Short Communication

Dermatology 2008;216:152155 Received: January 17, 2007

Accepted: June 28, 2007
DOI: 10.1159/000111512

Association between Psoriasis and the

Metabolic Syndrome
A Cross-Sectional Study

A.D. Cohen a, b M. Sherf a, b L. Vidavsky a D.A. Vardy a, b J. Shapiro a J. Meyerovitch a, c

a Research and Health Planning Department, Health Planning and Policy Division, Clalit Health Services,
Omer/Tel Aviv, b Siaal Research Center for Family Medicine and Primary Care, Ben-Gurion University, Beer-Sheva,
and c Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Childrens
Medical Center of Israel, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel

Key Words 48,681 controls. In the case group, there Introduction

Metabolic syndrome Psoriasis
Abstract
Background: Previous reports have shown
an association between inflammatory dis-
eases such as systemic lupus erythematosus
or rheumatoid arthritis and the metabolic
syndrome. Recent data demonstrate that
psoriasis is an inflammatory disease, sug-
gesting that psoriasis may be one of the
components of the metabolic syndrome.
Objective: To assess the association be-
tween psoriasis and the metabolic syn-
drome. Methods: A cross-sectional study
was performed utilizing the database of the
Clalit Health Services. Case patients were de-
fined as patients with a diagnosis of psoriasis
vulgaris. Controls were randomly selected
from the list of Clalit Health Services enroll-
ees. The proportions of components of the
metabolic syndrome (ischemic heart dis-
ease, hypertension, diabetes, obesity and
dyslipidemia) were compared between case
and control patients by univariate analyses.
2 tests were used to compare categorical
parameters between the groups. Logistic
and linear regression models served to mea-
sure the association between psoriasis and
the metabolic syndrome. Results: The study
included 16,851 patients with psoriasis and
were 8,449 men (50.1%) and 8,402 women
(49.9%), with a mean age of 42.7 years (SD =
20.3, range = 2111). Diabetes mellitus was
present in 13.8% of the patients with psoria-
sis as compared to 7.3% of the controls (p !
0.001). Hypertension occurred in 27.5% of
the patients with psoriasis and in 14.4% of
the controls (p ! 0.001). Obesity was present
in 8.4% of the patients with psoriasis as op-
posed to 3.6% of the controls (p ! 0.001).
Ischemic heart disease was observed in
14.2% of the patients with psoriasis as com-
pared to 7.1% of the controls (p ! 0.001). Mul-
tivariate models adjusting for age, gender
and smoking status of the patients demon-
strated that psoriasis was associated with
the metabolic syndrome (OR = 1.3, 95% CI =
1.11.4), ischemic heart disease (OR = 1.1,
95% CI = 1.01.2), diabetes mellitus (OR = 1.2,
95% CI = 1.01.3), hypertension (OR = 1.3,
95% CI = 1.21.5) and obesity (OR = 1.7, 95%
CI = 1.51.9). Limitations: The study is de-
signed as a case-control study, thus an asso-
ciation alone was proven and not causality.
Conclusion: Our findings demonstrate a
possible association between psoriasis and
the metabolic syndrome. Appropriate treat-
ment of the metabolic syndrome may be an
important part of the management of pa-
tients with psoriasis.
Copyright 2008 S. Karger AG, Basel
The metabolic syndrome is a combi-
nation of diabetes mellitus, hypertension,
obesity and hyperlipidemia. The patho-
physiology of the metabolic syndrome is
attributed to insulin resistance. Systemic
inflammation occurs in patients with the
metabolic syndrome, which is evident as
a number of inflammatory markers such
as TNF are often increased [13]. Recent
studies have demonstrated an association
between inflammatory diseases such as
systemic lupus erythematosus or rheu-
matoid arthritis and the metabolic syn-
drome [46].
Psoriasis is an inflammatory disorder
of the skin and in some patients the joints.
The inflammatory process in psoriasis is
evident histologically by the lymphocytic
infiltration of the dermis and the neutro-
philic infiltration of the epidermis. In-
flammatory cytokines are elevated in pa-
tients with psoriasis with increased secre-
tion of Th-1 cytokine. Inflammatory
markers such as TNF play a role in both the
metabolic syndrome and psoriasis [79].
Several reports have demonstrated a
possible association between psoriasis and
diabetes mellitus, hypertension, myocar-
dial infarction and heart failure and obe-
sity. However, the majority of these studies

2008 S. Karger AG, Basel Arnon D. Cohen, MD, MPH

10188665/08/21620152$24.50/0 Dermatology Service, Southern District
Fax +41 61 306 12 34 Clalit Health Services, PO Box 4317
E-Mail karger@karger.ch Accessible online at: Omer 84965 (Israel)
www.karger.com www.karger.com/drm Tel. +972 8 625 4202, Fax +972 8 625 4237, E-Mail arcohen@clalit.org.il
 Table 1. Proportion of diseases in the metabolic syndrome in patients with psoriasis and in the control group

Psoriasis patients Control group OR p value

(n = 16,850) (n = 48,677)

