(20 )

Ayanlowo O, Akinkugbe A. Clinical pattern of psoriasis in patients seen at a tertiary hospital in Nigeria. J ClinSci 2016;13:137-42.

Psoriasis is a chronic, papulosquamous disorder of the skin with variable morphology, characterized by
periods of remission and reactivity

Psoriasis has been estimated to affect 1–3% of the world’s population but is noted to be rare in the Africans
and North American Indians. Hospital based retrospective Study conducted in Nigeria Psoriasis was found
the prevalence of psoriasis in study population were 1.13% with male predominance , alcohol, and drugs were the most
reported predisposing factors to psoriasis. All types of psoriasis were found, and plaque psoriasis was the most common

Psoriasis is currently thought to result from genetically determined immune dysregulation (innate and
adaptive immunity) resulting in production of large amount of cytokines such as tumor necrosis factor-,
interferon-, IL-12 and recently implicated IL-17 and IL-23

Subsequently, there is resultant epidermal proliferation with loss of differentiation; dilatation and
proliferation of the dermal blood vessels and accumulation of inflammatory cells such as neutrophils and
T-lymphocytes

The immune dysregulation is thought to be stimulated byan undetermined antigen, provoked by

environmental factors such as trauma, infections, stress, drugs, sunlight, and metabolic derangement

Several genes have been associated with psoriasis; however, only PSORS1 is well-characterized and
confirmed in 30–50% of patients

Clinical features of psoriasis vary in morphology, extent of disease, duration, periodicity of flares, and
response to therapy.

The most common morphology is inflamed,edematous skin plaques, and coalescing papules covered with
silvery white scales. The characteristic redness and edema of inflammation are more obvious in white
skinned persons, whereas in blacks, it is less conspicuous or absent. The clinical types include plaque
psoriasis, guttate psoriasis, pustular psoriasis, erythrodermic psoriasis, scalp psoriasis, nail psoriasis, and
psoriatic arthritis
 20) Melsew Getinet Tsegaw and Dawit Bezabih Ayele, 2018. “Frequencies of psoriasis and its complications among type - ii diabetes
cases: a meta-analysis of short critical correlational reviews from 2010 through 2016” International Journal of Current Research in Life Sciences,
7, (08), 2542-2551

Skin disease is one of the most common human illnesses which pervades all cultures, occurs at all ages, and affects between 30
and 70% of individuals. Its detrimental effects on health range from physical incapacity to death .
Skin remains the 18th leading cause of health burden worldwide (Hay,2010). Patients of skin disease tend to experience physical,
emotional and socio-economic embarrassment in the society. Psoriasis is one amongst these notorious auto-immune disorders
that have deep psychological and social impacts.

Psoriasis involves the skin and nails, and is associated with a number of comorbidities,
Individuals with Psoriasis are reported to be at increased risk of developing other serious clinical conditions such as
cardiovascular and other non-communicable diseases (International Diabetes Federation,2014).
Psoriasis causes great physical, emotional and social burden. Quality of life (QoL), in general, is often significantly impaired
it can also corroborate other metabolism related problems. Specifically, chronic inflammation in Psoriasis leads to increased
insulin-like growth factor-II (IGF-II) in the skin and blood of Psoriasis patients.
IGF-II promotes epidermal proliferation and is also implicated in promoting atherosclerosis, in modulating body fat mass and
lipid metabolism in mice, and is linked to diabetes and hyperlipidemia in animal and human models (Rapp, 1999)
.
Studies have shown that, compared with the general population, patients with psoriasis are more frequently overweight
(25≤BMI<30) or obese (BMI>30)..

awareness amongst clinicians and the public at large, as

Psoriasis is increasing in magnitude with co-morbidities of
Diabetes mellitus disease in an alarming rate nationally and
globally, as a result, the clinician will design better treatment
modalities and improve the quality of life of the patient based
on the current generated knowledge and to be a base line data
for further researcher who are interested to investigate this
issue.

Psoriasis is a prototypical Th-1 inflammatory disease characterized by expansion and activation of Th-1 T cells, antigen
presenting cells, and Th-1 cytokines. Similarly, chronic Th-1 inflammation is an important to the pathophysiology of obesity,
Metabolic Syndrome, Diabetes, Atherosclerosis, and Myocardial Infarction.
circulating levels of Th-1 cytokines, adhesion molecules such as ICAM-1 and E-selectin,and angiogenic factors, such as vascular
endothelial growth factor (VEG-F) are elevated in Psoriasis, obesity, and coronary artery disease
The inflammatory mediators of these conditions have pleiotropic effects on diverse processes such as angiogenesis, insulin
signaling, adipogenesis, lipid metabolism, immune cell trafficking, and epidermal proliferation

Therefore, the metabolic aspects of chronic Th-1 inflammation, angiogenesis, and epidermal hyper-proliferation in Psoriasis have
the potential to impact other conditions such as Diabetes, Atherosclerosis, and Thrombosis. Conversely, inflammatory molecules
and hormones produced in conditions such as obesity, Diabetes and Atherosclerosis may influence the pathogenesis of Psoriasis
by promoting susceptibility to the development of Psoriasis or through increasing the severity of established Psoriasis

. Chronic inflammation can lead to dysfunction in a variety of organ systems. Th-1 inflammatory cytokines such as TNF-α are
elevated in the skin and blood of patients with Psoriasis and are critical to recruiting T cells to the skin and joints, promoting
angiogenesis, and epidermal hyper-proliferation. Similarly, TNF-α is secreted in adipose tissue and is an important feature
of the chronic low level inflammation seen in obesity. Insulin resistance, which is common to Psoriasis and the metabolic
syndrome, may be mediated in part through inflammatory cytokines such as TNF
Although inflammatory cytokines such as TNF have beenextensively studied, emerging data have recently demonstrated
the central role of IL-20 and IL-17 in the pathogenesis of Psoriasis. IL-17 is secreted by a new subclass of CD4+ cells,the Th17
cell, and plays an important role in the pathogenesis

(19) Asrat Endrias, Menakath Menon, Mihretu Wodeyes, Tamrat Abebe, Mohammed Mehdi, Ezra Belay, Daniel Seifu. Oxidative
Stress and
Human Psoriasis Diseases. American Journal of Laboratory Medicine. Vol. 5, No. 4, 2020, pp. 118-124. doi:
10.11648/j.ajlm.20200504.16

In Ethiopia, according to some studies, up to 80% ofpeople have one or more skin diseases.

