10.5826/dpc.1203a144
Background: Early onset psoriasis (EOP) and late onset psoriasis (LOP) differs regarding genetic background, clinical presentation, and course of disease.
Objective: In this study, comparison of EOP and LOP regarding systemic inflammatory comorbidities which are frequently seen in psoriasis and determination of possible differences is aimed.
Methods: A total of 160 plaque psoriasis patients; 121 with EOP and 39 with LOP were enrolled for the study. Data was collected with face-to-face questionnaire and patients’ medical chart evaluation. Collected data included medical and family history, clinical features and parameters indicating severity of psoriasis, results of laboratory work-up, physical and dermatological examination findings, presence of joint and nail involvement and associated inflammatory systemic comorbidities such as cardiovascular diseases (CVD), diabetes mellitus (DM), hypertension (HT), metabolic syndrome (MS), obesity.
Results: Nail involvement and PsA occurred more rapidly in LOP compared to EOP (p&lt;0.01, p&lt;0.01). Compared frequencies in LOP and EOP were 7.7% vs 0.8% for CVD, 38.5% vs 14% for HT, 33.3% vs 9.9% for DM and 44.7% vs 24.8% for MS respectively. CVD, HT, DM and MS were significantly more frequent in LOP compared to EOP (p=0.045, p=0.001, p&lt;0.01, p=0.022). Results of multivariate analysis performed taking into account the age, gender, severity parameters of disease, alcohol consumption, smoking habits, and other concurrent systemic comorbidities revealed LOP to be an independent risk factor for CVD and DM (p&lt;0.01, R2: 0.036, p&lt;0.01, R2: 0.077). &nbsp;
Conclusion: LOP seems to interact with systemic comorbidities hence generating more severe inflammatory burden and shows a more rapid course.
text/xml
2160-9381
2102
en
Sibel Dogan Gunaydin
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
psoriasis, comorbidity, early onset psoriasis, late onset psoriasis, inflammation
Comparison of early (EOP) and late onset psoriasis (LOP) regarding systemic inflammatory comorbidities: LOP is a more rapid subtype of psoriasis
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2022-07-28
2021-10-13
2022-07-28
2022-09-13
e2022144
Dermatol Pract Concept
Background: Early onset psoriasis (EOP) and late onset psoriasis (LOP) differs regarding genetic background, clinical presentation, and course of disease.
Objective: In this study, comparison of EOP and LOP regarding systemic inflammatory comorbidities which are frequently seen in psoriasis and determination of possible differences is aimed.
Methods: A total of 160 plaque psoriasis patients; 121 with EOP and 39 with LOP were enrolled for the study. Data was collected with face-to-face questionnaire and patients’ medical chart evaluation. Collected data included medical and family history, clinical features and parameters indicating severity of psoriasis, results of laboratory work-up, physical and dermatological examination findings, presence of joint and nail involvement and associated inflammatory systemic comorbidities such as cardiovascular diseases (CVD), diabetes mellitus (DM), hypertension (HT), metabolic syndrome (MS), obesity.
Results: Nail involvement and PsA occurred more rapidly in LOP compared to EOP (p&lt;0.01, p&lt;0.01). Compared frequencies in LOP and EOP were 7.7% vs 0.8% for CVD, 38.5% vs 14% for HT, 33.3% vs 9.9% for DM and 44.7% vs 24.8% for MS respectively. CVD, HT, DM and MS were significantly more frequent in LOP compared to EOP (p=0.045, p=0.001, p&lt;0.01, p=0.022). Results of multivariate analysis performed taking into account the age, gender, severity parameters of disease, alcohol consumption, smoking habits, and other concurrent systemic comorbidities revealed LOP to be an independent risk factor for CVD and DM (p&lt;0.01, R2: 0.036, p&lt;0.01, R2: 0.077). &nbsp;
Conclusion: LOP seems to interact with systemic comorbidities hence generating more severe inflammatory burden and shows a more rapid course.
Sibel Dogan Gunaydin
2022/07/28
10.5826/dpc.1203a144
e2022144
Hacettepe University, Faculty of Medicine, Department of Dermatology and Venereology; Hacettepe University, Graduate School of Medical Sciences, Department of Pediatric Basic Sciences, Immunology, Ankara, Turkey
2160-9381
psoriasis, comorbidity, early onset psoriasis, late onset psoriasis, inflammation
en
e2022144
Comparison of early (EOP) and late onset psoriasis (LOP) regarding systemic inflammatory comorbidities: LOP is a more rapid subtype of psoriasis
https://dpcj.org/index.php/dpc/article/download/2102/1701
                    Dermatology Practical & Conceptual


      Comparison of Early and Late Onset Psoriasis
    (EOP and LOP) Regarding Systemic Inflammatory
      Comorbidities: LOP is a More Rapid Subtype
                      of Psoriasis
                                 Leyla Huseynova Terzi1, Sibel Dogan Gunaydin1,2


