Does Systemic Anti-Psoriatic Treatment Impact the Risk of Cardiovascular Disease? A Review Over Cardiovascular Imaging Studies.

Psoriasis is an immune-mediated inflammatory disease associated with an increased risk of cardiovascular disease (CVD). The risk of CVD increases with the severity of psoriasis, and exposure to systemic inflammation may partly explain the increased risk of CVD in these patients. This raises the question of whether anti-psoriatic treatment, in addition to treating the skin lesions, also lowers the risk of developing CVD. Different types of studies have examined the impact of systemic anti-psoriatic treatments on the risk of CVD in patients with psoriasis and epidemiological observational studies with, e.g., myocardial infarction and stroke as outcomes, and clinical studies investigating circulating inflammatory biomarkers in the blood indicate that anti-psoriatic therapy has a protective effect; however, no randomized controlled trial (RCT) has examined the impact of systemic anti-psoriatic treatment on future hard cardiovascular endpoints. This narrative review provides an overview of the clinical cardiovascular imaging studies examining the effect of systemic anti-psoriatic treatment on the risk of subclinical CVD in patients with psoriasis. We found a total of 24 clinical imaging studies, where 16 of these were observational cohort studies and eight were RCTs. The observational studies suggest an improvement in the risk of subclinical CVD based on different cardiovascular imaging biomarkers; however, the RCTs showed inconsistent results and mainly included vascular inflammation as the outcome. Future RCTs including other imaging biomarkers as surrogates for subclinical CVD, with longer follow-up and with hard cardiovascular endpoints are warranted to address whether systemic anti-psoriatic treatments reduce the risk of CVD.

The USP46 complex deubiquitylates LRP6 to promote Wnt/ß-catenin signaling.

The relative abundance of Wnt receptors plays a crucial role in controlling Wnt signaling in tissue homeostasis and human disease. While the ubiquitin ligases that ubiquitylate Wnt receptors are well-characterized, the deubiquitylase that reverses these reactions remains unclear. Herein, we identify USP46, UAF1, and WDR20 (USP46 complex) as positive regulators of Wnt signaling in cultured human cells. We find that the USP46 complex is similarly required for Wnt signaling in Xenopus and zebrafish embryos. We demonstrate that Wnt signaling promotes the association between the USP46 complex and cell surface Wnt coreceptor, LRP6. Knockdown of USP46 decreases steady-state levels of LRP6 and increases the level of ubiquitylated LRP6. In contrast, overexpression of the USP46 complex blocks ubiquitylation of LRP6 by the ubiquitin ligases RNF43 and ZNFR3. Size exclusion chromatography studies suggest that the size of the USP46 cytoplasmic complex increases upon Wnt stimulation. Finally, we show that USP46 is essential for Wnt-dependent intestinal organoid viability, likely via its role in LRP6 receptor homeostasis. We propose a model in which the USP46 complex increases the steady-state level of cell surface LRP6 and facilitates the assembly of LRP6 into signalosomes via a pruning mechanism that removes sterically hindering ubiquitin chains.

"In the beginning, I said I wouldn't get it.": Hesitant adoption of the COVID-19 vaccine in remote Alaska between November 2020 and 2021.

Achieving sufficient COVID-19 vaccination coverage has been hindered in many areas by vaccine hesitancy. Many studies based on large survey samples have characterized vaccine refusal, but there are fewer in-depth qualitative studies that explore hesitant adoption: the middle-ground between vaccine acceptance and refusal, and how individuals may move across this continuum depending on their lived experience. For this paper, we use the narratives of 25 adults living in off-road, predominately Alaska Native communities to describe the complex decision-making processes undertaken by 'hesitant adopters', defined in our study as those who completed their initial COVID-19 series despite reporting hesitancy. Interviewees' stories help illustrate how hesitant adopters' decision-making processes involved making sense of information through interactions with trusted individuals, lived experiences, observations, emotions, and personal motivations. For the majority of these hesitant adopters' (n = 20, 80%) interpersonal interactions were key in helping to make the decision to get vaccinated. Over half of the interviewees (n = 14, 56%) described how conversations with individuals they trusted, including healthcare providers, family, friends, and interactions through their professional network made them feel safe. One third of the hesitant adopters (n = 7, 28%) attributed their decision to get vaccinated based on the influence of Alaska Native Elders including their knowledge, personal experiences, as well as being motivated by the desire to protect them. Independent research was also important to about a quarter of hesitant adopters (n = 6, 24%), and for these interviewees it was the process of gathering information on their own and learning from others, especially healthcare providers who could answer their questions and alleviate their concerns. This paper illustrates the temporality of vaccine decision-making: vaccine acceptance for those who are hesitant may be an ongoing process that is influenced by personal experience, relationships, and context.

