Elza Alex
LITHUANIAN UNIVERSIT
The Clinical Association between
Psoriasis and
Department of Skin and Venereal Diseases
Supervisor: Prof. Dr.SkaidraValiukevičienė, MD, PhD LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
The Clinical Association between
Psoriasis and Diabetes Mellitus
Department of Skin and Venereal Diseases
Final Master’s Thesis
Elza Alex
1/1/2020 Faculty of Medicine VI Group 32 Prof. Dr.SkaidraValiukevičienė, MD, PhD Kaunas, Lithuania, 2020 1 Y OF HEALTH SCIENCESThe Clinical Association between
Mellitus
Elza Alex
Table of Contents
i. ABSTRACT ...
ii. ACKNOWLEDGEMENT ... iii. CONFLICT OF INTEREST
iv. ABBREVIATIONS ... 1. INTRODUCTION ... 1.1. Background ...
1.1.1. Definitions ... 1.1.2. Symptoms and Severity
1.1.3. A New Hypothesis ... 1.1.4. The Purpose of the Study
1.2. Aim and Objectives ... 2. METHODS AND MATERIALS
2.1. Data Sources and Searches 2.2. Inclusion and Exclusion Criteria 2.3. Exluded Studies ... 2.4. Data Extraction ... 2.5. Study Selection ... 3. RESULTS AND DISCUSSION
3.1. Mechanistic Link between Psoriasis and Diabetes 3.2. T2DM in Ps patients compared with controls 3.3. Bidirectional association
3.4. T2DM and Ps age + sex 3.5. T2DM and age of Ps onset
3.6. T2DM and Ps severity ... 3.7. Study Strengths... 3.8. Study Limitations ... 4. CONCLUSIONS AND RECOMMENDATIONS References ... ... ... INTEREST ... ... ... ... ...
Symptoms and Severity ... ... The Purpose of the Study ...
... METHODS AND MATERIALS ...
Sources and Searches ... Inclusion and Exclusion Criteria ...
... ... ...
RESULTS AND DISCUSSION ... between Psoriasis and Diabetes...
T2DM in Ps patients compared with controls ... Bidirectional association ... T2DM and Ps age + sex ... and age of Ps onset ... ... ...
... CONCLUSIONS AND RECOMMENDATIONS ...
Elza Alex
i. ABSTRACT
Aim: The principal aim of this thesis is
further probe into the relationship between psoriasis type 2 diabetes mellitus, a disease of insulin
Methods: The primary method was to u psoriasis and type 2 diabetes mellitus 10 observational studies were entered
determine the eligibility of the report for inclusion in the analysis. To be included, original studies needed to fulfil the following criteria
Case-control Cross-sectional Cohort design Human studies English studies
Limitation of 10 years; evaluation of diabete Analysis that compared patients with psoriasis vs
Results: All the included observational studies in this review reported increased incidence of T2DM among patients with psoriasis. Among the
diabetes association with psoriasis ranged from 0.91 Conclusion: This literature review identified that p therefore, they had a higher prevalence and incidence
healthy control subjects. Moreover, there was a positive correlation between
and the risk of developing diabetes. As the severity increases, the risk of diabetes also independent of other risk factors.
of this thesis is to review current scientific literature to investigate and relationship between psoriasis, an autoinflammatory skin
disease of insulin resistance.
The primary method was to utilise scientific databases, namely PubMed, using mellitus within ten years. Among the 186 identified publications
entered in the analysis. All the abstracts identified were read to eligibility of the report for inclusion in the analysis. To be included, original studies needed to fulfil the following criteria:
evaluation of diabetes in conjunction with psoriasis s that compared patients with psoriasis vs control groups
All the included observational studies in this review reported increased
incidence of T2DM among patients with psoriasis. Among the 10 studies, the adjusted OR of diabetes association with psoriasis ranged from 0.91-2.37.
This literature review identified that patients with psoriasis were more insulin prevalence and incidence of Type 2 Diabetes M
Moreover, there was a positive correlation between
and the risk of developing diabetes. As the severity increases, the risk of diabetes also independent of other risk factors.
3 literature to investigate and inflammatory skin and joint disease and
PubMed, using keywords: identified publications, only in the analysis. All the abstracts identified were read to eligibility of the report for inclusion in the analysis. To be included, original studies
s in conjunction with psoriasis
All the included observational studies in this review reported increased prevalence and 10 studies, the adjusted OR of
Elza Alex
ii. ACKNOWLEDGEMENT
I would like to express my sincere gratitude continuous support and unparalleled
invaluable guidance assisted greatly I would like to extend my gratitud and support.
A special thanks to all the staff in the department of skin and venereal diseases as well as the faculty for its continued academic excellence.
iii. CONFLICT OF INTEREST
The author reports no conflicts of interest.
ACKNOWLEDGEMENT
sincere gratitude to my advisor Prof. Dr.Skaidra unparalleled academic supervision she provided throughout
assisted greatly to finish the research on time and to the required standard tude to my family and particularly my fiancé
to all the staff in the department of skin and venereal diseases as well as the faculty for its continued academic excellence.
CONFLICT OF INTEREST
The author reports no conflicts of interest.
4 Valiukevičienė, for the provided throughout this journey. Her
and to the required standard. and particularly my fiancé for endless motivation
Elza Alex
iv. ABBREVIATIONS
aHR– Adjusted Hazard Ratio aRR– Adjusted Risk Ratio β-cell– Beta-Cell
BMI– Body Mass Index BSA– Body Surface Area CI– Confidence Interval CRP– C Reactive Protein CS– Corticosteroids CVD– Cardiovascular Diseases DL– Dyslipidemia DM– Diabetes Mellitus HR– Hazard Ratio HT– Hypertension
ICD9– International Classification of Diseases, 9 IL– Interleukin
IR– Incidence Ratio KM– Kaplan-Meier
MS– Metabolic Syndrome OR– Odds Ratio
PASI– Psoriasis Area and Severity Index Ps– Psoriasis
PsA–Psoriatic Arthritis QoL– Quality of Life RR–Risk Ratio
T2DM–Type 2 Diabetes Mellitus TNFα– Tumor Necrosis Factor α
International Classification of Diseases, 9th Revision
Psoriasis Area and Severity Index
ellitus α
Elza Alex
1. INTRODUCTION
1.1. Background
1.1.1. Definitions
Psoriasis (Ps) is a non-contagious, inflammation, with a world prevalence of
major health issue that affects many body systems dermatologist, Dr. Andy Blauvelt.
skin appearing as sharply demarcated, erythematous inflammatory processes can affect se
also affects both men and women
Till date, scientists are uncertain of the exact cause of psoriasis, but we believe a combination of genetic predisposition, immune response and environmental risk factors all play a pivotal role in the development of psoriasis. Although we know it is a hereditary c
behind the inheritance is complex and not yet fully understood trigger psoriasis to flare, such as infections, stress, trauma Ps is characterised by dendritic antigen
cytokines, keratinocyte hyperproliferation and recruitment of other immune cells to the site of infection. [6] However, in psoriasis, the chronic T
inflammation and formation of the psoriatic plaque.
