10.5826/dpc.1201a32
Introduction: Visceral adipose tissue (VAT) has a greater relationship with the genesis of the metabolic syndrome and the pathology associated with obesity.
Methods: A cross-sectional study of patients with moderate-severe psoriasis in the Psoriasis Unit of the San Cecilio University Hospital in Granada in the period July 1, 2020 - December 31, 2020, was performed. All the patients (n = 110) were receiving biological therapy to control the disease. The variables measured included age, sex, time since diagnosis, weight, height, body mass index (BMI), visceral and total fat, and severity parameters. The visceral fat index was evaluated using a bioimpedance scale, considering a cut-off point for a healthy level &lt; 12.
Results: Our sample consisted of 110 patients with a mean age of 47.47 years, with a clear predominance of males (61.7% of patients). After testing for normality using the Kolmogorov-Smirnov test, the Mann-Whitney U test for nonparametric data for independent samples was used, which revealed significant differences between the number of previous treatments and visceral fat (U = -2.235, P = 0.025). No statistically significant differences were found when correlating total fat or visceral fat with BMI.
Conclusions: The results presented lead us to consider if the levels of VAT could be a factor that contributes to some extent to therapeutic refractoriness. The determination of VAT using bioimpedance scales in patients with moderate-severe psoriasis is a valuable method to measure VAT.
text/xml
2160-9381
1802
en
Jose Carlos Ruiz-Carrascosa
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
severity
Study of the Visceral Adipose Tissue in a Cohort of Patients with Moderate-Severe Psoriasis Treated with Biological Therapy
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-02-02
2021-05-23
2022-02-02
2022-02-09
e2022032
Dermatol Pract Concept
Introduction: Visceral adipose tissue (VAT) has a greater relationship with the genesis of the metabolic syndrome and the pathology associated with obesity.
Methods: A cross-sectional study of patients with moderate-severe psoriasis in the Psoriasis Unit of the San Cecilio University Hospital in Granada in the period July 1, 2020 - December 31, 2020, was performed. All the patients (n = 110) were receiving biological therapy to control the disease. The variables measured included age, sex, time since diagnosis, weight, height, body mass index (BMI), visceral and total fat, and severity parameters. The visceral fat index was evaluated using a bioimpedance scale, considering a cut-off point for a healthy level &lt; 12.
Results: Our sample consisted of 110 patients with a mean age of 47.47 years, with a clear predominance of males (61.7% of patients). After testing for normality using the Kolmogorov-Smirnov test, the Mann-Whitney U test for nonparametric data for independent samples was used, which revealed significant differences between the number of previous treatments and visceral fat (U = -2.235, P = 0.025). No statistically significant differences were found when correlating total fat or visceral fat with BMI.
Conclusions: The results presented lead us to consider if the levels of VAT could be a factor that contributes to some extent to therapeutic refractoriness. The determination of VAT using bioimpedance scales in patients with moderate-severe psoriasis is a valuable method to measure VAT.
Jose Carlos Ruiz-Carrascosa
2022/02/02
10.5826/dpc.1201a32
e2022032
Dermatology Department, Hospital Universitario San Cecilio, Granada, Spain
2160-9381
severity
en
e2022032
Rivers JP, Powell-Wiley TM, Dey AK, et al. Visceral Adiposity in Psoriasis is Associated With Vascular Inflammation by 18F-Fluorodeoxyglucose Positron-Emission Tomography/Computed Tomography Beyond Cardiometabolic Disease Risk Factors in an Observational Cohort Study. JACC Cardiovasc Imaging. 2018;11(2 Pt 2):349-357. DOI: 10.1016/j.jcmg.2017.08.014. PMID: 29055628. PMCID: PMC5803350.
Study of the Visceral Adipose Tissue in a Cohort of Patients with Moderate-Severe Psoriasis Treated with Biological Therapy
https://dpcj.org/index.php/dpc/article/download/1802/1470
                    Dermatology Practical & Conceptual


