|Year : 2018 | Volume
| Issue : 2 | Page : 82-86
Co-Morbidities in psoriatic versus non-psoriatic patients
Rana Omar Al Houssien1, Afaf Al Sheikh2
1 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
2 Division of Dermatology, Department of Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
|Date of Web Publication||2-Apr-2018|
Dr. Rana Omar Al Houssien
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh
Background: Psoriasis is a chronic dermatological disorder which involves inflammatory and immune mechanisms. It affects the outer surfaces of the body including skin, hair and nails. It has been related to extracutaneous manifestations and systemic disorders. The aim of this study is to compare the chronic illnesses, including diabetes, hypertension, dyslipidaemia, hypothyroidism and abnormal renal and liver profiles, among patients with psoriasis and patients who had appendectomy.
Methods: A case–control study took a place in Riyadh. It included a case group of psoriatic patients and a control group of appendectomy patients. Each one had patients from both genders of all age groups. Data were collected by reviewing patients' charts to obtain demographic information, blood pressure, blood glucose level, lipid profile, kidney function, liver function and thyroid function.
Results: A total of 140 patients were included (74 males and 66 females). They have been divided into a case group of psoriatic patients and a control group of appendectomy patients, each had 70 participants. The mean age for both groups was 46 ± 18 and 41 ± 15 years, respectively. The proportion of psoriatic patients having diabetes (64%) was found to be higher than the proportion of control patients (46%) (odds ratio [OR], 2.85; 95% confidence interval [CI], 1.12–7.28; P = 0.03). Abnormal renal profile was significantly associated with psoriasis (21%) in comparison to control (3%) (OR, 12.74; 95% CI, 2.28–68.29; P = 0.004).
Conclusion: Patients with psoriasis were found to have an increased risk of developing major co-morbid disorders including diabetes, liver and renal function profile abnormalities. This indicates the importance of checking if this group of patients have co-morbid disorders.
Keywords: Chronic, co-morbid, diabetes, diseases, dyslipidaemia, hypertension, obesity
|How to cite this article:|
Al Houssien RO, Al Sheikh A. Co-Morbidities in psoriatic versus non-psoriatic patients. J Health Spec 2018;6:82-6
| Introduction|| |
Psoriasis is a chronic dermatological disease. It involves immune and inflammatory process. It affects the epidermal keratinocytes leading to hyperproliferation and shedding of the skin cells. Genetic, immunological and environmental factors play a crucial part in the development of the disease. The main affected cell line is T-cells. It can be triggered by trauma, infections, sun, medications or smoking. The disease appears as well-defined lesions of pruritic silvery scaly erythematous plaques affecting the extensor surfaces of the body especially elbows and knees. It can affect hair and nails, too. It can also be presented as guttate, pustular or other forms. Psoriasis is diagnosed clinically and managed by avoiding triggers, moisturising creams, topical steroids and phototherapy. The prevalence of psoriasis is about 2%–3% worldwide. Its prevalence among the paediatric group is 0.5%–2%. It equally affects males and females. The peak onset of the disease is bimodal, one is at 16 years (females) or 22 years (males) and a second peak is at 60 years (females) or 57 years (males).
Psoriasis has been related to extracutaneous manifestations and systemic disorders. Some of these disorders are cardiovascular co-morbid illnesses; for example, hypertension, diabetes, obesity and metabolic syndrome. This relationship between psoriasis and medical co-morbidities has been shown in international studies. Two studies from Malaysia identified that overweight, hypertension, dyslipidaemia, diabetes mellitus, ischaemic heart disease and stroke were co-morbidities associated with adult psoriatic patients., Overweight was the most common (33%) of these diseases. A study from the United States by Yeung et al. demonstrated that an increased severity of psoriasis is associated with an increased prevalence of co-morbidities. A study from Bosnia and Herzegovina by Salihbegovic et al. showed that the proportion of high blood pressure in psoriatic patients was 54%.
There are studies that showed the relationship between psoriasis and the metabolic syndrome. A study from the United States by Love et al. identified that the prevalence of the metabolic syndrome was 40% among psoriasis cases and 23% among controls (odds ratio [OR]: 1.96; 95% confidence interval [CI], 1.01–3.77). Another paper from the United States by Armstrong et al. showed that severe psoriasis was associated with increased prevalence of metabolic syndrome than milder forms (OR: 2.26; 95% CI, 1.70–3.01). A study from Barcelona by Albareda et al. demonstrated that the prevalence of the metabolic syndrome among psoriatic patients was 53% as compared to 34% in the control group (OR: 3.63; 95% CI, 1.65–8.03).
