Psoriasis andthe Heart

A positive approach

to psoriasis and

psoriatic arthritis

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Psoriasis and the HeartThis leaflet has been written to help you understandmore about the psoriasis-heart connection and includeswhat you can change, what you cannot change,recognising the warning signs and taking action to helpreduce your risk.

What is psoriasis?Psoriasis (sor-i’ah-sis) is a long-term (chronic) scalingdisease of the skin, which affects 2-3% of the UKpopulation. It usually appears as red, raised, scalypatches known as plaques. Any part of the skin surfacemay be involved but the plaques most commonly appearon the elbows, knees and scalp. It can be itchy but isnot usually painful. Nail changes,including pitting and ridging,are present in 40% to 50%of people with psoriasisalone. 10% to 20% ofpeople with psoriasis willdevelop psoriatic arthritis.There does not seem tobe any link between theseverity of the psoriasisaffecting the skin and theseverity of psoriatic arthritis. Formore detailed information on psoriasissee our leaflets What is Psoriasis? and What isPsoriatic Arthritis?

What happens in psoriasis?Normally a skin cell matures in 21- 28 days and duringthis time it travels to the surface, where it is lost in aconstant, invisible shedding of dead cells. In patches ofpsoriasis the turnover of skin cells is much faster, around4-7 days, and this means that even live cells can reachthe surface and accumulate with dead cells. Thisprocess is the same wherever it occurs on the body. Theextent of psoriasis and how it affects an individual variesfrom person to person. Some may be mildly affectedwith a tiny patch hidden away which does not bother

them, while others may have large, visible areas of skininvolved that significantly affect daily life andrelationships. Psoriasis is not contagious, you cannotcatch it from another person. The cause of psoriasis iscurrently unknown.

Heart (cardiovascular) diseaseHeart disease is the second most commonly reportedlong-term disease, after musculoskeletal conditions, inthe UK. In the general population, 1.5 million men and1.1 million women are affected. The prevalenceincreases for those aged 75 or older, to 1 in 4 men and1 in 5 women. The most common form of disease that involves the

heart and blood vessels is hardening of the arteries(atherosclerosis). It occurs when cholesterol and fattydeposits clog the blood vessels, slowing blood flow andpreventing the delivery of oxygen and nutrients to theheart, brain and other organs. This may result in angina,heart attack or stroke. Heart disease can be life-threatening. There are lots of risk factors for developingheart disease, many of which can be avoided orminimised.

The psoriasis-heart connectionThe major risk factors for heart disease include diabetes,obesity, high blood pressure (hypertension), andincreased low-density lipoprotein (LDL), often known asbad cholesterol. Research shows that risk factors forheart disease are more frequently found in people withpsoriasis than in people without the condition. It isunclear why this is the case but it may explain why therecan be an increased rate of heart disease in people withpsoriasis. People with psoriasis may also be more likelyto make lifestyle choices which increase their heartdisease risk further. The good news is that you can takeaction against many of these risk factors and reduceyour risk of heart disease.

Medical research has also found that psoriasis itself maybe a risk factor for developing heart disease. In one

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study, young people with severe psoriasis were threetimes more likely to have a heart attack than those of thesame age who did not have psoriasis. Research from theUK has suggested that the risk of heart disease isgreater for those who have psoriasis and inflammatoryarthritis. However, other studies have reported thatpeople with psoriasis have no additional risk of heartdisease due to their psoriasis. There is currently aconsiderable amount of research being undertaken toexplore the psoriasis-heart connection more fully.

What you can changeYou may be able to reduce your risk of heart disease bydoing something about the following issues.

High blood pressure: High blood pressure orhypertension (consistently above 140/90 mmHg) cannarrow and eventually block theblood vessels that carryblood around your body.It also places additionalstrain on the heart, withthe potential to lead toa heart attack. Veryhigh blood pressurecan result in bloodvessels in the brainbursting, causing a stroke.Hypertension often has nosymptoms, so be sure to have yourblood pressure checked every year.

High blood cholesterol: Cholesterol and triglyceridesare types of fat that are vital to healthy cell function, butthey can also block and narrow the blood vessels,leading to a heart attack or stroke. High cholesterollevels are associated with high-fat diets, smoking,inactivity and a family history of high cholesterol. Eatinga balanced diet, being physically active, not smokingand reducing salt and alcohol consumption cansignificantly reduce your cholesterol levels. Some peoplemay also require medication to control their bloodcholesterol. It is important to note that cholesterol is

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produced by the liver and despite low cholesterol dietssome people still require medication to help reduceblood cholesterol levels. At the present time, the targethealthy cholesterol level is the same for individuals withand without psoriasis.

