Diagnosis and management of psoriasis

Whan B. Kim; Dana Jerome; Jensen Yeung

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Psoriatic patients: New emerging comorbidities?
Martin Hofmeister and Farid Mouissi

Published on: 08 June 2017
RE: Psoriatic patients: Do you smoke?
Dr. Martin Hofmeister and Dr. Farid Mouissi Mouissi

Published on: 19 May 2017
RE: Psoriasis: Obesity is an underestimated modifiable risk factor
Martin Hofmeister and Farid Mouissi

Published on: 02 May 2017

Published on: (8 June 2017)
Page navigation anchor for Psoriatic patients: New emerging comorbidities?
Psoriatic patients: New emerging comorbidities?
Martin Hofmeister, Dr., Consumer Centre of the German Federal State of Bavaria, Department Food and Nutrition, Germany
Other Contributors:
Farid Mouissi, Dr.
Dear Editor,

To the good review article “Diagnosis and management of psoriasis” by Dr. Kim et al., we would like to make one further comment [1]. In the principles of psoriasis management, it is important not only to consider classic co-morbidities such as psoriatic arthritis, cardiovascular disease or psychological/psychiatric disorders but also to incorporate "new" emerging co-morbidities into the diagnosis.

For example, current studies show a bidirectional association between obstructive sleep apnea (OSA) and psoriasis (e.g. increased oxidative stress and systemic inflammation, intermittent hypoxemia, upper airway obstruction) [2-6]. The prevalence of OSA in psoriasis patients is significantly increased in comparison to the general population (36%-81.8% versus 2%-4%) [7]. Clinicians should therefore remember that patients with psoriasis may have an undiagnosed OSA [4, 8]. A practical approach would be to use a simple validated screening tool for OSA such as the STOP-Bang questionnaire (snoring, tiredness, observed apnea, high blood pressure (STOP) - body mass index, age, neck circumference and gender (Bang)) [9, 10].

Furthermore, the prevalence of non-alcoholic fatty liver disease [11-14], celiac disease [15, 16], osteoporosis, and pathological fractures is significantly higher in patients diagnosed with psoriasis [17, 18].

Psoriasis also adversely affects the risk and severity of periodontitis [19, 20]. In a recent pooled meta-anal...
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Dear Editor,

To the good review article “Diagnosis and management of psoriasis” by Dr. Kim et al., we would like to make one further comment [1]. In the principles of psoriasis management, it is important not only to consider classic co-morbidities such as psoriatic arthritis, cardiovascular disease or psychological/psychiatric disorders but also to incorporate "new" emerging co-morbidities into the diagnosis.

For example, current studies show a bidirectional association between obstructive sleep apnea (OSA) and psoriasis (e.g. increased oxidative stress and systemic inflammation, intermittent hypoxemia, upper airway obstruction) [2-6]. The prevalence of OSA in psoriasis patients is significantly increased in comparison to the general population (36%-81.8% versus 2%-4%) [7]. Clinicians should therefore remember that patients with psoriasis may have an undiagnosed OSA [4, 8]. A practical approach would be to use a simple validated screening tool for OSA such as the STOP-Bang questionnaire (snoring, tiredness, observed apnea, high blood pressure (STOP) - body mass index, age, neck circumference and gender (Bang)) [9, 10].

Furthermore, the prevalence of non-alcoholic fatty liver disease [11-14], celiac disease [15, 16], osteoporosis, and pathological fractures is significantly higher in patients diagnosed with psoriasis [17, 18].

Psoriasis also adversely affects the risk and severity of periodontitis [19, 20]. In a recent pooled meta-analysis of five studies with 312,584 participants, the risk ratio of psoriasis in patients with periodontitis was 1.55 (95% confidence interval (CI) 1.35-1.77) compared with those without periodontitis [21]. Psoriasis also has an influence on sexual function: Evidence shows that psoriatic patients have a significantly higher risk of erectile dysfunction compared to the general population [22-25]. In addition, current research provides a possible link between psoriasis and adverse pregnancy outcomes, such as preterm birth and low birth weight, which must be further evaluated [26-29].