Diabetes mellitus (DM) is a disorder of carbohydrate metabolism that is associated with chronic hyperglycemia. Type 2 diabetes mellitus (T2DM) has reached epidemic proportions worldwide and is combination of insulin resistance and pancreatic β cell dysfunc
aetiology, yet its prevalence is profoundly
habits and lifestyle. In 1966, the importance of inflammation in the interplay between psoriasis and diabetes mellitus was first proposed
have assessed the association between the two
Although both chronic conditions are phenotypically diverse, they share several genetic and immunological abnormalities with a common mechanism of inflammation.
pathophysiology linking both is still ambiguous and yet to be uncovered fully. Numerous theories on how both these diseases are linked have been proposed and yet many are still unsure which disease
contagious, chronic autoimmune disorder that causes widespread , with a world prevalence of 2-4%. [1] "Psoriasis is more than just a skin disease, it is a
that affects many body systems”- these were the words of a renowned dermatologist, Dr. Andy Blauvelt. [2]. Although, the primary manifestation of the disease is on the
demarcated, erythematous, scaly and pruritic plaques. affect several other parts of the body. [4]It may occur men and women alike.
scientists are uncertain of the exact cause of psoriasis, but we believe a combination of genetic predisposition, immune response and environmental risk factors all play a pivotal role in the Although we know it is a hereditary condition, the exact mechanism heritance is complex and not yet fully understood. Furthermore
s infections, stress, trauma and certain medications
dendritic antigen-presenting cells, T-lymphocytes release proinflammatory cytokines, keratinocyte hyperproliferation and recruitment of other immune cells to the site of
in psoriasis, the chronic T-cell activation results in a persi inflammation and formation of the psoriatic plaque. [7]
Diabetes mellitus (DM) is a disorder of carbohydrate metabolism that is associated with chronic hyperglycemia. Type 2 diabetes mellitus (T2DM) has reached epidemic proportions worldwide and is
insulin resistance and pancreatic β cell dysfunction. A disease prevalence is profoundly influenced by certain factors such as
he importance of inflammation in the interplay between psoriasis and proposed by Brownstein [8]and thereafter several
have assessed the association between the two. [9]
Although both chronic conditions are phenotypically diverse, they share several genetic and with a common mechanism of inflammation.
pathophysiology linking both is still ambiguous and yet to be uncovered fully. Numerous theories on how both these diseases are linked have been proposed and yet many are still unsure which disease 6 chronic autoimmune disorder that causes widespread skin "Psoriasis is more than just a skin disease, it is a these were the words of a renowned he primary manifestation of the disease is on the , scaly and pruritic plaques. [3] However, may occur at any age and
scientists are uncertain of the exact cause of psoriasis, but we believe a combination of genetic predisposition, immune response and environmental risk factors all play a pivotal role in the ondition, the exact mechanism Furthermore, environmental factors
medications. [5]
lymphocytes release proinflammatory cytokines, keratinocyte hyperproliferation and recruitment of other immune cells to the site of cell activation results in a persistent cycle of
Diabetes mellitus (DM) is a disorder of carbohydrate metabolism that is associated with chronic hyperglycemia. Type 2 diabetes mellitus (T2DM) has reached epidemic proportions worldwide and is disease of multifactorial certain factors such as ethnic origin, dietary he importance of inflammation in the interplay between psoriasis and thereafter several observational studies
Elza Alex
originated initially. [1] Speculations arise causative or due to the result of living standards
of psoriasis have significant effects on a patient’s quality of life, which on many occasions leads to change in their lifestyle, resulting in increased rates of smoking, alcohol consumption, psychological stress and sedentary lifestyle. Certain habits alone contribute to both the components of the metabolic syndrome (i.e. obesity, glucose intolerance and h
cardiovascular disease and diabetes).
1.1.2. Symptoms and Severity
Symptoms of psoriasis can vary, usually affecting the skin with silvery scaling, which is both itchy and painful. They appear on restricted areas, especially elbows, knees, scalp or lower back, though it can appear anywhere on the body
progression of concomitant other autoimmune deficiencies such as with Ps are at significant risk for depression and metabolic syndrome dyslipidemia, arterial hypertension, and insulin resistance.
diseases (CVD) and T2DM. [11]
Figure 1. The most common areas affected
Speculations arise as to whether these associations are fundamentally causative or due to the result of living standards observed in psoriatic patients. Signs and symptoms of psoriasis have significant effects on a patient’s quality of life, which on many occasions leads to lifestyle, resulting in increased rates of smoking, alcohol consumption, psychological . Certain habits alone contribute to both the components of the metabolic syndrome (i.e. obesity, glucose intolerance and hypertension) as well as its comorbidities (including cardiovascular disease and diabetes). [11]
Symptoms of psoriasis can vary, usually affecting the skin with silvery scaling, which is both itchy on restricted areas, especially elbows, knees, scalp or lower back, though it can appear anywhere on the body (Fig. 1). The systemic spread of the disease
other autoimmune deficiencies such as psoriatic arthritis (PsA)
with Ps are at significant risk for depression and metabolic syndrome (MS), which include obesity, dyslipidemia, arterial hypertension, and insulin resistance. MS increases the risk of cardiovascular
. The most common areas affected by plaques: elbows, knees, scalp or lower back [3] 7 as to whether these associations are fundamentally observed in psoriatic patients. Signs and symptoms of psoriasis have significant effects on a patient’s quality of life, which on many occasions leads to lifestyle, resulting in increased rates of smoking, alcohol consumption, psychological . Certain habits alone contribute to both the components of the metabolic ypertension) as well as its comorbidities (including
Symptoms of psoriasis can vary, usually affecting the skin with silvery scaling, which is both itchy on restricted areas, especially elbows, knees, scalp or lower back, though it spread of the disease represents the psoriatic arthritis (PsA). People , which include obesity, increases the risk of cardiovascular
Elza Alex
Psoriasis can be mild, moderate or severe
on how much the disease affects the body, or how psoriasis affects the quality of life of an It is noted in patients with moderate
their Quality of Life (QoL). It is accepted that stigmatisation and employment problems
1.1.3. A New Hypothesis
Whether the treatment of psoriasis questions whether the management of conditions such as psoriasis are
reasonable costs, and relatively good safety profile.