(17) Arch Dermatol. 2011;147(4):419-424.Published online December

20,2010.doi:10.1001/archdermatol.2010.370

A survey by the National Psoriasis Foundation found that 75% of patients with psoriasis reported a moderate tolarge
negative impact of the disease on the quality of their life, with an alteration of everyday activities
The negative impact of psoriasis may not be limited to its cutaneous or psychosocial manifestations. Previous
studies have suggested a link between psoriasis,
a common inflammatory disorder, and individual components of the metabolic syndrome, such as obesity,
hypertension, diabetes, and dyslipidemia

Recent studies have estimated a prevalence of 15% to 24% for the metabolic syndrome in the general population

ASSESSMENT OF THE METABOLIC SYNDROME

Our primary definition of the metabolicsyndrome was based on the revised criteria from NCEP ATP III. 12 According to the
revised NCEP ATP III criteria, participants with 3 or more of the following criteria were defined as having the metabolic
syndrome: abdominal obesity (waist circumference, 102 cm in men and 88 cm in women); hypertriglyceridemia (triglycerides,
150 mg/dL [to convert to millimoles per liter, multiply by 0.0113]); low levels of high-density lipoprotein cholesterol (40 mg/dL
[to convert to millimoles per liter, multiply by 0.0259] in men and 50 mg/dL in women); high blood pressure (130/85 mm Hg);
and high fasting glucose levels (100 mg/dL [to convert to millimoles per liter, multiply by 0.0555])

The prevalence of the metabolic syndrome was 40% among psoriasis cases and 23% among controls. According to
2008 US census data, the projected number of patients with psoriasis aged 20 to 59 years with the metabolic
syndrome was 2.7 million.
The most common feature of the metabolic syndrome among patients with psoriasis was abdominalobesity, followed
by hypertriglyceridemia and low levels of high-density lipoprotein cholesterol
(16) Gisondi Paolo, Fostini Anna Chiara, Foss` a Irene, Girolomoni Giampiero, Targher Giovanni, Psoriasis and
the metabolic syndrome, Clinics in Dermatology (2017), doi: 10.1016/j.clindermatol.2017.09.005

Chronic plaque psoriasis is an immune-mediated inflammatory skin disease that is

strongly associated with the clinical features of the metabolic syndrome (MetS),
including abdominal obesity, hypertension, atherogenic dyslipidemia, type 2 diabetes,
insulin resistance, and non-alcoholic fatty liver disease. The strength of these
associations has been repeatedly confirmed by several observational studies. In
particular, the prevalence of MetS in patients with psoriasis ranges from 20 to 50%, with
a risk of having MetS that is at least double in psoriatic patients compared to non-
psoriatic control individuals.

MetS is also more common in patients with severe psoriasis than in those with mild skin
disease

Emerging evidence now suggests that psoriasis and MetS share multiple metabolic risk
factors, genetic background, and pathogenic pathways. The association between
psoriasis and MetS has important clinical implications.
Systemic conventional treatments should be used with caution in psoriatic patients with
MetS, because they could adversely impact on the coexisting metabolic disorders,
especially in the case of their chronic use.
Biologics appear to have a different safety profile compared to conventional treatments,
so that they are usually more tolerated. Collectively, dermatologists should pay close
attention to the early recognition of coexisting metabolic disorders and give appropriate
pharmacologic and non-pharmacologic (hypo-caloric diet and regular exercise)
recommendations to their patients
Introduction
Chronic plaque psoriasis is an inflammatory skin disease affecting 2–3% of the general
adult population.1 Psoriasis may have a negative impact on the physical and
psychosocial status of patients. About one third of patients have symptoms of
arthropathy, which may be very disabling in the more severe cases;2 moreover,
moderate to severe psoriasis is frequently associated with metabolic disorders including
obesity, diabetes, dyslipidemia, non-alcoholic fatty liver disease, and MetS.
Dermatologists could play an important role in
the early recognition and assessment of these comorbidities, selecting appropriate
treatments for psoriasis, and giving the correct recommendations on diet and physical
activity to patients. We provide an overview on general aspects of MetS and frequency
of its association with psoriasis to highlight putative pathogenic links between psoriasis
and metabolic disorders, as well as to facilitate the management of psoriasis with
pharmacologic treatments and lifestyle interventions

Definition, epidemiology and principles of management of MetS

MetS is a pathologic condition typically characterized by the combination of various
interrelated metabolic disorders that include abdominal obesity, insulin resistance,
dysglycemia, atherogenic dyslipidemia, and hypertension.
however, it is still unclear whether MetS has a single cause, and it appears that it can
be precipitated by multiple underlying risk factors. The most important of these
underlying risk factors are abdominal obesity and insulin resistance. Other associated
conditions can include physical inactivity, aging, hormonal imbalance, and genetic or
ethnic predispositions
Various diagnostic criteria for MetS have been proposed by different scientific
organizations over the past decade These clinical definitions for the diagnosis of MetS
often share the same risk abnormalities but do differ in the detail and criteria

It is important to note that many cardio metabolic risk factors that contribute to MetS are
acquired and potentially modifiable. The mainstay of management for MetS is lifestyle
intervention, which includes a hypocaloric diet, regular physical exercise, smoking
cessation, and reduction of daily alcohol intake. 4,8,9 When lifestyle intervention is not
sufficient, appropriate pharmacologic interventions to target the individual features of
MetS should be used Metformin and glitazones (pioglitazone), by improving
hepatic/peripheral insulin sensitivity, are the most widely used pharmacologic agents for
the treatment of MetS. Some novel drugs, such as glucagon like peptide-1 (GLP-1)
agonists and sodium glucose transporter-2 (SGLT-2) inhibitors, might also be an
alternative pharmacologic option, particularly in patients with established type 2
diabetes,
because they also may reduce body weight.10 Lipid-lowering agents, such as statins,
are
indicated in the presence of dyslipidemia, even in combination with either fibrates or
omega-3 fatty acids, principally to treat atherogenic dyslipidaemia (typically
characterized
by high triglycerides and low HDL-cholesterol levels). 4,10,11 An anti-hypertensive drug
therapy with renin-angiotensin-system inhibitors represents a safe and well-tolerated
first
option in presence of the hypertension. 12 Finally, clinicians should also consider bariatric
surgery for patients with severe obesity. Bariatric surgery, as an effective
nonpharmacologic treatment to decrease body weight in patients with severe obesity,
markedly diminshes all clinical features of MetS (including type 2 diabetes

