|Year : 2020 | Volume
| Issue : 1 | Page : 29-33
Relation between insulin resistance and severity of psoriasis in Egyptian patients
Noha Ezzat Mohamad1, Esam Elshimi2
1 Dermatology and Venereology Department, Faculty of Medicine, Fayum University, Egypt
2 Hepatology Department, National Liver Institute, Menoufia University, Al Minufiyah, Egypt
|Date of Submission||26-Apr-2019|
|Date of Acceptance||26-Aug-2019|
|Date of Web Publication||6-Jan-2020|
Shebin Elkom, Menoufia
Source of Support: None, Conflict of Interest: None
Background Psoriasis is an immune-mediated disease of multifactorial etiology. The prevalence of insulin resistance (IR) in patients with psoriasis has been extensively studied. The prevalence varies based on many factors such as aging, genetics, diet, and sedentary lifestyle.
Aim To study the association between psoriasis and IR and detection of the correlation between level of IR and the psoriasis severity.
Patients and methods A total of 30 patients with psoriasis and similar number of age-matched and sex-matched controls were enrolled in this study. Patients and controls were subjected to the following measurements: systolic and diastolic blood pressure, BMI, serum triglycerides, cholesterol, low-density lipoprotein, high-density lipoprotein, fasting plasma glucose, serum insulin, and IR. Assessment of psoriasis severity was done using psoriatic area severity index score.
Results A statistically significant difference regarding serum insulin, IR, fasting plasma glucose, triglyceride, low-density lipoprotein, systolic blood pressure, diastolic blood pressure, and BMI was found between patients and controls. A positive correlation between psoriasis severity and level of IR was also found.
Conclusion and recommendation Patients with psoriasis had strong association with IR. The level of IR correlated with severity of psoriasis. Dermatologists and internists should give more attention toward screening and early recognition of associated metabolic disorders and IR. Correction of metabolic syndrome and IR should be initiated in this group of patients.
Keywords: insulin resistance, psoriasis, severity
|How to cite this article:|
Mohamad NE, Elshimi E. Relation between insulin resistance and severity of psoriasis in Egyptian patients. Egypt J Dermatol Venerol 2020;40:29-33
|How to cite this URL:|
Mohamad NE, Elshimi E. Relation between insulin resistance and severity of psoriasis in Egyptian patients. Egypt J Dermatol Venerol [serial online] 2020 [cited 2021 Aug 4];40:29-33. Available from: http://www.ejdv.eg.net/text.asp?2020/40/1/29/275177
| Introduction|| |
Psoriasis is a common chronic inflammatory disorder of skin and joints characterized by red scaly papules and plaques, affecting any part of the body, especially extensors such as elbows, knees, scalp, and lumbar area. Its prevalence ranges from 2 to 3% of the general population .
The exact etiology of psoriasis remains unknown, but genetic predisposition, environmental factors, and immune factors are implied to play a major role in its pathogenesis .
Psoriasis was found to be directly related to the BMI, which raises the suspicion of the presence of such association between psoriasis and insulin resistance (IR), which may further explain psoriasis-associated comorbidities .
IR is an impaired physiologic response to insulin, which causes an insufficiency of glucose production in the liver and impaired glucose transport in fat tissue and skeletal muscle .
Elevated inflammatory mediators in patients with psoriasis, such as increased C-reactive protein, T-helper 1 cytokines, and platelet activators, can be linked to the development of obesity and IR. Metabolic syndrome is a name given to a group of conditions including dyslipidemia, diabetes mellitus, hypertension, and central obesity, which may further increase heart disease risk, stroke, and IR .
| Aim|| |
The aim was to study the association between psoriasis and IR and the correlation with psoriasis severity to the level of IR.
| Patients and methods|| |
This case–control study was conducted in the period between January 2018 and June 2018 and included two groups (patients and controls):
Patient group included 30 patients with psoriasis, and they were aged between 20 and 50. They were selected from the outpatient clinics of Dermatology Department, Al-Zahraa University Hospital and Fayoum University Hospital. There were 15 females and 15 males, and they were divided into three subgroups according to psoriatic area severity index (PASI) score: group I included 16 patients with mild psoriasis, group II included five patients with moderate psoriasis, and group III included nine patients with severe psoriasis.