1 Hacettepe University, Faculty of Medicine, Department of Dermatology and Venereology, Ankara, Turkey
2 Hacettepe University, Graduate School of Medical Sciences, Department of Pediatric Basic Sciences, Immunology, Ankara, Turkey



Key words: psoriasis, comorbidity, early onset psoriasis, late onset psoriasis, inflammation
Citation: Huseynova Terzi L, Dogan Gunaydin. Comparison of early (EOP) and late onset psoriasis (LOP) regarding systemic inflammatory
comorbidities: LOP is a more rapid subtype of psoriasis. Dermatol Pract Concept. 2022;12(3):e2022144. DOI: https://doi.org/10.5826/
dpc.1203a144
Accepted: November 28, 2021; Published: July 2022
Copyright: ©2022 Tognetti et al. 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: All authors have contributed significantly to this publication.
Corresponding author: Leyla Huseynova Terzi, MD, Hacettepe University, Faculty of Medicine, Department of Dermatology and Venereology 9.
entrance, 06100 Sıhhiye, Ankara, Turkey, +90 312 305 17 04- 17 06, Fax: +90 312 880 58 08, E-mail: leyla.huseynova@ymail.com




  ABSTRACT              Introduction: Early onset psoriasis (EOP) and late onset psoriasis (LOP) differ regarding genetic
                        background, clinical presentation and course of disease.
                        Objectives: In this study, comparison of EOP and LOP regarding systemic inflammatory comorbidi-
                        ties which are frequently seen in psoriasis and determination of possible differences is aimed.
                        Methods: A total of 160 plaque psoriasis patients (121 with EOP and 39 with LOP) were enrolled for
                        the study. Data was collected with face-to-face questionnaire and patients medical chart evaluation.
                        Collected data included medical and family history, clinical features and parameters indicating severity
                        of psoriasis, results of laboratory work-up, physical and dermatological examination findings, presence
                        of joint and nail involvement and associated inflammatory systemic comorbidities such as cardiovas-
                        cular diseases (CVD), diabetes mellitus (DM), hypertension (HT), metabolic syndrome (MS), obesity.
                        Results: Nail involvement and PsA occurred more rapidly in LOP compared to EOP (P < 0.01, P <
                        0.01). Compared frequencies in LOP and EOP were 7.7% versus 0.8% for CVD, 38.5% versus 14% for
                        HT, 33.3% versus 9.9% for DM and 44.7% versus 24.8% for MS, respectively. CVD, HT, DM and MS
                        were significantly more frequent in LOP compared to EOP (P = 0.045, P = 0.001, P < 0.01, P = 0.022).
                        Results of multivariate analysis performed taking into account the age, gender, severity parameters of
                        disease, alcohol consumption, smoking habits and other concurrent systemic comorbidities revealed
                        LOP to be an independent risk factor for CVD and DM (P < 0.01, R2: 0.036, P < 0.01, R2: 0.077).
                        Conclusions: LOP seems to interact with systemic comorbidities hence generates more severe inflam-
                        matory burden and shows a more rapid course.



