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Study |

Psoriasis and the Risk of Diabetes and Hypertension:  A Prospective Study of US Female Nurses FREE

Abrar A. Qureshi, MD, MPH; Hyon K. Choi, MD, DrPH; Arathi R. Setty, MD, MPH; Gary C. Curhan, MD, ScD
[+] Author Affiliations

Author Affiliations: Channing Laboratory, Department of Medicine (Drs Qureshi, Choi, Setty, and Curhan), and Department of Dermatology (Dr Qureshi), Brigham and Women's Hospital and Harvard Medical School, and Department of Epidemiology, Harvard School of Public Health (Dr Curhan), Boston, Massachusetts.


Arch Dermatol. 2009;145(4):379-382. doi:10.1001/archdermatol.2009.48.
Text Size: A A A
Published online

Objective  To evaluate the independent association between psoriasis and risk of diabetes and hypertension.

Design  A prospective study of female nurses who were followed up from 1991 to 2005.

Setting  Nurses' Health Study II, a cohort of 116 671 US women aged 27 to 44 years in 1991.

Participants  The study included 78 061 women who responded to a question about a lifetime history of physician-diagnosed psoriasis in 2005. Women who reported a diagnosis of diabetes or hypertension at baseline were excluded.

Main Outcome Measure  New diagnosis of diabetes or hypertension, obtained from biennial questionnaires.

Results  Of the 78 061 women, 1813 (2.3%) reported a diagnosis of psoriasis. During the 14 years of follow-up, a total of 1560 incident cases (2%) of diabetes and 15 724 incident cases (20%) of hypertension were documented. The multivariate-adjusted relative risk of diabetes in women with psoriasis compared with women without psoriasis was 1.63 (95% confidence interval, 1.25-2.12). Women with psoriasis were also at an increased risk for the development of hypertension (multivariate relative risk, 1.17; 95% confidence interval, 1.06-1.30). Age, body mass index, and smoking status did not significantly modify the association between psoriasis and risk of diabetes or hypertension (P values for interaction, ≥.07).

Conclusions  In this prospective analysis, psoriasis was independently associated with an increased risk of diabetes and hypertension. Future studies are needed to find out whether psoriasis treatment will reduce the risk of diabetes and hypertension.

Psoriasis is a chronic inflammatory skin disease that affects between 1% and 3% of the population1 and poses a lifelong burden.2 Recent studies indicate that psoriasis is associated with an increased risk of comorbidity3 and mortality.4 Systemic inflammation in psoriasis and an increased prevalence of unhealthy lifestyle factors have been independently associated with obesity, insulin resistance, and an unfavorable cardiovascular risk profile.5 Diabetes and hypertension are responsible for major morbidity and mortality in the United States.69 Previous cross-sectional studies have demonstrated that individuals with psoriasis have a higher prevalence of obesity, diabetes, and hypertension.10,11 Individuals with mild psoriasis had a slightly higher risk of diabetes (relative risk [RR], 1.13) and hypertension (RR, 1.03) after adjustment for age, sex, and body mass index (BMI).12 In a case-control study from Israel, the risk of diabetes (RR, 1.27) was higher in individuals with psoriasis.13 Among a group of psoriatic individuals in Italy, diabetes mellitus occurred more frequently in those younger than 50 years.14 Individuals with psoriasis were more likely to have cardiovascular risk factors, including hypertension,12 and myocardial infarctions at a younger age.15

More than 80% of individuals with diabetes develop hypertension, and approximately 20% of individuals with hypertension develop diabetes.16 In patients with hypertension and diabetes, the pathogenesis of cardiovascular disease is multifactorial, but recent evidence points toward the presence of a low-grade inflammatory process.16 Inflammatory markers (eg, C-reactive protein) have been shown to predict the development of diabetes1719 and hypertension.20 To our knowledge, this is the first study to prospectively examine the association between psoriasis and diabetes or hypertension in a cohort of US women.

Study Population

The Nurses Health Study (NHS) II is an ongoing longitudinal study of 116 671 female registered nurses from 15 states in the United States who were between the ages of 25 and 42 years when they completed and returned a baseline questionnaire in 1989. The cohort is followed up with biennial questionnaires, and the follow-up rate exceeded 90% for each 2-year period.

