What is Psoriatic March?
The "psoriatic march" is a conceptual framework describing how chronic systemic inflammation in psoriasis may sequentially drive the development of metabolic disorders and ultimately cardiovascular disease through a cascade of insulin resistance, endothelial dysfunction, and atherosclerosis. 1
The Inflammatory Cascade
The psoriatic march represents a progression where:
Chronic systemic inflammation from psoriasis initiates insulin resistance, which subsequently triggers endothelial cell dysfunction, leading to atherosclerosis and ultimately myocardial infarction or stroke 1
This concept parallels the "atopic march" seen in allergic diseases, but instead of progressing through different allergic manifestations, psoriasis drives cardiovascular pathology through sustained inflammatory mediators 1
The underlying mechanism involves inappropriate activation of T cells and dendritic cells with release of inflammatory cytokines including IL-1, IL-6, IL-12, IL-17, IL-23, and TNF-α, which are responsible for both skin manifestations and systemic inflammation 2
Clinical Significance and Timing
The sequence of disease onset matters significantly for cardiovascular risk:
When psoriasis serves as the "initiator" (metabolic disorders develop after psoriasis onset), patients have lower cardiovascular risk (HR = 1.64 for cardiovascular events) compared to when psoriasis serves as an "amplifier" 3
When psoriasis acts as the "amplifier" (occurring in patients with pre-existing metabolic disorders), the cardiovascular risk is substantially higher (HR = 2.78 for cardiovascular events) 3
This distinction has therapeutic implications: methotrexate was associated with reduced cerebrovascular event risk (HR = 0.22) specifically when psoriasis served as the disease amplifier 3
Systemic Disease Recognition
Psoriasis must be recognized as a multisystem inflammatory disease, not merely a skin condition:
Associated comorbidities include psoriatic arthritis, inflammatory bowel disease, metabolic syndrome components (diabetes, hypertension, dyslipidemia), cardiovascular disease, and lymphoma 2
Dermatologists play a critical role in identifying the full morbidity spectrum of psoriatic disease, as they care for the majority of psoriasis patients 2
The systemic inflammation contributes to increased mortality from cardiovascular disease, making early recognition and aggressive management essential 1
Important Clinical Caveat
While the psoriatic march concept is not yet formally proven through prospective interventional studies, it is strongly supported by observational evidence and provides a useful framework for understanding why aggressive systemic treatment of psoriasis may reduce cardiovascular morbidity and mortality beyond just improving skin disease 1.