cardiovascular disease attributable to psoriasis than they are to develop a melanoma, he said.

One study demonstrated a link between psoriasis and several cardiovascular risk factors, including smoking, obesity, dyslipidemia, hypertension, and diabetes, said Dr. Gelfand, who was one of the authors of the study (J. Am. Acad. Dermatol. 2006;55;829-35).

Furthermore, a population-based cohort study involving more than 130,000 psoriasis patients – including more than 3,800 with severe psoriasis - and up to 5 controls per patient, suggested that psoriasis confers an independent risk for myocardial infarction, particularly in young patients with severe psoriasis. The adjusted relative risk of MI in a 30-year-old patient with mild psoriasis was 1.29, and in a 30-year-old with severe psoriasis was 3.01. The adjusted relative risk of MI in a 60-year old with mild psoriasis was 1.08, and in a 60-year-old with severe psoriasis was 1.36, Dr. Gelfand and his colleagues reported (JAMA 2006;296:1735-41).

That study was conducted using the General Practice Research Database of medical records in the United Kingdom, which includes more than 9 million patients and more than 40 million person-years of follow-up data from 1987 to 2002, he said, adding that at least 12 papers have confirmed an association between psoriasis and cardiovascular disease independent of traditional risk factors for cardiovascular disease.

Although the available data on psoriasis and cardiovascular disease demonstrate the biologic credibility of an association, as well as a plausible time sequence suggesting causation, dose response has been demonstrated in only a few studies, and the strength of the study design has been variable, Dr. Gelfand said.

Although most studies have found an effect – along with a modest but clinically important strength of association similar to the association seen in heart disease, hypertension, and diabetes – data from a randomized controlled trial are needed before a causal relationship between psoriasis and cardiovascular disease can be confirmed, and before a link between aggressive treatment of psoriasis and a reduced risk of cardiovascular disease can be demonstrated, he said in an interview, adding that it currently remains unclear whether aggressive treatment will lower cardiovascular disease risk.

However, the U.S. Preventive Services Task Force, the American Diabetes Association, and the National Cholesterol Education Program recommend that severe psoriasis patients over age 21 years undergo blood pressure screening at each office visit; that those aged 45 years and older undergo fasting blood glucose testing every 3 years (unless they have diabetes risk factors, in which case they should undergo screening earlier and more often); and that those aged 20 years and older undergo cholesterol screening every 5 years.

Existing data also support recommendations for addressing concerns about infection and cancer risk in patients with psoriasis, Dr. Gelfand said.

Patients with severe psoriasis are 65% more likely to die of an infection than are those without psoriasis (Br. J. Dermatol. 2010;163:586-92). Specifically, studies have shown that streptococcal pharyngitis is a risk factor for guttate psoriasis, and that HIV is a risk factor for severe psoriasis, he said, noting that it is recommended that patients be screened for streptococcal infection with guttate flares, and that they be screened for HIV if they have severe psoriasis.

It is also important that patients with psoriasis be routinely vaccinated – prior to initiation of immunosuppressive therapy – against influenza and pneumonia. Vaccination against hepatitis B in patients at risk for infection should also be considered, as well as vaccination against zoster in patients aged 60 and older.

As for cancer, it is a concern in psoriasis patients because of the chronic use of immunosuppressive therapies, comorbid behaviors, and chronic inflammation, Dr. Gelfand said. Patients with severe psoriasis are 41% more likely to die of cancer than are those without psoriasis.

Studies have shown – although not consistently – that psoriasis may be linked with lung, liver, pancreatic, breast, colon, bladder, and kidney cancer. Lymphoma is also a particular concern, with cutaneous T-cell lymphoma having the strongest association.

As with cardiovascular disease, however, findings are not strong or consistent enough to confirm a causal effect of psoriasis on cancer risk, or to clarify whether any association is a disease effect or treatment effect.

Still, the available findings are concerning enough that biopsy should be considered in severe disease, especially if clinical features are not classic, and in those who fail to respond to treatment, because cutaneous T-cell lymphoma may progress rapidly in those on immunosuppressive therapy.

"Always consider a skin biopsy in patients with atypical features of psoriasis and those not responding to treatment," Dr. Gelfand said.

Also, encourage patients to stay up to date on age-appropriate cancer screening. According to Centers for Disease Control guidelines, women aged 21-70 years should undergo cervical cancer screening every 2-3 years, women aged 50-74 years should undergo screening for breast cancer by mammography every 2 years, and men and women aged 50-75 years should undergo screening for colon cancer by fecal occult blood testing every year, by flexible sigmoidoscopy every 5 years, and by colonoscopy every 10 years, he said.

Dr. Gelfand has been an investigator and/or consultant for Amgen, Abbott, Centocor, Pfizer, Celgene, Novartis, and Genentech. He reported having no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.

Studies show that severe psoriasis is associated with a 50% increased risk of mortality and up to 5 years of life lost, according to Dr. Joel M. Gelfand.

The leading causes of death in psoriasis patients are cardiovascular disease, infection, and cancer, which account for 34%, 22%, and 21% of deaths, respectively (Br. J. Dermatol. 2010;163:586-92), Dr. Gelfand said at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Although there are not yet enough data to confirm a causal effect between psoriasis and these leading causes of death, the findings do have implications for managing patients with psoriasis, he said. Data have consistently demonstrated an association between psoriasis and cardiovascular disease, with numerous published studies linking the two conditions.

