Monday, 18 Mar 2019

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Dermatology Guidelines for Psoriatic Comorbidities

The JAAD has published joint guidelines from the American Academy of Dermatology (AAD) and National Psoriasis Foundation (NPF) on the approach, management and dermatolgist roles for select comorbid conditions. 

A multidisciplinary work group that compried psoriasis experts consisting of dermatologists (including private practitioners), a rheumatologist, a cardiologist, and representativies from a patient advocacy organization convened to develop this comorbidity research. This guideline was addressed by consensus after a review of the medical literature (1980-2017) on disorders that may accompany psoriasis including extracutaneous manifestations, comorbid conditions, mental health, psychosocial wellness, and quality of life (QoL).

The Dermatolgists role select conditions is detailed below:

  1. Psoriatic arthritis - Dermatologists play an important role in screening for PsA and informing psoriasis patients about the association between psoriasis and arthritis, using a proactive approach to patient education and a consistent approach to routine screening for signs and symptoms of PsA will facilitate the earliest possible detection. Patients should be encouraged to notify their dermatologists or primary care providers if a musculoskeletal concern (eg, morning joint stiffness, swelling) arises that cannot be explained otherwise. Consultation with a rheumatologist may be considered and pursued if available.
  2. Cardiovascular disease - Because the risk factors for cardiovascular disease are commonly associated with psoriasis, dermatologists should inform patients regarding this association and ensure the patient is engaged with his or her primary care provider or cardiologist for appropriate screening. Such screening measures may include height, weight, blood pressure, blood glucose, hemoglobin A1C, lipid levels, abdominal circumference, and calculation of BMI. Efforts aimed at lifestyle modification (dietary changes to achieve and maintain a normal BMI, smoking cessation, exercise regimen) are also important. Screening intervals may vary between patients on the basis of their individual risk factors and overall health. Consultation with cardiologists and other specialists should be performed as deemed necessary by the dermatologist or primary care provider to confirm diagnoses and establish a treatment plan.
  3. Metabolic syndrome - patients with psoriasis should be informed about the risk for metabolic syndrome and be evaluated according to national guidelines by their primary care provider or dermatologists for its components by measuring blood pressure, waist circumference, fasting blood glucose and/or hemoglobin A1C, and fasting lipid levels. The dermatologist should advise patients to practice a healthy lifestyle (appropriate diet, regular exercise, smoking cessation, and mental wellness) and communicate with the patient's primary care provider so that psoriatic patients are evaluated and appropriately treated for these comorbitities. Referral to the appropriate health care provider or specialist might be necessary to confirm these diagnoses and establish an appropriate treatment plan. 
  4. Obesity - Patients with moderate-to-severe psoriasis should have their obesity status determined annually. This includes measuring height, weight, waist circumference, and calculating BMI. Patients of obesity class 1 or higher (BMI >30 kg/m2) and/or abdominal obesity should be referred to their primary care physician for further education and evaluation. Psoriatic patients already being monitored for obesity should be encouraged to maintain a healthy lifestyle and keep regularly scheduled follow-up visits with their primary care provider or dermatologist.
  5. Hypertension - Hypertension is a leading cause of death worldwide and a prominent feature of psoriasis patients. Whether psoriasis and hypertension are closely related is less clear because large, well-controlled, high-quality studies have failed to consistently demonstrate this important relationship.  Studies support the association of psoriasis and hypertension, which is strongest in patients with more severe disease. Patients should be screened for HTN. Some psoriasis medication can induce or worsen hypertension. For example, cyclosporine commonly causes new-onset hypertension or worsening of pre-existing hypertension. The calcium-channel blocker amlodipine is often found to successfully reverse the effects of cyclosporine-induced hypertension.
  6. Dyslipidemia - Dyslipidemia plays a prominent role in cardiovascular disease, and some studies have found an association between psoriasis and dyslipidemia, all physicians caring for patients with moderate-to-severe psoriasis should ensure that patients have screening lipid tests performed periodically. But not all studies have shown a significant relationship between psoriasis and dyslipidemia.
  7. Mental health - Dermatologists should be aware of the association between depression, anxiety, and psoriasis and address it with their patients. It is important to monitor for signs and symptoms of mental illness in psoriatic patients. The improvement in mental health of psoriatic patients treated with biologic therapies and the modified Goeckerman regimen support the use of these therapeutic agents to manage psoriasis and simultaneously improve anxiety, depression, and suicidal ideation, if present. Awareness and identification of suicidal ideation might reduce suicidality in these patients.
  8. Lifestyle choices - Both smoking and excessive alcohol ingestion are associated with psoriasis and its severity. Increased usage of either substance further affects disease severity, while cessation can improve psoriasis over time. Dermatologists should strongly advise patients with psoriasis to avoid smoking and limit alcohol intake for overall health improvement and to help improve skin disease. In addition, excessive alcohol intake (and subsequent liver disease) limits some systemic treatment options available for patients and/or limits their efficacy. Because patients might need targeted counseling, therapeutics and support for successful discontinuation or moderation of alcohol and tobacco, referral to appropriate experts, and resources is warranted.