Original Article | Dermatol Pract Concept. 2022;12(3):e2022144                                                                        1
Introduction                                                        of dermatology between 1st October 2018 and 1st March
                                                                    2019 were enrolled for the study. Patients with disease onset
Psoriasis is a chronic, multifactorial inflammatory skin            before age of 40 years were accepted as EOP and patients
disease with a polygenic background and variable clinical           with disease onset equal or after 40 years were considered
presentations. Nowadays, it is more frequently referred as          to have LOP. The study was approved by the ethic commit-
“psoriatic disease” due to its association with systemic co-        tee of non-invasive clinical studies of Hacettepe University
morbidities such as psoriatic arthritis (PsA), obesity (OB),        (ID GO 18/1057-30).
cardiovascular diseases (CVD), diabetes mellitus (DM), hy-
pertension (HT), metabolic syndrome (MS) and inflamma-
                                                                    Methods
tory bowel diseases (IBD).
    Psoriasis is classified based upon phenotypic presentation,     Questionnaire
association with human leukocyte antigen (HLA) and age              The face-to-face questionnaire consisted of 5 main sec-
at onset [1]. Henseler and Christophers have observed that          tions: (1) patient demographics; (2) psoriasis characteristics;
clinical characteristics of psoriasis differ according to the age   (3) concurrent comorbidities; (4) physical and dermatologi-
of onset [2]. In patients who developed psoriasis before age        cal examination; (5) laboratory studies.
40, psoriasis tends to be more severe, recurrent and resistant
to treatment. Thus, they offered new classification of psoriasis    Patient demographics
based upon the age of onset; psoriasis which developed before       Age, gender, place of birth, place of residence was recorded.
40 years was accepted as early onset psoriasis (EOP) and
                                                                    Psoriasis characteristics
psoriasis which developed after 40 years as late onset pso-
                                                                    Age of onset of the disease, existence of nail involvement, age
riasis (LOP). Although this cut-off point have been used by
                                                                    at the onset of nail involvement, type of nail involvement,
several authors, others have used a wide range of cut-off point
                                                                    existence of concomitant PsA, age at the onset of PsA, family
(30-50 years), thus limiting comparisons between studies
                                                                    history of psoriasis and PsA and age at the onset of psoriasis
[1,3–6].
                                                                    and PsA of the family member, received treatment regimens
    Differences in the clinical characteristics and course of
                                                                    and duration of the treatment were recorded. Duration of
the disease, response to treatment, genetic predisposition and
                                                                    active psoriatic disease was also required to be evaluated. To
psychosocial effects in EOP and LOP have been reported in
                                                                    make this assessment; active psoriatic disease was defined as
previous studies. EOP have been shown to be more severe and
                                                                    existence of cutaneous psoriatic lesions affecting more than
pose recurrent flares, positive family history, Koebner phe-
                                                                    3% of body surface area with or without given treatments
nomenon and association with HLA-C [3–5,7–9]. EOP was
                                                                    and was calculated for each patient. Hospitalizations due to
also claimed to have more prominent psychosocial effect and
                                                                    psoriasis and any existed erythroderma attacks were also
requirement for systemic treatment is usually more frequent
                                                                    recorded. Existent or previous psoriatic nail involvement in-
[1,7,10]. Epidemiologic studies have demonstrated association
                                                                    cluding onycholysis, pitting, subungual hyperkeratosis and
of psoriasis with systemic inflammatory diseases, but to our
                                                                    oil-drop sign were questioned in detail and recorded. Joint
knowledge there is only one report comparing EOP and LOP
                                                                    involvement was questioned based on the previous diagno-
regarding concomitant systemic inflammatory comorbidities,
                                                                    sis of PsA established by a rheumatologist. All patients were
which found OB to be more frequent in LOP than EOP [1].
                                                                    also filled out rheumatologic screening questionnaire (RSQ)
                                                                    regarding existence of PsA. RSQ included 5 items: (I) exis-
Objectives                                                          tence of joint and muscle pain at rest, (II) existence of neck,
                                                                    waist or back pain awakening at nights, (III) existence of
Based on previous literature and lack of data in this aspect,
                                                                    pain, edema and tenderness in hands or feet joint, (IV) his-
we aimed to compare inflammatory comorbidities along
                                                                    tory of morning stiffness lasting for more than 20 minutes,
with clinical characteristics and severity of psoriatic dis-
                                                                    and (V) existence of tenderness while stepping on heels in the
ease and possibly determine differences in EOP and LOP in
                                                                    mornings [11]. Patients were also consulted to rheumatol-
this study.
                                                                    ogy department based on the suspicion of PsA according to
                                                                    RSQ (patients with one or more positive answers to 5 items
Methods                                                             were consulted) and consultation results were added to the
                                                                    study data.
Patients
Data was collected by a face-to-face questionnaire and medi-        Concurrent comorbidities
cal chart evaluation. Patients older than 18 years of age with      Any previous diagnosis of concurrent systemic inflammatory
plaque psoriasis who were on follow-up at our department            comorbidities comprising HT, DM, NASH, CVD, DLP, MS,



