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Steven R. Feldman, MD, PhD: Welcome to Medscape InDiscussion: Psoriasis. I'm your host, Dr Steve Feldman. This is episode two of this year's six-part series on psoriasis management. Today, we'll focus on three important comorbidities in individuals with psoriasis: cardiovascular disease, psoriatic arthritis, and mental health issues. We have a lot to cover; this is going to be a lightning round with three guests.
We'll start by delving into how cardiovascular disease and psoriasis are linked. Many people may think of psoriasis as a cosmetic skin disorder, but it's an inflammatory disease with considerable internal impact. With me for the cardiovascular portion of this discussion is the former National Institutes of Health (NIH) section chief of inflammation and cardiometabolic diseases, and the founding principal investigator of the largest cohort study to date that is examining the impact of psoriasis on cardiometabolic disease. He left the NIH to pursue his work on an international scale and is clinical professor of medicine at George Washington University in our nation's capital. He has cross-linked the fields of cardiology and dermatology by publishing the results of several studies about the impact of psoriasis on cardiometabolic health. Welcome, Dr Nehal Mehta.
Nehal Mehta, MD, MS: Steve, it's great to be here. Thanks for having me. I'm so excited to talk about all the research as well as the clinical implications of cardiovascular disease in psoriasis.
Feldman: Yes, the work you've been doing is groundbreaking. It may be the hottest area of research in dermatology. Let's start with this question: What is the relative risk for a major adverse cardiovascular event in people with psoriasis compared with the general population?
Mehta: There are a couple of good studies — observational databases — that show that people with severe psoriasis have about a 50%-60% increased risk for heart attack, stroke, and dying from that heart attack or stroke. If you have mild psoriasis, that number is anywhere between 10% and 15%. It's a real risk factor.
Feldman: One of the things that I look at when I'm reviewing manuscripts is to try to figure out what the absolute risk is when somebody says, "Oh, there's a big relative risk." I know that the work that came out of the University of Pennsylvania using Great Britain's research database found that if you had severe psoriasis and you were between the ages of 20 and 30 years old, you were at a two- to threefold increased risk of having a heart attack, which sounds terrible, until you realize that the baseline risk for a 20- to 30-year-old having a heart attack is roughly zero. So, two to three times that? Is it so much? What is the absolute risk that we're talking about?
Mehta: It varies by age, Steve; I'm glad you brought that up. In fact, the more severe the disease is and the younger the patient is, the higher the absolute risk. Now, you're correct; the absolute risk may not translate into a clinical event, but the cumulative risk does take some time. So, in terms of numbers, if your age is between 40 and 50 years, the relative risk is 1.47 — so, a 47% increase if you have severe psoriasis. That's a real number. It's 1.47 — nothing relative about it; it's an absolute risk. If you compare this with that of an 80-year-old, where the risk due to age is higher, the risk for psoriasis is lower; it's about 20% — 1.2. So, age matters a great deal. But my message to you — my message to the listeners — is that the younger you are and the more severe your disease is, the more it affects your cardiometabolic health.
Feldman: So, these patients are often seeing a dermatologist. Dermatologists don't normally do EKGs, and we don't even measure blood pressure most of the time. What cardiovascular screening should we be doing for our patients with psoriasis?
Mehta: There are three things — I call them the "Mehta three B's": You should get your body mass index checked; you should get your blood pressure checked; and you should get your blood checked for glucose and cholesterol. You'll find that starting with the first diagnosis of psoriasis, if a patient is educated that there is a risk for high blood pressure, there's a risk for obesity, and there's a risk of high cholesterol, it's easier then to discuss with them the risk for heart attack and the risk for stroke. So, first diagnosis, and then every 5 years thereafter, a patient should be screened for these three B's. And yes, it should start with children. We have compelling evidence in two studies that insulin resistance and obesity start very early on in children with psoriasis.
Feldman: I get the sense that these three B's are probably the most important screening to get done but not the most exciting; for dermatologists that would be if treating the psoriasis would reduce the cardiovascular risk. Does it? I mean, psoriasis is an inflammatory disease, and it's the inflammation that's causing the risk, right? So, if I get rid of that inflammation, maybe I reduce the cardiovascular risk?