Control group included 20 females and 10 males, with their ages ranging between 20 and 50 years. They had no history of any chronic skin disease.
Ethical approval was obtained and written informed consent was obtained from every patient.
| Methods|| |
All participants were subjected to the following: history taking, general examination to exclude any systemic illness, and dermatologic examination to exclude any other skin disease. The classification of BMI of the patients was done according to Forbes and Jackson  as follows: BMI from 25 to 29 kg/m2 was considered as mild overweight, 30–34 kg/m2 was considered as moderate overweight, 35–40 kg/m2 was considered as morbid overweight, and underweight was considered when the BMI less than 18 kg/m2. Measurement of blood pressure was done using sphygmomanometers. Measurement of fasting blood glucose level, serum cholesterol, triglycerides (TGs), high-density lipoprotein (HDL), cholesterol, low-density lipoprotein (LDL) cholesterol, and serum insulin was also done. Homeostatic Model Assessment for IR (HOMA) was measured using the updated model [(fasting insulin (m IU/ml)×fasting glucose (mmol/l)/22.5], and value above 2.5 was considered to indicate IR .
All statistical calculations were done using Microsoft excel version 10 and statistical package for the social sciences (SPSS, version 20.00; SPSS, Inc., Chicago, IL, USA) statistical program .
- Comparison of values was done using the t-test, and the one-way analysis of variance and post-hoc least significant difference tests were used to analyze percentage and mean±SD for 2 or more than two groups.
- The Pearson linear correlation coefficient was estimated to show the relationship of the physiological parameters with each other .
- Level of significant (P value) was stated as follows: P value more than 0.05 is considered nonsignificant, P value up to 0.05 is considered significant, and P value up to 0.01 is considered highly significant.
| Results|| |
This study was conducted on 30 patients with psoriasis and 30 age-matched and sex-matched healthy individuals who served as a control. The patient group consisted of 15 females and 15 males, and their ages ranged between 20 and 50 years (mean±SD: 34.47±10.92 years), whereas the control group consisted of 20 females and 10 males, and their age ranged between 20 and 50 years (mean±SD: 30.40±9 years) (P>0.05; [Table 1]).
|Table 1 Comparison between cases and control regarding age, sex, systolic blood pressure, diastolic blood pressure, serum insulin, insulin resistance, FPB, cholesterol, triglyceride, high-density lipoprotein, low-density lipoprotein, and BMI|
Click here to view
Diastolic blood pressure of patients with psoriasis was significantly higher (mean±SD: 71.50±9.31 mmHg) than control group (mean±SD: 66.47±6.55 mmHg) (P=0.019), and also systolic blood pressure of patients with psoriasis was significantly increased (mean±SD: 118.17±9.87 mmHg), compared with control group (mean±SD: 99.33±5.98 mmHg) (P=0.000; [Table 1]).
There was a significant increase in IR in patients with psoriasis (mean±SD: 3.98±1.76) compared with control group (mean±SD: 2.890±2.07) (P=0.034), and also serum insulin was significantly increased in patients with psoriasis (mean±SD: 16.56±4.33 mIU/ml) compared with control group (mean±SD: 12.785±8.13 mIU/ml) (P=0.029; [Table 1]).
Regarding fasting plasma glucose (FPG), there was a significant increase of FPG level in patients with psoriasis (mean±SD: 91.77±15.18 mg/dl), compared with control group (mean±SD: 82.27±12.35 mg/dl) (P=0.010; [Table 1]).
