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The skinny on psoriasis and weight loss
Author's Accepted Manuscript
The skinny on psoriasis and weight loss Lisa F. Pfingstler, Eric W. Hossler
PII: DOI: Reference:
S1550-7289(14)00199-3 http://dx.doi.org/10.1016/j.soard.2014.04.029 SOARD1995
To appear in:
Surgery for Obesity and Related Diseases
www.elsevier.com/locate/buildenv
Cite this article as: Lisa F. Pfingstler, Eric W. Hossler, The skinny on psoriasis and weight loss, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j. soard.2014.04.029 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: The skinny on psoriasis and weight loss Abstract: Numerous epidemiologic studies link psoriasis and obesity. Recent studies have shown remission or improvement in psoriasis after weight loss surgery. This editorial reviews the literature and aims to address important findings as well as directions for future studies. Keywords: psoriasis; obesity; bariatric surgery; metabolic syndrome Over the past several years, numerous epidemiologic studies have linked psoriasis to a pro‐inflammatory state and adverse health outcome, including an increase in overall mortality. The pro‐inflammatory state of psoriasis appears to have the most profound impact on cardiovascular health, with numerous cardiovascular risk factors being linked to psoriasis, including type 2 diabetes mellitus, hypertension, hyperlipidemia, and obesity. Not only is psoriasis more common in obese patients, but as body mass index increases, so too does the severity of psoriasis1. As outlined by Romero‐Talamas, several case reports and small case series document improvement in psoriasis after weight loss surgery2. These data suggest that excess adipose tissue is at least partially responsible for the development and maintenance of psoriasis, perhaps through secretion of pro‐inflammatory cytokines such as tumor necrosis factor (TNF)‐α. It stands to reason, therefore, that weight loss could be an important adjunct to successful treatment of the patient with comorbid psoriasis. In the current article, Romero‐Talamas et al performed a retrospective chart review of 33 morbidly obese individuals with psoriasis who underwent weight loss surgery. They found that 13 patients (39.4%) had improvement in their psoriasis, measured either by reduction in involved body surface area (BSA) or the need for less intensive anti‐psoriatic medication, while 1
only one patient worsened. Importantly, the greater the weight loss, the more likely the patients were to see a postoperative improvement in the severity of their psoriasis. Although the reduction in BSA affected by psoriasis was only 4% absolute difference, this was statistically significant2. To our knowledge, this is the first study to show surgical weight loss can decrease physician‐measured BSA, adding a significant piece of information to our current knowledge regarding the relationship between psoriasis and obesity. What patients with psoriasis are most likely to benefit from weight loss surgery? Late onset psoriasis is more frequently associated with obesity and greater waist circumference compared with early onset form4, and patients with a family history of psoriasis have an earlier age of onset5. It may be that those patients with a strong genetic predisposition have psoriasis largely driven by genetics rather than by factors such as excess weight2,3. This supposition is supported by both the current study and in the study by Hossler et al, where increasing age was associated with an improved response rate2, 3. Prospective studies will likely be more effective in teasing out the factors that predict response to weight loss surgery.
Is bariatric surgery more effective for treating psoriasis than traditional weight loss
methods? Bariatric surgery, when compared to non‐surgical weight loss, is associated with higher rates of remission of diabetes and the metabolic syndrome as well as superior quality of life outcomes8, and it may be that the same is true with regards to psoriasis. In the current study by Romero‐Talamas et al, weight loss improved psoriasis by an average of 4% reduction in absolute BSA.2 However, Naldi et al recently showed that a 20 week dietary plan and associated exercise program resulted in a mean reduction of body mass index by 3% and a median
2
psoriasis area and severity index (PASI) reduction of 48%6. Gisondi et al found that a 24‐week low calorie diet was able to significantly improve the response to low dose cyclosporine in a group of obese patients7. Therefore, although direct comparison studies are lacking, we believe that weight loss by any method is important for optimizing treatment. Why is weight loss effective for psoriasis? The answer lies in the close association between psoriasis and the patient’s internal inflammatory milieu. Obesity and the metabolic syndrome are associated with high levels of circulating pro‐inflammatory cytokines including TNF α, interleukin (IL)‐6, IL‐17, and IL‐23, and many of these cytokines are not only seen in psoriatic plaques, but are important targets of biologic therapies for psoriasis. Studies have also shown that these same inflammatory cytokines decrease with weight loss. There is also preliminary evidence that systemic anti‐psoriatic medications, including methotrexate and TNF‐ α inhibitors, have not only been shown to improve skin disease, but also to reduce the risk of cardiovascular morbidity and mortality,9 perhaps by reducing levels of circulating proinflammatory cytokines. However, these powerful medications carry significant risks of side effects as well as substantial financial cost. If weight loss, either by traditional or surgical methods, can show lasting improvement, then patients may be spared from intensive, sometimes lifelong treatment with these systemic medications. Future investigations into the cost effectiveness of these interventions would be beneficial as well. In summary, psoriasis is a multifactorial disease which requires a multimodal and multispecialty approach to treatment. It is important to include weight loss management in our counseling of psoriasis patients, not only for their skin disease, but also their overall well‐being.