(26)

It is worrying how MetS have recently become highly prevalent in modern society, not only in the USA,
but also in Europe, some Asian countries, and Latin America . It has been reported that changes in
lifestyle promoting exercise are key in preventing and managing MetS , supporting the theory of central
obesity plays an important role in its pathophysiology .
Considering how mere lifestyle changes could prevent MetS, early detection becomes a necessity to not
only promote a healthier lifestyle as a whole, but also to devise clinical diagnostic methods aimed to
easily identify people at risk, and therefore avoid possible MetS-associated CVD and T2D incidence

Metabolic Syndrome Epidemiology: A widereaching problem

The worldwide prevalence of MetS has steadily risen over the years, hand-in-hand with the development of
industrialization and globalization (43,44). MetS have been currently estimated to affect approximately 30 % of the
global population and is associated with an increased risk of morbidity and mortality that is two to three times higher
compared to healthy subjects (45). MetS incidence seems to increase with age (46) and is inclined to affect women
more frequently, which points out sex as an important intervening factor in its appearance

Factors associated with metabolic syndrome: A biopsychosocial approach

various genome-wide association (GWA) studies carried out along the years have identified some candidate genes
capable of altering many metabolic pathways, such as insulin signaling,lipid metabolism, glucose uptake, and
appetite regulation

Concerning lifestyle-related factors, certain dietary patterns arise as the likeliest to increase
MetS incidence. The Western diet has long been singled out as the main culprit, characterized by high-sugar, high-
fat food, with excessive red meat and refined flour consumption
The empty calorie diet is also responsible for increasing the risk for MetS, typically distinguished by alarmingly low
fruit and vegetable intake added to high-fat food and refined sugar consumption
Regarding psychobiological habit Lowto moderate alcohol consumption is linked to alower prevalence of MetS, and
has a favorable effect on some metabolic aspects, resulting in a significant HDL-c increase

Additionally, smoking is also consistently associated with MetS incidence, as the risk for MetS rises with the
number of cigarettes smoked

Conversely, decreased daily physical activity in healthy young adults has been associated with negative metabolic
consequences, including a drop in insulin sensitivity, and an alarming increase of visceral fat
Therefore, it is clear that MetS is a common consequence of leading an unhealthy lifestyle, rife with physical
inactivity, high-calorie diet ,smoking and/or drinking habits, added to preexistent genetic and epigenetic factors that
further tip the balance in favor of MetS

THE STANDARD IN METABOLIC SINDROME MANAGEMENT

The foundations of MetS management are essentially lifestyle modifications, like changes in dietary and
exercise habits (148). Moreover, current evidence supports that diet and exercise, along with
pharmacologic and surgical interventions, may inhibit the progression of MetS to T2D or CVD (149-151).
Before providing the evidence that every physician should consider when approaching a patient with
metabolic syndrome, it is worth mentioning that proper management is focused on each altered
component. For purely academic purposes, therapeutical strategies will be subdivided into
pharmacological and non-pharmacological
Non-pharmacological management A healthy lifestyle is the pillar of MetS treatment. Diet, physical
activity, sleep, emotion control, and avoidance of tobacco and other drugs that affect satiety or body
weight are crucial targets, each of which requires a systematic evaluation and a patient-centered
intervention

Diet Lifestyle modifications and weight loss are considered the most important initial steps of MetS
treatment. Westernized diets are strongly associated with a higher risk of developing metabolic
syndrome . Conversely, different diets like Mediterranean-style diets, characterized by high dairy, fish,
wine, and cereal grain intakes seem to be associated with lower risk and, possibly, MetS resolution in
already diagnosed patients, especially when combined with exercise programs . Regarding wine
consumption, epidemiologic studies suggest that moderate wine intake may protect against MetS
onset . Besides, diets that promote fruits, vegetables, and low-fat dairy products consumption such as
the DASH (Dietary Approaches to Stop Hypertension)–style diet, show positive effects lowering BP and
may lower the risk of stroke and CVD ; what is more, even modest adherence to the DASH diet is
associated with a lower risk of all-cause mortality . Likewise, other current popular diets have been
related to MetS parameters improvement. Such is the case of ketogenic diets, which can be defined as
the calculated limitation of dietary carbohydrate intake to boost ketones production and promote a
metabolic effect that balances glycemia and minimizes insulin requirements . Beneficial effects of a
“wellformulated” ketogenic diet are known to be weight loss , significant total cholesterol reduction,
increased HDL-c, and a shift in size and volume of LDL particles , a phenomenon that appears even more
robust in patients with diabetes .
 Physical Activity Exercise is considered to be one of the main interventions to treat MetS. Currently,
physical activity recommendation is at least 150-175 min/week, in conjunction with dietary energy
restriction, targeting weight loss of 5 %-7 %. The latter has demonstrated reductions of 40 %- 70 % in the
risk of developing T2D in people with impaired glucose tolerance (165). Also, exercises can be of
moderate-intensity for at least 30 minutes at a time, 5 days per week (ideally, 7 days per week), and
maintaining long-term adherence (165). Along these lines, a recent systematic review of 53 studies that
evaluated 66 lifestyle intervention programs reported that, compared with usual care, diet and physical
activity promotion programs reduced T2D incidence, body weight, and fasting blood glucose while
improving other cardiometabolic

Surgical treatment Bariatric surgery (BS) and trans catheter bariatric embolotherapy
the two surgical options that have demonstrated positive effects on obesity or MetS management
The first is a therapeutic alternative for obesity, which is comprised of several surgical procedures able
to generate structural and metabolic changes in the digestive system, hence allowing weight loss ). In
addition, the main indications for BS in adults are patients aged between 18 and 55 years, BMI ≥40
kg/m2 or BMI between 35-39.9 kg/m2 in combination with some obesity-related comorbidity (T2D, HBP,
obstructive apnea sleep) and history of therapeutic failure in weight loss or the inability to maintain it
for ≥ 18 months after the administration of pharmacological and non-pharmacological treatment under
specialized supervision; that is to say, this is one of the last options to manage MetS

