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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 2  |  Issue : 2  |  Page : 64-68

Metabolic syndrome in patients with psoriasis: A hospital-based case–control study


Department of Dermatology, Venereology, Leprosy, Sri Siddhartha Medical College, Tumakuru, Karnataka, India

Date of Web Publication10-Jul-2018

Correspondence Address:
Veena Thimmappa
Room No 15, Department of Dermatology, Venereology, Leprosy, Sri Siddhartha Medical College, Skin OPD, OPD Block, Tumakuru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CDR.CDR_41_17

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  Abstract 

Background: Psoriasis is a chronic inflammatory skin disease with an increased risk of cardiovascular disease. Metabolic syndrome (MS) increases the risk of cardiovascular diseases and type 2 diabetes mellitus. Previous studies indicate a higher prevalence of MS in psoriatic patients. Objectives: The objective of the study was to determine the frequency of occurrence of MS and its individual components in patients with psoriasis. Methodology: This study was a hospital-based, case–control study involving fifty adult patients with psoriasis and fifty age- and gender-matched controls. Blood pressure, body mass index, waist circumference, fasting lipid profile, and blood sugar were assessed in all subjects. MS was diagnosed by the presence of three or more of the South Asian Modified National Cholesterol Education Program's Adult Treatment Panel III criteria. Results: MS was significantly more common in psoriatic patients than in controls (38% vs. 22%, P = 0.043). Psoriatic patients had higher prevalence of raised fasting blood sugar (32% vs. 16%, P = 0.0334), hypertriglyceridemia (34% vs. 18%, P = 0.037), low high-density lipoprotein (50% vs. 20%, P = 0.00093), and hypertension (38% vs. 20%, P = 0.025). Raised values of waist circumference as a measure of central obesity though not statistically significant (P = 0.08) were found higher in psoriatic cases. The mean age of the psoriatic patients in years was 48 ± 17.1. Mean duration of the disease was 9.2 ± 8 years. There was no correlation between the severity and duration of psoriasis with MS. Conclusion: MS is frequent in patients with psoriasis. This highlights the need for screening of all psoriatic patients for early diagnosis and treatment of associated MS.

Keywords: Body mass index, diabetes mellitus, hypertension, metabolic syndrome


How to cite this article:
Gangaiah N, Aysha Roshin N S, Thimmappa V, Shivanna R. Metabolic syndrome in patients with psoriasis: A hospital-based case–control study. Clin Dermatol Rev 2018;2:64-8

How to cite this URL:
Gangaiah N, Aysha Roshin N S, Thimmappa V, Shivanna R. Metabolic syndrome in patients with psoriasis: A hospital-based case–control study. Clin Dermatol Rev [serial online] 2018 [cited 2018 Nov 18];2:64-8. Available from: http://www.cdriadvlkn.org/text.asp?2018/2/2/64/236338


  Introduction Top


Psoriasis is a chronic inflammatory immune-mediated disease affecting 1%–3% of the world population [1],[2] and in India (0.44%–2.8%[3]). It predominantly affects the skin with scaly plaques involving mainly the extensors surfaces of the limbs, scalp, and lumbosacral area [Figure 1].[4] The etiology remains partly unknown, but both genetic and environmental factors are implicated.[5] Recent reports have shown an increased risk for the metabolic syndrome (MS) and cardiovascular comorbidities in patients with psoriasis.[6]
Figure 1: Chronic plaque psoriasis involving elbow

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MS is a constellation of risk factors which are of metabolic origin and are accompanied by increased risk of cardiovascular disease and type 2 diabetes mellitus.[7] Major factors that may contribute are obesity, physical inactivity, cigarette smoking, hyperhomocysteinemia, and psychological stress.[8] This often appears to be related to common pathogenetic pathways. In contrast to syndromes, which comprise symptoms that appear synchronously, comorbidities reflect as timely unrelated secondary diseases involving the same or additional organs. Over the past few decades, there has been an alarming increase in the prevalence of MS in industrialized as well as developing nations in the world.[7] The associations of psoriasis and MS present early opportunities of diagnosing and treating MS in psoriasis patients which could lead to a substantial reduction in the morbidity and mortality.

