Continuing medical education
Psoriasis: Which therapy for which patient: Psoriasis comorbidities and preferred systemic agents

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Psoriasis is a systemic inflammatory disease associated with increased risk of comorbidities, such as psoriatic arthritis, Crohn's disease, malignancy, obesity, and cardiovascular diseases. These factors have a significant impact on the decision to use one therapy over another. The past decade has seen a paradigm shift in our understanding of the pathogenesis of psoriasis that has led to identification of new therapeutic targets. Several new drugs have gained approval by the US Food and Drug Administration, expanding the psoriasis armamentarium, but still a large number of patients continue to be untreated or undertreated. Treatment regimens for psoriasis patients should be tailored to meet the specific needs based on disease severity, the impact on quality of life, the response to previous therapies, and the presence of comorbidities. The first article in this continuing medical education series focuses on specific comorbidities and provides insights to choose appropriate systemic treatment in patients with moderate to severe psoriasis.

Section snippets

Psoriatic arthritis

Psoriatic arthritis develops in ≤30% of patients, but severe deforming arthritis is much less common, seen in about 5% patients. Psoriasis usually precedes joint manifestations in ≤85% patients by 10 years on average; however, in approximately 15% of cases, arthritis either precedes or occurs simultaneously with skin disease.3, 4, 5, 6 There is a paucity of validated tools for the assessment of drug efficacy in patients with psoriatic arthritis; therefore, American College of Rheumatology (ACR)

Crohn's disease

Psoriasis and Crohn's disease (CD) are chronic inflammatory disorders with similarities in genetic susceptibilities and immune-mediated inflammation.38, 39, 40 Several studies have reported a high rate of co-occurrence of psoriasis and IBD.41, 42, 43, 44, 45, 46

Traditional agents

The association of methotrexate with malignancies is not clear in patients with psoriasis. In a long-term study of 248 psoriasis patients treated with methotrexate, 10 patients developed malignant neoplasms including lymphomas, but this study concluded that methotrexate therapy for psoriasis did not contribute to the development of neoplasms.71 However, there are several reports of newly diagnosed Epstein–Barr virus–associated lymphomas in patients with psoriasis who were taking methotrexate.72

Obesity

Moderate to severe psoriasis is associated with the metabolic syndrome, which includes obesity, hyperlipidemia, and diabetes mellitus.99 Patients with psoriasis tend to be more obese than age- and sex-matched individuals without psoriasis.100, 101

Cardiac diseases

Gelfand et al120 published the landmark study that identified psoriasis as an independent risk factor for cardiovascular diseases. Chronic inflammation is a hallmark for psoriasis and is also known to play an important role in atherosclerosis, which explains the increased risk of MACEs in patients with psoriasis.121, 122, 123, 124

Congestive heart failure

The association between psoriasis and congestive heart failure (CHF) is unclear, but it is suggested that moderate to severe psoriasis increases the risk of heart failure.139, 140

Multiple sclerosis

Recent Danish- and US-based studies reported a significant association between multiple sclerosis (MS) and psoriasis, although the precise mechanism of this association is still not clear.151, 152, 153 In contrast, a few other studies did not identify any association between psoriasis and MS.154, 155

Lupus

Psoriasis and lupus erythematosus (LE) are both immune-mediated diseases but their coexistence is rare. Zalla et al171 reported that 0.69% of patients with psoriasis have SLE and 1.1% of patients with SLE have psoriasis.

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    Funding sources: None.

    Dr Lebwohl is an employee of Mount Sinai and receives research funds from Abbvie, Boehringer Ingelheim, Eli Lilly, IncyteJanssen/Johnson & Johnson, Leo Pharmaceuticals, MedImmune/AstraZeneca, Novartis, Pfizer, Sciderm, Valeant, and ViDac. Dr Lebwohl is also a consultant for Allergan, Aqua, Boehringer-Ingelheim, LEO Pharma, Menlo, Mitsubishi, Promius, and Theravance. Dr Kaushik has no conflicts of interest to disclose.

    Reprints not available from the authors.

    Date of release: January 2019

    Expiration date: January 2022

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