Mehta: You know, Steve, you would hope so. The answer is that we're still dissecting it. But you might wonder why a cardiologist is in this field at all. I was using psoriasis as an example, as a model disease, to say, "Hey, if you can see inflammation, you treat it, and that inflammation goes away, will your cardiovascular or cardiometabolic diseases get better?" We have dissected this out over a 10-year period of time in our cohort study, and we found three things: First, treating the disease is important; it reduces systemic inflammation. Second, treating the disease is important; it curbs insulin resistance due to the reduction in systemic inflammation, so that diabetes and metabolic syndrome, as well as obesity itself, will improve. The third and most important thing is that anecdotal observational evidence through databases, as well as some of our own observational work, suggests that if you treat the disease and you drop its severity down from severe to mild over a period of time as short as 1 year, you will see an improvement in both subclinical atherosclerosis, as well as the age of the artery, through a reduction in vascular and coronary inflammation.
What we don't have, Steve, are good randomized trials. We don't have a 1A or even a 1B indication. We have not done a randomized trial showing that treating disease improves cardiovascular outcomes. But there is time to do so. My message would be that treating the disease is important for improving quality of life. Treating the disease is important cosmetically. You're going to hear later that treating the disease is important for mental health. You're going to hear from our next expert that treating the disease is important for reducing the incidence of other comorbid diseases, including psoriatic arthritis. So, even though we don't have the magic bullet yet for cardiovascular disease itself, we do have quite a lot of evidence that keeping this disease once thought to be cosmetic at bay is extremely important in reducing the risk for other comorbid diseases.
Feldman: I'm wondering about absolute risk again. So, I'm old. I have high cholesterol, and my preventive cardiologist said, "Steve, take a statin." So, I looked at the risk calculator, and if I take my statin regularly, I can reduce my cardiovascular risk of having an MI over the next 10 years by about 30%, which sounds like a lot until you look at the baseline risk of 7%, so the 30% reduction takes me to 5% — so, 7% to 5%. Even if treating the psoriasis was as potent as a statin is, those are the kind of numbers we'd be looking at.
Mehta: That's a great analogy, Steve. That is exactly how I explain the impact of what we've seen on the treatment of severe psoriasis with biologic therapy on coronary inflammation, noncalcified burden, and, most recently, lipid-rich necrotic core. It's approximately 8% to 10%, which is about what a statin does. Yes, you're right about the relative risks being larger, and the absolute risks being smaller, but it is also 2% of a risk reduction in a steep curve. So, it depends on where you want to take your risk points, right? So here, if there's something that you can do to reduce something two percentage points, I would do it. In cardiovascular epidemiology, we have always thought that a 2% to 5% risk reduction is very important for absolute risk prevention when you look at a population level. So, I think you should keep taking that statin, and I think people should treat their skin disease and take it seriously in psoriasis.
Feldman: You know, I get the sense, just to summarize, that this is kind of like the retirement money match that you get. It's like free money, because you want to treat the psoriasis as you said, and you want to get people well — get their skin cleared up — get rid of the itching and the cracking, the pain, the misery, and the social implications and make their joint pain go away. You get all that by doing the treatment plus the "free money" benefit of cardiovascular improvement. Nehal, thank you so much for your time today.
Mehta: Steve, thanks for having me.
Feldman: Now, we'll shift the lens to psoriatic arthritis. How prevalent and impactful is psoriatic arthritis as a comorbidity for psoriasis? Should we be screening? What's the best way to screen? To answer these questions, we have the director of the clinical immunology research unit and the principal investigator on clinical trials testing the efficacy of anti-tumor necrosis factor (TNF) agents and other biologics in the treatment of psoriatic arthritis. He also has a research lab, where he spends most of his time. He's professor of medicine at the University of Rochester School of Medicine and works in its division of allergy and immunology and rheumatology at the center for musculoskeletal research. He is Dr Christopher Ritchlin. Welcome, Chris.
Christopher T. Ritchlin, MD, MPH: Thank you, Steve. It's a pleasure to be here.