Ischemic heart disease 2,387 (14.2) 3,479 (7.1) 2.1 [2.02.3] <0.001
Diabetes mellitus 2,324 (13.8) 3,556 (7.3) 2.0 [1.92.1] <0.001
Hypertension 4,627 (27.5) 7,017 (14.4) 2.2 [2.22.3] <0.001
Obesity 1,419 (8.4) 1,768 (3.6) 2.4 [2.32.6] <0.001

Figures in parentheses are percentages and values in square brackets represent 95% CI.

were anecdotal, based on small sample siz-
es or not controlled [1015].
The purpose of the current study was
to assess the association between psoriasis
and the metabolic syndrome using data
mining techniques utilizing the Clalit
Health Services (CHS) database.
Methods
The study was designed as a retrospec-
tive case-control study using data mining
techniques utilizing the CHS database.
The CHS is the largest managed care or-
ganization in Israel, serving a population
of approximately 3,800,000 enrollees. The
CHS have a comprehensive computerized
database that has continuous real-time in-
put from pharmaceutical, medical and ad-
ministrative computerized operating sys-
tems.
In the CHS database, the diagnoses of
chronic diseases such as ischemic heart
disease, diabetes, hypertension and pso-
riasis are validated by systematic method-
ology. The CHS perform the process of
validation by logistic checks (such as
comparing diagnoses from various sourc-
es) and by direct validation of the diagno-
ses by the treating physicians of each pa-
tient.
Case patients were defined as having
psoriasis when there was at least 1 docu-
mented diagnosis of psoriasis in the medi-
cal records between the years registered by
CHS physicians. The diagnosis of psoriasis
was confirmed by use of medications
which are explicitly prescribed in Israel to
patients with psoriasis (e.g. Neotigason) or
use of PUVA therapy. Three control pa-
tients were randomly selected for each case
patient. The control group was randomly
selected from the list of CHS enrollees,
sampling the general population. The di-
agnoses of obesity, hypertension, diabetes
and ischemic heart disease were taken
from the CHS chronic diseases registry.
The metabolic syndrome was defined in
the current study as obesity plus any 2 of
the following criteria: raised triglycerides,
reduced HDL cholesterol, hypertension or
diabetes.
The proportions of patients with meta-
bolic-syndrome-associated diseases (dia-
betes, hypertension, ischemic heart dis-
ease, dyslipidemia, obesity) were com-
pared between case and control patients by
univariate analyses. 2 tests were used to
compare categorical and t tests to com-
pare continuous parameters between the
groups. Logistic and linear regression
models were applied to measure the asso-
ciation between psoriasis and the metabol-
ic syndrome. Statistical analysis was per-
formed with SPSS software.
Results
The study included 16,851 patients
with psoriasis and 48,681 controls. The
mean age of the case patients was 42.7
years (SD = 20.3, range = 2111) and that
of the controls was 51.0 years (SD = 19.1,
range = 0100). In the case group, there
were 8,449 men (50.1%) and 8,402 women
(49.9%). In the control group, there were
23,363 men (48.0%) and 25,318 women
(52.0%).
The proportions of ischemic heart dis-
ease, diabetes mellitus, hypertension and
obesity were increased in patients with
psoriasis as compared to the control group
(table 1). Total cholesterol and triglyceride
levels were increased in patients with pso-
riasis as compared to the control group.
HDL cholesterol level was decreased in pa-
tients with psoriasis as compared to the
control group (table 2).
The associations between psoriasis and
hypertension, diabetes or obesity were
more pronounced in the younger age
group [e.g. the OR for obesity in patients
with psoriasis as compared to the control
group were 2.2 (95% CI = 1.72.7) in pa-
tients below the age of 35 years and 1.6
(95% CI = 1.41.8) in patients above the age
of 65 years]. The association between pso-
riasis and ischemic heart disease was sta-
tistically significant only in patients above
the age of 35 years.
The associations between psoriasis and
hypertension, diabetes or obesity were
similar in females and males. The associa-
tion between psoriasis and ischemic heart
disease was more pronounced in males
(OR = 2.3, 95% CI = 2.22.5) as compared
to females (OR = 1.8, 95% CI = 1.72.0).
Multivariate models adjusting for age
and gender demonstrated that psoriasis
was associated with the metabolic syn-
drome, ischemic heart disease, diabetes
mellitus, hypertension, obesity and dyslip-
idemia (table 3).
Discussion
In the current study we observed that
psoriasis was associated with ischemic
heart disease, diabetes mellitus, hyperten-
sion, dyslipidemia and obesity. Our study
supports a previous observation by Hen-
seler and Christophers [11], Herron et al.
[12], Mallbris et al. [15] and other reports
that have been published previously [10,
13, 14]. Although our study was conducted
retrospectively, we propose that there is an
association between psoriasis and the met-
abolic syndrome.
The metabolic syndrome is a combi-
nation of diabetes mellitus type 2 (or in-
sulin resistance), hypertension, central
obesity and combined hyperlipidemia

