Laura Ferris, MD, PhD

A retrospective observational study of nearly 1200 prior biologic-experienced adult patients with psoriasis now receiving either secukinumab (n=780) or ixekizumab (n=411), both of which inhibit IL-17A, examined drug persistence after 18 months. Ixekizumab was associated with significantly higher rates of high treatment adherence (42% vs 35%; P = .019) and persistence (44.9% vs 36.9%; P = .007) and lower discontinuation (48.4% vs 56.0%; P = .018) and switching (26.6% vs 34.0%; P = .009) rates than secukinumab. Both drugs are dosed monthly after an initial loading dose (Blauvelt A et al. Dermatol Ther (Heidelb).

With several biologic options available, patients may be switched from one biologic to another if they are not having an adequate response. Separate studies have shown that patients with an inadequate response to ustekinumab are likely to have a better response when switched to brodalumab or guselkumab, although this does not tell us if one is more likely to be effective than the other. In a recent matching-adjusted indirect comparison study using data for patients with psoriasis who responded inadequately to ustekinumab and switched to receive brodalumab (n=121) or guselkumab (n=135) the authors found that brodalumab was associated with greater improvements than guselkumab in inadequate responders to ustekinumab with a PASI 100 rate at week 36 of 40.3% for brodalumab vs 20.0% for guselkumab; P < 0.001. (Hampton P et al. Psoriasis (Auckl).

While biologics have revolutionized the treatment of psoriasis, not all patients with extensive disease desire or are appropriate for a systemic therapy. Topical steroids, the most commonly used topical psoriasis therapy, still carry some risk of systemic absorption and are associate with cutaneous side effects such as atrophy with prolonged use. Tarpinarof 1% cream is a novel aryl hydrocarbon receptor modulating agent that has been shown in phase 3 studies to be an effective treatment for psoriasis when applied once a day. A recent open label study of 21 adult patients with extensive plaque psoriasis (20% or more body surface area (BSA) involvement, mean baseline BSA 27.2%) who applied tapinarof cream 1% QD daily showed that 94.7% of patients had a decrease in their PASI score (mean PASI decrease of 59.6%). Despite the large BSA being treated, tapinarof plasma concentration were low and remained below the quantification level in the majority (67.9%) of samples tested. There were also no concerning EKG changes such as QT prolongation. Folliculitis and headache were the most common adverse events (each reported by 4 patients) (Jett JE et al. Am J Clin Dermatol).

These studies all provide valuable data in helping us to make the best treatment decisions for patients with moderate to severe plaque psoriasis.

A retrospective observational study of nearly 1200 prior biologic-experienced adult patients with psoriasis now receiving either secukinumab (n=780) or ixekizumab (n=411), both of which inhibit IL-17A, examined drug persistence after 18 months. Ixekizumab was associated with significantly higher rates of high treatment adherence (42% vs 35%; P = .019) and persistence (44.9% vs 36.9%; P = .007) and lower discontinuation (48.4% vs 56.0%; P = .018) and switching (26.6% vs 34.0%; P = .009) rates than secukinumab. Both drugs are dosed monthly after an initial loading dose (Blauvelt A et al. Dermatol Ther (Heidelb).

With several biologic options available, patients may be switched from one biologic to another if they are not having an adequate response. Separate studies have shown that patients with an inadequate response to ustekinumab are likely to have a better response when switched to brodalumab or guselkumab, although this does not tell us if one is more likely to be effective than the other. In a recent matching-adjusted indirect comparison study using data for patients with psoriasis who responded inadequately to ustekinumab and switched to receive brodalumab (n=121) or guselkumab (n=135) the authors found that brodalumab was associated with greater improvements than guselkumab in inadequate responders to ustekinumab with a PASI 100 rate at week 36 of 40.3% for brodalumab vs 20.0% for guselkumab; P < 0.001. (Hampton P et al. Psoriasis (Auckl).