Pharmacological management
Pharmacologic interventions may lessen the contribution of MetS to T2D, coronary diseases, stroke, and other
disabilities, but it is not the kickoff

Hypertension
Current hypertension treatment is based on the recommendations of the Seventh Report of the Joint
NationalCommittee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) guidelines
to achieve a goal blood pressure (BP) of less than 140/90 mmHg or less than 130/80 mmHg in T2DMpatients

Similarly, the statements above are identical to those recently published by The International Society of
Hypertension (ISH) where the essential objective is BP reduction by at least 20/10 mmHg, ideally less than 140/90
mmHg, and the optimal goal in <65 years is <130/80 mmHg if tolerated (but >120/70 mmHg), and in those
≥65years the target BP is <140/90 mmHg if tolerated, but it is advised to consider an individualized BP target in the
context of frailty

Furthermore, some authors encourage to use angiotensin-converting enzyme inhibitors (ACEI) and angiotensin
receptor blockers (ARBs) rather than diuretics or beta-blockers when medication is indicated, given that the latter
may induce insulin resistance, weight gain, and increase the risk of hyperglycemia because of the decrease perfusion
to skeletal muscle

Dyslipidemia
The management of elevated LDL-C brings into consideration all of the statins. Statins are a class of drugs that, in
their active hydrolyzed form, are specific inhibitors of 3-hydroxy- 3-methylglutaryl-coenzyme A (HMG-CoA)
reductase, which is responsible for catalyzing the conversion of HMG-CoA to mevalonate, an earlyrate-limiting step
in the cholesterol biosynthesis pathway

but the treatment scheme should be individualized and titrated to achieve guideline-recommended goals
Accordingly, in patients with a high risk of atherosclerotic cardiovascular disease (ASCVD) maximally tolerated
statin therapy to reduce LDL-C levels by ≥50 % is recommended
Notably, statin therapy is associated with a modest increase in the risk of new-onset diabetes;
thus, patients should be reassured that the benefits of statins in preventing cardiovascular disease events far
outweigh the potential risk of hyperglycemia

Cholesterol guidelines from the American College of Cardiology emphasize the use of statins over non-statin
therapies

Hyperglycemia and obesity

typically, hyperglycemia management in patients with metabolic syndrome starts with lifestyle changes and an
insulin-sensitizing agent, such as metformin (197,198). Moreover, in patients with metabolic syndrome who are also
in the highest-risk quartile of progression to diabetes, metformin 850 mg, twice a day, reducesthe risk by about 20 %
over 3 years
In contrast, intensive lifestyle modification over 10 years reduces the absolute risk of diabetes by 34 % and
metformin reduces the risk by 18 % for all patients at increased risk
Additionally, metformin enhances weight reduction and improves lipid profile, by modestly reducing cholesterol
and triglyceride levels and vascular integrity; hence, it can be considered as the first-choice drug in diabetics with a
BMI greater than 27 %

Notably, weight loss goals in non-diabetic patients with a BMI >30 kg/m2 or with a BMI> 27 kg/m2 alongside
comorbidities is > 5 %; conversely, in diabetic patients a > 3 % weight loss is expected after a 3-month treatment

Orlistat and liraglutide are two of the treatments approved for clinical use in obesity. The former is a potent and
selective pancreatic lipase inhibitor that reduces intestinal fat absorption and visceral abdominal fat
(15)

Psoriasis is a chronic inflammatory skin disorder in which proinflammatory cytokines including IL-6 and TNF-α
increase both locally and systematically. It is thought that chronic inflammation results in metabolic diseases and
proinflammatory cytokines give rise to the development of atherogenesis, peripheral insulin resistance, hypertension, and type 2
diabetes.

Department of Dermatology, Goztepe Training and Research Hospital, Istanbul, Turkey 22 November 2011; Accepted 21
December 2011 Study consisted of 115 plaquetype psoriasis patients and 140 healthy individuals
Compared to the control group, metabolic syndrome, diabetes mellitus, and hypertension were found to be
higher in psoriasis patients. Metabolic syndrome was increased by 3-folds in psoriasis patients and was more prevalent in women
than in men. It was determined that the prevalence of metabolic syndrome was higher in psoriasis patients after the age of 40.
Metabolic syndrome was not related to smoking, severity of psoriasis, and duration of disease

Recent research reported an association between psoriasis and metabolic disorders such as obesity, dyslipidemia,
and type II DM and it is shown that severe psoriasis might be associated with increased mortality rate due to
cardiovascular disorders.
Since psoriasis is characterized by a systemic inflammation which involves numerous cytokines and inflammatory
markers in particular TNF-α, it may predispose the patients to metabolic disorders

not receiving any systemic or local antipsoriatic treatmentfor the last 4 weeksInformation sheets
for the patients included age, gender, weight, height, body mass index (BMI), waist circumference, smoking habits,
blood pressure, age of onset, and duration of the diseaseSeverity of psoriasis was assessed by psoriasis area severity
index (PASI) and accepted as severe in patients with PASI > 10 and mild/moderate in patients with PASI ≤ 10 .
BMI was calculated as weight/height (kg/m2) and metabolic syndrome was diagnosed in the presence of central
obesity in addition to two or more criteria of the International Diabetes Foundation: waist circumference ≥94 cm in
men or ≥80 cm in women; hypertriglyceridemia ≥150 mg/dL; HDL <40 mg/dL in men or <50 mg/dL in women;
blood pressure ≥130/85 mmHg; fasting blood glucose ≥100 mg/dL.

