Prevalence of Advanced Liver Fibrosis in Patients With Severe Psoriasis.

IMPORTANCE: Advanced liver fibrosis is a precursor to cirrhosis, a leading cause of mortality. People with severe psoriasis are at risk for liver disease, but our understanding of advanced fibrosis in individuals with psoriasis is limited. OBJECTIVES: To describe the prevalence of and evaluate the clinical factors associated with advanced liver fibrosis in people with severe psoriasis. DESIGN, SETTING, AND PARTICIPANTS: The Co-morbidities in Severe Psoriasis study, a prospective observational cohort study in a large center serving London and Southeast England, was conducted from October 18, 2012, to April 2, 2015; 400 adults with severe psoriasis (Psoriasis Area Severity Index score, ≥10) were recruited from outpatient clinics. Statistical analysis was conducted from October 2, 2016, to March 3, 2017. MAIN OUTCOMES AND MEASURES: The primary outcome was a diagnosis of advanced liver fibrosis determined by transient elastography, a noninvasive criterion standard test. Clinical factors evaluated included psoriasis-specific and metabolic indices, alcohol use, and methotrexate exposure. RESULTS: Of 400 patients recruited (108 women and 289 men; mean [SD] age, 49.5 [13] years), 333 had a successful transient elastography scan and were included in final analysis. Forty-seven patients (14.1%; 95% CI, 10.4%-17.9%) had advanced liver fibrosis as diagnosed by transient elastography. The clinical factors that produced the best-fit model for advanced fibrosis were central obesity (waist circumference), insulin resistance, aspartate aminotransferase level, platelet count, psoriasis disease severity, and reduced alcohol use (R2 = 0.54). CONCLUSIONS AND RELEVANCE: Findings from this study suggest that advanced fibrosis is common in severe psoriasis. Abdominal obesity (by waist circumference) and insulin resistance were associated with the presence of advanced fibrosis. Longitudinal work to characterize the hepatic sequelae of central obesity, insulin resistance, and inflammation as well as the influence of systemic drugs (methotrexate and biologics) will inform future personalized therapeutic decision-making. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02174367.

An ulcerated nodule on the nose.

A 75-year-old retired nurse, originally from Barbados, presented to her general practitioner (GP) with a scaling ulcerated nodule on the left side of her nose. She was taking medication for type 2 diabetes, hypertension and glaucoma, but was otherwise well with no systemic symptoms. Her GP diagnosed a patch of eczema; however, a trial of topical steroids was not effective and she was referred to dermatology. A skin biopsy confirmed the clinical suspicion that this patient had a nodular basal cell carcinoma (BCC). BCCs account for 75% of all skin cancers; they very rarely metastasise, but can spread to invade local structures. Our patient has type VI skin. Skin cancer is rare in patients with skin type VI; however, in this group, morbidity and mortality are disproportionately high in relation to cancer incidence.

Psoriasis and cardiovascular disease: where is the risk?

In this issue, Dowlatshahi et al. publish results from their population-based study in Rotterdam showing that, despite an increase in body mass index and smoking, individuals with psoriasis have no increased risk of incident cardiovascular disease. These results should be interpreted with caution: the study included relatively small numbers of patients with psoriasis, most of whom had mild disease.