Review
National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening

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There have been several articles and reports in recent months about comorbidities and risks that affect psoriasis patients in addition to their underlying disease. This piece reviews the current literature and begins to address what should be done with this new information by updating the clinician about what health screening tests, preventative exams, and referrals should be considered in this population.

Section snippets

General cardiovascular risk

Studies dating back several decades of patients hospitalized for psoriasis or from tertiary care referral clinics have shown that psoriasis is associated with increased occlusive vascular disease, including cardiovascular risk (CVR).5, 6 In initial assessments, the increased risk of MI and vaso-occlusive disease was attributed to the increased prevalence of risk factors. These risk factors have been attributed to behaviors such as obesity and smoking which are thought to be provoked by the

Metabolic syndrome

Metabolic syndrome has received an increased focus in the field of psoriasis.25 A hospital-based case control study has shown an increased prevalence of metabolic syndrome in psoriasis patients that is independent of psoriasis severity.26 Metabolic syndrome is a combination of metabolic risk factors in an individual, including abdominal obesity, atherogenic dyslipidemia, elevated bood pressure, insulin resistance or glucose intolerance, prothrombotic state, and a proinflammatory state. While

Behavioral-driven risk cardiovascular risk

The increased risk for CVD in psoriasis patients may also be mediated through behaviorally driven CVR factors, such as smoking, obesity, and depression.

Alcohol intake

While alcohol consumption has not been identified as a marker for increased CVR per se, it is a behavioral-driven factor which has, with some controversy, been linked to the onset of psoriasis, increased psoriasis severity, and decreased response to treatment. Less well-studied are the end results of alcohol-related comorbidities, such as cirrhosis and hepatocellular carcinoma. Multiple studies have shown that increased alcohol use, and in some cases, abuse, are independent risk factors for

Infection

Good data on the risk of both cutaneous and systemic infection in patients with psoriasis are very limited. Moreover, the few available reports give contrasting answers. In patients with erythrodermic psoriasis, there seems to be a significant risk of staphylococcal septicemia.63, 64 However, while psoriatic patients have similar abnormalities in cutaneous barrier function to patients with atopic dermatitis, they have far fewer cutaneous infections.65 This finding has been related to a cytokine

Malignancies

Because the pathogenesis of psoriasis has a strong immunologic basis,77 some have raised the concern that psoriasis could be associated with an increased risk of lymphoma. While some studies suggest an increased risk of lymphoma in patients with psoriasis,78, 79, 80, 81, 82, 83, 84, 85, 86 other studies do not support this association.87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97 The largest study evaluating this association is a retrospective, population-based cohort study that enrolled 153,197

Psoriatic arthritis

Psoriatic arthritis (PsA) is an inflammatory arthritis associated with psoriasis, usually seronegative for rheumatoid factor.111 PsA occurs in about 6% to 40% of patients with psoriasis, depending on the population studied. PsA prevalence has been reported to vary with the severity of psoriasis.112 It affects men and women equally, at an average age of 36 years, between 7 to 10 years after the onset of psoriasis. A clinical feature which distinguishes patients with PsA from patients with

Other immune-mediated inflammatory diseases

Patients with immune-mediated inflammatory diseases (IMIDs) generally appear to be at higher risk of developing another IMID.127 In addition to psoriatic arthritis, specific reports include an association of psoriasis with Crohn's disease.128, 129, 130 In a series of case-control studies, 7% to 11% of patients with Crohn's disease were diagnosed with psoriasis compared to 1% to 2% of controls.131, 132, 133 Relatives of subjects diagnosed with either Crohn's or psoriasis also have been shown to

Conclusion

Psoriasis is a complex disease that affects organs other than the skin in a significant number of cases. For the health care professional treating psoriasis, the minimum recommended screening for CVD, obesity, depression, infections, malignancies, psoriatic arthritis, and other IMIDs has been provided. While more research is needed to determine if additional screening is indicated for these patients, we feel this summary should result in a dialogue on how to best diagnose, monitor, and treat

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    Supported by the National Psoriasis Foundation and the National Institutes of Health grant K23AR051125-01, National Institute of Arthritis and Musculoskeletal and Skin Diseases (Dr Gelfand).

    Disclosures: Dr Kimball is an investigator and consultant for Abbott, Centocor, and Amgen, and receives funding for a fellowship from Centocor. Dr Gladman is a consultant to Abbott, Amgen, Centocor, Schering-Plough, and Wyeth and received unrestricted research grant support from Abbott Canada, Amgen-Wyeth Canada, Schering Plough Canada, Pfizer Canada, and Wyeth Global. Dr Gelfand is an investigator for or receives grant support from Amgen, Abbott, and Centocor. He is a consultant for Amgen, Centocor, and Genentech and his practice provides phototherapies. Dr Gordon has received research support and honoraria from Abbott, Amgen, and Centocor. Dr Horn was an employee of the National Psoriasis Foundation. The National Psoriasis Foundation receives unrestricted funding from Abbott Immunology, Amgen and Wyeth, Astellas Pharma, Inc, Barrier Therapeuics, Beiersdorf, Centocor, Daavlin, Galderma Laboratories, Genentech, National Biologic Corporation, Neutrogena, Photomedex, Stiefel Laboratories, and Warner Chilcott. Dr Korman is an investigator for or receives grant support from Abbott Laboratories, Amgen, Astellas, Biogen Idec, Centocor, Genentech, Genmab, Novartis, Peplin, and Seattle Genetics. He is also a speaker or consultant for Abbott Laboratories, Amgen, Genentech, Genmab, Novartis, and Peplin, and his practice provides phototherapy services. Dr Korver has received some fellowship support from Amgen and Centocor. Dr Krueger is a consultant or advisory board member for Abbott, Almirall, Alza, Amgen, Astellas, Barrier Therapeutics, Boehringer Ingleheim, Bristol Myers Squibb, Centocor, Connetics, Genentech, Genzyme, L'Oreal, Magen Biosciencs, MedaCorp, Medicis, Novartis, Schering Plough, Warner Chilcot, and ZARS. He owns equities and stock options in/from ZARS. Dr Krueger has received lecture fees from Abbott, Amgen, Astellas, Boehringer Ingleheim, Centocor, Connetics, and Warner Chilcott, and partial stipend support for a clinical research fellowship from Abbott, Amgen, and Centocor. Dr Strober is a speaker, advisor, and/or investigator for Amgen-Wyeth, Abbott, Centocor, Astellas, and Genentech. Dr Lebwohl is an investigator for Abbott Laboratories, Amgen, Astellas, Centocor, Connetics, Galderma, Genentech, 3M, Novartis, and Warner Chilcott. He is also a consultant for Abbott, Amgen, Astellas, BristolMyersSquibb, Centocor, Connetics, Galderma, Genentech, 3M, Novartis, Pfizer, and Warner Chilcott and speaker for Abbott, Amgen, Astellas, Centocor, Chester Valley, Connetics, Galderma, Genentech, 3M, Novartis, PharmaDerm, and Warner Chilcott, and his practice provides phototherapy services.

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