3
As dermatologists, we have the privilege of closely following patients with psoriasis which allows for ample opportunities to counsel on life style changes and weight loss strategies. Our responsibility also extends to educating other practitioners who care for patients with psoriasis. A study published in 2012 by Parsi et al showed that only 45% of surveyed primary care or cardiology physicians were aware that psoriasis was associated with worse cardiovascular outcomes10. As dermatologists we have the opportunity to serve as an intermediary between specialties in the overall care for patients with psoriasis who may have other undiagnosed comorbidities. Kimball et al demonstrated a high prevalence of undiagnosed and undertreated cardiovascular risk factors in patients with moderate to severe psoriasis. Their results suggested that less than 10% of patients have optimally managed risk factors11. In addition to complying with the standard atherosclerosis prevention and treatment guidelines as suggested by a consensus statement in the American Journal of Cardiology for optimizing risk factors in patients with psoriasis12, it is imperative that we always consider the idea of bariatric surgery and appropriately refer patients when warranted. References:
1. Marino MG, Carboni I, De Felice C, Maurici M, Franco E. Risk factors for psoriasis: a retrospective study on 501 outpatient clinical records. Ann Ig 2004; 16(6):753‐8. 2. Romero‐Talamas H, Aminian A, Corcelles R, Fernandez AP, Schauer PR, Brethauer S. Psoriasis Improvement After Bariatric Surgery. Surgery and Obesity Related Diseases 2014.
4
3. Hossler EW, Maroon MS, Mowad CM. Gastric bypass surgery improves psoriasis. J Am Acad Dermatol 2011; 65;198‐200. 4. Heredi, E., Csordas A., Clemens M et al. The prevalence of obesity is increased in patients with late compared with early onset psoriasis. Annals of Epidemiology 2013; 23:688‐92 5. Nestle FO, Kaplan DH, Barker J. Psoriasis. N Engl J Med 2009; 361(5):496‐509. 6. Naldi L, Conti A, Cazzaniga S et al; Psoriasis Emilia Romagna Study Group. Diet and physical exercise in psoriasis: a randomized controlled trial. British Journal of Dermatology 2014; 170:634‐42. 7. Gisondi P, Del Giglio M, Di Francesco V, Zamboni M, Girolomoni G. Weight loss improves the response of obese patients with moderate‐to‐severe chronic plaque psoriasis to low‐dose cyclosporine therapy: a randomized, controlled, investigator‐blinded clinical trial. Am J Clin Nutr 2008; 88:1242‐7. 8. Gloy VL, Briel M, Bhatt DL et al. Bariatric surgery versus non‐surgical treatment for obesity: a systemic review and a meta‐analysis of randomised controlled trials. BMJ 2013; 347:f5934. 9. Hugh J, Van Voorhees AS, Nijhawan RI et al. From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies. J Am Acad Dermatol. 2014 Jan;70(1):168‐77. 10. Parsi KK, Brezinski EA, Lin TC, Li CS, Armstrong AW. Are patients with psoriasis being screened for cardiovascular risk factors? A study of screening practices and awareness among primary care physicians and cardiologists. J Am Acad Dermatol 2012; 67(3): 357‐62.
5
11. Kimball AB, Szapary P, Mrowietz U et al. Underdiagnosis and undertreatment of cardiovascular risk factors in patients with moderate to severe psoriasis. J Am Acad Dermatol 2012; 67(1):76‐ 85. 12. Friedewald VE, Cather JC, Gelfand JM et al. AJC Editor’s Consensus: Psoriasis and Coronary Artery Disease. Am J Cardiol 2008; 102:1631‐43.