Physical inactivity: Being inactive can double your riskof heart attack and stroke. You don’t have to exercisestrenuously to enjoy the health benefits. Start with a goalof 30 minutes of daily activity, such as walking orgardening. Gradually increase the amount and intensity.If activity causes pain or if you are unsure aboutembarking on any exercise programme, consult yourdoctor. It may also be helpful to read our leafletPhysiotherapy and Exercise: Psoriatic Arthritis.

Diabetes: It is essential that you manage your bloodsugar level carefully if you have diabetes, as more than80% of people with diabetes die of heart disease.

Excess weight : Your weight can put you at risk ofdeveloping heart disease, as well as developing highblood pressure, high cholesteroland diabetes. People whocarry weight around theirmiddle (apple-shaped)versus around theirhips (pear-shaped) areat greater risk of heartproblems. Even amodest reduction inweight – as little as 10%– can significantly reduceyour chances of having aheart attack or stroke ordeveloping diabetes, as well as improving your overallwellbeing.

Smoking: Stopping smoking is one of the mostimportant steps to take for a healthy heart. The healthrisks associated with smoking include atherosclerosis,an increased risk of blood clots, reduced oxygen in theblood, increased blood pressure and cholesterol, andheart disease.

Excessive alcohol consumption: There is someevidence that a moderate amount of alcohol (particularlyred wine) may be good for your heart; however, toomuch alcohol can contribute to various health problems,including heart disease. If you dodrink alcohol, limit yourself tono more than one or twostandard drinks (one pintof regular strengthlager; one 5-oz glassof wine; 1-oz of spirits)a day and to a weeklymaximum of ninedrinks for women andfourteen drinks for men.Remember: for certainmedications you will be advised toavoid alcohol (for example methotrexate), so do makesure your healthcare provider is aware of your alcoholconsumption.

Stress: Stress presents double trouble for people withpsoriasis, increasing not only your risk of heart disease,but also psoriasis flares. It is important to learn how toreduce and deal with your stress in a healthy way ratherthan resorting to unhealthy strategies such as smoking,drinking and overeating. Exercise, yoga and relaxationtechniques can be effective. However, there are manyways you can engage in healthy stress release, such aslistening to music, meeting with friends or pursuing ahobby. You may also wish to talk to your doctor aboutcounselling or medication.

What you cannot changeSome risk factors for heart disease cannot be changed.These include:

� Gender: Men over the age of 55 andpostmenopausal women are at the greatest risk ofheart disease.

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� Increasing age: The risks of heart attacks andstroke increase with age.

� Ethnicity: People of African or South Asian descentare more likely to have diabetes and high bloodpressure and are therefore at greater risk of heartdisease and stroke

� Family history: If a brother, sister or parentdeveloped heart disease before the age of 55 orhad a stroke before the age of 65, you arestatistically at higher risk.

If you are worried about any of the issues outlinedabove, talk to your doctor or healthcare advisor, who willbe able to provide you with reassurance andexplanations of your individual risk factors.

Are you concerned?If you have any of the risk factors for heart disease thatyou cannot change, it is especially important to try toreduce those risks which you can change.

If you are worried about any of the issues outlined above,talk to your doctor or healthcare advisor, who will be ableto provide you with reassurance and explanations ofyour individual risk factors.

Your doctor may measure your blood pressure or takesome blood tests. Often these are performed in themorning after an overnight fast. Your doctor may checkyour blood glucose or cholesterol levels. Depending onyour risk factors for heart disease, you may beprescribed medication to help you. Some medications,collectively called statins, which can help controlcholesterol, have several additional health benefits.Other possible medications, known as beta-blockers,are helpful for blood pressure but can cause worseningof psoriasis. If a new medication seems to be affectingyou in an adverse way, please consult your doctorimmediately.

Some medications for the treatment of psoriasis cancause high blood pressure (ciclosporin) or change thelevels of triglycerides/cholesterol (acitretin). If yourdermatologist is considering these medications, he orshe will check your blood pressure and take blood testsregularly.

Angina

� Pain: Discomfort or pain, generally in the chest,neck, jaw and/or shoulder that can be triggered byphysical activity but eased by rest. The pain mayfeel like a heaviness, tightness or pressure.

� Shortness of breath (with or without chest pain):Generally triggered by physical activity and relievedby rest.

If you notice these symptoms seek the attention ofyour GP as soon as possible.