  9. Quality of life - Psoriasis is a multisystem disease which might negatively affect several facets of a patient's life, including interpersonal relationships, work participation, and sexual health. The etiology of the impairment can be due to skin involvement and exacerbated by arthritis and erectile dysfunction. Concomitant mental health disorders, including anxiety and depression, might also be present and play a role. Dermatologists should sensitively raise these topics with psoriasis patients, providing validation of patient concerns and optimizing empowerment. The use of systemic therapy to address the disease appears to improve overall psychosocial wellbeing, especially pertaining to employment and sexual activity. It is important to emphasize that not all medications, both topical and systemic, as well as phototherapy have been studied in this regard. This represents a gap in our knowledge of those treatment modalities.
  10. Inflammatory bowel disease - There is an established association between IBD and psoriasis, and patients with IBD on TNFi therapy might develop new-onset psoriasiform eruptions. Patients should be informed of this relationship by their dermatologist; attention should be paid to signs and symptoms of bowel disease that would warrant further evaluation by the patient's primary care provider or gastroenterologist. If psoriasiform skin disease develops in patients with IBD while they are on TNFi therapy, the approach to treatment of both the bowels and skin should be individualized.
  11. Malignancy - Dermatologists should be aware of the increased incidence of certain malignancies in patients with psoriasis and inform their patients accordingly. A proactive approach to age-appropriate cancer screening should occur, with referral to appropriate specialists if a patient displays signs or symptoms concerning for an underlying malignancy. Dermatologists should actively assess the skin of psoriatic patients not only for psoriasis involvement, but also for the development of skin cancer, and manage them accordingly. Patients with skin findings atypical for psoriasis or whose psoriasis does not respond appropriately to therapy, should be considered for skin biopsy to rule out cutaneous T-cell lymphoma.
  12. Renal disease - Dermatologists should be aware of the independent association of renal disease and psoriasis while also appreciating that other psoriatic comorbidities and their treatments, for example NSAIDs for arthritis, can negatively affect the kidneys. Because the association is strongest in patients with severe psoriasis, testing may be considered more frequently in such patients. In addition to blood urea nitrogen and creatinine, a urine microalbumin should be assessed to detect occult renal disease. Patients with evidence of CKD should be referred to their primary care provider or a nephrologist for further assessment and management. Providers should use caution when psoriasis patients are placed on nephrotoxic drugs, and the medications should be discontinued immediately if newly acquired renal disease is suspected. As nephrotoxicity risk from medication increases with age, and renal clearance decreases with age, renal impairment over time should be considered when psoriatic patients are placed on potentially nephrotoxic medications.
  13. Sleep apnea - These studies demonstrate that patients with psoriasis are at increased risk for OSA. Whether this risk is correlated to BMI is unknown. Similar to other comorbidities, the risk for OSA varies according to severity of psoriasis. Psoriasis patients who have classical risk factors for OSA should be referred to the appropriate health care provider for further evaluation. Psoriasis patients with OSA should be tested for OSA-associated risk factors, such as obesity, hypertension, and diabetes.
  14. COPD - These findings reveal that psoriatic patients are more likely to develop COPD than nonpsoriatic patients. Furthermore, patients with severe psoriasis are more likely to have COPD than those with mild disease. Dermatologists should be aware of this association and inform patients regarding the relationship. Attention to COPD risk factors should be given. Patients should be advised to discontinue smoking to reduce their risk of developing COPD.
  15. Uveitis - Dermatologists should be aware of the increased incidence of uveitis in psoriatic patients. Both providers and patients should understand the signs and symptoms of uveitis are nonspecific and that suspicious ocular signs and symptoms should be further investigated by an ophthalmologist. These symptoms include redness of the eye (with or without pain), blurred vision, and photosensitivity.208 Early detection allows initiation of treatment to prevent ocular damage.208 Dermatologists should consider human leukocyte antigen B27 arthritis in patients with psoriasiform skin changes and uveitis and refer them as deemed appropriate.
  16. Hepatic disease - Dermatologists should be aware of the increased prevalence of NAFLD in patients with psoriasis. While there is an independent association between psoriasis and NAFLD, patients with metabolic syndrome and/or PsA are particularly at risk. In addition, systemic medications used to treat psoriasis can be deleterious to liver function. Unidentified liver disease enables progression of liver damage, which can lead to fibrosis and cirrhosis. Early identification allows management and monitoring. The identification of liver disease might alter the treatment options chosen for the patient's psoriasis.
Disclosures: 
The author has no conflicts of interest to disclose related to this subject

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