Comorbidities in Psoriasis

Living with psoriasis, you are very aware most people only see the external symptoms of psoriasis, which include raised, red patches of skin covered in silvery scales. New research is starting to shine a light on another important aspect of living with psoriasis—the increased risk for developing other conditions, classified as comorbidities or co-existing conditions.

Comorbidities associated with psoriasis include psoriatic arthritis (PsA), depression, cardiovascular disease, and more. The presence of comorbid conditions can affect a person’s health and the type of treatment they receive.

The term “comorbidity” is used to refer to the presence of more than one health condition in the same person. For example, if you have both psoriasis and depression, you are said to have comorbid psoriasis and depression. Comorbid conditions are usually ones that are chronic or lifelong.

Comorbidity tends to be associated with difficulty finding effective treatments, worse health outcomes, and increased medical costs. Having comorbid conditions challenges the way doctors treat psoriasis and researchers stress the importance of a personalized and comprehensive care approach in persons who live with more than one chronic disease.

Psoriasis is a skin condition that causes skin cells to multiply at a much higher rate than what is considered normal. This causes a build-up of skin cells and an appearance of plaques—raised red patches covered in a white buildup of dead skin cells called scales. Psoriasis is not contagious, but it has been said to run in families. According to the National Psoriasis Foundation, psoriasis affects up to 125 million people worldwide. Additionally, up to 30% percent of people with psoriasis will go on to develop psoriatic arthritis (PsA), an autoimmune disease that causes joint pain and inflammation in addition to skin inflammation.

Psoriasis has been recognized as a condition affecting multiple body systems (multi-systemic). This is because, like other autoimmune conditions, psoriasis starts in the immune system. Your immune system generally attacks infections and other foreign substances, but in the case of autoimmune diseases, it attacks healthy cells instead. One report from the Brazilian Annals of Dermatology (Anais Brasileiros de Dermatologia) reports up to 73% of people with psoriasis have at least one comorbidity.

According to a 2018 report in the journal Seminars in Cutaneous Medicine and Surgery, the most common comorbidities of psoriasis are “psoriatic arthritis, cardiovascular disease, metabolic syndrome, overweight/obesity, inflammatory bowel disease, and depression."

Being aware of known, potential comorbidities of psoriasis early on can help you and your doctor make better treatment decisions, including creating a plan to potentially slow down or prevent comorbidities, and improve your quality of life. To achieve this, your treating doctor may include screening for potential psoriasis comorbidities that he or she thinks may have an impact on you down the road.

For example, research shows “depression and suicidal ideation are much more common in psoriasis.” In this case, a dermatologist would not be able to address the specific issues of depression and suicidal thoughts. However, he or she can inform you of your options and refer you to the appropriate specialist or doctor.

Many people with psoriasis will go on to develop PsA. In general, the more severe your psoriasis, the higher the risk for developing PsA. Identifying PsA early in people with psoriasis can be a challenge. But early diagnosis is vital in order to get control of PsA before it damages a person’s joints or causes permanent disability.

Unfortunately, early diagnosis is not always possible. In fact, one study reported in 2015 in the Journal of European Academy of Dermatology and Venereology, finds 1 in 10 people with psoriasis have undiagnosed PsA. Further, the impact of quality of life in people with undiagnosed PsA is substantial.

Research shows a link between psoriasis and cardiovascular disease, especially if a person has severe psoriasis. The report’s authors stress the importance of detailed screening and management for cardiovascular disease in people with psoriasis. Chronic inflammation is likely to blame for the increased risk for cardiovascular disease and stroke, as inflammation is can cause damage to arteries over time.

Treating psoriasis properly can reduce the risk of heart attack or stroke. Researchers have found biologic drug treatment targets immune system activity that causes both chronic skin inflammation and early plaque buildup that would eventually clog arteries and restrict blood flow. These findings mean biologic therapies can not only treat inflammation, but also reduce the risk for cardiovascular disease risk.

Metabolic syndrome is a collection of conditions occurring together that increase the risk of heart disease, stroke, and type 2 diabetes. These conditions include elevated blood pressure, high blood sugar, excess body fat in the waist, and abnormal cholesterol or triglyceride levels. Having one condition doesn’t mean a person has metabolic syndrome but having two or more of these conditions increases the risk for complications, including type 2 diabetes and stroke.

According to a study reported in 2017 in the Anais Brasileiros de Dermatologia, people with psoriasis are six times more likely to have metabolic syndrome, this in comparison to others without psoriasis. The researchers further note these higher incidences emphasize the need for early treatment and screening of metabolic syndrome in psoriasis patients.

Inflammation affects the way the body’s cells absorb sugar from the food you eat. This causes extra sugar to build up in the blood, resulting in diabetes or worsening symptoms of the condition.

You can manage type 2 diabetes with weight loss, exercise, and by eating high-fiber foods. If you have psoriasis, you should have blood sugar levels checked regularly.

Obesity means having too much body fat. This is different than just being overweight, which means weighing too much, as weight tends to be associated with more than fat, and includes muscle and bone weight, and body water.

Researchers know people with psoriasis are more likely to be obese, this in comparison to others in the general population. Further, weight loss can improve psoriasis and PsA and even prevent psoriasis development people are obese.

There is a connection between psoriasis and inflammatory bowel disease (IBD). Findings from a 2018 systematic review and meta-analysis in the journal JAMA Dermatology suggest psoriasis is significantly associated with IBD. This is because the same genes that increase the risk for psoriatic disease also increase the risk for IBD. Talk to your doctor if you experience symptoms of IBD, including diarrhea, abdominal pain, and bloody stools.

Depression is a common complication of psoriasis that generally comes about from quality of life issues relating to body image and living with skin pain and other skin problems. According to the National Psoriasis Foundation, depression is the top comorbidity of psoriasis. Further, people with psoriasis use anti-depressants at much higher rates than others in the general population. While treatment can help reduce the effect of depression, the best way to improve depression and quality of life is to better manage and treat psoriasis.

Depression is defined as a feeling of persistent sadness or loss of interest. Symptoms may include changes to sleep, appetite, energy levels, daily behaviors, and self-esteem. Depression can also be associated with suicidal thoughts (thinking about or planning suicide).

Psoriasis is associated with a number of other conditions, including osteoporosis, uveitis, and liver and kidney disease. Osteoporosis is known for causing bones to become weak and brittle and its connection to psoriasis is due to chronic inflammation that eventually leads to bone weakness. Uveitis is an inflammatory eye condition and the increased risk is due to the fact psoriasis and uveitis share similar genetic characteristics.

Severe psoriasis is associated with liver disease, especially nonalcoholic fatty liver disease (NAFLD) and cirrhosis. Severe psoriasis also poses an increased risk for kidney disease. Inflammatory conditions are known for causing damage to the kidneys or liver, either directly or through whole-body inflammation that eventually leads to organ damage.

Psoriasis has also been connected to increased risk for infections, sleep disorders, chronic obstructive pulmonary disease (COPD), and sexual dysfunction.

It is important to be aware of diseases that may be associated with psoriasis. Being informed about these conditions can help you to be upfront with your doctor about new or worsening symptoms you experience. Even if you don’t think symptoms are linked to psoriasis or a comorbid condition, trust that your dermatologist or other treating doctor can identify these, address risk factors, request screening for comorbid conditions, and refer you to other doctors or specialists. Additionally, you can reduce your risk for psoriasis comorbid conditions by making healthy lifestyle choices, including eating healthy and exercising, and following your doctor-prescribed treatment plan.