According to current data, there appears to be a bidirectional relationship between schizophrenia and psoriasis. In this pathogenic crosstalk, T helper 17 and calcium signaling pathways, pro-inflammatory cytokines, protein tyrosine phosphatase, non-receptor type 1 gene (PTPN1), as well as variants in the human leukocyte antigen gene region, play a possible key role [30-33]. In a large nationwide retrospective cohort study in Taiwan, for example, the adjusted hazard ratio of psoriasis associated with schizophrenia was 2.32 (95% CI 1.81-2.98) [33].

Primary care physicians/practitioner and other front-line health care professionals treating psoriatic patients should be aware of these associated - frequently underdiagnosed and undertreated - emerging co-morbidities.

Sincerely,

Dr. Martin Hofmeister, Consumer Centre of the German Federal State of Bavaria, Department Food and Nutrition, Germany

Dr. Farid Mouissi, APSSES Laboratory, Institute of Physical Education and Sports, Hassiba Ben Bouali University of Chlef, Algeria

References

1. Kim WB, Jerome D, Yeung J. Diagnosis and management of psoriasis. Can Fam Physician 2017;63(4):278-85.

2. Hirotsu C, Nogueira H, Albuquerque RG, Tomimori J, Tufik S, Andersen ML. The bidirectional interactions between psoriasis and obstructive sleep apnea. Int J Dermatol 2015;54(12):1352-8.

3. Egeberg A, Khalid U, Gislason GH, Mallbris L, Skov L, Hansen PR. Psoriasis and Sleep Apnea: A Danish Nationwide Cohort Study. J Clin Sleep Med 2016;12(5):663-71.

4. Papadavid E, Dalamaga M, Vlami K, Koumaki D, Gyftopoulos S, Christodoulatos GS, et al. Psoriasis is associated with risk of obstructive sleep apnea independently from metabolic parameters and other comorbidities: a large hospital-based case-control study. Sleep Breath 2017 May 8. doi: 10.1007/s11325-017-1507-4. [Epub ahead of print].

5. Henry AL, Kyle SD, Chisholm A, Griffiths CE, Bundy C. A cross-sectional survey of the nature and correlates of sleep disturbance in people with psoriasis. Br J Dermatol 2017 Mar 17. doi: 10.1111/bjd.15469. [Epub ahead of print].

6. Gupta MA, Simpson FC, Vujcic B, Gupta AK. Obstructive sleep apnea and dermatologic disorders. Clin Dermatol 2017;35(3):319-27.

7. Gupta MA, Simpson FC, Gupta AK. Psoriasis and sleep disorders: a systematic review. Sleep Med Rev 2016;29:63-75.

8. Shalom G, Dreiher J, Cohen A. Psoriasis and obstructive sleep apnea. Int J Dermatol 2016;55(11):e579-84.

9. Nagappa M, Liao P, Wong J, Auckley D, Ramachandran SK, Memtsoudis S, et al. Validation of the STOP-Bang questionnaire as a screening tool for obstructive sleep apnea among different populations: a systematic review and meta-analysis. PLoS One 2015;10(12):e0143697.

10. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: a practical approach to screen for obstructive sleep apnea. Chest 2016;149(3):631-8.

11. Candia R, Ruiz A, Torres-Robles R, Chavez-Tapia N, Mendez-Sanchez N, Arrese M. Risk of non-alcoholic fatty liver disease in patients with psoriasis: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2015;29(4):656-62.

12. Narayanasamy K, Sanmarkan AD, Rajendran K, Annasamy C, Ramalingam S. Relationship between psoriasis and non-alcoholic fatty liver disease. Prz Gastroenterol 2016;11(4):263-69.

13. Ganzetti G, Campanati A, Molinelli E, Offidani A. Psoriasis, non-alcoholic fatty liver disease, and cardiovascular disease: Three different diseases on a unique background. World J Cardiol 2016;8(2):120-31.

