JUSINDO, Vol. 6 No. 2, Juli 2024

p-ISSN: 2303-288X, e-ISSN: 2541-7207

Jurnal Sehat Indonesia: Vol. 6, No. 2, Juli 2024 | 719

A Study of Association of Psoriasis and Type 2 Diabetes Mellitus: A

Comprehensive Systematic Review

Marvelo Surya Rahman Djohar

, Bambang Ratio Setiyarso

RS Dewi Sri Karawang, Indonesia

Email: [email protected], [email protected]

ABSTRACT

Keyword:

Diabetes mellitus is a significant risk factor in psoriasis, a

chronic inflammatory disease with a high genetic

predisposition. The association between psoriasis and diabetes

mellitus is inconsistent, with some studies finding a higher risk

of metabolic disorders in psoriasis patients. However, meta-

analytical studies confirm a significant association between

adult psoriasis and obesity, hypertension, diabetes,

dyslipidemia, and metabolic syndrome. Understanding this

association can help develop treatments and plans to alleviate

the burden of these conditions. This systematic review focused

on full-text English literature published between 2014 and

2024, adhering to PRISMA 2020 principles. Without a DOI,

editorials and review papers that were published in the same

journal as the submission were not accepted. ScienceDirect,

PubMed, and SagePub were among the many web resources

used to compile the literature. Using reliable resources,

including Science Direct, SagePub, and PubMed, the study

examined over 7,000 publications. Following the

determination that eight publications warranted further

inquiry, a more thorough examination of the full corpus was

conducted. Diabetes mellitus risk in psoriasis patients is

significantly increased due to insulin resistance, a common

pathogenic mechanism in both psoriasis and metabolic

syndrome. Treatment can reduce this risk by reducing

proinflammatory cytokines and increasing anti-inflammatory

cytokine.

Diabetes Mellitu;

Psoriasis; Metabolic;

Association

Coresponden Author: Marvelo Surya Rahman Djohar

Email: [email protected]

Artikel dengan akses terbuka dibawah lisensi

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Introduction

Psoriasis is a chronic inflammatory disease that has a high genetic predisposition.

The incidence of this disease varies according to location, with Scandinavian regions

having the highest prevalence (11%) and some African and Asian countries having the

lowest (Rendon & Schäkel, 2019). There are different clinical subtypes of psoriasis, the

most common of which is plaque psoriasis (psoriasis vulgaris). Other variants include

guttate psoriasis, inverse psoriasis, pustular psoriasis, erythrodermic psoriasis, nail

psoriasis, and scalp psoriasis (Mirghani et al., 2023).

Psoriasis affects multiple body parts,

including the skin, joints, oral cavity, scalp, and nails. It is also associated with other

conditions such as psychiatric diseases, cardiometabolic issues, and streptococcal

infections, as well as factors such as smoking, alcohol consumption, and obesity (Griffiths

et al., 2021). Psoriasis is considered an immune-mediated systemic disease and

is associated with various comorbidities, which significantly impact patients,

communities, and healthcare systems (Korman, 2020). Chronic inflammation and

keratinocyte hyperproliferation are initiated by genetic predisposition and environmental

triggers, leading to a chronic proinflammatory process that releases interleukins, tumor

necrosis factor, and interferons. Targeting the inflammatory pathways and cytokines

contributing to the disease pathogenesis can revolutionize psoriasis treatment (Baliwag et

al., 2015; Mirghani et al., 2023). It is important to note that psoriasis shares its

pathogenesis with various comorbidities, including metabolic-associated fatty liver

disease, dyslipidemia, hypertension, diabetes, and myocardial infarction (Wu et al.,

2022).

Research has appeared that psoriasis isn't fair restricted to skin clutters. Psoriatic

patients are at an expanded hazard of other maladies, such as Crohn's infection,

cardiovascular illness, hypertension, diabetes mellitus, and metabolic disorder

(Davidovici et al., 2010). Numerous observational considers have been conducted to

examine the predominance and rate of metabolic disarranges in patients with psoriasis.

