CC BY
40РОЛЬ ЭНДОКРИННЫХ ИЗМЕНЕНИЙ И ОЖИРЕНИЯ В ПАТОГЕНЕЗЕ И ВОЗНИКНОВЕНИИ ПСОРИАЗА
Умарова Мухаббат Абдунабиева Хакима Абдурахимов Абдухалим Нугманов Озодбек Тошпулатов Бекмирза Андижанский государственный медицинский институт
Андижан, Узбекистан
Хотя было отмечено много изменений в лечении и патогенезе псориаза, его этиология остается неясной. Псориаз является хроническим распространенным заболеванием кожи, которое оказывает наибольшее влияние на качество жизни пациента. Несколько экзогенных факторов и эндогенных гормональных изменений могут служить возбудителем псориаза. Кожа имеет настоящую эндокринную систему, которая играет очень важную роль при многих системных заболеваниях. Ряд факторов связан с псориазом, и гормоны и ожирение также могут влиять на его развитие. Гормоны, влияющие на клинические проявления псориаза: глюкокортикоиды, адреналин, гормоны щитовидной железы, половые гормоны и инсулин.
Ключевые слова: псориаз, половые гормоны, пролактин, глюкокортикоиды, адреналин, тиреоидные гормоны.
PSORIAZNING PATOGENEZI VA KELIB CHIQISHIDA ENDOKRINOLOGIK O'ZGARISHLAR VA SEMIRISHNING ROLI
Psoriazni davolash va patogenezida ko'plab o'zgarishlar qayd etilganiga qaramay, uning etiologiyasi noaniqligicha qolmoqda. Psoriaz - bu surunkali, keng tarqalgan teri kasalligi bo'lib, bemorning hayot sifatiga eng yuqori darajada ta'sir qiladi. Bir necha ekzogen omillar va endogen gormonal o'zgarishlar psoriazning qo'zg'atuvchisi bo'lib xizmat qilishi mumkin. Terida haqiqiy endokrin tizim mavjud, bu juda ko'p tizimli kasalliklarda juda muhim o'rin tutadi. Qator omillar psoriaz kasalligi bilan bog'liq bo'lib, uning rivojlanishiga gormonlar va semizlik ham ta'sir qilishi mumkin. Psoriazning klinik ko'rinishlariga ta'sir ko'rsatadigan gormonlar: glyukokortikoidlar, epinefrin, qalqonsimon gormonlar, jinsiy gormonlar va insulin.
Kalit so'zlar: psoriaz, jinsiy gormonlar, prolaktin, glyukokortikoidlar, epinefrin, qalqonsimon gormonlar.
THE ROLE OF ENDOCRINOLOGICAL CHANGES AND OBESITY IN THE PATHOGENESIS
AND ORIGIN OF PSORIASIS
In spite of the fact that many developments are recorded in the treatment and pathogenesis of psoriasis, its etiology still remains obscure. Psoriasis is a chronic, common skin disease, which affects the patient's quality of life to the highest degree. Several exogenous factors and endogenous hormonal changes may act as triggers for psoriasis. The skin possesses a true endocrine system, which is very important in multiple systemic diseases. A number of conditions are associated with psoriasis, and its severity can also be influenced by hormones and obesity. Hormones which can influence the psoriasis clinical manifestations: glucocorticoids, epinephrine, thyroid hormones, prolactin, sex hormones and insulin.
Key words: psoriasis, sex hormones, prolactin, glucocorticoids, epinephrine, thyroid hormones.
DOI: 10.24411/2181-0443/2020-10080
Introduction: Psoriasis vulgaris, an immunologically mediated skin disease, is a common disorder, having as main pathogenetic mechanisms the chronic inflammation and keratinocytes hyperproliferation [1]. The keratinocytes differentiation is altered and the expression of genes in the psoriasis plaque may also be affected [2]. The antimicrobial peptides and proteins production during the innate and adaptive immune response reflect the genetic susceptibility to psoriasis [3]. Psoriasis vulgaris is not a life threatening disease, but it affects severly the quality of life; there is still no causative treatment [4]. Due to the psoriasis chronicity and the absence of a curative definitely treatment [5], the disease prevalence remains a question [6]. In addition the role of endocrinological factors in the origin of psoriasis has long been known. It can be especially difficult in the first stage of pregnancy [7]. The onset of psoriasis vulgaris may be at any age, but two peaks were observed, around 20-30 and over 50 years of age [9]; pediatric psoriasis can reach about 30% of all cases [10]. The early onset of chronic plaque psoriasis in white population was associated with 36 genetic loci [11], a finding which supports the assumption that the age of onset is, at least partially, genetically determined [12].
