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Psoriasis

Background

Psoriasis results from a complex interaction of the immune cells, skin cells, and inflammatory messengers called cytokines, resulting in an inflammatory cascade that affects not only the skin but tissues throughout the body (Monteleone 2011; Traub 2007; Jariwala 2007; Cai 2012). The skin lesions typical of psoriasis arise when this inflammatory cascade causes skin cells to multiply too quickly. The new skin cells move to the outermost layer of skin in only a few days rather than weeks. Older skin cells cannot be shed fast enough, so they pile up on the surface as thick, silvery, flaky areas of dead skin. Redness and swelling develop as a result of increased blood flow from newly formed capillary blood vessels. This formation of new blood vessels is called angiogenesis and is an important contributor to psoriasis (Liew 2012; AAD 2015; NIH 2013; Das 2009).

Psoriasis Subtypes

There are several subtypes of psoriasis, and an individual can have more than one subtype.

Table 1: Subtypes of Psoriasis

Subtypes

Description

Plaque psoriasis

Most common form; red plaques covered by thick, silvery, shiny scales

Guttate psoriasis

Drop-shaped lesions on the trunk, limbs, and scalp; often triggered by streptococcal sore throat (pharyngitis)

Pustular psoriasis

Characterized by uninfected pus blisters on the palms and soles; may be prompted by medication, stress, infection, or certain chemicals

Inverse psoriasis

Smooth red lesions located in the armpits, groin, under the breasts and in other skin folds; often occurs in obese patients and aggravated by friction and sweating

Erythrodermic psoriasis

Reddening and scaling of skin over large area of the body; may be a reaction to severe sunburn, corticosteroid treatment, or poorly controlled psoriasis

(NIH 2013; Usatine 2013; Schalock 2014; Hall 2015; Armstrong 2014)

Psoriatic Arthritis

Up to 30% of psoriasis patients are diagnosed with an inflammatory joint disease called psoriatic arthritis, though many remain undiagnosed. The pathophysiology of psoriatic arthritis is complex and not completely understood. Scientists suspect that autoimmunity underlies this condition, and an autoantibody correlating with psoriatic arthritis (anti-carbamylated protein) has recently been described (Chimenti 2015). In 10‒15% of psoriatic arthritis cases, joint disease develops before skin symptoms (Villani 2015; Goldman 2016; Hall 2015). Psoriatic arthritis can affect any joint in the body, and can range from mild to severe; frequent flare-ups and remissions are common (Lee 2010; NLM 2015; Girolomoni 2009; Traub 2007). A severe, destructive form of psoriatic arthritis known as arthritis mutilans afflicts a subset of patients. Large prospective studies suggest obesity is a significant risk factor for psoriatic arthritis (Love 2012; Li 2012; Elsevier BV 2015; Goldman 2016).

Psoriatic skin lesions can appear as much as two decades before the onset of arthritis. The severity of skin disease and joint inflammation are not related (Elsevier BV 2015; Hall 2015). Psoriasis of the skin and psoriatic arthritis may be different manifestations of the same underlying inflammatory disease (Hebert 2012; Traub 2007).

Psoriasis and Cardiovascular Disease

The link between psoriasis and cardiovascular disease is especially strong (Gelfand 2006; Ryan 2015; Ni 2014; Girolomoni 2009; Siegel 2013; Spah 2008). In an observational study involving more than half a million subjects, 30-year-old male patients with severe psoriasis were more than three times as likely to have a heart attack over an average of more than five years of follow-up compared with controls without psoriasis (Gelfand 2006). Cardiovascular disease also contributes to a 5-year reduction in life expectancy among individuals with moderate-to-severe psoriasis (Ryan 2015).

In one study, patients with severe plaque psoriasis were found to have significantly greater arterial stiffness compared with healthy controls (Gisondi 2009). In a separate controlled study, coronary artery calcification—another indicator of cardiovascular disease—was more prevalent in psoriasis patients (Ludwig 2007).

According to a consensus statement issued by the National Psoriasis Foundation, patients with psoriasis represent a high-risk cardiovascular disease population. Screening for cardiovascular risk factors in patients with moderate-to-severe psoriasis is strongly advised (Doukaki 2013).