Read Full Article HerePsoriasis Action Month marks a time to raise awareness about a systemic inflammatory disease with effects that extend far beyond the skin.
“Despite the skin being the most visible manifestation of this condition, psoriasis is more than a skin disease,” Rebecca Y. Dufner, MD, MBA, FAAD, a dermatologist at U.S. Dermatology Partners, told Healio. “Inflammation does not necessarily stop at the skin. Psoriasis affects everything.”
According to the National Psoriasis Foundation, 125 million people worldwide have psoriasis. Of this patient population, 80% have overweight or obesity — conditions which can lead to further confounding comorbidities such as type 2 diabetes, stroke and high cholesterol, as Healio previously reported. In 2006, psoriasis was formally declared an independent risk factor for heart attacks after a landmark study showed the risk remained unchanged after adjusting for metabolic and cardiovascular factors.
The impacts of psoriasis extend to the mind as well, with one study finding that psycho-cognitive factors could impact quality of life more than objective disease severity for some. Many other studies have also demonstrated that patients with psoriasis face ongoing stigmatization, embarrassment and depression, according to Dufner.
The National Psoriasis Foundation has dedicated August to improving psoriasis education and awareness, designating it as Psoriasis Action Month. Healio spoke with Dufner about recognizing psoriasis, its systemic health implications and advances in treatment.
Healio: What are the signs and symptoms of psoriasis, and what separates it from conditions like eczema?
Dufner: The classic presentation of psoriasis is well-defined, thicker plaques with scale. They are often found in places like the elbows, knees, scalp and lower back. Psoriasis can itch, but eczema tends to be much more intensely itchy and is considered the itchier condition. Psoriasis can also affect the nails and joints, which gives us these important clues that we are really dealing with a systemic inflammatory disease.
While psoriasis and eczema can look similar and a diagnosis may not be obvious from one visit, things like distribution, morphology, degree of scale, nail findings and the patient’s history can help distinguish these two conditions.
Healio: What are some other comorbidities commonly seen with psoriasis and why?
Dufner: Because psoriasis is a systemic inflammatory condition, the biggest comorbidities I think about are psoriatic arthritis, which includes involvement of the joints, cardiovascular and metabolic disease, and mental health conditions such as anxiety and depression.
We believe that chronic systemic inflammation plays a role, but there are also shared risk factors like obesity, smoking and metabolic dysfunction. When I diagnose psoriasis, I am not just looking at the skin. I am also asking about joint symptoms, making sure that the patient is getting appropriate preventative healthcare and checking that they have a primary care physician.
Healio: What is the association between psoriasis and cardiometabolic risks, and how do you think that should be managed?
Dufner: Patients with psoriasis, particularly those with more extensive or severe disease, do have an increased burden of cardiometabolic disease. The important clinical takeaway here is that dermatologists should recognize that psoriasis is a cardiovascular risk-enhancing condition. For this reason, dermatologists should make sure that patients are receiving appropriate screenings and traditional risk factor management, which are usually performed through primary care.
However, dermatologists can also pay attention to a patient’s blood pressure, lipids, glucose or HbA1c when appropriate, as well as body weight, smoking habits and alcohol use.
Healio: How has the treatment landscape changed for psoriasis, especially within the past decade?
Dufner: The past decade has transformed psoriasis.
Psoriasis was a disease largely managed with very broad immunosuppressive medications such as methotrexate, cyclosporine and tumor necrosis factor-alpha inhibitors. Although we still use these medications today, they are less frequently prescribed.
Highly selective medications, including interleukin-23 and -17 inhibitors, have changed our goals. We are now targeting complete or near-complete skin clearance, aiming for PASI 90 to 100 where we once strived for PASI 75. We are also seeing new small molecule inhibitors, including oral pills such as tyrosine kinase 2 inhibitors and, most recently, an IL-23 inhibitor.
We have so many options for patients now that we did not have before. Many of our prior medications came with significant monitoring requirements, adverse effects and a modest level of clearance. Today, we are looking at highly targeted biological therapies and achieving much better control and outcomes for our patients.
Healio: Outside of medications, how might diet and lifestyle play roles in managing psoriasis?
Dufner: The answer to this is very nuanced.
There is no single “psoriasis diet” that I recommend to everybody, and I would be cautious about advising patients to follow restrictive diets that promise to cure psoriasis or dramatically alter the underlying condition. We know that maintaining a healthy weight can improve psoriasis severity and response to some treatments, so I encourage patients, especially those who are overweight or have metabolic comorbidities, to follow a balanced, nutrient-rich diet and participate in regular physical activity.
We have observed that GLP-1s, which cause weight loss, can trigger complicated improvements in patients with psoriasis. There may be a role for specific dietary interventions in select patients, but I do not recommend a “broad strokes” diet for everyone.
Healio: How can dermatologists help a patient who may be struggling with their psoriasis diagnosis?
Dufner: This is an important question. The mental comorbidities that come with a disease like psoriasis can sometimes fall lower on the priority list, remaining unaddressed during visits when they should not be ignored.
First, I want to acknowledge that psoriasis can have a profound emotional and social impact. Patients might feel embarrassed. They might feel stigmatized. They might feel frustrated. Sometimes they are told that their disease is “just a skin condition,” making them feel minimized. It impacts how they sleep, how they work, how they dress, their intimate relationships, how they socialize and how they feel about themselves.
Because we know psoriasis can affect these things, we need to directly ask patients about their quality of life when creating individualized treatment plans. By asking these questions, we can be informed on how aggressively we should treat their disease so the patient can achieve their treatment goals.
Lastly, if we are seeing signs of significant anxiety, depression or social withdrawal, we should not hesitate to partner with our mental health colleagues. This is not a reflection of dermatology’s limited abilities. It is simply a part of comprehensive psoriasis care for the whole patient.
