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Dermatology

Long-term Outcomes and Prognosis in New-Onset Psoriasis

Educational Objective
To describe the clinical course and identify possible indicators of long-term outcomes in psoriasis.

1 Credit CME

JAMA Dermatology

Published Online: April 14, 2021

Original Investigation

Article Information and Disclosures

Axel Svedbom, MsC^1,2;

Lotus Mallbris, MD^1,3;

Per Larsson, MD⁴;

Pernilla Nikamo, PhD¹;

Katarina Wolk, MD⁵;

Petra Kjellman, MD⁶;

Enikö Sonkoly, MD^1,7;

Liv Eidsmo, MD^1,7;

Ulla Lindqvist, MD⁸;

Mona Ståhle, MD^1,7

Author Affiliations

¹Division of Dermatology and Venereology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
²ICON Clinical Research, Stockholm, Sweden
³Eli Lilly, Indianapolis, Indiana
⁴Division of Rheumatology, Department of Medicine Karolinska Institutet, Stockholm, Sweden
⁵Optimuskliniken, Stockholm, Sweden
⁶Diagnostiskt Centrum Hud, Stockholm, Sweden
⁷Dermatology and Venereology Clinic, Karolinska University Hospital, Stockholm, Sweden
⁸Department of Medical Sciences, Rheumatology, Uppsala University, Sweden

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Key Points

Question What are the prognostic factors for the clinical course of psoriasis?

Findings In this 10-year cohort study of 721 patients with recent-onset psoriasis, 52% of the patients with plaque phenotype, high disease activity, and scalp lesions developed severe disease, compared with 11% of patients with low disease activity at inclusion.

Meaning Patient characteristics at onset can help to estimate the long-term course of psoriasis with good discriminatory power.

Abstract

Importance Psoriasis is a heterogeneous disease. Improved understanding of prognosis and long-term outcomes in new-onset psoriasis may improve care.

Objective To describe the clinical course of psoriasis and identify possible indicators of long-term outcomes.

Design, Setting, and Participants The Stockholm Psoriasis Cohort was a noninterventional inception cohort study enrolling patients between 2001 and 2005. The present study was conducted from January 15, 2019, to February 5, 2021. At enrollment and 10 years, patients were examined by dermatologists and rheumatologists. Data from examinations were complemented by questionnaires, medical records, and registers. A total of 721 patients with recent-onset psoriasis (<12 months duration), 15 years or older were recruited using advertising and referrals from a broad range of health care settings.

Main Outcomes and Measures Disease severity and psoriatic arthritis (PsA). Recursive partitioning and regression models were implemented to identify probable indicators of long-term outcomes.

Results A total of 721 patients (median [interquartile range] age, 39 [27-55] years; 405 [56%] women), including 542 (75%) with plaque-onset and 174 (24%) with guttate-onset psoriasis, were enrolled. The median follow-up was 9.6 years (interquartile range, 8.8-10.4 years). The cumulative incidence of severe psoriasis at 12 years from enrollment was 21%. Among 509 patients examined clinically after 10 years, 77 of 389 patients (20%) with plaque onset and 56 of 116 (48%) with guttate onset had minimal disease activity without treatment, and 120 of 509 (24%) had PsA. Recursive partitioning identified strata with distinct risks for severe skin disease and PsA: the cumulative incidence of severe disease in patients with plaque phenotype, above-median disease activity, and scalp lesions was 52% (95% CI, 41%-64%), compared with 11% (95% CI, 8%-14%) in patients with below-median disease activity at inclusion; and 48 of 82 patients (59%) with peripheral enthesitis had PsA after 10 years compared with 37 of 304 patients (12%) without initial joint pain (P < .001). Smoking (hazard ratio, 1.70; 95% CI, 1.10-2.63) and activating genes in the interleukin-23 (IL-23) pathway (odds ratio, 1.55; 95% CI, 1.14-2.11) were also significantly associated with a severe disease course. Systemic therapy at or before enrollment was associated with a lower risk for severe disease at 10 years compared with later initiation of systemic therapy (odds ratio, 0.24; 95% CI, 0.06-0.90).

Conclusions and Relevance The findings of this cohort study suggest that combinations of clinical characteristics at onset and activating genes in the IL-23 pathway are significantly associated with the clinical course of psoriasis, whereas joint pain and peripheral enthesitis may indicate the probability of PsA. Patients within those categories merit specialist referral and closer follow-up. The possibility of modifying the disease course with early systemic intervention should be tested.

