Psoriasis: Gelfand JM

Menter A, Korman NJ, Elmets CA, Feldman SR, Gelfand JM, Gordon KB, Gottlieb A, Koo JY, Lebwohl M, Lim HW, Van Voorhees AS, Beutner KR, Bhushan R, Anonymous00035. · Baylor University Medical Center, Dallas, Texas, USA. · J Am Acad Dermatol. · Pubmed #19217694 No free full text.

Abstract: Psoriasis is a common, chronic, inflammatory, multi-system disease with predominantly skin and joint manifestations affecting approximately 2% of the population. In this third of 6 sections of the guidelines of care for psoriasis, we discuss the use of topical medications for the treatment of psoriasis. The majority of patients with psoriasis have limited disease (<5% body surface area involvement) and can be treated with topical agents, which generally provide a high efficacy-to-safety ratio. Topical agents may also be used adjunctively for patients with more extensive psoriasis undergoing therapy with either ultraviolet light, systemic or biologic medications. However, the use of topical agents as monotherapy in the setting of extensive disease or in the setting of limited, but recalcitrant, disease is not routinely recommended. Treatment should be tailored to meet individual patients' needs. We will discuss the efficacy and safety of as well as offer recommendations for the use of topical corticosteroids, vitamin D analogues, tazarotene, tacrolimus, pimecrolimus, emollients, salicylic acid, anthralin, coal tar, as well as combination therapy.

Kimball AB, Gladman D, Gelfand JM, Gordon K, Horn EJ, Korman NJ, Korver G, Krueger GG, Strober BE, Lebwohl MG, Anonymous00020. · Department of Dermatology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts 02114, USA. · J Am Acad Dermatol. · Pubmed #18313171 No free full text.

Abstract: There have been several articles and reports in recent months about comorbidities and risks that affect psoriasis patients in addition to their underlying disease. This piece reviews the current literature and begins to address what should be done with this new information by updating the clinician about what health screening tests, preventative exams, and referrals should be considered in this population.

Pariser DM, Bagel J, Gelfand JM, Korman NJ, Ritchlin CT, Strober BE, Van Voorhees AS, Young M, Rittenberg S, Lebwohl MG, Horn EJ, Anonymous00184. · Department of Dermatology, Eastern Virginia Medical School, Norfolk, VA, USA. · Arch Dermatol. · Pubmed #17310004 links to  free full text

Abstract: OBJECTIVES: A task force of the National Psoriasis Foundation Medical Board was convened to evaluate the current severity criteria of mild, moderate, and severe psoriasis and to make recommendations concerning a 2-tiered categorization of severity based on current clinical practice and related to intent to treat. PARTICIPANTS: This volunteer task force, led by David M. Pariser, MD, included Jerry Bagel, MD, Joel M. Gelfand, MD, MSCE, Neil J. Korman, MD, PhD, Christopher T. Ritchlin, MD, Bruce E. Strober, MD, PhD, Abby S. Van Voorhees, MD, and Melodie Young, MSN, RN, ANP. Meetings were held by teleconference and were coordinated and funded by the National Psoriasis Foundation. EVIDENCE: This task force reviewed psoriasis severity criteria and other published psoriasis consensus statements. Current standards of care and expert opinion were used to inform the process. CONSENSUS PROCESS: Based on meetings of the task force and under the guidance of David M. Pariser, MD, a statement was drafted by Elizabeth J. Horn, PhD, presented to the task force, and reviewed and approved by the task force. This statement was then reviewed and approved by Robert E. Kalb, MD, Gerald G. Krueger, MD, and Alan Menter, MD. The National Psoriasis Foundation Medical Board reviewed and endorsed this statement by a majority vote on March 2, 2006, at the medical board meeting. CONCLUSIONS: This clinical consensus statement proposes a 2-tiered system for plaque psoriasis therapy that reflects more accurately than the current system how patients are treated in clinical practice. This statement, focused on plaque psoriasis, is intended to assist medical professionals and insurance payers in understanding these 2 categories of patients with psoriasis and choosing appropriate therapies for these patients.

Gelfand JM. · No affiliation provided · Arch Dermatol. · Pubmed #17875885 No free full text.

This publication has no abstract.

Richardson SK, Gelfand JM. · Florida State University College of Medicine/Dermatology Associates of Tallahassee, 1714 Mahan Center Boulevard, Tallahassee, FL 32308, USA. · Adv Dermatol. · Pubmed #19256309 No free full text.