While biologics have revolutionized the treatment of psoriasis, not all patients with extensive disease desire or are appropriate for a systemic therapy. Topical steroids, the most commonly used topical psoriasis therapy, still carry some risk of systemic absorption and are associate with cutaneous side effects such as atrophy with prolonged use. Tarpinarof 1% cream is a novel aryl hydrocarbon receptor modulating agent that has been shown in phase 3 studies to be an effective treatment for psoriasis when applied once a day. A recent open label study of 21 adult patients with extensive plaque psoriasis (20% or more body surface area (BSA) involvement, mean baseline BSA 27.2%) who applied tapinarof cream 1% QD daily showed that 94.7% of patients had a decrease in their PASI score (mean PASI decrease of 59.6%). Despite the large BSA being treated, tapinarof plasma concentration were low and remained below the quantification level in the majority (67.9%) of samples tested. There were also no concerning EKG changes such as QT prolongation. Folliculitis and headache were the most common adverse events (each reported by 4 patients) (Jett JE et al. Am J Clin Dermatol).

These studies all provide valuable data in helping us to make the best treatment decisions for patients with moderate to severe plaque psoriasis.

A retrospective observational study of nearly 1200 prior biologic-experienced adult patients with psoriasis now receiving either secukinumab (n=780) or ixekizumab (n=411), both of which inhibit IL-17A, examined drug persistence after 18 months. Ixekizumab was associated with significantly higher rates of high treatment adherence (42% vs 35%; P = .019) and persistence (44.9% vs 36.9%; P = .007) and lower discontinuation (48.4% vs 56.0%; P = .018) and switching (26.6% vs 34.0%; P = .009) rates than secukinumab. Both drugs are dosed monthly after an initial loading dose (Blauvelt A et al. Dermatol Ther (Heidelb).

With several biologic options available, patients may be switched from one biologic to another if they are not having an adequate response. Separate studies have shown that patients with an inadequate response to ustekinumab are likely to have a better response when switched to brodalumab or guselkumab, although this does not tell us if one is more likely to be effective than the other. In a recent matching-adjusted indirect comparison study using data for patients with psoriasis who responded inadequately to ustekinumab and switched to receive brodalumab (n=121) or guselkumab (n=135) the authors found that brodalumab was associated with greater improvements than guselkumab in inadequate responders to ustekinumab with a PASI 100 rate at week 36 of 40.3% for brodalumab vs 20.0% for guselkumab; P < 0.001. (Hampton P et al. Psoriasis (Auckl).

While biologics have revolutionized the treatment of psoriasis, not all patients with extensive disease desire or are appropriate for a systemic therapy. Topical steroids, the most commonly used topical psoriasis therapy, still carry some risk of systemic absorption and are associate with cutaneous side effects such as atrophy with prolonged use. Tarpinarof 1% cream is a novel aryl hydrocarbon receptor modulating agent that has been shown in phase 3 studies to be an effective treatment for psoriasis when applied once a day. A recent open label study of 21 adult patients with extensive plaque psoriasis (20% or more body surface area (BSA) involvement, mean baseline BSA 27.2%) who applied tapinarof cream 1% QD daily showed that 94.7% of patients had a decrease in their PASI score (mean PASI decrease of 59.6%). Despite the large BSA being treated, tapinarof plasma concentration were low and remained below the quantification level in the majority (67.9%) of samples tested. There were also no concerning EKG changes such as QT prolongation. Folliculitis and headache were the most common adverse events (each reported by 4 patients) (Jett JE et al. Am J Clin Dermatol).

These studies all provide valuable data in helping us to make the best treatment decisions for patients with moderate to severe plaque psoriasis.

Biologic therapy is generally reserved for patients with more moderate-to-severe psoriasis, often defined as BSA ≥10% or PASI of ≥10. Notably, these criteria are all clinician-performed. The Dermatology Life Quality Index (DLQI) measures the impact of the disease on the patient with a score of 0-5, 6-10, and 11-30 indicating mild, moderate, and severe disease, respectively. In a cross-sectional, observational study, 72.4% of psoriasis patients who qualified for systemic therapy initiation based on PASI and/or BSA had a DLQI of less than 10. Conversely, 10.4% of patients with a DLQI score higher than 10 did not qualify for systemic therapy based on PASI and/or BSA. This study highlights the complementary value of considering both clinician and patient determinants of disease severity when choosing a psoriasis therapy (Barbieri JS et al.)