 Study of the Visceral Adipose Tissue in a Cohort of
  Patients with Moderate-Severe Psoriasis Treated
              with Biological Therapy
                                  Ruiz-Villaverde Ricardo, Ruiz-Carrascosa José C


1 Dermatology Department, Hospital Universitario San Cecilio, Granada, Spain



Key words: psoriasis, biological therapy, visceral adipose tissue, treatment, severity.
Citation: Ruiz-Villaverde R, Ruiz-Carrascosa JC. Study of the visceral adipose tissue in a cohort of patients with moderate-severe psoriasis
treated with biological therapy. Dermatol Pract Concept. 2022;12(1):e2022032. DOI: https://doi.org/10.5826/dpc.1201a32
Accepted: August 21, 2021; Published: January 2022
Copyright: ©2022 Ruiz-Villaverde and Ruiz-Carrascosa. This is an open-access article distributed under the terms of the Creative
Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted
noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: Both authors have contributed significantly to this publication.
Corresponding author: Ricardo Ruiz-Villaverde. Servicio de Dermatología. Hospital Universitario San Cecilio, Granada, Spain.
E-mail: ismenios2005@gmail.com




  ABSTRACT              Introduction: Visceral adipose tissue (VAT) has a greater relationship with the genesis of the metabol-
                        ic syndrome and the pathology associated with obesity.
                        Methods: A cross-sectional study of patients with moderate-severe psoriasis in the Psoriasis Unit of
                        the San Cecilio University Hospital in Granada in the period July 1, 2020 - December 31, 2020, was
                        performed. All the patients (n = 110) were receiving biological therapy to control the disease. The vari-
                        ables measured included age, sex, time since diagnosis, weight, height, body mass index (BMI), visceral
                        and total fat, and severity parameters. The visceral fat index was evaluated using a bioimpedance scale,
                        considering a cut-off point for a healthy level < 12.
                        Results: Our sample consisted of 110 patients with a mean age of 47.47 years, with a clear predom-
                        inance of males (61.7% of patients). After testing for normality using the Kolmogorov-Smirnov test,
                        the Mann-Whitney U test for nonparametric data for independent samples was used, which revealed
                        significant differences between the number of previous treatments and visceral fat (U = -2.235, P =
                        0.025). No statistically significant differences were found when correlating total fat or visceral fat
                        with BMI.
                        Conclusions: The results presented lead us to consider if the levels of VAT could be a factor that con-
                        tributes to some extent to therapeutic refractoriness. The determination of VAT using bioimpedance
                        scales in patients with moderate-severe psoriasis is a valuable method to measure VAT.