Abstract: The onset of psoriatic disease and its associated comorbidities involves the interplay among a myriad of genetic and environmental risk factors. As we gain further insight into the immunopathogenesis of psoriasis, we hope it will provide the basis for the development of safer, more efficacious, and more durable therapeutics in the future. Given its enormous toll on patient health and quality of life, steps should be taken to prevent or decrease the risk for psoriasis-associated comorbidities through behavior modification and use of preventative health screenings and treatments. Future studies will need to be performed to determine if successful treatment of psoriasis will lead to a decreased risk for developing psoriasis-associated comorbidities over time.

Friedewald VE, Cather JC, Gelfand JM, Gordon KB, Gibbons GH, Grundy SM, Jarratt MT, Krueger JG, Ridker PM, Stone N, Roberts WC. · Department of Internal Medicine, The University of Texas Medical School at Houston, Houston, Texas, USA. · Am J Cardiol. · Pubmed #19064017 No free full text.

This publication has no abstract.

Azfar RS, Gelfand JM. · Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA. · Curr Opin Rheumatol. · Pubmed #18525354 No free full text.

Abstract: PURPOSE OF REVIEW: The scientific literature linking psoriasis to metabolic syndrome, and its components, as well as atherosclerosis and myocardial infarction has rapidly expanded. Increasingly, epidemiological studies are establishing the directionality of these associations and psoriasis' role as an independent risk factor in developing these outcomes. RECENT FINDINGS: Psoriasis is associated with metabolic syndrome, and its components, such as obesity, diabetes, and hypertension. Obesity has been shown to be an independent risk factor for the development of psoriasis, and is also associated with more severe psoriasis. Psoriasis is associated with diabetes, coronary artery disease, and an increased risk for myocardial infarction independent of traditional risk factors for these disorders. These phenotypically diverse conditions share similar pathologic changes such as chronic inflammation, angiogenesis, oxidative stress, and selected susceptibility genes and loci. SUMMARY: The broad literature linking psoriasis to metabolic disorders has led to changes in standard of care recommendations for patients with psoriasis. In particular, practitioners are encouraged to screen psoriasis patients, especially when disease is severe, for metabolic disorders and cardiovascular risk factors and institute appropriate prevention strategies. Additional studies investigating the role of psoriasis activity and severity as an independent risk factor for developing metabolic disorders, atherosclerosis, and myocardial infarction and the role of psoriasis treatment in altering the risk of developing these serious morbidities are urgently needed.

Feldman SR, Gelfand JM, Stein Gold L, Jones SD. · Center for Dermatology Research, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA. · Cutis. · Pubmed #17367042 No free full text.

Abstract: Approximately 14% of patients with psoriasis have moderate or severe disease defined as affecting 3% to 10%, or greater than 10%, of body surface area (BSA), respectively. In the context of topical therapy, extensive disease refers to psoriasis involving 10% to 30% of BSA for which topical therapy might not have been considered optimum in the past because of patient preference and/or convenience. Treatment of patients with extensive disease traditionally has focused on phototherapy and/or systemic therapy with agents such as cyclosporine, methotrexate, and oral retinoids; these agents can improve outcomes in patients beyond those afforded by traditional topical monotherapy. Biologic therapy (e.g., alefacept, efalizumab, etanercept) provides dermatologists with additional treatment options for patients with extensive psoriasis, for whom topical treatments typically have been considered adjunct therapy for focal resistant lesions. A new 2-compound topical ointment containing calcipotriene 0.005% and betamethasone dipropionate 0.064% has demonstrated efficacy in patients with severe psoriasis, an outcome that previously was difficult to achieve with topical therapy. Advantages of the 2-compound ointment include rapid onset of action and a relative lack of systemic toxicity. This effective topical agent may expand the psoriasis population that can be considered candidates for topical treatment.

Lebwohl M, Gelfand JM, Tan MH. · Department of Dermatology, Mount Sinai School of Medicine, New York, New York, USA. · Adv Dermatol. · Pubmed #10643493 No free full text.

This publication has no abstract.

Gelfand JM, Kimball AB, Mostow EN, Chiou CF, Patel V, Xia HA, Freundlich B, Stevens SR. · Department of Dermatology and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA. · Value Health. · Pubmed #18489665 No free full text.