Interdependence of psoriasis and insulin. A possible pathogenetic link between psoriasis and atherosclerosis has been identified by S. Boehncke and other scientists. They took 39 consecutive "moderate" grade "severe plaque" type psoriasis patients for the study. The intima-media thickness of the carotid artery was measured using ultrasound and an oral glucose tolerance test was performed to assess the homeostasis model of insulin resistance (HOMA). Thus, a correlation between BMI and HOMA (P <0 • 0 2 ) as well as BMI and vascular wall thickness (P <0 • 05) was successfully identified. As for psoriasis, they also found that there was a significant correlation between psoriasis area and weight index (PASI) and insulin secretion. They also found that several measurements of insulin resistance were significantly associated with PASI [14].
Interdependence of psoriasis and stress hormones. Endocrine and immune reactions are both highly influenced by stress. At the same time, the evolution is marked by the important stressful moments in life. The hypothalamic-pituitary-suprarenal axis controls the stress hormones, cortisol and epinephrine, which are antagonists and have important effects on immune system. Immune cells (macrophages, lymphocytes T and B) express beta-adrenergic receptor and epinephrine induces multiple but dual immune responses: promotes macrophages responses through increasing secretion of cytokines TNF-a, IL-1, IL-10, and regulates the level of T and B lymphocyte function. Also, it has bee observed that an acute activation of the sympathetic nervous system attenuates the innate immune response. The immunomodulation in stress takes place through intersections in signaling cascade at different levels: for example, stress signals in immune response are regulated through the key Nuclear Factor-kappaB (NF-kB) and the epinephrine stimulation of (32-adrenergic receptors, expressed on immune cells, intersect with the NF-kB signaling cascade. Glucocorticoids prevent the inflammatory changes by inhibiting the migration of leukocytes and suppressing T cells. The stimulation of epinephrine and adrenergic receptors may also exert some corticosteroid effects. The cortisol response to stress is diminished in psoriasis. The psoriatic patients present higher levels of epinephrine and adrenocorticotropic hormone and lower levels of cortisol and corticotrophin releasing factor. Epinephrine can modulate the remission phase and cortisol the eruption phase. The stress link in psoriasis is sustained also by the fact that a regular physical activity may have favorable effect on psoriasis evolution. Through metabolic and psycho-neuro-immune effects, a regular exercise influences positively the metabolic comorbidities, lowers the risk and the onset of psoriasis [15,32].
Interdependence of psoriasis and thyroid hormones. Propylthiouracil, an antithyroid preparation, was successfully used both in local and systemic treatment of psoriasis. Although the mechanism of action was unclear, it was suggested that this drug
might have a regulatory effect on the T cells in the psoriasis plaque. Propylthiouracil increased the number of total and suppressor/cytotoxic T cells and reduced activated lymphocytes in psoriatic plaques. Other anti-thyroid agents, such as methimazole and thiamazole, have also been used successfully in the treatment of psoriasis. This means that thyroid hormones may have unknown effects on the disease. It is postulated that T3 receptors may play a role in the synthesis of keratin. The existence of T3 receptors on the skin was also proved. Propylthiouracil, which is known to be an anti-thyroid drug, may affect the keratin synthesis process by binding to nuclear T3 receptors. It is also known that T3 has a major role in the regulation of cell growth and differentiation. Moreover, it has been stated that T3 and T4 have hyperproliferative effect on the skin by EGF. In this study the serum TT4 and FT3 levels were significantly higher in psoriatics than in the control group. The average PASI scores were significantly higher in these patients and this may be due to the direct or indirect effects of thyroid hormones on the course of psoriasis. Thus excessive production of thyroid hormones may aggravate psoriasis. The skin may be a target organ for thyroid hormones and these hormones increase EGF and therefore accelerate epidermal proliferation. The role of these hormones on the etiopathogenesis of psoriasis will become clearer when the effect of thyroid hormones on keratinocytes and the anti-proliferative effect of anti-thyroid drugs on psoriasis are better demonstrated with experimental studies. Meanwhile, it may be useful to check the thyroid function in patients with uncontrolled and relapsing psoriasis [16].