within topical CS means so they are easily absorbed into the skin, eventually circulation and can potentially cause
ambiguous concept attempts to understand the topical CS and whether it is directly
Figure 2. Psoriasis coverage and severity: Mild (limited disease with <3% of BSA affected), Moderate (scattered disease with 3
>10% of BSA affected). [12]
Psoriasis can be mild, moderate or severe as displayed in Fig. 2. The extent
on how much the disease affects the body, or how psoriasis affects the quality of life of an
It is noted in patients with moderate to severe psoriasis that the condition has a detrimental effect on It is accepted that psoriasis is linked to depression,
ation and employment problems. [12]
psoriasis alters incident diabetes is still a mystery
questions whether the management of psoriasis is the actual cause behind diabetes soriasis are widely treated by topical corticosteroids (CS)
reasonable costs, and relatively good safety profile. The miniature size of the molecules contained so they are easily absorbed into the skin, eventually
can potentially cause side effects including hyperglycaemia and glucosuria. understand the reality behind the effects of systemic absorption of and whether it is directly linked to T2DM. [13]
. Psoriasis coverage and severity: Mild (limited disease with <3% of BSA affected), (scattered disease with 3-10% of BSA affected) and Severe (extensive dise
8 of the diseases depends on how much the disease affects the body, or how psoriasis affects the quality of life of an individual. that the condition has a detrimental effect on depression, anxiety, social
Elza Alex
1.1.4. The Purpose of the Study
The main reasons for choosing this topic were because both psoriasis and diabetes are two popular chronic diseases worldwide, yet no cure has been found for neither and both share several common pathophysiological pathways. The
shedding further light into the mechanistic link can be a driving factor in how th are diagnosed and treated in the future.
related to features of metabolic syndrome, which is factors, including obesity, dyslipidemia,
predispose to increased risk of CVD of studies cite no direct association
tudy
reasons for choosing this topic were because both psoriasis and diabetes are two popular , yet no cure has been found for neither and both share several common pathophysiological pathways. The relationship between both diseases remains controversial
shedding further light into the mechanistic link can be a driving factor in how th
are diagnosed and treated in the future. An overwhelming majority claim that psoriasis is
of metabolic syndrome, which is the constellation of known cardiovascular risk obesity, dyslipidemia, hypertension and insulin resistance.
CVD and higher morbidity and mortality. Meanwhile, direct association between the two. [14]
Elza Alex
1.2. Aim and Objectives
Aim:
Objectives:
• To provide a review of the literature analysing the association between psoriasis and diabetes mellitus
1.
• To review shared pathogenesis of psoriasis and type 2 diabetes mellitus2.
• To compare the prevalence and incidence of diabetes between patients with psoriasis and those without psoriasis
3.
• To understand whether diabetes prevalence is linked to patient age, gender or severity of psoriasis
4.
• To determine whether the age of psoriasis onset increases the risk of incidence of diabetes
To provide a review of the literature analysing the association between psoriasis and diabetes mellitus
To review shared pathogenesis of psoriasis and type 2 diabetes mellitus
To compare the prevalence and incidence of diabetes between patients with psoriasis and those without psoriasis
To understand whether diabetes prevalence is linked to patient age, gender or severity of psoriasis
To determine whether the age of psoriasis onset increases the risk of incidence of
10
To provide a review of the literature analysing the association between psoriasis
To review shared pathogenesis of psoriasis and type 2 diabetes mellitus
To compare the prevalence and incidence of diabetes between patients with
To understand whether diabetes prevalence is linked to patient age, gender or
Elza Alex
2. METHODS AND MATERIAL
2.1. Data Sources and Searches
Previously published literatures that were relevant to the topic in discussion here searching in PubMed using keywords “psoriasis”, “type 2 diabetes
were applied as illustrated in Table 1
to the inclusion and exclusion criteria according to
Table 1. Filters parameters and associated settings Filter Parameters Date Language Species Age Sex Type
2.2. Inclusion and Exclusion C
Table 2. Inclusion and exclusion criteria for choosing relevant studies Inclusion
Cohort, cross-sectional, case
Presented original data from studies Provided comparison control groups Provided odds ratio (OR), risk ratio (RR)
or hazard ratio (HR) estimates with confidence intervals (CIs)
Considered DM as a specific outcome event
T2DM was confirmed with standardised criteria
THODS AND MATERIALS
Data Sources and Searches
that were relevant to the topic in discussion here in PubMed using keywords “psoriasis”, “type 2 diabetes mellitus”. Then
able 1. The resulting records were screened to inclusion and exclusion criteria according to the title, abstract and full paper.
parameters and associated settings
Filter Setting Within 10 years English
Humans Adults
Men and/or women Full Text
Inclusion and Exclusion Criteria
. Inclusion and exclusion criteria for choosing relevant studies
Exclusion ase-control
Presented original data from studies comparison control groups Provided odds ratio (OR), risk ratio (RR) or hazard ratio (HR) estimates with confidence intervals (CIs)
as a specific outcome
with standardised
No free full text Small subject groups
Reported incident Ps, not DM
Not focusing on the direct relationship between psoriasis and diabetes
Assessed only PsA
Assessed only atherosclerosis
Assessed only other skin or inflamma disorders
Focused only on treatment Focused only on genetics
11 that were relevant to the topic in discussion here were extracted by mellitus”. Then additional filters to ensure that they adhere title, abstract and full paper.
Exclusion
Small subject groups
Reported incident Ps, not DM
Not focusing on the direct relationship between psoriasis and diabetes
PsA
atherosclerosis
Assessed only other skin or inflammatory
Elza Alex
2.3. Exluded Studies
Fig. 3 summarises the details of the excluded studies. During the literature search, a total of 63 studies were eliminated according to exclusion criteria.
The author decided to exclude: case reports, reviews or meta studies with small sample size which could result in false were not free to access (n=2), with no
either on treatment or genetics (n=9), assessed other diseases (n=12), failed to consider diabetes as a specific outcome event (n=6) and reported incident of psoriasis whilst no information on d
(n=2). 4 Assessed only other skin or inflammatory disorders 1 Assessed only atherosclerosis 6 Failed to consider DM as specific outcome event 2 Reported incident Ps, not DM 2 Small subject groups
summarises the details of the excluded studies. During the literature search, a total of 63 studies were eliminated according to exclusion criteria.