With so many therapeutic options, it is increasingly common for patients to switch from one biologic to another. Many factors that go into the decision to switch therapies. A retrospective study of 115 adult patients with psoriasis found that the primary factor driving switching was lack of sufficient efficacy in treating skin disease. Having concomitant psoriatic arthritis increased the likelihood of switching by 2.69-fold (Akdogan N et al.). These findings suggest that shared decision making with dermatology, rheumatology, and the patient may help in choosing a treatment plan that best addresses both skin and joints.

One consideration when counseling patients about their likelihood of response to a second or third biologic is that in several clinical trials, biologic-naïve patients tend to have higher PASI responses to biologics than do heavier and biologic-experienced patients. A recent retrospective study found that receiving one or more biologic receiving was associated with a lower likelihood of achieving a PASI75 response to guselkumab (Hung YT et al.). However, in a real-life multicenter study including 57 adult patients with moderate-to-severe psoriasis receiving risankizumab, more biologic-experienced patients reached PASI 100 at weeks 36 and 52 (71.8% and 69.2%, respectively) compared with biologic-naïve patients (50.0% and 37.5%, respectively) (Gerdes S et al.). While both studies were small and no firm conclusions or comparisons can be drawn, real-world data from large multicenter studies that evaluate multiple therapies may guide us in choosing the best therapy for challenging patients who are often underrepresented in clinical trials. Understanding how switching within vs. between classes (TNF, IL-17, and IL-23 inhibitors) impacts efficacy will also help in making choices about biologic switches.

Biologic therapy is generally reserved for patients with more moderate-to-severe psoriasis, often defined as BSA ≥10% or PASI of ≥10. Notably, these criteria are all clinician-performed. The Dermatology Life Quality Index (DLQI) measures the impact of the disease on the patient with a score of 0-5, 6-10, and 11-30 indicating mild, moderate, and severe disease, respectively. In a cross-sectional, observational study, 72.4% of psoriasis patients who qualified for systemic therapy initiation based on PASI and/or BSA had a DLQI of less than 10. Conversely, 10.4% of patients with a DLQI score higher than 10 did not qualify for systemic therapy based on PASI and/or BSA. This study highlights the complementary value of considering both clinician and patient determinants of disease severity when choosing a psoriasis therapy (Barbieri JS et al.)

With so many therapeutic options, it is increasingly common for patients to switch from one biologic to another. Many factors that go into the decision to switch therapies. A retrospective study of 115 adult patients with psoriasis found that the primary factor driving switching was lack of sufficient efficacy in treating skin disease. Having concomitant psoriatic arthritis increased the likelihood of switching by 2.69-fold (Akdogan N et al.). These findings suggest that shared decision making with dermatology, rheumatology, and the patient may help in choosing a treatment plan that best addresses both skin and joints.

One consideration when counseling patients about their likelihood of response to a second or third biologic is that in several clinical trials, biologic-naïve patients tend to have higher PASI responses to biologics than do heavier and biologic-experienced patients. A recent retrospective study found that receiving one or more biologic receiving was associated with a lower likelihood of achieving a PASI75 response to guselkumab (Hung YT et al.). However, in a real-life multicenter study including 57 adult patients with moderate-to-severe psoriasis receiving risankizumab, more biologic-experienced patients reached PASI 100 at weeks 36 and 52 (71.8% and 69.2%, respectively) compared with biologic-naïve patients (50.0% and 37.5%, respectively) (Gerdes S et al.). While both studies were small and no firm conclusions or comparisons can be drawn, real-world data from large multicenter studies that evaluate multiple therapies may guide us in choosing the best therapy for challenging patients who are often underrepresented in clinical trials. Understanding how switching within vs. between classes (TNF, IL-17, and IL-23 inhibitors) impacts efficacy will also help in making choices about biologic switches.