Interdependence of psoriasis and sex hormones. Extremely high levels of hormonal and immunological changes occur during pregnancy, as maternal adaptations to the developing fetus. The evolution of psoriasis is variable during pregnancy [17]. At mid pregnancy (around 30th week of gestation), the patients' psoriatic symptoms can diminish (in >50%) or worsening (in >20%) [18]. A possible explanation could be that at this moment, there is an immunity shift from Th2 to Th1, mainly due to the increased levels of estrogen, progesterone and cortisol (Figure 1) [19]. Other chronic immune diseases Th1-driven were shown to improve during pregnancy, such as multiple sclerosis [20] and rheumatoid arthritis [21]. Therefore, it was supposed that the increased hormone levels improve the psoriatic symptoms [22]. Due to the decrease in hormonal levels after parturition and during menopause, the psoriasis severity seems to accentuate. In these conditions, it was assumed that the flares occurring in the postpartum period represent rather a return to the initial level than a true worsening [18]. A moderate or severe form of psoriasis can increase the risk for a poor outcome in pregnancy [23], abortions, eclampsia, premature rupture of membranes, or macrosomia [24], but this can be due to the multiple comorbidities associated with psoriasis, which can represent risk factors in pregnancy. Definitely, psoriasis does not represent a contraindication for a pregnancy [22]. If a systemic treatment is necessary, mothers are told not to nurse because the drugs may be excreted in milk [25]. During menopause, the estrogen level decline and a low-grade inflammation may appear [26], meaning that menopause may aggravate the psoriasis evolution [27]. This fact is in concordance with the observation that after menopause the incidence of chronic inflammatory diseases in women became closer or higher than the incidence in males [28]. The epidermis, dermis and hair follicle and the associated sebaceous glands express androgen receptors, and the skin is an important androgen target [29]. Androgen hormones influence the homeostasis of the epidermal barrier, the growth and differentiation of the hair and the sebaceous gland [30]. They also antagonize the macrophage's production of vascular endothelial growth factor (VEGF), which can prolong the inflammation and the wound healing. The adrenal androgens decrease in chronic inflammatory diseases and the therapies based on androgen can aggravate/exacerbate psoriasis [31]. Prolactin (PRL) is the pituitary hormone of lactation and reproduction. The epidermal keratinocytes express receptors for prolactin and the
hormone has proliferative effects on keratinocytes , epithelial cells, and lymphocytes. There is a true "PRL-skin connection". PRL exerts a variety of immunostimulative effects which may promote the development of psoriasis: it enhances keratinocytes chemokine production (IL-17) and favors infiltration with Th lymphocytes, stimulates IFN-y production and promotes angiogenesis, regulates the maturation of T cells. According to those multiple immune roles, hyperprolactinemia was observed in several autoimmune diseases (lupus erythematosus, rheumatoid arthritis, Sjogren's syndrome, Hashimoto's thyroiditis, multiple sclerosis). PRL is involved in the psoriasis etiopathogenesis and this role of prolactin is sustained by the observations that psoriasis can be aggravated during the development of prolactinoma. A significant decrease in prolactin level in patients with psoriasis was noticed after systemic treatment. Several studies have shown a positive relation between serum prolactin levels and psoriasis severity. Bromocriptine, used in prolactinoma, may be useful in the psoriasis treatment [32].
Figure 1: Positive and negative effects of estrogens, differently mediated by ER-a and ER-p [19]
Interdependence of psoriasis and obesity. Also, there is a relationship between leptin, obesity and psoriasis. But there are contradictive reports regarding the leptin levels in psoriasis, significantly decreased or higher. But, an argument for the leptin molecular link between psoriasis and metabolic comorbidities is represented by the higher serum levels of leptin in overweight or obese psoriatic patients. Strongly associated with insulin resistance are both psoriasis and obesity. In both, there are also common pro-inflammatory pathways involved (TNF-a, IL-6). Reducing the obesity chronic low-level inflammation may improve insulin sensitivity and leptin levels [32]. Association between Psoriasis and Obesity One of the first reports about the relationship between psoriasis and obesity came from Sweden in a study including 159,200 individuals who were followed up over a 10-year period [33] . In the study, the authors found an association between women with psoriasis and obesity. In 1995, Henseler and Christophers [34] conducted a registry-based
