Psoriasis: skin symptoms may be just the tip of the iceberg

World Psoriasis Day will have a more poignant focus this year as the International Psoriasis Council (IPC) issues a ‘call to action’ to medical experts to elevate psoriasis on the public health agenda by undertaking a more thorough therapeutic approach. Recommendations include the need to review current guidelines to ensure a more holistic approach to the management of psoriasis, taking into account the many potential co-morbidities, to prevent this significant health burden escalating. It is essential that physicians are vigilant about monitoring patients for signs of co-morbid conditions and are educated on all the therapeutic options available.

These recommendations come following a collaborative Consensus Meeting convened by the IPC held at the 15th European Academy of Dermatology and Venereology (EADV) Congress earlier this month. Multi-disciplinary medical professionals from around the globe reviewed the inflammatory nature of psoriasis and how it might be linked to co-morbid conditions such as obesity, cardiovascular disease (including hypertension, and myocardial infarction), type II diabetes and liver disease.

Dr Bruce Strober, assistant professor in the department of dermatology at New York University School of Medicine, commented, “Mounting data suggest that psoriasis is a component of an inflammatory state that nurtures significant co-morbidities. It is likely that in some patients both psoriasis and obesity are co-dependent manifestations of an underlying dysfunctional pathophysiologic state. It is important that the overall management of psoriasis is significantly improved to ensure that patients are diagnosed early, appropriately treated and regularly monitored for signs of co-morbidity.”

Among the data presented at the meeting was a statistical study of over 10,000 patients in clinical trials conducted over the past 5 years, showing that psoriasis patients are more likely to have body mass index (BMI) measurements in the overweight and obese ranges than members of the general population. Building on this point, Dr Gerald Krueger of the University of Utah presented a study which indicated that psoriasis and obesity are endpoints of a shared etiology in which one may promote the other.

Important data indicating an increased risk of cardiovascular disease was presented for the first time at the meeting. A large study by Dr Joel Gelfand of the University of Pennsylvania, recently published in the Journal of the American Medical Association, highlighted that psoriasis may be an independent risk factor for heart attack, particularly in young individuals with severe disease. Patients in their 40s with severe psoriasis were more than twice as likely to suffer a heart attack than people without the skin disease. Dr Gelfand’s findings also shed light on potential health risks for overweight psoriasis patients. These data are supported by a case-control study presented at the meeting showing that twice the number of psoriasis patients (60%) had coronary artery calcification than non-psoriasis patients (30%).

Other studies presented at the meeting indicated that patients suffer from their skin disease much more than previously understood. One trial showed that almost half of 1,000 psoriasis patients tested were likely to be clinically depressed, and another demonstrated an increased tendency to use alcohol and tobacco among psoriasis patients.

The consensus group agreed there is overwhelmingly sufficient data supporting the linkage of psoriasis to increased co-morbid risk and to mandate furture investigations funded by both government and industry. Professor Wolfram Sterry, a board member of IPC who chaired the consensus meeting concluded, “Psoriasis is a serious condition in its own right that is exacerbated by its association with co-morbidities. It is essential that physicians understand the severity of the disease and all its manifestations and integrate therapy in a way that provides a treatment that is as broad as possible to cover all the ongoing pathogenetic events.”

Asked about the outlook for the future, Dr Menter, President of IPC is optimistic: “The hope is that now that we understand better the systemic inflammatory nature of psoriasis, we can work closely with our colleagues in medicine and research to improve the general health of our psoriasis patients by using the full spectrum of medications, including the new biologic agents.”

Drs. Sterry, Menter, and Strober are currently working on a paper that will summarise the consensus of the IPC meeting, investigate the relationship between psoriasis and co-morbidities, discuss important areas for research on these issues, and issue recommendations for clinical management of psoriasis patients at risk of developing co-morbid conditions. For now it is important that everyone touched by psoriasis recognises the severity of the condition and the profound lifelong impact it has on health.