A discussion on providers monitoring for comorbidities and complications caused by psoriasis.
Peter L. Salgo, MD: Let me ask, before we move along, some obvious questions that I suspect don’t really have hard answers. Does metabolic syndrome lead to psoriasis, or does psoriasis lead to metabolic syndrome?
Steven Feldman, MD, PhD: I think from what I’ve heard from Joel, and putting things together with my understanding, there could be 3 things going on. One is that genetics could be causing both.
Peter L. Salgo, MD: Right. So “lead to” may not actually be the correct verb.
Steven Feldman, MD, PhD: That’s right. And then you may have people with psoriasis who, because of its effect on their psyche, their behavior changes in such a way that they become obese. And then you could have people who start as obese, and the inflammatory influences of obesity lead to psoriasis. So I suspect it’s some component of all 3.
Joel Gelfand, MD, MSCE, FAAD: Exactly. And I think clinically it’s not so important, actually, when it comes down to it. I think from a public health point of view, it’s important to understand the risk factors of psoriasis. We know from some well-done epidemiological studies that people who are overweight have higher rates of developing new onset psoriasis. So getting people to lose weight is probably a pretty important thing.
Peter Dehnel, MD: There’s an age component here as well. You can get this in pediatric age groups, but it seems that the incidence is higher as you get into the more, shall we say, senior population.
Joel Gelfand, MD, MSCE, FAAD: Well, this is really fascinating. It’s a lifelong disease. Once you develop it, most people are affected for life. And so the frequency starts rising as fast as usually in late adolescence, early 20s, but continues to go up over people’s lifetime. And I’ve had patients develop the disease in their mid-80s, usually in the setting of a stressful life event, for example.
Peter L. Salgo, MD: Knowing now there is this relationship between metabolic syndrome and psoriasis, the obvious questions is do enough practitioners know about this? Are they out there monitoring for this, or is this something that’s gone by the boards?
Joel Gelfand, MD, MSCE, FAAD: We know from a variety of research that’s been done, a lot of it in Europe, some in the United States, that this is an area that is under evaluated in patients with psoriasis. They’re under screened for cardiovascular risk factors. When they have cardiovascular risk factors, they tend to be under managed compared to other patients who have cardiovascular risk factors.
Peter L. Salgo, MD: Are dermatologists more than others monitoring for this comorbidity, or are they in the same bucket?
Joel Gelfand, MD, MSCE, FAAD: This research is fairly new, coming out in the last 10 years or so, so the standard of care is slowly evolving. The new AAD-NPF [American Academy of Dermatology-National Psoriasis Foundation] guidelines just came out and it’s the first guideline ever from the AAD about comorbidities and psoriasis. We need to start educating our peers about either screening for cardiovascular risk factors or encouraging a patient to see their primary care doctor and have those screens done in primary care.
Peter L. Salgo, MD: Let’s spell this out once and for all. The comorbidities and complications, if you have both metabolic syndrome and psoriasis, what are we looking at? Who wants to take that?
Joel Gelfand, MD, MSCE, FAAD: Well, I’ll start, maybe Steve can add to it. One is when you’re overweight or have metabolic disease, it makes psoriasis more challenging to treat. One is from a safety point of view, one of our gold standard drugs is methotrexate. Patients with psoriasis have higher rates of fatty liver disease that often makes them intolerant to methotrexate use over the long term. It’s more challenging to use. Some of our biologics that aren’t weight-based and have lower efficacy don’t work as well in people who are very overweight.
Peter L. Salgo, MD: Maybe they should be weight-based.
Joel Gelfand, MD, MSCE, FAAD: Well, often when they’re weight-based, or some of the newer therapies are just so effective on their own, they overcome that challenge. But we know patients who are heavier are likely to have a more challenging treatment course.
Peter L. Salgo, MD: Given this, given the need for practitioners to understand all this, do you guys have programs out there to educate practitioners about this? Are you paying for programs to do this?
Peter Dehnel, MD: From an insurer’s standpoint, that would be a great opportunity.