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Article Information

Accepted for Publication: February 23, 2021.

Published Online: April 14, 2021. doi:10.1001/jamadermatol.2021.0734

Corresponding Author: Mona Ståhle, MD, B2:01, Division of Dermatology and Venereology, Department of Medicine, Karolinska Universitetssjukhuset, Solna 171 76 Stockholm, Sweden (mona.stahle@ki.se).

Author Contributions: Mr Svedbom and Dr Ståhle had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Larsson, Lindqvist, Ståhle.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Svedbom, Ståhle.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Svedbom.

Obtained funding: Ståhle.

Administrative, technical, or material support: Nikamo, Wolk, Kjellman, Eidsmo, Lindqvist, Ståhle.

Supervision: Lindqvist, Ståhle.

Conflict of Interest Disclosures: Mr Svedbom is an employee of ICON Clinical Research, a contract research organization. Dr Mallbris is an employee of Eli Lilly and Company. Dr Ståhle has consulting agreements involving financial compensation with Eli Lilly and Company, AbbVie, Janssen, Leo Pharma, BMS, and Novartis. No other disclosures were reported.

Funding/Support: This study was funded by the Stockholm County Council, the Swedish Medical Research Council, Hudfonden, and the Swedish Psoriasis Association.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the pictured patients for granting permission to publish this information. We are also grateful to the patients for participating, Eva Vingård, PhD (Department of Medical Science, Uppsala University), for input on the clinical research forms, and Maria Lundqvist, BS, and Susanne Bergqvist, BS (Department of Dermatology Karolinska University Hospital), for supporting study operations.

References

WHO. Global Report on Psoriasis. World Health Organization;2016.

Nestle FO , Kaplan DH , Barker J . Psoriasis. N Engl J Med. 2009;361(5):496-509. doi:10.1056/NEJMra0804595 PubMed Google Scholar Crossref

Icen M , Crowson CS , McEvoy MT , Dann FJ , Gabriel SE , Maradit Kremers H . Trends in incidence of adult-onset psoriasis over three decades: a population-based study. J Am Acad Dermatol. 2009;60(3):394-401. doi:10.1016/j.jaad.2008.10.062 PubMed Google Scholar Crossref

Griffiths CE , Christophers E , Barker JN , et al. A classification of psoriasis vulgaris according to phenotype. Br J Dermatol. 2007;156(2):258-262. doi:10.1111/j.1365-2133.2006.07675.x PubMed Google Scholar Crossref

Boehncke WH , Schön MP . Psoriasis. Lancet. 2015;386(9997):983-994. doi:10.1016/S0140-6736(14)61909-7 PubMed Google Scholar Crossref

Ryan C , Korman NJ , Gelfand JM , et al. Research gaps in psoriasis: opportunities for future studies. J Am Acad Dermatol. 2014;70(1):146-167. doi:10.1016/j.jaad.2013.08.042 PubMed Google Scholar Crossref

Strober BE , Griffiths CE , O’Dell SJ , Tebbey PW , Barker JN ; International Psoriasis Council. Prioritizing the global research agenda in psoriasis: an International Psoriasis Council Delphi consensus exercise. Br J Dermatol. 2016;174(1):212-215. doi:10.1111/bjd.13980 PubMed Google Scholar Crossref

Barker J , Kimball AB , Tebbey PW , Sterry W . A strategic approach to setting the research agenda in psoriasis. Psoriasis Forum. 2011;17(2):97-102. doi:10.1177/247553031117a00202 Google Scholar Crossref

Ludvigsson JF , Andersson E , Ekbom A , et al. External review and validation of the Swedish National Inpatient Register. BMC Public Health. 2011;11:450. doi:10.1186/1471-2458-11-450 PubMed Google Scholar Crossref

Wettermark B , Hammar N , Fored CM , et al. The new Swedish Prescribed Drug Register—opportunities for pharmacoepidemiological research and experience from the first six months. Pharmacoepidemiol Drug Saf. 2007;16(7):726-735. doi:10.1002/pds.1294 PubMed Google Scholar Crossref