Abstract: OBJECTIVE: The 24-week Etanercept Assessment of Safety and Effectiveness (EASE) study evaluated the effectiveness and tolerability of continuous versus interrupted etanercept treatment in patients with moderate to severe plaque psoriasis. The objective of this analysis was to assess patient-reported outcomes (PROs) and health-care resource utilization (HRU) data from the EASE study. METHODS: Patients received open-label etanercept 50 mg twice weekly for 12 weeks and then received either continued or interrupted (single round of discontinuation and re-treatment with etanercept) etanercept 50 mg once weekly for the second 12 weeks. PROs included the following: 1) the patient global assessments of psoriasis, joint pain, and itching scores; 2) the Dermatology Life Quality Index; 3) the Medical Outcomes Study Short Form 36 vitality domain; 4) the Beck Depression Inventory; 5) the European Quality-of-Life Group Feeling Thermometer; and 6) a patient satisfaction survey. HRU was evaluated using the Economic Implications of Psoriasis patient questionnaire. RESULTS: Continuous treatment with etanercept 50 mg twice weekly for 12 weeks followed by 50 mg once weekly for 12 weeks produced sustained and clinically important improvements in PROs and reductions in HRU. Reductions in some outcome measures after treatment discontinuation at week 12 were observed in the interrupted group; however, most changes did not revert to baseline levels, consistent with some residual clinical effect, and re-treatment produced improvements similar to week 12 levels. CONCLUSIONS: Continuous etanercept treatment provided greater sustained improvements in PROs than interrupted therapy; however, interrupting etanercept therapy, if needed, has predictable and manageable effects.

Kurd SK, Smith N, VanVoorhees A, Troxel AB, Badmaev V, Seykora JT, Gelfand JM. · Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. · J Am Acad Dermatol. · Pubmed #18249471 No free full text.

Abstract: BACKGROUND: There is a need for safe, inexpensive, and effective psoriasis therapies. Many anecdotal accounts of patients' successful treatment with the alternative medicine curcumin exist. OBJECTIVE: We sought to determine the safety and efficacy of oral curcumin in patients with psoriasis. METHODS: We conducted a phase II, open-label, Simon's two-stage trial of 4.5 g/d of oral curcuminoid C3 complex in patients with plaque psoriasis. End points included improvement in Physicians Global Assessment score, Psoriasis Area and Severity Index score, and safety end points throughout the study. RESULTS: The intention-to-treat analysis response rate was 16.7% (95% confidence interval: 2%, 48%) and both responders achieved a Psoriasis Area and Severity Index 75 score. There were no study-related adverse events that necessitated participant withdrawal. LIMITATIONS: Small sample size and lack of placebo group are limitations. CONCLUSION: The response rate was low and possibly caused by a placebo effect or the natural history of psoriasis. Large placebo-controlled studies are necessary before recommending oral curcumin as a psoriasis treatment.

Menter A, Reich K, Gottlieb AB, Bala M, Li S, Hsu MC, Guzzo C, Diels J, Gelfand JM. · Psoriasis Research Unit, Baylor Research Institute, Dallas,TX, USA. · J Drugs Dermatol. · Pubmed #19137767 No free full text.

Abstract: INTRODUCTION: Infliximab is indicated for severe plaque psoriasis (PsO). The investigators compared safety event rates in infliximab PsO trials with those of the general United States and PsO populations. METHODS: Integrated data (n=1373 patients) were compared with external databases. RESULTS: The analyses reported here are based on 1106 patient years and 116 patient years of follow-up in the infliximab group and the placebo group, respectively. The standardized mortality ratio in infliximab-treated patients (0.17 [95% confidence interval [CI]: 0.00-0.92], 1 patient died) was lower than that of the general PsO population. No death occurred in the placebo group. Comparing with the psoriasis population, the standardized incidence ratios (SIRs) for hospitalization were 1.16 (95% CI: 0.92-1.43) in infliximab-treated patients and 1.07 (95% CI: 0.46-2.11) in placebo-treated patients. For serious infection, the SIRs were 1.28 (95% CI: 0.78-1.97) in infliximab-treated patients and 1.47 (95% CI: 0.18-5.32) in placebo patients. The incidence of tuberculosis (TB) among infliximab-treated patients was 0.18 per 100 patient-years (95% CI: 0.02-0.65). No TB occurred in the placebo group. Standardized incidence ratio for malignancy (excluding nonmelanoma skin cancers) was 0.39 (95% CI: 0.05-1.42; 2 malignancies) in infliximab-treated patients. No malignancy occurred in the placebo group. LIMITATIONS: Exclusion criteria in clinical studies may bias selection of subjects who are healthier than the general population. Additionally, the limited number of patients followed over a maximum of 1 year can limit the ability to detect infrequent events or those events that require prolonged follow-up to detect. Nonmelanoma skin cancers were excluded from the analysis. Finally, populations and adverse event definitions may have differed in external databases and studies. CONCLUSION: Based on the data from external databases, mortality, hospitalization, and serious infection rates in infliximab-treated patients were generally comparable to or less than that of the PsO population. Internal malignancy rates were similar to that expected in the general US population. However, the limitations of these data must be considered when compared with the totality of the safety profile of infliximab generated across all indications.