COVID-19 vaccine decision-making in remote Alaska between November 2020 and November 2021.

Vaccine hesitancy is an ongoing barrier to achieve sufficient COVID-19 vaccination coverage. Although there are many studies globally of vaccine hesitancy based on large survey samples, there are fewer in-depth qualitative studies that explore vaccine hesitancy and acceptance as a spectrum of decision-making. In this paper, we begin to describe vaccination decision-making among 58 adults living in remote Alaska based on three waves of online surveys and follow-up semi-structured interviews conducted between November 2020 and November 2021. The survey question of intention was not a predictor of adoption for about one third of the interviewees who were unvaccinated when they took the survey (n=12, 35%). Over half of all interviewees (n=37, 64%) had vaccine-related concerns, including 25 vaccinated individuals (representing 57% of vaccinated interviewees). Most interviewees reported that they learned about COVID-19 vaccines through interpersonal interactions (n=30, 52%) and/or a variety of media sources (n=29, 50%). The major facilitators of acceptance were trust in the information source (n=20, 48% of the 42 who responded), and learning from the experiences of family, friends, and the broader community (n=12, 29%). Further, trust and having a sense of agency appears to be important to interviewee decision-making, regardless of vaccination status and intention.

Blood Cell Biomarkers of Inflammation and Cytokine Levels as Predictors of Response to Biologics in Patients with Psoriasis.

For people with psoriasis, biomarkers aiding in the personalization of treatment with biologics are needed. We examined the usefulness of several biomarkers of inflammation in this respect. The neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), and the systemic immune-inflammation index (SII) were measured in patients with psoriasis initiating TNF-α inhibitors (n = 131), IL-17/IL-17R inhibitors (n = 65), or IL-23/IL-12/23 inhibitors (n = 50). The blood levels of tumor necrosis factor (TNF)-α, interleukin (IL)-1ß, interferon (IFN)-γ, IL-17A, IL-6, soluble IL-6 receptor (sIL-6R), and soluble IL-6 signal transducer (sIL-6ST) were measured in patients initiating adalimumab (n = 62) or IL-17/IL-17R inhibitors (n = 24). Treatment response was defined by a psoriasis area and severity index (PASI) ≤ 2 three months after treatment initiation. Responders to TNF-α inhibitors had a lower NLR at baseline than non-responders (median and interquartile range (IQR) 2.15 (1.67-2.86) vs. 2.54 (1.88-3.55); p = 0.04). Responders to treatment with adalimumab had lower IL-6 levels at baseline than non-responders (0.99 (0.42-1.4) vs. 1.62 (0.96-2.41) pg/mL; p = 0.02). For the majority of patients, the IL-17A, IL-1ß, and IFN-γ levels were below quantification limits. NLR and IL-6 may serve as predictive biomarkers of treatment response to TNF-α inhibitor therapy in patients with psoriasis.

Waning humoral and cellular immunity after COVID-19 vaccination in patients with psoriasis treated with methotrexate and biologics: a cohort study.

