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COMMENTARY
Year : 2017  |  Volume : 146  |  Issue : 6  |  Page : 677-679

Psoriasis & cardiovascular morbidity: The missing links?


1 Department of Dermatology, All India Institute of Medical Sciences, Raipur, India
2 Department of Biochemistry, Pondicherry Institute of Medical Sciences, Puducherry, India

Date of Submission27-Oct-2017
Date of Web Publication13-Apr-2018

Correspondence Address:
Satyaki Ganguly
Department of Dermatology, All India Institute of Medical Sciences, Raipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_1714_17

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How to cite this article:
Ganguly S, Ray L. Psoriasis & cardiovascular morbidity: The missing links?. Indian J Med Res 2017;146:677-9

How to cite this URL:
Ganguly S, Ray L. Psoriasis & cardiovascular morbidity: The missing links?. Indian J Med Res [serial online] 2017 [cited 2018 Apr 22];146:677-9. Available from: http://www.ijmr.org.in/text.asp?2017/146/6/677/230131

Psoriasis is a chronic papulosquamous disorder with considerable morbidity. The prevalence of psoriasis varies between 0.09 and 11.43 per cent of the population [1]. It used to be considered a disorder of cutaneous hyperproliferation. However, over the course of the last two to three decades, psoriasis has also been found to be associated with a number of systemic abnormalities. Simultaneously, new hypotheses have been proposed which focus on the continued systemic inflammation and T-cell-mediated mechanisms to explain the cutaneous and joint manifestations. It primarily involves Th1- and Th17-mediated pathways, involving the release of proinflammatory cytokines such as interleukin-6 (IL-6), interferon-γ (IFN-γ) and tumour necrosis factor-alpha (TNF-α). TNF-α is one of the most important mediators in the pathogenesis of psoriasis, and many of the biologics used in the treatment of psoriasis are TNF-α antagonists [2].

Psoriasis has been conclusively proven to be associated with cardiovascular diseases such as myocardial infarction, heart failure and also metabolic syndrome [3]. In addition, hypertension, dyslipidaemia, insulin resistance and obesity have also been shown to be associated with psoriasis independently, apart from as components of metabolic syndrome [4].

Increased reactive oxygen species (ROS) production in neutrophils, keratinocytes and fibroblasts has been described in psoriasis [5]. In fact, ROS production can induce cell proliferation in different systems, possibly resulting in epidermal hyperproliferation in psoriasis [5]. In normal aerobic cells, antioxidant production balances out oxidative stress. Reduced glutathione (GSH) is a potent antioxidant, known to be depleted by free radical and other oxidative agents. Increased production of ROS as well as deficient antioxidant protection leads to oxidative stress. TNF-α can also act as an inducer of ROS production through impaired mitochondrial biogenesis and activation of NADPH oxidase. In psoriasis patients, increased ROS production may be due to deficient antioxidant mechanisms and in turn can lead to increased oxidation of polyunsaturated fatty acids [6]. The increased ROS production consequent to the inflammatory processes also causes increased formation of lipid oxidation and peroxidation products. Malondialdehyde (MDA) is one of the lipid peroxidation products.

Earliest event in the process of atherogenesis is abnormal oxidation of low-density lipoprotein (LDL) particles. Of the LDL sub-fractions, it is the small-dense LDL (sdLDL) which is more atherogenic. The sdLDL not only easily accumulates in the arterial walls to initiate atherosclerosis, but it also has a greater potential to get oxidised and get accumulated in macrophages. These lipid-laden macrophages known as foam cells play a pivotal role in the development of atherosclerotic plaque. Oxidised LDL (OxLDL), the product of oxidation of LDL, therefore, indicates the intensity of atherogenesis of the vessel wall. It also attracts macrophages and T-lymphocytes, damages the endothelial cells and stimulates the release of pro-inflammatory molecules [7].