The author decided to exclude: case reports, reviews or meta-analysis (n=19), duplicates (n=3), studies with small sample size which could result in false-positive results (n=2), publications that were not free to access (n=2), with no appropriate control groups (n=6), with no ORs (n=2), centred either on treatment or genetics (n=9), assessed other diseases (n=12), failed to consider diabetes as a specific outcome event (n=6) and reported incident of psoriasis whilst no information on d
EXLCUSION
(n=63)
19 Case reports, reviews, meta-analyses 3 Duplicate publications 2 No free full 8 Focused only on treatment 1 Focused only on genetics 7 Assessed only PsA 4 Assessed only other skin or inflammatory disorders 2 Small subject groupsFigure 3. Excluded studies
12 summarises the details of the excluded studies. During the literature search, a total of 63
analysis (n=19), duplicates (n=3), positive results (n=2), publications that appropriate control groups (n=6), with no ORs (n=2), centred either on treatment or genetics (n=9), assessed other diseases (n=12), failed to consider diabetes as a specific outcome event (n=6) and reported incident of psoriasis whilst no information on diabetes
Elza Alex
2.4. Data Extraction
The following details were collated for every study as shown in later sections: The first author’s last name,
Year of publication, Country of origin, Study design,
Characteristics of participants (sample size, age and sex),
The odds ratios (ORs) of psoriasis associated with diabetes along with the corresponding 95% confidence intervals (CIs).
2.5. Study Selection
The process of study selection is detailed in
186 hits, which were reduced to 73 after activating the for inclusion and exclusion criteria.
exclusion criteria (Fig. 3). All abstracts were evaluated and Finally, 10 articles and abstracts were included
psoriasis and diabetes. The studies were studies (n=7), case-control studies (n=
and described based on their focus; studies linking gender of patient with Ps (n=4),
risk of incidence of diabetes (n=2)
(n=1). These research were conducted in diverse settings, including large outpatient da insurance claims, or inpatient samples.
outcomes and the overall summary results for studies of psoriasis and diabetes the studies and their participants are listed in
were collated for every study as shown in later sections: e first author’s last name,
haracteristics of participants (sample size, age and sex),
s) of psoriasis associated with diabetes along with the corresponding 95% confidence intervals (CIs).
study selection is detailed in Fig. 4. The initial search in PubMed yielded a total of to 73 after activating the filters. The rest of the records were screened for inclusion and exclusion criteria. From the 73 literatures obtained, 63 were excluded
abstracts were evaluated and assessed for eligibility articles and abstracts were included that reported the clinical
The studies were published between 2010 and 2020 and
control studies (n=1) and cross-sectional studies (n=3). The studies were divided and described based on their focus; studies linking T2DM prevalence to severity of Ps
(n=4), examined whether the age at which Ps was diagnose
of diabetes (n=2) and highlighting bidirectional association between Ps and T2DM were conducted in diverse settings, including large outpatient da
patient samples. Both Table 3 and Fig. 8 presents the i and the overall summary results for studies of psoriasis and diabetes
are listed in Table 4.
13 were collated for every study as shown in later sections:
s) of psoriasis associated with diabetes along with the corresponding 95%
Elza Alex
Studies included into systematic review
Titles and abstracts are screened after initial filter application
Records identified through database search using keywords "psoriasis" and "type 2 diabetes mellitus"
Figure 4. Literature search and study selection are shown using Prisma flow chart.
Inclusion
Studies included into systematic review (n=10)
Eligibility
Studies excluded (n=63)
Screening
Titles and abstracts are screened after initial filter application
Identification
Records identified through database search using keywords "psoriasis" and "type 2 diabetes mellitus" (n=186)
. Literature search and study selection are shown using Prisma flow chart.
14
Titles and abstracts are screened after initial filter application (n=73)
Records identified through database search using keywords "psoriasis" and "type 2 diabetes mellitus"
Elza Alex
3. RESULTS AND DISCUSSION
3.1. Mechanistic Link between Psoriasis and Diabetes
Overactive dendritic cells aim to capture ‘foreign invaders’
12, which activates IL-17-producing T cells, Th1 cells and Th22 cells. These cells excite the production of high levels of circulating IL1, IL
proinflammatory cytokines play a driving force in the pathogenesis of psoriasis and on insulin resistance and pancreatic β cell function:
cell apoptosis.T2DM is an epiphenomenon to psoriasis because
patients with psoriasis leads to insulin resistance, a significant precursor of T2DM. Also, there is an emphasis on how insulin associated with the differentiation of keratinoc
IL-1β causes insulin resistance in keratinocytes. IL
and uncontrolled proliferation viewed in psoriatic plaques. between the two diseases.
Furthermore, stigmatising psoriatic skin lesions catalyse an isolated and unhealthy lifestyle, hence why obesity, inactivity and smoking were more preva
population. Fig. 6 illustrates how environmental factors increase the risk of developing T2DM. Figure 5. Theory on the role of inflammation in the shared pathogenesis of Ps a
RESULTS AND DISCUSSION
between Psoriasis and Diabetes
Overactive dendritic cells aim to capture ‘foreign invaders’ by releasing interleukin (IL)
producing T cells, Th1 cells and Th22 cells. These cells excite the production of high levels of circulating IL1, IL-6 and tumour necrosis factor α (TNF
play a driving force in the pathogenesis of psoriasis and
on insulin resistance and pancreatic β cell function: interrupts with insulin signalling and forces beta .T2DM is an epiphenomenon to psoriasis because systemic inflammation present in patients with psoriasis leads to insulin resistance, a significant precursor of T2DM. Also, there is an emphasis on how insulin associated with the differentiation of keratinocytes. Inflammatory mediator 1β causes insulin resistance in keratinocytes. IL-β heavily contributes to the poor differentiation and uncontrolled proliferation viewed in psoriatic plaques. Fig. 5 summaries the potential link
Furthermore, stigmatising psoriatic skin lesions catalyse an isolated and unhealthy lifestyle, hence why obesity, inactivity and smoking were more prevalent in patients with Ps compared to the general
illustrates how environmental factors increase the risk of developing T2DM. . Theory on the role of inflammation in the shared pathogenesis of Ps a
15 by releasing interleukin (IL)-23 and IL-producing T cells, Th1 cells and Th22 cells. These cells excite the
necrosis factor α (TNF-α). These play a driving force in the pathogenesis of psoriasis and have a dual effect interrupts with insulin signalling and forces
beta-systemic inflammation present in patients with psoriasis leads to insulin resistance, a significant precursor of T2DM. Also, there is an ytes. Inflammatory mediator β heavily contributes to the poor differentiation summaries the potential link
Elza Alex
3.2. T2DM in Ps patients compared with controls
All the studies principally report a higher risk of T2DM in patients with psoriasis when compared to the general population. Of note, Armesto
T2DM than non-Ps patients (12% vs 6.1%, OR: 2.11 (1
HT, DL, smoking and alcohol consumption, this difference remained significant (OR=2.14, 95% CI: 1.38-3.33).
