We’ve all come to learn over the past few years that psoriasis is extremely complicated. Many believe it to be just a skin disease; nothing more than bumpy red patches covered with white scales and joint pain. However, we are learning that several comorbidities, like diabetes and metabolic syndrome, are being fostered through this terrible skin disease.
Dr. Hawley, an associate clinical professor of dermatology at Michigan State University College of Osteopathic Medicine and medical director of The Derm Institute of West Michigan in Grand Rapids, MI, sat down with Dr. Lawrence Green, the section editor of The Dermatologist’s Psoriasis Center of Excellence and clinical professor of dermatology at George Washington School of Medicine in Washington, DC. They discussed on The Dermatologist Podcast about the ins and outs of treating psoriasis patents with obesity and the risks of cardiometabolic disease. Though psoriasis can be exhausting and daunting to discuss for other physicians, being a specialist in the field, Dr. Hawley was eager to tackle this.
Upon diving into research and understanding how these diseases are interrelated, Dr. Hawley found psoriasis patients have twice the prevalence of both obesity and type to 2 diabetes, which is an astounding number. There are many factors that could contribute to this, a lot of which is lifestyle choices, but that doesn’t account for the 5-10% of psoriasis patients who still have an increase in obesity and metabolic disease. This could infer that there could be some sort of genetic mechanism influencing the diseases. Dr. Hawley discusses further, “There’s a lot of shared inflammatory markers in all of these. It’s no surprise TNF-alpha is one of the more notable ones. There is data, though, that’s emerging that suggests IL-17 and IL-23 may also be playing a role in psoriasis and obesity and diabetes” (Hawley, 2020).
When it comes to treating obese patients, it can be strenuous and heart-breaking. Psoriasis is complicated for all patients no matter what their weight is, and treatments are not a one-size-fits-all. Dr. Hawley clarified that obese patients are at a higher risk for severe psoriasis, more comorbidities like liver disease, and an increase in depression.
Here are some ways Dr. Hawley treats psoriasis with obesity:
- She steers away from the use of Methotrexate in the heavier population that also carries these comorbidities.
- Fixed-dosing TNFs are a little less efficacious in heavier patients, but there’s a lot of data coming out that shows that they may protect against the formation of some of these comorbidities.
- Consider Remicade, which tends to fare well in the heavier patients because it is weight-based dosing. That is always an option if they don’t respond to any other tried biologics.
- Cimzia, which was studied in a heavier patient population, tends to do well in her obese patients. (Not mentioned in podcast).
Dr. Hawley wraps up the podcast by reminding physicians of her priority, which is understanding your patient’s skin journey. There is so much to learn about each individual. When it comes to psoriasis, the idea of a one-size-fits-all treatment or biologic for patients is just not a reality. Dr. Hawley urges physicians to get patients back often at the beginning of their treatment courses. Get to know them and then chip away at the comorbidities slowly. You don’t have to do it all in one visit. Working with your patients to develop a relationship and instill confidence in you as their physician is a great start.