14. Mantovani A, Gisondi P, Lonardo A, Targher G. Relationship between Non-Alcoholic Fatty Liver Disease and Psoriasis: A Novel Hepato-Dermal Axis? Int J Mol Sci 2016;17(2):217.

15. Bhatia BK, Millsop JW, Debbaneh M, Koo J, Linos E, Liao W. Diet and psoriasis, part II: celiac disease and role of a gluten-free diet. J Am Acad Dermatol 2014;71(2):350-8.

16. Ungprasert P, Wijarnpreecha K, Kittanamongkolchai W. Psoriasis and risk of celiac disease: a systematic review and meta-analysis. Indian J Dermatol 2017;62(1):41-6.

17. Kathuria P, Gordon KB, Silverberg JI. Association of psoriasis and psoriatic arthritis with osteoporosis and pathological fractures. J Am Acad Dermatol 2017;76(6):1045-53.

18. Ogdie A, Harter L, Shin D, Baker J, Takeshita J, Choi HK, et al. The risk of fracture among patients with psoriatic arthritis and psoriasis: a population-based study. Ann Rheum Dis 2017;76(5):882-5.

19. Egeberg A, Mallbris L, Gislason G, Hansen PR, Mrowietz U. Risk of periodontitis in patients with psoriasis and psoriatic arthritis. J Eur Acad Dermatol Venereol 2017;31(2):288-93.

20. Keller JJ, Lin HC. The effects of chronic periodontitis and its treatment on the subsequent risk of psoriasis. Br J Dermatol 2012;167(6):1338-44.

21. Ungprasert P, Wijarnpreecha K, Wetter DA. Periodontitis and risk of psoriasis: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol 2017;31(5):857-62.

22. Cabete J, Torres T, Vilarinho T, Ferreira A, Selores M. Erectile dysfunction in psoriasis patients. Eur J Dermatol 2014;24(4):482-6.

23. Molina-Leyva A, Jimenez-Moleon JJ, Naranjo-Sintes R, Ruiz-Carrascosa JC. Sexual dysfunction in psoriasis: a systematic review. J Eur Acad Dermatol Venereol 2015;29(4):649-55.

24. Bardazzi F, Odorici G, Ferrara F, Magnano M, Balestri R, Patrizi A. Sex and the PASI: patients affected by a mild form of psoriasis are more predisposed to have a more severe form of erectile dysfunction. J Eur Acad Dermatol Venereol 2016;30(8):1342-8.

25. Egeberg A, Hansen PR, Gislason GH, Skov L, Thyssen JP. Erectile Dysfunction in Male Adults With Atopic Dermatitis and Psoriasis. J Sex Med 2017;14(3):380-86.

26. Yang YW, Chen CS, Chen YH, Lin HC. Psoriasis and pregnancy outcomes: a nationwide population-based study. J Am Acad Dermatol 2011;64(1):71-7.

27. Lima XT, Janakiraman V, Hughes MD, Kimball AB. The impact of psoriasis on pregnancy outcomes. J Invest Dermatol 2012;132(1):85-91.

28. Bobotsis R, Gulliver WP, Monaghan K, Lynde C, Fleming P. Psoriasis and adverse pregnancy outcomes: a systematic review of observational studies. Br J Dermatol 2016;175(3):464-72.

29. Rademaker M, Agnew K, Andrews M, Armour K, Baker C, Foley P, et al. Psoriasis in those planning a family, pregnant or breast-feeding. The Australasian Psoriasis Collaboration. Australas J Dermatol. 2017 May 23. doi: 10.1111/ajd.12641. [Epub ahead of print].

30. Chen SJ, Chao YL, Chen CY, Chang CM, Wu EC, Wu CS, et al. Prevalence of autoimmune diseases in in-patients with schizophrenia: nationwide population-based study. Br J Psychiatry 2012;200(5):374-80.