study including 42,461 individuals of whom 2,941 (7%) had psoriasis and found a significantly higher prevalence of obesity in patients with psoriasis. More recently, a case-control study of 560 patients with psoriasis demonstrated that the risk of psoriasis in an overweight (BMI 26-29) or obese (BMI > 30) population was higher than in normal-weight individuals (odds ratio, OR, 1.6 and 1.9, respectively) [35] . Another registry-based study including 127,706 subjects with mild psoriasis (not receiving systemic therapy or phototherapy) and 3,854 persons with severe psoriasis (treated with systemic therapy or phototherapy) demonstrated a higher risk of obesity in those with severe psoriasis (OR, 1.8) than in those with mild psoriasis (OR, 1.3) [36] . Similar findings were made by another group in a study with 16,851 patients with psoriasis, which showed that patients under 35 years of age were more likely to be overweight (OR, 2.2) than those above the age of 65 (OR, 1.6) relative to healthy subjects [37] . It seems, therefore, that the association between psoriasis and obesity has been firmly established. Indeed, a meta-analysis of 16 observational studies including a total of 2.1 million subjects (201,831 with psoriasis) demonstrated that compared with individuals from the general population, patients with psoriasis are at significantly higher odds of obesity, with a pooled OR of 1.46 for mild psoriasis and an OR of 2.23 for severe psoriasis [11] . However, the direction of the relationship is still being debated, and current epidemiological evidence is inadequate to establish which comes first, psoriasis or obesity. Herron et al. [38] conducted a retrospective study and asked 557 patients with psoriasis about their body weight at the age of 18 and prior to the onset of psoriasis. At the same time, they asked the participants to record their current weight after the onset of psoriasis. Those who reported being overweight at the age of 18 did not have an increased risk for psoriasis, but the ones who went on to develop psoriasis had a higher propensity for obesity. The findings are suggestive of psoriasis occurring before obesity [38] . This notion is supported by the results of Mallbris et al. [39] , who compared 200 patients within 12 months of onset of psoriasis to healthy controls and found no significant difference in BMI between the groups. In fact, the prevalence of obesity was higher in the control group (13%) than in the group of patients with psoriasis (10%) [39] . However, evidence strongly suggests that obesity is an independent risk factor for psoriasis. Supporting this hypothesis is a large prospective cohort study including 78,626 American female nurses followed for 14 Downloaded by: 80.82.77.83 - 4/9/2017 11:47:50 AM Psoriasis and Obesity Dermatology DOI: 10.1159/000455840 3 years with 892 incident cases of psoriasis [40] . The study found a graded positive association between BMI measured at multiple time points and the risk of incident psoriasis. When BMI, updated every 2 years, was analyzed and compared with a BMI of 21.0-22.9, the relative risks of psoriasis were 1.40 (95% confidence interval, CI, 1.13- 1.73) for a BMI of 25.0-29.9, 1.48 (95% CI, 1.15-1.91) for a BMI of 30.0-34.9, and 2.69 (95% CI, 2.12-3.40) for a BMI of 35.0 or greater ( p < 0.001). For BMI at the age of 18 years, the relative risk for the top BMI category ( > 30.0) was 1.73 (95% CI, 1. 2 4-2.41), and that for a lower BMI category (< 0.001). Weight gain from the age of 18 years, higher waist circumference, hip circumference, and waist-hip ratio were all associated with a higher risk of incident psoriasis [40] . In 2010, Bryld et al. [41] conducted a study exploring the temporal relationship between obesity and psoriasis. The study cohort included 309,152 school children and found that, for women, severe psoriasis resulting in hospitalization in adulthood was preceded by an increased BMI at the age of 12. Several studies have demonstrated that white adipose tissue is a crucial site in the formation of proinflammatory adipokines which include the classical cytokines such as IL-6, TNF-a, and the specific molecules leptin, adiponectin, and resistin (Table 1) [42].
Obesity Biological effects
Adiponectin X Appetite T Insulin sensitivity T Glucose uptake by white adipose tissue and skeletal muscle T Oxidation of free fatty acid in liver and skeletal muscle T
Leptin Í Resting energy expenditure T Lipolysis T Hepatic lipogenesis 1
Resistin Í Insulin resistance T Free fatty acid release by white adipose tissue T
Visfatin Í Probably insulin-like effects
Table 1. Biol ogical effects and regulation of major adipokines in the obese state
Conclusion: Even though the sex hormones and prolactin are the most implicated in psoriasis pathogenesis and clinical manifestations, there are a lot of other hormonal mechanisms with significant influence on the evolution of psoriasis, therefore new therapeutic ways need to be explored. At the same time, a hormonal assessment should be performed in patients with psoriasis, in order to correctly diagnose and treat pathologies that may be related with psoriasis exacerbations. Due to the pathogenic complexity, there a curative treatment for psoriasis is still missing and hormonal therapeutic interventions may relieve the clinical phenomena in psoriasis. Evidence is strongly suggestive that obesity, through pro-inflammatory pathways, predisposes to the development of psoriasis and that obesity aggravates existing psoriasis. While larger, randomized trials are needed to fully elucidate the potential effect of weight reduction on the severity of psoriasis, current knowledge supports the necessity of nutritional care as part of the management of psoriasis, in particular as weight loss has a substantial and positive effect on the cardiovascular risk profile in these patients. Also, treating overweight patients with psoriasis imposes certain problems such as increased risk of adverse events, reduced efficacy of biologicals, and higher treatment costs, which further underscore that weight reduction in these patients should be one of the aims of their management.