Regarding the lipid profile in the studied groups, there was a significant increase in serum cholesterol level in patients with psoriasis (mean±SD: 178.27±37 mg/dl), compared with control group (mean±SD: 157.07±27 mg/dl) (P=0.016). There was a significant increase in serum TG level in patients with psoriasis (mean±SD: 114.00±41 mg/dl) compared with control group (mean±SD: 94.17±33.06 mg/dl) (P=0.046). The serum LDL level was significantly increased in patients with psoriasis (mean±SD: 110.87±37.03 mg/dl) compared with control group (mean±SD: 91.10±25.72 mg/dl) (P=0.046), whereas the HDL level was decreased in patients with psoriasis (mean±SD: 44.57±11.58 mg/dl), compared with control group (mean±SD: 47.13±13.11 mg/dl), but this was not statistically significant (P=0.425; [Table 1]).
BMI of patients with psoriasis was significantly increased (mean±SD: 24.70±3.89 kg/m2), compared with control group (mean±SD: 22.67±2.77 kg/m2) (P=0.023; [Table 1]).
With increased psoriasis severity, there was a significant increase in the level of IR (P=0.016; [Table 2]).
Regarding the correlation between PASI score and IR, the level of IR tends to be significantly increased in patients with psoriasis according to their PASI (P=0.004; [Figure 1]).
|Figure 1 Positive correlation between psoriatic area severity index and insulin resistance.|
Click here to view
Regarding the nail involvement, there was a significant increase in IR in seven patients with nail involvement (mean±SD: 9.12±10.64), compared with patients without nail involvement (mean±SD: 3.08±1.70) (P=0.005; [Table 3]).
|Table 3 Comparison of nail and genital involvement with respect to insulin resistance in patients with psoriasis|
Click here to view
There was a significant increase of level of IR in eight patients with genital involvement (mean±SD: 6.33±6.27), compared with patients without genital involvement (mean±SD: 2.72±1.52) (P=0.016; [Table 3]).
Regarding family history of psoriasis, there was an increase in IR and PASI in 23 patients with no family history of psoriasis (mean±SD: 3.83±4.15–14.59±11.98), compared with seven patients with positive family history of psoriasis (mean±SD: 3.20±1.81–11.50±8.93), but this was not statistically significant (P>0.05; [Table 4]).
|Table 4 Comparison of insulin resistance values with respect to patients’ family history|
Click here to view
| Discussion|| |
Psoriasis is a chronic and complex immune-mediated dermatologic disorder. The inflammatory process involved in its pathogenesis is responsible for several associated comorbidities . Overproduction of the inflammatory mediators such as C-reactive protein levels, tumor necrosis factor (TNF)-α, and platelet activators can be linked to the development of IR, obesity, atherosclerosis, and myocardial infarction .
The aim of this study was to assess the association between psoriasis and IR and to correlate its level with psoriasis severity. We have included 30 patients with psoriasis and compared their results with the results of 30 age-matched and sex-matched healthy controls.
We have found a significant increase in the level of serum insulin, IR, and FPG between patients with psoriasis and controls, whereas IR had no relation with age, sex, family history, or duration of psoriatic disease.
Our findings were in agreement with previous studies ,. We have argued these findings to the presence of countless number of inflammatory cytokines released in psoriasis such as interleukin-1 (IL-1), TNF-α and IL-6, which may induce endothelial dysfunction, altered glucose metabolism, and IR. Moreover, a genetic link may be present between psoriasis and IR through TNF-α gene NcoI polymorphism that increases insulin levels and decreases sensitivity to insulin .
However, Drateln et al. , Malekzad et al. , and El-Ramly et al.  have found no difference between patients with psoriasis and control. Genetic variation and different lifestyles and food habits of studied patients may explain the discrpripancies between the results of these studies.
Our findings showed significant correlation between levels of IR and severity of psoriasis, especially in patients with genital and nail involvement. Boehncke et al.  findings were in agree with ours, but Ucak et al.  have found no significant relations of both HOMA-IR and HOMA β-cell indices with PASI score of patients with psoriasis.