Ludvigsson JF , Almqvist C , Bonamy AK , et al. Registers of the Swedish total population and their use in medical research. Eur J Epidemiol. 2016;31(2):125-136. doi:10.1007/s10654-016-0117-y PubMed Google Scholar Crossref

Mallbris L , Larsson P , Bergqvist S , Vingård E , Granath F , Ståhle M . Psoriasis phenotype at disease onset: clinical characterization of 400 adult cases. J Invest Dermatol. 2005;124(3):499-504. doi:10.1111/j.0022-202X.2004.23611.x PubMed Google Scholar Crossref

Christophers E , Sterry W. Psoriasis. In: Fitzpatrick TB, Elsen AZ, Wolff K, Freedberg IM Austen KF, eds. Dermatology in General Medicine. 4th ed. McGraw-Hill; 1993:489-514.

Fredriksson T , Pettersson U . Severe psoriasis—oral therapy with a new retinoid. Dermatologica. 1978;157(4):238-244. doi:10.1159/000250839 PubMed Google Scholar Crossref

Langley RG , Ellis CN . Evaluating psoriasis with psoriasis area and severity index, psoriasis global assessment, and lattice system Physician’s Global Assessment. J Am Acad Dermatol. 2004;51(4):563-569. doi:10.1016/j.jaad.2004.04.012 PubMed Google Scholar Crossref

Egeberg A , Nast A . A critical eye on registry data in psoriasis. Br J Dermatol. 2017;177(1):245-246. doi:10.1111/bjd.15309 PubMed Google Scholar Crossref

Svensson B , Holmström G , Lindqvist U ; Psoriatric Arthritis Register Group of the Swedish Society for Rheumatology. Development and early experiences of a Swedish psoriatic arthritis register. Scand J Rheumatol. 2002;31(4):221-225. doi:10.1080/030097402320318413 PubMed Google Scholar Crossref

Taylor W , Gladman D , Helliwell P , Marchesoni A , Mease P , Mielants H ; CASPAR Study Group. Classification criteria for psoriatic arthritis: development of new criteria from a large international study. Arthritis Rheum. 2006;54(8):2665-2673. doi:10.1002/art.21972 PubMed Google Scholar Crossref

Nikamo P , Lysell J , Ståhle M . Association with genetic variants in the IL-23 and NF-κB pathways discriminates between mild and severe psoriasis skin disease. J Invest Dermatol. 2015;135(8):1969-1976. doi:10.1038/jid.2015.103 PubMed Google Scholar Crossref

de Jong EM . The course of psoriasis. Clin Dermatol. 1997;15(5):687-692. doi:10.1016/S0738-081X(97)00023-0 PubMed Google Scholar Crossref

Fortes C , Mastroeni S , Leffondré K , et al. Relationship between smoking and the clinical severity of psoriasis. Arch Dermatol. 2005;141(12):1580-1584. doi:10.1001/archderm.141.12.1580 PubMed Google Scholar Crossref

Hägg D , Eriksson M , Sundström A , Schmitt-Egenolf M . The higher proportion of men with psoriasis treated with biologics may be explained by more severe disease in men. PLoS One. 2013;8(5):e63619. doi:10.1371/journal.pone.0063619 PubMed Google Scholar

Busse K , Liao W . Which psoriasis patients develop psoriatic arthritis? Psoriasis Forum. 2010;16(4):17-25. doi:10.1177/247553031016a00403 PubMed Google Scholar Crossref

Eder L , Polachek A , Rosen CF , Chandran V , Cook R , Gladman DD . The development of psoriatic arthritis in patients with psoriasis is preceded by a period of nonspecific musculoskeletal symptoms: a prospective cohort Study. Arthritis Rheumatol. 2017;69(3):622-629. doi:10.1002/art.39973 PubMed Google Scholar Crossref

Wilson FC , Icen M , Crowson CS , McEvoy MT , Gabriel SE , Kremers HM . Incidence and clinical predictors of psoriatic arthritis in patients with psoriasis: a population-based study. Arthritis Rheum. 2009;61(2):233-239. doi:10.1002/art.24172 PubMed Google Scholar Crossref

Menter A . Psoriasis and psoriatic arthritis treatment. Am J Manag Care. 2016;22(8)(suppl):s225-s237.PubMed Google Scholar

Ingram JT . The significance and management of psoriasis. BMJ. 1954;2(4892):823-828. doi:10.1136/bmj.2.4892.823 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.