Selected Skin Diseases With Systemic Involvement

Marcelo Ruiz, MD; Pilar Valdés, MD; Kenneth Tomecki, MD


Skin Therapy Letter. 2013;18(4) 

In This Article

Psoriasis and Cardiovascular Disease

Psoriasis is a chronic relapsing inflammatory disease of the skin that affects 1–3% of the population.[16,17] Dermatologists are well familiarized with the clinical presentation, subtypes, and histologic features of psoriasis, but there is still much to learn about disease physiopathology, systemic consequences, and how these factors influence therapy. At present, there is great interest in elucidating the potential link between psoriasis and significant comorbidities, such as an increased risk for metabolic dysfunction and cardiovascular disease (CVD), which could be explained by a systemic inflammatory process. As we know, a complex interplay between environmental and genetic factors sets the scene for psoriasis-initiating events, allowing activation of the immune system and generation of effector T cells that reside in the skin and interact with keratinocytes. Chronic inflammation is maintained through the action of key cytokines (e.g., tumor necrosis factor-alfa).[18] Systemic inflammation could be responsible for subsequent insulin resistance, endothelial cell dysfunction, and atherosclerosis.[17,19–21]

Different population-based cohort studies indicate that there is a higher risk for myocardial infarction (MI) in psoriasis patients,[22–27] with increased risk of cardiovascular death and all-cause mortality.[28,29] These findings are independent to the presence of other major cardiac risk factors and comparable to them in the magnitude of risk, similar to diabetes mellitus. However, there is also controversial evidence against these results.[30–32] According to most of the studies that found an increased risk, clinical characteristics of psoriasis patients that are related to a higher risk are young age (<50 years), severe skin affection (defined by Psoriasis Area and Severity Index or the need of systemic therapy) and psoriatic arthritis (PsA). The incidence of cerebrovascular and peripheral vascular disease could also be higher among psoriasis patients compared to the general population.[23,33,34]

In light of this evidence, it is critical to know whether systemic therapies do have a cardioprotective effect and a preventive role in the development of CVD in severe psoriasis patients, as this answer could change current paradigms of treatment. There are already some published studies addressing this issue. By measurements of biomarkers of cardiovascular risk (e.g., C-reactive protein, homocysteine, and lipid profile), direct evaluation of atherosclerotic progression (e.g., carotid ultrasonography), and assessment of MI risk, promising results have been reported showing beneficial effects of different systemic agents when compared to patients using only topical therapy.[35–39] However, a recent study that compared MI risk in psoriasis patients after being treated with phototherapy, traditional systemic agents, or different biologics, found no overall relevant changes in MI risk.[35] At the moment, there is still a lack of evidence supporting the use of systemic therapies for the prevention of CVD in psoriasis patients. Therefore, larger multicenter studies are needed to confirm this data and the longterm safety profiles of biologic drugs.

Regular screening for CVD risk factors is recommended in psoriasis,[40,41] especially for patients with severe disease and PsA, but the fact that other cardiac risk factors (e.g., obesity or metabolic syndrome) are more common in psoriasis[42–44] points out that this practice could be beneficial for all psoriatics, allowing early implementation of preventive measures.[45] A detailed history inquiring about diabetes, dyslipidemia or hypertension should be performed, together with the evaluation of blood pressure, body mass index and waist circumference at least every 2 years. Fasting serum lipoproteins, blood glucose and glycosylated hemoglobin should be determined at least every 5 years, or every 2 years if other risk factors are present. Another recommended approach is to undertake these assessments every 6 months in patients receiving systemic therapy and yearly in those undergoing topical treatment.[40,41,45]