References:
1. Gudjonsson JE, Elder JT. Psoriasis: epidemiology. Clin Dermatol. 2007;25(6):535-546.
2. Liu Y, Krueger JG, Bowcock AM. Psoriasis: genetic associations and immune system changes. Genes Immun. 2007;8(1):1-12.
3. Batycka-Baran A, Maj J, Wolf R, Szepietowski JC. The new insight into the role of antimicrobial proteins-alarmins in the immunopathogenesis of psoriasis. J Immunol Res. 2014 doi: 10.1155/2014/628289.
4. Schafer T. Epidemiology of psoriasis. Review and the German perspective. Dermatology. 2006;212(4):327-337.
5. Naldi L. Epidemiology of psoriasis. Curr Drug Targets Inflamm Allergy. 2004;3(2):121-128.
6. Christophers E. Psoriasis-epidemiology and clinical spectrum. Clin Exp Dermatol. 2001;26(4):314-320.
7. Kurd SK, Gelfand JM. The prevalence of previously diagnosed and undiagnosed psoriasis in US adults: results from NHANES 2003-2004. J Am Acad Dermatol. 2009;60(2):218-224.
8. Chandran V, Raychaudhuri SP. Geoepidemiology and environmental factors of psoriasis and psoriatic arthritis. J Autoimmun. 2010;34(3):J314-J321.
9. Xhaja A, Shkodrani E, Frangaj S, Kuneshka L, Vasili E. An epidemiological study on trigger factors and quality of life in psoriatic patients. Mater Sociomed. 2014;26(3):168-171.
10. Raychaudhuri SP, Gross J. A comparative study of pediatric onset psoriasis with adult onset psoriasis. Pediatr Dermatol. 2000;17(3):174-178.
11. Hébert HL, Bowes J, Smith RL, Flynn E, Parslew R, Alsharqi A, et al. Identification of loci associated with late-onset psoriasis using dense genotyping of immune-related regions. Br J Dermatol. 2015;172(4):933-939.
12. L0nnberg AS, Skov L, Duffy DL, Skytthe A, Kyvik KO, Pedersen OB, et al. Genetic Factors Explain Variation in the Age at Onset of Psoriasis: A Population-based Twin Study. Acta Derm Venereol. 2016;96(1):35-38.
13. S. Boehncke, D. Thaci, H. Beschmann , R.J. Ludwig, H. Ackermann, K. Badenhoop, W-H. Boehncke (2007). Psoriasis patients show signs of insulin resistance. Wiley Online Library. doi:10.1111/j.1365-2133.2007.08190.x
14. Susanna Mosca, Paola Gargiulo, Nicola Balato, Luisa Di Costanzo, Antonio Parente, Stefania Paolillo, Fabio Ayala, Bruno Trimarco, Filippo Crea, Pasquale Perrone-Filardi (2014). Ischemic cardiovascular involvement in psoriasis: A systematic review. International Journal of Cardiology. doi:10.1016/j.ijcard.2014.10.092
15. Bea A. Weigl MD. (2001) The significance of stress hormones (glucocorticoids, catecholamines) for eruptions and spontaneous remission phases in psoriasis. International Journal of Dermatology. doi:10.1046/j.1365-4362.2000.00800.x
16. Ozer Arican , Kaan Bilgic , Kadriye Koc (2004). The effect of thyroid hormones in psoriasis vulgaris. Indian Journal of Dermatology, Venereology and Leprology. doi:2004/70/6/353/13477
17. Schmutz JL. Dermatological diseases influenced by pregnancy. Presse Med. 2003;32(38):1809-1812.
18. Murase JE, Chan KK, Garite TJ, Cooper DM, Weinstein GD. Hormonal effect on psoriasis in pregnancy and post partum. Arch Dermatol. 2005;141(5):601-606.
19. Piccinni M, Scaletti C, Maggi E, Romagnani S. Role of hormone-controlled Th1- and Th2-type cytokines in successful pregnancy. J Neuroimmunol. 2000;109(1):30-33.
