Previous epidemiological studies have demonstrated a high prevalence of cardiovascular (CV) risk factors in psoriasis patients, including metabolic syndrome, cigarette smoking, obesity, hypertension, ...diabetes mellitus, insulin resistance and dyslipidaemia. An increase in CV morbidity and mortality attributable to psoriasis is still under question.
Primary objective: to assess CV morbidity and mortality in psoriasis and psoriatic arthritis (PsA) including stroke, coronary artery disease, myocardial infarction (MI) and peripheral artery disease. Secondary objectives: to assess if psoriasis per se is an independent CV risk factor and if psoriasis severity is a predictor of CV risk. We also evaluated the effect of conventional systemic treatments for psoriasis on CV mortality.
A systematic literature search was carried out from 1980 to December 2011, in the Embase, Medline and Cochrane Library databases, in English and French using a combination of keywords including (Psoriasis) OR (Psoriatic arthritis) AND (Myocardial infarction) OR (Coronaropathy) OR (Stroke) OR (Cardiovascular) AND (Methotrexate) AND (Ciclosporin) AND (Retinoids).
Of the 929 identified references, 33 observational studies evaluating the rates of cardiovascular events (CVE) in patients with psoriasis and PsA compared with controls were selected. Meta‐analysis of both cohort and cross‐sectional studies showed an increased risk of MI with Odds Ratio (OR) of 1.25 (95% CI 1.03–1.52) and 1.57 (95% CI 1.08–2.27) in psoriasis and PsA, respectively, compared with the general population. The risk of MI was more pronounced for patients having severe psoriasis and for patients with psoriasis of early onset. It remained significantly elevated after controlling for major CV risk factors. The meta‐analysis identified a small, but significant association between psoriasis, PsA and coronary artery disease with an OR between 1.19 (95% CI 1.14–1.24) for cross‐sectional studies, 1.20 (95% CI 1.13–1.27) for cohort studies and 1.84 (95% CI 1.09–3.09) for case–control studies. The risk of coronary artery disease seemed to be more pronounced in patients with severe psoriasis and in patients with psoriasis of early onset. The meta‐analysis assessing the risk of stroke gave inconclusive results: analysis of cross‐sectional studies suggested that psoriasis patients had a slightly higher risk of stroke with an OR of 1.14 (95% CI 1.08–1.99), whereas the meta‐analysis of cohort studies failed to show an association. There was also an increased risk of peripheral artery disease in psoriasis. No significant increased risk of CV mortality could be shown for both psoriasis and PsA patients. The use of methotrexate was associated with a reduced incidence of cardiovascular disease in two studies. The use of etretinate was associated with a reduction of CV mortality in one study. Potential selection bias such as the ‘healthy user effect’ prevents from drawing definite conclusions.
There may be a small, but significant increased risk of CVE, but not of CV mortality in psoriasis and PsA patients. The psoriasis attributable risk remains difficult to assess due to confounding factors. The moderate quality of CV risk factors reporting in studies should be acknowledged. In addition, heterogeneity in study design, outcome definition and assessment represent major limitations. Nevertheless, screening and management of CV risk factors are important in psoriasis.
Background Oral 8‐methoxypsoralen–UV‐A (PUVA) and narrowband UV‐B (NB‐UVB or UVB TL‐01) are effective and widely used treatments for chronic plaque psoriasis. Although the role of PUVA therapy in ...skin carcinogenesis in humans with psoriasis has been clearly demonstrated, there is still controversy regarding the risk of skin cancer with NB‐UVB. Furthermore, there is no clear evidence about the maximum cumulative number of sessions not to be exceeded in a lifetime.
Objectives To assess the respective cutaneous carcinogenic risks of PUVA or NB‐UVB in psoriasis; to estimate the respective dose‐relationship between skin cancers and PUVA or NB‐UVB; to estimate a maximum number of sessions for PUVA or NB‐UVB not to be exceeded in a lifetime.
Methods A systematic literature search was carried out in Medline, Embase and Cochrane Library databases from1980 to December 2010 in English and French, with the keywords ‘Psoriasis’ AND ‘UVB therapy’ AND ‘UVA therapy’ AND ‘cancer’ AND ‘skin’ OR ‘neoplasm’ OR ‘cutaneous carcinoma’ OR ‘melanoma’.
Results Of 243 identified references, 49 published studies were included. Most of them (45/49) concerned PUVA therapy, with 41 assessing the risk of non‐melanoma skin cancers (NMSC) following PUVA. All publications referring to the US prospective PUVA follow‐up study revealed an increased risk of NMSC with the following characteristics: risk most pronounced for squamous cell carcinomas developing even with low exposures and increasing linearly with the number of sessions, tumors occurring also on non‐exposed skin including invasive penile tumors, risk persisting after cessation of treatment. An increased risk of basal cell carcinomas was observed in patients receiving more than hundred PUVA sessions.
The four prospective European studies selected in our review and most of the pre‐1990 European and US retrospective studies failed to find a link between exposure to PUVA and skin cancer. Only the most recent cohorts, including three large long‐term retrospective European studies comparing records with their respective national cancer registries reported on an independent increased risk of NMSC with PUVA, The risk was lower as compared to the US prospective PUVA follow‐up study.