Ascertainment Of Psoriasis

In 2005, NHS II participants were asked whether they had ever received a physician diagnosis of psoriasis and, if so, the date of diagnosis. Of the 84 039 women who responded to the psoriasis question in 2005, a total of 2169 reported a physician diagnosis of psoriasis. After women with diabetes or hypertension at baseline in 1991 were excluded, 78 061 women remained in the analysis, 1813 of whom reported psoriasis. Therefore, 356 women with psoriasis were excluded because of baseline diabetes or hypertension. For this study, follow-up was started in 1991 because it is the first year for which we have corresponding information on smoking and alcohol status.

Ascertainment Of Diabetes And Hypertension

Self-reported incident hypertension and incident diabetes cases were recorded from 1991 to 2005. We excluded women who first reported concomitant diabetes and hypertension on the same questionnaire during follow-up so that diabetes and hypertension could be evaluated as independent outcomes. Previously, medical record review confirmed a documented blood pressure reading greater than 140/90 mm Hg in 100% of women in the NHS I who reported hypertension; also, self-reported hypertension was predictive of subsequent cardiovascular events.21

Covariates

Date of birth and height were reported on the 1989 questionnaire. The participants reported their current weight on the biennial mailed questionnaires. The baseline and biennial follow-up questionnaires asked about smoking status and alcohol intake. Physical activity was defined as the number of metabolic equivalent hours per week; specifically, the number of metabolic equivalent hours was calculated as a product of the time invested in an activity every week and the energy expenditure required by the activity.

Statistical Analysis

Women accrued person-time from the return of the 1991 questionnaire until they reported a diagnosis of diabetes or hypertension or were censored at the end of the follow-up period in 2005. New psoriasis diagnoses were updated every 2 years. We used Cox proportion hazards modeling to estimate the age-adjusted and multivariate RRs of incident diabetes and hypertension in women who had reported a physician diagnosis of psoriasis compared with those who did not. We categorized BMI (calculated as weight in kilograms divided by height in meters squared) at baseline and at each questionnaire cycle into 6 categories (<21.0, 21.0-22.9, 23.0-24.9, 25.0-29.9, 30.0-34.9, and ≥35.0). To minimize residual confounding by BMI in categories, we also considered BMI as a continuous variable. Smoking status was categorized (never, current, or past), as was alcohol intake (1-4, 5-9, 10-14, 15-29, and ≥30 g/wk). Physical activity was categorized in quintiles of metabolic equivalent hours per week. We explored potential interactions by age (<45 years vs ≥45 years), BMI (<25.0 vs ≥25.0), and smoking status (never, current, or past) by testing the significance of interaction terms added to our final multivariate models. For all rate ratios, we calculated 95% confidence intervals (CIs). All statistical analyses were performed using SAS software, version 9.1 (SAS Institute Inc, Cary, North Carolina). The institutional review board of Partners Health Care System, Boston, Massachusetts, approved this study.

Over the 14-year follow-up, 1560 incident cases of diabetes and 15 724 incident cases of hypertension occurred. There was no substantial difference in the mean age between women with and without psoriasis (Table 1). Mean BMI, alcohol intake, and proportions of current and past smokers were higher in the psoriasis group. Among women with psoriasis, there were 60 incident cases (3.3%) of diabetes. Compared with women without psoriasis, the age-adjusted RR of diabetes in women with psoriasis was 2.08 (95% CI, 1.60-2.69) (Table 2). This RR remained significantly elevated (RR, 1.63; 95% CI, 1.25-2.12) after further adjustment for BMI, smoking status, alcohol intake, and physical activity. None of the 60 women who reported psoriasis and diabetes had type 1 diabetes.

Table Graphic Jump LocationTable 1 Baseline Characteristics of Women Who Self-reported a Diagnosis of Psoriasis Between 1991 and 2005
Table Graphic Jump LocationTable 2. Age-Adjusted and Multivariate Relative Risks (RRs) for the Development of Diabetes and Hypertension Among Women With Psoriasis

Of women with psoriasis, 386 (21.3%) developed incident hypertension. This proportion of women with hypertension and psoriasis represented an increased risk of hypertension (age-adjusted RR, 1.32; 95% CI, 1.19-1.45) that was attenuated but remained significant after multivariate adjustment (RR, 1.17; 95% CI, 1.06-1.30). We also evaluated possible effect modification by age, BMI, and smoking status in multivariate models. The association between psoriasis and risk was not modified by BMI for diabetes (P = .65) or hypertension (P = .07). There was also no effect modification by smoking status for diabetes or hypertension (P ≥ .50). Because women with psoriasis may be more likely to see a physician, and therefore more likely to be diagnosed as having diabetes or hypertension, we performed additional analyses after limiting the population to those women who underwent at least 1 physical examination during follow-up. There was no material change in the results.