Taken together, findings from several of these studies suggest that patients with psoriasis are at increased risk of myocardial infarction, stroke, and cardiovascular death, and that those with severe psoriasis have the greatest risks, said Dr. Gelfand of the department of dermatology at the University of Pennsylvania in Philadelphia.

The clinical significance of these findings is striking; patients with severe psoriasis, for example, are 15 times more likely to die prematurely as a result of cardiovascular disease attributable to psoriasis than they are to develop a melanoma, he said.

One study demonstrated a link between psoriasis and several cardiovascular risk factors, including smoking, obesity, dyslipidemia, hypertension, and diabetes, said Dr. Gelfand, who was one of the authors of the study (J. Am. Acad. Dermatol. 2006;55;829-35).

Furthermore, a population-based cohort study involving more than 130,000 psoriasis patients – including more than 3,800 with severe psoriasis - and up to 5 controls per patient, suggested that psoriasis confers an independent risk for myocardial infarction, particularly in young patients with severe psoriasis. The adjusted relative risk of MI in a 30-year-old patient with mild psoriasis was 1.29, and in a 30-year-old with severe psoriasis was 3.01. The adjusted relative risk of MI in a 60-year old with mild psoriasis was 1.08, and in a 60-year-old with severe psoriasis was 1.36, Dr. Gelfand and his colleagues reported (JAMA 2006;296:1735-41).

That study was conducted using the General Practice Research Database of medical records in the United Kingdom, which includes more than 9 million patients and more than 40 million person-years of follow-up data from 1987 to 2002, he said, adding that at least 12 papers have confirmed an association between psoriasis and cardiovascular disease independent of traditional risk factors for cardiovascular disease.

Although the available data on psoriasis and cardiovascular disease demonstrate the biologic credibility of an association, as well as a plausible time sequence suggesting causation, dose response has been demonstrated in only a few studies, and the strength of the study design has been variable, Dr. Gelfand said.

Although most studies have found an effect – along with a modest but clinically important strength of association similar to the association seen in heart disease, hypertension, and diabetes – data from a randomized controlled trial are needed before a causal relationship between psoriasis and cardiovascular disease can be confirmed, and before a link between aggressive treatment of psoriasis and a reduced risk of cardiovascular disease can be demonstrated, he said in an interview, adding that it currently remains unclear whether aggressive treatment will lower cardiovascular disease risk.

However, the U.S. Preventive Services Task Force, the American Diabetes Association, and the National Cholesterol Education Program recommend that severe psoriasis patients over age 21 years undergo blood pressure screening at each office visit; that those aged 45 years and older undergo fasting blood glucose testing every 3 years (unless they have diabetes risk factors, in which case they should undergo screening earlier and more often); and that those aged 20 years and older undergo cholesterol screening every 5 years.

Existing data also support recommendations for addressing concerns about infection and cancer risk in patients with psoriasis, Dr. Gelfand said.

Patients with severe psoriasis are 65% more likely to die of an infection than are those without psoriasis (Br. J. Dermatol. 2010;163:586-92). Specifically, studies have shown that streptococcal pharyngitis is a risk factor for guttate psoriasis, and that HIV is a risk factor for severe psoriasis, he said, noting that it is recommended that patients be screened for streptococcal infection with guttate flares, and that they be screened for HIV if they have severe psoriasis.

It is also important that patients with psoriasis be routinely vaccinated – prior to initiation of immunosuppressive therapy – against influenza and pneumonia. Vaccination against hepatitis B in patients at risk for infection should also be considered, as well as vaccination against zoster in patients aged 60 and older.

As for cancer, it is a concern in psoriasis patients because of the chronic use of immunosuppressive therapies, comorbid behaviors, and chronic inflammation, Dr. Gelfand said. Patients with severe psoriasis are 41% more likely to die of cancer than are those without psoriasis.

Studies have shown – although not consistently – that psoriasis may be linked with lung, liver, pancreatic, breast, colon, bladder, and kidney cancer. Lymphoma is also a particular concern, with cutaneous T-cell lymphoma having the strongest association.

As with cardiovascular disease, however, findings are not strong or consistent enough to confirm a causal effect of psoriasis on cancer risk, or to clarify whether any association is a disease effect or treatment effect.

Still, the available findings are concerning enough that biopsy should be considered in severe disease, especially if clinical features are not classic, and in those who fail to respond to treatment, because cutaneous T-cell lymphoma may progress rapidly in those on immunosuppressive therapy.

"Always consider a skin biopsy in patients with atypical features of psoriasis and those not responding to treatment," Dr. Gelfand said.

Also, encourage patients to stay up to date on age-appropriate cancer screening. According to Centers for Disease Control guidelines, women aged 21-70 years should undergo cervical cancer screening every 2-3 years, women aged 50-74 years should undergo screening for breast cancer by mammography every 2 years, and men and women aged 50-75 years should undergo screening for colon cancer by fecal occult blood testing every year, by flexible sigmoidoscopy every 5 years, and by colonoscopy every 10 years, he said.

Dr. Gelfand has been an investigator and/or consultant for Amgen, Abbott, Centocor, Pfizer, Celgene, Novartis, and Genentech. He reported having no relevant financial disclosures. SDEF and this news organization are owned by Elsevier.