BACKGROUND: mRNA-based COVID-19 vaccines have short- and long-term efficacy in healthy individuals, but their efficacy in patients with psoriasis receiving immunomodulatory therapy is less studied. OBJECTIVES: To investigate long-term immunity after COVID-19 vaccination in patients with psoriasis receiving immunomodulatory therapy. METHODS: A prospective cohort study including patients (n = 123) with psoriasis receiving methotrexate (MTX) or biologics and controls (n = 226). Only mRNA-based COVID-19 vaccines administered with standard intervals between doses were investigated. Markers of immunity included SARS-CoV-2 spike glycoprotein-specific IgG and IgA, neutralizing capacity, and interferon-γ release from T cells stimulated with peptides of the SARS-CoV-2 spike glycoprotein. RESULTS: The proportion of IgG responders was lower 6 months after vaccination in patients receiving anti-tumour necrosis factor (TNF) treatment compared with controls. Anti-TNF treatment was associated with lower IgG levels (ß = -0.82, 95% confidence interval -1.38 to -0.25; P = 0.001). The median neutralizing index was lower in the anti-TNF group [50% inhibition (interquartile range [IQR] 37-89)] compared with controls [98% inhibition (IQR 96-99)]; P < 0.001. Cellular responses were numerically lowest in the anti-TNF group. CONCLUSIONS: Treatment with anti-TNF has an impact on the immunity elicited by mRNA-based COVID-19 vaccination in patients with psoriasis, resulting in a faster waning of humoral and cellular markers of immunity; however, the clinical implications are unknown.

Characterization of circulating extracellular traps and immune responses to citrullinated LL37 in psoriasis.

Background: The DNA-binding peptide LL37 is a suspected autoantigen in psoriasis. It can be found in neutrophil extracellular traps (NETs) which have been suggested to play a role in the pathogenesis of the disease. Citrullination, the conversion of peptidyl-arginine into peptidyl-citrulline, can be implicated in the formation of NETs. We hypothesized that citrullination increases LL37 immunogenicity and that NETs are a source of LL37. Objectives: We aimed to characterize cytokine responses of B cells and T cells to native and citrullinated LL37 (citLL37) and determine the prevalence and composition of circulating NETs in patients with psoriasis and healthy blood donors (HDs). Methods: Mononuclear cells (MNCs) and serum were isolated from 20 HDs and 20 patients with psoriasis. The MNCs were stimulated with native LL37 and citLL37 and the proportion of cytokine-positive B cells and T cells was determined by flow cytometry. Circulating antibodies against native LL37 and citLL37 as well as circulating NETs were measured by ELISA, as was the content of LL37, citLL37, and IgG in the NETs. Results: CitLL37, but not native LL37, induced IFN-γ-production by T cells and B cells from psoriasis patients, as well as IL-10-production by the patients' CD4+ T cells. Serum from 40% of patients and 55% of HDs contained circulating NETs, of which 63% and 27%, respectively, contained LL37. Only two patients had NETs containing citLL37 and IgG antibodies were found in NETs from three patients and one HD. Post-hoc analysis of the cytokines produced by B cells and T cells after stimulation with citLL37 revealed two clusters of patients consisting of 10 high-responders and 9 low-responders. The high-responders were those that had circulating NETs in combination with an earlier age of onset of the disease. Conclusion: Citrullinated but not native LL37 elicits IFN-γ-responses by T cells and B cells from psoriasis patients, particularly those with circulating NETs and early disease onset, suggesting a role of citLL37 as an autoantigen in this subgroup of patients.

Psychometric properties of Spanish-language MMPI-3 scores in a Puerto Rican parental fitness evaluation setting.

The Minnesota Multiphasic Personality Inventory (MMPI) family of instruments have long been used in child custody and parental fitness evaluation (PFE) contexts, spanning from the original MMPI to the recently released MMPI-3. In addition to updating the English-language normative sample and expanding content coverage, the MMPI-3 was released with a U.S. Spanish-language normative sample. The present study sought to examine the psychometric properties of the Spanish-language MMPI-3, specifically in a PFE context. The sample consisted of individuals who were evaluated for parental fitness at a multisite private practice in Puerto Rico. A combined gender comparison group sample with equal number of men and women (n = 238) produced mean T scores that were within half a standard deviation of the Spanish-language normative sample on all scales. Scores on the Symptom Validity Scale were meaningfully higher among women (n = 247) relative to the normative sample, and the mean juvenile conduct problems score among men (n = 119) was meaningfully higher than that of the normative sample. Reliability estimates were generally adequate, with some reflecting low internal consistency; however, low standard errors of measurement indicated that low alpha estimates were a function of range restriction rather than measurement imprecision. Limitations, including the need for the accumulation of validity evidence, are discussed. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

IL-17 Pathway Members as Potential Biomarkers of Effective Systemic Treatment and Cardiovascular Disease in Patients with Moderate-to-Severe Psoriasis.

