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Psoriasis

ETIOLOGY​/RISK FACTORS

Obesity/BMI​

  • Compared with patients with a BMI <25, overweight (BMI 25-30), class 1 obesity (BMI 30-34.9), and class 2/3 obesity (BMI 35-39.9, 40 or greater) had a 19%, 43%, and 83% increased risk of psoriasis when controlling for age, sex, race, and smoking status. 34118300

Diet

Ultra-processed Foods

  • Using data from the NutriNet-Santé cohort, active psoriasis had significantly higher UPF (as defined by the NOVA system) intake compared to those without psoriasis. Association remained significant even after adjusting for age, BMI, alcohol intake, and comorbidities. 

NATURAL HISTORY

Guttate Psoriasis​​

Risk of Progression to Chronic Psoriasis 39362337

  • The overall lifetime risk of developing a chronic form of psoriasis was: chronic plaque psoriasis (12.45%), psoriatic arthritis (7.71%), generalized pustular psoriasis (2.89%), palmoplantar pustular psoriasis (2.90%), erythrodermic psoriasis (3.24%), and nail psoriasis (2.36%)​.  Most of the risk for plaque psoriasis was within the first year, but development years out was not rare.  These figures were quite a bit lower than previous studies which were 25-39%. (cit 1-3)

COMORBITIES

Cardiovascular Risk

GlycA as a marker of systemic inflammation mediates between PASI and CV risk (39565616)

  • GlycA is a glycan biomarker of systemic inflammation.

  • Higher PASI scores were associated with higher GlycA levels.​

  • Elevated GlycA levels were associated with both subclinical atherosclerosis (measured as noncalcified coronary burden, NCB) and cardiovascular events.​

  • Higher PASI scores were associated with both subclinical atherosclerosis and future cardiovascular events.

  • Mediation by GlycA is partial.  It mediated 16.6% of the association between PASI and subclinical atherosclerosis and 37.4% of the association between PASI and cardiovascular events.​ This raises questions about whether GlycA is an ideal marker of inflammation in this context.

Mitigating Risk with Adequate Treatment

  • Patients treated with interleukin-23 inhibitors (IL-23i) had a significantly lower risk of developing CV-related comorbidities compared to biologic-naïve psoriasis patients, with odds ratios (OR) of 0.39 for dyslipidemia, 0.34 for hypertension, 0.37 for diabetes, and 0.24 for MACEs​. Compared to other biologic classes, IL-23i still demonstrated the lowest CV risk, while tumor necrosis factor inhibitors (TNFi) were associated with a higher risk of hypertension, diabetes, and MACEs. (39423931)  This is contrast to prior literature that generally supported TNFi as cardioprotective, which potentially could be explained by differences in study design and patient selection. 

TREATMENT​

Overall Efficacy

Blauvelt A, Noe MH. The Best Psoriasis Medications Emerge. JAMA Dermatol. 2024. PMID: 37966815.

  • This was a clinical evidence synopsis based largely on a recent Cochrane review that looked to summarize the best systemic treatment of psoriasis out of the 12 biologics and 5 oral medications approved by the FDA.

  • Out of the biologics, the most effective were: 1) infliximab, 2) bimekizumab, 3) ixekizumab, 4) risankizumab.  There was no clinical difference in effectiveness of these 4 drugs. 

  • For oral medications, rank order efficacy was: 1) deucravacitinib, 2) methotrexate, 3) cyclosporine, 4) apremilast, 5) acitretin. 

  • The IL-17 inhibitors and IL-23 inhibitors were the best in terms of classes of medications. ​

Predicting response to therapy

Clinical Characteristics Associated With Response to Biologics in the Treatment of Psoriasis: A Meta-analysis [published correction appears in JAMA Dermatol.] 2024. PMID: 38888917.

  • Paraphrased results: Overall, 40 studies, 21,438 patients. Previous exposure to biologics OR 0.44, current smoking OR 0.78, previous smoking OR 0.81, higher BMI OR 0.96, older age OR 0.99 were negatively associated with achieving PASI 90 at 6 months in observational studies. In RCTs, only BMI of 30 or higher was negatively associated with treatment response: OR 0.57. ​

Phototherapy​

  • Home phototherapy is as effective as office-based phototherapy. 39319513​

Topical Therapies

Tapinarof 1% cream (Vtama)​

Biologic Therapies

Bimekizumab

  • The adjudicated suicidal ideation and behavior rate was found to be no different across 9 phase 2/3 clinical trials when compared to general psoriasis patients and those taking IL-17A/IL-23 inhibitors. 38447700  ​

Guselkumab

Dosing extension

  • In patients who are super responders (PASI 0 at week 20 and 28), decreased dosing frequency to q16wks was noninferior to standerd q8wk dosing at 68wks. 39083288 

Ixekizumab

  • Some patients treated with IL-17A blockers develop eczema/urticaria during treatment.  Mast cell degranulation is an early feature of psoriasis, and the interaction between IL-17A inhibitors and IL-17A+ mast cells may the reason some patients develop these reactions.  Patients that have ixekizumab related urticaria appear to develop earlier relapse of psoriasis upon withdrawl of drug.  38244613

Secukinumab

  • Pooled cohort of 12,319 patients taking secukinumab for psoriasis, PsA, and ankylosing spondylitis.  No cases of active TB reported.  13 cases of latent TB activation reported (0.1%). 33001147

  • Secukinumab > ustekinumab. 33263718​​

Systemic Oral Medications​

Deucravacitinib

  • 1 year and 3 year PASI 90 is 45.6% and 48.1%, resp. 39602111

  • No indicated increased rate of malignancy or VTE over 3 years. 39602111 

  • ~1-2% risk of serious infection per year (2.5 per 100 patient years including COVID, 0.9 per 100 patient years excluding COVID over 3 years). 39602111

  • Minor increase in shingles over 3 years (0.6 for treatment vs 0.4 for placebo per 100 patient years). 39602111

Impact on Comorbidities

  • Given psoriasis is increasingly being regarded as a systemic disease, there is question regarding whether or not treatment modifies the risk of comorbidities.  In this study, patients with psoriasis had a higher risk of drug-induced liver injury (suspected to be from polypharmacy including OTC meds, and possible contribution from MTX), affective bipolar disease, and cardiovascular disease which contributed to an increased mortality.  Use of biologic drugs attenuated this mortality risk by nearly half. 38387852

External Medicine

 Conceived 2016

DISCLAIMER: This website is a collection of primary literature and the opinions of the website creators on that literature.  It is not intended to be used for the practice of medicine or the delivery of medical care in the absence of other appropriate credentials (like a medical degree).  Discuss any information with your doctor before pursuing treatments mentioned on this site.  

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