Six studies assessed the risk of melanoma following PUVA therapy: two of the three US publications coming from the same PUVA prospective follow‐up study revealed an increased risk with more than doubled incidence of both invasive and in situ melanoma among patients exposed to at least 200 PUVA treatments compared with patients exposed to lower doses, whereas the three retrospectives European studies, comparing the incidence of melanoma in PUVA users with national cancer registers, did not find any increased risk of melanoma.
No increased risk of skin cancer was evidenced in the four studies specifically assessing the potential carcinogenic risk of NB‐UVB
Conclusion There is an increased risk of skin cancer following PUVA, shown by both US and European studies. The greater risk measured by the US studies may be at least partly explained by high UVA dose exposure and the lighter phototypes of the treated patients. The lack of prospective studies in psoriasis patients treated with NB‐UVB constitutes a barrier to the robust assessment of carcinogenic risk of this phototherapy technique.
The relationship between psoriasis and increased cancer risk is debated.
The aim of this study was to evaluate if there is an increase in the background risk of cancer in psoriasis patients compared ...with the general population.
A systematic literature search was performed on PubMed, Embase and Cochrane databases, using the keywords ‘Psoriasis Majr AND Neoplasms’, from 1980 to January 2012. Meta‐analysis was performed based on observational studies showing consistency in cancer risk assessment methods.
Of the 1080 articles retrieved, 37 references were selected. There may be an increased risk of some solid cancers in psoriasis: respiratory tract cancer standardized incidence ratio (SIR) = 1.52, 95% confidence interval (CI) 1.35–1.71, upper aerodigestive tract cancer (SIR = 3.05, 95% CI 1.74–5.32), urinary tract cancer (SIR = 1.31, 95% CI 1.11–1.55) and liver cancer (SIR = 1.90, 95% CI 1.48–2.44). The risk of non‐Hodgkin lymphoma appears slightly increased in psoriasis (SIR = 1.40, 95% CI 1.06–1.86). Psoriasis patients have an increased risk of squamous cell carcinoma (SIR = 5.3, 95% CI 2.63–10.71) and basal cell carcinoma (SIR = 2.00, 95% CI 1.83–2.20), whereas the risk of melanoma is not increased.
There was a large heterogeneity in studies assessing cancer risk in psoriasis preventing from including all studies in meta‐analysis.
This systematic literature review shows a small increased risk of some solid cancers in psoriasis, especially those linked to alcohol drinking and cigarette smoking. A higher risk of non‐melanoma skin cancers, especially squamous cell carcinoma, is shown, mainly due to previous exposure to 8‐methoxypsoralen‐ultraviolet‐A (PUVA), ciclosporin and possibly methotrexate.
Since 2000, targeted therapies (TT) have revolutionized the management of psoriasis and more recently atopic dermatitis, the second main indication for phototherapy. They are now considered as an ...alternative to conventional treatments. Fears surrounding the introduction of TT have been thought to have decreased demand for phototherapy. However, little is known about recent trends in real-world use of phototherapy.
Background Treatment adherence has been recognized as an important issue in the management of chronic diseases such as psoriasis.
Objective The aim of this work was to analyse data about topical ...treatment adherence in psoriasis.
Methods Systematic literature review (62 references) between 1980 and 2011 (database: PubMed, Embase and Cochrane; Mesh keywords: Patient Compliance Mesh OR Medication Adherence Mesh AND Psoriasis Mesh; limits: date of publication >1980, humans subjects, written in French or English, aged ≥19 years). Two parameters were evaluated: (i) the ratio of number of product applications performed vs. number of applications expected according to physician recommendations, (ii) the ratio of amount of product used vs. amount of product prescribed.
Results A total of 22 studies were selected. Nine studies reported on the frequency of topical treatment application in a real world setting. Five studies showed a frequency of applications varying between 50% and 60% of those expected. Because of the high variability in medication adherence assessment methods, the data could not be combined. Twelve articles reported on the frequency of topical treatment application in randomized controlled trials with adherence varying between 55% and 100%. Concerning the amount of product use, four studies showed patients applied between 35% and 72% of the recommended dose during a treatment period of 14 days to 8 weeks. The most frequently mentioned reasons for non‐adherence to topical treatment were low efficacy, time consumption and poor cosmetic characteristics of topical agents. Patients experiencing adherence issues were significant younger, were men, had younger age at onset of psoriasis and had a higher self‐assessed severity. To improve adherence, the following strategies were suggested: to give patients information about psoriasis, to recognize social impact, to give written instructions for use such as a care plan, to explain side effects of topical therapies, to choose treatment and its cosmetic properties in agreement with the patient.
Conclusions Literature data about topical treatment adherence are heterogeneous and scarce. They confirm the limited topical treatment adherence in psoriasis in real life, much lower than what is reported in randomized controlled trials. Therapeutic education and clear instructions on the use of topical agents are necessary to improve adherence. Studies are needed to identify predictors of limited adherence and to identify interventions improving adherence to topical medications in psoriasis.
PDF