Biologic therapy is generally reserved for patients with more moderate-to-severe psoriasis, often defined as BSA ≥10% or PASI of ≥10. Notably, these criteria are all clinician-performed. The Dermatology Life Quality Index (DLQI) measures the impact of the disease on the patient with a score of 0-5, 6-10, and 11-30 indicating mild, moderate, and severe disease, respectively. In a cross-sectional, observational study, 72.4% of psoriasis patients who qualified for systemic therapy initiation based on PASI and/or BSA had a DLQI of less than 10. Conversely, 10.4% of patients with a DLQI score higher than 10 did not qualify for systemic therapy based on PASI and/or BSA. This study highlights the complementary value of considering both clinician and patient determinants of disease severity when choosing a psoriasis therapy (Barbieri JS et al.)

With so many therapeutic options, it is increasingly common for patients to switch from one biologic to another. Many factors that go into the decision to switch therapies. A retrospective study of 115 adult patients with psoriasis found that the primary factor driving switching was lack of sufficient efficacy in treating skin disease. Having concomitant psoriatic arthritis increased the likelihood of switching by 2.69-fold (Akdogan N et al.). These findings suggest that shared decision making with dermatology, rheumatology, and the patient may help in choosing a treatment plan that best addresses both skin and joints.

One consideration when counseling patients about their likelihood of response to a second or third biologic is that in several clinical trials, biologic-naïve patients tend to have higher PASI responses to biologics than do heavier and biologic-experienced patients. A recent retrospective study found that receiving one or more biologic receiving was associated with a lower likelihood of achieving a PASI75 response to guselkumab (Hung YT et al.). However, in a real-life multicenter study including 57 adult patients with moderate-to-severe psoriasis receiving risankizumab, more biologic-experienced patients reached PASI 100 at weeks 36 and 52 (71.8% and 69.2%, respectively) compared with biologic-naïve patients (50.0% and 37.5%, respectively) (Gerdes S et al.). While both studies were small and no firm conclusions or comparisons can be drawn, real-world data from large multicenter studies that evaluate multiple therapies may guide us in choosing the best therapy for challenging patients who are often underrepresented in clinical trials. Understanding how switching within vs. between classes (TNF, IL-17, and IL-23 inhibitors) impacts efficacy will also help in making choices about biologic switches.

High-potency topical steroids such as clobetasol are commonly used as first-line treatment for psoriasis. A recent study (Sidgiddi S et al. Dermatol Ther (Heidelb). 2021 Aug 28) compared the efficacy and safety of clobetasol 0.05% vs. 0.025% cream.  Patients were randomized to receive either clobetasol 0.05% cream or one of two different formulations of clobetasol 0.025% cream twice a day for two weeks. PGA success rates (clear or almost clear skin) were higher with the 0.025% formulations (38.9% and 36.8%) than with the 0.05% cream (30.8%). Safety also appeared to be better or comparable with the 0.025% formulation as measured by the proportion of patients with an abnormal ACTH stimulation test (20.7% and 17.2% in the 0.025% group compared with 30.0% in the 0.05% group). Due to the small study size (88 subjects) these differences did not reach statistical significance, although they suggest that high efficacy and perhaps better safety (reduced hypothalamic–pituitary–adrenal axis suppression) can be achieved with lower concentration formulations of clobetasol cream.

The oral phosphodiesterase 4 inhibitor apremilast is FDA-approved to treat psoriasis and psoriatic arthritis and recent studies have shown that it is more effective than placebo in treating patients with mild-moderate psoriasis and scalp psoriasis. A recent prospective cohort study followed 45 adult patients with plaque and nail psoriasis with a fingernail Nail Psoriasis Severity Index (NAPSI) score of 12 or more treated with apremilast 30 mg twice daily for 52 weeks (Muñoz-Santos C et al. J Dermatol. 2021 Aug 12). The primary endpoint, the percentage of patients with a Nail Assessment in Psoriasis and Psoriatic Arthritis-Patient Benefit Index of 2 or more at week 52, was achieved in 52% of patients. A median improvement of 53% in fingernail NAPSI score and a mean reduction in nail pain of 68% were observed at week 52.  These findings show that apremilast can be useful in improving the quality-of-life impairment caused by nail psoriasis.