2                                                                       Original Article | Dermatol Pract Concept. 2022;12(3):e2022144
OB was noted. Patients who had physical examination and/           were presented as mean ± standard deviation (SD) or median
or laboratory findings indicative of definite disease according    (range), as appropriate and compared with adjustments us-
to below mentioned criteria despite lack of previous diagnosis,    ing Fisher exact tests (for categorical variables) and Student
they were referred to concordant specialist for further evalu-     two-sample t tests or Wilcoxon rank-sum tests (for contin-
ation, the results of this consultations were also added to this   uous variables), subject to normality assumptions being sat-
study data. HT was accepted as having systolic blood pressure      isfied. Associations between the age at the time of diagnosis
≥ 150 mmHg and diastolic blood pressure ≥ 90 mmHg in pa-           and binary comorbidity outcomes were evaluated using mul-
tients ≥ 60 years and systolic blood pressure ≥ 140 mmHg and       tiple logistic regression adjusted for age and other relevant
diastolic blood pressure ≥ 90 mmHg in patients < 60 years [12].    confounders.
Fasting blood glucose ≥ 126 mg/dl and random blood glucose
≥ 200 mg/dl was accepted as DM [13]. DLP was defined as
total cholesterol levels > 200 mg/dl, LDL cholesterol > 100 mg/    Results
dl, HDL cholesterol < 40 mg/dl, TG >150 mg/dl and non-HDL
                                                                   Demographic Data and Disease Characteristics
cholesterol > 130 mg/dl, as proposed by American Endocri-
                                                                   in EOP and LOP
nology Association [14]. MS was accepted as having any three
                                                                   Data of 160 patients; 75.62% (N = 121) with EOP and
of the following five criteria: 1. obesity: waist circumference
                                                                   24.38% (N = 39) with LOP was analyzed and shown in
≥ 102 cm in men and ≥ 88 cm in women; 2. dyslipidemia: TG >
                                                                   Table 1. Family history of psoriasis was more frequent in
150 mg/dl or having pharmacologic treatment (Rx); 3. dyslip-
                                                                   EOP significantly. Family history of psoriasis was most fre-
idemia (second, separate criteria): HDL cholesterol < 40 mg/dl
                                                                   quently positive in the first-degree relatives in EOP and LOP:
in men and HDL cholesterol < 35 mg/dl in women or Rx; 4.
                                                                   23.1%, N = 28 and 10.3%, N = 4, respectively.
HT: systolic blood pressure ≥ 130 mmHg and diastolic blood
pressure ≥ 85, or Rx; 5.hyperglycemia fasting blood glucose ≥
100 mg/dl or Rx [15]. CVD included history of MI, coronary         Assessment of Severity of Psoriasis in EOP
artery by-pass surgery, balloon angioplasty or coronary artery     and LOP
stent, cerebrovascular accident or peripheral atherosclerotic      Severity of psoriasis was accessed depending on BSA per-
vascular disease. OB was defined BMI ≥ 30 [16].                    centage, PASI score, active duration of the disease without
                                                                   any treatment and under treatment, history of hospitaliza-
Physical and dermatologic examination
                                                                   tions due to psoriasis and number of erythroderma attacks
Physical and dermatological examination findings ob-               and no statistically significant difference was found in any
tained during examination in the last 6 months were                parameters between EOP and LOP (Table 2).
noted. Physical examination findings included blood pres-
sure, height, weight and waist circumference. Obtained
                                                                   Physical Examination Findings in EOP and LOP
dermatologic examination results comprised PASI score
                                                                   Physical examination findings in EOP and LOP are shown in
and affected body surface area (BSA). The severity of
                                                                   Table 3. Indicative findings of comorbidities such as HT and
psoriasis was classified as mild (BSA ≤ 10; PASI ≤ 10) or
                                                                   OB, eg systolic and diastolic blood pressure and BMI were
moderate-to-severe (BSA > 10 and PASI > 10). Systemic
                                                                   significantly higher in LOP than EOP statistically (P = 0.005,
treatment regimen, duration of systemic treatment, dura-
                                                                   P = 0.047 and P = 0.020).
tion of active disease (both under treatment and without
any treatment), number of erythroderma attacks and hos-
pitalization due to psoriasis were also collected to assess        Laboratory Studies in EOP and LOP
the severity of psoriasis.                                         Laboratory work-up findings of the patients are shown in
                                                                   Table 4. Parameters indicating increased systemic inflam-
Laboratory studies
                                                                   mation, eg Red Cell Distribution Width (RDW), C-Reactive
Obtained laboratory test results conducted during the last
                                                                   Protein (CRP) and Erythrocyte Sedimentation Rate (ESR)
6 months including complete blood count, fasting blood glu-
                                                                   were statistically higher in LOP than in EOP respectively
cose, C-reactive protein (CRP), total cholesterol (TC), high
                                                                   (P = 0.017, P = 0.006, P = 0.001). Fasting blood glucose was
density lipoprotein cholesterol (HDL), low density lipopro-
                                                                   also higher in LOP (P = 0.002).
tein cholesterol (LDL), triglycerides (TG), blood urea nitro-
gen (BUN) were recorded.
                                                                   Systemic Treatments in EOP and LOP
Statistical Analysis                                               Duration of systemic treatment was 42.09 ± 44.41 months in
Statistical analysis was performed using Statistical Package       all patients, 44.41 ± 45.76 in EOP and 34.91 ± 39.65 months
for the Social Science (SPSS) version 20.0. Patient group data     in LOP showing no significant difference (P = 0.158).



Original Article | Dermatol Pract Concept. 2022;12(3):e2022144                                                                 3
                    Table 1. Demographics and family history of psoriasis in EOP and LOP
                                                  Total patients                  EOP                        LOP
                 Variables                          (N = 160)                   (N = 121)                  (N = 39)                P
 Gender
 male, N (%)                                         90 (56.3)                  72 (59.5)                  18 (46.2)             0.144
 female, N (%)                                       70 (43.8)                  40 (40.5)                  21 (53.8)
 Age, years,                                       44.73 ± 13.66              40.46 ±12.24                57.95±8.40
                                                                                                                                 <0.01
 mean±SD (range)                                      (18-75)                       (18-65)                 (41-75)
 Age at onset of psoriasis, years,                 27.24±15.06                 20.07±8.45                 49.49±7.20
                                                                                                                                 <0.01
 mean±SD (range)                                       (4-67)                        (4-38)                 (41-67)
 Family history of psoriasis, N (%)                   64 (40)                   57 (47.1)                   7 (17.9)             0.001
EOP = early onset psoriasis; LOP = late onset psoriasis; SD = standard deviation.