Sommer et al. reported that there is a significant association between psoriasis and type II DM,
hypertension, hyperlipidemia, and coronary artery disease and MS is increased by twofolds in a study they
conducted in 581 patients .MS was more prevalent in women
and female gender increased the prevalence of MS by 3-fold

(14) A Cross-Sectional Study in the Italian PopulationA total of 720 patients were enrolled (n = 360
per group).
The prevalence of MetS was 26.84 % in the
psoriatic population and 15.16 % in the control population

Psoriasis is a common, chronic, inflammatory skin disease, which affects about 2–3 % of the population worldwide
While the risk of mortality for patients with mild psoriasis is similar to that for the general population, there
is an increased overall mortality risk for patients with severe psoriasis . Even though psoriasis was considered to be
confined to the skin until recently, it is now accepted as a chronic
inflammatory disease with systemic manifestations mirroring those of other autoimmune diseases, such as
rheumatoid arthritis and Crohn’s disease . The pathogenesis of psoriasis includes both genetic
predisposition and precipitating factors, which lead to
activation of the immune system [6–8]. Recent evidence
suggests that the psoriatic autoimmune process might start
as a local inflammatory mechanism leading to permanent
activation of T cells, thus producing inflammatory mediators. Consequently, lesions might evolve in an interplay
between cells and mediators of the immune system with
innate and adaptive functions, and skin epithelium and
connective tissue cells [8].
The metabolic syndrome (MetS) is a cluster of cardiovascular risk factors, including glucose intolerance or
insulin resistance, dyslipidemia, hypertension, and central
obesity [9]. MetS is associated with greater cardiovascular
risk and is a predictor of cardiovascular disease, diabetes,
and stroke [10]. There is strong evidence showing an
association between MetS and psoriasis. A diagnosis of
MetS is more frequent in psoriatic patients than in the nonpsoriatic population and, furthermore, it is directly
correlated with disease duration [11].
As MetS confers a substantial disease burden, including
an increased risk of stroke, type 2 diabetes mellitus, coronary artery disease, and fatty liver disease [10], an
understanding of its association with psoriasis is important.
The majority of the reported studies examining the relationship between psoriasis and MetS were performed in
American and European countries, and relate to specific
populations, which may be differentiated by factors that
influence the development of MetS, including diet and
lifestyle. As data on the prevalence of MetS in Italian
patients with psoriasis are limited, we undertook a crosssectional study to determine the prevalence of MetS and to
examine the implications of disease severity, type 2 diabetes mellitus, and cardiovascular disease in a large cohort
of Italian psoriatic patients representative of the whole
population.
2 Material and Methods
2.1 Study Protocol
We planned a cross-sectional study involving 13 dermatological clinics in Italy (two in the north, seven in the
central regions, two in the south, and two on the two main
Italian islands), which were required to enroll a total of 720
subjects (360 psoriatic patients and 360 control subjects).
The primary endpoint was comparison of the prevalence of
MetS in the two groups, as defined by National Cholesterol
Education Program–Adult Treatment Panel (NCEP–
ATP III) criteria (a diagnosis of MetS is made if at least
three of the following items are present: waist circumference [120 cm in males and [88 cm in females; level of
blood triglycerides C150 mg/dL; high-density lipoprotein
[HDL] cholesterol level B40 mg/dL in males and B50 mg/
dL in females; fasting glucose level C110 mg/dL; blood
pressure C130/85 mm Hg [12]).
Secondary endpoints included evaluation of the association between the Psoriasis Area and Severity Index
(PASI) value and the prevalence of MetS, and between
the PASI value and each MetS diagnostic factor. Furthermore, the prevalence of type 2 diabetes mellitus,
diabetes risk, and cardiovascular risk was assessed i
(11) A hospital-based, cross-sectional study with 244 psoriatic patients and 163 control subjects with skin
diseaseClinical Center of Serbia, Belgrade, from October 2011 to October 2012

The adjusted odds ratios (ORs) and 95% confdence intervals (CI) for psoriasis patients vs. non-psoriasis patients were
2.66 (95% CI, 1.58-4.42) for metabolic syndrome, 3.81 (95% CI, 2.30-6.31) for hypertension, 2.29 (95% CI, 1.39-3.78) for
central obesity, 1.92 (95% CI, 1.08-3.41) for hyperglycemia, 1.87 (95% CI 1.18-2.96) for low high-density lipoprotein
cholesterol level, and 1.42 (95% CI, 0.87-1.04) for hypertriglyceridemia

A higher prevalence of metabolic syndrome and its components in patients with psoriasis than in controls, regardless
of disease severity, emphasizes the need for early treatment and follow-up of all psoriatic patients with respect to
metabolic diseases

(10)
psoriasis patients appear to be at higher risk for diabetes mellitus and cardiovascular disease

(9) 2007 British Association of Dermatologists • British Journal of Dermatology 2007 157, pp68–73 We performed a hospital-based
case–control study on 338 adult patients with chronic plaque psoriasis and 334 patients with skin diseases other than
psoriasis.
Metabolic syndrome was significantly more common in psoriatic patients than in controls (30Æ1% vs. 20Æ6%,
odds ratio 1Æ65, 95% confidence interval 1Æ16–2Æ35; P = 0Æ005) after the age of 40 years. Psoriatic patients
also had a higher prevalence of hypertriglyceridemia and abdominal obesity, whereas hyperglycaemia, arterial
hypertension
Metabolic syndrome was significantly more common in psoriatic patients
than in controls (30.1% vs. 20.6%, odds ratio 1.65, 95% confidence interval
1.16–2.35; P = 0.005) after the age of 40 years.

Relevant data collected included age, gender, weight, height, body mass index
(BMI), waist circumference, blood pressure, smoking habit,
age of psoriasis onset, type and severity of psoriasis, presence
and distribution of psoriatic arthropathy and concomitant
medications. BMI was calculated as weight (kg) ⁄height (cm2).
To determine waist circumference, we located the upper hip
bone and placed a measuring tape at the level of the uppermost part of the hipbone around the abdomen (ensuring that
the tape measure was horizontal). The tape measure was snug
but did not cause compressions on the skin. Blood pressure
was recorded as the average of two measurements after subjects had been sitting for 5 min. Severity of psoriasis was
assessed according to Psoriasis Areaand Severity Index
(PASI),19 body surface area (BSA) measurement and static
Physician’s Global Assessment (PGA).20 Chronic plaque psoriasis was considered localized or disseminated when it covered
less or more than 10% of the BSA. Metabolic syndrome was
diagnosed in the presence of three or more criteria of the
National Cholesterol Education Program’s Adult Panel III (ATP
III): waist circumference > 102 cm in men or > 88 cm in
women; hypertriglyceridaemia > 1Æ7 mmol L)1; high-density
lipoprotein (HDL) cholesterol < 1Æ0 mmol L)1 in men or
< 1Æ3 mmol L)1 in women; blood pressure > 135 ⁄85 mmHg;
fasting plasma glucose > 6Æ1 mmol L)1.21 Venous samples
were taken at the enrolment visit after the subjects had fasted
overnight (at least 8 h). Serum cholesterol and triglycerides
were measured with enzymatic procedures. Plasma glucose
was measured using a glucose oxidase method

(8) Nisa N, Qazi MA. Prevalence of metabolic syndrome in patients with psoriasis. Indian J Dermatol Venereol Leprol
2010;76:662-5.

