psoriasis and occlusive vascular disease
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British Journal ofDermatology {1978) 9 9, 469.
Clinical and Laboratory Investigations
Psoriasis and occlusive vascular disease
C H A R L E S J . M C D O N A L D A N D P A U L C A L A B R E S I
Section
of Medicine, Division of Biology and Medicine, Brown University, Department of Medicine,
Roger
Williams General Hospital, 825 Chatkstone Avenue, Providence, RI 02908, U.S.A.
Accepted for publication 17 April 1978
S U M M A R Y
To test the hypothesis that psoriasis is associated with an increased incidence of occlusive vascular
disease (thrombophlebitis, myocardial infarction, pulmonary cmbolization, and ccrebrovascular
accident), the clinical records of 323 psoriatic and 325 no n-psoriatic patienrs adm itted to the derm a-
tology service of the Roger Williams General Hospital were examined. The data obtained in this
study suggest that (i) the occurrence rate of occlusive vascular disease is significantly greater in the
psoriatic than in the non-psoriatic dermatological patient. This is particularly true in the male popu-
lation; (2) psoriasis predisposes to occlusive vascular disease; and (3) the psoriatic patient with certain
predisposing factors is at greater risk of experiencing an occlusive vascular episode than both the n on -
predisposed psoriatic and the non -psoriadc dermatological patient.
It is well known among dermatologists and dermatopathologists that patients with psoriasis have
microvascular abnormalities in normal skin as well as in the skin affected with psoriasis (Braverman,
Cohen & O'Kce fe, 1972; Braverman, 1972; Levi & Cu rri, 1973). How ever, no one has previously
associated psoriasis with an increased incidence of large vessel disease. Reed
et al.
(1973) proposed an
association between psoriatic arthritis and occlusive vascular disease. Our present interest in this
area was stimulated by a number of uncontrolled observations that appeared to associate the admini-
stration of a specific antimetabolic agent to patients having severe, recalcitrant psoriasis and an
increased occurrence of occlusive vascular episodes in these patients. These observations led us to
search the current literature for reports of psoriasis and occlusive vascular disease occurring in both
treated and untreated patients and to a rapid review of a representative sample of the clinical records of
our untreated psoriatic patients. Both reviews indicated that psoriatic patients experienced more
episodes of occlusive vascular disease than would be expeaed in a normal population (Reed et al.y
1961; Nyfors, 1968; Black
et ai^
1964; Roenigk, Fowler-Bergfeld & Curtis, 1969; Ryan & Baker,
1969).
These findings led us to hypothesize that there is a greater than normal incidence of occlusive
vascular disease associated with psoriasis (McDonald & Calabresi, I973a,b,c).
Presented at the 58th Annual Session of the American College of Physicians April 1977.
Reprint requests to: Dr Charles J.McDonald, Department of Medicine,
Roger
Williams
General Hospital
825
Chalkstone Avenue, Providence, RI 02908, U.S.A.
0007-0963/78/1100-0469102.00 '0 1978 British Association of Dermatologists
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470
C.y.McDonald and P.Calabresi
We then reviewed the clinical records ofallpsoriatic patients and a similar num ber of non-psoriat
dermatological patients seen and examined by one of us (C.J.M.) at the Roger Williams Genera
Hospital from i July 1968 to 31Decem ber 1972. We now wish to repo n the findings of a retrospectiv
study designed to test the hypothesis tha t the psoriatic patient suffers an abnorm ally high incidence o
and has a greater predisposition to, occlusive vascular disease {i.e. coronary thrombosis, thrombo
phlebitis, cerebrovascular accidents, and pulmonary embolization).
MATERIALS AND METHODS
A total of648 patients' records from the Roger Williams General Hospital were sequentially selecte
and examined using information entered in each record from 1 July 1968 to 31 December 1972. T
study was limited to the number of occlusive vascular episodes which were recorded as occurrin
between i January 1968 and 31 December 1972. All occlusive vascular episodes had been previousl
documented by appropriate clinical and laboratory examinations. Typical diseases of the non
psoriatic patient group included atopic eczema, ec2ematous dermatitis, acute and chronic allerg
contact dermatitis, urticarias (acute and chronic), collagen vascular diseases, alopecias, ichthyose
etc.
