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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
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.


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.

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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.

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