Psoriasis was also found associated with diabetes and hypertension. A study from the United States by Armstrong et al. showed that psoriasis was associated with an increased prevalence and incidence of diabetes (OR: 1.59; 95% CI, 1.38–1.83). This association was increased with the severe forms of psoriasis. Another study from the United States showed that patients with psoriasis were more likely to develop microvascular complications of diabetes (P < 0.001) and macrovascular complications (P = 0.001). A study from the United States identified that hypertension was more prevalent among patients with psoriasis (OR: 1.58; 95% CI, 1.42–1.76).
Locally, the relationship between psoriasis and cardiovascular co-morbid disorders has been slightly investigated. A study from Riyadh Military Hospital by Alsufyani et al. showed that psoriasis was associated with an increased risk of obesity and metabolic syndrome.
Saudi Arabia recently has an increased prevalence of cardiovascular co-morbid disorders. It was estimated that diabetic patients have reached to 7 million, a 10-fold increase in the past three generations. The prevalence of hypertension was found to be 26%. Psoriatic patients had higher risks of developing systemic diseases. Therefore, the aim of this study was to determine the risk of the major chronic medical co-morbidities in psoriasis among Saudis.
| Materials and Methods|| |
It was a case–control study which included a case group of psoriatic patients and a control group of appendectomy patients from both genders of all age groups.
The study was conducted in King Abdulaziz Medical City (KAMC) in Riyadh, Saudi Arabia. Data collection was achieved by the research investigators using a structured data collection form.
The inclusion criteria were to include psoriatic and appendectomy patients of KAMC from both genders who did not have any genetic or immunodeficiency diseases. The case group was selected based on the clinical diagnosis of any type of psoriasis with unspecified PASI score aged 12 years and above, whereas the control group was the patients who had appendectomy aged 12 years and older. The appendectomy patients were chosen as controls because they are usually young, as psoriatic patients, and are not known to increase the risks of chronic illnesses investigated in this study.
The ratio between the case and the control groups was 1:1. Matching was done for age and gender.
Data were gathered and retrieved from patients' charts review. Age, gender, height and weight were initially collected. Then, other variables regarding co-morbid chronic illnesses were collected including blood pressure, blood sugar level, lipid profile, kidney function, liver function and thyroid function.
The criteria used for the diagnosis of chronic diseases, investigated in the study, were based on the medical records. Hence, patients were previously diagnosed with the disease and having abnormal findings (vital signs or laboratory tests). Moreover, hypertension was diagnosed based on three separate abnormal blood pressure readings (>140/90 mm Hg) and diabetes was based on two separate abnormal fasting blood glucose (FBG) (>126 mg/dL) and haemoglobin A1C (6.5%) levels. For dyslipidaemia, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) levels were obtained (LDL <130 mg/dL or HDL <40 mg/dL). Thyroid was evaluated based on thyroid-stimulating hormone and T4 levels. For liver and kidney, they were evaluated by obtaining alanine transaminase/aspartate transaminase/alkaline phosphatase and creatinine/glomerular filtration rate, respectively.
The sample size was estimated based on OR of 3.63 and the expected prevalence of the metabolic syndrome which includes hypertension, diabetes, dyslipidaemia and obesity to be 34% in the control group. The estimated sample size came up to be 46 for each of case and control groups based on 95% confidence level.
Statistics and analysis
The collected data were entered and analysed using SPSS version 23(IBM Corp., NY, USA). In the descriptive statistics, frequency and mean were used for categorical and numerical variables, respectively. To identify the association between variables, Chi-square test and bivariate analysis using the OR were used (P < 0.05 was considered statistically significant).
| Results|| |
The final sample size of 140 patients (each group had 70 patients) between 12 and 83 years old included 53% males and 47% females who were fit to the inclusion criteria. For the case group, the mean age was 46 ± 18 years and the median was 44.5 years. For the control group, the mean age was 41 ± 15 years and the median was 38 years [Figure 1]. [Table 1] represents the distribution of co-morbidities among participants based on sex. Males had higher proportions of hypertension, diabetes, liver and renal diseases while females were higher in dyslipidaemia, thyroid diseases, overweight and obesity.
[Table 2] shows frequencies and proportions of all variables for each group. Males were 37 (53%) and females were 33 (47%) for both of the case and control groups. For blood pressure, psoriatic patients who had hypertension were 33 (43%) and control patients were 31 (44%). The proportion of patient having diabetes, assessed by measuring FBG, was 64% (n = 45) for psoriasis and was 46% (n = 32) for the control. Dyslipidaemic patients were 43 (61%) in the case group and 41 (59%) in the control, and they were assessed by measuring cholesterol, triglyceride, LDL and HDL levels. For weight, patients were classified according to their body mass index (BMI) into 6 categories. Overweight patients were 18 (29%) and obese patients (obese I, obese II and morbid obese) were 26 (42%) for case, and for control, there were 33 (33%) overweight and 29 (41%) obese patients. Other co-morbid disorders and essential laboratory investigations are shown in [Table 2].
