Patients with psoriasis are at an increased risk of hypertension, and when present, hypertension is more severe in patients with psoriasis. However, hypertension often goes underdiagnosed and undertreated in this population, which can contribute to increased overall morbidity and mortality.
Objective:
To review the relationship between psoriasis and hypertension and provide practical screening and treatment recommendations for dermatologists to address hypertension in patients with psoriasis.
Evidence Review:
PubMed and MEDLINE databases were searched for hypertension and psoriasis. Consensus was reached by the authors based on published work and clinical experience for recommendations on screening, monitoring, diagnosis, and treatment of hypertension in patients with psoriasis.
Findings:
Hypertension is more prevalent, and often more severe, in the psoriasis population. This review summarizes recommendations for annual hypertension screening in patients with psoriasis, as well as diagnostic cutoffs and initial therapies for dermatologists to consider. Referral to primary care for continued hypertension management and additional referral recommendations based on comorbidities are described.
Conclusions and Relevance:
Psoriasis is a common dermatologic diagnosis in the United States. Dermatologists should be fully aware of appropriate screening, diagnosis, and initial management of hypertension in this population to help improve morbidity and mortality.
JamesPAOparilSCarterBL, et al.2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–520.
2.
GuoFHeDZhangWWaltonRG. Trends in prevalence, awareness, management, and control of hypertension among United States adults, 1999 to 2010. J Am Coll Cardiol. 2012.
3.
AzfarRSGelfandJM. Psoriasis and metabolic disease: epidemiology and pathophysiology. Curr Opin Rheumatol. 2008;20(4):416–422.
4.
NeimannALShinDBWangXMargolisDJTroxelABGelfandJM. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol. 2006;55(5):829–835.
5.
PreeceJF. Raised blood pressure and psoriasis. J R Coll Gen Pract. 1977;27(185):713–715.
6.
EnaPMadedduPGloriosoNCerimeleDRappelliA. High prevalence of cardiovascular diseases and enhanced activity of the renin-angiotensin system in psoriatic patients. Acta Cardiol. 1985;40(2):199–205.
7.
HenselerTChristophersE. Disease concomitance in psoriasis. J Am Acad Dermatol. 1995;32(6):982–986.
8.
PearceDJMorrisonAEHigginsKB, et al.The comorbid state of psoriasis patients in a university dermatology practice. J Dermatolog Treat. 2005;16(5-6):319–323.
9.
SommerDMJenischSSuchanMChristophersEWeichenthalM. Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res. 2006;298(7):321–328.
10.
CohenADGilutzHHenkinYZahgerDShapiroJBonnehDYVardyDA. Psoriasis and the metabolic syndrome. Acta Derm Venereol. 2007;87(6):506–509.
11.
CohenADSherfMVidavskyLVardyDAShapiroJMeyerovitchJ. Association between psoriasis and the metabolic syndrome. A cross-sectional study. Dermatology. 2008;216(2):152–155.
12.
KayeJALiLJickSS. Incidence of risk factors for myocardial infarction and other vascular diseases in patients with psoriasis. Br J Dermatol. 2008;159(4):895–902.
13.
KimballABRobinsonDJrWuY, et al.Cardiovascular disease and risk factors among psoriasis patients in two US healthcare databases, 2001-2002. Dermatology. 2008;217(1):27–37.
14.
TamLSTomlinsonBChuTT, et al.Cardiovascular risk profile of patients with psoriatic arthritis compared to controls—the role of inflammation. Rheumatology (Oxford). 2008;47(5):718–723.
15.
WuYMillsDBalaM. Psoriasis: cardiovascular risk factors and other disease comorbidities. J Drugs Dermatol. 2008;7(4):373–377.
16.
ChangYTChenTJLiuPC, et al.Epidemiological study of psoriasis in the national health insurance database in Taiwan. Acta Derm Venereol. 2009;89(3):262–266.
17.
DriessenRJBoezemanJBVan De KerkhofPCDe JongEM. Cardiovascular risk factors in high-need psoriasis patients and its implications for biological therapies. J Dermatolog Treat. 2009;20(1):42–47.
18.
PrignanoFRicceriFPescitelliL, et al.Comparison of body weight and clinical-parameter changes following the treatment of plaque psoriasis with biological therapies. Curr Med Res Opin. 2009;25(9):2311–2316.
19.
ProdanovichSKirsnerRSKravetzJDMaFMartinezLFedermanDG. Association of psoriasis with coronary artery, cerebrovascular, and peripheral vascular diseases and mortality. Arch Dermatol. 2009;145(6):700–703.
20.
QureshiAAChoiHKSettyARCurhanGC. Psoriasis and the risk of diabetes and hypertension: a prospective study of US female nurses. Arch Dermatol. 2009;145(4):379–382.
21.
MutairiNAFaragSAMutairiAAShiltawyMA. Comorbidities associated with psoriasis: an experience from the Middle East. J Dermatol. 2010;37(2):146–155.
22.
AugustinMGlaeskeGRadtkeMAChristophersEReichKSchaferI. Epidemiology and comorbidity of psoriasis in children. Br J Dermatol. 2010;162(3):633–636.