                              Table 2. Comparison of disease severity in EOP and LOP
                                                    Total patients                EOP                       LOP
                  Variables                           (N = 160)                 (N = 121)                 (N = 39)                P
 BSA, %                                               3.50 ± 8.65              3.34 ± 8.58              3.99 ± 8.96
 mean±SD (range)                                        (0-74.5)                (0.1-74.7)                (0-37.8)              0.636
 PASI                                                 3.46 ± 6.42              3.16 ± 6.07              4.37 ± 7.43
 mean±SD (range)                                       (0-53.10)                (0.2-53.10)                (0-36)               0.460
 Active disease without Rx, months                   24.46 ± 49.59            28.62 ± 55.26            11.54 ± 20.57
 mean±SD (range)                                        (0-360)                     (0-360)                (0-96)               0.083
 Active disease with Rx, months                      28.29 ± 68.68            33.78 ± 77.57            11.26 ± 18.32
 mean±SD (range)                                        (0-492)                     (0-492)                (0-72)               0.334
 History of hospitalization
 Number of positive history, N (%)                     28 (17.5)                    24 (19.8)             4 (10.3)              0.171
 Number of hospitalizations                           0.38 ± 1.25              0.35 ± 0.90              0.49 ± 1.99
 mean±SD (range)                                         (0-12)                       (0-5)                (0-12)               0.380
 History of erythroderma
 number of positive history, N (%)                      12 (7.5)                    11 (9.1)               1 (2.6)              0.296
 Number of erythroderma                               0.13 ± 0.55              0.16 ± 0.61              0.05 ± 0.32
 mean±SD (range)                                          (0-5)                       (0-5)                 (0-2)               0.187
BSA = body surface area; EOP = early onset psoriasis; LOP = late onset psoriasis; PASI = psoriasis area and severity index; Rx = systemic
treatment; SD = standard deviation.


                               Table 3. Physical examination findings in EOP and LOP
                                                 Total patients                 EOP                        LOP
                 Variables                         (N = 160)                  (N = 121)                  (N = 39)                 P
 Systolic BP, mm/Hg                             118.17 ± 13.39             116.24 ± 12.46            124.18 ± 14.55
 mean±SD (range)                                    (90-160)                   (90-150)                 (100-160)               0.005
 Diastolic BP, mm/Hg                             79.31 ± 10.94              78.14 ± 10.02             82.95 ± 12.86
 mean±SD (range)                                    (50-120)                   (50-100)                  (60-120)               0.047
 BMI, kg/m   2
                                                  28.02 ± 4.93              27.62 ± 5.16               29.27 ± 3.94
 mean±SD (range)                                 (16.67-46.90)              (16.67-46.90)             (21.39-39.40)             0.020
 Waist circumference/men, cm                     102.07 ±13.55             101.13 ±13.97              105.83 ±11.31
 mean±SD (range)                                    (76-143)                   (76-143)                  (79-129)               0.190
 Waist circumference/women, cm                   99.80 ± 13.29              98.67 ±14.62              102.42 ± 9.29
 mean±SD (range)                                    (76-149)                   (76-149)                  (84-127)               0.282

BMI = body mass index; BP = blood pressure; EOP = early onset psoriasis; LOP = late onset psoriasis; SD = standard deviation.


4                                                                            Original Article | Dermatol Pract Concept. 2022;12(3):e2022144
                                     Table 4. Laboratory findings in EOP and LOP
                                               Total patients              EOP                         LOP
                Variables                        (N = 160)               (N = 121)                   (N = 39)                P
 Hemoglobin, gr/dL                              14.71 ± 1.46            14.85 ± 1.43               14.28 ± 1.48
 mean±SD (range)                                 (9.6-17.6)              (9.6-17.6)                 (11.0-17.2)            0.035
 WBC, x10 /µL
            3
                                              7069 ± 1716.37          6973 ±1701.75              7364 ± 1750.11
 mean±SD (range)                               (3800-13400)            (3900-11800)               (3800-13400)             0.222
 Platelets, x10 /µL
                3
                                            230597±60028.87         227699 ±58982.59           239589 ± 63101.30
 mean±SD (range)                              (24600-424000)          (24600-381000)            (137000-424000)            0.283
 RDW, %                                         13.99±1.64              13.84 ± 1.33               14.46 ± 2.34
 mean±SD (range)                                   (12-27)                (12-20.1)                 (12.5-27.1)            0.017
 Fasting blood glucose, mg/dL                  97.75 ± 25.77           94.84 ± 22.37              106.65 ± 32.92
 mean±SD (range)                                  (68-260)                (68-203)                   (77-260)              0.002
 CRP, mg/L                                      0.52 ± 0.81             0.45 ± 0.59                 0.76 ± 1.28
 mean±SD (range)                                 (0.02-7.90)             (0.02-5.59)                (0.15-7.99)            0.006
 ESR, mm/hour                                   11.61 ± 9.52            10.30 ± 8.58              16.56 ± 11.30
 mean±SD (range)                                   (2-54)                  (2-37)                      (2-54)              0.001
CRP = C-reactive protein; EOP = early onset psoriasis; ESR = erythrocyte sedimentation rate; LOP = late onset psoriasis; MCV = mean
corpuscular volume; MPV = mean platelet volume; NLR = neutrophil lymphocyte ratio; RDW = red cell distribution width; SD = standard
deviation; WBC = white blood cells.