T h e data retrieved from the records consisted of the following : (a) sex, (b) age, (c) age at the onse
of psoriasis, (d) percent of body coverage of psoriasis, (e) history of predisposing factors other tha
psoriasis, (f) the type of occlusive vascular incident (repeated episodes of the same disease wer
totalled and counted as a single occurrence. Occurrences of dissimilar diseases in the same patie
were identified separately and recorded as such), and (g) age at the time of the occlusive vascula
event.
Data retrieval for non-psoriatic patients followed the same format except for items (c) and (d).
Each psoriatic patient was matched with a non-psoriatic patient of similar age (within 5 years) an
having a recorded general medical history of similar completeness. The study population containe
approximately equal numbers of males and females. Females receiving birth control pills were no
admitted to the study.
Several analytical approaches were employed in examining the hypothesis: (a) the incidence o
occlusive vascular disease in the psoriatic patient was contrasted with that of the non-psoriatic patien
population, (b) the predisposition of the psoriatic population to occlusive vascular disease was con
trasted with that of the non-psoriatic population, (c) the psoriatic population was examined alone
see if a relationship existed between th e extent and d uration of psoriasis and the likelihood of occlusiv
vascular disease. Additional information obtained for analysis included: (a) association between ag
sex, predisposition, and the incidence of occlusive vascular disease, (b) relative frequency of differen
occlusive vascular episodes, (c) relative significance of psoriasis in the event that it proved to be
predisposition towards occlusive vascular disease.
To stratify the populations into predisposed and non-predisposed groups, a list of faaors pr
disposing and possibly predisposing to occlusive vascular episodes was derived from the literatu
(Sartwell, 1969). Predisposing factors included a past or present history of heart disease (angin
valvular heart disease, cardiac arrhythmias, arteriosclerotic heart disease, congestive heart failur
etc.),
hypertension, deep vein varicosities, chronic venous stasis and peripheral oedema, obesit
anaemia, diabetes mellitus, extensive abdominal surgery, cirrhosis of the liver with peripheral oedem
previously elevated serum clotting factors such as elevated fibrinogen levels, and abnormal lipi
profiles. Possible predisposing factors included family history of diabetes mellitus, previous limite
abdominal surgery, liver disease, rheumatic heart disease with and without valvular defects, famil
history of clotting episodes, and family history of cardiovascular disease.
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Psoriasis
and
occlusive vascular disease
471
An analysisof the separate categoriesofocclusive vascular diseasewas not performed becausethe
numberofpositive responses within each categorywassmall.
RESULTS
Table
i
shows
the
occurrence rate of venous
and
arterial occlusive vascular disease
in
predisposed
and
non-predisposed psoriaticandnon-psoriatic malesand females aboveandbelow50yearsof
age.In
each age/sex group rates of occurrence of occlusive v ascular disease were significantly higher (P 50
Female,
Age
50
Predisposed
Non-predisposed
Predisposed
Non-predisposed
Predisposed
Non-p redisposed
Predisposed
Non-predisposed
3/St
37-5*
1/61
1-6
12/30
40
0
0/42
o-o
r/ii
9-1
0/71
0 0
9/49
18-4
0/51
o-o
1/10 3-75
IO-O
0/60 (0-98)
0 - 0
3/24 (9-6)
1 2 5
0/37 (0)
0 0
1/23 (2-09J
4 3
0/77 (0)
0 0
4/40 (7-35)
10-o
0/54 (0)
o-o
0 / 8
0 - 0
I/6I
1-6
r/30
3-3
0/42
0 - 0
4/11
36-4
0/71
0 - 0
6/49
12-2
0/51
0 -0
o/io (0)
0 - 0
0/60 (0-98)
O 'O
4/24 (O'S)
1 6 7
0/37 (0)
O 'O
2/23 (8-36)
8-7
0/77 (0)
0 - 0
3/40 (4-90)
7-S
0/54 Co)
O-o
3/8
37-5
2/61
3
3
13/30
4 3 3
0/42
0 - 0
5/II
4 5 4
0/71
0 - 0
15/49
3 0 6
0/51
0 - 0
i/io (375)
I o-o
0/60 (1-97)
0 - 0
7/24 (ro-4)
29-2
0/37 (0)
0 - 0
3/23 (I0-5)
13-0
0/77 (0)
o-o
7/40 (12-2)
17-5
0/54 (0)
0 0
*
P-values
(a)
Psoriasis
vs
non-psoriasis P
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472
C.J.McDonald and P.Calabresi
predisposed non-psoriatic group of lo male patients below age 50 had experienced the same rate
occurrence of arterial disease as was observed in the same age group of predisposed psoriatics, the
would have suffered approximately 375 clotting episodes instead of a single episode.
