The impact of psoriasis extends beyond the skin and can affect various aspects of a patient’s health. Such impacts include comorbidities such as cardiovascular disease (CVD), psoriatic arthritis, anxiety, and depression. These comorbidities and considerations for addressing them were discussed in a CME satellite symposium at the 2024 Fall Clinical Dermatology Conference.

Following this presentation, featured expert Joel M. Gelfand, MD, MSCE, was interviewed by Conference Reporter Associate Editor-in-Chief Rick Davis. Dr Gelfand’s clinical perspectives on this topic are presented here.

I consider cardiometabolic disease to be the most important comorbidity associated with psoriasis. It is the most prevalent comorbidity; patients with psoriasis have about a 50% increased risk of developing atherosclerotic cardiovascular disease (ASCVD), which is the leading cause of excess mortality in people with moderate to severe psoriasis. Patients with psoriasis are more likely to have traditional CV risk factors than the general population, such as insulin resistance, abnormal cholesterol levels, obesity, and hypertension. The more severe their skin disease is, the more likely this is to be the case. In addition, inflammation in the arteries and atherosclerosis may trigger inflammation in the skin. By identifying and treating ongoing cardiometabolic disease in people with psoriasis, we can lower their risk of developing associated conditions, including diabetes, heart attack, stroke, and premature death.

A variety of studies have shown that patients with psoriasis are underscreened for CV risk factors, and, if risk factors are identified, they are less likely to be adequately treated. Patients with psoriasis are often treated by dermatologists who may not have the time for, or be comfortable with, identifying and managing CV risk factors. Ideally, the dermatologist would educate the patient about the risk of psoriasis-related CVD. Since we are already ordering labs when we put patients on a biologic, we can also check lipids, hemoglobin A1C, and blood pressure levels at that time. I do this routinely in my clinical practice and work collaboratively with a preventive cardiologist. Together, we identify a ton of undiagnosed ASCVD.

To help dermatologists improve patient outcomes, we are developing and testing the approach of using a centralized care coordinator at the National Psoriasis Foundation (NPF) to help dermatologists and patients get better control of CV risk factors. In this research, called the CP3 study, if any abnormalities in lipids or blood pressure are identified, the patient can meet virtually with a care coordinator at the NPF. The care coordinator takes the time to explain how skin disease relates to CVD, makes diet and exercise recommendations, and connects the patient back to their primary care physician or a cardiologist with guideline-based recommendations for medical therapy if additional intervention is needed. A centralized care coordination model like this may help address the problem of a disjointed medical system and relieve the burden on the dermatologist, as was discussed at the 2024 Fall Clinical Dermatology Conference in our CME satellite symposium on the comorbidities of psoriasis.

Psoriatic arthritis is another important comorbidity that is common in patients with psoriasis. In those with more severe skin involvement, the prevalence of psoriatic arthritis is approximately 20% to 30%. Patients often may not recognize that joint pain can be related to their skin disease, so dermatologists play a central role in alerting patients to what psoriatic arthritis is, screening for it, and either managing it themselves or referring patients to a rheumatologist. If patients have symptoms of inflammatory arthritis, that will change our treatment algorithm. We can choose specific medications that can help relieve symptoms and prevent the disease from progressing in the joints.

Psoriasis can also have a psychological impact on patients, as anxiety and depression can frequently occur with this disease. It can be a vicious cycle: the burden and stigmatization of psoriasis can stimulate or aggravate anxiety and depression, and the presence of anxiety and depression can impact their ability to seek treatment and follow treatment regimens for psoriasis. In most cases, mood will improve when we treat the psoriasis. However, for some patients, treatment can be a paradoxical experience. Their skin is clearer, but they may still internally feel stigmatized, and it may be especially painful for them to realize that they may still feel terrible even after their skin has cleared. We need to be prepared to build awareness for our patients, empathize with what they are experiencing, and direct them to the care they need if they are having difficulty managing the emotional aspects of their disease.