Original Article | Dermatol Pract Concept. 2022;12(1):e2022032                                                                             1
Introduction                                                            Methods
Adipose tissue generally considered a useful annex to provide           A cross-sectional study of patients with moderate-severe
protection, heat, and energy, has surpassed these activities, and       psoriasis in the Psoriasis Unit of the San Cecilio University
as its study progresses it has positioned itself as an organ with       Hospital in Granada in the period July 1, 2020 - December
neuroimmune-endocrine functions. Through the production of              31, 2020 was performed. Patients were obtained by consec-
molecules such as hormones, antimicrobials, cytokines, and adi-         utive sampling. All patients signed an informed consent that
pokines, it participates in the function of various cells and organs,   they could revoke at any time during the study. The study is
which allows it to intervene in the defense and homeostasis of the      approved by the Ethics Committee of our hospital with code
body. Fat deposits are different from each other, even between          HUSC-DER-005.
those of the same type of adipose tissue. Each one is complex,             The diagnosis of moderate-severe psoriasis was estab-
made up of different cells, with different functions and variations     lished when the patient met the following requirements
both in gene expression and in their response to hormones (the          (Psoriasis Area Severity Index [PASI] > 10, Body Surface Area
subcutaneous of the thighs responds to sex hormones, the neck,          [BSA] > 10 and / or Dermatology Life Quality Index [DLQI]
upper back and abdomen to corticosteroids) [1].                         > 10). All the patients were receiving biological therapy to
     Visceral adipose tissue (VAT) is divided into omental or           control the disease.
epiploic and mesenteric. It occupies the spaces between the                The variables measured included age, sex, time since diag-
abdominal organs and keeps them in place. It has lymph nodes            nosis, weight, height, BMI, visceral and total fat, and severity
and a greater number of blood vessels and adrenergic receptors          parameters (PASI, BSA, DLQI). All previous treatments
than the rest of the white adipose tissue. Adipocytes in visceral       that the patient had received, including systemic treatments
tissue also express a greater number of receptors for cortico-          and biological treatments, were considered. Treatment with
steroids, and in obesity, the enzyme 11 beta-hydroxysteroid             biologically effective UVB phototherapy was excluded as a
dehydrogenase is overexpressed, which generates active sub-             treatment to consider. Only the overall number of treatments
stances from inactive glucocorticoids, stimulating adipogenesis         was considered in those patients where the cause of switching
and increase visceral fat. Therefore, visceral adipose tissue           was a primary or secondary failure, excluding safety reasons.
has a greater relationship with the genesis of the metabolic               The visceral fat index was evaluated using a bioimpedance
syndrome and the pathology associated with obesity [2, 3].              scale (Kanthor®), considering a cutoff point for a healthy level
     The most accurate way to measure visceral fat level is             < 12 [4, 5].
with a computerized tomography (CT) or magnetic resonance                  The statistical software IMB SPSS version 25 in its macOS
imaging (MRI) scan. But without doubt, the most practical               version was used for all analyses. The Kolmogorov Smirnov
and simple way that will allow us to also measure many                  test was used to test the normality of the data. Measures of
other parameters with greater or lesser precision depending             central tendency and dispersion were used depending on the
on their quality is through a bioimpedance scale. Our body is           nature of the data. Outcome variables were selected according
normally made up of 50% to 70% water. Fat tissue barely has             to clinical criteria. The visceral fat variable was categorized
10% so it is a worse conductor, generating resistance to the            according to the healthy cutoff point < 12 in a binomial
passage of electricity. This fact is used by bioimpedance scales        variable for the analyses. Spearman correlation test for
to measure the time it takes for the electricity to pass through        non-parametric samples as well as the Mann-Whitney U test
our body. Considering our weight, age and race, the percent-            for independent samples were used to study the association
age of body fat, visceral and bone density may be calculated.           and relationship between the variables collected. A statistical
                                                                        significance level of P < 0.05 was set.

Objectives
                                                                        Results
• To know the total and average visceral fat composition
    in a cohort of patients with moderate-severe psoriasis              Our sample consisted of 110 patients with a mean age of
    treated with biological therapy in a tertiary hospital using        47.47 years, with a clear predominance of males (61.7% of
    a biompedance scale.                                                patients). The whole sample was placed to the right of the
• Establish the correlation of visceral adipose tissue with             cutoff point considered as pathological in relation to the
    the body mass index (BMI) of the patients that make up              determination of visceral fat. The rest of the characteristics
    this cohort.                                                        evaluated are reported in Table 1.
• Establish if there is a relationship with the number of                  After testing for normality using the Kolmogorov-Smirnov
    treatments and, therefore, refractoriness to them in patients       test, the Mann-Whitney U Test for nonparametric data for
    with moderate-severe psoriasis.                                     independent samples was used, which revealed significant