This prospective study demonstrated an increased risk of diabetes and hypertension in women with psoriasis, even after adjustment for age, BMI, alcohol intake, and smoking status. Therefore, our study advances previous findings from cross-sectional studies and emphasizes the need to better understand the mechanisms that underlie these associations.

The risk of diabetes among individuals with psoriasis has been shown in cross-sectional studies to be elevated, with an RR between 1.27 and 2.48,4,10,13,14,2225 consistent with our prospective study. Although obesity and the metabolic syndrome had been proposed as an explanation for this increased risk,5 we found that the risk of diabetes was independent of BMI. Inflammation could be a biologically plausible mechanism underlying this association; insulin resistance has previously been attributed to inflammation,26,27 and elevated C-reactive protein levels are predictive of diabetes.17,18 Alternatively, therapy for psoriasis may promote development of diabetes, especially if patients were treated with systemic steroids. In our study, information on psoriasis-related therapy was not available. Nonetheless, systemic steroids are not the standard of care for psoriasis in the United States and are typically avoided in patients with psoriasis owing to the potential for disease worsening.28 The topical steroids that are often used in the treatment of psoriasis may be systemically absorbed if they are used on large body surface areas for extended periods.29 The long-term use of topical steroids on large body surface areas could explain the observed increase in risk for diabetes, although adherence with long-term topical steroids use is generally low.30,31

An increased risk of hypertension of 1.2- to 2-fold has been reported in cross-sectional studies. In our study, individuals with psoriasis were at a slightly increased risk for hypertension. Although psoriasis and hypertension share common risk factors, such as smoking and obesity, we observed an independent association between psoriasis and hypertension after adjusting for smoking status and BMI. Potential explanations for this association include systemic inflammation and psoriasis treatment. As mentioned above, psoriasis is a chronic inflammatory disease,32 and inflammation is a risk factor for hypertension.5,11,12 In one study, although the risk for other cardiovascular risk factors was higher in severe psoriasis, a similar association between psoriasis severity and risk of hypertension was not found.12 Previous work has shown that elevated levels of C-reactive protein were associated with a 52% increase in the risk of hypertension developing in women.33 Systemic therapy for psoriasis with medications such as cyclosporine may increase the risk of hypertension directly, albeit this risk is low34; we did not have data on therapy in our study, but long-term cyclosporine use in psoriasis is not common.35 Individuals with psoriasis may also be less likely to exercise owing to physical or social discomfort,36 thereby increasing their risk for hypertension. In our study, we controlled for physical activity and found no material change in risk for hypertension.

Our study was predominantly restricted to white women. Therefore, we cannot generalize these results to men or other racial groups. Our study was observational; thus, we cannot rule out the possibility that unmeasured factors might have contributed to the observed associations. While we observed no material change in the results that excluded the individuals who underwent at least 1 physical examination during follow-up, we cannot eliminate potentially increased ascertainment of our outcomes among women with psoriasis. A major strength of the study was the detailed collection of information on BMI, smoking status, and alcohol. Similar to other epidemiological studies of psoriasis,15,3739 we did not confirm the nurses' self-reported physician diagnosis of psoriasis clinically with an examination by a dermatologist. Previous validation studies in the NHS I for another skin condition, ie, basal cell carcinoma, found self-reports to be more than 90% accurate.21,40 While we expect the overall accuracy of self-reported physician diagnosis of psoriasis to be high among registered nurses, the corresponding accuracy against a dermatologist's examination is not available. Confirming our results using more specific case definitions of psoriasis and evaluating for various psoriasis subtypes, severity, and treatment effects would be valuable.

In conclusion, our prospective study indicates that women with psoriasis have an increased risk for diabetes and hypertension, confirming the findings from previous cross-sectional studies. These data illustrate the importance of considering psoriasis a systemic disorder rather than simply a skin disease. Further research is needed to better understand the mechanisms underlying these associations and to find out whether psoriasis therapy can reduce the risk for diabetes and hypertension.