Hence, this study was conducted to assess the role of psoriasis as a risk factor for the development of MS and its clinical profile.


  Methodology Top


This study was conducted between July 2015 and December 2016, in a tertiary care center, after obtaining approval by the Institutional Ethics Committee. The study was a hospital-based case–control study involving a series of fifty patients. Inclusion criteria for patients were age ≥18 years and those presenting with characteristic clinical features of psoriasis irrespective of gender, type, severity, treatment status, and disease duration of at least 6 months. The controls were taken from patients attending the dermatology outpatient department for disorders other than psoriasis. Patients and controls with familial hyperlipoproteinemia, thyroid disorders, and other medical diseases congenital or acquired which can predispose the patient to abnormal lipid profile, hypertension, and glucose intolerance, those on medications such as oral contraceptive pills, systemic corticosteroids, and retinoids, which can alter serum lipid profile, blood glucose, and blood pressure, and pregnant and lactating women were excluded from the study. The source population for cases and controls was the same. Informed consent was obtained from all patients and patient characteristics were recorded on a standard pro forma.

Relevant data included demographic data, age at onset, duration of disease, type and severity of psoriasis, treatment received, systemic diseases with duration in relation to psoriasis, family history of relation of affected member, history of smoking and alcoholism, weight, height, body mass index (BMI), waist circumference, body surface area (BSA) involved, Psoriasis Area and Severity Index (PASI) score, and blood pressure. Waist circumference, BMI, and blood pressure were measured as per standard protocols, and severity of psoriasis was assessed according to PASI and percentage of BSA involvement. Laboratory parameters such as fasting blood sugar (FBS) and fasting lipid profile were done in all patients. Serum cholesterol and triglycerides were measured with enzymatic procedures. Plasma glucose was measured using a glucose oxidase method.

MS was diagnosed by the presence of three or more of five criteria as proposed by the updated National Cholesterol Education Program Adult Treatment Panel III (ATP III), with Asian modification for waist circumference. The criteria are:

  1. Central obesity: Waist circumference ≥90 cm in men and ≥80 cm in women
  2. Hypertriglyceridemia: Triglyceride ≥150 mg/dl or on specific medications
  3. Low high-density lipoprotein (HDL) cholesterol: <40 mg/dl for men and <50 mg/dl for women
  4. Hypertension: Blood pressure ≥130 mmHg systolic and ≥85 mmHg diastolic or on specific medications
  5. Fasting blood glucose: ≥100 mg/dl or on specific medications or previously diagnosed type 2 diabetes mellitus.[9]


Statistical analysis

The data were analyzed using SPSS for windows, version 16.0. (Chicago, SPSS Inc, USA). Descriptive statistics were reported using mean and standard deviation for the continuous variables and numbers and percentages for the categorical variables. Independent t-test was used to compare the mean values between cases and controls. Chi-square test was used to test the association between study variables and cases/controls. P ≤ 0.05 was considered to be statistically significant.


  Results Top


Demographic and diseases characteristic of the study population is given in [Table 1]. Males were the predominant sex in our study, with a male-to-female ratio of 2.3:1. The maximum number of psoriatic cases (n = 13) (26%) were noted in the age group of 31–40 years. Disease duration in cases ranged from 6 months to 33 years, whereas the PASI score of the fifty patients with psoriasis ranged from 0.5 to 25.8.
Table 1: Demographic and diseases characteristic in study population

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Based on modified National Cholesterol Education Programs ATP III criteria, MS was diagnosed in 19 (38%) patients with psoriasis and 11 (22%) of control population, with a statistically significant P = 0.043 (P < 0.05). We also observed the higher prevalence of individual components of MS such as triglyceride levels, HDL cholesterol, blood pressure, FBS, and central obesity in patients with psoriasis than controls with statistically significant values for hypertriglyceridemia, low HDL, hypertension, and raised fasting blood glucose [Table 2].
Table 2: Comparison of metabolic parameters in cases and controls

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Psoriatic patients with MS had a mean age greater than those without MS, suggesting that increasing age is a risk factor for MS. Average duration of psoriasis was almost similar in those with and without MS. We failed to find a relation between the presence of MS and duration of psoriasis. PASI scoring as a measure of disease severity as well as mean BSA involvement was found to be lower in psoriatic patients with MS, compared to those without MS, suggesting that risk of MS in psoriatic patients was not related to these parameters. In our study, we noted that psoriatic patients who presented with MS had a higher BMI than psoriatic patients who had no MS, with a P = 0.172 which was not statistically significant.