Psoriasis is a chronic inflammatory condition associated with atherosclerotic cardiovascular disease (CVD). Systemic anti-psoriatic treatments mainly include methotrexate and biological therapies targeting TNF, IL-12/23 and IL-17A. We profiled plasma proteins from patients with moderate-to-severe psoriasis to explore potential biomarkers of effective systemic treatment and their relationship to CVD. We found that systemically well-treated patients (PASI < 3.0, n = 36) had lower circulating levels of IL-17 pathway proteins compared to untreated patients (PASI > 10, n = 23). Notably, IL-17C and PI3 were decreased with all four examined systemic treatment types. Furthermore, in patients without CVD, we observed strong correlations among IL-17C/PI3/PASI (r ≥ 0.82, p ≤ 1.5 × 10-12) pairs or between IL-17A/PASI (r = 0.72, p = 9.3 × 10-8). In patients with CVD, the IL-17A/PASI correlation was abolished (r = 0.2, p = 0.24) and the other correlations were decreased, e.g., IL-17C/PI3 (r = 0.61, p = 4.5 × 10-5). Patients with moderate-to-severe psoriasis and CVD had lower levels of IL-17A compared to those without CVD (normalized protein expression [NPX] 2.02 vs. 2.55, p = 0.013), and lower IL-17A levels (NPX < 2.3) were associated with higher incidence of CVD (OR = 24.5, p = 0.0028, 95% CI 2.1-1425.1). As a result, in patients with moderate-to-severe psoriasis, we propose circulating IL-17C and PI3 as potential biomarkers of effective systemic anti-psoriatic treatment, and IL-17A as potential marker of CVD.

Biomarkers of subclinical atherosclerosis in patients with psoriasis.

Psoriasis is linked with increased risk of cardiovascular disease (CVD) that is underestimated by traditional risk stratification. We conducted a large-scale plasma proteomic analysis by use of a proximity extension assay in 85 patients with a history of moderate-to-severe psoriasis with or without established atherosclerotic CVD. Differentially expressed proteins associated with CVD were correlated with subclinical atherosclerotic markers including vascular inflammation determined by 18F-fluorodeoxyglucose positron emission tomography/computed tomography, carotid intima-media thickness (CIMT), carotid artery plaques, and coronary artery calcium score (CCS) in the patients without CVD and statin treatment. We also examined the association between the neutrophil-to-lymphocyte ratio (NLR) and subclinical atherosclerosis. In unadjusted analyses, growth differentiation factor-15 (GDF-15) levels and NLR were increased, while tumor necrosis factor (TNF)-related activation-inducing ligand (TRANCE) and TNF-related apoptosis-induced ligand (TRAIL) levels were decreased in patients with established CVD compared to those without CVD. Among patients with psoriasis without CVD and statin treatment, GDF-15 levels were negatively associated with vascular inflammation in the ascending aorta and entire aorta, and positively associated with CIMT and CCS. NLR was positively associated with vascular inflammation in the carotid arteries. Our data suggest that circulating GDF-15 levels and NLR might serve as biomarkers of subclinical atherosclerosis in patients with psoriasis.

Neutrophil Pathways of Inflammation Characterize the Blood Transcriptomic Signature of Patients with Psoriasis and Cardiovascular Disease.

BACKGROUND: Patients with psoriasis have an increased risk of atherosclerotic cardiovascular disease (CVD). The molecular mechanisms behind this connection are not fully understood, but the involvement of neutrophils have drawn attention as a shared inflammatory factor. METHODS: RNA sequencing using the Illumina platform was performed on blood from 38 patients with moderate to severe psoriasis; approximately half had prior CVD. The neutrophil to lymphocyte ratio (NLR) was obtained from blood samples. Subclinical atherosclerosis was assessed by 18F-fluorodeoxyglucose positron emission tomography/computed tomography and ultrasound imaging. Transcriptomic analysis for differential expression and functional enrichment were performed, followed by correlation analyses of differentially expressed genes (DEGs), NLR and subclinical measurers of CVD. RESULTS: 291 genes were differentially expressed between patients with psoriasis with and without CVD. These included 208 upregulated and 83 downregulated DEGs. Neutrophil degranulation was identified as the most significant process related to the upregulated DEGs. Genes for the neutrophil-associated markers MPO, MMP9, LCN2, CEACAM1, CEACAM6 and CEACAM8 were identified as being of special interest and their mRNA levels correlated with NLR, high-sensitive C-reactive protein and markers of subclinical CVD. CONCLUSIONS: Patients with psoriasis and CVD had an increased expression of genes related to neutrophil degranulation in their blood transcriptome compared with patients with psoriasis without CVD. NLR may be a potential biomarker of subclinical CVD in psoriasis.