Traditional systemic therapies such as methotrexate and acitretin are cost-effective options for many psoriasis patients. The association of psoriasis with other comorbid conditions, particularly cardiovascular disease, has raised awareness of the importance of considering how therapies impact not just skin disease but also the risk posed by these psoriasis-associated comorbidities. A large Taiwanese retrospective cohort study compared patients treated with methotrexate (13,777) or acitretin (6,020) and found that in comparison to those treated with acitretin, patients treated with methotrexate were at lower risk of experiencing adverse cardiovascular outcomes, including ischemic heart disease and stroke, (adjusted hazard ratio [aHR], 0.84; 95% confidence interval [CI], 0.76-0.94) and had a lower risk of all-cause mortality (aHR, 0.75; 95% CI, 0.66-0.85).

Many disease and patient factors must be considered when choosing the right therapy for a patient. These studies provide valuable information to incorporate into this process and highlight the utility of topical and oral therapies for psoriasis.

High-potency topical steroids such as clobetasol are commonly used as first-line treatment for psoriasis. A recent study (Sidgiddi S et al. Dermatol Ther (Heidelb). 2021 Aug 28) compared the efficacy and safety of clobetasol 0.05% vs. 0.025% cream.  Patients were randomized to receive either clobetasol 0.05% cream or one of two different formulations of clobetasol 0.025% cream twice a day for two weeks. PGA success rates (clear or almost clear skin) were higher with the 0.025% formulations (38.9% and 36.8%) than with the 0.05% cream (30.8%). Safety also appeared to be better or comparable with the 0.025% formulation as measured by the proportion of patients with an abnormal ACTH stimulation test (20.7% and 17.2% in the 0.025% group compared with 30.0% in the 0.05% group). Due to the small study size (88 subjects) these differences did not reach statistical significance, although they suggest that high efficacy and perhaps better safety (reduced hypothalamic–pituitary–adrenal axis suppression) can be achieved with lower concentration formulations of clobetasol cream.

The oral phosphodiesterase 4 inhibitor apremilast is FDA-approved to treat psoriasis and psoriatic arthritis and recent studies have shown that it is more effective than placebo in treating patients with mild-moderate psoriasis and scalp psoriasis. A recent prospective cohort study followed 45 adult patients with plaque and nail psoriasis with a fingernail Nail Psoriasis Severity Index (NAPSI) score of 12 or more treated with apremilast 30 mg twice daily for 52 weeks (Muñoz-Santos C et al. J Dermatol. 2021 Aug 12). The primary endpoint, the percentage of patients with a Nail Assessment in Psoriasis and Psoriatic Arthritis-Patient Benefit Index of 2 or more at week 52, was achieved in 52% of patients. A median improvement of 53% in fingernail NAPSI score and a mean reduction in nail pain of 68% were observed at week 52.  These findings show that apremilast can be useful in improving the quality-of-life impairment caused by nail psoriasis.

Traditional systemic therapies such as methotrexate and acitretin are cost-effective options for many psoriasis patients. The association of psoriasis with other comorbid conditions, particularly cardiovascular disease, has raised awareness of the importance of considering how therapies impact not just skin disease but also the risk posed by these psoriasis-associated comorbidities. A large Taiwanese retrospective cohort study compared patients treated with methotrexate (13,777) or acitretin (6,020) and found that in comparison to those treated with acitretin, patients treated with methotrexate were at lower risk of experiencing adverse cardiovascular outcomes, including ischemic heart disease and stroke, (adjusted hazard ratio [aHR], 0.84; 95% confidence interval [CI], 0.76-0.94) and had a lower risk of all-cause mortality (aHR, 0.75; 95% CI, 0.66-0.85).

Many disease and patient factors must be considered when choosing the right therapy for a patient. These studies provide valuable information to incorporate into this process and highlight the utility of topical and oral therapies for psoriasis.