6
The skinny on psoriasis and weight loss Lisa F. Pfingstler, Eric W. Hossler
PII: DOI: Reference:
S1550-7289(14)00199-3 http://dx.doi.org/10.1016/j.soard.2014.04.029 SOARD1995
To appear in:
Surgery for Obesity and Related Diseases
www.elsevier.com/locate/buildenv
Cite this article as: Lisa F. Pfingstler, Eric W. Hossler, The skinny on psoriasis and weight loss, Surgery for Obesity and Related Diseases, http://dx.doi.org/10.1016/j. soard.2014.04.029 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title: The skinny on psoriasis and weight loss Abstract: Numerous epidemiologic studies link psoriasis and obesity. Recent studies have shown remission or improvement in psoriasis after weight loss surgery. This editorial reviews the literature and aims to address important findings as well as directions for future studies. Keywords: psoriasis; obesity; bariatric surgery; metabolic syndrome Over the past several years, numerous epidemiologic studies have linked psoriasis to a pro‐inflammatory state and adverse health outcome, including an increase in overall mortality. The pro‐inflammatory state of psoriasis appears to have the most profound impact on cardiovascular health, with numerous cardiovascular risk factors being linked to psoriasis, including type 2 diabetes mellitus, hypertension, hyperlipidemia, and obesity. Not only is psoriasis more common in obese patients, but as body mass index increases, so too does the severity of psoriasis1. As outlined by Romero‐Talamas, several case reports and small case series document improvement in psoriasis after weight loss surgery2. These data suggest that excess adipose tissue is at least partially responsible for the development and maintenance of psoriasis, perhaps through secretion of pro‐inflammatory cytokines such as tumor necrosis factor (TNF)‐α. It stands to reason, therefore, that weight loss could be an important adjunct to successful treatment of the patient with comorbid psoriasis. In the current article, Romero‐Talamas et al performed a retrospective chart review of 33 morbidly obese individuals with psoriasis who underwent weight loss surgery. They found that 13 patients (39.4%) had improvement in their psoriasis, measured either by reduction in involved body surface area (BSA) or the need for less intensive anti‐psoriatic medication, while 1
only one patient worsened. Importantly, the greater the weight loss, the more likely the patients were to see a postoperative improvement in the severity of their psoriasis. Although the reduction in BSA affected by psoriasis was only 4% absolute difference, this was statistically significant2. To our knowledge, this is the first study to show surgical weight loss can decrease physician‐measured BSA, adding a significant piece of information to our current knowledge regarding the relationship between psoriasis and obesity. What patients with psoriasis are most likely to benefit from weight loss surgery? Late onset psoriasis is more frequently associated with obesity and greater waist circumference compared with early onset form4, and patients with a family history of psoriasis have an earlier age of onset5. It may be that those patients with a strong genetic predisposition have psoriasis largely driven by genetics rather than by factors such as excess weight2,3. This supposition is supported by both the current study and in the study by Hossler et al, where increasing age was associated with an improved response rate2, 3. Prospective studies will likely be more effective in teasing out the factors that predict response to weight loss surgery.
Is bariatric surgery more effective for treating psoriasis than traditional weight loss
methods? Bariatric surgery, when compared to non‐surgical weight loss, is associated with higher rates of remission of diabetes and the metabolic syndrome as well as superior quality of life outcomes8, and it may be that the same is true with regards to psoriasis. In the current study by Romero‐Talamas et al, weight loss improved psoriasis by an average of 4% reduction in absolute BSA.2 However, Naldi et al recently showed that a 20 week dietary plan and associated exercise program resulted in a mean reduction of body mass index by 3% and a median
2
psoriasis area and severity index (PASI) reduction of 48%6. Gisondi et al found that a 24‐week low calorie diet was able to significantly improve the response to low dose cyclosporine in a group of obese patients7. Therefore, although direct comparison studies are lacking, we believe that weight loss by any method is important for optimizing treatment. Why is weight loss effective for psoriasis? The answer lies in the close association between psoriasis and the patient’s internal inflammatory milieu. Obesity and the metabolic syndrome are associated with high levels of circulating pro‐inflammatory cytokines including TNF α, interleukin (IL)‐6, IL‐17, and IL‐23, and many of these cytokines are not only seen in psoriatic plaques, but are important targets of biologic therapies for psoriasis. Studies have also shown that these same inflammatory cytokines decrease with weight loss. There is also preliminary evidence that systemic anti‐psoriatic medications, including methotrexate and TNF‐ α inhibitors, have not only been shown to improve skin disease, but also to reduce the risk of cardiovascular morbidity and mortality,9 perhaps by reducing levels of circulating proinflammatory cytokines. However, these powerful medications carry significant risks of side effects as well as substantial financial cost. If weight loss, either by traditional or surgical methods, can show lasting improvement, then patients may be spared from intensive, sometimes lifelong treatment with these systemic medications. Future investigations into the cost effectiveness of these interventions would be beneficial as well. In summary, psoriasis is a multifactorial disease which requires a multimodal and multispecialty approach to treatment. It is important to include weight loss management in our counseling of psoriasis patients, not only for their skin disease, but also their overall well‐being.
