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A clinical study of psoriasis and its association with co-morbid conditions.

Byline: Chandramohan Kudligi, Suman Gurunathgouda Odugouda, Vidya Kuntoji, Pradeep Vittal Bhagwat, Dinesh Prasad Asati, Elangkathiravan Dhayaneethi and Kaivalyam

Objectives

The study aimed (1) to compare incidence of co-morbidities among psoriatic patients (cases) and nonpsoriatic patients (controls), (2) to determine the association between psoriasis and various co-morbidities and (3) to determine the relationship between the severity of psoriasis and co-morbidities.

Methods

We performed a hospital-based case-control study involving 100 psoriatic patients (cases) and 100 age- and sex-matched nonpsoriatic patients (controls) from the dermatology outpatient department in a government teaching institute. Detailed history and examination was followed by relevant investigations. The severity of psoriasis was assessed according to Psoriasis Area and Severity Index (PASI), and body surface area (BSA) measurement. Cardiovascular risk factors were assessed by using the definition for metabolic syndrome, which includes the presence of three or more of the National Cholesterol Education Program's Adult Panel III (ATP III) criteria.

Results

The study revealed statistically significant association of psoriasis with metabolic syndrome (27% vs 8%, p = 0.0004) and psoriatic arthritis. Psoriatic patients had significantly higher levels of triglycerides (24% vs 8%, p = 0.002) and fasting blood sugar (23 % vs 8%, p = 0.003) along with significantly lower HDL levels (29 % vs 7%, p = 0.000, in males and 7% vs 2%, p = 0.043 in females). Abdominal obesity was more prevalent in psoriatic patients (24 % vs 9%, p = 0.02 in male and 9 % vs 3%, p = 0.033 in females). Neither metabolic syndrome nor psoriatic arthritis correlated with the severity of psoriasis.

Conclusion

There was higher prevalence of metabolic syndrome in patients with psoriasis. However, its presence did not correlate with either severity or duration of the psoriasis. Hence, we suggest that all patients need to be evaluated for metabolic syndrome irrespective of severity of psoriasis which is the risk factor for systemic diseases.

Key words

Psoriasis, metabolic syndrome, comorbidities.

Introduction

Psoriasis is a chronic, inflammatory cell-mediated, genetically determined, common dermatological disorder affecting skin, nails, joints and associated with various systemic associations.1,2 The disease is characterized by epidermal hyperproliferation, abnormal keratinocyte differentiation, angiogenesis with blood vessel dilatation, and Th1 and Th17 inflammation.3 The chronic inflammatory nature of psoriasis is also thought to predispose patients to other diseases with an inflammatory component, the most notable being cardiovascular and metabolic disorders. This concept is supported by studies showing that psoriasis is associated with cardiovascular risk factors such as diabetes, obesity, hypertension, dyslipidemia, and smoking.4,5 One of the strong predictors of cardiovascular disease is metabolic syndrome which is a cluster of risk factors including central obesity, atherogenic dyslipidemia, hypertension and glucose intolerance.6

Hypertension which is a predictor of cardiovascular disease may be related to the increased levels of angiotensin-converting enzyme, endothelin-1(ET-1) and renin in patients with psoriasis,7 whereas increased insulin resistance is due to TNF-a which plays a central role in the immune-pathogenesis of psoriasis.

The objectives of this study were to determine the association between psoriasis and various co-morbidities like diabetes mellitus, dyslipidemia, hypertension, cardiovascular disease etc., to compare incidence of comorbidities among psoriatic patients (cases) and nonpsoriatic patients (controls) and to determine the relationship between the severity of psoriasis and comorbidities.

Methods

This was a hospital-based case-control, observational, cross-sectional study involving a series of 100 psoriatic patients (cases) and 100 controls from the dermatology outpatient department in government teaching institute. The study was conducted from November 2012 to October 2014 after being approved by the Institutional Ethical Committee. Subjects of age 18 years and above with all clinical forms of psoriasis except for pustular and erythrodermic psoriasis were included in the study and patients who were pregnant or breast feeding or receiving disease modifying systemic therapy within 6 weeks from the date of enrolment were excluded. 100 age and sex-matched controls were enrolled among nonpsoriatic patients of other dermatological conditions attending the dermatology outpatient department.

