Does Treatment Affect Risk?
Often, psoriasis treatments are relegated to being elective or cosmetic, but another important consideration is whether psoriasis treatments decrease CV disease risk. So far, studies have shown mixed results. Some preliminary data found that treatments like methotrexate (MTX) and etanercept, a biologic tumor necrosis factor (TNF)-alpha inhibitor, protected the heart, but other treatments may increase the burden of CV disease.
“This is an emerging area with incomplete data, and many studies assess surrogate measures of CV events (i.e., advanced imaging) rather than actual events,” Dr. Schwartz notes. “This is because many biological therapies for psoriasis are relatively new, with the exception of disease-modifying anti-rheumatic drugs (DMARDs) and TNF inhibitors, and extremely long-term follow-up of 10 to 20 years is often required for assessment of CV events. With these caveats, treatment with anti-inflammatory therapies does appear to reduce the risk of vascular inflammation and major CV events in patients with psoriasis. However, the type of therapy matters. For example, biological therapies and DMARDs appear to improve outcomes, whereas corticosteroids and nonsteroidal anti-inflammatory drugs worsen outcomes.”
For now, Dr. Schwartz says, “I would encourage all patients and physicians to aggressively pursue a treat-to-target approach for psoriasis and PsA. Remember that it is not ‘just’ a rash, and that poorly controlled skin disease probably translates to poorly controlled systemic inflammation and increased CV risk. These recommendations are strongly based on the most recent American Academy of Dermatology and National Psoriasis Foundation (NPF), NPF/American College of Rheumatology and European League Against Rheumatism guidelines.”
Further inquiry is warranted into psoriasis treatments and heart health because if there are benefits, it would reinforce that psoriasis treatment – like psoriasis – is more than skin deep. This would also likely contribute to a greater prevalence of individuals getting treatment. 
There is a growing understanding of the link among psoriasis, PsA and heart disease. We are learning that not only is it important to treat psoriatic disease, but also to treat the patient as a whole. This includes evaluating for major comorbidities, such as CV disease.
“Remember that traditional risk factors tend to underestimate CV disease risk and that many patients are underdiagnosed and undertreated,” says Dr. Schwartz. “Patients should encourage their health care provider to consider psoriasis as a diabetes equivalent when calculating individual risk of CV disease. This means that goals for blood pressure, blood sugar and cholesterol treatments will be different from those of a patient without psoriasis – and that their [health care provider] may have a lower threshold to refer a patient for stress testing or imaging of coronary arteries.”
Dr. Schwartz’s parting words for patients and their loved ones are: “Don’t be afraid to advocate for yourself when it comes to CV risk screening and reduction. The evaluation and treatment of psoriasis and PsA is a rapidly evolving clinical field with new diagnostic studies and treatments emerging every year. Use patient education and advocacy resources, such as NPF, NIH and the American College of Rheumatology, to inform yourself about these developments, and talk to your physician(s) if you have any questions or concerns.”
1. 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.
2. Grundy SM, Stone NJ, Bailey AL, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol. 2019 Jun 25;73(24):3234-3237]. J Am Coll Cardiol. 2019;73(24):3168-3209. doi:10.1016/j.jacc.2018.11.002.
3. What is Cardiovascular Disease? www.heart.org. https://www.heart.org/en/health–topics/consumer–healthcare/what–is–cardiovascular–disease. Accessed January 14, 2021.
4. Reed WB, Becker SW, Rohde R, Heiskell CL. Psoriasis and arthritis. Clinicopathologic study. Arch Dermatol. 1961;83:541-548. doi:10.1001/archderm.1961.01580100005001.
5. Teklu M, Zhou W, Kapoor P, et al. Metabolic Syndrome and its Factors are Associated with Non-Calcified Coronary Plaque Burden in Psoriasis: An Observational Cohort Study [published online ahead of print, 2020 Dec 21]. J Am Acad Dermatol. 2020;S0190-9622(20)33238-2. doi:10.1016/j.jaad.2020.12.044.
6. Horn EJ, Fox KM, Patel V, Chiou CF, Dann F, Lebwohl M. Are patients with psoriasis undertreated? Results of National Psoriasis Foundation survey. J Am Acad Dermatol. 2007;57(6):957-962. doi:10.1016/j.jaad.2007.06.042.
7. Takeshita J, Wang S, Shin DB, et al. Effect of psoriasis severity on hypertension control: a population-based study in the United Kingdom. JAMA Dermatol. 2015;151(2):161-169. doi:10.1001/jamadermatol.2014.2094.
8. Langan SM, Seminara NM, Shin DB, et al. Prevalence of metabolic syndrome in patients with psoriasis: a population-based study in the United Kingdom. J Invest Dermatol. 2012;132(3 Pt 1):556-562. doi:10.1038/jid.2011.365.
9. Arnett DK, Blumenthal RS, Albert MA, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines [published correction appears in Circulation. 2019 Sep 10;140(11):e649-e650] [published correction appears in Circulation. 2020 Jan 28;141(4):e60] [published correction appears in Circulation. 2020 Apr 21;141(16):e774]. Circulation. 2019;140(11):e596-e646. doi:10.1161/CIR.0000000000000678.
10. Mehta NN, Krishnamoorthy P, Yu Y, et al. The impact of psoriasis on 10-year Framingham risk. J Am Acad Dermatol. 2012;67(4):796-798. doi:10.1016/j. jaad.2012.05.016.
11. Takeshita J, Grewal S, Langan SM, et al. Psoriasis and comorbid diseases: Implications for management. J Am Acad Dermatol. 2017;76(3):393-403. doi:10.1016/j. jaad.2016.07.065.
12. Ports WC, Fayyad R, DeMicco DA, Laskey R, Wolk R. Effectiveness of Lipid-Lowering Statin Therapy in Patients With and Without Psoriasis. Clin Drug Investig. 2017;37(8):775-785. doi:10.1007/s40261-017-0533-0.
13. Margolis D, Bilker W, Hennessy S, Vittorio C, Santanna J, Strom BL. The risk of malignancy associated with psoriasis. Arch Dermatol. 20