3
As dermatologists, we have the privilege of closely following patients with psoriasis which allows for ample opportunities to counsel on life style changes and weight loss strategies. Our responsibility also extends to educating other practitioners who care for patients with psoriasis. A study published in 2012 by Parsi et al showed that only 45% of surveyed primary care or cardiology physicians were aware that psoriasis was associated with worse cardiovascular outcomes10. As dermatologists we have the opportunity to serve as an intermediary between specialties in the overall care for patients with psoriasis who may have other undiagnosed comorbidities. Kimball et al demonstrated a high prevalence of undiagnosed and undertreated cardiovascular risk factors in patients with moderate to severe psoriasis. Their results suggested that less than 10% of patients have optimally managed risk factors11. In addition to complying with the standard atherosclerosis prevention and treatment guidelines as suggested by a consensus statement in the American Journal of Cardiology for optimizing risk factors in patients with psoriasis12, it is imperative that we always consider the idea of bariatric surgery and appropriately refer patients when warranted. References:
1. Marino MG, Carboni I, De Felice C, Maurici M, Franco E. Risk factors for psoriasis: a retrospective study on 501 outpatient clinical records. Ann Ig 2004; 16(6):753‐8. 2. Romero‐Talamas H, Aminian A, Corcelles R, Fernandez AP, Schauer PR, Brethauer S. Psoriasis Improvement After Bariatric Surgery. Surgery and Obesity Related Diseases 2014.
4
3. Hossler EW, Maroon MS, Mowad CM. Gastric bypass surgery improves psoriasis. J Am Acad Dermatol 2011; 65;198‐200. 4. Heredi, E., Csordas A., Clemens M et al. The prevalence of obesity is increased in patients with late compared with early onset psoriasis. Annals of Epidemiology 2013; 23:688‐92 5. Nestle FO, Kaplan DH, Barker J. Psoriasis. N Engl J Med 2009; 361(5):496‐509. 6. Naldi L, Conti A, Cazzaniga S et al; Psoriasis Emilia Romagna Study Group. Diet and physical exercise in psoriasis: a randomized controlled trial. British Journal of Dermatology 2014; 170:634‐42. 7. Gisondi P, Del Giglio M, Di Francesco V, Zamboni M, Girolomoni G. Weight loss improves the response of obese patients with moderate‐to‐severe chronic plaque psoriasis to low‐dose cyclosporine therapy: a randomized, controlled, investigator‐blinded clinical trial. Am J Clin Nutr 2008; 88:1242‐7. 8. Gloy VL, Briel M, Bhatt DL et al. Bariatric surgery versus non‐surgical treatment for obesity: a systemic review and a meta‐analysis of randomised controlled trials. BMJ 2013; 347:f5934. 9. Hugh J, Van Voorhees AS, Nijhawan RI et al. From the Medical Board of the National Psoriasis Foundation: The risk of cardiovascular disease in individuals with psoriasis and the potential impact of current therapies. J Am Acad Dermatol. 2014 Jan;70(1):168‐77. 10. Parsi KK, Brezinski EA, Lin TC, Li CS, Armstrong AW. Are patients with psoriasis being screened for cardiovascular risk factors? A study of screening practices and awareness among primary care physicians and cardiologists. J Am Acad Dermatol 2012; 67(3): 357‐62.
5
11. Kimball AB, Szapary P, Mrowietz U et al. Underdiagnosis and undertreatment of cardiovascular risk factors in patients with moderate to severe psoriasis. J Am Acad Dermatol 2012; 67(1):76‐ 85. 12. Friedewald VE, Cather JC, Gelfand JM et al. AJC Editor’s Consensus: Psoriasis and Coronary Artery Disease. Am J Cardiol 2008; 102:1631‐43.
6