Be that as it may, the comes about are conflicting and changed. Whereas a few studies

have found a better chance of metabolic clutters in psoriasis patients compared to the

common populace, others have detailed no noteworthy distinction or indeed a lower

chance. These incongruities can be ascribed to contrasts in ponder plan, populace

characteristics, symptomatic criteria, perplexing variables, and result degree (Alajroush

et al., 2024).

Psoriasis and metabolic clutter may come together due to shared

immunopathogenesis counting ceaseless low-level aggravation intervening by pro-

inflammatory cytokines such as IFN-gamma, IL-17, IL-23, and TNF-alpha (Esser et al.,

2014). In addition, a number of consider have associated insulin-like improvement

calculate 1 (IGF-1) as a shared authority inside the keratinocyte increase in psoriasis and

the progression of diabetes and hyperlipidemia (Azfar & Gelfand, 2008). Diabetes

mellitus could be a gather of metabolic disorders characterized by high blood sugar levels

and a lack of the generation or activity of insulin (Mamizadeh et al., 2019). Although

several researchers have studied the association between psoriasis and diabetes, their

Jurnal Sehat Indonesia: Vol. 6, No. 2, Juli 2024 | 721

findings are inconsistent. Therefore, a combined analysis of various studies was

conducted to establish a single result (Mamizadeh et al., 2019). I In pediatric bunches

with psoriasis, a few considers have watched the next hazard of metabolic co-morbidities

than in control bunches (Cho et al., 2021). Thus, it is suggested to screen for metabolic

comorbidities in pediatric patients with psoriasis. Be that as it may, the level of prove is

low (Osier et al., 2017).

Meta-analytical ponders have affirmed a critical affiliation

between grown-up psoriasis and corpulence, hypertension, diabetes, dyslipidemia, and

metabolic disorder (Cho et al., 2021). Understanding the affiliation between psoriasis and

diabetes mellitus given to certain individuals can be valuable in making plans and

medications to understanding easing this maladies. The reason of this efficient writing

audit was to distinguish the relationship between psoriasis and diabetes mellitus found in

considers conducted over the past ten a long.

Research Methods

Protocol

The author of this work meticulously adhered to the Preferred Reporting Items for

Systematic Review and Meta-Analysis (PRISMA) 2020 guidelines to ensure that the

study complied with all regulations. The chosen methodology was thoughtfully crafted to

ensure precise and coherent research outcomes.

Criteria for Eligibility

This consider gives a comprehensive investigation of investigate conducted over

the past decade on the relationship between psoriasis and diabetes mellitus. Through

intensive information investigation, this venture points to illustrate and improve persistent

care methods. The essential objective of this proposition is the importance of key themes

that can be found in a assortment of scholarly works.

To ensure the accuracy of the data utilized in this study, strict inclusion and

exclusion criteria were implemented. A piece must have been published in English

between 2014 and 2024 to be considered for inclusion. Exclusion criteria include

published reviews, editorials, submissions lacking a DOI, and duplicate journal entries.

Search Strategy

The study's keywords include "diabetes mellitus, psoriasis, association,

relationship, connection, outcomes, incidence, risk factor". For this research, the

following Boolean MeSH keywords were entered into the databases: (((“Diabetes

Mellitus”[MeSH Terms] OR “Diabetes Mellitus “[All Fields] AND “Psoriasis”[All

Fields]) OR (“Diabetes Mellitus”[MeSH Terms] OR “Association”[All Fields] AND

“psoriasis”[All Fields]) AND (“Association”[MeSH Terms] OR “relationship”[All

Fields] OR “connection”[All Fields] OR “outcomes”[MeSH Subheading] OR

“incidence”[All Fields] OR “risk factor”[All Fields]))).

Data retrieval

Before embarking on this comprehensive examination, the writers meticulously

reviewed the title and abstract of each article to determine its relevance. Only studies that

Jurnal Sehat Indonesia: Vol. 6, No. 2, Juli 2024 | 722

met the inclusion criteria and aligned with the article's objectives were given greater

consideration. Through a series of searches, a clear and recurring pattern emerged.

