“Treatment effectiveness of conventional oral therapies, and of the newer biologic treatments, for moderate-to-severe psoriasis is much lower in real-world clinical practice than in clinical trials,” explains Ireny Y.K. Iskandar, PhD. “Factors that might impact response to treatment are wide-ranging and generally poorly understood, aside from high body weight, which has been linked with poor response to treatment. This indicates that other unknown factors may be important in determining response to treatment. The potential impact of alcohol abuse on response to treatment for psoriasis has not been examined. Therefore, the aim of our study was to understand the real-world levels of alcohol abuse among patients with moderate-to-severe psoriasis and to investigate whether alcohol abuse influences the response to treatment among this patient population.”

For a paper published in the British Journal of Dermatology, Dr. Iskandar and colleagues conducted a prospective cohort study in which response to systemic therapies was evaluated with the Psoriasis Area and Severity Index (PASI). The CAGE (Cut down, Annoyed, Guilty, Eye opener) questionnaire was used to assess alcohol misuse and a multivariable factional polynomial linear regression model was used to analyze factors related to change in PASI score between baseline and follow-up. The study included 266 patients.

Alcohol Abuse & High Body Weight Linked With Poor Response

“We found that alcohol abuse and high body weight were both associated with poorer response to treatment,” Dr. Iskandar says. “Patients receiving conventional therapies were more likely to have a poorer response compared to patients receiving the newer biologic treatments. In addition, patients receiving conventional therapies were less likely to adhere to treatment schedules as compared with those receiving biologic treatments.”

For every one-point increase in the CAGE score—a patient-reported measure of estimated alcohol misuse—the PASI increased by 1.40 points (95% CI, 0.04-2.77), the researchers note. Therefore, a maximum change in CAGE score from 0 to 4 would correlate with an increase in the PASI by 5.60 points (95% CI, 0.16-11.08). Patients who are obese are more likely to have a PASI that is 1.84 points (95% CI, 0.48-3.20) higher than those who are non-obese. In addition, patients treated with conventional therapies were more likely to have poor response to treatment (ie, a PASI that is 4.39 points higher [95% CI, 2.84-5.95] than patients receiving biologic treatments) (Table).

Clinical Teams Can Play an Important Role

The researchers stress that it’s important for clinicians to be aware of the substantial psychological distress and psychosocial challenges that patients with psoriasis may experience, which can lead to chronic alcohol misuse and dependence as coping mechanisms. The study found that at least 40% of the cohort reported psychological distress.
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“Our study offers evidence that alcohol abuse and obesity are linked to poor response to treatment in patients on systemic therapies,” Dr. Iskandar concludes. “However, these are modifiable factors that point to the critical role that clinicians play in supporting lifestyle behavioral changes in people with psoriasis. Interventions to avoid or manage alcohol abuse and weight gain should form a key part of psoriasis health management. Patients may also need additional support to understand the connection between these lifestyle factors and their skin health, as this study underscores how these factors detrimentally impact psoriasis treatment effectiveness. Routine screening is also recommended to detect early signs of hazardous, harmful, and dependent alcohol consumption among people with psoriasis.”

Dr. Iskandar and colleagues agree that it would be interesting to see whether their results can be duplicated independently. “The economic, social, and health consequences of alcohol abuse are substantial and excessive alcohol may worsen psoriasis, affect the efficacy of treatment, and increase the risk that people with psoriasis die earlier than peers of the same age and sex in the general population,” she says.