PSORIASIS and COMORBIDITIES – CEREBRAL VASCULAR AND PERIPHERAL ARTERY DISEASE

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Continuing our series on Psoriasis and Comorbidities

CHART 1: Comorbidities Associated with Psoriasis 1,2,3

Metabolic Syndrome –

Cerebral Vascular Disease – stroke

Peripheral Artery Disease – PAD

Cerebral Vascular Disease – stroke

A study found that cerebral (brain) vascular disease and peripheral arterial disease was also significantly more likely to be diagnosed in patients with psoriasis than in controls. 1 Cerebral vascular diseases are conditions that are caused by problems that affect the blood supply to the brain. Including:-

  • stroke– a serious medical condition where one part of the brain is damaged by a lack of blood supply or bleeding into the brain from a burst blood vessel 
  • transient ischemic attack (TIA) – a temporary fall in the blood supply to one part of the brain, resulting in brief symptoms similar to stroke 
  • subarachnoid haemorrhage – a type of stroke where blood leaks out of the brain’s blood vessels on to the surface of the brain
  • vascular dementia – persistent impairment in mental ability resulting from stroke or other problems with blood circulation to the brain 2

The results of a study looking at the association between psoriasis and stroke found that patients with severe psoriasis have a 44% increased risk of stroke, a potentially devastating co-morbidity. The risk of stroke in patients with psoriasis could not be explained by both common and rare major risk factors for stroke as identified in routine medical practice, suggesting that psoriasis may be an independent risk factor for stroke. Patients that are classified as having mild psoriasis had a statistically significant increased risk of stroke, however, this association was very modest and of limited clinical significance for the individual patient. The data showed that a patient with mild psoriasis has an excess risk of stroke attributable to psoriasis of 1 in 4115 per year, whereas a patient with severe psoriasis has an excess risk of stroke attributable to psoriasis of 1 in 530 per year. 3

Peripheral Artery Disease – PAD

Peripheral artery disease (PAD) is a narrowing of the peripheral arteries to the legs, stomach, arms, and head which can cause symptomatic claudication (blockage) and may lead to amputation. 1

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In patients with psoriasis the diagnosis of peripheral arterial disease was found to be greater than in patients without psoriasis but with dyslipidemia (those with abnormal amount of lipids in the blood) or in smokers.4

Several studies have shown that presence and severity Cerebral vascular diseases (CVD) are related to presence and severity of Carotid Artery Disease (CAD) and PAD. In one study, significant CAD was observed in 25.4% of patients presenting with ischemic stroke. Among this stroke group, patients had a elevenfold likelihood of CAD compared to an age-matched general population. In other studies, PAD has been reported in 20 to 36% of patients with CVD.5

The prevalence of CAD in PAD patients is particularly high. In a systematic review of PAD studies, between 1966?2005, reported that CAD coexisted in 62% of patients when detected using stress tests, and in 90% of patients if the disease was detected by coronary angiography. Another review of the existing literature confirmed these findings, showing that 50% of those presenting with PAD have symptoms of CAD or electrocardiographic abnormalities, 90% have abnormalities on coronary angiography, and 40% have duplex evidence of carotid artery disease.5

A person’s risk also increases if they are over the age of 50  and who 6 : –

  • Smoke or used to smoke – If you smoke or have a history of smoking have up to four times greater risk of P.A.D.
  • Have diabetes – One in every three people over the age of 50 with diabetes is likely to develop P.A.D. This will be further increased for psoriasis patients with diabetes.
  • Have high blood pressure – Also called hypertension, high blood pressure raises the risk of developing plaque in the arteries.
  • Have high blood cholesterol – Excess cholesterol and fat in your blood contribute to the formation of plaque in the arteries, reducing or blocking blood flow to your heart, brain, or limbs.
  • Have a personal history of vascular disease, heart attack, or stroke. If you have been diagnosed with heart disease, you increase your risk of also developing PAD by 1 in 3.

The signs and symptoms of the disease include 6 :

  • Claudication (obstruction of the arteries) – causing fatigue, heaviness, tiredness, cramping in the leg muscles (buttocks, thigh, or calf) that occurs during activity e.g. walking or climbing stairs. This pain or discomfort goes away once the activity is stopped and after resting.
  • Experiencing pain in the legs and/or feet that disturbs your sleep.
  • Sores or wounds on toes, feet, or legs that heal slowly, poorly, or not at all.
  • Colour changes in the skin of the feet, including paleness or purply blueness. The purply blue colouration of psoriasis plaques is especially seen in psoriasis patients who also have diabetes.
  • A lower temperature in one leg compared to the other leg.
  • Poor nail growth and decreased hair growth on toes and legs.