31. Yin X, Wineinger NE, Wang K, Yue W, Norgren N, Wang L, et al. Common susceptibility variants are shared between schizophrenia and psoriasis in the Han Chinese population. J Psychiatry Neurosci 2016;41(6):413-21.

32. Yin X, Lin Y, Shen C, Wang L, Zuo X, Zheng X, et al. Integration of expression quantitative trait loci and pleiotropy identifies a novel psoriasis susceptibility gene, PTPN1. J Gene Med 2017;19(1-2).e2939.

33. Yu S, Yu CL, Huang YC, Tu HP, Lan CE. Risk of developing psoriasis in patients with schizophrenia: a nationwide retrospective cohort study. J Eur Acad Dermatol Venereol 2017 May 3. doi: 10.1111/jdv.14303. [Epub ahead of print].
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Competing Interests: None declared.
Published on: (19 May 2017)
Page navigation anchor for RE: Psoriatic patients: Do you smoke?
RE: Psoriatic patients: Do you smoke?
Dr. Martin Hofmeister, MD, Consumer Centre of the German Federal State of Bavaria, Department Food and Nutrition
Other Contributors:
Dr. Farid Mouissi Mouissi, MD
Dear Editor:

We thank Dr. Kim et al. for their recently published review article “Diagnosis and management of psoriasis” [1]. We agree with the authors, but in addition to lifelong healthy eating habits and an active lifestyle of psoriasis patients, which we have already pointed out in an eLetter [2], there is one more important lifestyle aspect worth mentioning. Tobacco smoking is an independent risk factor for psoriasis: Smoking habits negatively affect the development of psoriasis and the disease severity (e.g. oxidative stress, free radical damage, vascular endothelial dysfunction). A dose-effect relationship of smoking intensity, duration, and pack-years of smoking is also documented [3, 4]. First reports about the possible significant association between psoriasis and smoking have been published more than 25 years ago [5]. In a pooled meta-analysis of 25 case-control studies (676,045 study participants and 146,934 psoriatic patients), the odds ratio (OR) of psoriasis among smokers was 1.78 (95% confidence interval (CI) 1.53-2.06) and 1.62 (95% CI 1.33-1.98) in former smokers. In this meta-analysis, Armstrong et al. also evaluated three cohort studies (the Nurses' Health Study, the Nurses' Health Study II, and the Health Professionals' follow-up study) for the association between smoking and incidence of psoriasis: Compared with nonsmokers, the risk of incident psoriasis was 1.81 (95% CI 1.38-2.36) in those who smoked 1-14 cigarettes per day and...
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Dear Editor:

We thank Dr. Kim et al. for their recently published review article “Diagnosis and management of psoriasis” [1]. We agree with the authors, but in addition to lifelong healthy eating habits and an active lifestyle of psoriasis patients, which we have already pointed out in an eLetter [2], there is one more important lifestyle aspect worth mentioning. Tobacco smoking is an independent risk factor for psoriasis: Smoking habits negatively affect the development of psoriasis and the disease severity (e.g. oxidative stress, free radical damage, vascular endothelial dysfunction). A dose-effect relationship of smoking intensity, duration, and pack-years of smoking is also documented [3, 4]. First reports about the possible significant association between psoriasis and smoking have been published more than 25 years ago [5]. In a pooled meta-analysis of 25 case-control studies (676,045 study participants and 146,934 psoriatic patients), the odds ratio (OR) of psoriasis among smokers was 1.78 (95% confidence interval (CI) 1.53-2.06) and 1.62 (95% CI 1.33-1.98) in former smokers. In this meta-analysis, Armstrong et al. also evaluated three cohort studies (the Nurses' Health Study, the Nurses' Health Study II, and the Health Professionals' follow-up study) for the association between smoking and incidence of psoriasis: Compared with nonsmokers, the risk of incident psoriasis was 1.81 (95% CI 1.38-2.36) in those who smoked 1-14 cigarettes per day and 2.29 (95% CI 1.74-3.01) in those who smoked 25 cigarettes or more per day [3].

