Patients with psoriasis at an increased risk of avascular necrosis

1. In a population-based cohort study of over 28 000 patients with psoriasis and their age- and sex-matched controls, patients with psoriasis was associated with an increased risk of avascular necrosis (AVN).

2. In patients with psoriasis, AVN risk was positively associated with male sex, age younger than 30 years, corticosteroid use, severe psoriasis, and psoriatic arthritis.

Evidence Rating Level: 3 (Average)       

Study Rundown: Psoriasis is a chronic, inflammatory skin disease mediated by pro-inflammatory cytokines. Although many chronic inflammatory disorders are associated with increased risk of AVN. there is a paucity of evidence that links psoriasis and AVN. Given the similar mechanisms proposed for pathogenesis and the shared comorbidities between these disorders, the purpose of this study was to assess the risk of AVN in a cohort of patients with psoriasis.

The study retrospectively investigated the incidence of AVN in a population-based cohort of over 28 000 patients with psoriasis and over 110 000 age- and sex-matched controls. At the conclusion of the study, psoriasis was associated with an increased risk of AVN. The results of this study demonstrate that psoriatic patients with localized pain in a weight bearing joint may require further evaluation for AVN, especially with a history of corticosteroid use. This study is strengthened by the use of a large, nationally representative, population-based cohort that was matched with respect to age, sex, and medical history of diabetes mellitus, hip fracture, and alcohol dependence. However, this study was limited by the lack of matching of patients and controls for hyperlipidemia, kidney transplantation, hypertension, cardiovascular disease, obesity, chronic kidney disease, medication use (including bisphosphonates and corticosteroids), as well as other confounders which were not documented in the database. Multi-center prospective trials that control for these AVN risk factors may improve the validity of the study.

Click to read the study in JAAD

Relevant Reading: Incidence of osteonecrosis associated with corticosteroid therapy among different underlying diseases: prospective MRI study

In-Depth [retrospective cohort]: This study retrospectively evaluated the association between psoriasis and AVN via a population-based cohort of Taiwanese patients selected from a National Health Insurance Research Database. Overall, this study identified 28 268 patients with psoriasis and 113 072 controls without psoriasis matched for age, sex, and medical history of diabetes mellitus, hip fracture, and alcohol dependence. Stratified Cox regression models were utilized to calculate the risk of developing AVN. Multivariate analyses were adjusted for medical history, medication use, and topical and systemic corticosteroids use. The risk of AVN was higher in patients with psoriasis (adjusted HR: 1.96; 95%CI 1.62-2.38). The risk for developing AVN among patients with psoriasis was significantly higher in men, in those with severe and mild psoriasis, in those with and without psoriatic arthritis (PsA), and in those who did and did not use oral or parenteral steroids. Among patients with psoriasis, the risk for AVN was higher for men (HR: 2.20; 95%CI 1.77-2.72) than for women (HR: 1.30; 95%CI 0.84-1.99), for patients with severe psoriasis (HR: 3.21; 95%CI 2.09-4.92) than for those with mild psoriasis (HR 1.75; 95%CI 1.42-2.17), for patients with PsA (HR: 4.34; 95%CI 1.80-10.45) than for those without PsA (HR 1.88; 95%CI 1.55-2.29), and for patients who used oral or parenteral steroids (HR 4.92; 95%CI 1.49-16.25) than for those who used systemic corticosteroids (HR 1.94; 95%CI 1.59-2.37).

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