To improve your general health, mobility, and in order to reduce the risk of heart attack, stroke, and/or amputation it is critical that you reduce any symptoms that you may have of PAD :-

  • Quit smoking – Consult with your health care provider to develop an effective cessation plan and ensure you stick to it. This is especially important for psoriasis patients as smoking can be an aggravating trigger for those with chemical sensitivities.
  • It is important to lower your high blood pressure, cholesterol, and blood glucose levels. Consult with your health care provider.
  • Follow a healthy eating plan. Choose foods that are low in saturated fat, trans fat, and cholesterol. Be sure to increase your vegetable intake especially green vegetables, and those fruits as identified in your consultation with our Psoriasis Eczema Clinic Practitioners.
  • Adopt a more physical lifestyle. Aim for 30 minutes of moderate-intensity activity e.g. walking at least 3-4 times per week.
  • Reduce your weight – If you are overweight or obese, work with your health care provider to develop a supervised weight loss plan.

 

REFERENCES

  • Prodanovich S, Kirsner RS, Kravetz JD, Ma F, Martinez L, Federman DG. Association of Psoriasis with Coronary Artery, Cerebrovascular, and Peripheral Vascular Diseases and Mortality. Arch Dermatol. 2009;145(6):700-703. doi:10.1001/archdermatol.2009.94
  • http://www.nhs.uk/conditions/Cerebrovascular-disease/Pages/Definition.aspx
  • Gelfand JM, Dommasch E, Shin DB, et al. The Risk of Stroke in Patients with Psoriasis. The Journal of investigative dermatology. 2009;129(10):2411-2418. doi:10.1038/jid.2009.112.
  • Prodanovich S. et al.; Association of Psoriasis with Coronary Artery, Cerebrovascular, and Peripheral Vascular Diseases and Mortality; Arch Dermatol. 2009;145(6):700-703. doi:10.1001/archdermatol.2009.94
  • Shar A.M. et al.; Coronary, Peripheral and Cerebrovascular Disease: a Complex Relationship; Herz 33 · 2008 · Nr. 7 © Urban & Vogel
  • NHLBI Diseases and Conditions Index: Peripheral Arterial Disease (P.A.D.) www.nhlbi.nih.gov/health/dci/ Diseases/pad/pad_what.html

PSORIASIS AND COMORBIDITIES

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WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

INCREASED RISK

The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

CHART 1: Comorbidities Associated with Psoriasis

Occular Inflammation –

Iritis

Uveitis

Episcleritis

Psychological and Psychiatric Disorders – Depression

anxiety

Suicide

Addiction

Inflammatory Bowel Disease –

Crohn’s Disease

Ulcerative Colitis

Celiac Disease

Irritable Bowel Syndrome

Metabolic Syndrome –

Cardiovascular Disease – Arterial hypertension/ Atherosclerosis Nonalcoholic fatty liver disease Lymphoma

Chronic obstructive pulmonary disease

Sleep apnea

Celiac disease

Parkinson’s disease

Lymphomas

Insulin Resistant Diabetes

Obesity

Dyslipidemia (Raised cholesterol)

Psoriatic Arthritis

Spondyloarthropathies

Periodontitis

Desquamative gingivitis 

Fissured and geographical tongue 

Renal Disease

Chronic Kidney Disease

Sudden sensorineural hearing loss (SSNHL) 

1, 2, 3

Overall, ophthalmological (eye) problems occur in about 10% of the cases of psoriasis and include blepharitis, conjunctivitis, keratitis, xerophthalmia, corneal abscess, cataract, orbital myositis, symblepharon, chorioretinopathy, uveitis and ectropion with trichiasis and madarosis secondary to eyelid involvement.

The association between obesity and psoriasis has been the subject of several reviews and studies confirm that a positive correlation exists between body weight and the prevalence and severity of psoriasis. It has been proposed that psoriasis might lead to obesity through progressive social isolation, poor eating habits, depression, increased alcohol consumption, and decreased physical  activity (more pronounced in patients with psoriatic arthritis). But another hypothesis is that obesity predisposes patients to psoriasis.

