PSORIASIS: A LINK WITH HYPERLIPIDEMIA; AN OBSERVATION IN GENERAL PRACTICE.

Iyer D*, Woods P**

Greyfriars GP Surgery, South Square, Boston PE21 6JU, Lincolnshire, UK

* Foundation year 2 Doctor

** General Practitioner

ABSTRACT:

Psoriasis is a common, chronic, relapsing, inflammatory skin disorder with a strong genetic basis (4). It is characterised by changes in the normal cycle of epidermal development that lead to epidermal hyperproliferation, hyperplasia of keratinocytes, vascular changes, inflammation and infiltration of T cells. Studies have shown its association with increased risk for developing atherosclerotic and cardiovascular disease. Confounding variables like smoking, obesity and lifestyle, have not yet been determined, but may have some contribution to the disorder. This short review is an observation from our General Practice Surgery, of patients with an established diagnosis of Psoriasis, having associated lipid abnormalities.

KEY WORDS:

Psoriasis, lipids

METHOD:

A retrospective analysis of patients with psoriasis, attached to our GP Surgery was performed. These patients had an established diagnosis Psoriasis, and also had evidence of lipid abnormalities. Confounding variables were not considered for this study.

RESULTS:

The total number of patients seen at our Practice was 10079, Out of which 333 of them were diagnosed to have Psoriasis. It was found that amongst these, 28 of them had established lipid abnormalities, which was roughly around 8.5%.

CONCLUSION:

Patients with Psoriasis have been noted to develop lipid abnormalities. It has been reported, in a cohort study by Mallbris and colleagues, they noted significant and potentially detrimental lipid abnormalities in the case (Psoriasis) vs Control Groups (6). Maintaining normal lipid levels would be an overall benefit to decrease the secondary risk factors for Atherosclerotic and Cardiovascular diseases.

INTRODUCTION:

Psoriasis is a common skin disorder, which presents with inflamed red patches covered with silvery scales. Current Research suggests that the inflammatory mechanisms are immune based and most likely initiated and maintained primarily by T cells in the dermis (4). Psoriasis is known to cause an increase in the risk for Myocardial Infarction, which may be attributed to changes in the plasma lipid and lipoprotein composition in these patients.

LITERATURE REVIEW:

Psoriasis is an independent risk factor for Myocardial Infarction and this risk is greatest in young patients with severe psoriasis, according to Gelfand and colleagues (8). Both genetic and environmental factors have been implicated in the pathophysiology of Psoriasis. Plaque psoriasis, the most commonly occurring type is associated with HLA-B13, B17 and Cw6.

In a paper on psoriasis pathogenesis, Alessandrini et al described abnormalities in enzymes involved in lipid formation in the stratum corneum of patients with psoriasis ( Alessandrini et al, 2004)(10). Lamellar sheets of lipids within the stratum corneum contain ceramides, cholesterol, and free fatty acids, which are essential in regulating epidermal permeability to water and water soluble material. Ceramides are generated by degradation of glucosylceramides by glucoceramide – β – glucosidase and by hydrolysis of sphingomyelin by sphingomyelinase(10).

OBSERVATION:

Total Practice Population: 10079

Age Range Included in this study: 50 – 80 yrs

Parameter	Males	Females
Total Number	4964	5115
With Psoriasis	160	173
With Psoriasis + Lipid Abnormalities	13	15

Normal Values of lipids:

Cholesterol: <5 mmol/l

Fasting Triglycerides: <2 mmol/l

LDL Cholesterol: <3 mmol/l

Parameter	Percentage
Patients with Psoriasis	3.30%
Patients with Psoriasis + Lipid Abnormalities	8.40%
- Psoriasis with Raised Cholesterol	78.57%
- Psoriasis with Raised LDL	89.28%
- Psoriasis with Raised Triglycerides	50%

DISCUSSION:

Psoriasis is a chronic, relapsing, inflammatory skin disorder characterised by accumulation of T cells and neutrophils, vascular changes, and regenerative keratinocyte proliferation and differentiation.

Plaque Psoriasis is the most common type of Psoriasis. Other types include:

Guttate Psoriasis: Primarily affects people younger than 30 and is usually triggered by a bacterial infection (3).
Pustular Psoriasis: This rare form can occur in widespread patches or in smaller areas over hands, feet or fingertips.
Inverse Psoriasis: Mainly affecting skin in the axillae, groin, under the breasts, genitals and extensor surfaces, with minimal scaling.
Erythrodermic Psoriasis: Least common type, with red peeling rash, may be triggered by sun burn, or medications.
Psoriatic Arthritis: Associated with pitting and discolouration of nails, swollen and painful joints.

Elements of innate immunity, such as keratinocytes and Antigen Presenting Cells (APC), and of the acquired immunity, such as T Cells, are believed to participate in the induction of a cutaneous process which is quite similar to the physiological defence and repair mechanism. Antigen Presenting Cells are believed to migrate from the skin to the regional lymph nodes, where they interact with T Cells. Presentation of an as yet unidentified antigen to the T Cells, as well as other co stimulatory signals, is responsible for the triggering of an immune response, which results in T cell activation and subsequent release of cytokines. Interaction of Adhesion molecules on the APCs, initiate the co stimulatory signals, such as Lymphocyte function – associated antigen and Intercellular Adhesion Molecule-1, with their respective receptors CD2 and LFA-1 on T cells. These T cells when released into circulation return back into the skin. Reactivation of T cells in the dermis and epidermis combined with the local effects of cytokines like Tumour Necrosis Factor, lead to inflammation, Cell mediated immune responses, and epidermal hyperproliferation seen in patients with Psoriasis(4).

Some studies have showed the presence of high levels of Serum Lipoprotein (a), and Triglycerides in patients with established psoriasis, compared to normal subjects.

Our Study also does show a marked raise in Cholesterol, LDL and Triglycerides, in those patients with severe Psoriasis. In contrast to some previously reported studies, total Cholesterol, LDL and HDL concentrations did not correlate with psoriasis disease severity (6).

It would be worthwhile, to record the serum lipids of patients presenting with Psoriasis. Advising life style changes and if necessary treating lipid abnormalities, would definitely help in reducing the secondary risk factors for Atherosclerotic and Cardiovascular Diseases.

ACKNOWLEDGEMENTS:

I would like to thank my GP, Dr. Woods, for his patient guidance and encouragement. I would also like to thank all involved in helping me get the patient statistics, and analysis.

REFERENCES:

1. http://www.merck.com/mmhe/sec18/ch203/ch203i.html (Accessed on 1/11/06)

2. http://ard.bmjjournals.com/cgi/content/full/64/suppl_2/ii30 (Accessed on 1/11/06)

3. http://www.mayoclinic.com/health/psoriasis/DS00193/DSECTION=1

(Accessed on 1/11/06)

4. http://www.emedicine.com/DERM/topic365.htm (Accessed on 1/11/06)

5. http://cat.inist.fr/?aModele=afficheN&cpsidt=13510486 (Accessed on 1/11/06)

6. http://www.medscape.com/viewarticle/531079_3 (Accessed on 1/11/06)

7. http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=1501948&pageindex=2#page (Accessed on 1/11/06)

8. http://www.medicalnewstoday.com/medicalnews.php?newsid=53875

(Accessed on 1/11/06)

9. http://www.eadv2005.com/scientific/workshops/W14.2.doc (Accessed on 1/11/06)

10. http://www.nature.com/jid/journal/v123/n6/full/5602577a.html

(Accessed on 1/11/06)

First Published April 2007

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