2                                                                           Original Article | Dermatol Pract Concept. 2022;12(1):e2022032
        Table 1. Clinical and anthropometric                           events, which have characteristically been associated with
          characteristics of the participants.                         elevated BMI [4].
                                                                          Although BMI is a clinical marker of obesity, this obesity
        Outcome                           Values
                                                                       is an heterogeneous condition with varying CV and meta-
 Age                       47.47 ± 13.47 yearss                        bolic manifestations [6]. Obesity causes increased levels of
 Gender                                                                proinflammatory cytokines (TNFα and IL6). High levels of
    Male                   74 (61.7)                                   TNFα would produce a reduction in adiponectin levels, which
    Female                 46 (38.3)                                   would lower HDL cholesterol levels, increase triglycerides
 Time since diagnosis      22.84 ± 12.81 years                         and insulin resistance. This leads to an increase in VAT and
 (years)                                                               IL6 levels that perpetuate the inflammatory process [5]. In
 Weight (kg)               82.79 ± 21.00                               our study, it is shown in a cohort of 110 patients treated with
 Height (m)                1.70 ± 0.1                                  biological therapy that the mean is right at the cutoff point
 BMI                       28.49 ± 6.10                                considered pathological for visceral fat levels (11.97 +/- 7.30;
 Visceral Fat              11.97 ± 7.30                                VAT > 12) and we reported a statistical correlation with the
 Total Fat                 29.02 ± 11.36                               number of previous treatments the patient had received. This
 PASI                      12.93 ± 5.23                                makes us wonder if these levels could be a factor that con-
                                                                       tributes to some extent to therapeutic refractoriness. We were
 BSA                       15.18 ±7.42
                                                                       unable to find statistically significant differences when trying
 DLQI                      11.72 ± 4.66
                                                                       to establish a correlation between BMI levels and visceral fat
Data are presented as mean ± standard deviation or n (%),              levels. Interestingly, the mean BMI of the presented cohort
as appropriate.                                                        does not exceed 30 points that mark the limit of obesity, but
                                                                       there is a clear overweight, as well as the levels of visceral fat
                                                                       that have not reached the limit considered as pathological.
differences between the number of pre-treatments and vis-
                                                                          Different techniques (mainly imaging) have been pos-
ceral fat: U = -2.235; P = 0.025). These results showed a
                                                                       tulated to determine VAT. Coronary CT angiography is a
positive correlation between high levels of visceral fat with
                                                                       non-invasive imaging technique, of great prognostic utility
a greater number of previous treatments. No statistically
                                                                       and a predictor of CV events. Sajja et al have shown in a
significant differences were found when correlating total fat
                                                                       one-year study that the reduction in VAT volume measured
or visceral fat with BMI (Table 2).
                                                                       by this technique is associated with an improvement in the
                                                                       coronary artery burden [7].

Conclusions                                                               Other techniques include ultrasonography (USG), which
                                                                       is regarded as a radiation technique with a lower cost than
Psoriasis is a chronic inflammatory disease that is associated         the one of CT [8]. USG measures the maximal thickness of
with a high degree of systemic and vascular inflammation.              preperitoneal mass at the anterior surface of the liver and the
It is known to cause an increase in cardiovascular (CV) risk           minimal thickness of subcutaneous fat in the upper median
factors, coronary artery disease and myocardial infarction.            abdomen. Gönul et al performed the first study using this
VAT is associated with this vascular inflammation and CV               technique, in which they concluded a higher prevalence of



                Table 2. Bivariate correlations between number of previously treatments and
                                          anthropometric variables.
                                                                                                                        Number of
                                                                                           Categorised Visceral         previously
                                 Age           Gender            BMI         Total Fat             Fat                  treatments
 Age                                         0,015          0.411**        0.180*          0.087                      -0.023
 Gender                      0,015                          -0.231*        -0.392**        -0.433**                   0.119
 BMI                         0.411**         -0.231*                       0.691**         0.629**                    -0.059
 Total Fat                   0.180*          -0.392**       -691**                         0.733**                    -0.158
 Categorised visceral fat 0,087              -0.433**       0-629**        0.733**                                    -0.205*
 Number of previously        -0,023          0.119          -0.059         -0.158          -0.205*
 treatments

Spearman correlation coefficient. *Correlation is significant at the 0.05 level; **Correlation is significant at the 0.01 level.