All 10 studies confirmed that psoriasis is strongly associated with an increased prevalence and incidence of T2DM. The potential mechanistic link between these diseases is systemic inflammation, which deteriorates the function of β
development of T2DM. Elevated levels of CRP and IL
patients and these mediators can significantly increase the risk of T2DM. Furthermore, psoriatic keratinocytes release proinflammatory cytokines, like IL
precedes the development of diabetes. Figure
T2DM in Ps patients compared with controls
All the studies principally report a higher risk of T2DM in patients with psoriasis when compared to the general population. Of note, Armesto et al. [16] stated that psoriatic patients suffered more from Ps patients (12% vs 6.1%, OR: 2.11 (1.39-3.20). After adjustment for age, sex, BMI, HT, DL, smoking and alcohol consumption, this difference remained significant (OR=2.14, 95% CI:
All 10 studies confirmed that psoriasis is strongly associated with an increased prevalence and incidence of T2DM. The potential mechanistic link between these diseases is systemic inflammation, which deteriorates the function of β-cell and increases insulin resistance, both of which favour the development of T2DM. Elevated levels of CRP and IL-6 are commonly noted among psoriatic patients and these mediators can significantly increase the risk of T2DM. Furthermore, psoriatic matory cytokines, like IL-1β, which induces insulin resistance and precedes the development of diabetes.
Figure 6. The development of T2DM [15]
16 All the studies principally report a higher risk of T2DM in patients with psoriasis when compared to stated that psoriatic patients suffered more from adjustment for age, sex, BMI, HT, DL, smoking and alcohol consumption, this difference remained significant (OR=2.14, 95% CI:
Elza Alex
3.3. Bidirectional association
Chiu et al. [17] concentrates on the potential bidirectional relation between both the chronic conditions. Kaplan-Meier
(KM)-cohort than in the non-T2DM (KM)-cohort (1.2% vs 0.7%). The adjusted HR (aHR) was 1.40, 95% CI: 1.20-1.63, signifying patients with T2DM have a higher possibility of suffering from psoriasis. Whereas, KM-based cumulative T2DM incidences of 18.7% and 13.1% in Ps and non
respectively. The aHR for incident T2DM was higher in patients with psoriasis (1.38, 95% CI: 1.20 1.58), meaning subjects with psoriasis have a higher risk of develop
Although the incidences of DM among psoriasis subjects were higher than of psoriasis among diabetes cases, the aHR for psoriasis among T2DM cases was 1.40, 95% CI: 1.20
resembled that of diabetes among Ps cases (aHR: 1.38, 95% CI: 1.
conclude that T2DM and psoriasis are more than just coincidental comorbidities. He claims that T2DM increases the risk of subsequent psoriasis and psoriasis onset in turn increases the risk of T2DM development.
Only one study reviewed the bidirectional relationship between the two, which was a major limitation since it can yield false-positive results and may over
3.4. T2DM and Ps age + sex
Four studies [17-20] assessed whether factors including sex and age in patients with psoriasis would influence the probability of DM and the outcomes of these studies all
The Nurses’ Health Study[19] demonstrates a significantly increased risk psoriasis only among younger women. (NHS II: aRR =1.25, 95% CI: 1.05
participants who were younger than 60 years from the Nurses' Health Study (women) and the Health Professionals' Follow-Up Study (men), ther
especially in women (RR: 1.35, 95% CI: 0.89
psoriasis and T2DM among individuals younger than 60 years old and shows an increased risk among women rather than men. Whereas, Fernandez
syndrome showed higher probabilities in patients with psoriasis, men or women. Men diagnosed with Ps had a significantly higher risk of MS than women with Ps until about 7
estimated probabilities become extremely alike. Women over the age of about 75 years showed
Bidirectional association
concentrates on the potential bidirectional relation between both the chronic - based cumulative incidence of psoriasis was higher in the T2DM T2DM cohort (1.2% vs 0.7%). The adjusted HR (aHR) was 1.40, 95% CI: 1.63, signifying patients with T2DM have a higher possibility of suffering from psoriasis.
based cumulative T2DM incidences of 18.7% and 13.1% in Ps and non
respectively. The aHR for incident T2DM was higher in patients with psoriasis (1.38, 95% CI: 1.20 1.58), meaning subjects with psoriasis have a higher risk of developing T2DM.
Although the incidences of DM among psoriasis subjects were higher than of psoriasis among diabetes cases, the aHR for psoriasis among T2DM cases was 1.40, 95% CI: 1.20
resembled that of diabetes among Ps cases (aHR: 1.38, 95% CI: 1.20-1.58). This particular
conclude that T2DM and psoriasis are more than just coincidental comorbidities. He claims that T2DM increases the risk of subsequent psoriasis and psoriasis onset in turn increases the risk of
e study reviewed the bidirectional relationship between the two, which was a major limitation positive results and may over-estimate the magnitude of an association.
T2DM and Ps age + sex
assessed whether factors including sex and age in patients with psoriasis would influence the probability of DM and the outcomes of these studies all indicate
demonstrates a significantly increased risk of T2DM associated with psoriasis only among younger women. (NHS II: aRR =1.25, 95% CI:
1.05-participants who were younger than 60 years from the Nurses' Health Study (women) and the Health Up Study (men), there was a noticeable trend towards increased risk of T2DM, especially in women (RR: 1.35, 95% CI: 0.89-2.05. These values imply a strong association between psoriasis and T2DM among individuals younger than 60 years old and shows an increased risk
n rather than men. Whereas, Fernandez-Armenteros et al. [20]
syndrome showed higher probabilities in patients with psoriasis, men or women. Men diagnosed had a significantly higher risk of MS than women with Ps until about 7
estimated probabilities become extremely alike. Women over the age of about 75 years showed 17 concentrates on the potential bidirectional relation between both the chronic based cumulative incidence of psoriasis was higher in the T2DM T2DM cohort (1.2% vs 0.7%). The adjusted HR (aHR) was 1.40, 95% CI: 1.63, signifying patients with T2DM have a higher possibility of suffering from psoriasis.
based cumulative T2DM incidences of 18.7% and 13.1% in Ps and non-Ps subjects, respectively. The aHR for incident T2DM was higher in patients with psoriasis (1.38, 95% CI:
1.20-ing T2DM.
Although the incidences of DM among psoriasis subjects were higher than of psoriasis among diabetes cases, the aHR for psoriasis among T2DM cases was 1.40, 95% CI: 1.20-1.63, which This particular study[17] conclude that T2DM and psoriasis are more than just coincidental comorbidities. He claims that T2DM increases the risk of subsequent psoriasis and psoriasis onset in turn increases the risk of
e study reviewed the bidirectional relationship between the two, which was a major limitation estimate the magnitude of an association.