English was the sole language accepted for full-text entries. The most rigorous screening

process resulted in content that satisfied all predetermined inclusion criteria and was

directly applicable to the study's subject matter. Research that did not conform to these

parameters was generally disregarded, and their findings were not accorded significant

weight. The assessment encompassed a wide range of information, including factors,

titles, authors, publication dates, locations, and study methodologies.

Quality Assessment and Data Synthesis

Each article's titles and abstracts were scrutinized by the writers themselves to

determine which ones necessitated further investigation. The next step involved

thoroughly reviewing each document that was initially qualified for inclusion in the

review. The assessment results were used as a basis for choosing the review papers. By

expediting the process of selecting publications for further scrutiny, this criterion

facilitated a more thorough evaluation of previous research and the circumstances that

warranted its review.

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Figure 1 Article search flow chart

Result and Discussion

In the beginning stages of our research, our team diligently compiled a vast

collection of publications from highly regarded databases, including Science Direct,

PubMed, and SagePub. After a meticulous three-tier screening process, we pinpointed

eight papers that were deemed highly pertinent to our ongoing systematic investigation.

From there, we honed in on specific areas for further examination and conducted a

comprehensive review of each manuscript. To help streamline our analysis, we've

included a succinct summary of the evaluated content in Table 1 for your convenience.

Records identified from:

PubMed (n = 1.462)

Science Direct (n = 6.237)

Sagepub (n = 857)

Records removed before the

screening:

Duplicate records removed (n =

134)

Records marked as ineligible by

automation tools (n= 0)

Records removed for other

reasons (n = 0)

Records screened

(n = 8.422)

Records excluded

Before 2014 (n = 5.145)

Wrong study design (n = 3.062)

Wrong intervention (n = 0)

Reports sought for retrieval

(n = 215)

Reports not retrieved (n = 85)

Reports assessed for eligibility

(n = 130)

Reports excluded:

Data irrelevant for this topic (n =

122)

Studies included in systematic

review (n = 8)

Identification of studies via databases and registers

Identification

Screening

Included

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Table 1 The Literature Included in This Study

Author

Origin

Method

Sample

Result

Rodriguez-

Zuniga et

al.

(2017)

Multicenter

Systematic

Review

studies

We discovered that 31.4% of

psoriasis patients had

metabolic syndrome (MS).

Studies conducted in Europe

(in Germany, Italy, the United

Kingdom, Norway, and

Denmark) found a lower risk

of multiple sclerosis than

studies conducted in the

Middle East (in Israel,

Turkey, and Lebanon).

Singh et al.

(2017)

USA

Meta Analysis

studies

We specifically examined the

data from 35 observational

studies involving 1,450,188

participants from 20

countries, 46,714 of whom

had psoriasis. Random effects

analysis yielded a pooled odds

ratio of 2.14. A graphic

visualization using a funnel

plot and an Egger test both

revealed publication bias.

This thorough meta-analysis

indicates that, in comparison

to the general population,

psoriasis patients have

increased odds of having

metabolic syndrome.

Mamizadeh

et al.

(2019)

Iran

Systematic

Review

studies

The estimated OR was found

to be 1.69 (95% CI

[Confidence Interval]: 1.51-

1.89; P<0.001) based on an

analysis of 38 eligible studies

with 922870 cases and

12808071 controls. Based on

the study design and the

nation of study, subgroup

analysis was carried out, and

the results were significant

(test for subgroup differences:

P=0.025 and P<0.001,

respectively).

Cho et al.

(2021)

Korea

Meta Analysis

studies

There were sixteen distinct

studies that met the inclusion

criteria in the meta-analysis.

In children with psoriasis, the

pooled odds ratios for obesity

(13 studies), hypertension (8

studies), diabetes mellitus (8

studies), dyslipidemia (7

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studies), and metabolic

syndrome (4 studies) were

2.40, 2.73, 2.01, and 7.49,

respectively.