Heart attack:

� A heart attack may begin with the angina-likesymptoms described above (pain and shortness ofbreath). The pain is usually very severe, comes onsuddenly and does not go away with rest.

� Nausea, indigestion or vomiting.

� Sweating or cool, clammy skin.

� Feelings of fear or anxiety.

Stroke:

� Sudden weakness or sudden numbness in the face,arm or leg, especially on one side of the body, evenif temporary.

� Sudden confusion or difficulty speaking orunderstanding, even if temporary.

� Trouble seeing with one or both eyes.

If you notice symptoms suggestive of a heart attack orstroke, seek emergency medical attention as soon aspossible.

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Take action!

� Do not smoke. If you are a smoker, take steps toreduce the amount you smoke.

� Maintain a healthy weight. If your waist measuresmore than 102 centimetres (40 inches) for men or88 centimetres (35 inches) for women, talk to yourGP about weight loss strategies.

� Eat a balanced diet, including whole grains, cereals,vegetables, fruit, lower-fat dairy products, leanermeats and food prepared with little to no fat. Avoidsaturated and trans-fats; instead use olive oil,which is high in desirable monounsaturated fats.

� Control your portion sizes. An easy method fordetermining meal portions is to use two open handsas your measure for vegetables; one closed handfor carbohydrates, such as pasta or rice; oneclosed hand for fruit; the palm of your hand formeat or protein alternative; and the tip of yourthumb for fats, such as oil, margarine or butter.

Portion size

� Limit alcohol intake.

� Deal with stress in a healthy way.

� Be physically active for at least 30 minutes mostdays of the week.

� Drink more water. Although there is no strictguideline, replacing fluids is important and youshould aim to drink at least 2-3 litres of water a day,particularly during warm or hot weather.

References

Gelfand JM, Weinstein R, Porter SB, Neimann AL, BerlinJA, Margolis DJ. Prevalence and treatment of psoriasisin the United Kingdom: A population-based study. ArchDermatol 2005; 141: 1537-41.

Cohen MR, Reda DJ, Clegg DO. Baseline relationshipsbetween psoriasis and psoriatic arthritis: analysis of 221patients with active psoriatic arthritis. Department ofVeterans Affairs cooperative study group onseronegative spondyloarthropathies. J Rheumatol 1999;26:1752-6.

Gelfand JM, Neimann AL, Shin DB, Wang X, MargolisDJ, Troxel AB. Risk of myocardial infarction in patientswith psoriasis. JAMA 2006; 296: 1735-41.

Martyn-Simmons CL, Ranawaka RR, Chowienczyk P,Crook MA, Marber MS, Smith CH, Barker JN. Aprospective case-controlled cohort study of endothelialfunction in patients with moderate to severe psoriasis.Br J Dermatol 2011; 164: 26-32.

Kessler R. Under their skin. Nature 2012; 492: S64-5.www.diabetes.co.uk

Parisi R, Rutter MK, Lunt M, Young HS, Symmons DP,Griffiths CEM, Ashcroft DM; Identification andManagement of Psoriasis Associated ComorbidiTy(IMPACT) project team. Psoriasis and the risk of majorcardiovascular events: cohort study using the clinicalpractice research database. J Invest Dermatol 2015;135: 2189-97.

Fur the r re fe rences used in p roduct ion o f PAPAA i n f o rm a t i o n c a n b e f o u n d a t :www.papaa/org.resources/references

About this information

This material was produced by PAPAA. Please be awarethat research and development of treatments is ongoing.

For the latest information or any amendments to thismaterial please contact us or visit our website:

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www.papaa.org The site contains information ontreatments and includes patient experiences and casehistories.

Original text written by Ms Jennifer Black and Dr HelenS Young, 2008.

Fully reviewed and revised by Dr Helen S Young, seniorlecturer and honorary consultant in dermatology, The University of Manchester, Manchester AcademicHealth Science Centre, Department of Dermatology,Salford Royal Hospital (Hope), Stott Lane, Salford, M68HD in July 2013 and August 2015

A lay and peer review panel has provided key feedbackon this leaflet. The panel includes people with or affectedby psoriasis and/or psoriatic arthritis.

Published: December 2015

Review date: July 2018

©PAPAA

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The charity for peoplewith psoriasis and psoriatic arthritis

PAPAA, the single identity of the Psoriatic Arthropathy Alliance and the

Psoriasis Support Trust.

The organisation is independently funded and is aprincipal source of information and educationalmaterial for people with psoriasis and psoriatic

arthritis in the UK.

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bias or agendas.

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