Psoriasis contributes to increased cardiovascular risk through numerous mechanisms. The interplay between psoriasis and cardiovascular health requires a comprehensive approach to risk assessment and management, involving collaboration across the care team.

The current thinking is that a multifactorial process leads patients with psoriatic disease to have a higher risk of heart attacks and strokes, with increased mortality. For example, several genetic studies suggest that developing psoriasis later in life may actually be a sign of underlying atherosclerotic disease. Another theory that involves inflammation is that the inflammatory pathways that are active in psoriasis promote thrombosis and atherosclerosis. In addition, the underdiagnosis and undertreatment of the shared risk factors of hypertension, diabetes, and hyperlipidemia are major problems. If we could better identify and treat the cardiovascular risk factors that mingle with psoriasis, we could likely lower the risk. Lifestyle issues are another consideration to address. Smoking, anxiety, depression, and stress can also aggravate cardiovascular risk.

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Our group at the University of Pennsylvania has done work showing that, for every 10% increase in psoriasis body surface area, there is a corresponding 20% increased risk of developing diabetes, independent of body weight. Of course, obesity is also a related factor. Obesity is likely a causal risk factor for developing psoriasis based on genetic and epidemiological studies. Moreover, not only is obesity a risk factor for cardiovascular disease but it is also very prevalent among people with psoriasis. For instance, in a recent “real-world” study that we did, half of patients with psoriasis had obesity. Obesity is also a risk factor for developing psoriatic arthritis and is associated with a reduced response to treatment and an increased risk of losing response to biologic treatment. We know that when people with psoriasis who are overweight or obese lose weight, their psoriasis becomes easier to control. We need better data, ideally randomized placebo-controlled trials, to determine what the GLP-1 agents do in psoriatic disease. However, in my practice, I already routinely recommend that patients with psoriasis and a body mass index of greater than or equal to 27 see my colleague, who is a GLP-1 expert. In my clinical experience, this has been very helpful, and initial studies suggest that GLP-1 inhibitors can improve psoriasis.

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We need a management plan that incorporates holistic approaches and includes the following: (1) adequately managing psoriatic disease; (2) identifying traditional cardiovascular risk factors and managing them appropriately; and (3) helping patients manage their disease burden with tools that include stress management, maintaining an adequate diet, exercise, and smoking cessation. All of these components are important for optimizing cardiovascular health when patients are living with a chronic inflammatory condition such as psoriasis.

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Does the systemic treatment of psoriasis lower cardiovascular risk? We do not have sufficient large-scale, placebo-controlled trials to indicate whether the existing treatments that can clear psoriasis can also lower the risk of heart disease, although there have been some positive observational studies for TNF-α inhibitors. This is a multifactorial process, which is why a holistic approach is important.