Pediatric Psoriasis Comorbidities

Nicole W. Kittler, MD; Kelly M. Cordoro, MD


Skin Therapy Letter. 2020;25(5):1-6. 

In This Article

Metabolic Syndrome, Dyslipidemia, Hypertension, Nonalcoholic Fatty Liver Disease

There is an increased prevalence of metabolic syndrome among pediatric patients with psoriasis, with rates up to 30%.[26,27] This increased risk may reflect the combination of both psoriasis and obesity, rather than psoriasis alone.[28] While lipids may be normal in children with psoriasis, other markers of atherogenesis have been shown to be significantly elevated, including serum apolipoprotein B concentrations, decreased HDL and reduced cholesterol efflux capacity, a measure of HDL function.[19]

The increased risk of early myocardial infarctions (MI) in patients with psoriasis has been well established. A 30 year-old man with severe psoriasis has a relative risk of having an MI of 3.1 compared to non-psoriatic matched controls.[29] Risk for early cardiovascular disease likely begins in childhood or young adulthood, though the relationship between psoriasis and the independent risk factors that lead to MI remains to be delineated.

In adults, psoriasis constitutes an independent risk factor for type 2 diabetes,[30] and earlier age of onset of psoriasis may increase that risk.[31] While studies have shown increased insulin resistance among pediatric psoriasis patients, this correlates most strongly with obesity,[19,24] and therefore the true effect of psoriasis on risk of type 2 diabetes remains to be determined. There is limited data on a potential association between psoriasis and hypertension in children and adolescents, although adult studies support a correlation. Hospitalized children with psoriasis have been found to have an increased risk of hypertension (relative risk 2.63),[32] although these results may not be generalizable to otherwise healthy children with psoriasis. Psoriasis has been identified as an independent risk factor for the development of nonalcoholic fatty liver disease (NAFLD) in adults.[33] Pediatric studies are needed to identify the risk of NAFLD in childhood psoriasis.

The association between psoriasis, metabolic syndrome and, ultimately, cardiovascular disease can be understood as a "psoriatic march", where psoriasis and obesity lead to systemic inflammation, insulin resistance, endothelial dysfunction, atherosclerosis and eventually cardiovascular and cerebrovascular diseases (Figure 2).[34] The goal of caring for pediatric patients is always prevention. The psoriatic march is a useful conceptual framework for understanding the severe downstream effects of psoriasis and obesity, and for explaining the importance of prevention and early intervention. The preventive effects of early and aggressive treatment for psoriasis in pediatric patients on risk of MI and other long-term outcomes remains to be delineated.

Figure 2.

Psoriatic march.
Adapted from Boehncke et al. Experimental Dermatology, 2011.34

The psoriasis CSI has advocated following the AAP and National Heart, Lung, Blood Institute recommendations[35] for screening of metabolic syndrome:

  • Fasting lipid panel at ages 9–11 years and again at 17–21 years. Additional screening based on risk profile.

  • Annual hypertension screening beginning at age 3 years.

  • Fasting glucose every 3 years starting at age 10 years or puberty if patient is overweight and has 2+ risk factors. Additional screening based on risk profile.

  • Alanine transferase (ALT) measurement starting at age 9–11 years if obese or overweight with additional risk factors, prediabetes or diabetes, dyslipidemia, obstructive sleep apnea or family history of NAFLD/nonalcoholic steatohepatitis (NASH, an advanced form of NAFLD). Additional and repeat screening based on risk profile.

Complete recommendations are delineated in Table 2.