Why patients with this common skin condition should have their joint and heart health checked

Plagued by the skin condition psoriasis since her teens, Anna McFadyen knows only too well that her problems go much deeper.

For the psoriasis is linked to her painful joints, as a result of psoriatic arthritis, an inflammatory type of arthritis.

And recently she's learned that the skin condition has raised her risk of another problem, heart disease.

Psoriasis is an autoimmune condition where the immune system attacks healthy skin cells, speeding up the rate at which they are renewed, causing crusty, red and often painful 'plaques' on the skin.

It affects one in 50 people in the UK: for some it's just a minor problem, but in severe cases it can lead to cracked, bleeding skin all over the body, low self-esteem and depression.

However, what many patients - or doctors - don't know is that it is also associated with a raised risk of other serious conditions.

And experts are concerned patients aren't getting the regular checks they need to monitor this, or taking the steps to prevent worsening health.

'I now know I'm at higher risk of a heart attack or stroke because of my psoriasis,' says Anna, 50, who runs her own sustainable clothing business, and lives in South London with her partner Jon, 51, an IT director.

'But I only discovered this after paying for private blood tests after by chance reading about the risks.'

These tests revealed Anna has high levels of lipoprotein A, a type of fat that can stick to the blood vessel walls and clog them up. After her blood tests, Anna was referred for an ultrasound scan which revealed that her carotid arteries, the blood vessels in the neck that supply the brain, were narrowed.

Carotid artery disease causes up to a third of all strokes.

'This is all the more shocking as I look after myself,' she says. 'I'm not overweight - my BMI is 22, in the healthy range - I exercise, eat healthily, don't smoke and rarely drink alcohol. It's purely the psoriasis-related inflammation that is driving my risk,' says Anna.

The exact cause of psoriasis is not clear. It's thought the condition is linked to a mixture of genes and environmental triggers, including stress, infection and certain medications such as non-steroidal anti-inflammatory drugs.

The good news for patients is that treatments have improved over the past 20 years, says Professor Chris Griffiths, a consultant dermatologist at King's College Hospital in London.

Traditionally, psoriasis has been treated with messy creams and ointments such as coal tar preparations and UV light therapy. More recently patients have been prescribed immunosuppressant drugs such as methotrexate.

But treatment has been transformed by biologics - drugs made from live human or animal proteins, which block the action of certain immune cells. A review by the authoritative Cochrane Centre this year concluded that biologics - infliximab, bimekizumab, ixekizumab and risankizumab - were the most effective treatments for psoriasis and people taking any one of these (they're self-adminstered by injection) can hope for a marked reduction in the condition.

And while only the most severe cases have been able to get these medications on the NHS (they cost £10,000 a year per patient), the patents on some have run out, so cheaper, generic versions called biosimilars are now available.

'Although we can't offer a cure yet, we can offer good control of symptoms in terms of quality of life for most people, which is quite important when you consider how psoriasis used to ruin people's lives,' says Professor Griffiths.

'In the 1980s, our dermatology wards were full of psoriasis patients being hospitalised for four weeks at a time for coal tar treatment and light therapy, and they might have had to do that a couple of times a year. But now inpatient treatment is rare.'

However, experts say there is still not enough recognition of the secondary implications of psoriasis. An estimated 30 per cent of people with psoriasis will develop psoriatic arthritis, for example.

A 2018 survey by the Global Healthy Living Foundation found 96 per cent of patients received at least one misdiagnosis before they were correctly diagnosed; 30 per cent said it took five years or more. Delay in diagnosis can lead to irreversible joint damage.

Separately, scientists have known about the link with heart disease since 2006, when Professor Joel Gelfand, a dermatologist at the University of Pennsylvania in the U.S., published a landmark paper showing a higher risk of heart attacks in people with psoriasis.

And now new research, in the Journal of Investigative Dermatology, has identified a potential mechanism. It revealed that in around 30 per cent of psoriasis patients there was reduced blood flow in the small blood vessels (called microvascular dysfunction), even though they had no symptoms of heart disease or blockages in large arteries.

The researchers, from the University of Padua in Italy, concluded that this was the result of inflammation caused by psoriasis, saying: 'We should diagnose and actively search for microvascular dysfunction in patients with psoriasis, as this population is at particularly high risk.'

Under guidelines by the National Institute for Health and Care Excellence (NICE), psoriasis patients should have annual reviews to check for psoriatic arthritis and be assessed for cardiovascular disease after diagnosis and then every five years.

This kind of monitoring can help. 'We set up rapid access clinics in Manchester in 2017 and found that even in patients with early psoriasis, between a quarter and a third had high blood pressure, raised cholesterol or depression,' says Professor Griffiths.

'One in five had joint symptoms severe enough to warrant a referral to a rheumatologist.

'Screening for these risk factors early means they can be controlled with therapies and lifestyle changes - and the earlier you do this the better,' he adds. 'The problem is, in the UK we don't start screening for high blood pressure and raised cholesterol until the age of 40 - but I would argue this should be done much earlier in a person with psoriasis.'

Worryingly, David Chandler, chief executive of the Psoriasis and Psoriatic Arthritis Alliance, says care for psoriasis patients varies across the country.

'I was a patient member of the NICE committee that drew up the guidelines and I pushed for the annual review, but my experience personally and from feedback from our helpline is it doesn't happen and psoriasis doesn't get taken seriously enough.

'Patients are not having routine scans for psoriatic arthritis or having blood tests and other checks routinely. We don't want to scare people, but need to alert them to potential associated conditions.'

In terms of prevention, the American Academy of Dermatology says treating moderate to severe psoriasis may also reduce the risk of a stroke or heart attack, and that methotrexate and biologic drugs may reduce the risk of heart and blood vessel diseases.

Biologics have been shown to cut the risk of heart attacks, says Professor Griffiths. 'We don't know if this is due to an improvement of psoriasis symptoms or just an ancillary benefit of the drug.'

Since discovering her own raised risk of heart attack and stroke, Anna says she's taking even more care of herself. After she was diagnosed with psoriasis at 17, she has tried all the standard treatments, including coal tar creams, steroid creams and methotrexate - with varying degrees of success.

She was then prescribed the biologic drug Humira, which reduced her plaques (at their worst they covered 30 per cent of her body) to around 5 per cent of her skin.

It was transformative, but she was on the drug for eight years and 'was worried about the long-term side-effects, which include a slightly raised risk of cancer.

'I'm now managing with steroid creams for my nails, aloe vera gel and CBD ointment, which I pay for privately (CBD may have anti-inflammatory properties although this is not proven).

'I now have to bear the risk of heart disease in mind, too.'

To reduce inflammation in her body, she was already swimming regularly, eating a Mediterranean-style diet and avoiding alcohol, plus practising meditation to manage stress. But now she's also on statins and has regular check-ups and scans of her arteries.

'It all seems to be working for my skin apart from some plaques on my elbows, but I wouldn't hesitate to go back on biologics if my symptoms flared severely again, especially if there's more evidence that the drug can help prevent heart disease too,' says Anna.

'I'm lucky I attend specialist NHS clinics which manage my condition holistically. I don't think people are aware of how psoriasis is associated with major complications. It's a serious disease in its own right, but the skin symptoms are just the tip of the iceberg.'

• papaa.org