Kirsner, Robert S.

Marchione, Robb

Rico, Tace

Elsevier - Publisher Connector 

Vascular Disease in Psoriasis 

© 2009 The Society for Investigative Dermatology www.jidonline.org 2327
journal clubFor the article: http://dx.doi.org/10.1038/jid.2009.112
QUESTIONS
1. What data exist regarding an association between vascular disease and psoriasis?
2. What methods were employed to evaluate the risk of stroke in patients with psoriasis?
3. What were the major findings of this study?
4. What are the limitations of this study?
5. How might the results of this study influence patient care?
The past decade has been a roller-coaster ride for patients with psoriasis. Excitement 
surrounding the advent of biologic agents for the treatment of psoriasis has been 
displaced by sobering reports that patients with psoriasis are at increased risk for 
severe vascular disease (Shelling et al., 2008). This increased risk is imparted by both 
a predilection for patients with psoriasis to have traditional vascular disease risk 
factors (e.g., diabetes, hypertension, smoking, dyslipidemia) (Federman et al., 2009) 
and the recent recognition that psoriasis itself is an independent risk factor for 
vascular disease (Gelfand et al., 2006). The latter is probably mediated by systemic 
inflammation associated with psoriasis, similar to that observed in patients with 
rheumatoid arthritis. Patients whose psoriasis develops at a young age and those 
with more severe disease are at the greatest risk (Gelfand et al., 2006).
Initial psoriasis comorbidity studies focused on cardiovascular disease, but 
atherosclerosis is a systemic disease (Prodanovich et al., 2009). It is reasonable 
to postulate that if the likelihood of myocardial infarction is increased in patients 
with psoriasis, other manifestations of atherosclerosis, such as stroke, might also be 
more common in these patients. Stroke is a leading cause of mortality, and many who survive experience functional 
disability, with up to 30% being permanently disabled and 20% requiring institutional care (Rosamond et al., 2008).
Gelfand and colleagues returned to a large medical-records database in the United Kingdom that they had used 
previously for epidemiological research (Gelfand et al., 2009, this issue) to study the association between psoria-
sis and stroke. Nearly 133,000 patients with psoriasis included in this database were evaluated (129,143 with mild 
psoriasis, 3,603 with severe psoriasis) and compared with more than half a million matched control patients for 
the risk of stroke. Patients with psoriasis were more likely to have vascular disease risk factors than were controls. 
After adjusting for major risk factors for stroke, patients with psoriasis were found to be more likely to suffer a 
stroke. For mild psoriasis, a 6% increase in risk was identified (hazard ratio 1.06, 95% confidence interval 1.01–1.11); 
for severe psoriasis, the increased risk was determined to be 43% (1.43, 95% confidence interval 1.1–1.87).
Through the following questions, we examine this paper in greater detail. For discussion and brief answers, 
please refer to the supplementary information linked to the online version of the paper at http://www.nature.com/jid.
references
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Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB (2006) Risk of myocardial infarction in patients with psoriasis. J Am Med Assoc 296:1735–41
Gelfand jM, Dommasch ED, Shin Db, azfar rS, Kurd SK, Wang X et al. (2009) The risk of stroke in patients with psoriasis. J Invest Dermatol 129:2411–8
Prodanovich S, Kirsner RS, Kravetz JD, Ma F, Martinez L, Federman DG (2009) Association of psoriasis with coronary artery, cerebrovascular, and peripheral 
vascular diseases and mortality. Arch Dermatol 145:700–3
Rosamond W, Flegal K, Furie K, Go A, Greenlund K, Haase N et al. (2008) Heart disease and stroke statistics—2008 update. A report from the American Heart 
Association Statistics Committee and Stroke Statistics Subcommitee. Circulation 117:e25–146
Shelling ML, Federman DG, Prodanovich S, Kirsner RS (2008) Psoriasis and vascular disease: an unsolved mystery. Am J Med 121:360–5
Vascular Disease in Psoriasis
Tace Rico1, Robb Marchione1 and Robert S. Kirsner1
Journal of Investigative Dermatology (2009) 129, 2327. doi:10.1038/jid.2009.268
1Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA


Tace Rico

Robb Marchione

Robert S. Kirsner

Crossref