TABLE 2. Observed vs expected occlusive vascular occurrences (325 non-
psoriatics)
Observed Expected
Observed
rate (
Expected Relative
rate ( ) risk
Arterial
Venous
Combined
9
9
18
2 3 8
150
388
2-8
2-8
5-5
7-3
11-9
x-6
22
Tab le 2 summ arizes the observed versus expected occurrence of arterial and venous disease amon
the combined group of 325 non-psoriadc patients (i.e. the amount of vascular disease actually o
served in the group of non-psoriatic patients versus what they would have been expected to hav
experienced if vascular disease was as prevalent in the group as it was in the psoriatic population).
Once the significance of various factors was demonstrated, the relationship between occurrence o
thrombosis and age and percent body coverage of the psoriatic patients was estimated. Contour graph
in Figs1 and 2 are helpful in understanding the relationships between the variables of
age^
duratio
DURATION OF PSORIASIS IN YEARS
FIGURE I. Relationship between age and duration of disease and the occurrence of occlusive
vascular disease in 323 psoriatic patients.
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Psoriasis and occlusive vascular disease
473
percen t body coverage, and occlusive vascular disease. D uration of psoriatic disease did not appear
to have an effect on the patients' likelihood of experiencing an occlusive vascular episode. The per
cent of the body covered by psoriasis, while not appearing to be as significant as age in effecting an
increase in occlusive vascular occtirrences, does appear to have some effect, especially in the older
age group.
90 r
0 55
0 15 30 45 6 0 75 9 0
PERCENTAGE COVERAGE OF PSO RIAS IS
FIGURE 2 . Relationship between age and p ercent b ody coverage of psoriasis and the occurrence of
occlusivc vascular disease in 323 psoriatic patients. In orde r to determine this relationship in any age
group and any degree of body coverage using this graph, a straight line is drawn perpendicular to
the axis of the age and percen t body coverage selected. Th ese two lines will intersect at some poin t
on the graph This point of intersection will correspond to the expected occurrence rate of occlusive
vascular disease.
E.\ample,A 65-year-old male with 15 ,. body coverage has a 15 ,, chance of having an occlusive
episode. With 35?u body coverage his chances rise to 25 .
DISCUSSION
Using retrospective data, we have attempted to study the hypothesis that patients who have psoriasis
suffer an abnormally high prevalence of various occlusive vascular diseases. We recognize the many
criticisms of retrospectively gathered data in supporting or refuting a hypothesis (Feinstein, 1973).
However, there is broad support for the use of retrospectively gathered data, and it is our belief that
such data can, and in this situation do, indicate that our original conjecture is valid and worthy of
rigorous testing in a well-planned and properly designed prospective study (Sartwell, 1974).
The data obtained in this study suggest (a) the occurrence rate of occlusive vascular episodes is
significantly greater in the psoriatic than in the non-psoriatic patient. In averaging data from the five
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47 4 C.J.McDo nald and
P.Calabresi
age/sex/predisposition categories in which ai least one arterial occlusive vascular incident took place
the association between the presence of psoriasis and the occurrence of occlusive vascular disease i
statistically highly significant (P
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Psoriasis and occlttsive vascular disease 475
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