Feldman: We did some research on our psoriasis population years ago and found, using the Short Form 36 as a general measure of quality of life, that the quality of life of patients with psoriasis was reduced more than with other medical diseases — more than with diabetes, hypertension, heart attacks, and believe it or not, even cancer — both in terms of the psychological and physical dimensions. This was a highly cited paper in the dermatology literature. Although we really focused on psoriasis, most of that physical impact was caused by the arthritis associated with psoriasis. How common is arthritis in patients with psoriasis?
Ritchlin: If you take patients across the board, about 25%-30% of patients with psoriasis will develop psoriatic arthritis. Typically, psoriasis precedes the onset of arthritis by several years. So, it's quite prevalent. As you've mentioned — and I know your paper very well; I quoted it — it really has a major negative impact on quality of life and function for patients. It's a huge comorbidity in terms of how it affects patients and how they live.
Feldman: There's this dogma that psoriatic arthritis comes after psoriasis; I'm sure that many times it does. But I've often wondered if psoriatic arthritis might occur before psoriasis just as often. When that happens, it's hard to know whether it's psoriatic arthritis. It might get called something else — seronegative rheumatoid arthritis, for example — just because it might be hard to make the diagnosis of psoriatic arthritis if there's no obvious psoriasis there.
Ritchlin: Happens all the time. We see it quite commonly and that's why it's well known. In a recent study presented at our national meeting 2 months ago, which looked at the comparison between rheumatoid arthritis and psoriatic arthritis — I'll call psoriatic arthritis PsA — a PsA diagnosis was much delayed compared with an RA diagnosis, and therapies were introduced much later and to a much lesser degree for similar burdens of disease. So, this is a major issue. The other thing — and Nehal knows this very well — is that if you image psoriasis in patients who have no musculoskeletal pain, you find all sorts of bony changes in their musculoskeletal system — some of which are subclinical, because they're not having symptoms — but they have evidence of tendonitis. Some of these patients show arthritis on imaging. So, I think that a lot of patients with psoriasis are not diagnosed with PsA but have ongoing musculoskeletal inflammation.
Feldman: Years ago, I asked an interested rheumatologist what we dermatologists should do to screen patients for psoriatic arthritis. I think the bottom line was they said to ask about joint pain, joint stiffness, back pain, and fatigue — I'm not going to ask about fatigue. What would be your approach? What would be your recommendations to other physicians for how the non-rheumatologist should screen for psoriatic arthritis in patients with psoriasis?
Ritchlin: I think those are the recommendations you just quoted that we made several years ago. More recent work from Lihi Eder of the University of Toronto showed that fatigue was an early symptom of psoriatic arthritis and very prevalent in those patients who went on to develop PsA. So, I think fatigue is important. Now, obviously, other reasons include that fact that a lot of our patients are heavy, as Nehal mentioned, and a lot of them have sleep apnea. Other things can lead to fatigue, but it's very important in arthritis. The other things you mentioned — joint pain, stiffness, and back pain — of patients with psoriatic arthritis, 40% will have involvement of their sacroiliac joint or spine, and many of them are not necessarily symptomatic when you see them. However, the presence of back inflammation dictates a certain kind of therapy because there are some medications that work for that and others that don't. So, it's important to know whether your patient has inflammatory back pain in the setting of psoriasis.
Feldman: I like to think that these screening questions are all I need to screen patients, and if I get positive results, I'll have a very high sensitivity for detecting psoriatic arthritis. Do you want me to be doing any kind of physical exam as well as part of the screening process?
Ritchlin: I think that's a lot to ask for dermatology to do, given the burden of your day. I work in a combined clinic with dermatology here in Rochester. I know there have been several questionnaires published that determine whether psoriasis patients are at risk for psoriatic arthritis. I think that's probably a better way to go, in terms of trying to screen. Patients can complete the questionnaire while in the waiting room, so it's not impinging on the time that you spend with them. An assistant or nurse can score the questionnaire, then see if a patient scored above the threshold, and we might think about a referral. I think that's a better way to do it.
Feldman: I have the impression that if somebody did have any kind of arthritic symptoms, then a complete musculoskeletal exam would be needed, including a range of motion and evaluation of gait. I'm not going to do that.