Metabolic syndrome was signifcantly more common in psoriatic patients than in controls 42(28%) vs
9(6%), odds ratio (OR) = 6.09, P<0.05. Psoriatic patients also had a
signifcantly higher prevalence of hypertriglyceridaemia (73/150 among cases vs 24/150
among controls; P<0.05), arterial hypertension (74/150 among cases vs 24/150 among
controls; P<0.05) and impaired fasting plasma glucose levels (27/150 among cases vs 04/150
among controls; P<0.05). Psoriatic patients with metabolic syndrome had mean disease
duration of 13.67±11.87 years against 6.46±5.80 years in those without metabolic syndrome

A total of 859 psoriasis patients and 1,718 controls were recruited in an ageand sex-matched cross-sectional study.
Metabolic syndrome occurred in 14.3% of the psoriasis patients as opposed to 10.0% of the control participants (P =
0.001). Psoriasis patients had a higher prevalence of overweight/obesity, hyperglycemia and dyslipidemia when
compared with controls. Meanwhile, psoriasis patients with metabolic syndrome were older, and had an older age of
onset and a longer disease duration when compared with those without metabolic syndrome.

 Worldwide psoriasis prevalence rates range from 0.6 percent to 4.8 percent( uptodate )
Psoriasis affects men and women equally , and is seen in all races. Although psoriasis can
begin at any age, there seem to be two peaks in onset: one between ages 20 and 30 and
another between 50 and 60

Although genetic predisposition clearly plays a role in the development of psoriasis

environmental and behavioral factors frequently affect the course of disease. Numerous
potential "triggers" for psoriasis have been identified, such as infection, physical or
psychological stress, and medications; however, they are not common to every patient.

Patients with psoriasis tend to show improvement in summer months, likely due to greater
exposure to ultraviolet radiation from sunlight and perhaps to increased relative humidity.

Smoking is associated with an increased risk of psoriasis and also with increased severity of
psoriasis
 8 In study done in india 2010 prevalence of metabolic syndrome were increased in psoriatic patient as compare to
the control group( 28 %vs 6%)

30 And also in study done in germany ,brasil hospital based studyin 2017 MS prevalence in psoriasis patients (49.4%)
with controls (35.0%) show hih in psoriasis

29 The current study aimed to examine the association of metabolic syndrome with
psoriasis in an Afghan population 2021 The prevalence of metabolic syndrome was
higher among patients with psoriasis compared to controls (36.8% vs 21.1%) with OR of
2.18 (p=0.009).
Overweight/obesity was more prevalent among cases compared
to controls (65.8% vs 41.2%)

1 ) Retrospective design study done in 2016 Ankara, Turkey The prevalence of metabolic syndrome was higher
in women than in men. Psoriasis was more severe in patients with central obesity, diabetes and smoking than in
those without
(p<0.05 for each)
Metabolic syndrome was found in
12.6% of the patients [central obesity (38.7%), hypertension (14.3%), dyslipidemia (18.6%), diabetes (9.2%)], while
50.3% had
smoking, and 3.3% had alcohol consumption

2) study done singapor in 2009 The prevalence of MetS was 45.1%. MetS was 44%
more prevalent in patients older than 50 years (p = 0.02). which is 3 fold increasement from the general population

4) study in England in 2011 directly assessed psoriasis severity relates

to the prevalence of metabolic syndrome and its components A population-based, cross-sectional study
Psoriasis is associated with metabolic syndrome and the association increases with increasing disease severity
National Cholesterol Education Program Adult Treatment Panel III criteria.

6) hospital based cross-sectional study in china in 2018 on prevalence of metabolic disorder has shown Metabolic syndrome
occurred in 14.3% of the psoriasis patients as opposed to 10.0% of the control participants

7) study in Belgium Metabolic syndrome is more prevalent in patients with PsO than in PsA patients, mainly determined
by the higher prevalence of abdominal obesity in PsO compared with PsA group.
Received: 6 August 2012; Accepted: 15 November 2012

12 study in California 2010 patients with PsA have a very high prevalence of metabolic syndrome, which
predisposes them to an increased risk of both diabetes and ASCVD.

Metabolic syndrome was significantly more common in psoriatic patients

9) Study in Italy 2007
than in controls (30Æ1% vs. 20Æ6%, odds ratio 1Æ65, 95% confidence interval
1Æ16–2Æ35; P = 0Æ005) after the age of 40 years.
Psoriatic patients also had a
higher prevalence of hypertriglyceridemia and abdominal obesity, whereas
hyperglycemia, arterial hypertension and high-density lipoprotein cholesterol
plasma levels were similar
Although psoriasis patients were more frequently smokers, the association of psoriasis with metabolic syndrome was
independent from smoking. There was no correlation between severity of psoriasis and prevalence of metabolic
syndrome
11) A hospital-based, cross-sectional study in Serbia 2017 failed to fnd any statistically signifcant association
between the
metabolic syndrome and clinical severity of psoriasis
A higher prevalence of metabolic syndrome and its components in patients with psoriasis than in controls, regardless
of disease severity

14 a cross-sectional study involving 13 dermatological clinics in Italy 2014 The prevalence of MetS was 26.84 % in
the psoriatic population and 15.16 % in the control population

15 2011 turky Metabolic syndrome was increased by 3-folds in psoriasis patients and was more prevalent in women
than in men. It was determined that the prevalence of metabolic syndrome was higher in psoriasis patients after the age of 40.
Metabolic syndrome was not related to smoking, severity of psoriasis, and duration of disease.

17 study in bosten 2010 The prevalence of the metabolic syndrome was

40% among psoriasis cases and 23% among controls.

