People with psoriasis, known to be at higher risk of heart attack, had a lower risk when treated with drugs known as tumor necrosis factor (TNF) inhibitors, such as Enbrel, Humira or Remicade, compared to medicines applied to the skin, according to new research.

Those on oral medicines such as cyclosporine, methotrexate, Soriatane, or given light therapy had nearly the same reduction in risk, compared to those on skin-based -- or topical -- medicines.

The study was a look back at almost 9,000 patients with the skin disorder psoriasis. They got four different types of treatments. Researchers compared the number of heart attacks in the groups during a four-year follow-up.

The inflammation associated with the skin condition is also linked to an increased risk of heart attack and other vascular problems such as stroke.

"We found those in the TNF inhibitor group had a 50% reduction in heart attack compared to the topical agent group," says Jashin J. Wu, MD, director of dermatology research and associate dermatology residency program director at Kaiser Permanente Los Angeles Medical Center.

"Those in the phototherapy or oral medicine group had a 46% reduction compared to topical," he says. The research found only a link, he says, not cause and effect.

The study results are published in the Archives of Dermatology.

What Does Moderate to Severe Psoriasis Look Like?
Psoriasis & Heart Attack: Why?

Psoriasis affects about 3% of Americans, according to Wu.

In psoriasis, the immune system sends out faulty signals. The growth cycle of skin cells speeds up too much, according to the National Psoriasis Foundation.

There are five types. The most common, called plaque, looks like red, raised patches covered with silvery white dead skin cells.

Psoriasis can occur anywhere on the body, including eyelids, ears, mouth, lips, hands, feet, skin folds, and nails, according to the foundation.

It is not just a cosmetic problem. Psoriasis keeps the body in a constant inflammatory state. That increases the risk of heart attack and other problems, including diabetes, according to Wu and other experts.
Psoriasis & Heart Attack Risk: Study Details

Wu wanted to see if one treatment was better than another for reducing heart attack risk.

At the study start, in 2004, no one had had a heart attack. Wu's team looked at the incidence of heart attack until November 2010.

Of the 8,845 patients, who were on average about 53 years old:

    5,075 were on topical medicines applied to the skin
    2,097 were on oral medicines, such as acitretin (Soriatane), cyclosporine (Gengraf, Neoral, Sandimmune, Sangcya), and methotrexate (Rheumatrex, Trexall); or on light therapy (also called phototherapy)
    1,673 were on TNF inhibitors, including Enbrel (etanercept), Humira (adalimumab), or Remicade (infliximab).

During the follow-up, heart attacks occurred in:

    152 on topical medicines
    41 on oral or light therapy
    28 on TNF inhibitors


When Wu compared TNF inhibitors directly with the oral medicine and light therapy, the TNF inhibitors were found only slightly better in reducing heart attack risk.

Wu says he combined the oral agent and light therapy groups to simplify the research.

There was no information available on the severity of the psoriasis, Wu says.

Generally, topical medications are offered first, and if they don't give enough relief, patients may be offered the other treatments.

Topical treatments slow down the rapid growth of skin cells and reduce the inflammation. Light therapy slows down the rapid cell growth. Oral medicines such as methotrexate and the TNF inhibitors reduce inflammation in the entire body.

It is possible some with severe disease chose to get topical treatment, Wu says.

Wu reports receiving research grants from Abbott Laboratories, Amgen, and Pfizer. All market or are developing psoriasis medicines.

None of the grants are related to the current study. The study was supported by Kaiser Permanente Garfield Memorial Fund.
Psoriasis Treatments: Cost Considerations

TNF inhibitor treatment is very costly. The drugs are given by injection or intravenously. Annual cost for the three drugs evaluated in the study ranges from about  $17,000 to $23,000 a year. Some patients pay only a copay.

Generic methotrexate is about $20 a month, or about $250 a year.

However, patients on that drug do need to undergo routine lab tests for monitoring.

Patients in the Kaiser plan get light therapy for the cost of a visit copayment, Wu says.

He says patients with severe disease, in particular, may want to consider long-term benefits of reducing inflammation.

"If you have severe psoriasis, it may be beneficial to be on some sort of treatment -- TNF inhibitors, methotrexate, that in itself will help with the psoriasis and may help with systemic inflammation and reduce accompanying diseases," Wu says.
Psoriasis Treatments & Heart Attacks: Perspective

"This study gives the patient a little more comfort in knowing if their psoriasis is severe enough to warrant treatment, TNF inhibitors, photo therapy, and oral agents compared to topical treatment may reduce the risk of having a heart attack," says Nehal N. Mehta, MD, chief of the section of inflammatory and cardiometabolic diseases at the National Heart, Lung and Blood Institute.

"People used to think psoriasis was a cosmetic disease," he says. The new research, he says, supports the notion that treating severe psoriasis with TNF inhibitors, oral agents, or light therapy may improve heart attack risk.