patient care perspectives
Psoriasis, Inflammatory Bowel Disease, and Multiple Sclerosis: Links and Risks
Patients with psoriasis are at increased risk of a number of autoimmune inflammatory disorders, including inflammatory bowel disease (IBD) and multiple sclerosis (MS). Currently available psoriasis treatments have the potential to have a positive or negative impact on these linked disorders.
Professor of Dermatology and Epidemiology
“When evaluating a patient with psoriatic disease, it is important to know specifically whether they have a history of conditions such as ulcerative colitis, Crohn’s disease, optic neuritis, MS, or Guillain-Barré syndrome, or if they have a family history of any of these disorders.”
The data linking psoriasis to IBD are stronger than they are for MS, but there is certainly enough evidence to suggest some connection between psoriasis and MS. Regardless, both IBD and MS are clinically important conditions to consider when treating a patient with psoriasis. Many of the psoriasis therapies that are available can affect these other autoimmune inflammatory conditions, either positively or negatively. When evaluating a patient with psoriatic disease, it is important to know specifically whether they have a history of conditions such as ulcerative colitis, Crohn’s disease, optic neuritis, MS, or Guillain-Barré syndrome or if they have a family history of any of these disorders. A family history of IBD or demyelinating disease tells you that the individual is going to be at higher risk for these other health problems over time.
In a patient who has a family history of MS, for both medical and clinical reasons, you may not want to use a tumor necrosis factor inhibitor (TNFi). That patient is going to be more prone to develop MS. And, if they do develop MS, you will not know whether it was their underlying genetics, the TNFi, or a combination of the 2 that brought out this problem. Further, when a family history is present, someone close to the patient may have been devastated by one of these diseases; for instance, a patient might have had a parent who died of MS. In that context, you would not want to offer them a treatment that has MS as a warning in the label. When we have other options available to us, it is nice to be able to acknowledge and share the patient’s concerns about their risks and consider agents that act through other pathways.
Psoriasis may coexist with MS or IBD, and it is important to understand how to treat patients with both. Some of the TNFi agents are quite effective in patients with IBD, whereas other therapies such as interleukin-17 antagonists can induce or exacerbate IBD. Ustekinumab in high doses can be effective for IBD, in addition to its role in managing psoriatic disease. Other agents such as tofacitinib are approved for ulcerative colitis and have some benefits in patients with psoriatic arthritis or cutaneous psoriasis. Many individuals in my practice have a family history of MS. Dimethyl fumarate is US Food and Drug Administration approved for the treatment of MS, and this drug also has some benefits in the treatment of psoriasis. If you are working in a multidisciplinary environment and you have a patient with psoriasis and MS, you might want to let the neurologist know that, if they choose to treat the patient with dimethyl fumarate, it is likely to help the patient’s skin disorder as well. By being knowledgeable about the various available treatment options for related inflammatory diseases in those with psoriasis, you could help guide complex decision making in a way that can achieve better outcomes for patients.
Ellinghaus D, Ellinghaus E, Nair RP, et al. Combined analysis of genome-wide association studies for Crohn disease and psoriasis identifies seven shared susceptibility loci. Am J Hum Genet. 2012;90(4):636-647. doi:10.1016/j.ajhg.2012.02.020
Hohenberger M, Cardwell LA, Oussedik E, Feldman SR. Interleukin-17 inhibition: role in psoriasis and inflammatory bowel disease. J Dermatolog Treat. 2018;29(1):13-18. doi:10.1080/09546634.2017.1329511
Kaushik SB, Lebwohl MG. Psoriasis: which therapy for which patient: psoriasis comorbidities and preferred systemic agents. J Am Acad Dermatol. 2019;80(1):27-40. doi:10.1016/j.jaad.2018.06.057
Silfvast-Kaiser AS, Homan KB, Mansouri B. A narrative review of psoriasis and multiple sclerosis: links and risks. Psoriasis (Auckl). 2019;9:81-90. doi:10.2147/PTT.S186637
Sulaimani J, Cluxton D, Clowry J, et al. Dimethyl fumarate modulates the Treg-Th17 cell axis in patients with psoriasis. Br J Dermatol. 2020 May 21. doi:10.1111/bjd.19229
Takeshita J, Grewal S, Langan SM, et al. Psoriasis and comorbid diseases: Epidemiology. J Am Acad Dermatol. 2017;76(3):377-390. doi:10.1016/j.jaad.2016.07.064