Psoriasis is associated with vascular disease

Psoriasis is a common inflammatory skin disease which affects around 100 million people of all ages worldwide [1, 2] with a prevalence in developed countries between 1.5 - 5%. Its classic presentation is typified by a chronic relapsing disease, characterised by raised plaques with silver scale which can have significant psychological and social effects for the patient and their families alike  [3, 4]. 

Psoriasis, particularly when severe, is associated with vascular disease.

Associations with Psoriasis

For many years, psoriasis was seen as a skin disease with a chronic, unpredictable course with low mortality. Whilst there is suggestion that patients with psoriasis are at a reduced risk of developing urticaria, acne and atopic dermatitis [5], research has highlighted that psoriasis increases the risk to an individual of developing  other conditions. Psoriatic arthritis has probably been the longest known associated condition since it was first discovered in a Saxon skeleton [6] and was latterly described in 1647 by Columbo [7].

It is only in the last few decades that other associations have been uncovered. In 1995, a study of 2941 hospitalised patients with psoriasis investigated co-morbidities and found a statistical significance with the following  [8]:

·         Tonsillitis

·         Psoriatic Arthritis

·         Obesity

·         Diabetes (particularly type 2)

·         Hypertension

·         Cardiovascular disease

Further studies have concurred with these findings [9] and discovered associations with inflammatory bowel diseases such as Crohn’s – with a seven-fold increase in prevalence in patients with psoriasis [10] and increased risk of metabolic syndrome [11] .

 

Psoriasis and vascular disease

 

Vascular disease has been a known associate of psoriasis for many years. In 1974, McDonald and Calabresi suspected a link and in 1978 demonstrated the higher prevalence of occlusive vascular disease, particularly in male patients, across all age groups. Patients with psoriasis were twice as likely to develop cardiovascular events than patients without the skin disease [12, 13]

A subsequent meta-analysis in 2013 of 14 cohorts looked at risks for cardiovascular mortality, stroke, and myocardial infarction analysing risks stratifying  groups of patients with varying degrees of psoriasis. The main findings were slightly increased risk in patients with psoriasis as a population, however significant risk was identified in individuals with severe psoriasis (defined as those on systemic therapies or with previous hospital admissions for their psoriasis) and those older patients with extensive skin disease [14]. The effects of additional risk factors such as smoking, hyperlipidaemia, obesity and alcohol use needs further research to help complete the picture.

How does psoriasis link with vascular disease?

The key to understanding many of the associations is the inflammatory component. Psoriasis is a disease driven by the body’s own immune system and release of inflammatory cytokines or interleukins (IL) - including tumour necrosis factor (TNF-α), interferon (IFN-ƴ), interleukin (IL-17, IL-22, IL-23 and IL-1b). Proportional to the amount of inflammation, many of these mediators will escape from the skin into the circulation [15], remaining active, and exerting downstream inflammatory effects [5]. In atherosclerosis, the mediators driving the psoriatic plaque have been shown to have reciprocal effects with the developing atherosclerotic plaque – driven by the inflammatory state [16].

Implications for practice

Detection of sub-clinical atherosclerosis is difficult in psoriasis and  patients are  likely to die up to 5 years earlier due to cardiovascular disease. Studies have shown that the femoral artery is particularly vulnerable  to this complication in psoriasis compared to the carotid artery [17, 18] consequently, ultrasound screening of the artery is recommended as more sensitive to detect early disease in patients with cardiovascular risk factors [19].

When a patient presents with a history of psoriasis, the practitioner should be mindful of the potential implications and associations. Psoriasis has a significant effect on the patient’s quality of life, as shown by many studies and this should be appreciated in any management plan. The association between peripheral vascular disease and psoriasis should be appreciated. Consequently, a comprehensive patient assessment should include the usual vascular and neurological assessments to highlight any undetected early peripheral vascular disease, particularly in patients with more widespread skin involvement.

A question that is being asked, is whether modern biological drugs being taken for psoriasis (which suppress inflammatory cytokines) have any effect on the development of associated  conditions such as atherosclerosis. A recent study from Korea examined over 8000 patients, (in a 20-year period) taking biological drugs. Although patients had improved mood disorders and a reduction in cancer and psoriatic arthritis incidence, there was no benefit significant in cardiovascular disease. However, sub-analysis showed potential benefits to some patients dependant on the their personal risks and the type of biological drug taken [20]. As a caveat, it should be remembered many of the newer biological agents do not have longevity and consequently their broader or longer-term protective effects are not yet known.

