Psoriasis and Inflammation More Than Skin Deep
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See Article by Mehta et al
Psoriasis is an immune-mediated proinflammatory skin condition with a reported prevalence of 2%.1 Patients with psoriasis have an increased prevalence of cardiovascular disease, including acute myocardial infarction, that is not explained by traditional cardiovascular risk factors alone.2 Indeed, severe psoriasis is associated with a 57% increased risk of cardiovascular death.2,3 What is the explanation for this association? Systemic inflammation has been put forward as a potential explanation for the link between psoriasis and cardiovascular disease, with trial evidence linking psoriasis severity and the degree of systemic inflammation.4 It may be reasonable therefore to assume that drugs targeting inflammation, such as tumor necrosis factor-α antagonists, would result in decreased cardiovascular events. However, clinical end point trials of anti-inflammatory interventions in patients with psoriasis would be challenging to deliver given the magnitude and cost of phase 3 clinical end point trials. Consequently, proof-of-concept phase 2 trials are needed to demonstrate impact on plausible mechanistically linked surrogate measures of potential clinical efficacy before embarking on such large clinical end point trials. Such was the premise for the phase 2 clinical trial conducted by Mehta et al5 presented in this issue of Circulation: Cardiovascular Imaging.
We would like to commend the authors for an extremely rigorous study design that assessed the role of tumor necrosis factor-α inhibition on vascular inflammation in patients with psoriasis. Major trial strengths included the double-blind randomization of the adalimumab. This is an essential component of such a phase 2 trial that should not be understated. Moreover, an active comparator was welcome although this too could have been masked with a control light exposure not emitting UVA light. Vascular inflammation was measured using the gold standard of 18F-fluorodeoxyglucose positron emission tomography/computed tomography. This …