A recent Canadian meta-analysis of 22 studies also showed an increased prevalence of smoking in psoriasis patients (relative risk 1.88 (95% CI, 1.66-2.13)) compared with those without psoriasis [4]. It is therefore not surprising that the practical evidence-based recommendations for the management of co-morbidities in rheumatoid arthritis, psoriasis, and psoriatic arthritis from the Canadian Dermatology-Rheumatology Comorbidity Initiative are also recommended: “Smoking status should be determined in all patients with rheumatoid arthritis, psoriatic arthritis, and psoriasis and smoking cessation should be encouraged” [6]. Even primary care physicians/practitioner and other front-line health care professionals should not miss this patient-centered recommendation and evaluate psoriatic patients’ smoking status [7, 8]. Many of the proven cardiovascular, metabolic, musculoskeletal, and psychological comorbidities associated with psoriasis are negatively affected by smoking additionally: cardiovascular disease, metabolic syndrome, diabetes, chronic obstructive pulmonary disease, chronic kidney disease, psoriatic arthritis, several cancers, and depression [9-17].

Family physicians can play a pivotal role in inducing their psoriatic patients to stop smoking and improve the cumulative patients’ quality of life (example of a smoking cessation resource from Health Canada: http://www.hc-sc.gc.ca/hc-ps/tobac-tabac/quit-cesser/index-eng.php). The initial prompt from a medical professional is very important to stimulate the awareness of the multiple risks of smoking [8].

According to the current systematic analysis from the Global Burden of Disease Study, 6.4 million deaths (95% uncertainty interval (UI) 5.7-7.0 million) were attributable to smoking worldwide in 2015 (11.5% of global deaths). And besides, smoking was responsible for the loss of 148.6 million (95% UI 134.2-163.1) disability-adjusted life-years (DALYs) worldwide (6.0% of global DALYs) [18]. Also to achieve long-term control of psoriasis and its co-morbidities, please ask your patients: “Do you smoke?” respectively “Do you want to quit?”

Sincerely,

Dr. Martin Hofmeister, Consumer Centre of the German Federal State of Bavaria, Department Food and Nutrition, Germany
Dr. Farid Mouissi, APSSES Laboratory, Institute of Physical Education and Sports, Hassiba Ben Bouali University of Chlef, Algeria

References
1. Kim WB, Jerome D, Yeung J. Diagnosis and management of psoriasis. Can Fam Physician 2017;63(4):278-85.

2. Hofmeister M, Mouissi F. RE: Psoriasis: Obesity is an underestimated modifiable risk factor. Canadian Family Physician Online [eLetter] 2 May 2017. Available from: http://www.cfp.ca/content/63/4/278/tab-e-letters#re-psoriasis-obesity-is.... Accessed 2017 May 17.

3. Armstrong AW, Harskamp CT, Dhillon JS, Armstrong EJ. Psoriasis and smoking: a systematic review and meta-analysis. Br J Dermatol 2014;170(2):304-14.

4. Richer V, Roubille C, Fleming P, Starnino T, McCourt C, McFarlane A, et al. Psoriasis and smoking: a systematic literature review and meta-analysis with qualitative analysis of effect of smoking on psoriasis severity. J Cutan Med Surg 2016;20(3):221-7.

5. Mills CM, Srivastava ED, Harvey IM, Swift GL, Newcombe RG, Holt PJ, Rhodes J. Smoking habits in psoriasis: a case control study. Br J Dermatol 1992;127(1):18-21.

6. Roubille C, Richer V, Starnino T, McCourt C, McFarlane A, Fleming P, et al. Evidence-based recommendations for the management of comorbidities in rheumatoid arthritis, psoriasis, and psoriatic arthritis: expert opinion of the Canadian Dermatology-Rheumatology Comorbidity Initiative. J Rheumatol 2015;42(10):1767-80.