Correspondence: Abrar A. Qureshi, MD, MPH, Channing Laboratory, Department of Medicine, Brigham and Women's Hospital, 45 Francis St, 221L, Boston, MA 02115 (abrar.qureshi@channing.harvard.edu).

Accepted for Publication: July 25, 2008.

Author Contributions: Dr Qureshi had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Qureshi, Choi, Setty, and Curhan. Acquisition of data: Qureshi, Choi, and Curhan. Analysis and interpretation of data: Qureshi, Choi, and Curhan. Drafting of the manuscript: Qureshi and Choi. Critical revision of the manuscript for important intellectual content: Qureshi, Choi, Setty, and Curhan. Statistical analysis: Qureshi and Curhan. Obtained funding: Qureshi. Administrative, technical, or material support: Qureshi, Setty, and Curhan. Study supervision: Qureshi, Choi, and Curhan.

Financial Disclosure: Dr Qureshi has been a consultant and speaker for Abbott, Amgen, and Genentech.

Funding/Support: This work was partly supported by grants K07CA10897/NCI (Dr Qureshi) and CA050385/NCI from the National Cancer Institute.

Role of the Sponsors: The sponsor had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript.

Additional Contributions: Elaine Coughlan-Gifford assisted with data analysis and programming.

Christophers  E Psoriasis—epidemiology and clinical spectrum. Clin Exp Dermatol 2001;26 (4) 314- 320
PubMed Link to Article
Kimball  ABJacobson  CWeiss  SVreeland  MGWu  Y The psychosocial burden of psoriasis. Am J Clin Dermatol 2005;6 (6) 383- 392
PubMed Link to Article
Pearce  DJMorrison  AEHiggins  KB  et al.  The comorbid state of psoriasis patients in a university dermatology practice. J Dermatolog Treat 2005;16 (5-6) 319- 323
PubMed Link to Article
Mallbris  LRitchlin  CTStahle  M Metabolic disorders in patients with psoriasis and psoriatic arthritis. Curr Rheumatol Rep 2006;8 (5) 355- 363
PubMed Link to Article
Wakkee  MThio  HBPrens  EPSijbrands  EJNeumann  HA Unfavorable cardiovascular risk profiles in untreated and treated psoriasis patients. Atherosclerosis 2007;190 (1) 1- 9
PubMed Link to Article
Nakagami  TQiao  QTuomilehto  J  et al.  Screen-detected diabetes, hypertension and hypercholesterolemia as predictors of cardiovascular mortality in five populations of Asian origin: the DECODA study. Eur J Cardiovasc Prev Rehabil 2006;13 (4) 555- 561
PubMed Link to Article
Hu  GSarti  CJousilahti  P  et al.  The impact of history of hypertension and type 2 diabetes at baseline on the incidence of stroke and stroke mortality. Stroke 2005;36 (12) 2538- 2543
PubMed Link to Article
Livingston  EHKo  CY Effect of diabetes and hypertension on obesity-related mortality. Surgery 2005;137 (1) 16- 25
PubMed Link to Article
Ravipati  GAronow  WSAhn  CAlappat  RMMcClung  JAWeiss  MB Incidence of new stroke or new myocardial infarction or death at 39-month follow-up in patients with diabetes mellitus, hypertension or both with and without microalbuminuria. Cardiology 2008;109 (1) 62- 65
PubMed Link to Article
Gibson  SHPerry  HO Diabetes and psoriasis. AMA Arch Derm 1956;74 (5) 487- 488
PubMed Link to Article
Cohen  ADSherf  MVidavsky  LVardy  DAShapiro  JMeyerovitch  J Association between psoriasis and the metabolic syndrome: a cross-sectional study. Dermatology 2008;216 (2) 152- 155
PubMed Link to Article
Neimann  ALShin  DBWang  XMargolis  DJTroxel  ABGelfand  JM Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol 2006;55 (5) 829- 835
PubMed Link to Article
Shapiro  JCohen  ADDavid  M  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
PubMed Link to Article
Binazzi  MCalandra  PLisi  P Statistical association between psoriasis and diabetes: further results. Arch Dermatol Res 1975;254 (1) 43- 48
PubMed Link to Article
Gelfand  JMNeimann  ALShin  DBWang  XMargolis  DJTroxel  AB Risk of myocardial infarction in patients with psoriasis. JAMA 2006;296 (14) 1735- 1741
PubMed Link to Article
Savoia  CSchiffrin  EL Vascular inflammation in hypertension and diabetes: molecular mechanisms and therapeutic interventions. Clin Sci (Lond) 2007;112 (7) 375- 384
PubMed Link to Article
Pradhan  ADManson  JERifai  NBuring  JERidker  PM C-reactive protein, interleukin 6, and risk of developing type 2 diabetes mellitus. JAMA 2001;286 (3) 327- 334