Kurd SK, Gelfand JM. · Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA. · J Am Acad Dermatol. · Pubmed #19022533 No free full text.

Abstract: BACKGROUND: Psoriasis is a predictor of morbidity. It is important to determine the extent to which psoriasis remains undiagnosed. OBJECTIVE: To determine the prevalence of psoriasis. METHODS: We conducted a cross-sectional study using the National Health and Nutrition Examination Survey 2003-2004. RESULTS: The prevalence of diagnosed psoriasis was 3.15% (95% confidence interval [CI], 2.18-4.53), corresponding to 5 million adults. Approximately 17% of these patients have moderate to severe psoriasis based on body surface area report and 25% rate psoriasis a large problem in everyday life. The prevalence of undiagnosed active psoriasis by conservative estimate was 0.4% (95% CI, 0.19-0.82), corresponding to approximately 600,000 US adults, and 2.28% (95% CI, 1.47-3.50) by a broader definition, corresponding to 3.6 million US adults. Undiagnosed patients had a trend toward being more likely to be male, nonwhite, less educated, and unmarried compared with patients who had received a diagnosis. LIMITATIONS: The method for determining the presence of psoriasis had limited ability to detect mild disease and only fair interrater agreement. CONCLUSION: More than 5 million adults have been diagnosed with psoriasis. A large number have undiagnosed psoriasis and there are important disparities which may be associated with not receiving medical attention.

Gelfand JM, Troxel AB, Lewis JD, Kurd SK, Shin DB, Wang X, Margolis DJ, Strom BL. · MSCE, Department of Dermatology, University of Pennsylvania School of Medicine, 2 Maloney Bldg, 3600 Spruce St, Philadelphia, PA 19104, USA. · Arch Dermatol. · Pubmed #18086997 links to  free full text

Abstract: OBJECTIVE: To determine the risk of mortality in patients with psoriasis. DESIGN: Cohort study. SETTING: General practitioners participating in the General Practice Research Database in the United Kingdom, 1987-2002. PATIENTS: Mild psoriasis, defined as any patient with a diagnostic code of psoriasis but no history of systemic therapy; severe psoriasis, any patient with a diagnostic code of psoriasis and a history of systemic therapy consistent with severe psoriasis. The unexposed (control) population was composed of patients with no history of a psoriasis diagnostic code. Control patients were selected in a 5:1 ratio from the same practice and date in practice as the patients with psoriasis. MAIN OUTCOME MEASURE: Hazard ratio (HR) of time to death using Cox proportional hazards models adjusted for age and sex. RESULTS: There was no overall effect of mild psoriasis on mortality (HR, 1.0; 95% confidence interval [CI], 0.97-1.02), whereas patients with severe psoriasis demonstrated an increased overall mortality risk (HR, 1.5; 95% CI, 1.3-1.7). The association of severe psoriasis with mortality persisted after adjustment for risk factors for mortality (HR, 1.4; 95% CI, 1.3-1.6) and after exclusion of patients with inflammatory arthropathy (HR, 1.5; 95% CI, 1.3-1.8). Male and female patients with severe psoriasis died 3.5 (95% CI, 1.2-5.8) and 4.4 (95% CI, 2.2-6.6) years younger, respectively, than patients without psoriasis (P < .001). CONCLUSION: Severe but not mild psoriasis is associated with an increased risk of death.

Lebwohl M, Bagel J, Gelfand JM, Gladman D, Gordon KB, Hsu S, Kalb RE, Kimball AB, Korman NJ, Krueger GG, Mease P, Morison WL, Paller A, Pariser DM, Ritchlin C, Strober B, Van Voorhees A, Weinstein GD, Young M, Horn L. · Department of Dermatology, Mount Sinai School of Medicine, New York, New York, USA. · J Am Acad Dermatol. · Pubmed #17980456 No free full text.