Ritchlin: Exactly. If our dermatologists detect possible joint pain, they'll go ahead and order serologies and x-rays. So, by the time I see them, that's all been carried out, and it really speeds things up considerably. These are people who clearly are having arthritic symptoms. It's not like they're screening people who don't have arthritis.
Feldman: I wouldn't know what x-rays to order. What x-rays should I be requesting?
Ritchlin: We have them x-ray the hands if they're having hand pain. We x-ray the feet and the anterior posterior (AP) pelvis, which looks at the back. So, those three films, unless they're having specific pain in the knee, then obviously you're going to x-ray the knee. But generally, most patients are having their symptoms in the hands, feet, and low back.
Feldman: Hands, feet, and AP pelvis.
Ritchlin: Yes, because that shows you the sacroiliac joints.
Feldman: I'm going to write that down. So, we're going to screen and we're going to find these patients, but is it going to make a difference in their long-term outcome?
Ritchlin: A study published several years ago in Ireland showed that even a delay of 6 months in initiating treatment had a major negative impact on outcomes. Surprisingly, it was quite a negative impact. So, yes, timely diagnosis can improve response and outcomes.
Feldman: Super. So, to summarize, the take-home message is that the joint involvement in psoriasis has a huge effect on patients' lives. We want to catch it early. I don't know if you must catch psoriasis early, because if we treat it, the skin appears to go back to normal — which is one of the things I love about being a dermatologist. But in the joints, you can get permanent destruction. So, screening and then treating early are valuable.
Ritchlin: Absolutely. The other question that we're studying now is whether early intervention to treat psoriasis can lower the likelihood of developing psoriatic arthritis or decreasing the severity. There have been three studies published recently that evaluated different databases. The problem with the databases is inherent bias, for which we can't control. Also, a lot of the coding for PsA is not what we would really like. We're now doing a study in which we're intervening in patients with psoriasis who have abnormal ultrasounds and no musculoskeletal symptoms, and we're treating them with placebo vs a biologic agent. The outcome is the development of psoriatic arthritis. Hopefully, in a couple of years, we'll have some answers to that question.
Feldman: That's extraordinarily exciting. Chris, thank you so much for being with us today.
Ritchlin: Thank you, Steve. It was a pleasure.
Feldman: Now let's shift to mental health and psoriasis. To discuss this highly relevant and timely topic, we have an internationally recognized researcher and teacher. He's a board-certified dermatologist and clinical psychologist whom I've known for years. He's known for his compassion in the clinical arena. The author of publications on psoriasis, acne, rosacea, aging, and the psychological benefits of skin enhancements. I present Dr Richard Fried. Welcome, Rick.
Richard Fried, MD, MPH: Hi, Steve. Great to be here.
Feldman: It's such a pleasure to talk with you. Before we had treatments that cleared psoriasis, patients needed empathy more than anything else. With your expertise in both psychology and dermatology, how do you see the impact of psoriasis on patients' lives before and after their treatment?
Fried: Twenty-five years ago, when I first entered the field, I knew psoriasis was a big deal. As the years have gone by, it has become clear that psoriasis has a protean impact on all spheres of the human's functioning: our work, our play, our intrapsychic lives, and our sexual lives. Often, that impact is directly correlated to the severity of the illness, but just as often it is not. Even the smallest amount of psoriasis can have a devastating impact. The impact is sometimes very evident. People say, "I'm depressed; I'm miserable; I'm sleeping all the time; I'm not sleeping at all." Often, though, it's subclinical. They do not realize how much psoriasis has stolen from them — how much of their happiness, their energy, and their engagement. It's an insidious loss; it happens slowly. Only after treatment do patients realize how much psoriasis had cost them. It can be a wonderful experience as they gain back the lives that they've lost. Many patients just don't know what steps to take. Because they are not conscious of how much psoriasis has debilitated them, sometimes it takes a bit more prodding to get them to move forward with legitimate therapy. And that's something we can do in a very efficacious and safe way with our modern tools.
Feldman: So, with these great new drugs — we have injectables, new orals — we're able to clear patients of psoriasis to an extent never seen before. Now that I can do that, do I still need to be empathetic?