7. Young M, Aldredge L, Parker P. Psoriasis for the primary care practitioner. J Am Assoc Nurse Pract 2017;29(3):157-78.

8. McIvor A, Kayser J, Assaad JM, Brosky G, Demarest P, Desmarais P, et al. Best practices for smoking cessation interventions in primary care. Can Respir J 2009;16(4):129-34.

9. Egeberg A, Skov L. Management of cardiovascular disease in patients with psoriasis. Expert Opin Pharmacother 2016;17(11):1509-16.

10. Colditz GA, Philpott SE, Hankinson SE. The Impact of the Nurses' Health Study on Population Health: Prevention, Translation, and Control. Am J Public Health 2016;106(9):1540-5.

11. Singh S, Young P, Armstrong AW. Relationship between psoriasis and metabolic syndrome: a systematic review. G Ital Dermatol Venereol 2016;151(6):663-77.

12. Ungprasert P, Srivali N, Thongprayoon C. Association between psoriasis and chronic obstructive pulmonary disease: a systematic review and meta-analysis. J Dermatolog Treat 2016;27(4):316-21.

13. Gonzalez-Parra E, Dauden E, Carrascosa JM, Olveira A, Botella R, Bonanad C, et al. Kidney disease and psoriasis. A new comorbidity? Actas Dermosifiliogr 2016;107(10):823-29.

14. Xia J, Wang L, Ma Z, Zhong L, Wang Y, Gao Y, et al. Cigarette smoking and chronic kidney disease in the general population: a systematic review and meta-analysis of prospective cohort studies. Nephrol Dial Transplant 2017;32(3):475-487.

15. Li W, Han J, Qureshi AA. Smoking and risk of incident psoriatic arthritis in US women. Ann Rheum Dis. 2012;71(6):804-8.

16. Chiesa Fuxench ZC, Shin DB, Ogdie Beatty A, Gelfand JM. The risk of cancer in patients with psoriasis: a population-based cohort study in the health improvement network. JAMA Dermatol 2016;152(3):282-90.

17. Lewinson RT, Vallerand IA, Lowerison MW, Parsons LM, Frolkis AD, Kaplan GG, et al. Depression is associated with an increased risk of psoriatic arthritis among patients with psoriasis: a population-based study. J Invest Dermatol 2017;137(4):828-35.

18. GBD 2015 Tobacco Collaborators. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015. Lancet 2017;389(10082):1885-906.

Conflict of Interest:

None declared
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Competing Interests: None declared.
Published on: (2 May 2017)
Page navigation anchor for RE: Psoriasis: Obesity is an underestimated modifiable risk factor
RE: Psoriasis: Obesity is an underestimated modifiable risk factor
Martin Hofmeister, Dr., Consumer Centre of the German Federal State of Bavaria, Department Food and Nutrition, Germany
Other Contributors:
Farid Mouissi, Dr.
Dear Editor,

We congratulate Dr. Kim et al. for their very interesting review article “Diagnosis and management of psoriasis” in the April 2017 issue of the Canadian Family Physician [1]. There is one lifestyle aspect worth mentioning. First reports about the possible significant association between psoriasis and obesity have been published more than 40 years ago [2]. In 2012, a meta-analysis of 16 observational studies (2.1 million study participants and 201,831 psoriatic patients) has found that patients with psoriasis have a more than 50% increased odds of obesity compared with the general population, with a pooled odds ratio (OR) of 1.46 for mild psoriasis (95% confidence interval (CI) 1.17-1.82) and an OR of 2.23 (95% CI 1.63-3.05) for moderate-to-severe psoriasis [3]. There is now a strong evidence for this bidirectional relationship [4]. The "Canadian Psoriasis Guidelines Addendum Committee" has also listed obesity among the associated comorbidities and recommends “Advise obese patients to lose weight for potential skin benefits” [5].