Peter L. Salgo, MD: I caught the conditional there, a condition. That would be a great opportunity.
Peter Dehnel, MD: I think there is, in general, a great opportunity for insurers, if you will, to step up to the plate in a broader sense. And this is an area that frankly before preparing for this conversation we’re having this morning, I was not aware of that strong association between metabolic syndrome and psoriasis. It’s another one of those areas where we can put on a population health hat, and we can start working down this pathway.
Peter L. Salgo, MD: Are dermatologists as a group beginning to refer their patients with psoriasis and metabolic syndrome to cardiologists? Are they doing that?
Joel Gelfand, MD, MSCE, FAAD: I think it’s pretty variable. It’s one of the issues with healthcare across the country, as I’m sure as an insurer that’s something that you guys try to work on, is having more standardized uptake of evidence-based principles, if you will. I think it’s probably very different from doctor to doctor. Some dermatologists work in small practices. They may be more insulated, have a hard time working with a collaborator like that. I’m at a university center. We have a cardiovascular prevention clinic. Targeting patients with psoriasis for cardiovascular prevention is part of the new ACC-AHA [American College of Cardiology-American Heart Association] guidelines. It’s in the cardiology literature now. They understand the importance of screening patients and looking at risk factor reduction in these patients.
Steven Feldman, MD, PhD: I think this is a new area for dermatology. We did some work some years ago looking at how often doctors of different specialties would even check a blood pressure on patients. And dermatologists were the third least likely specialty.
Peter L. Salgo, MD: Is that right?
Steven Feldman, MD, PhD: Yes, behind psychiatrists and ophthalmologists. They were the only ones doing it less than we were.
Joel Gelfand, MD, MSCE, FAAD: Even my dentist checks my blood pressure.
Steven Feldman, MD, PhD: Wow.
Peter L. Salgo, MD: That’s news.
Steven Feldman, MD, PhD: From an evidence standpoint, I don’t know that we have prospective studies yet that show that if a dermatologist sends patients to a cardiovascular specialist, the outcome is improved. I don’t think we have data yet that say if dermatologists screen for metabolic syndrome that outcomes, short or long, death rates, are improved. I think it would be very hard to do those studies. Metabolic syndrome being so common, I don’t know that I should be treating my heavy psoriasis patients any different than my heavy non-psoriasis patients. Maybe they should equally be sent over to at least their primary care doctor. I think to some extent dermatologists believe that by the time you see us, you’ve probably seen a primary care doctor anyway, that they should be managing your cardiovascular issues.
Peter L. Salgo, MD: But I don’t think they’re aware of that relationship.
Joel Gelfand, MD, MSCE, FAAD: Right. And often they think of the dermatologist as their doctor. Most patients, especially due to co-pays and how busy people are these days, are seeing a dermatologist for psoriasis, that’s the only doctor they’re seeing. And so there’s a lot of undiagnosed hypertension in these patients, a lot of undiagnosed dyslipidemias and things of that nature.
Peter Dehnel, MD: Before you throw me off the stage here….
Peter L. Salgo, MD: That’s not going to happen.
Peter Dehnel, MD: OK. I’m just curious. One scenario would be where a dermatologist’s office actually has somebody within their office who is maybe the metabolic syndrome specialist, not necessarily another physician, maybe an advanced practice nurse, maybe an RN level nurse, could help to manage those aspects of metabolic syndrome. Is that something that you would see as a possibility in this space?
Joel Gelfand, MD, MSCE, FAAD: I think it’s certainly a possibility. I think the challenge is that dermatology practice is set up to deal with dermatologic conditions, and there are a lot of them, the cancers, serious problems like melanomas, other inflammatory diseases. We treat dozens, if not hundreds, of different conditions of the skin.
Steven Feldman, MD, PhD: Or thousands.
Peter L. Salgo, MD: Or thousands.
Joel Gelfand, MD, MSCE, FAAD: That’s right. That makes it challenging operationally I’d say, also being patient-centered.