Newer drugs like the Glucagon-like peptide 1 receptor agonists GLP-1R (such as Ozempic and Mounjaro) may have a role as early review of evidence have shown reduced systemic inflammation through weight loss and potential for reduction of systemic inflammatory effects and improvement in psoriatic disease [21] - I have discussed some early findings in my other blog published this month.

 

References

1.            Mehrmal S, Uppal P, Nedley N, Giesey RL, Delost GR: The global, regional, and national burden of psoriasis in 195 countries and territories, 1990 to 2017: A systematic analysis from the Global Burden of Disease Study 2017. J Am Acad Dermatol 2021, 84:46–52.

2.            Wei J, Wang Y, Chen Y, Wang Z, Dai X, Gelfand JM, Bachelez H, Chen X, Xiao Y, Shen M: Global Burden of Psoriasis from 1990 to 2021 and Potential Factors: A Systematic Analysis. J Invest Dermatol 2025.

3.            Endo K, Higaki Y, Cho A, Sugimoto Y, Ikumi K, Okamura M, Matsuo M, Tada Y: Disease Impact and Burden of Psoriasis Vulgaris in Visible Body Areas in Japan: A Qualitative Study. The Journal of Dermatology 2025, n/a.

4.            Martínez-García E, Arias-Santiago S, Valenzuela-Salas I, Garrido-Colmenero C, García-Mellado V, Buendía-Eisman A: Quality of life in persons living with psoriasis patients. J Am Acad Dermatol 2014, 71:302–307.

5.            Mrowietz U, Elder JT, Barker J: The importance of disease associations and concomitant therapy for the long-term management of psoriasis patients. Arch Dermatol Res 2006, 298:309–319.https://www.nejm.org/doi/abs/10.1056/NEJM197304262881715

6.            Rogers J, Watt I, Dieppe P: Arthritis in Saxon and mediaeval skeletons. Br Med J (Clin Res Ed) 1981, 283:1668–1670.

7.            Espinoza LR: The History of Psoriatic Arthritis (PsA): From Moll and Wright to Pathway-Specific Therapy. Curr Rheumatol Rep 2018, 20:58.

8.            Henseler T, Christophers E: Disease concomitance in psoriasis. J Am Acad Dermatol 1995, 32:982–986.

9.            Pearce DJ, Morrison AE, Higgins KB, Crane MM, Balkrishnan R, Fleischer Jr AB, Feldman SR: The comorbid state of psoriasis patients in a university dermatology practice. Journal of Dermatological Treatment 2005, 16:319–323.

10.         Christophers E: Comorbidities in psoriasis. Clin Dermatol 2007, 25:529–534.

11.         Zimmet P, Magliano D, Matsuzawa Y, Alberti G, Shaw J: The Metabolic Syndrome: A Global Public Health Problem and A New Definition. Journal of Atherosclerosis and Thrombosis 2005, 12:295–300.

12.         McDonald CJ, Calabresi P: Psoriasis and occlusive vascular disease. Br J Dermatol 1978, 99:469–475.

13.         McDonald CJ, Calabresi P: Occlusive vascular disease in psoriatic patients. N Engl J Med 1973, 288:912.

14.         Samarasekera EJ, Neilson JM, Warren RB, Parnham J, Smith CH: Incidence of Cardiovascular Disease in Individuals with Psoriasis: A Systematic Review and Meta-Analysis. J Invest Dermatol 2013, 133:2340–2346.

15.         Arican O, Aral M, Sasmaz S, Ciragil P: Serum Levels of TNF-α, IFN-γ, IL-6, IL-8, IL-12, IL-17, and IL-18 in Patients With Active Psoriasis and Correlation With Disease Severity. Mediators Inflamm 2005, 2005:201561.

16.         Wierzbowska-Drabik K, Lesiak A, Skibińska M, Niedźwiedź M, Kasprzak JD, Narbutt J: Psoriasis and Atherosclerosis-Skin, Joints, and Cardiovascular Story of Two Plaques in Relation to the Treatment with Biologics. Int J Mol Sci 2021, 22.

17.         Lee S-H, Lee S, Seo HS, Koh SB, Eom M, Hong S-P: Impact of Biologics on Comorbidities in Patients with Psoriasis or Psoriatic Arthritis. Biomedicines 2025, 13:2219.

18.         Paschou IA, Sali E, Paschou SA, Psaltopoulou T, Nicolaidou E, Stratigos AJ:

 J Eur Acad Dermatol Venereol 2025, 39:2047–2055.