High-potency topical steroids such as clobetasol are commonly used as first-line treatment for psoriasis. A recent study (Sidgiddi S et al. Dermatol Ther (Heidelb). 2021 Aug 28) compared the efficacy and safety of clobetasol 0.05% vs. 0.025% cream.  Patients were randomized to receive either clobetasol 0.05% cream or one of two different formulations of clobetasol 0.025% cream twice a day for two weeks. PGA success rates (clear or almost clear skin) were higher with the 0.025% formulations (38.9% and 36.8%) than with the 0.05% cream (30.8%). Safety also appeared to be better or comparable with the 0.025% formulation as measured by the proportion of patients with an abnormal ACTH stimulation test (20.7% and 17.2% in the 0.025% group compared with 30.0% in the 0.05% group). Due to the small study size (88 subjects) these differences did not reach statistical significance, although they suggest that high efficacy and perhaps better safety (reduced hypothalamic–pituitary–adrenal axis suppression) can be achieved with lower concentration formulations of clobetasol cream.

The oral phosphodiesterase 4 inhibitor apremilast is FDA-approved to treat psoriasis and psoriatic arthritis and recent studies have shown that it is more effective than placebo in treating patients with mild-moderate psoriasis and scalp psoriasis. A recent prospective cohort study followed 45 adult patients with plaque and nail psoriasis with a fingernail Nail Psoriasis Severity Index (NAPSI) score of 12 or more treated with apremilast 30 mg twice daily for 52 weeks (Muñoz-Santos C et al. J Dermatol. 2021 Aug 12). The primary endpoint, the percentage of patients with a Nail Assessment in Psoriasis and Psoriatic Arthritis-Patient Benefit Index of 2 or more at week 52, was achieved in 52% of patients. A median improvement of 53% in fingernail NAPSI score and a mean reduction in nail pain of 68% were observed at week 52.  These findings show that apremilast can be useful in improving the quality-of-life impairment caused by nail psoriasis.

Traditional systemic therapies such as methotrexate and acitretin are cost-effective options for many psoriasis patients. The association of psoriasis with other comorbid conditions, particularly cardiovascular disease, has raised awareness of the importance of considering how therapies impact not just skin disease but also the risk posed by these psoriasis-associated comorbidities. A large Taiwanese retrospective cohort study compared patients treated with methotrexate (13,777) or acitretin (6,020) and found that in comparison to those treated with acitretin, patients treated with methotrexate were at lower risk of experiencing adverse cardiovascular outcomes, including ischemic heart disease and stroke, (adjusted hazard ratio [aHR], 0.84; 95% confidence interval [CI], 0.76-0.94) and had a lower risk of all-cause mortality (aHR, 0.75; 95% CI, 0.66-0.85).

Many disease and patient factors must be considered when choosing the right therapy for a patient. These studies provide valuable information to incorporate into this process and highlight the utility of topical and oral therapies for psoriasis.

Several recent studies have evaluated that association between psoriasis and known comorbidities including cardiovascular disease, non-alcoholic fatty liver disease (NAFLD), and malignancy. Several recent studies have added to our understanding of the relationship between these conditions.

Using the largest database of hospitalized patients in the United States, Edgen et al found that hospitalization rates for patients with psoriasis are increasing. While the proportion of patients with psoriasis hospitalized with psoriasis as a primary diagnosis decreased about four-fold over a 20-year period (1999-2018), incidence of hospitalizations with any diagnosis of psoriasis has increased. Hospitalized psoriasis patients are increasingly more likely to have other comorbid conditions as during the study period the proportion of hospitalized psoriasis patients with a Charlson Comorbidity Index score of 3 or higher increased from 13.9% to 30.9%. Psoriasis severity, medication use, and reasons for hospitalization were not reported. The authors suggest that screening and management of comorbidities in the outpatient setting may help reduce preventable psoriasis hospitalizations.