Genetic (e.g. HLA-Cw6, HLA-B27), epigenetic, environmental and immune-mediated factors are involved in the interaction/pathogenesis of obesity and psoriasis. In this pathogenic crosstalk the following pro-inflammatory cytokines and adipokines in adipose tissue play a key role: tumor necrosis factor-alpha, interleukin (IL)-6, IL-18, IL-23, leptin, resistin, visfatin, and the anti-inflammatory adiponectin [4]. It...
Show More

Dear Editor,

We congratulate Dr. Kim et al. for their very interesting review article “Diagnosis and management of psoriasis” in the April 2017 issue of the Canadian Family Physician [1]. There is one lifestyle aspect worth mentioning. First reports about the possible significant association between psoriasis and obesity have been published more than 40 years ago [2]. In 2012, a meta-analysis of 16 observational studies (2.1 million study participants and 201,831 psoriatic patients) has found that patients with psoriasis have a more than 50% increased odds of obesity compared with the general population, with a pooled odds ratio (OR) of 1.46 for mild psoriasis (95% confidence interval (CI) 1.17-1.82) and an OR of 2.23 (95% CI 1.63-3.05) for moderate-to-severe psoriasis [3]. There is now a strong evidence for this bidirectional relationship [4]. The "Canadian Psoriasis Guidelines Addendum Committee" has also listed obesity among the associated comorbidities and recommends “Advise obese patients to lose weight for potential skin benefits” [5].

Genetic (e.g. HLA-Cw6, HLA-B27), epigenetic, environmental and immune-mediated factors are involved in the interaction/pathogenesis of obesity and psoriasis. In this pathogenic crosstalk the following pro-inflammatory cytokines and adipokines in adipose tissue play a key role: tumor necrosis factor-alpha, interleukin (IL)-6, IL-18, IL-23, leptin, resistin, visfatin, and the anti-inflammatory adiponectin [4]. It should be mentioned at this point that obesity can adversely affect the effectiveness of treatment with cyclosporine, methotrexate, or biologicals on the severity of psoriasis (decreases response to systemic/biologic therapies and increases risk of adverse treatment effects) [4].

It has also been documented many times that psoriasis patients have reduced levels of physical activity compared with those without psoriasis. Regular physical activity can positively influence psoriasis severity as well as the incidence of the numerous associated comorbidities through simultaneous epigenomic, antihyperglycemic, antihyperlipidemic, antihypertensive, antioxidative, anti-inflammatory, cardioprotective, and psycho-emotional effects. Family physicians should encourage all psoriasis patients to be more physically active and identify physical activity barriers particularly among overweight/obese psoriasis patients. In our opinion, training and support for lifestyle behaviour change principles and techniques would also be desirable for clinicians and very valuable in the management of psoriasis [6].

Although further research is urgently needed, a brief indication of the potential effectiveness of lifestyle modifications and obesity management of patients with psoriasis should be included in a clinical review and primary care update.

Sincerely,

Dr. Martin Hofmeister, Consumer Centre of the German Federal State of Bavaria, Department Food and Nutrition, Germany
Dr. Farid Mouissi, APSSES Laboratory, Institute of Physical Education and Sports, Hassiba Ben Bouali University of Chlef, Algeria

References

1. Kim WB, Jerome D, Yeung J. Diagnosis and management of psoriasis. Can Fam Physician 2017;63(4):278-85.
2. Binazzi M, Calandra P, Lisi P. Statistical association between psoriasis and diabetes: further results. Arch Dermatol Res 1975;254(1):43-8.
3. Armstrong AW, Harskamp CT, Armstrong EJ. The association between psoriasis and obesity: a systematic review and meta-analysis of observational studies. Nutr Diabetes 2012;2:e54.
4. Correia B, Torres T. Obesity: a key component of psoriasis. Acta Biomed 2015;86(2):121-9.
5. Canadian Psoriasis Guidelines Addendum Committee. 2016 Addendum to the Canadian Guidelines for the Management of Plaque Psoriasis 2009. J Cutan Med Surg 2016;20(5):375-431.
6. Schmitt-Egenolf M. Physical activity and lifestyle improvement in the management of psoriasis. Br J Dermatol 2016;175(3):452-3.
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Competing Interests: None declared.