Dollarphotoclub_89167346 Obesity dollarphotoclub_78137972-liver-disease dollarphotoclub_92450146-diabetes

It is considered, however, that the low-grade chronic proinflammatory state present in both these conditions increases the risk of comorbidity, including a higher likelihood of developing diabetes or metabolic syndrome, and an increase in cardiovascular disease. 6

It is very important for newly diagnosed psoriasis patients to be screened for diabetes, liver disease, renal disease, and dyslipidaemia (high cholesterol) at the time of diagnosis, due to the fact that treatment for psoriasis may complicate treatment for the comorbid condition, or the comorbid condition may complicate the treatment for psoriasis.

SSNHL is defined as hearing loss of at least 30 dB (decibels) in 3 sequential frequencies in the standard pure tone audiogram for 3 days or less. The condition has an estimated incidence of between 5 and 30 cases per 100,000 per year. According to background information provided by the study authors, the average age at which SSNHL occurs is 50 to 60 years, and it equally affects men and women. Most cases are unilateral (one ear), with only 5% being bilateral (two ear involvement). The condition can be mild, moderate, or severe to profound and can affect high, low, or all frequencies. Tinnitus occurs in about 80% of patients and vertigo in about 30%. Up to 80% of patients report a feeling of ear fullness.7 Auto-immunity is described as an etiology of Sudden or Progressive Sensory neural Hearing Loss; similarly autoimmunity is described as an etiology for many skin diseases like Psoriasis etc. In one study researchers found that Psoriasis patients have, after 6 years of follow up; a 1.51 times higher risk incidence of developing SSNHL than those in the control group.8

For psoriasis patients who have had their psoriasis for several years, it is important that they have a yearly medical check up to ensure that they have not developed any comorbid conditions.

Changing one’s lifestyle may also be of benefit in either delaying comorbidity, or in controlling both their psoriasis and their comorbid condition. Such changes would include cessation of smoking, reducing or ceasing intake of alcohol, reducing sugar intake, changing ones diet to include more green vegetables, less red meat and if obese, losing weight.

 Read our BLOGS – Psoriasis and Diet – Part 1 and 2, Psoriasis and Alcohol, Psoriasis and Smoking

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Agnieszka B. Owczarczyk-Saczonek , Roman Nowicki; The association between smoking and the prevalence of metabolic syndrome and its components in patients with psoriasis aged 30 to 49 years; Postep Derm Alergol 2015; XXXII (5): 331–336 DOI: 10.5114/pdia.2015.54743
  • Dediol I. et al.; ASSOCIATION OF PSORIASIS AND ALCOHOLISM: PSYCHODERMATOLOGICAL ISSUE; Psychiatria Danubina, 2009; Vol. 21, No. 1, pp 9–13
  • Carrascosa J.M. et al.; Obesity and Psoriasis: Inflammatory Nature of Obesity, Relationship Between Psoriasis and Obesity, and Therapeutic Implications; Actas Dermosifiliogr.2014;105:31-44 – Vol. 105 Num.1 DOI: 10.1016/j.adengl.2012.08.024
  • Schreiber BE. et al.; Sudden sensorineural hearing loss.; Lancet.2010 Apr 3;375(9721):1203-11. doi: 10.1016/S0140-6736(09)62071-7.
  • Sesha Prasad, M. Sreedhar Rao, A. V. S. Hanumantha Rao, D. Satyanarayana, S. Muneeruddin Ahmed, M. Mahendra Kumar. “Audiological Evaluation in Auto: Immune Skin Diseases- A Clinical Study of 124 Patients”. Journal of Evolution of Medical and Dental Sciences 2015; Vol. 4, Issue 30, April 13; Page: 5128-5137, DOI: 10.14260/jemds/2015/749

 

HEALTHY SKIN and WATER INTAKE- PART 2

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There are a number of challenges in trying to link chronic dehydration and fluid consumption to various diseases and health outcomes:-

Only a limited number of good studies have been  conducted to date. More long-term studies are needed.  Larger patient numbers need to be included in future studies. 

There are difficulties in assessing patient daily fluid  intake and compliance is difficult to monitor. Hydration status constantly changes and hydration can be difficult to measure in some patients especially when daily fluid requirements vary widely from patient to patient.