Cintoni et

al.

(2023)

Italy

Review

Our analysis demonstrates

that leading a healthy lifestyle

can have a positive impact on

how the illness progresses.

The severity of psoriasis is

thought to improve when a

healthy weight is maintained

along with physical activity

and wise dietary decisions.

Yes, a Mediterranean diet

high in fiber, vitamins, and

polyphenols may help manage

the symptoms of psoriasis.

This diet works well not only

because it reduces

inflammation but also because

it can help regulate gut

microbiota and prevent

dysbiosis, which is linked to a

number of autoimmune

disorders.

Mirghani et

al.

(2023)

Saudi Arabia

Meta Analysis

7 studies

Diabetes and hypertension

were found to be associated

with psoriasis at odds ratios of

1.38, 95% CI 1.17-1.64; P-

value 0.0002, chi-square

224.93, and 1.60, 95% CI

1.41-1.81, P-value 0.00001,

chi-square 226.59,

respectively. Significant

variation was noted

(heterogeneity I2 = 97%, P <

0.001).

Sodagar et

al.

(2023)

Iran

Meta Analysis

studies

Individuals with psoriasis,

hidradenitis suppurative,

vitiligo, androgenetic

alopecia, and lichen planus

are more likely than the

general population to develop

metabolic syndrome or

diabetes. Insulin resistance,

hypertension, and elevated

blood lipids are more common

in people with seborrheic

dermatitis and rosacea.

Particularly in Spain and

Thailand, a strong correlation

between metabolic syndrome

and skin conditions has been

discovered.

Jurnal Sehat Indonesia: Vol. 6, No. 2, Juli 2024 | 726

Alajroush et

al.

(2024)

Saudi Arabia

Meta Analysis

studies

Psoriasis showed a strong

correlation with hypertension

(HTN, 35%), hyperlipidemia

(19%), diabetes mellitus (DM,

18% increased incidence), and

obesity (25%). Meta-analyses

revealed significant

heterogeneity, especially with

regard to DM.

precise survey of 45 ponders by Rodriguez-Zuniga et al. found a noteworthy affiliation

between psoriasis and MS, with a pooled chances proportion (OR) of 1.42 and moo heterogeneity.

The ponder too found that planned ponders had a gently higher hazard for MS. Systemic treatment

decreased the hazard for MS. Geographic area and quality did not altogether influence the

association between psoriasis and MS (Rodríguez-Zúñiga & García-Perdomo, 2017).

According to think about by Singh et al. (2017) soriasis patients had an altogether higher

predominance of metabolic disorder than non-psoriasis controls. It was found that the recurrence

of metabolic disorder was dose-dependent on the seriousness of psoriasis, with higher chances

proportions for serious cases.

Patients with psoriasis are more likely to develop diabetes mellitus, according to a current

study by Maamizadeh et al. that combined the data of 38 studies, supporting the conclusions of a

prior meta-analysis. Psoriasis and diabetes mellitus had a 1.69 (95% CI: 1.51-1.89; P<0.001)

overall odds ratio (Mamizadeh et al., 2019).

Children with psoriasis have considerably higher chances of hypertension, diabetes

mellitus, dyslipidemia, and metabolic syndrome, according to a study by Cho et al. A pooled odds

ratio of 2.73 indicated that children with psoriasis had a significantly higher prevalence of these

conditions. There is a strong correlation between psoriasis and these health problems, as the

studies also showed that children with psoriasis have higher odds of dyslipidemia and metabolic

syndrome (Cho et al., 2021).

Research conducted by Cintoni et al. has demonstrated a strong correlation between

metabolic disorders such as diabetes, obesity, celiac disease, and vitamin deficiencies, and

psoriasis. Chronic non-communicable diseases like Crohn's disease, depression, metabolic

syndrome, cardiovascular disease, and cancer are linked to psoriasis. According to recent

research, metabolic disorders linked to gut-microbiota dysbiosis may be triggers or causes of

psoriasis (Sodagar et al., 2023).