C-reactive protein (CRP) belongs to the pentraxin superfamily of calcium-dependent ligand binding plasma proteins. It is synthesized in the liver in response to IL-6 which is in turn upregulated by IL-1 and TNF-α. Being an acute phase protein, CRP is a sensitive indicator of inflammation which shows a linear relationship between increase in the value and extent of inflammation and consequently tissue injury. CRP has been positively correlated with disease severity in psoriasis [8]. On the other hand, CRP is also an independent risk factor for cardiovascular diseases [8]. The possible mechanisms include binding of CRP to phosphatidylcholine of LDL and deposition of CRP in atherosclerotic plaques. It plays a central role in atherosclerosis from early stages of recruitment of inflammatory cells to the final stage of plaque rupture. Therefore, CRP, which is indicative of the inflammatory process in psoriasis, could be the reason behind arterial stiffness and premature development of atherosclerosis in psoriasis patients. High-sensitivity CRP (hsCRP) refers to the lower detection limit of the assay and has been proven to be an independent vascular risk factor [8].

Cytokines of both Th1 and Th17 pathway increase generation of ROS in psoriasis patients. ROS generation occurs from two sources; exogenous sources such as cigarette smoking and endogenous sources such as leukocyte inflammatory responses [9]. Probably, chronic inflammation results in a condition of oxidative stress in psoriasis, which leads to oxidation of LDL-forming OxLDL. This OxLDL and CRP get incorporated in the atherosclerotic plaque, followed by rupture of the atherosclerotic plaque and formation of the thrombus [7].

Many studies have found higher OxLDL, MDA and hsCRP levels and lower GSH levels in psoriasis patients compared to controls, but the levels have not always correlated with the severity of psoriasis [10],[11],[12],[13],[14],[15]. It has also been found that after TNF-α stimulation, human aortic smooth muscle cells and coronary artery endothelial cells show increased ROS generation, possibly by induction of NADPH oxidase [16].

In this background, the research work by Asha et al[17] published in this issue assumes significance. They compared LDL oxidising products such as OxLDL, OxLDL/LDL ratio, lipid peroxidation end-products such as serum MDA, antioxidant enzymes such as GSH and inflammatory markers such as hsCRP between 150 psoriasis patients and matched controls. As expected, serum cholesterol and triglyceride levels were significantly higher in psoriasis patients compared to controls. Interestingly, even though serum LDL of psoriasis patients was not significantly higher than controls, plasma OxLDL level as well as OxLDL/LDL ratio were significantly higher in psoriasis patients. MDA and hsCRP levels were significantly higher whereas GSH was significantly lower in psoriasis patients compared to controls. Therefore, the authors have suggested that psoriasis patients have deficient intrinsic antioxidant system, higher oxidative stress, higher risk of atherogenesis, increased inflammation of the atherosclerotic plaques as well as evidence of systemic inflammation. This clearly elucidates the link between psoriasis, oxidant/antioxidant imbalance, inflammation, atherosclerosis and increased cardiovascular morbidity. Further, they also showed a correlation between the severity of psoriasis and all these parameters, proving that as the severity of psoriasis increases, risk of oxidative stress, inflammation and atherosclerosis also increases. They also found that plasma MDA was positively correlated with OxLDL, which in turn was positively correlated with hsCRP.

An important aspect of cardiovascular risk in psoriasis patients will be assessment of effects of different psoriasis treatment modalities if any on the cardiovascular outcome. Treatments such as acitretin and cyclosporine may contribute to the development of cardiovascular risk factors such as hypertension and dyslipidaemia, whereas phototherapy and biologics are not known to have these side effects [7]. Assessment of effect of treatment for psoriasis was outside the scope of the case-control study conducted by Asha et al[17]. Therefore, a well-designed cohort study to assess the impact of different systemic treatments for psoriasis including biologics on oxidative stress, lipid profile and markers of systemic inflammation will be the logical next step in the future.