Both NAFLD and cardiovascular disease are well-known psoriasis comorbidities, Gonzalez-Cantaro et al studied two cohorts of patients to better define the relationship between these two conditions. In a European cohort of 76 psoriasis patients and 76 control patients, psoriasis patients with NAFLD had a higher prevalence of subclinical atherosclerosis than both psoriasis patients without NAFLD (61% vs 23%) and age, sex, and BMI-matched controls with NAFLD (61% vs 32%). Psoriasis patients were also more likely that control patients to have insulin resistance, higher weight circumference, and dysplipidemia. Among 162 psoriasis patients who underwent PET and coronary CT angiography, higher hepatic FDG uptake (indicating NAFLD) was associated higher atherosclerotic disease burden. Importantly, both the NAFLD and CAD were subclinical in these patients. While the cross-sectional study design precludes any conclusions about causality, physicians should be aware that these two comorbidities are related. Lower waist circumference and greater physical activity were both associated with lower rates of NAFLD among patients with psoriasis, providing some guidance for counseling patients.

Several recent studies have found that cancer rates among patients with psoriasis are higher than what is observed in the general population. The association of psoriasis with lymphohematologic malignancies (LHM) has been controversial. A systematic review and meta-analysis of 25 observational studies including over 2.5 million subjects (Bellinato et al.) found a 1.55-fold increased risk of LHM in patients with moderate to severe psoriasis. Strikingly, the risk of cutaneous T cell lymphoma (CTCL) was increased 6.22-fold, with more severe psoriasis being associated with the highest risk of CTCL. A causal relationship cannot be established from this type of studies, but the authors hypothesize that drugs used to treat psoriasis or the chronic T cell activation caused by active disease may contribute to the risk of LMH. Additionally, psoriasis and CTCL can share clinical features and some cases may be due to misdiagnosis. Interestingly, two psoriasis comorbities, diabetes and obesity, are also associated with an increased risk of LHM.

Early identification and management of comorbidities can help in reducing morbidity and mortality. With so many psoriasis treatments available, understanding how different therapies may impact comorbid conditions is important in helping dermatologists to choose the best therapy for each individual patient.

Several recent studies have evaluated that association between psoriasis and known comorbidities including cardiovascular disease, non-alcoholic fatty liver disease (NAFLD), and malignancy. Several recent studies have added to our understanding of the relationship between these conditions.

Using the largest database of hospitalized patients in the United States, Edgen et al found that hospitalization rates for patients with psoriasis are increasing. While the proportion of patients with psoriasis hospitalized with psoriasis as a primary diagnosis decreased about four-fold over a 20-year period (1999-2018), incidence of hospitalizations with any diagnosis of psoriasis has increased. Hospitalized psoriasis patients are increasingly more likely to have other comorbid conditions as during the study period the proportion of hospitalized psoriasis patients with a Charlson Comorbidity Index score of 3 or higher increased from 13.9% to 30.9%. Psoriasis severity, medication use, and reasons for hospitalization were not reported. The authors suggest that screening and management of comorbidities in the outpatient setting may help reduce preventable psoriasis hospitalizations.

Both NAFLD and cardiovascular disease are well-known psoriasis comorbidities, Gonzalez-Cantaro et al studied two cohorts of patients to better define the relationship between these two conditions. In a European cohort of 76 psoriasis patients and 76 control patients, psoriasis patients with NAFLD had a higher prevalence of subclinical atherosclerosis than both psoriasis patients without NAFLD (61% vs 23%) and age, sex, and BMI-matched controls with NAFLD (61% vs 32%). Psoriasis patients were also more likely that control patients to have insulin resistance, higher weight circumference, and dysplipidemia. Among 162 psoriasis patients who underwent PET and coronary CT angiography, higher hepatic FDG uptake (indicating NAFLD) was associated higher atherosclerotic disease burden. Importantly, both the NAFLD and CAD were subclinical in these patients. While the cross-sectional study design precludes any conclusions about causality, physicians should be aware that these two comorbidities are related. Lower waist circumference and greater physical activity were both associated with lower rates of NAFLD among patients with psoriasis, providing some guidance for counseling patients.