Compared to control subjects, patients with psoriasis had a higher odds ratio (1.38), 95%

confidence interval (1.17), P-value (0.0002), chi-square (224.93), and standard deviation (6.0) of

diabetes, according to the current meta-analysis by Mirghani et al. (2023).

Sodagar et al. investigated the connection between psoriasis and metabolic syndrome

(MetS) in 21 studies involving participants ranging in age from 35 to 53 on average. MetS has

been shown in nineteen studies to have a significant impact on psoriasis patients. Nonetheless,

two studies conducted in Tunisia and Macedonia revealed no correlation between MetS and

psoriasis, suggesting a possible association (Sodagar et al., 2023).

Alajroush et al. discovered a significant correlation between psoriasis and diabetes

mellitus (DM) in psoriatic patients. In comparison to non-psoriatic patients, the pooled RR of

Jurnal Sehat Indonesia: Vol. 6, No. 2, Juli 2024 | 727

DM2 in psoriatic patients was 1.18 (95% CI 1.16, 1.20), signifying an 18% rise in DM2 incidence

(Alajroush et al., 2024).

Discussion

Psoriasis is linked to several metabolic comorbidities, including obesity,

hypertension, diabetes, dyslipidemia, and metabolic syndrome. These conditions can

worsen the severity of psoriasis and increase the risk of developing it (Alajroush et al.,

2024; Lønnberg et al., 2016; Sodagar et al., 2023). Psoriasis is an immune-mediated

disease that causes inflammation and oxidative stress, leading to insulin resistance and

dyslipidemia (Brembilla & Boehncke, 2023). It shares many cardiovascular risk factors

with metabolic syndrome, such as abdominal obesity, hypertension, dyslipidemia, and

insulin resistance (Singh et al., 2017). People with psoriasis are 40% more likely to

develop metabolic syndrome than those without it. The psoriatic march concept explains

the connection between psoriasis and metabolic syndrome, which is increased systemic

inflammation (Rodríguez-Zúñiga & García-Perdomo, 2017).

Both psoriasis and

metabolic syndrome cause chronic inflammation, which contributes to insulin resistance

and endothelial cell dysfunction. This can lead to adverse cardiovascular events, such as

atherosclerosis (Gelfand & Yeung, 2012). The overproduction of pro-inflammatory

cytokines in psoriasis lesions can cause systemic resistance, endothelial dysfunction, and

oxidative stress (Gisondi et al., 2018). This inflammation can ultimately lead to metabolic

comorbidities. Insulin resistance, endothelial cell dysfunction, and cardiovascular disease

are all linked to psoriasis and metabolic syndrome (Coimbra et al., 2016). Recent meta-

analyses have indicated an 80% increased risk of developing metabolic syndrome in

people with psoriasis (Rodríguez-Zúñiga & García-Perdomo, 2017).

According to Rodriguez (2017), while the connection between psoriasis and

metabolic syndrome is significant, the association's strength is reduced due to low

heterogeneity and confidence intervals.

Psoriasis, a skin condition, has a considerable

impact on metabolic syndrome risk. The use of systemic treatment can reduce this risk by

decreasing proinflammatory cytokines' release and increasing anti-inflammatory

cytokines. Treatment-naive psoriasis patients show increased proinflammatory cytokines

and decreased anti-inflammatory cytokines, which normalize after treatment

(Dowlatshahi et al., 2013). Psoriasis treatment can also help improve metabolic risk and

psoriasis after MS treatment. Research has found that psoriasis patients have low levels

of the anti-inflammatory cytokine IL-10, suggesting that psoriasis treatment may help

reduce cardiovascular risk (Rodríguez-Zúñiga & García-Perdomo, 2017). Psoriasis

patients face more than twice the odds of metabolic syndrome than the general population.