  Discussion Top


Recent advances in our understanding the role of inflammatory cells and mediators in the pathogenesis of psoriasis have led to a shift from psoriasis being a skin disorder to that of a systemic inflammatory process that may increase the prevalence of other comorbid conditions in this patient population.[10] Psoriasis and MS are characterized by increase in the immunological activity of type 1 helper T cell, which suggests the hypothesis that psoriasis may be associated with MS because of shared inflammatory pathways. This study was done to compare the frequency of occurrence of MS in psoriatic patients to that of the control population.

In our study, males were the predominant sex, with a male-to-female ratio of 2.3:1 [Figure 2]. The maximum number of psoriatic cases (n = 13) (26%) was noted in the age group of 31–40 years. Duration of the disease ranged from 6 months to 33 years, and the PASI score of the 50 patients with psoriasis ranged from 0.5 to 25.8.
Figure 2: 52yr old male with large plaque with thick scales involving lower limbs

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With reference to the modified National Cholesterol Education Programs ATP III criteria, MS was diagnosed in 19 (38%) patients with psoriasis and 11 (22%) of control population, with a statistically significant P = 0.043 (P < 0.05). With reference to the prevalence of individual components of MS in psoriatic patients versus controls, we observed a higher prevalence of triglyceride levels, HDL cholesterol, blood pressure, FBS, and central obesity, with statistically significant values for hypertriglyceridemia, low HDL, hypertension, and raised fasting blood glucose.

The mean age of the psoriatic patients in our study was around 48 ± 17.1. The youngest age limit in this study was 20 years and the oldest patient in this series was an 84-year-old male. The maximum number of psoriatic cases (n = 13) (26%) was noted in the age group of 31–40 years with the least number in the age group of 51–60 years and >71 years (both 8%). The mean age of psoriatic patients with MS (49.9 ± 12.38) was higher than those without MS (46.81 ± 19.65), and this finding was similar to other case–control studies.[8],[11] The onset of psoriasis continues to be a lifelong threat. The earliest age of onset of psoriasis was noted at age 10 years and latest onset at around was 74 years in our observations. Mean age of onset of psoriasis in the total study population was 38.09 years.

Smoking habits were recorded higher in the cases than controls with 15 (30%) of the psoriatic males being current smokers compared to 11 (22%) in the control population. However, there was no statistically significant association noticed between patients with MS and smoking habits in our study. Case studies by Naldi et al.[12],[13] in Italy and Mills et al.[14] in the UK have supported the role of smoking as a risk factor in psoriasis. The frequency of alcohol consumption was seen to be more in the cases than controls with 13 (26%) of the psoriatic males being the current alcoholics compared to 8 (16%) in the control population. However, there was no statistically significant association noticed between patients with MS and alcohol consumption in our study. Alcohol has also been associated with excess morbidity and mortality in psoriatic patients as suggested by Kirby et al.[15] and Poikolainen et al.[16]

Many studies have been published on psoriasis and MS. Our study observed a higher frequency of occurrence of MS among psoriatic patients than the controls (38% vs. 22%, P ≤ 0.05) which is similar to case–control study by Gisondi et al. (30.1% vs. 20.6%, P = 0.005) and Nisa and Qazi.[8] Higher prevalence of MS in our study was probably due to lower cutoff of waist circumference taken for our study which was according to ethnic-specific values according to the International Diabetes Federation criteria.