Abstract: BACKGROUND: Biologics are widely used in the treatment of psoriasis and psoriatic arthritis. OBJECTIVE: Our aim was to arrive at a consensus on the kind of monitoring and the vaccinations that should be performed before and during biologic therapy. METHODS: Medical literature and data presented at meetings were reviewed and a consensus conference was held by members of the Medical Board of the National Psoriasis Foundation. RESULTS: Consensus was established on monitoring and vaccination practices that included discussion and recognition of variations in those practices. History, physical examination, chemistry screen with liver function tests, complete blood cell count, and platelet count and tuberculosis testing are widely obtained at baseline and with variable frequencies thereafter. Patients treated with efalizumab have platelet counts checked more often; liver function tests are repeated more frequently in patients treated with infliximab; patients taking tumor necrosis factor blockers undergo tuberculosis testing more often; and patients treated with alefacept have CD4 counts checked approximately every 2 weeks. Avoidance of live vaccines during biologic therapy and administration of essential vaccines before biologic therapy were discussed, although vaccination is performed only to a variable degree. There was no consistency in the measurement of antinuclear antibodies among the experts. LIMITATIONS: There are few evidence-based studies on monitoring practices for patients with psoriasis taking biologic therapies. CONCLUSIONS: In patients taking biologic therapies for psoriasis, monitoring of blood chemistries, blood counts, CD4 counts, antinuclear antibodies, tuberculin skin tests, history, and physical examination may be warranted depending on the particular therapy and the particular patient. Vaccination practices are also addressed.

Nijsten T, Meads DM, de Korte J, Sampogna F, Gelfand JM, Ongenae K, Evers AW, Augustin M. · Department of Dermatology, Erasmus MC, Rotterdam, The Netherlands. · J Invest Dermatol. · Pubmed #17495953 links to  free full text

Abstract: The dermatology life questionnaire index (DLQI) and the Skindex are the most commonly used dermatology-specific health-related quality of life (HRQOL) instruments. Although these tools are used in international surveys and clinical trials, the cross-cultural equivalence of their items has not been documented. We used differential item functioning (DIF), which is part of the Rasch model, to assess the impact of cultural background on the items of the DLQI and Skindex-29 and-17. The data of the 450 psoriasis patients, who attended in- and outpatient dermatology centers, was collected retrospectively from five European and one US center. The DLQI and Skindex-29 scales did not fit the Rasch model (P<0.0008) and 10/10 of the DLQI and 19/29 of the Skindex-29 items displayed significant DIF. Although the psychosocial scale of the Skindex-17 fitted the Rasch model, half or more of the items of the psychosocial (6/12) and the symptom scale (4/5) showed significant DIF across countries. These findings suggest that psoriasis patients from different countries respond differently to a substantial proportion of DLQI and Skindex items despite having the same level of underlying HRQOL impairment. Therefore, these instruments should not be used in their current form in international studies.

Pulitzer M, Li W, Hanson M, Singh F, Elenitsas R, Gelfand JM, VanVoorhees A, Seykora JT. · Department of Dermatology, University of Pennsylvania Medical School, Philadelphia, PA, USA. · J Cutan Pathol. · Pubmed #17244028 No free full text.

Abstract: BACKGROUND: Psoriasis is a prevalent, chronic cutaneous disorder associated with a T-cell lymphocytic infiltrate and altered keratinocyte growth. Some of the molecular features of enhanced keratinocyte growth include increased growth factor receptor activation leading to enhanced cellular tyrosine kinase activity. Receptor tyrosine kinases, including the epidermal growth factor (EGF) receptor, are important regulators of keratinocyte growth, and increased activity of this receptor has been detected in psoriasis. A recently discovered, novel regulator of Src tyrosine kinases, termed Src-activating and signaling molecule (Srcasm), has been shown to modulate EGF signaling and promote differentiation in human keratinocytes. Given the properties of Srcasm, it would be of interest to characterize its expression in psoriasis. In this study, the levels of Srcasm mRNA and protein are characterized, and the relationship of these experimental observations to the psoriasis pathogenesis is discussed. METHODS: The levels of Srcasm mRNA were determined by quantitative reverse transcriptase polymerase chain reaction (RT-PCR) on RNA isolated from unremarkable and lesional patient tissue. These data were supplemented by performing radioactive in situ hybridization on formalin-fixed biopsy specimens of psoriatic lesions and unremarkable epidermis. Expression of Srcasm protein was evaluated by protein immunohistochemistry and Western blotting of protein lysates derived from patient samples. RESULTS: All experimental modalities show that levels of Srcasm mRNA and protein were elevated in psoriatic lesions compared to unremarkable epidermis. CONCLUSIONS: Increased levels of Srcasm mRNA and protein are seen in psoriasis. Given what is known regarding Srcasm function, increased levels of this molecule in keratinocytes may represent a cell compensatory mechanism that is primed to re-establish a physiologic differentiation program.