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increased estimated probabilities of MS, as opposed to men. The T2DM incidence was the highest following psoriasis for patients aged over 50 yea
1.17-1.68). [17]Furthermore, Solomon
age; however, the HR gets lower with older age in both genders.
unclear whether age and/or sex of psoriatic patients played a role in the development of T2DM. Since this link could not be firmly established, it is recommended further work has to be undertaken in the future.
3.5. T2DM and age of Ps onset
Two types of psoriasis are present, Type 1 usually develops early, severely and is hereditary, while Type 2 psoriasis starts late. Li
psoriasis was diagnosed and the risk o
showed significant results only for cases diagnosed at <40 years (RR: 1.81, 95% CI: 1.14 than those diagnosed at 40-49 or
at a higher risk of T2DM, whereas the risk was lower among those with psoriasis at late conflicting statement was made by Armeesto
especially late-onset (onset age was >40years), and this
in sporadic (patients without familial history of Ps), severe psoriasis (PASI score the disease) and patients suffering from PsA.
highly recommended that further research is conducted to address the question of whether the psoriasis onset time has a role to play in T2DM development.
3.6. T2DM and Ps severity
Seven studies [20-26] systematically examined the risk of T2DM developing in patients with varying severity psoriasis in contrast with controls. Psoriasis Area and Severity Index (PASI) or measuring body surface area (BSA) affected are the most widely used tools for the measur
severity.
Parodi et al. [22]detail how the metabolic syndrome is far more commonly seen in patients with severe psoriasis. The prevalence of MS increases according to PASI severity with a prevalence of 20.4, 24 and 34% in the mild, mode
affected by MS increases by 2.7% for every unit increase in the PASI value. Psoriasis severity is a increased estimated probabilities of MS, as opposed to men. The T2DM incidence was the highest following psoriasis for patients aged over 50 years in an age-stratified study (HR: 1.40, 95% CI: Furthermore, Solomon et al.[18] note an increase in the incidence rate with older age; however, the HR gets lower with older age in both genders. From the studies analysed, it was unclear whether age and/or sex of psoriatic patients played a role in the development of T2DM. Since this link could not be firmly established, it is recommended further work has to be undertaken in the
age of Ps onset
Two types of psoriasis are present, Type 1 usually develops early, severely and is hereditary, while Type 2 psoriasis starts late. Li et al. [19] investigated the association between the age at which psoriasis was diagnosed and the risk of incident of T2DM for younger women (NHSII). The research showed significant results only for cases diagnosed at <40 years (RR: 1.81, 95% CI: 1.14
49 or ≥50 years. Individuals who developed psoriasis at an early ag at a higher risk of T2DM, whereas the risk was lower among those with psoriasis at late
conflicting statement was made by Armeesto et al. [16] that psoriasis is associated with T2DM, onset (onset age was >40years), and this association was also seen significantly higher in sporadic (patients without familial history of Ps), severe psoriasis (PASI score
the disease) and patients suffering from PsA. Due to the contradiction in these two studies, it is recommended that further research is conducted to address the question of whether the psoriasis onset time has a role to play in T2DM development.
T2DM and Ps severity
systematically examined the risk of T2DM developing in patients with varying severity psoriasis in contrast with controls. Psoriasis Area and Severity Index (PASI) or measuring body surface area (BSA) affected are the most widely used tools for the measur
detail how the metabolic syndrome is far more commonly seen in patients with severe psoriasis. The prevalence of MS increases according to PASI severity with a prevalence of 20.4, 24 and 34% in the mild, moderate and severe classes, respectively. The estimated risk of getting affected by MS increases by 2.7% for every unit increase in the PASI value. Psoriasis severity is a 18 increased estimated probabilities of MS, as opposed to men. The T2DM incidence was the highest stratified study (HR: 1.40, 95% CI: note an increase in the incidence rate with older From the studies analysed, it was unclear whether age and/or sex of psoriatic patients played a role in the development of T2DM. Since this link could not be firmly established, it is recommended further work has to be undertaken in the
Two types of psoriasis are present, Type 1 usually develops early, severely and is hereditary, while investigated the association between the age at which f incident of T2DM for younger women (NHSII). The research showed significant results only for cases diagnosed at <40 years (RR: 1.81, 95% CI: 1.14-2.89) rather ≥50 years. Individuals who developed psoriasis at an early age were at a higher risk of T2DM, whereas the risk was lower among those with psoriasis at late-onset. A that psoriasis is associated with T2DM, association was also seen significantly higher in sporadic (patients without familial history of Ps), severe psoriasis (PASI score≥10 at any time of Due to the contradiction in these two studies, it is recommended that further research is conducted to address the question of whether the
systematically examined the risk of T2DM developing in patients with varying severity psoriasis in contrast with controls. Psoriasis Area and Severity Index (PASI) or measuring body surface area (BSA) affected are the most widely used tools for the measurement of psoriasis
Elza Alex
Figure 7. Severity of Ps and T2DM: the greater the severity of Ps, the greater the risk of T2DM driving factor behind the metabolic syndrome, and it is observed frequently in patient
metabolic disorder leads to worsening in the severity of psoriasis.
A greater risk of T2DM is associated with increasing BSA affected by psoriasis independent of risk factors as illustrated in Fig. 7. The highest risk of developing T2DM is in patie
10% of their BSA affected by psoriasis in comparison to adults without Ps. Approximately 20% higher DM risk is observed for every 10% rise in BSA affected by Ps (i.e. 20,%, 30 percent, etc.) (HR=1,19, 95% CI: 1.03–1.39). Most studies ha
for T2DM and that the risk rises with increasing psoriasis severity. Despite these findings, Fernandez-Armenteros et al. [20]
higher severity of psoriasis and a greater association of DM (OR: 0.96. 95% CI: 0.74 implied that Ps is a marker for increased risk of T2DM regardless of its severity.
Lee et al.[24] claims that the incidence rate of T2DM was significantly higher in the Ps cohort (10.5 and 18.2 per 1000 person-years for patients with mild and severe Ps, respectively) than in the control cohort (5.39 per 1000 persons-years). In the severe Ps cohort, th
incidence of T2DM was 3.1%, 8.8% and 14%, respectively, and they were much higher than those shown in the mild Ps cohort. Also, for both mild and severe Ps cohort, KM estimates of survival curves for time to occurrence of DM
However, the main limitation of this study was that the National Health Insurance Research Database (NHIRD) lacked information available regarding PASI, meaning it did not cover the severity of the disease. There was some degree of misclassification of mild and
was defined according to a treatment
for severity and phototherapy as a surrogate for extensive ski
. Severity of Ps and T2DM: the greater the severity of Ps, the greater the risk of T2DM driving factor behind the metabolic syndrome, and it is observed frequently in patient
metabolic disorder leads to worsening in the severity of psoriasis.