Nail Involvement in EOP and LOP                                    and 20.5% (N = 8) of EOP and LOP patients respectively.
Psoriatic nail involvement was compared in EOP and LOP,            None of the patients referred to rheumatologic consultations
and results are shown in Table 5. The duration of disease          were diagnosed with PsA.
between onset of psoriasis and nail involvement was sta-
tistically significantly shorter in LOP than EOP (P < 0.01).       Concurrent Systemic Inflammatory Comorbidities
Duration of active psoriatic disease in patients with nail in-     in EOP and LOP
volvement was also significantly shorter in LOP than in EOP        Prevalence and age at onset of systemic inflammatory co-
(P < 0.01, P < 0.01).                                              morbidities in EOP and LOP are shown in Table 7. CVD,
    The most frequent psoriatic nail involvement was seen          HT, DM and MS were found significantly more frequent
as pitting, observed in 14% (N = 17) of EOP and 12.8% (N           in LOP compared to EOP (P = 0.045, P = 0.001, P < 0.01,
= 5) in LOP. Subungual hyperkeratosis was only observed in         P = 0.022).
5% (N = 6) of EOP, distal onycholysis was observed in 5%               In order to evaluate the effect of psoriasis subtype to the
(N = 6) and 10.3% (N = 4), oil-drop sign was observed in           development of concurrent systemic inflammatory comor-
5% (N = 6) and 2.3 % (N = 1) of EOP and LOP, respectively.         bidities, multivariate regression analysis was performed; age,
                                                                   gender, severity parameters of disease, alcohol consumption,
PsA in EOP and LOP                                                 smoking habits and other concurrent systemic comorbidities
Data regarding prevalence of PsA, age at onset of PsA, dura-       were taken into account (Table 8). Based on this analysis,
tion between onset of psoriasis and PsA, and active disease        LOP was found as an independent risk factor for CVD and
duration of patients with PsA with and without treatment           DM (P < 0.01, R2: 0.036; P < 0.01, R2: 0.077).
are shown in Table 6. Duration between onset of psori-                 Risk of CVD, DM, HT and MS were increased accordingly
asis and PsA was significantly shorter in LOP than EOP             with decades of psoriasis onset (P = 0.036, P = 0.007, P = 0.001,
(P < 0.01). Duration of active disease in PsA patients with or     P = 0.003). NASH, DLP and OB development risk was not
without systemic treatments was also significantly shorter in      found to be showing this relationship with psoriasis onset
LOP than EOP respectively (P = 0.002, P < 0.01).                   (P = 0.194, P = 0.158, P = 0.644).
    RSQ revealed morning stiffness in 10.7% (N = 13) of
EOP and 5.1 % (N = 2) of LOP. Muscle-joint complaints was
                                                                   Conclusions
observed in 9.1% (N = 11) and 10.3% (N = 4), small joints
complaints were found in 9.1% (N = 11) and 5.1% (N = 2),           As it was aimed, comparison of disease characteristics and
enthesis complaints were found in 14% (N = 17) and 12.8%           concurrent inflammatory comorbidities enabled us to spot
(N = 5) and axial complaints were noted in 14.9 % (N = 18)         the peculiar differences in EOP and LOP; we were also able



Original Article | Dermatol Pract Concept. 2022;12(3):e2022144                                                                     5
                                  Table 5. Psoriatic nail involvement in EOP and LOP
                                                   Total patients               EOP                     LOP
                  Variables                          (N = 160)                (N = 121)               (n = 39)                   P
 Nail involvement, n (%)                              87 (54.3)               68 (56.1)               19 (48.7)                0.415
 Age at nail involvement onset, years              34.29 ± 12.93            29.51 ± 10.23           49.85 ± 7.33
 mean±SD (range)                                       (10-70)                 (10-62)                 (37-70)                < 0.01
 Disease duration between Ps and nail                 7.4 ± 8.1               9.06 ± 8.5              2.1 ± 3.0             - a, < 0.01b
 involvement, years
 mean±SD (range)                                        (4-37)                  (0-37)                  (4-9)
 Concurrent nail involvement and                      28 (17.5)                 8 (6.6)               5 (12.8)           0.072 a, 0.041 b
 PsA, N (%)
 Active disease duration in patients with            30.63 ± 9.1             35 ± 48.32              16 ± 19.3           0.639 a, < 0.01 b
 nail involvement and Rx, months
 mean±SD
 Active disease duration in patients with            30.22 ± 9.8              34 ± 50.1              17 ± 18.2           0.027a, < 0.01 b
 nail involvement without Rx, months
 mean±SD
EOP = early onset psoriasis; LOP = late onset psoriasis; Ps = psoriasis; PsA = psoriatic arthritis; Rx = systemic treatment; SD = standard
deviation. P a: patients with psoriasis; Pb: between EOP and LOP