PubMed Link to Article
Yuan  GZhou  LTang  J  et al.  Serum CRP levels are equally elevated in newly diagnosed type 2 diabetes and impaired glucose tolerance and related to adiponectin levels and insulin sensitivity. Diabetes Res Clin Pract 2006;72 (3) 244- 250
PubMed Link to Article
Dehghan  Avan Hoek  MSijbrands  EJStijnen  THofman  AWitteman  JC Risk of type 2 diabetes attributable to C-reactive protein and other risk factors. Diabetes Care 2007;30 (10) 2695- 2699
PubMed Link to Article
Corrado  ERizzo  MMuratori  ICoppola  GNovo  S Association of elevated fibrinogen and C-reactive protein levels with carotid lesions in patients with newly diagnosed hypertension or type II diabetes. Arch Med Res 2006;37 (8) 1004- 1009
PubMed Link to Article
Colditz  GAMartin  PStampfer  MJ  et al.  Validation of questionnaire information on risk factors and disease outcomes in a prospective cohort study of women. Am J Epidemiol 1986;123 (5) 894- 900
PubMed
Brownstein  MH Psoriasis and diabetes mellitus. Arch Dermatol 1966;93 (6) 654- 655
PubMed Link to Article
Reeds  RE  JrFusaro  RMFisher  I Psoriasis vulgaris, I: a clinical survey of the association with diabetes mellitus. Arch Dermatol 1964;89205- 208
PubMed Link to Article
Ollendorff-Curth  H Psoriasis and diabetes mellitus  in GermanArch Klin Exp Dermatol 1966;227 (1) 240- 247
PubMed
Sommer  DMJenisch  SSuchan  MChristophers  EWeichenthal  M Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res 2006;298 (7) 321- 328
PubMed Link to Article
Duncan  BBSchmidt  MIPankow  JS  et al. Atherosclerosis Risk in Communities Study, Low-grade systemic inflammation and the development of type 2 diabetes: the Atherosclerosis Risk in Communities Study. Diabetes 2003;52 (7) 1799- 1805
PubMed Link to Article
Syrenicz  AGaranty-Bogacka  BSyrenicz  MGebala  AWalczak  M Low-grade systemic inflammation and the risk of type 2 diabetes in obese children and adolescents. Neuro Endocrinol Lett 2006;27 (4) 453- 458
PubMed
Brodell  RTWilliams  L A corticosteroid-induced flare of psoriasis: how to control or, better yet, avoid. Postgrad Med 1999;106 (7) 31- 32
PubMed Link to Article
Garden  JMFreinkel  RK Systemic absorption of topical steroids: metabolic effects as an index of mild hypercortisolism. Arch Dermatol 1986;122 (9) 1007- 1010
PubMed Link to Article
Chu  T Better patient compliance in psoriasis. Practitioner 2000;244 (1608) 238- 242, 244
PubMed
Zaghloul  SSGoodfield  MJ Objective assessment of compliance with psoriasis treatment. Arch Dermatol 2004;140 (4) 408- 414
PubMed Link to Article
Fitch  EHarper  ESkorcheva  IKurtz  SEBlauvelt  A Pathophysiology of psoriasis: recent advances on IL-23 and Th17 cytokines. Curr Rheumatol Rep 2007;9 (6) 461- 467
PubMed Link to Article
 Women's high CRP levels can predict hypertension. Healthcare Benchmarks Qual Improv 2004;11 (2) 20- 21
PubMed
Ho  VC The use of ciclosporin in psoriasis: a clinical review. Br J Dermatol 2004;150(suppl 67)1- 10
PubMed Link to Article
Grossman  RMChevret  SAbi-Rached  JBlanchet  FDubertret  L Long-term safety of cyclosporine in the treatment of psoriasis. Arch Dermatol 1996;132 (6) 623- 629
PubMed Link to Article
Mease  PJMenter  MA Quality-of-life issues in psoriasis and psoriatic arthritis: outcome measures and therapies from a dermatological perspective. J Am Acad Dermatol 2006;54 (4) 685- 704
PubMed Link to Article
Gelfand  JMStern  RSNijsten  T  et al.  The prevalence of psoriasis in African Americans: results from a population-based study. J Am Acad Dermatol 2005;52 (1) 23- 26
PubMed Link to Article
Nijsten  TMargolis  DJFeldman  SRRolstad  TStern  RS Traditional systemic treatments have not fully met the needs of psoriasis patients: results from a national survey. J Am Acad Dermatol 2005;52 (3, pt 1) 434- 444
PubMed Link to Article
Krueger  GKoo  JLebwohl  MMenter  AStern  RSRolstad  T The impact of psoriasis on quality of life: results of a 1998 National Psoriasis Foundation patient-membership survey. Arch Dermatol 2001;137 (3) 280- 284
PubMed
Hunter  DJColditz  GAStampfer  MJRosner  BWillett  WCSpeizer  FE Diet and risk of basal cell carcinoma of the skin in a prospective cohort of women. Ann Epidemiol 1992;2 (3) 231- 239
PubMed Link to Article

