Psoriasis and metabolic conditions were once viewed as separate clinical issues. Recent research suggests, however, that chronic inflammation may be a key factor connecting both psoriasis and metabolic conditions, underscoring the importance of disease control.

We now understand that patients with psoriasis are not limited to having a localized inflammatory state in the skin but rather have a chronic systemic inflammatory burden. In fact, many studies have shown that people with psoriasis have inflammation and elevated levels of proinflammatory mediators, including TNF-α, IL-6, or IL-17, not only in their psoriasis lesions but also in their blood.

The bedrock of the theory on the connection between psoriasis and metabolic disease is the concept that systemic inflammation pushes the patient toward metabolic disease. This is borne out by epidemiologic literature. We know that individuals with psoriasis have an almost 20% increased incidence of diabetes, a 35% increased incidence of hypertension, an almost 20% increased incidence of hyperlipidemia, and an approximately 25% increased incidence of obesity. In turn, these are risk factors for cardiovascular disease (CVD), heart attack, and stroke. Patients with severe psoriasis are also more likely to experience cardiac death compared with individuals who do not have psoriasis but are otherwise similar. Psoriasis is, in and of itself, an independent risk factor for CVD.

There are important lifestyle changes that we can help our patients with psoriasis undertake to reduce their risk of metabolic disease and CV outcomes, and perhaps improve their psoriasis as well. The first is smoking cessation. Smoking increases psoriasis severity and psoriasis risk in general. Additionally, we all know that smoking is also a risk factor for heart attack and stroke.

Similarly, weight loss and healthy dietary changes can be helpful in decreasing the risk of metabolic syndrome, diabetes, hypertension, hyperlipidemia, heart attack, and stroke. In addition, weight loss may reduce psoriasis severity in patients with obesity, and this weight loss, along with regular exercise, may also lead to improved mental health. If patients are feeling better, exercising more, and losing weight, it also decreases their risk of metabolic disease and CVD.

An interesting consideration is the increased use of GLP-1 medications for obesity. A lot of work has been done in several disease areas to determine whether treating obesity with GLP-1 medications improves other conditions. It is too early to know, and there are not strong data to help us fully understand whether these medications might improve someone’s metabolic situation as well as their psoriasis.

Another consideration is that people with psoriasis who also have diabetes or high blood pressure are more challenging to treat. For example, they are likely to need more than 1 medication to control their blood pressure. Clearly, it is important for us to maximize every opportunity to improve a patient’s metabolic parameters.

Does treating psoriasis with biologics, which presumably reduces the burden of systemic inflammation in the body, also reduce the risk or severity of metabolic comorbidities? At the moment, this topic is the holy grail of psoriatic disease research. Epidemiologic studies using large patient databases have found a trend toward a decrease in the risk of CV outcomes with the use of biologics compared with more traditional treatments such as methotrexate or phototherapy. Available data suggest that this is the case, but it is not a clear conclusion. Large studies that follow people over time may help advance our understanding of the impact of biologic therapy on metabolic comorbidities.