                                       Table 6. PsA characteristics in EOP and LOP
                                                  Total patients                EOP                       LOP
                 Variables                          (N = 160)                 (N = 121)                 (N = 39)                     P
 PsA, N (%)                                          41 (25.6)                33 (27.3)                 8 (20.5)                0.057
 Age at PsA onset, years                          38.98 ± 11.64             37.0 ± 11.49             47.13 ± 8.77
 mean±SD (range)                                      (10-71)                  (10-63)                  (37-71)                 0.025
 Duration between Ps and PsA, years               12.80 ± 11.46            15.72 ± 10.36              0.75 ± 7.36             -a, < 0,01b
 mean±SD (range)                                      (15-34)                   (1-34)                   (1-15)
 Active Ps duration in PsA patients                28.34 ± 9.2                34 ± 20.1                  6 ± 8.3           0.761 a, 0.002 b
 with Rx, months
 mean±SD
 Active Ps duration in PsA patients                27.98 ± 10.3               33 ± 15.1                 9 ± 18.1           0.803 a, < 0.0 b
 without Rx, months
 mean±SD
EOP = early onset psoriasis; LOP = late onset psoriasis; Ps = psoriasis; PsA = psoriatic arthritis; Rx = systemic treatment; SD = standard
deviation. Pa: patients with psoriasis; Pb: between EOP and LOP


to evaluate the sole contribution of psoriasis subtype (LOP)             along with calculations made for active disease duration and
to the developmental risk of certain comorbidities deter-                duration of time between onset of psoriasis and concurrent
mined as CVD and DM.                                                     inflammatory comorbidities. Although traditional markers
    Psoriasis is proven to cause serious systemic inflammation           of psoriasis severity such as PASI scores and BSA did not
however the exact tools to monitor the inflammatory bur-                 show any difference between EOP and LOP, we found that
den is yet to be discovered. Reports in literature concerning            LOP was associated with rapid development of psoriatic
the severity of psoriasis subtypes comparing EOP and LOP                 nail involvement and PsA in statistically significantly shorter
are few and contradictory. In these data, authors mostly                 periods of time despite shorter active disease durations with
used PASI score, BSA and duration of systemic treatment                  and without treatment. LOP was also found to associate with
to evaluate severity of psoriasis. Although some researches              higher levels of inflammatory serum markers like CRP, ESR
did not find significant difference in the severity of psoria-           and RDW. As a whole, our results strongly support that LOP
sis between EOP and LOP , others found EOP to be more                    poses heavier and rapid inflammatory burden. Accordingly,
severe than LOP [1,3,4,7,17]. In this study, evaluation of               we prioritize the determination of the disease subtype as EOP
psoriatic inflammation was assessed by severity parameters               or LOP and suggest exploring the duration of time between



6                                                                             Original Article | Dermatol Pract Concept. 2022;12(3):e2022144
               Table 7. Prevalence and age at onset of psoriatic comorbidities in EOP and LOP
                                         Total patients                    EOP                     LOP
              Variables                    (N = 160)                     (N = 121)               (N = 39)                    P
 CVD, N (%)                                    4 (2.5)                    1 (0.8)                3 (7.7)                   0.045
 Age at CVD onset, years                  50.75 ± 2.36                      51                 50.67 ± 1.67                0.929
 mean±SD (range)                              (49-54)                       51                   (49 -54)
 HT, n (%)                                    32 (20)                     17 (14)               15 (38.5)                  0.001
 Age at HT onset, years                   44.28 ± 8.23                 41.53 ± 5.37            47.40 ± 9.87
 mean±SD (range)                              (33-70)                     (33-53)                (39-70)                   0.165
 DM, N (%)                                    25 (15.6)                  12 (9.9)               13 (33.3)                  < 0.01
 Age at DM onset, years                   42.68 ± 9.79                 37.75 ± 7.70            47.23 ± 9.53                0.004
 mean±SD (range)                              (28-65)                     (28-57)                (38-65)
 NASH, N (%)                                  29 (18.1)                  22 (18.2)               7 (17.9)                  0.974
 Age at NASH onset, years                 39.21 ± 8.20                 37.48 ± 8.34            44.43 ± 5.38                0.045
 mean±SD (range)                              (20-59)                     (20-59)                (38-53)
 DLP, N (%)                                   99 (61.9)                  72 (59.5)              27 (69.2)                  0.392
 MS, N (%)                                    47 (29.6)                  30 (24.8)              17 (44.7)                  0.022
 OB, N (%)                                    46 (28.7)                  36 (29.8)              10 (25.6)                  0.622
CVD = cardiovascular disease; DLP = dyslipidemia; DM = diabetes mellitus; EOP: early onset psoriasis; HT = hypertension; LOP = late onset
psoriasis; MS = metabolic syndrome; NASH = non-alcoholic steatohepatitis; OB = obesity; SD = standard deviation.