Association between Psoriasis and the Dermatology 2008;216:152155 153

Metabolic Syndrome
(elevated LDL, decreased HDL, elevated Table 2. Cholesterol and triglyceride levels in patients with psoriasis and in the control
triglycerides). The diagnosis of the meta- group
bolic syndrome includes the diagnosis
that has been recently revised by the In- Psoriasis Control p
ternational Diabetes Federation [16] as patients group value
central obesity (according to ethnicity- (n = 16,850) (n = 48,677)
specific waist circumference) plus any 2
of the following criteria: (1) Raised tri- mean SD mean SD
glycerides: 1150 mg/dl (1.7 mmol/l), spe-
cific treatment for this lipid abnormality. Total cholesterol 194.8 39.7 193.2 40.0 <0.001
(2) Reduced HDL cholesterol: !40 mg/dl HDL cholesterol 48.3 12.9 49.6 13.4 <0.001
(1.03 mmol/l) in men, !50 mg/dl (1.29 LDL cholesterol 117.0 33.5 116.2 32.5 NS
mmol/l) in women, specific treatment for Triglycerides 147.8 88.8 138.5 85.1 <0.001
this lipid abnormality. (3) Raised blood
pressure: systolic 1130 mm Hg, diastolic
185 mm Hg, treatment of previously di-
agnosed hypertension. (4) Raised fasting Table 3. Regression models of the association between psoriasis and diseases in the
plasma glucose: fasting plasma glucose metabolic syndrome
1100 mg/dl (5.6 mmol/l), previously di-
agnosed type 2 diabetes.
Each component of the syndrome is a OR
target for a specific treatment. Drugs that
Metabolic syndrome 1.3 (1.11.4)
decrease insulin resistance (metformin
and thiazolidinediones) and altered life Ischemic heart disease 1.1 (1.01.2)
style reduce hyperglycemia and improve Diabetes mellitus 1.2 (1.01.3)
blood pressure and lipid profile. Previous Hypertension 1.3 (1.21.5)
studies have shown an increased risk of Obesity 1.7 (1.51.9)
atherosclerosis in patients with inflam- Triglyceride level 1.0 (1.01.3)
matory diseases such as systemic lupus HDL cholesterol level 0.9 (0.81.0)
erythematosus and rheumatoid arthritis
[46]. Our study demonstrates that pa- Figures in parentheses are 95% CI. In each model, the ORs are adjusted with age, gen-
tients with psoriasis have a significant as- der and smoking status of the subjects. The metabolic syndrome was defined in the cur-
sociation with each of the components of rent study as obesity plus any 2 of the following criteria: raised triglycerides, reduced
the metabolic syndrome. The possible ex- HDL cholesterol, hypertension or diabetes.
planation is attributed to the inflamma-
tory state mediated by altered function of
specific T cell subpopulations that occurs
in patients with the metabolic syndrome
and psoriasis.
Although we found a statistically sig- clude psoriasis severity as an independent and overeating, which leads to diseases
nificant difference in lipid levels between variable. that belong to the metabolic syndrome. It
the case and control groups, the clinical The regression models were adjusted is known that patients with psoriasis suf-
importance may be minor as the differenc- for age, gender and smoking and not for fer from a high proportion of depression
es are very small (table 2). other important confounders such as ge- [17], which indicates that the task of life-
In the current study cases were recruit- netic predisposition or alcohol consump- style changes would be difficult for these
ed from a large managed care organiza- tion. This was done because there is in- patients.
tion, using diagnoses assigned by the pri- complete data for these fields in the CHS Further prospective studies are needed
mary care physicians. Case patients were database. to establish our observation. However, we
also identified using medications which It is important to emphasize that asso- propose that psoriasis has a role as a new
are explicitly prescribed in Israel to pa- ciation alone was proven and not causali- risk factor for the metabolic syndrome.
tients with psoriasis (e.g. Neotigason) or ty. Cross-sectional studies are not able to It was observed in the multivariate
PUVA therapy. Therefore it is likely that establish a temporal sequence. Therefore models (table 3) that after adjustment for
more severe cases were identified. It is pos- it is not clear whether metabolic syndrome age, gender and smoking status, there was
sible that the association between psoriasis and its components are cause or conse- a substantial association between psoriasis
and the metabolic syndrome occurs only quence of psoriasis as it is also likely that and obesity or hypertension, with a less
in patients with moderate to severe psoria- patients with psoriasis change their life- imperative association between psoriasis
sis and not in patients with mild psoriasis. style habits including nutrition and smok- and diabetes or ischemic heart disease. Pa-
However, this distinction is beyond the ing. It is possible that the first event that tients with psoriasis have excessive pro-
scope of the current study and should be occurs is the onset of psoriasis, followed portions of obesity (70%), hypertension
investigated in prospective studies that in- by lifestyle changes that include smoking (30%), diabetes (20%) and ischemic heart

154 Dermatology 2008;216:152155 Cohen /Sherf /Vidavsky /Vardy /Shapiro /

Meyerovitch
disease (10%) as compared to the general
population. Thus, physicians taking care
of patients with psoriasis should consider
the concomitant presence of ischemic
heart disease, hypertension and diabetes
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