Figures

Tables

Table Graphic Jump LocationTable 1 Baseline Characteristics of Women Who Self-reported a Diagnosis of Psoriasis Between 1991 and 2005
Table Graphic Jump LocationTable 2. Age-Adjusted and Multivariate Relative Risks (RRs) for the Development of Diabetes and Hypertension Among Women With Psoriasis

References

Christophers  E Psoriasis—epidemiology and clinical spectrum. Clin Exp Dermatol 2001;26 (4) 314- 320
PubMed Link to Article
Kimball  ABJacobson  CWeiss  SVreeland  MGWu  Y The psychosocial burden of psoriasis. Am J Clin Dermatol 2005;6 (6) 383- 392
PubMed Link to Article
Pearce  DJMorrison  AEHiggins  KB  et al.  The comorbid state of psoriasis patients in a university dermatology practice. J Dermatolog Treat 2005;16 (5-6) 319- 323
PubMed Link to Article
Mallbris  LRitchlin  CTStahle  M Metabolic disorders in patients with psoriasis and psoriatic arthritis. Curr Rheumatol Rep 2006;8 (5) 355- 363
PubMed Link to Article
Wakkee  MThio  HBPrens  EPSijbrands  EJNeumann  HA Unfavorable cardiovascular risk profiles in untreated and treated psoriasis patients. Atherosclerosis 2007;190 (1) 1- 9
PubMed Link to Article
Nakagami  TQiao  QTuomilehto  J  et al.  Screen-detected diabetes, hypertension and hypercholesterolemia as predictors of cardiovascular mortality in five populations of Asian origin: the DECODA study. Eur J Cardiovasc Prev Rehabil 2006;13 (4) 555- 561
PubMed Link to Article
Hu  GSarti  CJousilahti  P  et al.  The impact of history of hypertension and type 2 diabetes at baseline on the incidence of stroke and stroke mortality. Stroke 2005;36 (12) 2538- 2543
PubMed Link to Article
Livingston  EHKo  CY Effect of diabetes and hypertension on obesity-related mortality. Surgery 2005;137 (1) 16- 25
PubMed Link to Article
Ravipati  GAronow  WSAhn  CAlappat  RMMcClung  JAWeiss  MB Incidence of new stroke or new myocardial infarction or death at 39-month follow-up in patients with diabetes mellitus, hypertension or both with and without microalbuminuria. Cardiology 2008;109 (1) 62- 65
PubMed Link to Article
Gibson  SHPerry  HO Diabetes and psoriasis. AMA Arch Derm 1956;74 (5) 487- 488
PubMed Link to Article
Cohen  ADSherf  MVidavsky  LVardy  DAShapiro  JMeyerovitch  J Association between psoriasis and the metabolic syndrome: a cross-sectional study. Dermatology 2008;216 (2) 152- 155
PubMed Link to Article
Neimann  ALShin  DBWang  XMargolis  DJTroxel  ABGelfand  JM Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol 2006;55 (5) 829- 835
PubMed Link to Article
Shapiro  JCohen  ADDavid  M  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
PubMed Link to Article
Binazzi  MCalandra  PLisi  P Statistical association between psoriasis and diabetes: further results. Arch Dermatol Res 1975;254 (1) 43- 48
PubMed Link to Article
Gelfand  JMNeimann  ALShin  DBWang  XMargolis  DJTroxel  AB Risk of myocardial infarction in patients with psoriasis. JAMA 2006;296 (14) 1735- 1741
PubMed Link to Article
