Comorbidities of Psoriasis: Awareness and Attention in Practice

 Because of the increasing knowledge that psoriasis is a disease that affects more than just the skin, there is a heightened awareness of and attention to its comorbidities. The systemic inflammation of psoriasis is postulated to affect other organ systems with some likely involvement of inflammatory mediators or immune response, with known associations with psoriatic arthritis (PsA), cardiovascular disease, metabolic syndrome, and inflammatory bowel disease.¹ There is also growing evidence of associations between psoriasis and malignancy, renal disease, sleep apnea, chronic obstructive pulmonary disease, uveitis, and hepatic disease.¹ With all these immune-mediated and inflammatory conditions, how can dermatologists appropriately treat psoriasis alongside these comorbidities?

Looking at Comorbidities
“That’s a good question,” said Alan Menter, MD, FAAD. Dr Menter is chairman of the division of dermatology and program director of the dermatology residency program at Baylor University Medical Center as well as director of the Baylor Research Center in Dallas, TX. He and Dr Aaron S. Farberg, assistant professor of dermatology at Baylor University Medical Center, addressed the question in their presentation, The Comorbidity Profile of Psoriasis, at the American Academy of Dermatology (AAD) Summer Meeting 2021.²

“The AAD and the National Psoriasis Foundation, or NPF, published six guidelines in 2019 and 2020, and the focus of one of the guidelines is comorbidities. It was a long guideline that discussed the 12 comorbid conditions associated with psoriasis,” explained Dr Menter. “I think it is very important that dermatologists now recognize that psoriasis is no longer considered a skin disease. It is a systemic, immune-mediated disease with multiple comorbidities, and we need to distinguish it as such so that these patients can receive the correct care.”

Dermatologists have an opportunity, he added, to help provide preventive care by addressing the comorbidities of psoriasis. In particular, psoriatic joint disease presents with various manifestations such as inflammatory arthritis of the peripheral joints or of the spine, mimicking rheumatoid arthritis or ankylosing spondylitis, respectively. The enthesitis, dactylitis, and spondylitis leads to a high impact on health-related quality of life, health care costs, and health care utilization, as well as progressive joint damage and higher mortality as attributed to cardiovascular disease.³ The guideline¹ recommends a proactive approach of screening patients for PsA at each psoriasis visit, and addressing psoriasis and PsA early with appropriate therapy or referral to a rheumatologist can reduce the long-term damage.

Similarly, cardiovascular disease can have lifelong impact, and common screening measures (eg, hypertension, diabetes, hyperlipidemia) could prevent more serious cardiovascular events.

“If a dermatologist has a patient with moderate to severe psoriasis and who is on a systemic or biologic therapy, it means the dermatologist is going to see the patient every 3 to 6 months,” said Dr Menter. “At each visit, there should be a minute or two taken to discuss potential comorbid conditions. Obviously, dermatologists are not cardiologists, but we should screen for cardiovascular disease. We can record the patient’s heart rate, we can check the cholesterol and lipid levels, and we can screen for hypertension. With this information, we can work with our cardiology colleagues to provide care for our patients.”

Dr Menter said that the cardiology specialty now recognizes the negative association of psoriasis and cardiovascular disease as well. Patients with psoriasis have a 4- to 5-year shorter lifespan due to this association,⁴ and a multidisciplinary approach with dermatology, cardiology, and primary care is important for the patient’s overall health. “We have to recognize cardiovascular disease when we see our patients with psoriasis, and a brief survey at each visit could help us get these patients the cardiology care they need sooner,” he added.

Specific Factors to Examine
Given the number of associations, dermatologists should develop a robust screening system or script for their patients with psoriasis.

“Number one, we should screen patients for those cardiovascular risks that we spoke about earlier,” said Dr Menter. In addition to checking heart rate, blood pressure, and lipid panel, dermatologists can check for edema. They can also ask the patient about their own care habits. “See how aware the patient is at each visit. Ask them if they are seeing a cardiologist or have seen one in the past, if the patient has any history of congestive heart failure, any history of pulse problems, etc,” he added. “We need to be aware of these factors and work with our patients and other specialties to ensure that patients get the appropriate care that they need.”

Mental health is also a critical area in need of screening. “Depression and suicidal ideation are common in the psoriasis population,” said Dr Menter. “I think we have recognized that in recent research, particularly with younger patients with moderate to severe disease. They do not enjoy living with a visible disease like psoriasis. Again, patients on systemic or biologic therapies are visiting the dermatologist multiple times per year, so we as dermatologists get to know these patients fairly well. Once we develop that relationship, we should start asking the patients some personal questions about their lifestyle—how depressed they feel, how sad they feel about their psoriasis, how is it affecting their interpersonal relationships with their family, with their friends, with their work colleagues, etc. I think it's important for dermatologists to work with our psoriasis population to ensure that depression and suicidal ideation is not an issue by gently approaching the topic.”

Addressing the various comorbidities of psoriasis may seem out of scope for dermatologists, but Dr Menter stressed the importance of providing whole-body care for this systemic inflammatory disease. Additionally, educating the patients on psoriasis being a systemic disease that can put them at higher risk especially for cardiovascular disease.

“Going through all the comorbidities with the psoriasis population is important,” he said. “The updated AAD-NPF joint guidelines on the awareness and attention to comorbidities is a good resource for dermatologists. Review the recommendations and work with your patients accordingly to make sure they have the care that they need on an individual basis.”

References

1. Elmets CA, Leonardi CL, Davis DMR, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol. 2019;80(4):1073-1113. doi:10.1016/j.jaad.2018.11.058
2. Menter A, Farberg AS. The co-morbidity profile of psoriasis. Presented at: American Academy of Dermatology Summer Meeting 2021; Tampa, FL; August 5-8, 2021.
3. Singh JA, Guyatt G, Ogdie A, et al. 2018 American College of Rheumatology/National Psoriasis Foundation guideline for the treatment of psoriatic arthritis. Arthritis Rheumatol. 2019;71(1):5-32. doi:10.1002/art.40726
4. Kivelevitch D, Schussler JM, Menter A. Coronary plauq characterization in psoriasis. Circulation. 2017;136(3):277-280. doi:10.1161/CIRCULATIONAHA.117.029126