Several recent studies have found that cancer rates among patients with psoriasis are higher than what is observed in the general population. The association of psoriasis with lymphohematologic malignancies (LHM) has been controversial. A systematic review and meta-analysis of 25 observational studies including over 2.5 million subjects (Bellinato et al.) found a 1.55-fold increased risk of LHM in patients with moderate to severe psoriasis. Strikingly, the risk of cutaneous T cell lymphoma (CTCL) was increased 6.22-fold, with more severe psoriasis being associated with the highest risk of CTCL. A causal relationship cannot be established from this type of studies, but the authors hypothesize that drugs used to treat psoriasis or the chronic T cell activation caused by active disease may contribute to the risk of LMH. Additionally, psoriasis and CTCL can share clinical features and some cases may be due to misdiagnosis. Interestingly, two psoriasis comorbities, diabetes and obesity, are also associated with an increased risk of LHM.

Early identification and management of comorbidities can help in reducing morbidity and mortality. With so many psoriasis treatments available, understanding how different therapies may impact comorbid conditions is important in helping dermatologists to choose the best therapy for each individual patient.

Several recent studies have evaluated that association between psoriasis and known comorbidities including cardiovascular disease, non-alcoholic fatty liver disease (NAFLD), and malignancy. Several recent studies have added to our understanding of the relationship between these conditions.

Using the largest database of hospitalized patients in the United States, Edgen et al found that hospitalization rates for patients with psoriasis are increasing. While the proportion of patients with psoriasis hospitalized with psoriasis as a primary diagnosis decreased about four-fold over a 20-year period (1999-2018), incidence of hospitalizations with any diagnosis of psoriasis has increased. Hospitalized psoriasis patients are increasingly more likely to have other comorbid conditions as during the study period the proportion of hospitalized psoriasis patients with a Charlson Comorbidity Index score of 3 or higher increased from 13.9% to 30.9%. Psoriasis severity, medication use, and reasons for hospitalization were not reported. The authors suggest that screening and management of comorbidities in the outpatient setting may help reduce preventable psoriasis hospitalizations.

Both NAFLD and cardiovascular disease are well-known psoriasis comorbidities, Gonzalez-Cantaro et al studied two cohorts of patients to better define the relationship between these two conditions. In a European cohort of 76 psoriasis patients and 76 control patients, psoriasis patients with NAFLD had a higher prevalence of subclinical atherosclerosis than both psoriasis patients without NAFLD (61% vs 23%) and age, sex, and BMI-matched controls with NAFLD (61% vs 32%). Psoriasis patients were also more likely that control patients to have insulin resistance, higher weight circumference, and dysplipidemia. Among 162 psoriasis patients who underwent PET and coronary CT angiography, higher hepatic FDG uptake (indicating NAFLD) was associated higher atherosclerotic disease burden. Importantly, both the NAFLD and CAD were subclinical in these patients. While the cross-sectional study design precludes any conclusions about causality, physicians should be aware that these two comorbidities are related. Lower waist circumference and greater physical activity were both associated with lower rates of NAFLD among patients with psoriasis, providing some guidance for counseling patients.

Several recent studies have found that cancer rates among patients with psoriasis are higher than what is observed in the general population. The association of psoriasis with lymphohematologic malignancies (LHM) has been controversial. A systematic review and meta-analysis of 25 observational studies including over 2.5 million subjects (Bellinato et al.) found a 1.55-fold increased risk of LHM in patients with moderate to severe psoriasis. Strikingly, the risk of cutaneous T cell lymphoma (CTCL) was increased 6.22-fold, with more severe psoriasis being associated with the highest risk of CTCL. A causal relationship cannot be established from this type of studies, but the authors hypothesize that drugs used to treat psoriasis or the chronic T cell activation caused by active disease may contribute to the risk of LMH. Additionally, psoriasis and CTCL can share clinical features and some cases may be due to misdiagnosis. Interestingly, two psoriasis comorbities, diabetes and obesity, are also associated with an increased risk of LHM.

Early identification and management of comorbidities can help in reducing morbidity and mortality. With so many psoriasis treatments available, understanding how different therapies may impact comorbid conditions is important in helping dermatologists to choose the best therapy for each individual patient.