Multiscale Biology of Cardiovascular Risk in Psoriasis: Protocol for a Case-Control Study.

BACKGROUND: Patients with psoriasis have increased risk of cardiovascular disease (CVD) independent of traditional risk factors. The molecular mechanisms underlying the psoriasis-CVD connection are not fully understood. Advances in high-throughput molecular profiling technologies and computational analysis techniques offer new opportunities to improve the understanding of disease connections. OBJECTIVE: We aim to characterize the complexity of cardiovascular risk in patients with psoriasis by integrating deep phenotypic data with systems biology techniques to perform comprehensive multiomic analyses and construct network models of the two interacting diseases. METHODS: The study aims to include 120 adult patients with psoriasis (60 with prior atherosclerotic CVD and 60 without CVD). Half of the patients are already receiving systemic antipsoriatic treatment. All patients complete a questionnaire, and a medical interview is conducted to collect medical history and information on, for example, socioeconomics, mental health, diet, and physical exercise. Participants are examined clinically with assessment of the Psoriasis Area and Severity Index and undergo imaging by transthoracic echocardiography, 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT), and carotid artery ultrasonography. Skin swabs are collected for analysis of microbiome metagenomics; skin biopsies and blood samples are collected for transcriptomic profiling by RNA sequencing; skin biopsies are collected for immunohistochemistry; plasma samples are collected for analyses of proteomics, lipidomics, and metabolomics; blood samples are collected for high-dimensional mass cytometry; and feces samples are collected for gut microbiome metagenomics. Bioinformatics and systems biology techniques are utilized to analyze the multiomic data and to integrate data into a network model of CVD in patients with psoriasis. RESULTS: Recruitment was completed in September 2020. Preliminary results of 18F-FDG-PET/CT data have recently been published, where vascular inflammation was reduced in the ascending aorta (P=.046) and aortic arch (P=.04) in patients treated with statins and was positively associated with inflammation in the visceral adipose tissue (P<.001), subcutaneous adipose tissue (P=.007), pericardial adipose tissue (P<.001), spleen (P=.001), and bone marrow (P<.001). CONCLUSIONS: This systems biology approach with integration of multiomics and clinical data in patients with psoriasis with or without CVD is likely to provide novel insights into the biological mechanisms underlying these diseases and their interplay that can impact future treatment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/28669.

Association between Vascular Inflammation and Inflammation in Adipose Tissue, Spleen, and Bone Marrow in Patients with Psoriasis.

Psoriasis is associated with atherosclerotic cardiovascular disease (CVD) with significant overlap of inflammatory pathways. A link between vascular inflammation and inflammation in multiple adipose tissue types, spleen, and bone marrow may exist. Therefore, we investigated these associations using 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) in patients with psoriasis (n = 83) where half had established CVD. Carotid ultrasound imaging was also performed. Inflammation was measured by FDG uptake in the aorta, visceral- (VAT), subcutaneous- (SAT), and pericardial (PAT) adipose tissues, and spleen and bone marrow, respectively. Vascular inflammation was associated with FDG uptakes in all adipose tissues, including VAT (ß = 0.26; p < 0.001), SAT (ß = 0.28; p < 0.001), PAT (ß = 0.24; p < 0.001), spleen (ß = 1.35; p = 0.001), and bone marrow (ß = 1.14; p < 0.001). Adjustments for age, sex, body mass index, and high sensitivity C-reactive protein did not change the results. These associations were generally preserved in the patients without prior CVD. No associations were observed between vascular inflammation and carotid intima-media thickness or presence of carotid plaques, respectively. The results suggest an inflammatory link between vascular and adipose tissues, spleen, and bone marrow in patients with psoriasis.

Systemic Treatment of Psoriasis with JAK Inhibitors: A Review.