A greater risk of T2DM is associated with increasing BSA affected by psoriasis independent of risk . The highest risk of developing T2DM is in patie
10% of their BSA affected by psoriasis in comparison to adults without Ps. Approximately 20% higher DM risk is observed for every 10% rise in BSA affected by Ps (i.e. 20,%, 30 percent, etc.) 1.39). Most studies have shown that psoriasis is an independent risk factor for T2DM and that the risk rises with increasing psoriasis severity. Despite these findings, [20]mention that no significant difference was discovered between a ity of psoriasis and a greater association of DM (OR: 0.96. 95% CI: 0.74
implied that Ps is a marker for increased risk of T2DM regardless of its severity.
claims that the incidence rate of T2DM was significantly higher in the Ps cohort (10.5 years for patients with mild and severe Ps, respectively) than in the control
years). In the severe Ps cohort, the 1-, 5-
incidence of T2DM was 3.1%, 8.8% and 14%, respectively, and they were much higher than those shown in the mild Ps cohort. Also, for both mild and severe Ps cohort, KM estimates of survival curves for time to occurrence of DM were much lower than those for the comparison group. However, the main limitation of this study was that the National Health Insurance Research Database (NHIRD) lacked information available regarding PASI, meaning it did not cover the severity of the se. There was some degree of misclassification of mild and severe Ps because disease severity was defined according to a treatment-based algorithm; they used systemic treatment as a substitute for severity and phototherapy as a surrogate for extensive skin involvement.
19 . Severity of Ps and T2DM: the greater the severity of Ps, the greater the risk of T2DM[10] driving factor behind the metabolic syndrome, and it is observed frequently in patients whose
A greater risk of T2DM is associated with increasing BSA affected by psoriasis independent of risk . The highest risk of developing T2DM is in patients with more than 10% of their BSA affected by psoriasis in comparison to adults without Ps. Approximately 20% higher DM risk is observed for every 10% rise in BSA affected by Ps (i.e. 20,%, 30 percent, etc.) ve shown that psoriasis is an independent risk factor for T2DM and that the risk rises with increasing psoriasis severity. Despite these findings, mention that no significant difference was discovered between a ity of psoriasis and a greater association of DM (OR: 0.96. 95% CI: 0.74-1.26). It simply implied that Ps is a marker for increased risk of T2DM regardless of its severity.
Elza Alex Table Study Li[19] Lee[24 Wan[25 Chiu [17 Solomon [ Armesto [ Fernandez-Armenteros Azfar [21 Parodi [22 Koch [23
Table 3. OR of T2DM association with Ps
Elza Alex
Figure 8. ORs and 95% CI Ranges
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No Study Country Study Design 1 Li [19], 2011 USA Cohort
2 Lee [24], 2014 Taiwan Cohort
3 Wan[25], 2017 UK Cohort
4 Chiu [17], 2020 Taiwan Cohort
5 Solomon[18], 2010
Canada Cohort
Data Source Cases Controls OR (95% CI) NHS NHS II HPFS 1189 1342 543 62,927 94,437 24,146 RR 1.01 (0.83-1.22) RR 1.25 (1.05-1.49) RR 0.91 (0.69-1.20) NHIRD 6611 Severe: 796 (12%) Mild: 5815 (88%) 6806 HR-Ps: 1.35 (1.11 HR-S: 2.06 (1.58 HR-M: 1.28 (1.05 THIN ≤2% BSA: 4216 3-10% BSA: 2915 >10% BSA:993 76,599 HR 1.21 (1.01-1.44) HR 1.01 (0.81-1.26) HR 1.64 (1.23-2.18) NHIRD 1947 7788 HR 1.38 (1.20-1.58) Population-based insurance programme of BC 40,346 442,033 HR 1.40 (1.30-1.50) 22 Adjusted by 1.22) 1.49) 1.20)
Age, smoking, alcohol intake, race, family history of DM, HT, DL, aspirin, multivitamin, postmenopausal hormone use, BMI : 1.35 (1.11-1.65) : 2.06 (1.58-2.68) : 1.28 (1.05-1.55)
Age, sex, pre-existing comorbidities and history of concomitant medications
1.44) 1.26) 2.18)
Age, sex, BMI
1.58) Age, sex, degree of
urbanisation, income group, comorbidities, medications used, number of outpatient visits in first year after the index date
Elza Alex 6 Armesto[26], 2011 Spain Case-control 7 Fernandez-Armentero[20], 2018 Spain Cross-sectional 8 Azfar [21], 2012 UK Cohort
9 Parodi[22], 2014 Italy Cross-sectional 10 Koch[23], 2015 Germany Cross-sectional
Cohort
OR Adjusted Odds Ratio, RR Risk Ratio, HR Hazard ratio, National Health insurance Research Database,
Hypertension, DL Dyslipidemia, BMI Body Mass index, Cooperative Health Research in the Region of Augsburg, Mild DD 661 661 2.14 (1.38-3.33) DD 6868` 391,833 2.01 (1.87-2.15) THIN 108,132 Mild: 101,870 Severe: 6229 430,716 HR 1.14 (1.10-1.18) HR 1.11 (1.07-1.15) HR 1.46 (1.30-1.65) DD 390 344 1.96 (1.22-3.14) KORA 199 3986 2.37(1.40-4.02) Allgemeine ortskrankenkas se Saxony database 44,623 1,766,475 RR 1.11 (1.08-1.14)
Hazard ratio, CI Confidence Interval, NR Not reported, Ps Psoriasis,
National Health insurance Research Database, HPFS Health Professionals’ Follow-Up Study, NHS Nurses’ Health Study, Body Mass index, BSA Body Surface Area, THIN The Health Improvement Network,
Cooperative Health Research in the Region of Augsburg, Allgemeine ortskrankenkasse Saxony database German Health insurance beneficiaries
23 Age, sex, BMI, HT, DL, alcohol, smoking habits NR
1.18) 1.15) 1.65)
Age, sex, BMI, HT, DL
Age, sex, BMI, alcohol, smoking habits
Age, sex, alcohol, smoking habits, years of education, physical activity, HT, HT treatment, DM, DM treatment, lipid-lowering treatment
1.14) Age, sex, hypertonia, DM, obesity, disorders of lipoprotein metabolism and other lipidemias
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3.7. Study Strengths
The study's strengths can be defined as factors that favourably drove
strengths associated with this literature review are identified and listed below. Strengths
A large number of subject groups including men and women with multiple age groups were included to achieve significant results
Ascertainment of the outcome, T2DM was validated with one of the following criteria: Self-reported type 2 diabetes mellitus
Having the criteria for the diagnosis of diabetes mellitus according to the International Classification of Diseases, 9
Studies have carefully assessed the relationship between Ps severity, age of onset and T2DM.