After taking signed informed consent, a demographic and biometric data was collected. Detailed history including duration and course of the disease, severity of the disease, presence of nail or joint involvement, treatment history, concomitant illnesses, family history of psoriasis, diabetes, and cardiovascular disease and personal habits (smoking, alcohol, tobacco consumption) was taken. Complete systemic and cutaneous examination was done which was followed by relevant investigations. The severity of psoriasis was assessed according to Psoriasis Area and Severity Index (PASI), and body surface area (BSA) measurement. PASI score of <10% was considered as mild and more than 10% as severe. BSA involvement of 102cm###24###9

Waist circumference (females)

###Normal###20###29

###> 88cm###9###3###0.033

Triglycerides

###Normal###76###92

###>150 mg/dl###24###8###0.002

Reduced HDL (males)

###Normal###42###61###0.000

###<40###29###7

Reduced HDL (females)

###Normal###22###30###0.043

### 130/85mmHg###21###17

Fasting blood sugar

###Normal###77###92###0.003

###>100mg/dl###23###8

Metabolic syndrome

###Present###27###8###0.0004

###Absent###73###92

H/o smoking

###Absent###76###81###0.389

###Present###24###19

H/o alcohol

###Absent###78###73###0.596

###Present###22###27

Liver function tests

###Normal###98###98###1

###Deranged###2###2

Depression###19###4###0.48

Among 11 psoriatic patients, 7 (63.6%) patients had nail involvement along with history of joint pain compared to 34 (38.2%) patients with no history of joint pain (p = 0.740); hence there was no significant association between patients with nail involvement and psoriatic arthritis. Nail involvement was seen in 41 (41%) patients. Among these, 17 patients had mild disease and 24 patients had severe disease. Among 59 patients without nail involvement, 35 patients had mild disease and 24 patients had severe disease showing no statistically significant (p = 0.079) association between nail involvement and severity of psoriasis. Among the nail changes, pitting was the most common finding followed by subungual hyperkeratosis, onycholysis and dystrophy.

Of 33 patients with raised waist circumference, 24 were male and 9 female and in control group there were 9 male and 3 female showing significant association of raised waist circumference in psoriatic cases compared to controls (p = 0.002). There were 24 (24%) patients with raised triglycerides compared to 8% controls (p = 0.002). The number of psoriatic patients with reduced HDL was 36, (29 males and 7 females) as compared to 9 (7 males and 2 females) among controls.

Twenty-one (21%) psoriatic patients had hypertension as compared to 17% controls (p = 0.471). Raised fasting blood sugar level (BSL) was observed in 23 (23%) patients compared to 8% controls (p = 0.003). Among 27 patients with metabolic syndrome, 15 (15%) patients had mild psoriasis and 12 (12%) patients had severe psoriasis (p = 0.665). Out of these 27 patients, 11 (11%) had psoriasis for <5 years and 16 (16%) had for more than 5 years (p = 0.878). Hence neither the severity nor the duration had any statistical association between metabolic syndrome, severity and duration of psoriasis. Association of hepatic system involvement was studied with the help of deranged liver function tests (LFTs). There were 2 patients with deranged LFT among cases and 2 patients among controls.

There was no statistically significant difference between cases and controls (Fisher exact test, p = 1). In our study, 4 (4%) patients had raised uric acid levels among cases and none among controls. There was no significant association between depression and psoriasis (p = 0.48).

Discussion

Psoriasis is a multisystem inflammatory disease where the skin and the joints are the primary targets. There are many reports that psoriatic patients tend to have concurrent illnesses that are termed as comorbidities, though there are remarkably few studies from India. Comorbidities can be physical and psychological (Table 2). Onumah et al.8 observed that the severity of psoriatic skin disease portends a serious risk for the development of these comorbidities. Patients with moderate to severe psoriatic skin disease have a higher association with these comorbidities which may be related through common pathogenic mechanisms. Psoriasis has bimodal age of onset, first peak at 15-20 years and second peak at 55-60 years but it can occur at any age. In Indians, highest incidence is reported in second decade or reproductive age group.9

In one study, age of the patients ranged from 18 years to 68 years and maximum number were in fourth decade. A study done in North India by Bedi et al.10 found the highest incidence to be in fourth decade which is similar to our study. Higher male: female ratio [2.4: 1] in our study group is similar to many studies reported from India.9 Extent and type of involvement of different body surface areas with psoriasis has a huge bearing on the overall prognosis, as well as the choice of the treatment. For this purpose, psoriasis area severity index [PASI] and body surface area [BSA] involved are the most frequently used measures, which attempt to define the severity of psoriasis.11 We classified our patients into mild [PASI of 10] type of psoriasis.

Table 2 Comorbidities associated with psoriasis.