Neimann AL, Hodinka RL, Joshi YB, Elkan M, Van Voorhees AS, Gelfand JM. · Department of Dermatology, University of Pennsylvania, 3600 Spruce Street, 2 Maloney Building, Philadelphia, PA 19104, USA. · Eur J Dermatol. · Pubmed #17101477 links to  free full text

Abstract: The association of psoriasis with latent human herpesvirus infection has not been well described. To better understand the relationship between severe psoriasis and its treatment with latent human herpesvirus infection, we performed a cross-sectional study to determine if patients with severe psoriasis and psoriasis patients treated with immunosuppressive therapies have higher rates of Epstein-Barr virus and human herpesvirus 6 replication compared to healthy controls. The prevalence of Epstein-Barr virus and human herpesvirus 6 replication was measured in white blood cells by quantitative polymerase chain reaction. We found no evidence of active viral replication in white blood cells of healthy controls (0/10; 95% confidence interval 0-0.26), patients with severe psoriasis (0/25; 95% confidence interval 0-0.11) or severe psoriasis patients on immunosuppressive treatment (0/26; 95% confidence interval 0-0.11). The results of this study suggest that neither severe psoriasis alone, nor in combination with immunosuppressive therapy, is associated with an increase in Epstein-Barr virus or human herpesvirus 6 replication in white blood cells.

Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM. · Dermatology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA. · J Am Acad Dermatol. · Pubmed #17052489 No free full text.

Abstract: BACKGROUND: Previous studies suggest that patients hospitalized for psoriasis have an increased frequency of a variety of cardiovascular comorbidities. Limited population-based data exist on this association, and few studies have determined which factors are independently associated with psoriasis. OBJECTIVE: We sought to determine whether the prevalence of the major cardiovascular risk factors was higher in mild and severe psoriasis than in patients without psoriasis. METHODS: We conducted a population-based study in the United Kingdom using the General Practice Research Database. Patients were classified as having severe psoriasis if they received a code for psoriasis as well as systemic therapy. Patients were defined as having mild psoriasis if they ever received a psoriasis code but no systemic therapy. Control subjects were selected from the same practices and start dates as psoriasis patients. Patients were classified as having risk factors if they received codes for diabetes, hypertension, hyperlipidemia, obesity, or smoking. Analyses were performed by using conditional logistic regression, and adjustments were made considering age, gender, person-years, and all cardiovascular risk factors. RESULTS: We identified 127,706 patients with mild psoriasis and 3854 with severe psoriasis. Respective prevalence rates of risk factors in those with severe psoriasis, mild psoriasis, and in controls were as follows: diabetes (7.1%, 4.4%, 3.3%), hypertension (20%, 14.7%, 11.9%), hyperlipidemia (6%, 4.7%, 3.3%), obesity (20.7%, 15.8%, 13.2%), and smoking (30.1%, 28%, 21.3%). Patients with mild psoriasis had a higher adjusted odds of diabetes (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.08-1.18]), hypertension (OR, 1.03; 95% CI, 1.01-1.06), hyperlipidemia (OR, 1.16; 95% CI, 1.12-1.21), obesity (OR, 1.27; 95% CI, 1.24-1.31), and smoking (OR, 1.31; 95% CI, 1.29-1.34) than controls. Patients with severe psoriasis had a higher adjusted odds of diabetes (OR, 1.62; 95% CI, 1.3-2.01), obesity (OR, 1.79; 95% CI, 1.55-2.05), and smoking (OR, 1.31; 95% CI, 1.17-1.47) than controls. Additionally, diabetes (OR, 1.39; 95% CI, 1.22-1.58) and obesity (OR, 1.47; 95% CI, 1.32-1.63) were more prevalent in those with severe psoriasis than with mild psoriasis. LIMITATIONS: The study was cross-sectional and therefore the directionality of the associations could not be determined. CONCLUSION: Multiple cardiovascular risk factors are associated with psoriasis. Cardiovascular risk factors that are key components of the metabolic syndrome are more strongly associated with severe psoriasis than with mild psoriasis.

Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB. · Department of Dermatology and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA 19104, USA. · JAMA. · Pubmed #17032986 links to  free full text

