expert roundtables

Taking on the Systemic Inflammatory Burden of Psoriasis

by Steven R. Feldman, MD, PhD; Joel M. Gelfand, MD, MSCE; and Alice B. Gottlieb, MD, PhD

Overview

Patients with moderate to severe plaque psoriasis may be at an increased risk for psoriatic arthritis, metabolic dysregulation, and cardiovascular disease. Routine screenings, risk factor reduction, and appropriate treatment are among the currently available tools to address this burden.

Q:

What are your thoughts on the systemic inflammatory burden of psoriasis?

Steven R. Feldman, MD, PhD

Professor of Dermatology, Pathology, and Social Sciences & Health Policy
Wake Forest School of Medicine
Winston-Salem, NC 

“Evaluating the systemic inflammatory burden of psoriasis is one of the most exciting areas of research in dermatology today.”

Steven R. Feldman, MD, PhD

At this point, I am not certain that we fully understand what the total systemic burden of psoriasis is, nor do we understand all of the implications. However, evaluating the systemic inflammatory burden of psoriasis is one of the most exciting areas of research in dermatology today.

In the interim, as relates to potentially curbing that risk, there are a few practical points to consider. First, many of the patients who are often seen by dermatologists are relatively young people who may be very healthy otherwise, aside from their skin disease. Such individuals may not be in regular contact with a primary care doctor and, therefore, they often have not been screened for the usual things. Knowing that these screenings are recommended and that people with psoriasis are at higher risk for comorbidities associated with systemic inflammation, it seems appropriate for dermatologists to make sure that patients get at least the routine disease screenings. As an aside, in my experience, dermatologists are among the physicians who are least likely to check a patient’s blood pressure, despite general recommendations that patients should have their blood pressure checked at every visit.

Joel M. Gelfand, MD, MSCE

Professor of Dermatology and Epidemiology
Perelman School of Medicine
University of Pennsylvania
Philadelphia, PA

“The greater the body surface area affected by psoriasis, the higher the likelihood that patients are going to develop psoriatic arthritis, diabetes, or cardiovascular disease over time.”

Joel M. Gelfand, MD, MSCE

We know that psoriasis is a disease of chronic inflammation, and we know patients are prone to other health problems that have shared pathophysiologies with inflammation. The most common is psoriatic arthritis, but cardiometabolic diseases are also common. Diabetes, insulin resistance, and cardiovascular disease are critical comorbidities, and patients with psoriasis seem to be more prone to developing these comorbidities in a manner that varies with the severity of their skin disease. The greater the body surface area affected by psoriasis, the higher the likelihood that patients are going to develop psoriatic arthritis, diabetes, or cardiovascular disease over time.

We currently lack blood markers to determine which patients with psoriasis will develop these comorbidities over time. If there is uncertainty regarding the presence of psoriatic arthritis, it may be helpful to obtain a C-reactive protein level and an erythrocyte sedimentation rate. If those levels are elevated, the patient may be more likely to progress to permanent joint damage. This would be a sign that referral to a rheumatologist may be appropriate or that a therapy that will treat both the psoriatic arthritis and the psoriasis should be considered.

Additionally, recognizing that some dermatologists are the only clinicians taking care of certain patients, consideration should be given to the higher risk of cardiovascular disease and diabetes in those with psoriasis. Somebody should be checking their blood pressure, screening them for diabetes, and checking their lipids. This is part of the approach to having a more comprehensive view of the disease. It is fairly easy for us as clinicians to perform these routine tests, including blood pressure, hemoglobin A1c, and a lipid profile, when needed.

Alice B. Gottlieb, MD, PhD

Clinical Professor and Medical Director
Mount Sinai Beth Israel Hospital
Department of Dermatology
Icahn School of Medicine at Mount Sinai
New York, NY

“I ask each patient at every visit about joint symptoms. Dermatologists are in the best position to detect early psoriatic arthritis and to make a difference in a patient’s disease course.”

Alice B. Gottlieb, MD, PhD

Both of my colleagues have alluded to challenges related to integrating care, so I will share one approach that has been very successful at our institution. We set up an autoimmune disease center that currently involves internal medicine, neurology, ophthalmology, and dermatology; it includes patients with psoriasis, psoriatic arthritis, collagen vascular disease, negative spondyloarthropathies, and hidradenitis suppurativa. We have a single point of contact for scheduling, and appointments are made within a matter of days. Whether the patient needs to see another specialist or a general practitioner, we can access these clinicians within the same institution. So, this is one approach that seems to work well.

