Main Complications of Severe Psoriasis Progression
Severe psoriasis is associated with numerous potentially life-threatening complications including cardiovascular disease, metabolic disorders, lymphoma, and significant mortality risk, with patients dying approximately 5 years younger than those without psoriasis. 1
Cardiovascular Complications
Cardiovascular disease represents one of the most serious complications of severe psoriasis:
- Increased myocardial infarction risk - Patients with severe psoriasis have a significantly higher risk of MI even after accounting for traditional cardiovascular risk factors (obesity, smoking, diabetes, hypertension) 1
- Accelerated atherosclerosis - The chronic inflammatory nature of psoriasis contributes to vascular disease development 1
- Increased mortality - Population-based studies show higher mortality rates in severe psoriasis patients, largely attributable to cardiovascular death 1
The link between psoriasis and cardiovascular disease appears to be related to the systemic inflammatory burden, similar to what is observed in rheumatoid arthritis. This suggests that psoriasis itself may be an independent risk factor for cardiovascular disease.
Metabolic Complications
Severe psoriasis progression is associated with several metabolic disorders:
- Diabetes mellitus - Higher incidence of insulin resistance and type 2 diabetes 1
- Hyperlipidemia - Elevated triglycerides and cholesterol levels 1
- Obesity - More common in psoriasis patients and may exacerbate disease severity 1
- Metabolic syndrome - Constellation of these risk factors further increasing cardiovascular risk 1
Immune-Related Complications
As psoriasis progresses, patients face increased risk of other immune-mediated conditions:
- Psoriatic arthritis - Affects up to 42% of psoriasis patients, potentially leading to deforming joint disease even with limited skin involvement 1
- Inflammatory bowel disease - Particularly Crohn's disease, with 3.8-7.5 times higher incidence than the general population 1
- Multiple sclerosis - Possible link between these conditions 1
Malignancy Risk
Severe psoriasis is associated with increased risk of certain cancers:
- Lymphoma - Overall increased risk (relative risk 1.34), with particularly elevated risk for:
- Cutaneous T-cell lymphoma (relative risk 10.75)
- Hodgkin's lymphoma (relative risk 3.18) 1
- Skin cancer - Especially in patients with extensive PUVA treatment history:
- 14-fold higher risk of squamous cell carcinoma after >250 PUVA treatments
- Increased melanoma risk in Caucasians with extensive PUVA exposure 1
Psychological and Behavioral Complications
Severe psoriasis often leads to significant psychological burden:
- Depression and anxiety - More common in psoriasis patients 1
- Suicidal ideation - Higher risk compared to general population 1
- Alcohol abuse - May both contribute to and result from psoriasis 1
- Smoking - Higher prevalence (37% vs 13% in general population), which may worsen disease severity 1
Medication-Related Complications
Long-term treatment with systemic medications can lead to additional complications:
- Methotrexate - Can cause hepatotoxicity, fibrosis, cirrhosis, bone marrow suppression, and opportunistic infections 2
- Cyclosporine - Associated with renal dysfunction, hypertension, and increased risk of skin malignancies 3
Rare but Severe Complications
- Erythrodermic psoriasis - A severe form that can lead to systemic symptoms including fever, chills, and generalized inflammation 4
- Transformation to pustular psoriasis - Can occur upon withdrawal or reduction of certain treatments 3
Clinical Implications
The multisystem nature of severe psoriasis requires comprehensive monitoring and management:
- Regular cardiovascular risk assessment
- Screening for metabolic disorders
- Vigilance for signs of psoriatic arthritis
- Monitoring for lymphoma and skin cancer
- Addressing psychological comorbidities
- Careful selection of treatments based on comorbidity profile
Understanding these complications is essential for appropriate management of patients with severe psoriasis to reduce morbidity and mortality and improve quality of life.