SAN DIEGO — Emerging scientific data on adults with psoriasis suggest that certain comorbidities, including metabolic syndrome and myocardial infarction, may accompany the disease.
People with psoriasis “have a tendency to be obese, have a higher rate of cardiovascular disease [and] higher rates of stroke over time; they tend to smoke more, and they have a higher prevalence of depression,” Dr. Lawrence F. Eichenfield said at a meeting on skin disorders sponsored by Rady Children's Hospital. “One [question] that needs to be addressed is, are those secondary factors because they have psoriasis and they feel depressed, and they're starting to eat and they get obese and have secondary cardiovascular effects? Or is it something about the psoriasis itself, something that is going along with inflammatory disease?”
One study found that 20- to 30-year-olds with severe psoriasis had a 310% increased risk of having a myocardial infarction, compared with age-matched controls who did not have the disease (JAMA 2006;296:1735-41).
“So in adults, the younger you are, the relatively higher risk you have,” said Dr. Eichenfield, chief of pediatric and adolescent dermatology at Rady Children's Hospital, San Diego.
At present, however, the effect of psoriasis treatment on the risk of myocardial infarction or on other comorbidities is unknown.
Also unknown is how these emerging findings in adults can be translated into pediatric and adolescent patients with psoriasis. “There is a real paucity of data,” said Dr. Eichenfield, who is also a professor of pediatrics and medicine at the University of California, San Diego. “In one prospectively designed study, we tested etanercept for psoriasis in children and adolescents. Clearly, there was a higher body mass index in that population compared with controls. The real question is, how much is the inflammatory component of psoriasis contributing to this?”
In adults, the prevalence of psoriasis is estimated to be 2.2%, he said. Of those, 25% have moderate to severe disease.
Data in children and adolescents vary, but the prevalence of psoriasis in that population ranges from 0.55% to 1.0%. There are no good prospective pediatric data, he said. “If you ask adults when their psoriasis began, about one-third of them say it began during childhood or adolescence.”
Plaque psoriasis, affecting up to 84% of cases, is the most common presentation in pediatric patients. “It's certainly the type of psoriasis that causes more trouble,” Dr. Eichenfield said. “Face and intertriginous areas are commonly affected in children, so many times we'll have individuals who present with scalp psoriasis, and then over a long period of time we start seeing more typical cutaneous plaques on the elbows, knees, and buttocks.”
Two medium- and low-potency topical therapies are approved for short-term use in pediatric psoriasis: mometasone furoate and alclometasone dipropionate.
Other topical therapies that are being used include other corticosteroids; topical calcipotriol; tars and anthracyclines; tazarotene; and topical calcineurin inhibitors.
For severe psoriasis, phototherapy is Dr. Eichenfield's intervention of choice “in terms of the relative risk-benefit” ratio, he said. “It seems reasonable.”
Other unapproved treatments currently being used in pediatric psoriasis include immunosuppressive agents, systemic retinoids, and biologic agents, all of which carry a significant risk of side effects and toxicities.
Dr. Eichenfield disclosed that he has received grant and research support from Amgen Inc., Galderma Laboratories LP, Obagi Medical Products Inc., and Johnson & Johnson. He has also received honoraria from Medicis Pharmaceutical Corp. and Ranbaxy Pharmaceuticals Inc., and serves as a consultant to Amgen, Galderma, Obagi, Medicis, and Stiefel Laboratories Inc.
For severe psoriasis, phototherapy is preferred. The relative risk- benefit is reasonable. DR. EICHENFIELD