In this study, patients with psoriasis had significantly higher TG, cholesterol, and LDL concentrations than controls, but no significant differences were found in the HDL. Patients with psoriasis experienced significantly higher BMI than controls, which may lead to increased production of inflammatory cytokines such as TNF-α and IL-6 that promote lipolysis and so increase of proatherogenic lipid profile . Our clinical findings go in line with other studies ,,.
However, Malekzad et al.  found significantly higher TG concentrations than the control, but no significant differences were found in the HDL-cholesterol level and other lipid profile.
In this study, there was a significant increase in BMI among patients with psoriasis than control. Obesity is accompanied by persistent low-grade inflammation manifested by increased levels of IL-6, TNF-a, IL-8, resistin, and leptin, which could increase psoriasis inflammation .
Similar findings were found in other studies ,. However, Boehncke et al.  and Malekzad et al.  have found no difference in BMI between both groups.
In Egypt, in the recent years, the changes in the dietary habits and the increase of sedentary lifestyles have led to marked increase of prevalence of obesity. Approximately 70% of Egyptians are categorized as obese. Moreover, according to the WHO statistics, Egypt is rated 14th place in the world. Several eating habits have been cited as potential leading factors for obesity, such as excessive eating and skipping breakfast. Eating foods rich in, sugar, salt, and fat and consumption of food lacking whole grains, vegetables, fruits, and legumes added more risks of overweight .
In this study, we found that the systolic and diastolic blood pressure levels were significantly higher in patients with psoriasis compared with controls. This is in line with a study reported by Malekzad et al. . The elevated blood pressure in patients with psoriasis could be explained by the associated high levels of angiotensin-converting enzyme, endothelin-1, and renin in patients with psoriasis, which lead to elevations in angiotensin-II and elevation of blood pressure .
The association between psoriasis severity and severity IR in Egyptian patients may be related genetic predisposition such as the presence of minor allele polymorphism of chemerin rs17173608 among Egyptians .
In Egyptian populations, in a study by Abd Elaziz et al. , metabolic syndrome was detected in 55% of included subjects and in 85.6 and 76.6% of diabetics and hypertensive patients, respectively.
The strengths of this study include its status as a case–control study in addition to its report in correlating psoriasis severity to level of IR.
This study has some limitations, including the small number of included subjects in addition to patients being not followed up.
Conclusion and recommendations
Patient with psoriasis had a strong association with IR. The level of IR correlated with severity of psoriasis. Screening for IR specially in patients with severe grade of psoriasis is strongly warranted for early detection and management of IR. Egyptian patients with psoriasis have high prevalence of IR, which calls for nationwide screening program for early detection and management of IR.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Boehncke S, Thaci D, Beschmann H, Ludwig RJ, Ackermann H, Badenhoop K, Boehncke WH. Psoriasis patients show signs of insulin resistance. Br J Dermatol 2007; 157:1249–1251.
Hoehn KL, Salmon AB, Hohnen-Behrens C, Turner N, Hoy AJ, Maghzal GJ et al.
Insulin resistance is a cellular antioxidant defense mechanism. Proc Natl Acad Sci USA 2009; 106:17787–17792.
Wellen KE, Hotamisligil GS. Inflammation, stress, and diabetes. J Clin Invest 2005; 115:1111–1119.
Madeira IR, Carvalho CN, Gazolla FM, de Matos HJ, Borges MA, Bordallo MA. Cut-off point for Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) index established from Receiver Operating Characteristic (ROC) curve in the detection of metabolic syndrome in overweight pre-pubertal children. Arq Bras Endocrinol Metab 2008; 52:1466–1473.
Akhyani M, Ehsani AH, Robati RM, Robati AM. The lipid profile in psoriasis: a controlled study. J Eur Acad Dermatol Venereol 2007; 21:1330–1332.
Forbes CD, Jacson WF. Color atlas and text of clinical medicine. London, New York: Elsevier Science. 2003. pp. 320–336.