Psoriasis is a prevalent chronic inflammatory disease. The inflammatory response is driven by T cells and mediated by multiple cytokines such as tumor necrosis factor and the interleukins IL-17 and IL-23. Moderate-to-severe psoriasis is treated systemically, using either biologics or conventional treatments with small-molecule drugs. The newer biologics are very effective and well tolerated, but not all patients respond to treatment with biologics, so there is a need for new treatment options for psoriasis. Janus kinase (JAK) inhibitors are a new drug class that may be of use in this respect. These inhibitors are already on the market for rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis. They block the intracellular signal pathway mediated by JAK and signal transducer and activator of transcription (STAT) proteins, thereby inhibiting gene transcription of proinflammatory cytokines. JAK inhibitors are currently being tested as potential treatments for psoriasis. They have shown clinical efficacy as measured by the Psoriasis Area and Severity Index 75 response in both phase 2 and 3 trials, and appear to be well tolerated overall. This review provides an overview of the mechanisms underlying the actions of JAK inhibitors in psoriasis, together with the results of clinical trials testing their efficacies when used to treat the disease.

Teaching and assessment strategies for nursing self-care competencies in Ontario's nursing education programs.

In Canada, nurses comprise half the healthcare employment sector, yet comparably, they are twice as likely to experience absenteeism due to occupational burnout. This issue is pronounced for entry-level nurses. The College of Nurses of Ontario (CNO) mandates professional practice standards and entry-level practice competencies; notably, these documents lack explicit performance expectations linked to nursing self-care. This lack of acknowledgment is reflected in what is known, which is little, about how self-care competencies are taught and assessed in nursing education programs. From a Program Director perspective, this study examined the strategies used to teach and assess self-care competencies in Ontario's nursing education programs. Survey results (n = 8), reported intention-action gaps highest (i.e., there is a need for increased teaching), in self-care competencies not mandated by the CNO (i.e., relationship, emotional, and spiritual self-care), whereas competencies mandated by the CNO (i.e., professionalism), were rated higher in relative teaching than importance. Given that self-care strategies (e.g. maintaining healthy interpersonal relationships and engaging in spiritual growth and mindfulness) have shown to be protective factors against workload stress, burnout, and job attrition, regulatory colleges need to consider mandating these self-care competencies within their professional practice standards and entry-level registered nurse practice guidelines.

Creating organizational value by leveraging the multihospital pharmacy enterprise.

PURPOSE: The results of a survey of multihospital pharmacy leaders are summarized, and a road map for creating organizational value with the pharmacy enterprise is presented. SUMMARY: A survey was designed to evaluate the level of integration of pharmacy services across each system's multiple hospitals, determine the most commonly integrated services, determine whether value was quantified when services were integrated, collect common barriers for finding value through integration, and identify strategies for successfully overcoming these barriers. The comprehensive, 59-question survey was distributed electronically in September 2016 to the top pharmacy executive at approximately 160 multihospital systems located throughout the United States. Survey respondents indicated that health systems are taking a wide range of approaches to integrating services systemwide. Several themes emerged from the survey responses: (1) having a system-level pharmacy leader with solid-line reporting across the enterprise increased the likelihood of integrating pharmacy services effectively, (2) integration of pharmacy services across a multihospital system was unlikely to decrease the number of pharmacy full-time equivalents within the enterprise, and (3) significant opportunities exist for creating value for the multihospital health system with the pharmacy enterprise, particularly within 4 core areas: system-level drug formulary and clinical standardization initiatives, supply chain initiatives, electronic health record integration, and specialty and retail pharmacy services. CONCLUSION: Consistently demonstrating strong organizational leadership, entrepreneurialism, and the ability to create value for the organization will lead to the system-level pharmacy leader and the pharmacy enterprise being well-positioned to achieve positive outcomes for patients, payers, and the broader health system.

[Comorbidity in connection with psoriasis is more than psoriatic arthritis].

Psoriasis is a common chronic inflammatory disease which is associated with extensive comorbidity, including psoriatic arthritis, cardiovascular and cardiometabolic disease, inflammatory bowel disease, malignancy, chronic kidney disease and depression. Clinical guidelines have been developed to target some of these comorbid diseases in patients with psoriasis and should be used by the treating physician.