Original Article | Dermatol Pract Concept. 2022;12(1):e2022032                                                                         3
metabolic syndrome in patients with psoriasis but with an           2. Rehrer CW, Karimpour-Fard A, Hernandez TL, et al. Regional
abdominal fat index similar to the control group [9]. As in            differences in subcutaneous adipose tissue gene expression.
our study, in this case with an imaging technique, the authors         Obesity (Silver Spring). 2012;20(11):2168-2173. DOI: 10.1038/
                                                                       oby.2012.117. PMID: 22627919; PMCID: PMC3434286.
were unable to establish a relationship between visceral fat
                                                                    3. Vohl MC, Sladek R, Robitaille J, et al. A survey of genes dif-
levels and other markers related to metabolic syndrome.                ferentially expressed in subcutaneous and visceral adipose tis-
    Finally, studies have also been conducted using 18F-Flu-           sue in men. Obes Res. 2004;12(8):1217-1222. DOI: 10.1038/
orodeoxyglucose positron-emission tomography to measure                oby.2004.153. PMID: 15340102.
VAT volume and its relationship with vascular inflammation          4. Toussirot E, Aubin F, Desmarets M, et al. Visceral adiposity in
in patients with psoriasis. It shows how new treatments for            patients with psoriatic arthritis and psoriasis alone and its rela-
                                                                       tionship with metabolic and cardiovascular risk. Rheumatology
moderate-severe psoriasis lower the volume of VAT and vas-
                                                                       (Oxford). 2021;60(6):2816-2825. DOI: 10.1093/rheumatology/
cular inflammation, which is why VAT is an important CV                keaa720. PMID: 33232483.
biomarker [10].                                                     5. Goolam Mahyoodeen N, Crowther NJ, Pillay L, et al. Relation-
    Our study has some limitations. It is a cross-sectional            ship of visceral fat and adipokines with cardiometabolic diseases
study, which has measured the visceral fat of our patients at          in psoriasis. Acta Derm Venereol. 2019; 99:1218–1223. DOI:
a specific and determined moment. Although there is indeed             10.2340/00015555-3327. PMID: 31580467.
                                                                    6. Budu-Aggrey A, Brumpton B, Tyrrell J, et al. Evidence of a causal
a statistically significant correlation between the number of
                                                                       relationship between body mass index and psoriasis: A mende-
previous biological treatments (used due to refractoriness to          lian randomization study. PLoS Med. 2019;16(1):e1002739.
treatment) and the levels of visceral fat, we have not been able       DOI:10.1371/journal.pmed.1002739. PMID: 30703100; PM-
to detect an association with other characteristics that have          CID: PMC6354959.
been used as biomarkers and prognoses factors in metabolic          7. Sajja A, Abdelrahman KM, Reddy AS, et al. Chronic inflammation
                                                                       in psoriasis promotes visceral adiposity associated with noncalci-
syndrome such as BMI. Furthermore, we have not been able
                                                                       fied coronary burden over time. JCI Insight. 2020;5(22):e142534.
to establish a correlation with imaging techniques already
                                                                       DOI: 10.1172/jci.insight.142534. PMID: 33104056; PMCID:
used in other studies due to the lack of availability of these         PMC7710282.
techniques in our centre.                                           8. Balci A, Balci DD, Yonden Z, et al. Increased amount of visceral
    As a conclusion to our study, we want to value the deter-          fat in patients with psoriasis contributes to metabolic syndrome.
mination of VAT using bioimpedance scales in patients with             Dermatology. 2010;220(1):32-37. DOI: 10.1159/000254482.
                                                                       PMID: 19887761.
moderate-severe psoriasis. Further studies are required to
                                                                    9. Gönül M, Tatar İ, Canpolat F, Işıl Kurmus G, Ergin C, Heki-
determine its correlation with other characteristics of the
                                                                       moğlu B. Evaluation of abdominal fat index by ultrasonography
disease and its positioning in relation to its determination           and its relationship with psoriasis and metabolic syndrome.
using other imaging techniques already discussed.                      Postepy Dermatol Alergol. 2017;34(5):453-456. DOI: 10.5114/
                                                                       ada.2017.71111. PMID: 29507560. PMCID: PMC5831280..
                                                                   10. Rivers JP, Powell-Wiley TM, Dey AK, et al. Visceral Adiposity in
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