Abstract: CONTEXT: Psoriasis is the most common T-helper cell type 1 (T(H)1) immunological disease. Evidence has linked T(H)1 diseases to myocardial infarction (MI). Psoriasis has been associated with cardiovascular diseases, but has only been investigated in hospital-based studies that did not control for major cardiovascular risk factors. OBJECTIVE: To determine if within a population-based cohort psoriasis is an independent risk factor for MI when controlling for major cardiovascular risk factors. DESIGN, SETTING, AND PATIENTS: A prospective, population-based cohort study in the United Kingdom of patients with psoriasis aged 20 to 90 years, comparing outcomes among patients with and without a diagnosis of psoriasis. Data were collected by general practitioners as part of the patient's medical record and stored in the General Practice Research Database between 1987 and 2002, with a mean follow-up of 5.4 years. Adjustments were made for hypertension, diabetes, history of myocardial infarction, hyperlipidemia, age, sex, smoking, and body mass index. Patients with psoriasis were classified as severe if they ever received a systemic therapy. Up to 5 controls without psoriasis were randomly selected from the same practices and start dates as the patients with psoriasis. A total of 556,995 control patients and patients with mild (n = 127,139) and severe psoriasis (n = 3837) were identified. MAIN OUTCOME MEASURE: Incident MI. RESULTS: There were 11,194 MIs (2.0%) within the control population and 2319 (1.8%) and 112 (2.9%) MIs within the mild and severe psoriasis groups, respectively. The incidences per 1000 person-years for control patients and patients with mild and severe psoriasis were 3.58 (95% confidence interval [CI], 3.52-3.65), 4.04 (95% CI, 3.88-4.21), and 5.13 (95% CI, 4.22-6.17), respectively. Patients with psoriasis had an increased adjusted relative risk (RR) for MI that varied by age. For example, for a 30-year-old patient with mild or severe psoriasis, the adjusted RR of having an MI is 1.29 (95% CI, 1.14-1.46) and 3.10 (95% CI, 1.98-4.86), respectively. For a 60-year-old patient with mild or severe psoriasis, the adjusted RR of having an MI is 1.08 (95% CI, 1.03-1.13) and 1.36 (95% CI, 1.13-1.64), respectively. CONCLUSIONS: Psoriasis may confer an independent risk of MI. The RR was greatest in young patients with severe psoriasis.

Gelfand JM, Shin DB, Neimann AL, Wang X, Margolis DJ, Troxel AB. · Department of Dermatology and Center for Clinical Epidemiology and Biostatistics University of Pennsylvania, Philadelphia, 19104, USA. · J Invest Dermatol. · Pubmed #16741509 links to  free full text

Abstract: Psoriasis is a common, chronic, inflammatory disease. Psoriasis has been hypothesized to be associated with an increased risk of lymphoma due to its pathophysiology, its treatments, or a combination of these factors. We performed a large population-based cohort study of the risk of lymphoma in psoriasis patients using the General Practice Research Database. We identified 153,197 patients with psoriasis and 765,950 corresponding subjects without psoriasis. Psoriasis patients who received a systemic treatment consistent with extensive disease were classified as severe (N=3,994) and those who did not receive systemic therapies were classified as mild (N=149,203). The analyses were adjusted for age, gender, and person-time using a Cox proportional hazards model. For mild and severe psoriasis patients, the respective adjusted relative risks for lymphoma and its subtypes were as follows: all lymphoma 1.34 (1.16, 1.54) and 1.59 (0.88, 2.89); non-Hodgkin's lymphoma 1.15 (0.97, 1.37) and 0.73 (0.28, 1.96); Hodgkin's lymphoma (HL) 1.42 (1.00, 2.02) and 3.18 (1.01, 9.97); cutaneous T-cell lymphoma (TCL) 4.10 (2.70, 6.23) and 10.75 (3.89, 29.76). Psoriasis is associated with an increased risk of lymphoma. The association is strongest for HL and CTCL. The excess risk of lymphoma attributed to psoriasis was 7.9/100,000 psoriasis patients per year. Although patients with psoriasis have an increased relative risk of lymphoma, the absolute risk attributable to psoriasis is low given that lymphoma is a rare disease and the magnitude of association is modest.

Gelfand JM, Weinstein R, Porter SB, Neimann AL, Berlin JA, Margolis DJ. · Center for Clinical Epidemiology and Biostatistics, and Department of Dermatology, University of Pennsylvania, 3600 Spruce Street, 2 Maloney Building, Philadelphia, PA 19104, USA. · Arch Dermatol. · Pubmed #16365254 links to  free full text

Abstract: OBJECTIVE: To measure the prevalence and treatment of psoriasis in the United Kingdom. DESIGN: Cross-sectional study to determine prevalence and cohort study to determine treatment patterns. SETTING: Outpatient practices of general practitioners. PATIENTS: We included in the analysis all patients who were registered with a general practitioner in the General Practice Research Database from 1987 to 2002. MAIN OUTCOME MEASURES: The prevalence and treatment of psoriasis. RESULTS: We identified 114 521 patients with psoriasis of a total population of 7 533 475 patients, yielding a prevalence of 1.5%. The prevalence of psoriasis increases more rapidly in young female patients compared with young male patients and declines significantly in patients 70 years and older, regardless of sex. Overall, 91.8% of patients with a diagnosis of psoriasis received a prescription for psoriasis treatment on or after the date of their first diagnostic code of psoriasis in the General Practice Research Database. Most of the patients (55.2%) received only 1 or 2 prescriptions for psoriasis in the first year after psoriasis was documented in the General Practice Research Database. CONCLUSIONS: The epidemiology of psoriasis in the General Practice Research Database population is similar to that of other epidemiologic studies of psoriasis performed in the United Kingdom, the United States, and other Western countries. Psoriasis carries a substantial burden given its high prevalence and its associated need for prescription therapy. Additional studies are necessary to determine why the prevalence of psoriasis increases more rapidly in female patients and to determine why the prevalence decreases in patients 70 years and older.

