Inside the New Psoriasis Guidelines, Part II

As more evidence supports the association between psoriasis and comorbid conditions, including cardiovascular disease (CVD) and depression, best practices for screening and managing patients with concomitant conditions are needed to develop effective treatment strategies. The American Academy of Dermatology and the National Psoriasis Foundation recently released two new guidelines outlining best practices for managing the inflammatory skin disease. The guidelines on biologics (covered in the April 2019 issue of The Dermatologist) offered some strategies for treating patients with concomitate conditions, such as inflammatory bowel disease (IBD) and psoriasis.¹ The second set of guidelines provides strategies for treating patients with various comorbid conditions. These recommendations on the management of comorbid conditions in patients with psoriasis include the latest evidence on the association between psoriasis and various comorbidities and guidance on screening.² This article, part II of our series on these new guidelines, outlines select recommendations and the role dermatologists play in treating these conditions. 

Treating Comorbidities

Psoriasis is a multisystem inflammatory disease that negatively impacts patients mentally and physically. “Providers will need to inquire about other comorbidities so patients can get the best care available,” said Craig A. Elmets, MD, professor of dermatology at the University of Alabama in Birmingham and co-chair of the guideline workgroup, in an interview with The Dermatologist. “Treating patients with psoriasis at this point requires knowledge of what comorbidities are and how they need to be addressed with the patient. This guideline provides practicing physicians with the latest evidence-based information about comorbidities associated with psoriasis.” The guidelines address screening and treatment of psoriatic arthritis (PsA), cardiovascular disease (CVD), metabolic syndrome, mental health conditions, lifestyle choices, IBD, malignancy, renal disease, sleep apnea, chronic obstructive pulmonary disease, uveitis, and hepatic disease.²

Psoriatic Arthritis 

The recommendations encourage a proactive approach to screening for PsA in patients with psoriasis and state that it is considered essential for each visit. “There are several evidence-based screening tools,” said Dr Elmets. “Dermatologists can decide on the appropriate one for their particular practice.” Physical exams can help establish inflammatory arthritis and enthesitis in patients with signs of inflammation, such as joint swelling, redness, and warmth in addition to tenderness. Furthermore, patients should be educated on the signs and symptoms of PsA, and consultation with a rheumatologist is recommended.²

Cardiovascular Disease

Several studies showed an association between psoriasis and major cardiovascular events and disease. The American Heart Association (AHA) and American College of Cardiology (ACC) now define psoriasis, and other inflammatory diseases, as risk factors for atherosclerotic CVD. Due to these strong associations, the authors recommend cardiovascular risk assessment for all patients with psoriasis, including screening for hypertension (Table 1), diabetes (Table 2), and hyperlipidemia. When using risk models, clinicians are recommended to introduce a 1.5 multiplication factor when assessing patients with psoriasis who have more than 10% affected body surface area or are candidates for systemic therapy or phototherapy. National guidelines should be used to manage a patient’s risk, and patients should be referred to a cardiologist as warranted.²

Metabolic Syndrome

Patients with psoriasis have a higher risk for metabolic syndrome, which consists of obesity, hypertension, dyslipidemia, and insulin resistance. Patients are diagnosed with metabolic syndrome if they have three or more of the following criteria: increased waist circumference above 40 inches in men and 35 inches in women; blood pressure above 130/85 mm Hg; fasting triglycerides above 150 mg/dL; fasting high-density lipoprotein levels above 40 mg/dL in men and above 50 mg/dL in women; and fasting glucose of 100 mg/mL or more.²

The guidelines recommend providers screen patients by measuring blood pressure, waist circumference, fasting blood glucose, and/or hemoglobin A_1C, and fasting lipid levels. Tests for assessing lipid levels include fasting total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides. Nonfasting tests are recommended over fasting.²

Also, certain medications are known to have adverse effects on lipid levels, such as acitretin and cyclosporine, and patients on these medications should be monitored routinely. Current evidence does not support the need to avoid certain antihypertensive medications; however, some medications used to treated psoriasis, such as cyclosporine, can cause new-onset hypertension or worsening hypertension.²

In addition to testing and referring patients to primary care providers to monitor type 2 diabetes and metabolic syndrome, the guidelines recommend providers educate patients on the associations between these conditions. Disease severity is influenced by obesity status, hypertension, dyslipidemia, and type 2 diabetes. Thus, importance of a healthy lifestyle, including maintaining a healthy diet, exercise, smoking cessation, reduced alcohol intake, and mental wellness, should be stressed to patients, the guidelines recommend.

Mental Health

Depression, anxiety, and suicidal ideation are also associated with psoriasis, and various studies have shown these mental health conditions impact disease severity. Patients should be screened for and educated on mental health comorbidities, as well as referred to appropriate specialists. The guideline authors noted that treatment of psoriasis simultaneously improved symptoms of depression, anxiety, and suicidal ideation.² 

Quality of Life

According to the guidelines, comprehensive care includes discussing quality of life concerns with patients. Psoriasis negatively affects interpersonal relationships, work productivity, and sexual health. The guidelines recommend that, if not initiated by the patient, providers broach these topics, validate patients’ concerns, and empower patients through dialogue and treatment.²

IBD, Cancers, and Other Comorbid Conditions

IBD, cancers, such as lymphohematopoietic cancers and nonmelanoma skin cancer, renal disease, obstructive sleep apnea, uveitis, and nonalcoholic fatty liver disease have all been associated with psoriasis. Awareness of these conditions, as well as of potential exacerbation from treatment in the case of IBD or of increased risk from treatment for skin cancer, are recommended to ensure patients receive early intervention. Patients should be educated on these associations and referred to appropriate specialists if necessary. More information about these comorbid conditions and recommendations can be found in the guidelines.²

Conclusion

Advances in the treatment of psoriasis have significantly improved patient care. To ensure the best care, the guidelines on the management of comorbid conditions encourage collaboration with other specialists and shared decision-making with patients for addressing comorbid conditions. 

References

1. Menter A, Strober BE, Kaplan DH, et al. Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with biologics. J Am Acad Dermatol. 2019;80(4):1029-1072. doi:10.1016/j.jaad.2018.11.057

2. 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

3. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13-e115. doi:10.1161/HYP.0000000000000065

4. American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes—2019. Diabetes Care. 2019;42(suppl 1):S13-S28. doi:10.2337/dc19-S002