The diseases that can be complicated or worsened by dehydration are multi-factorial and there are many differences among these diseases. 1

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There is, however, increasing evidence that even mild dehydration can play a role in the development of various morbidities (diseases) or conditions. The medical evidence for good hydration shows that it can assist in preventing or treating ailments such as:

  • Pressure ulcers   – Dehydration is a known risk factor for PU development because of its effect on blood volume and circulation and skin turgor and has been shown to be associated with an increased risk of developing pressure ulcers in 42% of residents in long-term care facilities, home care patients, and elderly patients.2                           
  • Wound healing – Fluid intake to correct impaired hydration, increases levels of  tissue oxygen and enhances ulcer healing.3
  •  Constipation – Studies have confirmed the recommendation to simply increase intake of fluids such as water to prevent constipation.4
  • Urinary infections – Urinary tract infections result from a bacterial contamination of      the genitourinary tract [35]. They are highly prevalent in both men and women of all age groups, but their frequency is about 50 times higher in adult women. More than half (50–60%)  present with at least one UTI at some stage during their lives. Increasing fluid intake and thereby increasing diuresis (the production of urine) has a diluting effect on contaminating bacteria and virulence factors. Secondly, consecutive to increased diuresis, is the flushing effect that occurs with each void, washing out contaminants and cleaning the epithelia. Also, increasing the frequency of voiding has a shrinking effect on the bladder, effectively reducing the available surface area on which bacteria can thrive.5
  • Chronic kidney disease – CKD is an inevitably progressive, serious condition     associated with impaired quality of life and early mortality, and its prevalence is increasing constantly. CKD is more common among women, men with CKD are 50% more likely than women to progress to end-stage renal disease (ESRD), defined as kidney failure requiring dialysis or transplantation. 44% of people with ESRD have a primary diagnosis of diabetes and 28% of hypertension. Some studies have suggested that increased fluid intake/urine output is associated with a delay in the onset or progression of CKD.6
  • Kidney stones – It is predicted that, based on the effects of global warming, the percentage of people living in areas designated as high risk for kidney stone formation would increase from 40% in 2000 to 56% by 2050, and up to 70% by 2095. This would result in a significant “climate-related” increase in kidney stone events.14  Drinking sufficient levels of fluid on a daily basis is an important part of kidney health. Dehydration, especially chronic dehydration, results in the production of urine which has a higher concentration of minerals and waste products. This can lead to the formation of crystals which can affect kidney function and contribute to certain kidney diseases, such as kidney stones. By moderately increasing water intake, to around two litres per day, you may reduce the risk of decline in kidney function 7
  • Stokes – Stroke conditions worsened or stayed the same in 42 percent of dehydrated patients, compared to only 17 percent of hydrated patients. Dehydrated stroke patients also had about a four times higher risk of their conditions worsening than hydrated patients.8
  • Low blood pressure – Even mild cases of dehydration can cause low blood pressure. Patients with mild dehydration may experience only thirst and dry mouth. Moderate dehydration may cause orthostatic hypotension –  a form of low blood pressure in which a person’s blood pressure falls when suddenly standing up or stretching, and severe dehydration                                             (hypovolemia) can lead to shock, kidney failure, confusion, acidosis, coma, and even death.
  • Diabetes – Hypernatremia dehydration is the most devastating type of dehydration because it can result in severe neurological damage from haemorrhage. Normally, an increased osmolality results in water conservation. This does not occur in central Diabetes Insipidus due to a malfunctioning hypothalamus. In hypernatremic dehydration, extracellular osmolality increases and water moves ou of the brain cells. This movement of water causes brain cells to shrink and the blood vessels tear as the brain is pulled away from the skull and the meninges. The tearing of blood vessels results in haemorrhaging and potential for thrombus formation.10
  • Cognitive impairment – Delirium is a common manifestation of dehydration that  clearly reflects the global impact of dehydration on cerebral function. However, the three areas of the brain most vulnerable to the effects of dehydration are the reticular activating system, which subserves attention and wakefulness; the autonomic structures that regulate psychomotor and regulatory functions; and the cortical and mid-brain structures that are responsible for thought, memory and erception.11
  • Dizziness – Dizziness, vertigo or light headedness can occur simply by changing positions, or moving your head or it can occur at the time of or during strenuous exercise.
  • Xerostomia –  also known as “dry mouth,” is a common but frequently overlooked condition that is typically associated with salivary gland hypofunction. It is estimated that 12-47% of the elderly and 10-19.3% of people in their early 30’s have been suffering from dry  mouth. Whilst dehydration may not be the single cause of this condition it can certainly aggravate or worsen the condition.12
  • Skin conditions – once the body becomes dehydrated and the skin dries out there is   a dysfunction in the skin barrier with an increase in water loss from the body and, subsequently, increased penetration of harmful substances from the environment. This causes the development of sensitization and initiates immune responses resulting in the inflammation of the skin. Skin barrier function depends on several factors including the level of hydration, cellular properties of corneocytes (skin cells), association of these cells in the stratum corneum and speed of changes (turnover) of these cells, amount and composition of intercellular lipids (oils), and skin surface pH (6-20). Water content of the stratum corneum and surface lipids form a balance, which is very important for the function and appearance of the skin, any disturbance of this balance leads to clinical manifestations in the form of dryness and pruritus (itch).13