20. Airas L. Hormonal and gender-related immune changes in multiple sclerosis. Acta Neurol Scand Suppl. 2015;132(199):62-70.
21. Falcón CR, Martínez FF, Carranza F, Cervi L, Motrán CC. In vivo expression of recombinant pregnancy-specific glycoprotein 1a inhibits the symptoms of collagen-induced arthritis. Am J Reprod Immunol. 2014;72(6):527-533.
22. Woidacki K, Zenclussen AC, Siebenhaar F. Mast cell-mediated and associated disorders in pregnancy: a risky game with an uncertain outcome? Front Immunol. 2014;5:231.
23. De Simone C, Caldarola G, Corbeddu M, Moro F, Tropea A, Moretta G, et al. A possible role of polycystic ovary syndrome for pregnancy complications in women with psoriasis. Drug Dev Res. 2014;75(Suppl 1):S64-S66.
24. Cohen-Barak E, Nachum Z, Rozenman D, Ziv M. Pregnancy outcomes in women with moderate-to-severe psoriasis. J Eur Acad Dermatol Venereol. 2011;25(9):1041-1047.
25. Ryan C, Korman NJ, Gelfand JM, Lim HW, Elmets CA, Feldman SR, et al. Research gaps in psoriasis:opportunities for future studies. J Am Acad Dermatol. 2014;70(1):146-167.
26. Figueroa-Vega N, Moreno-Frías C, Malacara JM. Alterations in adhesion molecules, pro-inflammatory cytokines and cell-derived microparticles contribute to intima-media thickness and symptoms in postmenopausal women. PLoS One. 2015;10(5):e0120990.
27. Pietrzak A, Czuczwar P, Mosiewicz J, Paszkowski T, Chodorowska G, Bartosinska J, et al.
Cardiovascular disease in psoriatic post-menopausal women. J Eur Acad Dermatol Venereol. 2015;29(6):1231-1234.
28. Gubbels Bupp MR. Sex, the aging immune system, and chronic disease. Cell Immunol. 2015;294(2): 102-110.
29. Alesci S, Bornstein SR. Neuroimmunoregulation of androgens in the adrenal gland and the skin. Horm Res. 2000;54(5-6):281-286.
30. Makrantonaki E, Zouboulis CC. Androgens and ageing of the skin. Curr Opin Endocrinol Diabetes Obes. 2009;16(3):240-245.
31. Atzeni F, Straub RH, Cutolo M, Sarzi-Puttini P. Psoriatic arthritis: clinical improvement and correlation with hormone axes in etanercept-treated patients. Ann N Y Acad Sci. 2010;1193:176-178.
32. Iulia IR, Constantin AM, Mihaela EM, REMUS IO. The role of hormones in the pathogenesis of psoriasis vulgaris.Clujul Medical. 2016; 89(1): 11-18.
33. Lindegärd B: Diseases associated with psoriasis in a general population of 159,2 00 middleaged, urban, native Swedes. Dermatologica 1986;172:298-304.
34. Henseler T, Christophers E: Disease concomitance in psoriasis. J Am Acad Dermatol 1995; 32:982-986.
35. Naldi L, Chatenoud L, Linder D, Belloni Fortina A, Peserico A, Virgili AR, et al: Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: results from an Italian case-control study. J Invest Dermatol 2005;125:61-67.
36. Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM: Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol 2006;55:829-835.
37. Cohen AD, Sherf M, Vidavsky L, Vardy DA, Shapiro J, Meyerovitch J: Association between psoriasis and the metabolic syndrome. Dermatology 2008;216:152-155.
38. Herron MD, Hinckley M, Hoffman MS, Papenfuss J, Hansen CB, Callis KP, et al: Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol 2005; 141:1727-1534.
39. Mallbris L, Granath F, Hamsten A, Stähle M: Psoriasis is associated with lipid abnormalities at the onset of skin disease. J Am Acad Dermatol 2006;54:614-621.
40. Setty AR, Curhan G, Choi HK: Obesity, waist circumference, weight change, and the risk of psoriasis in women: Nurses' Health Study II. Arch Intern Med 2007;167:1670-1675.
41. Bryld LE, S0rensen TI, Andersen KK, Jemec GB, Baker JL: High body mass index in adolescent girls precedes psoriasis hospitalization. Acta Derm Venereol 2010;90:488-493.
42. Jensen P. • Skov L. Psoriasis and Obesity. Dermatology 2016;232:633-639.
