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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