,
38 study in Johannesburg, South Africa The prevalence of metabolic syndrome (MetS) (52.4%
vs. 33.7%; P = 0.007), type 2 diabetes (T2D) (25.2% vs. 4.1%; P < 0.0001), and hypertension
(70.9% vs. 46.6%; P = 0.001) were all higher in the psoriasis group.
Goolam Mahyoodeen, N., Crowther, N. J., Snyman, T., Pillay, L., & Tikly, M. (2018). High burden of the metabolic
syndrome and its component disorders in South Africans with psoriasis. International Journal of
Dermatology. doi:10.1111/ijd.14348 

Metabolic syndrome criteria

39 Yamagishi, K., & Iso, H. (2017). The criteria for metabolic syndrome and the national health screening
and education system in Japan. Epidemiology and Health, 39,
e2017003. doi:10.4178/epih.e2017003

Metabolic Syndrome Measure Categorical Cut Points Elevated waist circumference* Population- and
country-specific definitions Elevated triglycerides (drug treatment for elevated triglycerides is an
alternate indicator†) 150 mg/dL (1.7 mmol/L) Reduced HDL-C (drug treatment for reduced HDL-C is an
alternate indicator†) 40 mg/dL (1.0 mmol/L) in males; 50 mg/dL (1.3 mmol/L) in females Elevated blood
pressure (antihypertensive drug treatment in a patient with a history of hypertension is an alternate
indicator) Systolic 130 and/or diastolic 85 mm Hg Elevated fasting glucose‡ (drug treatment of elevated
glucose is an alternate indicator) 100 mg/dL HDL-C indicates (40(Alberti et al(2009) Harmonizing the
Metabolic Syndrome DOI: 10.1161/CIRCULATIONAHA.109.192644)

A number of other lifestyle factors may have a relation to psoriasis

Psoriasis has been associated with obesity and higher body mass index (BMI) in adults and
children
(17) Arch Dermatol. 2011;147(4):419-424.Published online December
20,2010.doi:10.1001/archdermatol.2010.370

8 ) Nisa N, Qazi MA. Prevalence of metabolic syndrome in patients with psoriasis. Indian J
Dermatol Venereol Leprol 2010;76:662-5.
(20 ) Ayanlowo O, Akinkugbe A. Clinical pattern of psoriasis in patients seen at a tertiary
hospital in Nigeria. J ClinSci 2016;13:137-42.
20) Melsew Getinet Tsegaw and Dawit Bezabih Ayele, 2018. “Frequencies of psoriasis and its
complications among type - ii diabetes cases: a meta-analysis of short critical correlational
reviews from 2010 through 2016” International Journal of Current Research in Life Sciences,
7, (08), 2542-2555

31) Seth D, Cheldize K, Brown D, Freeman EF. Global Burden of Skin Disease: Inequities and
Innovations. Curr Dermatol Rep. 2017 Sep;6(3):204-210. doi: 10.1007/s13671-017-0192-7.
Epub 2017 Aug 7. PMID: 29226027; PMCID: PMC5718374.

(19) Asrat Endrias, Menakath Menon, Mihretu Wodeyes, Tamrat Abebe, Mohammed Mehdi,
Ezra Belay, Daniel Seifu. Oxidative Stress and Human Psoriasis Diseases. American Journal of
Laboratory Medicine. Vol. 5, No. 4, 2020, pp. 118-124. doi: 10.11648/j.ajlm.20200504.16

(16) Gisondi Paolo, Fostini Anna Chiara, Foss` a Irene, Girolomoni Giampiero, Targher
Giovanni, Psoriasis and the metabolic syndrome, Clinics in Dermatology (2017), doi:
10.1016/j.clindermatol.2017.09.005

30 Work carried out in the Dermatology Service of the Evangelic University Hospital of Curitiba, Paraná, Brasil.
DATE OF SUBMISSION: 23-Aug-2017 DATE OF ACCEPTANCE: 09-Sep-2017 CORRESPONDING AUTHOR: Thelma Skare
Rua Padre Anchieta, 2770.CEP 80730-000 - Curitiba -PR, Brasil. E-mail: tskare@onda.com.br
Literature review

 
Metabolic syndrome and psoriasis

MetS is a pathologic condition typically characterized by the combination of various interrelated

metabolic disorders that include abdominal obesity, insulin resistance,
dysglycemia, atherogenic dyslipidemia, and hypertension.

Various diagnostic criteria for MetS have been proposed by different scientific organizations
over the past decade These clinical definitions for the diagnosis of MetS often share the same
risk abnormalities but do differ in the detail and criteria
WHO defined MS as glucose intolerance, impaired glucose tolerance (IGT) or diabetes mellitus
(DM), and/or insulin resistance, together with two or more of the components listed below:
1. Raised arterial pressure, i.e., ≥140/90 mm of Hg
2. Raised plasma triglyceride (≥ 150 mg/dl) and/or low HDL-C (<35 mg/dl in men and <39
mg/dl in women)
3. Central obesity, i.e., waist/hip ratio (WHR) >0.9 in men and >0.85 in women and/or body
mass index (BMI) >30 kg/m2
4. Microalbuminuria, i.e., urinary albumin excretion rate ≥ 20 μgm/minute or
albumin/creatine ratio ≥ 30 μgm
The race- and gender-specific WC cutoffs suggested are as follows
 28

The exact underlying pathway linking the two diseases is complex and not fully understood.
However, in several studies, it has been observed that in both diseases inflammatory and anti-
inflammatory markers produce oxidative damage to nucleic acids DNA/RNA damage; 8-
hydroxy-2′-deoxyguanosine, 8- hydroxyguanosine, and 8-hydroxyguanine. Adipokines, secreted
by adipose tissue, increases insulin sensitivity and display antiatherogenic and anti-inflammatory
effects. Adiponectin causes insulinsensitizing effect by binding to the receptors AdipoR1 and
AdipoR2, prompting activation of adenosine monophosphate dependent kinase (AMPK),
peroxisome proliferator-activated receptor alpha (PPAR-α), and apparently other yet obscure
flagging pathways. Weight reduction essentially raises plasma adiponectin levels. Insulin
resistance, dyslipidemia, and atherosclerosis are related to a decrease in adiponectin levels.
Leptin is another major adipokine leptin. Its major role is to hinder hunger, fire up
thermogenesis, boost fatty acid oxidation, improve hyperglycemia, and diminish body weight
and fat. The other is resistin, which can trigger a proinflammatory state by regulating various
biological processes, thus contributing to inflammatory diseases and CRP, which is one of the
most used makers worldwide for inflammation. 27

In a recent study of 1.3 million German health care recipients, metabolic syndrome was 2.9-fold
more frequent among patients with psoriasis, and the most common diagnoses were hypertension
(35.6% in psoriasis vs 20.6% in control participants) and hyperlipidemia (29.9% vs 17.1%) and
in 2010 India hospital based case control study done ,metabolic syndrome was 4.6 fold more
frequent than the control.
Further more The prevalence of the metabolic syndrome was 40% among psoriasis cases and
23% among controls. According to 2008 US census data, the projected number of patients with
psoriasis aged 20 to 59 years with the metabolic syndrome was 2.7 million.