Recommended daily fluid intake

Approximate adequate daily intakes of fluids (including plain water, milk and other drinks) in litres per day include:

  • infants 0–6 months – 0.7 (from breastmilk or formula)
  • infants 7–12 months – 0.9 (from breastmilk, formula and other foods and drinks)
  • children 1–3 years – 1.0 (about 4 cups)
  • children 4–8 years – 1.2 (about 5 cups)
  • girls 9–13 years – 1.4 (about 5-6 cups)
  • boys 9–13 years          – 1.6 (about 6 cups)
  • girls 14–18 years – 1.6 (about 6 cups)
  • boys 14–18 years – 1.9 (about 7-8 cups)
  • Adult women – 2.1 (about 8 cups)
  • Adult men – 2.6 (about 10 cups).

These adequate intakes include all fluids, but it is preferable that the majority of intake is from plain water (except for infants where fluid intake is met by breastmilk or infant formula).

Sedentary people, people in cold environments, or people who eat a lot of high-water content foods (such as fruits and vegetables) may need less water. 14

Those working in heated environments or who do heavy work and sports players may also need to increase their water intake.

Care should be taken not to overhydrate.

Also read our blog “HEALTHY SKIN and WATER INTAKE – PART 1”

 

REFERENCES

  • Armstrong LE. Challenges of linking chronic dehydration and fluid consumption to health outcomes. J Amer Coll Nutr 70(11): S121-S127, 2012.
  • Horn Sd. Et al.; The National Pressure Ulcer Long-Term Care Study: Pressure Ulcer Development in Long-Term Care Residents; Journal of the American Geriatrics Society
  • Stotts NA, Hopf HW. The link between tissue oxygen and hydration in nursing home residents with pressure ulcers: preliminary data. Journal of Wound, Ostomy & Continence Nursing 2003;30:184-90
  • Arnaud MJ.; Mild dehydration: a risk factor of constipation?; European Journal of Clinical Nutrition (2003) 57, Suppl 2, S88–S95
  • Lotan Y. et al.; Impact of fluid intake in the prevention of urinary system diseases: a brief review; Curr Opin Nephrol Hypertens 2013, 22 (Suppl 1):S1–S10
  • Romero V. et al.; Kidney Stones: A Global Picture of Prevalence, Incidence, and Associated Risk Factors; Rev Urol. 2010 Spring-Summer; 12(2-3): e86–e96.
  • HYDRATION AND KIDNEY HEALTH; Natural Hydration Council UK:http://www.naturalhydrationcouncil.org.uk/wp-content/uploads/2015/03/NHC_hydration_and_kidney_health_FINAL.pdf
  • Bahouth MN. et al.; A Prospective Study of the Effect of Dehydration on Stroke Severity and Short Term Outcome; Abstract T MP86:2015; International Stroke Conference Moderated Poster Abstracts – Session Title: In-hospital Treatment Moderated Poster Tour:
  • Manouchehr Saljoughian; Hypotension: A Clinical Care Review; US Pharm. 2014;39(2):2-4
  • https://www.uspharmacist.com/article/hypotension-a-clinical-care-review#sthash.1Ku9Afv2.dpuf
  • Hospital Hydration Best Practice Toolkit The health and economic benefits of providing water; https://www2.rcn.org.uk/__data/assets/pdf_file/0003/70374/Hydration_Toolkit_-_Entire_and_In_Order.pdf
  • Hudson MJ.; Complications of Diabetes Insipidus: The Significance of Headache; Pediatric Nursing
  • Wilson MG. and Morley JE.; Impaired cognitive function and mental performance in mild dehydration; European Journal of Clinical Nutrition (2003) 57, Suppl 2, S24–S29
  • Mortazavi, H et al. “Xerostomia Due to Systemic Disease: A Review of 20 Conditions and Mechanisms.”Annals of Medical and Health Sciences Research 4 (2014): 503–510. PMC. Web. 4 Aug. 2016.
  • Knor T. et al.; Stratum Corneum Hydration and Skin Surface pH in Patients with Atopic Dermatitis; Acta Dermatovenerol Croat 2011;19(4):242-247
  • https://www.betterhealth.vic.gov.au/health/healthyliving/water-a-vital-nutrient