A meta-analysis of 35 studies has shown a dose-dependent relationship between the

severity of psoriasis and metabolic syndrome prevalence. As psoriasis is a systemic

disease with significant morbidity and mortality, healthcare providers must screen

psoriasis patients for cardiometabolic diseases and provide structured management.

Further research is necessary to determine the exact pathologic mechanisms shared by

these two diseases and the relationship directionality (Singh et al., 2017).

Jurnal Sehat Indonesia: Vol. 6, No. 2, Juli 2024 | 728

Diabetes and psoriasis share common pathogenic mechanisms, such as

inflammation, insulin resistance, and hyperglycemia. Inflammation is a characteristic

feature of psoriasis, which can trigger insulin resistance, commonly observed in psoriasis

patients (Abramczyk et al., 2020). A meta-analysis of 22 studies indicates that psoriatic

patients are at higher risk of diabetes (Cheng et al., 2012). Psoriasis patients with severe

symptoms have a higher likelihood of developing cardiovascular disease (CVD).

Inflammation can stimulate the proliferation of keratinocytes and fibroblasts, which are

risk factors for psoriatic lesions (Cintoni et al., 2023). In psoriasis, inflammatory

cytokines can raise IGF levels, which is reduced in both diabetes and psoriasis (Hu et al.,

2019). Hyperglycemia is closely associated with psoriatic inflammation, and a link

between serum glycated hemoglobin (HbA1c) and psoriasis PASI score has been

observed. Anti-inflammatory and anti-diabetic drugs, such as GLP-1 receptor agonists,

can improve psoriasis in patients with type 2 diabetes (Cintoni et al., 2023). Genetic

analysis supports that susceptibility genes for type 1 diabetes, type 2 diabetes, and

psoriasis overlap.

Inflammation plays a crucial role in the relationship between these

two conditions (Lowes et al., 2007). More research is required to identify the shared

pathophysiological mechanism and the precise relationship between these two systemic

disorders (Mamizadeh et al., 2019). Proper management and treatment of metabolic

comorbidities are crucial to prevent cardiovascular events and reduce the psoriasis

treatment response (Takeshita et al., 2017). However, studies targeting children and

adolescents are limited, and the association between metabolic comorbidities and

pediatric psoriasis is clear. Psoriasis is associated with a poor prognosis and increased

cardiovascular risks in pediatric patients. To reduce these risks, active detection and

management of high-risk groups are crucial. Treatment with biologics has been shown to

lower cardiovascular disease risk in adults. Further evidence-based guidelines are

necessary for adequate metabolic comorbidities screening and management (Cho et al.,

2021).

There is a strong correlation between psoriasis and diabetes, with significant

implications for cardiovascular health. A comprehensive meta-analysis found that

individuals with psoriasis had a notably higher prevalence of hypertension, even when

factors such as age and other cardiovascular risks were taken into account (Mirghani et

al., 2023). This risk was particularly elevated in patients with severe psoriasis,

underscoring the need for careful cardiovascular risk assessment among this population

(Duan et al., 2020). Given the known bidirectional relationship between diabetes and

hypertension, it is important to screen for hypertension among psoriasis patients to

prevent serious complications such as stroke and myocardial infarction (Parati & Piepoli,

2022).

Additionally, the association between psoriasis and diabetes mellitus has important

implications for therapeutic choices, including the use of lipid-lowering drugs with a low

risk of diabetes (Mirghani et al., 2023).

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Conclusion

Psoriasis patients are at a higher risk of developing diabetes due to the increased

inflammation and insulin resistance caused by the psoriatic march concept. This

inflammation contributes to endothelial cell dysfunction, leading to adverse

cardiovascular events. Treatment for psoriasis can reduce the risk of metabolic syndrome

by decreasing proinflammatory cytokines and increasing anti-inflammatory cytokines.

Psoriatic patients face a higher prevalence of hypertension, especially in severe cases,

underscoring the need for careful cardiovascular risk assessment. Anti-inflammatory and

anti-diabetic drugs, such as GLP-1 receptor agonists, can improve psoriasis in type 2

diabetes patients.

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