 
   References Top

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World Health Organization. Global Report on Psoriasis. Geneva: WHO; 2016. p. 7.  Back to cited text no. 1
    
2.
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Shapiro J, Cohen AD, David M, Hodak E, Chodik G, Viner A, et al. The association between psoriasis, diabetes mellitus, and atherosclerosis in Israel: A case-control study. J Am Acad Dermatol 2007; 56 : 629-34.  Back to cited text no. 4
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Kadam DP, Suryakar AN, Ankush RD, Kadam CY, Deshpande KH. Role of oxidative stress in various stages of psoriasis. Indian J Clin Biochem 2010; 25 : 388-92.  Back to cited text no. 5
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Pietrzak A, Michalak-Stoma A, Chodorowska G, Szepietowski JC. Lipid disturbances in psoriasis: An update. Mediators Inflamm 2010; 2010. pii: 535612.  Back to cited text no. 6
    
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Kaur S, Kingo K, Zilmer M. Psoriasis and cardiovascular risk-do promising new biomarkers have clinical impact? Mediators Inflamm 2017; 2017 : 7279818.  Back to cited text no. 7
    
8.
Vadakayil AR, Dandekeri S, Kambil SM, Ali NM. Role of C-reactive protein as a marker of disease severity and cardiovascular risk in patients with psoriasis. Indian Dermatol Online J 2015; 6 : 322-5.  Back to cited text no. 8
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Peluso I, Cavaliere A, Palmery M. Plasma total antioxidant capacity and peroxidation biomarkers in psoriasis. J Biomed Sci 2016; 23 : 52.  Back to cited text no. 9
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Vanizor Kural B, Orem A, Cimşit G, Yandi YE, Calapoglu M. Evaluation of the atherogenic tendency of lipids and lipoprotein content and their relationships with oxidant-antioxidant system in patients with psoriasis. Clin Chim Acta 2003; 328 : 71-82.  Back to cited text no. 10
    
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Relhan V, Gupta SK, Dayal S, Pandey R, Lal H. Blood thiols and malondialdehyde levels in psoriasis. J Dermatol 2002; 29 : 399-403.  Back to cited text no. 11
    
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Sikar Aktürk A, Özdoǧan HK, Bayramgürler D, Çekmen MB, Bilen N, Kıran R, et al. Nitric oxide and malondialdehyde levels in plasma and tissue of psoriasis patients. J Eur Acad Dermatol Venereol 2012; 26 : 833-7.  Back to cited text no. 12
    
13.
Pujari VM, Ireddy S, Itagi I, Kumar HS. The serum levels of malondialdehyde, vitamin e and erythrocyte catalase activity in psoriasis patients. J Clin Diagn Res 2014; 8 : CC14-6.  Back to cited text no. 13
    
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Baz K, Cimen MY, Kokturk A, Yazici AC, Eskandari G, Ikizoglu G, et al. Oxidant/antioxidant status in patients with psoriasis. Yonsei Med J 2003; 44 : 987-90.  Back to cited text no. 14
    
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Rajappa M, Shanmugam R, Munisamy M, Chandrashekar L, Rajendiran KS, Thappa DM, et al. Effect of antipsoriatic therapy on oxidative stress index and sialic acid levels in patients with psoriasis. Int J Dermatol 2016; 55 : e422-30.  Back to cited text no. 15
    
16.
Chen X, Andresen1 BT, Hill M, Zhang J, Booth F, Zhang C, et al. Role of reactive oxygen species in tumor necrosis factor-alpha induced endothelial dysfunction. Curr Hypertens Rev 2008; 4 : 245-55.  Back to cited text no. 16
    
17.
Asha K, Singhal A, Sharma SB, Arora VK, Aggarwal A. Dyslipidaemia & oxidative stress in patients of psoriasis: Emerging cardiovascular risk factors. Indian J Med Res 2017; 146 : 708-13.  Back to cited text no. 17
    




 

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