       Table 8. Multivariate regression analysis of impact of psoriasis subtype on concurrent systemic
                                         inflammatory comorbidities
                                                                                                                    Rx    Disease
                             HT         DM           IBD         NASH       CVD        DLP      MS          OB   duration duration
 HT                           -        0.158             -         -             -    -0.249   0.225   0.177         -              -
 DM                           -           -              -       0.167           -      -      0.235        -        -              -
 IBD                          -           -              -         -             -      -         -         -     0.217             -
 NASH                         -           -              -         -             -      -         -    0.219      0.249             -
 CVD                          -           -              -         -             -      -         -         -        -              -
 DLP                       -0.231         -              -         -             -      -      0.557        -     -0.194            -
 MS                        0.402       0.309             -         -             -    0.632       -         -        -              -
 OB                           -           -              -       0.220           -      -         -         -        -              -
 PASI                         -           -              -         -             -      -         -         -        -              -
 BSA                          -           -              -         -             -      -         -         -        -              -
 Ps subtype                   -        0.168             -         -        0.248       -         -         -        -           -0.747
 Gender                       -           -              -   -0.265         -0.163      -         -    0.182         -           0.101
 Duration of Rx               -           -        0.236         0.250           -      -         -         -        -              -
 Age                       0.403          -              -         -             -    0.224       -         -     1.009          0.663
 Disease duration             -           -              -         -             -      -         -         -     -0.516            -
 Duration of active           -           -              -         -             -      -         -         -        -           0.156
 disease without Rx.
 Duration of active           -           -              -         -             -      -      0.123        -        -           0.188
 disease with Rx
 Smoking                      -           -              -         -             -      -         -         -        -              -
 R Value
   2
                           0.288       0.237       0.056         0.200      0.133     0.451    0.538   0.115      0.325          0.620
 P Value                   0.000       0.000       0.003         0.000      0.000     0.000    0.000   0.000      0.000          0.000
BSA = body surface area; CVD = cardiovascular disease; DLP = dyslipidemia; DM = diabetes mellitus; HT = hypertension; IBD = inflamma-
tory bowel disease; MS = metabolic syndrome; NASH = nonalcoholic steatohepatitis; OB = obesity; PASI = psoriasis area and severity index;
Ps = psoriasis; Rx = systemic treatment.


Original Article | Dermatol Pract Concept. 2022;12(3):e2022144                                                                            7
onset of psoriatic involvements and comorbidities (psoriatic       adequate anti-psoriatic treatment choice is mandatory and is
nail, PsA, CVD, DM, HT, MS) and active disease duration for        lately recommended in psoriasis guidelines [22].
evaluating inflammation and its consequences in psoriasis.             EOP and LOP are two different types of psoriasis with
We believe that the all- together analysis of these parameters     different etiologies, clinical characteristics, laboratory indic-
with the traditional clinical severity scores may create a new     atives and concurrent systemic comorbidities. Despite similar
concept of approach for psoriasis follow-up.                       treatment regimens and shorter duration of active disease,
    Nail involvement is observed in 13%-50% of psoriasis           LOP causes faster nail and joint involvement in a shorter
patients and this rate increases to 80%-90% by age [18].           period of time and is more frequently associated with sys-
Reports on nail involvement in EOP and LOP differ; some            temic inflammatory comorbidities such as CVD, DM, HT and
report more frequent nail involvement in EOP, others found         MS. LOP was also found to be independent risk factor for
that LOP more frequently affect nails [3,5,10,17]. There           development of CVD and DM. From this aspect, we prioritize
are also studies showing no difference in nail involvement         the determination of the disease subtype as EOP or LOP and
between EOP and LOP [1,4,7]. We did not observe statis-            suggest LOP to be closely monitored for potential develop-
tically significant difference in both nail involvement and        ment of end-organ inflammatory comorbidities. LOP must be
type of nail involvement, neither. But interestingly, nails were   considered as the more rapid and aggressive type of psoriasis
found to be affected in significantly shorter duration in LOP      which provokes development of inflammatory comorbidities
in comparison with EOP. Similar to the findings observed           in shorter duration in comparison to EOP.
in psoriatic nail involvement, PsA was found to develop in
significant shorter periods of time in EOP. Generally, PsA
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Original Article | Dermatol Pract Concept. 2022;12(3):e2022144                                                                           9