3.8. Study Limitations
The study limitation can be defined as and efficacy of the review. The listed below.
Limitations
Only one author reviewed that data independently, therefore increasing the risk of bias and missing data.
For literature search, only one database (PubMed) was analysed and this would have affected the number of relevant studies selected. Several other well
reviewed.
Using the filter to search publications within ten the number of articles found.
In some studies, DM is self
There was no available information on
whether long-term use of topical steroids played a part in worsening cutaneous manifestations of Ps and whether they were associated with an increased risk of newly
None of these studies specifically examined any association between subtypes of Ps specific subtypes of Ps could b
strengths can be defined as factors that favourably drove the quality of the strengths associated with this literature review are identified and listed below.
arge number of subject groups including men and women with multiple age groups were included to achieve significant results
Ascertainment of the outcome, T2DM was validated with one of the following criteria: reported type 2 diabetes mellitus
Having the criteria for the diagnosis of diabetes mellitus according to the International Classification of Diseases, 9th Revision (ICD9)
assessed the relationship between Ps severity, age of onset and T2DM.
be defined as factors that could have created a negative effect on the quality limitations associated with this literature review are identified and
Only one author reviewed that data independently, therefore increasing the risk of bias and
For literature search, only one database (PubMed) was analysed and this would have affected the number of relevant studies selected. Several other well-respected databases have not been
to search publications within ten years and of English language may have limited the number of articles found.
In some studies, DM is self-reported so that recall bias could be possible
There was no available information on Ps-related treatment, so it was difficult to understand term use of topical steroids played a part in worsening cutaneous manifestations of Ps and whether they were associated with an increased risk of newly-diagnosed T2DM.
None of these studies specifically examined any association between subtypes of Ps specific subtypes of Ps could be more strongly associated with DM.
24 the quality of the review. The strengths associated with this literature review are identified and listed below.
arge number of subject groups including men and women with multiple age groups were
Ascertainment of the outcome, T2DM was validated with one of the following criteria:
Having the criteria for the diagnosis of diabetes mellitus according to the International
assessed the relationship between Ps severity, age of onset and T2DM.
negative effect on the quality limitations associated with this literature review are identified and
Only one author reviewed that data independently, therefore increasing the risk of bias and
For literature search, only one database (PubMed) was analysed and this would have affected the respected databases have not been
nd of English language may have limited
reported so that recall bias could be possible
related treatment, so it was difficult to understand term use of topical steroids played a part in worsening cutaneous manifestations of
diagnosed T2DM.
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4. CONCLUSIONS AND RECOMMENDATIONS
In conclusion, a strong correlation is evident from all the studies discussed here between Psoriasis and Diabetes Mellitus. Psoriatic patients are
much higher prevalence and incidence of Type 2 Diabetes Mellitus compared with the general population. In light of the evidence presented
systemic inflammation, leading to the dysregulation of T cells interactions and overexpression of circulating proinflammatory cytokines: IL
tolerance and T2DM.
The severity of psoriasis is positively related to
risk factors. The highest risk of developing T2DM is evident in patients with suffering from severe form (>10% of BSA affected by Ps) therefore these sets of patients must be well
adequately informed of the risks of developing T2DM.
dermatologists and cardiologists must perform routine and meticulous screening
detect early-onset diabetes, as an earlier intervention would indicate the fewer occurrence of subsequent DM- related comorbidities.
A second theory addresses a question previously posed but overlooked by many physicians: diabetogenic effects with the use of topical CS. This risk remains uncertain and if possible
prefer to opt for alternative treatment options. Irrespective of these findings, potent topical CS should be carefully administered and for the shortest time possible
particularly after long-term usage on large areas of damaged skin
The exact mechanism linking these two diseases still not fully understood; nevertheless, an increasing amount of literature has explored both
these conditions, which is an encouraging sign. Further experimental and non
must be conducted to firmly and scientifically establish the mechanistic links between the two inflammatory diseases, from which more effective treatment could be derived and thus delivered to those suffering.
AND RECOMMENDATIONS
In conclusion, a strong correlation is evident from all the studies discussed here between Psoriasis Psoriatic patients are more prone to insulin resistance; therefore, they have much higher prevalence and incidence of Type 2 Diabetes Mellitus compared with the general
In light of the evidence presented, it is possible to assume psoriasis is triggered by flammation, leading to the dysregulation of T cells interactions and overexpression of circulating proinflammatory cytokines: IL-1, IL-6 and TNF-α that predispose to impaired glucose
The severity of psoriasis is positively related to the risk of developing diabetes
The highest risk of developing T2DM is evident in patients with suffering from severe 10% of BSA affected by Ps) therefore these sets of patients must be well
adequately informed of the risks of developing T2DM. Furthermore, primary care physicians, and cardiologists must perform routine and meticulous screening
onset diabetes, as an earlier intervention would indicate the fewer occurrence of related comorbidities. [27]
A second theory addresses a question previously posed but overlooked by many physicians: enic effects with the use of topical CS. This risk remains uncertain and if possible
efer to opt for alternative treatment options. Irrespective of these findings, potent topical CS should be carefully administered and for the shortest time possible since systemic toxicity is common
term usage on large areas of damaged skin. [28]
The exact mechanism linking these two diseases still not fully understood; nevertheless, an increasing amount of literature has explored both metabolic and genetic links believed to connect these conditions, which is an encouraging sign. Further experimental and non
must be conducted to firmly and scientifically establish the mechanistic links between the two seases, from which more effective treatment could be derived and thus delivered to
25 In conclusion, a strong correlation is evident from all the studies discussed here between Psoriasis resistance; therefore, they have a much higher prevalence and incidence of Type 2 Diabetes Mellitus compared with the general it is possible to assume psoriasis is triggered by flammation, leading to the dysregulation of T cells interactions and overexpression of α that predispose to impaired glucose
the risk of developing diabetes independent of other The highest risk of developing T2DM is evident in patients with suffering from severe 10% of BSA affected by Ps) therefore these sets of patients must be well-educated and Furthermore, primary care physicians, and cardiologists must perform routine and meticulous screening of these patients to onset diabetes, as an earlier intervention would indicate the fewer occurrence of
A second theory addresses a question previously posed but overlooked by many physicians: enic effects with the use of topical CS. This risk remains uncertain and if possible many efer to opt for alternative treatment options. Irrespective of these findings, potent topical CS should since systemic toxicity is common
Elza Alex
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Psoriasis [Internet]. British Skin Foundation. [cited 6 March 2020]. Available from:
causes, symptoms, diagnosis, treatment, pathology [Internet]. Youtube. 2018 [cited 6 https://www.youtube.com/watch?v=G1f3rlO4E40.
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