23.
AugustinMReichKGlaeskeGSchaeferIRadtkeM. Co-morbidity and age-related prevalence of psoriasis: analysis of health insurance data in Germany. Acta Derm Venereol. 2010;90(2):147–151.
24.
CohenADWeitzmanDDreiherJ. Psoriasis and hypertension: a case-control study. Acta Derm Venereol. 2010;90(1):23–26.
25.
SchmittJFordDE. Psoriasis is independently associated with psychiatric morbidity and adverse cardiovascular risk factors, but not with cardiovascular events in a population-based sample. J Eur Acad Dermatol Venereol. 2010;24(8):885–892.
26.
KimballABGladmanDGelfandJM, et al.National Psoriasis Foundation clinical consensus on psoriasis comorbidities and recommendations for screening. J Am Acad Dermatol. 2008;58(6):1031–1042.
27.
ArmstrongAWLinSWChambersCJSockolovMEChinDL. Psoriasis and hypertension severity: results from a case-control study. PLoS One. 2011;6(3): e18227.
28.
AbelEADiCiccoLMOrenbergEKFrakiJEFarberEM. Drugs in exacerbation of psoriasis. J Am Acad Dermatol. 1986;15(5 pt 1):1007–1022.
29.
WheltonPKCareyRMAronowWS, et al.2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6): e13–e115.
30.
ArmstrongAWHarskampCTArmstrongEJ. The association between psoriasis and hypertension: a systematic review and meta-analysis of observational studies. J Hypertens. 2013;31(3):433–442; discussion 442-433.
31.
ElmetsCALeonardiCLDavisDMR, et al.Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol. 2019;80(4):1073–1113.
32.
InerotAEnerbackCEnlundF, et al.Collecting a set of psoriasis family material through a patient organisation; clinical characterisation and presence of additional disorders. BMC Dermatol. 2005;5:10.
33.
GisondiPTessariGContiA, et al.Prevalence of metabolic syndrome in patients with psoriasis: a hospital-based case-control study. Br J Dermatol. 2007;157(1):68–73.
34.
NaldiLChatenoudLBelloniA, et al.Medical history, drug exposure and the risk of psoriasis. evidence from an Italian case-control study. Dermatology. 2008;216(2):125–130; discussion 130-122.
35.
MadhurMSLobHEMcCannLA, et al.Interleukin 17 promotes angiotensin II-induced hypertension and vascular dysfunction. Hypertension. 2010;55(2):500–507.
36.
CohenADDreiherJShapiroYVidavskyLVardyDADavidoviciBMeyerovitchJ. Psoriasis and diabetes: a population-based cross-sectional study. J Eur Acad Dermatol Venereol. 2008;22(5):585–589.
37.
ShapiroJCohenADDavidM, et al.The association between psoriasis, diabetes mellitus, and atherosclerosis in Israel: a case-control study. J Am Acad Dermatol. 2007;56(4):629–634.
38.
von DratelnCRAbundisEMBalcazar MunozBRSaldanaRBOrtizMG. Lipid profile, insulin secretion, and insulin sensitivity in psoriasis. J Am Acad Dermatol. 2003;48(6):882–885.
39.
HerronMDHinckleyMHoffmanMS, et al.Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol. 2005;141(12):1527–1534.
40.
McGowanJWPearceDJChenJRichmondDBalkrishnanRFeldmanSR. The skinny on psoriasis and obesity. Arch Dermatol. 2005;141(12):1601–1602.
41.
SterryWStroberBEMenterA. Obesity in psoriasis: the metabolic, clinical and therapeutic implications. Report of an interdisciplinary conference and review. Br J Dermatol. 2007;157(4):649–655.
42.
HuertaCRiveroERodriguezLA. Incidence and risk factors for psoriasis in the general population. Arch Dermatol. 2007;143(12):1559–1565.
43.
NaldiLParazziniFBreviA, et al.Family history, smoking habits, alcohol consumption and risk of psoriasis. Br J Dermatol. 1992;127(3):212–217.
44.
NaldiLPeliLParazziniF. Association of early-stage psoriasis with smoking and male alcohol consumption: evidence from an Italian case-control study. Arch Dermatol. 1999;135(12):1479–1484.
45.
SettyARCurhanGChoiHK. Obesity, waist circumference, weight change, and the risk of psoriasis in women: Nurses’ Health Study II. Arch Intern Med. 2007;167(15):1670–1675.
46.
MannSJJamesGDWangRSPickeringTG. Elevation of ambulatory systolic blood pressure in hypertensive smokers. A case-control study. Jama. 1991;265(17):2226–2228.
47.
JankovicSRaznatovicMMarinkovicJJankovicJMaksimovicN. Risk factors for psoriasis: a case-control study. J Dermatol. 2009;36(6):328–334.
48.
RyderMISaghizadehMDingYNguyenNSoskolneA. Effects of tobacco smoke on the secretion of interleukin-1beta, tumor necrosis factor-alpha, and transforming growth factor-beta from peripheral blood mononuclear cells. Oral Microbiol Immunol. 2002;17(6):331–336.
