2.1. Psoriasis in the atopic
Unlike some observations carried out in northern Germany, links between psoriasis and atopy have been observed in France. This link needs to be investigated in all psoriatics with major pruritus. In fact, scratching produces a permanent Köebner, and eliminating pruritus makes for a considerable improvement in the psoriasis. Note that methotrexate and cyclosporine are effective treatments for severe atopy.
Even treated, hypertension contraindicates cyclosporine, but the existence of hypertension also interacts with psoriasis through the use of antihypertensive drugs. Beta-blockers are capable of provoking psoriasis, aggravating psoriasis or provoking psoriasiform toxidermia. Angiotensin-converting enzyme inhibitors and calcium inhibitors are equally capable of aggravating psoriasis. Faced with late-onset psoriasis or aggravation of psoriasis for reasons not understood, it is therefore important to ponder any part these drugs might have. The time-lag between starting to take the antihypertensive and the worsening of the psoriasis may be of several months, or indeed several years.
Diabetes, essentially type II, seems to be more common in psoriatics than in the control population, probably because of the metabolic syndrome. The diabetes interacts with the psoriasis treatment by means of frequent hypertriglyceridaemia, which can make more difficult to use retinoids and cyclosporine, and by means of hepatic steatosis, responsible for more frequent hepatic cytolysis on retinoids or methotrexate. Fat diabetes is often associated, perhaps because of overweight, with a degree of skin fragility that favours the development of psoriasis. Psoriasis in the diabetic has a tendency to be pruriginous and inflammatory. An improvement in diabetes, essentially through diet and physical activity, is often associated with an improvement of psoriasis.
Increase of body weight coincides very often with a worsening of psoriasis, particularly in adults. Furthermore, it is difficult to treat psoriasis in obese people because of the fragility of normal skin, decreasing the tolerance to topical treatment. The psoriatic lesions are often quite inflammatory. The skin folds are frequently affected and systemic treatment less tolerated . This decreased tolerance to systemic treatment may be the consequence of different pharmacokinetics modifications, particularly for the hydrophobic drugs that will accumulate in the fatty third sector. It may also be the consequence of the hepatic steatosis that is often associated. It is also possible that the appearance of obesity is often associated with a toxic lifestyle, a degree of neglect for the self-image, a certain inability to manage one’s affairs or certain types of depression. Moreover, it is noted that a psoriatic who is able to take himself in hand and slim down seems equally able to control better his psoriasis.
[|I do believe this is a very significant problem in psoriasis, above that in the general population. Comorbidities, in addition to hepatic steatosis, should also include cardiovascular disease, including hypertension, increased risk of diabetes, as well as potential increase in joint morbidity.|auteur215]
It must be explained to the patient that no one can treat psoriasis in an alcoholic and that cutting out the source of the intoxication is a preliminary to any therapeutic initiative. Alcohol alters in fact the pharmacokinetics of most systemic drugs, reduces their efficacy and increases the risk of side effects. In addition, the inability to break away from dependency bodes very badly for the ability to take charge of and manage a chronic illness. Some patients who do not suffer from alcoholism observe a psoriasis flare from one to three days after drinking alcohol even in normal amount. In these cases, a total alcohol intake restriction can be quite helpful.
The alcoholic can make use of all topical treatments, UVB phototherapy and balneo-PUVA therapy.
Retinoids may be used in the absence of hypertriglyceridaemia and if liver enzymes are within the normal range. A close follow-up of liver enzymes every two weeks may be necessary. In the event of alcoholic hepatic cytolysis, and if the patient has displayed the will to take responsibility for himself, it is possible to contemplate retinoids but only once the liver levels have normalized again.
Methotrexate is contraindicated for as long as the intoxication persists. If it is prescribed after the intoxication stops, it is wise to perform a hepatic biopsy puncture (or fibrotest + fibroscan) at the end of the first six months of treatment.
There is no data on cyclosporine used in psoriasis with alcoholic liver involvement.
Alcoholism is not a contraindication of biologicals.
2.6. Chronic hepatitis
Chronic autoimmune hepatitis and chronic viral hepatitis B or C pose the same problems as alcoholic hepatitis. To these can be added the interactions between treatments for hepatitis and psoriasis. The most commonly encountered problem being that psoriasis is exacerbated by the interferon prescribed to treat hepatitis C. Hepatotoxic antipsoriatic drugs cannot be used. Retinoids, which are only very mildly hepatotoxic, may be used with the hepatologist’s agreement and subjected to bimonthly biomonitoring. Cyclosporine may be equally used, with the hepatologist’s agreement while monitoring viral load development, as it is an immunosuppressant.
Acute life threatening hepatitis has been observed under Remicade?, whereas Raptiva? may increase liver enzymes. The prescription of biologicals on patients suffering from chronic hepatitis must be discussed with the hepatologist.
2.7. Renal insufficiency
Hydration of the skin is always very important in those suffering from renal insufficiency and may improve psoriasis.
UVB phototherapy poses no problem.
PUVA therapy can only be administered if the dialysis sessions are held after the PUVA therapy.
Soriatane may be used starting with extremely small doses, 10 mg every other day, while monitoring the effects of epithelial weakening most vigorously.
Methotrexate is contraindicated.
Conversely, when the patient is dialysed, cyclosporine can be used without any problem, since the risk of renal toxicity is no longer a problem.
Biologicals are not contraindicated on the account of kidney insufficiency.
2.8. Psoriasis and HIV
Psoriasis and seborrheic dermatitis are much more common in subjects suffering from acquired immunodeficiency than in the normal population (photo 95). Moreover, the psoriasis associated with HIV is often serious, generalized, given to being arthropathic. In these patients, all topical treatments may be used, but they are often insufficient.
Phototherapy and PUVA therapy may be used without any risk of aggravating the disease.
Retinoids are the treatment of choice.
Prescribing methotrexate for these immunodepressed patients is possible but only on second line, and an immunosuppressive drug like cyclosporine is contraindicated.
The use of biological treatments in these patients with high risk of infection is quite questionable.