Psoriatic arthritis

Depression

Hypertension

Diabetes

Metabolic syndrome

Cardiovascular disease, such as coronary artery

calcification and

myocardial infarction

Dyslipidemia

Crohn's disease and ulcerative colitis

Autoimmune diseases

Non-alcoholic fatty liver disease

Chronic obstructive pulmonary disease

Obstructive sleep apnea

Fifty-two patients had mild disease and 48% had severe disease. Most commonly, psoriasis presents as chronic, bilaterally symmetrical, well defined, erythematous, dry, red, scaly papules and plaques, Apart from this, there are several unique cutaneous manifestations, ranging from small papules (guttate psoriasis) to pustules (pustular psoriasis) and generalized erythema and scaling (erythrodermic psoriasis). In our study 91 cases [91%] presented with chronic plaque psoriasis, 2 cases (2%) had guttate psoriasis and 7% were diagnosed to have palmoplantar psoriasis. Bedi et al.12 reported chronic plaque psoriasis as the commonest type [90%] followed by erythrodermic psoriasis in 3% cases and guttate psoriasis in 0.94%. Arthritis occurs in about 5% to 10% of patients of psoriasis.13 In our study the number of patients with joint complaints11 was not significantly higher when compared to control group.10

Nail changes are seen in about 20% to 50% of psoriatics.13 The common changes are pitting of the nail plate. The finger nails are more frequently involved than toe nails. The incidence of nail involvement is higher if there is associated arthropathy. Prasad et al.14 studied 472 psoriatic patients. 40 patients had psoriatic arthropathy and out of these 40 patients, nail involvement was seen in 37 (92.5%) cases. In a study by Reich et al.15 out of 1511 patients, 20.6% had psoriatic arthritis and among these 68.6% showed nail involvement. In our study, out of 11 patients with psoriatic arthropathy, 7 (63.6%) patients showed nail involvement consistent with above-mentioned study. Comorbidities classically associated with psoriasis are psoriatic arthritis, Crohn's disease, psychological/ psychiatric disorders and uveitis.

In recent years, the metabolic syndrome as a whole and its individual components has been associated with psoriasis.16-18 Psoriasis is associated with metabolic syndrome, which encompasses obesity, raised triglycerides, low high density lipoprotein (HDL), insulin resistance, and hypertension. Its importance lies in its ability to predispose sufferers to cardiovascular disease.19 There are some reports that the association is stronger for severe psoriasis than for mild psoriasis20,21 but this association has still not been established beyond doubt as the number of studies are few and some studies have conflicting results.

The updated Adult Treatment Panel III (ATPIII) criteria for the diagnosis of metabolic syndrome includes three or more of the following: triglyceride [greater than or equal to] 150 mg/dl (1.7 mmol/l), HDL cholesterol < 40 mg/dl (1.03 mmol/l) in men and < 50 mg/dl (1.29 mmol/l) in women, fasting glucose[greater than or equal to]100mg previously diagnosed with type 2 diabetes, blood pressure [greater than or equal to] 130/85 mmHg or on antihypertensive medication, and central obesity (defined as waist circumference [greater than or equal to] 90 cm in men and [greater than or equal to] 80 cm in women, according to the ethnic criteria for Asians).22

The International Diabetes federation (IDF) requires central obesity (defined as waist circumference [greater than or equal to] 90 cm in men and [greater than or equal to] 80 cm in women for Asians, except for Japanese) plus two of the following four factors: triglycerides [greater than or equal to] 150 mg/dl, HDL cholesterol < 40 mg/dl in men and 20% body surface area). Intra-abdominal obesity was directly linked to the metabolic syndrome. Several studies have shown that psoriasis is associated with atherogenic dyslipidemia with increased blood levels of total cholesterol, triglycerides, low density lipoprotein (LDL), very low density lipoprotein, and lipoprotein A, and low levels of HDL and apolipoprotein B.28 Though observational studies have detected independent associations between psoriasis and hypertension, our study showed no significant association. However, fasting BSL was increased in 23 cases as compared to 8 controls with P value of 0.003 indicating significant association with psoriasis. Multiple case control studies linking psoriasis and components of the metabolic syndrome have been done with variable results (Table 3).

Psoriasis is associated with low self-esteem and the prevalence of anxiety and depressive disorders is 30% and 60%, respectively. Recently, a high prevalence of alexithymia was observed.37 About 10% of patients with psoriasis consider the possibility of suicide.38-40 Recent data shows that depression and anxiety are mainly found in women with family problems.41

In our study we found that incidence of depression was more among psoriatic patients (19%) compared to controls (4%). However, there was no statistical difference among the two groups in contrast to the study done by Esposito et al.39 and Devrimci-Ozguven et al.42 In conclusion, we have found higher prevalence of metabolic syndrome in patients with psoriasis. This association was not limited to severe cases but also occurs in mild cases and was not associated with duration of psoriasis. Hence, we suggest that all patients need to be evaluated for metabolic syndrome irrespective of severity of psoriasis which is the risk factor for systemic diseases.

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Date:Dec 31, 2016
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