Rössner SM, Neovius M, Mattsson A, Marcus C, Norgren S. HOMA-IR and QUICKI: decide on a general standard instead of making further comparisons. Acta Paediatr 2010; 99:1735–1740.
Snedecor GM, Cochran WG. Statistical methods-7th edition, lowa State Univ. Iowa, USA: Press, Ames. 1982. pp. 325–330.
Hardle W, Simar L. Applied multivariate statistical analysis. 2nd edition. USA: Springer. 2007. p. 420.
Ferdinando LB, Fukumoto PK, Sanches S, Fabricio LHZ, Skare TL. Metabolic syndrome and psoriasis: a study in 97 patients. Rev Assoc Med Bras (1992) 2018; 64:368–373.
Ucak S, Ekmecit TR, Basat O, Koslu A, Altuntas Y. Comparison of various insulin sensitivity indices in psoriatic patients and their relationship with type of psoriasis. J Eur Acad Dermatol Venereol 2006; 20:517–522.
Gottlieb AB, Chao C, Dann F. Psoriasis comorbidities. J Dermatolog Treat 2008; 19:5–21.
Reynoso-von Drateln C, Martínez-Abundis E, Balcázar-Muñoz BR, Bustos-Saldaña R, González-Ortiz M. Lipid profile, insulin secretion, and insulin sensitivity in psoriasis. J Am Acad Dermatol 2003; 48:882–885.
Malekzad F, Hejazi S, Abaei H, Robati R et al.
Insulin resistance in psoriasis. A case-control study. Iran J Dermatol 2011; 14:136–139.
El-Ramly AZ, El-Tawdy AM, Eissa MA, Emam HE, Mohamed NEA, Shaker O. Psoriasis and insulin resistance. Med J Cairo Univ 2010; 78:565–571.
Marques-Vidal P, Mazoyer E, Bongard V, Gourdy P, Ruidavets JB, Drouet L, Ferrières J. Prevalence of insulin resistance syndrome in southwestern France and its relationship with inflammatory and haemostatic markers. Diabetes Care 2002; 25:1371–1377.
Naldi L, Chatenoud L, Linder D, Belloni Fortina A, Peserico A, Virgili AR et al.
Cigarette smoking, body mass index, and stressful life events as risk factors for psoriasis: results from an Italian case-control study. J Invest Dermatol 2005; 125:61–70.
Herron MD, Hinckley M, Hoffman MS, Papenfuss J, Hansen CB, Callis KP, Krueger GG. Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol 2005; 141:1527–1534.
Dsouza PH, Kuruville M. Dyslipidemia in psoriasis: as a risk for cardiovascular disease. Int J Res Med Sci 2013; 1:53–57.
Pereira RR, Amladi ST, Varthakavi PK. A study of the prevalence of diabetes, insulin resistance, lipid abnormalities, and cardiovascular risk factors in patients with chronic plaque psoriasis. Indian J Dermatol 2011; 56:520–526.
] [Full text]
Piskin S, Gurkok F, Ekuklu G et al.
Serum lipid levels in psoriasis. Yonsei Med J 2003; 44:24–26.
Hassan NE, Wahba S, El-Alameey IR, El-Masry SA, AbuShady MM, Hameed ER et al.
Dietary behaviour pattern and physical activity in overweight and obese egyptian mothers: relationships with their children’s body mass index. Open Access Maced J Med Sci 2016; 4:353–358.
Mehanna ET, Mesbah NM, Ghattas MH, Saleh SM, Abo-Elmatty DM. Association of chemerin rs17173608 and vaspin rs2236242 gene polymorphisms with metabolic syndrome in Egyptian women. Endocr Res 2016; 41:43–48.
Abd Elaziz KM, Gabal MS, Aldafrawy OA, Abou Seif HA, Allam MF. Prevalence of metabolic syndrome and cardiovascular risk factors among voluntary screened middle-aged and elderly Egyptians. J Public Health (Oxf) 2015; 37:612–617.
[Table 1], [Table 2], [Table 3], [Table 4]