The most common feature of the metabolic syndrome among patients with psoriasis was
abdominal obesity, followed by hypertriglyceridemia and low levels of high-density lipoprotein
cholesterol
Management of metabolic syndrome in psoriasis pt
The mainstay of management for MetS is lifestyle intervention, which includes a hypocaloric
diet, regular physical exercise, smoking cessation, and reduction of daily alcohol intake.
When lifestyle intervention is not sufficient, appropriate pharmacologic interventions to target
the individual features of MetS
There are several factors to take into considerations before starting treatment in psoriatic
diseases(27)
Comorbidities ought to be considered when choosing the best possible medication and biological
treatment
Many cardio metabolic risk factors that contribute to MetS are acquired and potentially
modifiable. The mainstay of management for MetS is lifestyle intervention, which includes a
hypocaloric diet, regular physical exercise, smoking cessation, and reduction of daily alcohol
intake. When lifestyle intervention is not sufficient, appropriate pharmacologic interventions to
target the individual features of MetS should be used .16
Metformin and glitazones (pioglitazone), by improving hepatic/peripheral insulin sensitivity, are
the most widely used pharmacologic agents for the treatment of MetS.
Some novel drugs, such as glucagon like peptide-1 (GLP-1) agonists and sodium glucose
transporter-2 (SGLT-2) inhibitors, might also be an alternative pharmacologic option,
particularly in patients with established type 2 diabetes,because they also may reduce body
weight.
Lipid-lowering agents, such as statins, are indicated in the presence of dyslipidemia, even in
combination with either fibrates or omega-3 fatty acids, principally to treat atherogenic
dyslipidaemia (typically characterized by high triglycerides and low HDL-cholesterol levels)
An anti-hypertensive drug therapy with renin-angiotensin-system inhibitors represents a safe
and well-tolerated first option in presence of the hypertension.12 Finally, clinicians should also
consider bariatric surgery for patients with severe obesity.
Bariatric surgery, as an effective nonpharmacologic treatment to decrease body weight in
patients with severe obesity, markedly diminshes all clinical features of MetS

7 churton sarah
2013

Th1- and Th17-driven inflammation in psoriasis has the potential to impact other organs, leading to
comorbidities such as diabetes, hypertension, obesity and atherosclerosis; the inflammation associated
with these conditions may promote the development or worsening of psoriasis
The metabolic syndrome is a constellation of atherothrombotic inflammatory abnormalities predictive of
risk of T2DM and CVD. The National Cholesterol Education Program Adult Treatment Panel III defines
the metabolic syndrome as presence of at least three of the following five criteria [31] such as: •
Elevated waist circumference: men – >40 inches (102 cm), women – >35 inches (88 cm); • Elevated
triglycerides: ≥150 mg/dl (1.7 mmol/l); • Reduced high-density lipoprotein (HDL)-cholesterol: men –
When looking at individual components of the metabolic syndrome, only hypertriglyceridemia and
abdominal obesity were significantly elevated in psoriasis patients.
Hyper lipidemias
High circulating levels of cholesterol promote CVD, so lipid disturbance in psoriasis may have a greater
impact on cardiovascular disease risk. Multiple studies have associated psoriasis with dyslipidemia.
There has not been a consistent pattern of lipid abnormalities established across broad ranges of patient
populations, but elevated low-density lipoprotein (LDL) and decreased HDL are often seen
Psoriasis patients should be screened for dyslipidemia, given their risk for lipid abnormalities and CVD

Hu.s lanc 2017 k. Mechanistically, the presence of common inflammatory pathways, secretion of
adipokines, insulin resistance, angiogenesis, oxidative stress, microparticles, and hypercoagulability may
explain the association between psoriasis and cardiometabolic disorders

(2020 Kanda et.al ,) Nutrition influences the development and progress of psoriasis and its
comorbidities. Saturated fatty acids, simple sugars, red meat, or alcohol exacerbate psoriasis via the
activation of nucleotide-binding domain, leucine-rich repeats containing family, pyrin domain-
containing-3 inflammasome, tumor necrosis factor-α/interleukin-23/interleukin-17 pathway, reactive
oxygen species, prostanoids/leukotrienes, gut dysbiosis or suppression of regulatory T cells, while n-3
polyunsaturated fatty acids, vitamin D, vitamin B12, short chain fatty acids, selenium, genistein, dietary
fibers or probiotics ameliorate psoriasis via the suppression of inflammatory pathways above or
induction of regulatory T cells

Machado ,pinto (2016) It is believed that 73% of psoriasis patients have at least one comorbidity. Studies have
demonstrated the association of psoriasis with inflammatory bowel disease, uveitis, psychiatric disorders, metabolic
syndrome and its components and cardiovascular diseases
Ogawa e. sat(2018 )

Recently, the immunological pathomechanism has been clarified substantially. Whereas T-helper (Th)1
overactivation was thought to induce occurrence of psoriasis, it has been demonstrated that Th17 cells
play a key role. Th17 development is maintained by interleukin (IL)-23 mainly produced by dendritic
cells. Th17 cells produce various cytokines, including IL-17A, IL-17F and IL-22. IL-17A and IL22 induce not
only keratinocyte proliferation, but also tumor necrosis factor (TNF)-a, chemokine (C-X-C motif) ligand
(CXCL)1 and CXCL8 production. TNF-a accelerates the infiltration of inflammatory cells, including
lymphocytes, monocytes and neutrophils, from the peripheral blood into skin with dendritic cell
activation. In addition, antimicrobial peptides are overexpressed in psoriatic skin lesions, and the
antimicrobial peptide, LL-37, activates dendritic cells, which leads to the development of inflammation.
Furthermore, activation of nuclear factor-jB signal induces the expression of keratins 6 and 16 in
keratinocytes