What lies beneath
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Dermatologists play a key role in managing emerging comorbidities associated with psoriasis

The scaling inflammation of psoriasis can often be a sign that potential comorbidities are brewing beneath the skin’s surface. Dermatologists need to take the lead in educating patients on this potential threat and make sure they receive necessary assessments and treatment.

Range of conditions

The risk of comorbidities increases with the severity of psoriasis, and the conditions are varied. With this in mind, the National Psoriasis Foundation issued a clinical consensus on psoriasis comorbidities. The clinical consensus, reported in the Journal of the American Academy of Dermatology, listed comorbidities associated with psoriasis, including cardiovascular risk, metabolic syndrome, cancer, psoriatic arthritis, and others (2008;58:1031-1042).

“Cardiovascular diseases amongst people with psoriasis are probably the most common comorbidity experienced,” said Joel M. Gelfand, MD, medical director of the clinical studies unit and assistant professor of dermatology and epidemiology at the University of Pennsylvania. “It’s more common than psoriatic arthritis.” Findings from a 2006 study published in JAMA by Dr. Gelfand and his colleagues indicated that psoriasis may be an independent risk factor of myocardial infarction (2006;296:1735-1741).

Research suggests that patients with psoriasis carry a higher risk of anxiety, depression, and suicidality; Crohn’s disease; and other conditions (Arch Dermatol 2010;146:891-895; J Am Acad Dermatol 2003;48:805-821). [pagebreak]

The connection between psoriasis and co-morbidities is attributed to a number of potential causes. Several studies have shown that patients with psoriasis are more likely to be overweight (BMI >25) or obese (BMI > 30) than patients without psoriasis; therefore, they are more likely to have metabolic syndrome, which includes obesity, dyslipidemia, insulin resistance, and hypertension and increases the risk of cardiovascular disease, said Neil Korman, MD, PhD, professor of dermatology at Case Western Reserve University and clinical director of the Murdough Family Center for Psoriasis in Cleveland. This connection was discussed in Seminars in Cutaneous Medicine and Surgery (2010;29:10-15).

Other factors may contribute to comorbidities, as reported by Davidovici and colleagues in the Journal of Investigative Dermatology (2010;130:1785-1796).“Psoriasis is a systemic inflammatory disease that manifests in the skin,” Dr. Korman said. “But inflammation is thought to play a critical role in the comorbidities of cardiovascular disease, arthritis, and diabetes. It may also play a role in some of the psychiatric comorbidities, such as depression. And it may play a role in the lipid abnormalities.”

In addition, lifestyle choices such as smoking and drinking; coexisting conditions; and the psychological burden of a chronic illness may trigger comorbidities, said Gerald G. Krueger, MD, professor of dermatology and Benning Presidential Endowed Chair at the University of Utah School of Medicine. [pagebreak]

Managing comorbidities

When a patient seeks treatment for psoriasis, a dermatologist is often the primary physician a patient sees — and sometimes the only physician. Thus, frontline dermatologists need to stay ahead of the situation.

“Not all dermatologists will want to take care of the comorbidities themselves,” said Alexandra Kimball, MD, MPH, associate professor at Harvard Medical School. “For those who don’t wish to do that, however, it’s important to make sure that patients at risk for [comorbidities] are well linked into a primary care system.”

Patient education is key. Dermatologists should discuss likely risks with patients and make sure they are up-to-date with age-appropriate medical care, including routine assessments such as blood pressure checks, laboratory studies, and immunizations. Dermatologists should also encourage evaluation for depression when appropriate.

Cancer screenings are particularly important if immunosuppressant therapy is being considered. “If you have a 55-year-old woman and she’s never had a colonoscopy or mammogram, you probably want to make sure that’s been done, if possible, before you start an immunosuppressant regimen,” Dr. Gelfand said. If a patient has had abnormal Pap smears, her gynecologist should know that she will be taking a medication that could influence the risk of certain cancers, he added. [pagebreak]

Dermatologists should also counsel patients on ways to reduce their risks, such as losing weight, not smoking, and keeping blood pressure and lipids under control. Cardiovascular risk factors need to be managed aggressively. “Psoriasis of the skin is insight into what’s going on throughout the body, and it’s a reminder for the patient to do the things that we all should be doing: eating healthier, exercising, things of that nature,” Dr. Gelfand said.

Connecting with primary care physicians

Dermatologists should first determine if patients have a primary care physician — and encourage them to obtain one if they don’t. After referral to a primary care physician, continued follow-up is important. A primary care physician will be looking for conditions such as cardiovascular disease, arthritis, and diabetes. Then dermatologists need to work closely with primary care physicians, explaining the non-dermatological risks associated with psoriasis.

Dr. Krueger refers patients to rheumatologists when necessary and maintains a relationship with the patient’s primary care physician. If a patient doesn’t have a primary care physician, however, he explained that it may be more efficient to have the dermatologist’s clinical staff screen patients for comorbidities. “Many dermatologists have extended care providers. These providers will relish being given the responsibilities of caring for these comorbidities. With a small amount of training, they can manage most of these comorbidities very effectively,” Dr. Krueger said.

However, if patients have a primary care physician, they should be encouraged to follow up with that provider. [pagebreak]

Treatment benefits, challenges

Researchers are continuing to explore whether treating psoriasis reduces the risk of comorbidities.

Dr. Gelfand explained that studies in rheumatoid arthritis seem to suggest that methotrexate and tumor necrosis factor inhibitors could reduce the risk of cardiovascular events. However, because these were not randomized controlled trials, researchers don’t know for sure whether the drugs are responsible or other factors are involved. For example, a review and meta-analysis in the American Journal of Cardiology reported that when patients with chronic inflammatory disorders were treated with methotrexate, their risk of cardiovascular disease decreased (2011;108:1362-1370). A review and meta-analysis published in Arthritis Care Research (2011;63:522-529) demonstrated that treatment of patients with rheumatoid arthritis with anti-tumor necrosis alpha factor reduced cardiovascular events.

However, it’s not yet known if the same will hold true for psoriasis treatment and its impact on comorbidities. “We don’t know currently if treating the disease itself will lower the risk of cardiovascular problems and metabolic problems over time,” Dr. Gelfand said. “We just don’t know the answer to that yet, but we’re trying to figure it out.” [pagebreak]

Additionally, comorbidities present multiple challenges that frequently complicate treatment of the psoriasis itself. For example, overweight patients don’t respond as well to therapy, and patients who have had cancer may not be receptive to taking immunosuppressant therapies. “So I think the first issue is knowing what is going on with the patient’s health because we have to know all of these issues first,” Dr. Gelfand said. “And secondly, there should be a careful risk-versus-benefit discussion that you have to have with the patient.”

Beneath the surface

Increased awareness of psoriasis comorbidities continues to offer physicians an important perspective on skin disease.

“I think we need to think more broadly about other diseases that are common in dermatology and be thinking about concomitant issues that may arise in those conditions as well,” Dr. Kimball said. “Psoriasis is not the only disease that has profound inflammation associated with it, so I think [examining comorbidities] is a wake-up call for us to be thinking much more broadly about the patients we treat.”