49.
FuchsFDChamblessLEWheltonPKNietoFJHeissG. Alcohol consumption and the incidence of hypertension: The Atherosclerosis Risk in Communities Study. Hypertension. 2001;37(5):1242–1250.
50.
BehnamSMBehnamSEKooJY. Alcohol as a risk factor for plaque-type psoriasis. Cutis. 2005;76(3):181–185.
51.
NaldiLChatenoudLLinderD, 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(1):61–67.
52.
SettyARCurhanGChoiHK. Smoking and the risk of psoriasis in women: Nurses’ Health Study II. Am J Med. 2007;120(11):953–959.
53.
DeMarcoVGAroorARSowersJR. The pathophysiology of hypertension in patients with obesity. Nat Rev Endocrinol. 2014;10(6):364–376.
54.
RyanCAmorKTMenterA. The use of cyclosporine in dermatology: part II. J Am Acad Dermatol. 2010;63(6):949–972; quiz 973-944.
55.
GilbertsonEOSpellmanMCPiacquadioDJMulfordMI. Super potent topical corticosteroid use associated with adrenal suppression: clinical considerations. J Am Acad Dermatol. 1998;38(2 pt 2):318–321.
56.
LukeRG. Mechanism of cyclosporine-induced hypertension. Am J Hypertens. 1991;4(5 pt 1):468–471.
57.
van der SchaafMRHeneRJFloorMBlankestijnPJKoomansHA. Hypertension after renal transplantation. Calcium channel or converting enzyme blockade?Hypertension. 1995;25(1):77–81.
58.
AbmaEMBlankenRDe HeideLJ. Cushing’s syndrome caused by topical steroid therapy for psoriasis. Neth J Med. 2002;60(3):148–150.
59.
StaughtonRCAugustPJ. Cushing’s syndrome and pituitary-adrenal suppression due to clobetasol propionate. Br Med J. 1975;2(5968):419–421.
60.
WhiteWB. Defining the problem of treating the patient with hypertension and arthritis pain. Am J Med. 2009;122(5 suppl):S3–S9.
61.
MuntnerPShimboDCareyRM, et al.Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73(5): e35–e66.
62.
ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288(23):2981–2997.
63.
RosenthalAHerrmannJ. Hydrochlorothiazide-induced photosensitivity in a psoriasis patient following exposure to narrow-band ultraviolet B excimer therapy. Photodermatol Photoimmunol Photomed. 2019;35(5):369–371.
64.
JamersonKWeberMABakrisGL, et al.Benazepril plus amlodipine or hydrochlorothiazide for hypertension in high-risk patients. N Engl J Med. 2008;359(23):2417–2428.
65.
GilleaudeauPVallatVPCarterDMGottliebAB. Angiotensin-converting enzyme inhibitors as possible exacerbating drugs in psoriasis. J Am Acad Dermatol. 1993;28(3):490–492.
66.
O’BrienMKooJ. The mechanism of lithium and beta-blocking agents in inducing and exacerbating psoriasis. J Drugs Dermatol. 2006;5(5):426–432.
67.
CohenADKagenMFrigerMHalevyS. Calcium channel blockers intake and psoriasis: a case-control study. Acta Derm Venereol. 2001;81(5):347–349.
68.
TorreJJBloomgardenZTDickeyRA, et al.American Association of Clinical Endocrinologists medical guidelines for clinical practice for the diagnosis and treatment of hypertension. Endocr Pract. 2006;12(2):193–222.
69.
ZallaMJMullerSA. The coexistence of psoriasis with lupus erythematosus and other photosensitive disorders. Acta Derm Venereol Suppl (Stockh). 1996;195:1–15.
70.
WeberMASchiffrinELWhiteWB, et al.Clinical practice guidelines for the management of hypertension in the community a statement by the American Society of Hypertension and the International Society of Hypertension. J Hypertens. 2014;32(1):3–15.
71.
TsankovNKazandjievaJDrenovskaK. Drugs in exacerbation and provocation of psoriasis. Clin Dermatol. 1998;16(3):333–351.
ResingKAal-AlawiNBlomquistCFleckmanPDaleBA. Independent regulation of two cytoplasmic processing stages of the intermediate filament-associated protein filaggrin and role of Ca2+ in the second stage. J Biol Chem. 1993;268(33):25139–25145.
MarienhagenKLehnerFKlempnauerJHeckerHBorlakJ. Treatment of cyclosporine induced hypertension: results from a long-term observational study using different antihypertensive medications. Vascul Pharmacol. 2019;115:69–83.
76.
GelfandJMShinDBAlaviA, et al.A phase IV, randomized, double-blind, placebo-controlled crossover study of the effects of ustekinumab on vascular inflammation in psoriasis (the VIP-U Trial). J Invest Dermatol. 2020;140(1):85–93. e82.
77.
GelfandJMShinDBDuffinKC, et al.A Randomized placebo-controlled trial of secukinumab on aortic vascular inflammation in moderate-to-severe plaque psoriasis (VIP-S). J Invest Dermatol. 2020.