Pearson Chi-square was tested for all variables to compare case and control groups. Psoriasis was found to have a significant association with diabetes in which 64% of psoriatic patients were diabetic as compared to 46% diabetic controls (P = 0.03). Liver diseases were also significantly associated with psoriasis 17% (n = 12) in comparison to the control 4% (n = 3) (P = 0.01). Psoriatic patients with abnormal renal profile were 15 (21%) while control patients were 2 (3%) (P = 0.001) [Table 2].
[Table 3] shows the bivariate analysis to compare the two groups. Psoriatic patients had an increased risk of developing diabetes in comparison to non-psoriatic patients (OR, 2.85; 95% CI, 1.12–7.28; P = 0.03). Renal profile abnormalities were found to be significant in association to psoriasis when compared to the control group (OR, 12.47; 95% CI, 2.28–68.29; P = 0.004).
| Discussion|| |
This article is locally reviewing the prevalence and significance of co-morbidities among psoriatic patients. Hence, a control group of patients, who underwent appendectomy procedures, has been investigated, as a case group of psoriatic patients, for their cardiovascular co-morbid conditions including hypertension, diabetes, dyslipidaemia, overweight and obesity. Furthermore, they have been investigated for other conditions including thyroid, renal and liver functions.
In this study, it was found that psoriasis had an increased risk of developing diabetes and abnormal liver and renal function profiles. There were global studies supporting these findings. In the UK, Yeung et al. established that psoriasis was associated with higher prevalence of many co-morbid conditions including diabetes (OR = 1.22), diabetes with systemic complications (OR = 1.34), mild liver disease (OR = 1.41) and renal disease (OR = 1.28). Cohen et al. found that the proportion of patients having metabolic syndrome was increased in the case group of psoriatic patients when compared to the control group, with diabetes being one factor (OR = 1.6). In Taiwan, Chi et al. found that severe psoriasis was an independent risk factor for developing chronic kidney disease (CKD) (OR = 1.90) and end-stage renal disease (OR = 2.97). Furthermore, Chiu et al. identified that the risk of glomerulonephritis and CKD was increased in the case group of psoriasis compared to controls and the risk was greater with increased severity(hazards ratio [HR] =1.50 and HR = 1.28). In an Italian study, van der Voort et al. found that psoriasis was found to be significantly associated with non-alcoholic fatty liver disease (NAFLD), after adjusting cofactors including alcohol, smoking and metabolic syndrome (OR = 1.7). Another Italian study by Miele et al. found that psoriasis arthritis is an independent risk factor of developing NAFLD (OR = 3.94).
Other co-morbidities were found to have increased proportions in psoriatic patients when compared to the control group, yet there was not a significant association found between psoriasis and these variables when tested in this study. These co-morbid conditions included hypertension, dyslipidaemia, overweight, obesity and thyroid diseases. In the contrary, other studies found significant associations when comparing these variables between two groups of case and control. There was a study by Cohen et al. who found psoriasis was a risk factor for hypertension (OR = 1.4), dyslipidaemia (OR = 1.3) and obesity (OR = 1.4). Furthermore, a Danish study by Lønnberg et al. found a significant association between psoriasis and type 2 diabetes mellitus (OR = 1.53) and between psoriasis and increasing BMI (OR = 1.81) in individuals with a BMI <35.0.
The association between psoriasis and the metabolic syndrome, which includes diabetes, hypertension, dyslipidaemia and obesity, is overlapped. The pathomechanisms behind that are thought to be inflammatory and genetics. Gelfand and Yeung established that both inflammatory and genetic pathways are involved in the pathophysiology. Hence, Th-1 and Th-17 cells with cytokine (tumor necrosis factor-a and interleukin-6) dysregulation mediate the epidermal hyperplasia as well as obesity and insulin resistance. Furthermore, Azfar and Gelfand stated that psoriasis mediators including Th-1 cytokines, adhesion molecules and angiogenic factors were also increased in diabetes, dyslipidaemia and obesity through insulin signalling, lipid metabolism and adipogenesis. In India, Padhi and Garima found that chronic inflammation in addition to the oxidative stress is the major link between psoriasis, diabetes, hypertension and dyslipidaemia.
There are upsides and strong points supporting this study. Gender distribution was equal for both case and control groups. All major chronic co-morbidities were included to identify their significance among psoriatic patients.
Similarly, the study has some limitations including that the effect of psoriasis severity on developing co-morbidities has not be assessed. Furthermore, the psychological effect and quality of life have not been included in this research.
Our sincere gratitude is hereby extended to the College of Medicine of King Saud bin Abdulaziz University for Health Sciences and the Dermatology Department of King Abdulaziz Medical City for the overwhelming support which never ceased until this paper is structured. Also, we genuinely thank Dr. Aamir Omair for his valuable input and review of the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]