Savoia  CSchiffrin  EL Vascular inflammation in hypertension and diabetes: molecular mechanisms and therapeutic interventions. Clin Sci (Lond) 2007;112 (7) 375- 384
PubMed Link to Article
Pradhan  ADManson  JERifai  NBuring  JERidker  PM C-reactive protein, interleukin 6, and risk of developing type 2 diabetes mellitus. JAMA 2001;286 (3) 327- 334
PubMed Link to Article
Yuan  GZhou  LTang  J  et al.  Serum CRP levels are equally elevated in newly diagnosed type 2 diabetes and impaired glucose tolerance and related to adiponectin levels and insulin sensitivity. Diabetes Res Clin Pract 2006;72 (3) 244- 250
PubMed Link to Article
Dehghan  Avan Hoek  MSijbrands  EJStijnen  THofman  AWitteman  JC Risk of type 2 diabetes attributable to C-reactive protein and other risk factors. Diabetes Care 2007;30 (10) 2695- 2699
PubMed Link to Article
Corrado  ERizzo  MMuratori  ICoppola  GNovo  S Association of elevated fibrinogen and C-reactive protein levels with carotid lesions in patients with newly diagnosed hypertension or type II diabetes. Arch Med Res 2006;37 (8) 1004- 1009
PubMed Link to Article
Colditz  GAMartin  PStampfer  MJ  et al.  Validation of questionnaire information on risk factors and disease outcomes in a prospective cohort study of women. Am J Epidemiol 1986;123 (5) 894- 900
PubMed
Brownstein  MH Psoriasis and diabetes mellitus. Arch Dermatol 1966;93 (6) 654- 655
PubMed Link to Article
Reeds  RE  JrFusaro  RMFisher  I Psoriasis vulgaris, I: a clinical survey of the association with diabetes mellitus. Arch Dermatol 1964;89205- 208
PubMed Link to Article
Ollendorff-Curth  H Psoriasis and diabetes mellitus  in GermanArch Klin Exp Dermatol 1966;227 (1) 240- 247
PubMed
Sommer  DMJenisch  SSuchan  MChristophers  EWeichenthal  M Increased prevalence of the metabolic syndrome in patients with moderate to severe psoriasis. Arch Dermatol Res 2006;298 (7) 321- 328
PubMed Link to Article
Duncan  BBSchmidt  MIPankow  JS  et al. Atherosclerosis Risk in Communities Study, Low-grade systemic inflammation and the development of type 2 diabetes: the Atherosclerosis Risk in Communities Study. Diabetes 2003;52 (7) 1799- 1805
PubMed Link to Article
Syrenicz  AGaranty-Bogacka  BSyrenicz  MGebala  AWalczak  M Low-grade systemic inflammation and the risk of type 2 diabetes in obese children and adolescents. Neuro Endocrinol Lett 2006;27 (4) 453- 458
PubMed
Brodell  RTWilliams  L A corticosteroid-induced flare of psoriasis: how to control or, better yet, avoid. Postgrad Med 1999;106 (7) 31- 32
PubMed Link to Article
Garden  JMFreinkel  RK Systemic absorption of topical steroids: metabolic effects as an index of mild hypercortisolism. Arch Dermatol 1986;122 (9) 1007- 1010
PubMed Link to Article
Chu  T Better patient compliance in psoriasis. Practitioner 2000;244 (1608) 238- 242, 244
PubMed
Zaghloul  SSGoodfield  MJ Objective assessment of compliance with psoriasis treatment. Arch Dermatol 2004;140 (4) 408- 414
PubMed Link to Article
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