Gelfand JM, Gladman DD, Mease PJ, Smith N, Margolis DJ, Nijsten T, Stern RS, Feldman SR, Rolstad T. · Department of Dermatology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA 19104, USA. · J Am Acad Dermatol. · Pubmed #16198775 No free full text.

Abstract: BACKGROUND: Estimates of the prevalence of psoriatic arthritis vary widely and are usually not determined by population-based studies. OBJECTIVES: We sought to determine the prevalence of psoriatic arthritis and the impact of the disease on quality of life in the US population. METHODS: Patients were selected randomly from the US population and were interviewed by telephone. Cases were defined as patients who reported a physician diagnosis of psoriasis and psoriatic arthritis. RESULTS: Interviews of 27,220 persons were conducted; 601 of the interviewees had psoriasis and 71 had psoriasis and psoriatic arthritis. The prevalence of psoriatic arthritis was 0.25% (95% confidence interval [CI]: 0.18%, 0.31%). The prevalence of psoriatic arthritis among patients with psoriasis was 11% (95% CI: 9%, 14%) and varied substantially based on self-reporting of the extent of skin involvement with psoriasis. Thirty-nine percent of patients with psoriatic arthritis indicated that it was a large problem in everyday life. LIMITATIONS: Psoriatic arthritis was classified on the basis of the patient's self-report. CONCLUSION: Psoriatic arthritis affects an estimated 520,000 patients in the US population, and many rate it as a large problem in everyday life. The prevalence varies widely based on the extent of skin involvement, which demonstrates the importance of performing broadly representative studies to measure the prevalence of psoriatic arthritis.

Gelfand JM, Stern RS, Nijsten T, Feldman SR, Thomas J, Kist J, Rolstad T, Margolis DJ. · Department of Dermatology and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, PA 19104, USA. <> · J Am Acad Dermatol. · Pubmed #15627076 No free full text.

Abstract: BACKGROUND: Psoriasis is a common disease with substantial effects on quality of life. The prevalence of psoriasis in African Americans has been previously reported as rare. However, there have been no population-based studies to assess the prevalence and burden of psoriasis in African Americans. OBJECTIVE: We sought to measure the prevalence and burden of psoriasis in African Americans compared with Caucasians. METHODS: Patients were randomly selected from the United States population and were asked standard demographic questions. Patients who reported a physician diagnosis of psoriasis were asked additional questions related to quality of life. RESULTS: The total sample included 27,220 individuals of which 21,921 were Caucasian and 2443 were African American. The prevalence of psoriasis was 2.5% in Caucasian patients and was 1.3% in African American patients. African Americans had an approximately 52% reduction in the prevalence of psoriasis compared with Caucasians ( P < .0001). African Americans and Caucasians had similar impacts on quality of life and treatment satisfaction based on single global questions. CONCLUSION: Although psoriasis is less common in African Americans than in Caucasians, it is not rare in either demographic and carries a substantial burden in both groups.

Gelfand JM, Feldman SR, Stern RS, Thomas J, Rolstad T, Margolis DJ. · Department of Dermatology and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, USA. · J Am Acad Dermatol. · Pubmed #15523347 No free full text.

Abstract: BACKGROUND: Psoriasis is a common disease with substantial effects on quality of life. Few quality of life studies have been performed in psoriasis patients from the general US population. OBJECTIVE: To describe the determinants of quality of life in psoriasis patients from the US population. METHODS: Patients were randomly selected from the US population. Patients who identified themselves as having been diagnosed with psoriasis by a physician were invited to complete a more detailed survey about quality of life. RESULTS: Two hundred sixty-six psoriasis patients from the US population completed the detailed survey. Body surface area showed the strongest association with decrements in quality of life (Spearman 0.50, P < .0001). Younger patients and female patients also had statistically significant reductions in quality of life. Increasing psoriasis severity was associated with seeking care from multiple physicians and having decrements in income. CONCLUSION: Patients with more extensive skin involvement have greater reductions in quality of life. Female patients and young patients are affected to a greater extent.