With regard to the systemic inflammatory burden of psoriatic arthritis, we have evidence that a 6-month delay in diagnosis can lead to more disability and more joint damage. Yet, psoriatic arthritis frequently goes underdiagnosed. Psoriasis can precede psoriatic arthritis by 10 to 12 years, and it can be a warning sign. In one large study, 84% of patients who developed psoriatic arthritis had preceding skin lesions. As dermatologists, we can be the first to detect psoriatic arthritis, and this is important because we now have 4 tumor necrosis factor blockers and 2 interleukin-17 blockers that not only control signs and symptoms and improve quality of life but also inhibit radiographic progression.

As Dr Gelfand stated, patients with more severe skin disease are more likely to develop psoriatic arthritis; however, it is also true that psoriatic arthritis may develop in someone with very limited skin disease, albeit less commonly. For example, a patient with psoriasis and mild scalp disease might be treated topically and go on to develop psoriatic arthritis. Thus, I ask each patient at every visit about joint symptoms. Dermatologists are in the best position to detect early psoriatic arthritis and to make a difference in a patient’s disease course. We need to take ownership of at least asking about psoriatic arthritis and using screening tools.

References

American Academy of Dermatology Association. Skin conditions by the numbers. Accessed June 6, 2021. https://www.aad.org/media/stats-numbers

Armstrong AW, Koning JW, Rowse S, Tan H, Mamolo C, Kaur M. Initiation, switching, and cessation of psoriasis treatments among patients with moderate to severe psoriasis in the United States. Clin Drug Investig. 2017;37(5):493-501. doi:10.1007/s40261-017-0508-1

Armstrong AW, Siegel MP, Bagel J, et al. From the medical board of the National Psoriasis Foundation: treatment targets for plaque psoriasis. J Am Acad Dermatol. 2017;76(2):290-298. doi:10.1016/j.jaad.2016.10.017

Busse K, Liao W. Which psoriasis patients develop psoriatic arthritis? Psoriasis Forum. 2010;16(4):17-25.

Gladman DD, Antoni C, Mease P, Clegg DO, Nash P. Psoriatic arthritis: epidemiology, clinical features, course, and outcome. Ann Rheum Dis. 2005;64(suppl 2):ii14-ii17. doi:10.1136/ard.2004.032482

Haroon M, Gallagher P, FitzGerald O. Diagnostic delay of more than 6 months contributes to poor radiographic and functional outcome in psoriatic arthritis. Ann Rheum Dis. 2015;74(6):1045-1050. doi:10.1136/annrheumdis-2013-204858

Mahil SK, Wilson N, Dand N, et al; BADBIR Study Group and the PSORT Consortium. Psoriasis treat to target: defining outcomes in psoriasis using data from a real-world, population-based cohort study (the British Association of Dermatologists Biologics and Immunomodulators Register, BADBIR). Br J Dermatol. 2020;182(5):1158-1166. doi:10.1111/bjd.18333

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

More in Plaque Psoriasis

Thumb

Plaque Psoriasis

Interleukin-23p19 Inhibitors: Current Perspectives

Clinical Topic Updates by Alice B. Gottlieb, MD, PhD

Selective inhibitors of the interleukin-23p19 (IL-23p19) subunit have emerged as highly effective therapies for patients with moderate to severe pl...READ MORE

Thumb

Plaque Psoriasis

TNF Inhibitor–Induced Psoriasis

Clinical Topic Updates by Steven R. Feldman, MD, PhD

Psoriasis induced by tumor necrosis factor–α inhibitor (TNFi) therapy is a relatively uncommon side effect that may occur during the treatment of p...READ MORE

Thumb

Plaque Psoriasis

Psoriasis Flare or Diminishing Response to Treatment?

Patient Care Perspectives by Steven R. Feldman, MD, PhD

In patients with psoriasis, a disease flare may result from a loss of response (eg, due to antidrug antibodies), increased disease activity, or adh...READ MORE

More In Dermatology

Plaque Psoriasis

Use Of Small Molecule Drugs For Plaque Psoriasis

Expert Roundtables by Boni E. Elewski, MD; Steven R. Feldman, MD, PhD; and Bruce E. Strober, MD, PhD

Plaque Psoriasis

Newer And Pipeline Therapies And Biologics For Plaque Psoriasis

Expert Roundtables by Boni E. Elewski, MD; Steven R. Feldman, MD, PhD; and Bruce E. Strober, MD, PhD

Plaque Psoriasis

Screening For Psoriatic Arthritis And Axial Involvement: Tips For Dermatologists

Patient Care Perspectives by Bruce E. Strober, MD, PhD