Fried: Yes, because empathy goes a long way and psoriasis robs people of control. They feel out of control. It's capricious; it does what it wants, when it wants, where it wants. So being empathic and using simple empathic statements such as, "I very much understand and appreciate how difficult it is to live with psoriasis; I'm committed to doing this together and taking you to where you want to and need to be." Being empathic by saying, "Hey, I don't want to tease you either." I mean, if you've had psoriasis for a long time, you've been teased with this work for a while. I'm saying, "My tool bag is incredibly deep. I will not stop until we get you where you want to go, and we will take you there safely and comfortably."
Feldman: I feel like I'm pretty good at seeing psoriasis, making the diagnosis of psoriasis, and choosing a treatment based largely on the objective skin findings that I see. But what kind of psychological screening should I be doing as well?
Fried: I think when it comes to assessing psychological impact in the office setting of the non–mental-health professional, it should fall under the rubric of "KISS" in research — "Keep It Simple, Stupid." I think the Patient Health Questionnaire, the PHQ-2, is a quick, effective instrument. It simply asks two questions: number one: Little interest or pleasure in doing things and number two: Feeling down, depressed, or helpless. Those are two very poignant and helpful questions. The second is what I call the 3-second eye test. One of the things that we all learn from our nerdy beginning is that if you maintain eye contact for more than 2 or 3 seconds, you are either coming on to someone or challenging them to battle. So, particularly with my male patients, I'll look them in the eye and say, "Tell me something, Joe. How difficult is it to live with the psoriasis?" After 2 or 3 seconds, the tears start to well, and almost invariably, "I hate it, Doc." Women as a group are more forthcoming. After 2 or 3 seconds, they say, "Here's what it's robbing from my life." So, I don't think it has to be long standardized assessments. Make them think, make them feel, and give them a solution. "Have you lost interest in pleasure? Do you feel helpless sometimes? How burdened are you? How does that feel? Here's our solution, because together we can move forward in giving you the control over psoriasis that you need and that you want."
Feldman: But some patients may need more than that. When do I need to refer patients to a mental health professional?
Fried: That's a great question. If it's obvious that these patients are more distressed and suffering more than the simple "empathic statements" can manage, then the next step can be very useful and quite simple. There's something I refer to as the "skin emotion specialist." These are psychiatrists, psychologists, and social workers with special interest in skin diseases, such as psoriasis, who know that straightforward techniques can be very helpful in making people feel better, function better, and, in fact, making their treatments work better. These include things like mindfulness meditation and CBT — or cognitive-behavioral therapy — straightforward techniques. They can make their physiology and their emotional world much healthier.
Feldman: Rick, thanks for speaking to us about these mental health issues. Patients may not be aware of how much psoriasis is taking away from their lives. When we treat patients with psoriasis, they are experiencing such a tremendous benefit that we should feel good about what we're doing for people — both for their physical and mental health. Being empathetic is a helpful intervention beyond the great treatments we have, and we should be on the lookout for people who need more than that. Rick, thank you so much.
Fried: Steve, always a pleasure. Thanks so much.
Feldman: Thanks for joining our discussion on psoriasis comorbidities with Drs Nehal Mehta, Christopher Ritchlin, and Richard Fried. In the next episode, we'll be discussing the important issue of how to control limited psoriasis. This is so important because most people with psoriasis have only limited disease. Our guest will be dermatologist and researcher, Dr Kim Papp. Dr Papp has tremendous first-hand experience in studies of psoriasis treatments, so be sure to look for that next month on the Medscape app, Medscape.com, or other major podcast platforms. I'm Dr Steve Feldman for Medscape InDiscussion: Psoriasis. Thanks for listening.
Diagnostic Delay and Less Intensive Therapy for People With Psoriatic Arthritis Compared With Rheumatoid Arthritis: A Nested Matched Cohort Study From Within the UK National Early Inflammatory Arthritis Audit
Incidence and Prevalence of Psoriatic Arthritis in Patients With Psoriasis Stratified by Psoriasis Disease Severity: Retrospective Analysis of an Electronic Health Records Database in the United States
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Cite this: Can Psoriasis Care Limit CVD, PsA, and Depression? - Medscape - Apr 25, 2023.