It was noted that the largest group with MS was in the age group of 31–40 years and 41–50 years. MS was higher in cases than in controls from the third to fifth decade of life. Gisondi et al.[11] documented a higher prevalence of MS in psoriatic patients than controls after the age of 40 years. MS was more frequent after the age of 40 years in both cases and controls, i.e., in cases 68.4% (n = 13) and in controls 100% (n = 11) were having MS after 40 years. PASI scoring as a measure of disease severity as well as mean BSA involvement was found to be lower in our psoriatic patients with MS, compared to those without MS, suggesting that risk of MS in psoriatic patients was not related to these parameters [Table 3]. No significant correlation was found between PASI and BSA involvement and the prevalence of MS in Nisa and Qazi [8] study also.
Table 3: Descriptive characteristics of psoriatic patients with and without metabolic syndrome

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Raised values of waist circumference as a measure of central obesity, though not statistically significant (P = 0.08), were found higher in the psoriatic cases which was a finding similar in other studies.[8],[11] The mean BMI at 25.01 was higher in the psoriatic cases compared to the control population with mean BMI of 23.65. This was similar to earlier studies done by Kothiwala et al.[13] In our study we noted that psoriatic patients who presented with MS had a higher BMI (27.2 ± 6.09) than psoriatics who had no MS (23.66 ± 4.042) with a P = 0.172, which was not statistically significant.

We also observed the higher frequency of occurrence of individual components of MS like elevated triglycerides level, FBS, blood pressure, low HDL in patients with psoriasis than controls. A similar finding with statistically significant association was noted in the study by Kothiwala et al.[13] Sommer et al.[17] showed that psoriasis patients were likely to be at risk for the development of diabetes, hypertension, hyperlipidemia, obesity, coronary heart disease, and MS.

Psoriatic patients who presented with MS in our study had a later age of onset (49.9 ± 12.38) compared to those without the MS (46.8 ± 19.65). This observation was similar to the Kothiwala et al.'s study.[13] This finding could be due to an association between increasing metabolic risk factors which increase with age and hence precipitate psoriasis or vice versa. We failed to find a relation between the presence of MS and duration of psoriasis. This was similar to most of the studies done in India and abroad.[18],[19],[20],[21],[22]


  Conclusion Top


Psoriasis patients are more likely to have MS compared with the general population. In this study, we found a higher frequency of occurrence of MS in psoriasis patients than in controls. We could relate psoriasis to at least four components of MS, raised FBS values, hypertriglyceridemia, low HDL, and hypertension. Raised values of waist circumference as a measure of central obesity though not statistically significant were found higher in psoriatic cases. Our study is in agreement to other studies in literature. Hence, we conclude that psoriasis is a definitive risk for the development of MS.

Limitations

This study, however, has had its limitations. This was a hospital-based, time-bound study with a small sample size, which was the probable reason for the lack of statistical significance, in the analysis of most of the parameters. We failed to find a relation between the presence of MS and duration of psoriasis. These limitations would need further detailed studies.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

I would like to thank my entire department including my HOD, Dr. Narendra, Dr. Raghunath, Dr. Veena, as well as my colleagues for the support and encouragement.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Schön MP, Boehncke WH. Psoriasis. N Engl J Med 2005;352:1899-912.  Back to cited text no. 1
    
2.
Gelfand JM, Weinstein R, Porter SB, Neimann AL, Berlin JA, Margolis DJ, et al. Prevalence and treatment of psoriasis in the united kingdom: A population-based study. Arch Dermatol 2005;141:1537-41.  Back to cited text no. 2
    
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Dogra S, Yadav S. Psoriasis in India: Prevalence and pattern. Indian J Dermatol Venereol Leprol 2010;76:595-601.  Back to cited text no. 3
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Ghiasi M, Nouri M, Abbasi A, Hatami P, Abbasi MA, Nourijelyani K, et al. Psoriasis and increased prevalence of hypertension and diabetes mellitus. Indian J Dermatol 2011;56:533-6.  Back to cited text no. 4
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Padhi T, Garima. Metabolic syndrome and skin: Psoriasis and beyond. Indian J Dermatol 2013;58:299-305.  Back to cited text no. 7
    
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Alberti KG, Eckel RH, Grundy SM, Zimmet PZ, Cleeman JI, Donato KA, et al. Harmonizing the metabolic syndrome: A joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation 2009;120:1640-5.  Back to cited text no. 9
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Naldi L, Chatenoud L, Linder D, Belloni Fortina A, Peserico A, Virgili AR, et al. Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: Results from an Italian case-control study. J Invest Dermatol 2005;125:61-7.  Back to cited text no. 12
    
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