Psoriasis and the liver

Since the function of the liver is so very complex, it should not come as a surprise that it can play a role in a vast array of diseases. Like so many problems, psoriasis has been treated symptomatically as a skin problem but research is now coming along which links it to more profound causes and suggests that addressing liver damage may be the best way to treat psoriasis.

Psoriasis is a chronic inflammatory disease that affects the skin. Studies have shown that psoriasis is not merely a skin problem; psoriasis is linked with various comorbid conditions, especially obesity and metabolic syndrome , which are known risk factors for non-alcoholic fatty liver disease (NAFLD).

In the past decade, many studies have drawn attention to comorbid conditions in psoriasis, and preliminary epidemiological data suggest that psoriasis could be associated with the development of NAFLD. Non-alcoholic fatty liver disease includes a spectrum of conditions that range from simple fatty liver, which is relatively benign, to non-alcoholic steatohepatitis (NASH), which can give rise to fibrosis, cirrhosis, and end-stage liver disease . Moderate or severe conditions of psoriasis have a high prevalence of chronic liver disease . It is hypothesised that components of metabolic syndrome as the most likely pathogenic basis may play a role in the manifestation of NAFLD and psoriasis.

Uncontrolled studies have suggested that individuals with psoriasis or psoriatic arthritis may benefit from a diet supplemented with fish oil rich in eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Diet recommendations include consumption of cold water fish (preferably wild fish, not farmed) such as salmon, herring, and mackerel; extra virgin olive oil; legumes; vegetables; fruits; and whole grains; and avoid consumption of alcohol, red meat, and dairy products. The effect of consumption of caffeine (including coffee, black tea, mate, and dark chocolate) remains to be determined.

There is a higher rate of celiac disease among people with psoriasis. Disease severity generally decreases in people with celiac disease and those with anti-gliadin antibodies after the adoption of a gluten-free diet.

Previous studies have suggested links between psoriasis and health conditions such as obesity and metabolic syndrome that can lead to NAFLD, which can cause liver fibrosis and cirrhosis, and end-stage liver disease.

Metabolic syndrome can lead to heart problems and stroke. Its manifestations include high blood pressure, high cholesterol, excess abdominal fat, and other factors.

Many of those with moderate-to-severe psoriasis also have chronic liver disease, supporting the notion of a link between NAFLD and psoriasis.

To find evidence of a link, researchers studied 250 psoriasis patients. Their mean age was 44 and most were overweight, with an average body-mass index of 24.7 kg/m2).

Patients told the researchers how long they had had psoriasis and whether they had hypertension, dyslipidemia — increased cholesterol — and diabetes. Patients’ height, weight, and waistlines also were measured.

Doctors gave all the patients skin evaluations to confirm psoriasis, and a liver ultrasound to detect signs of NAFLD.

Forty-eight percent of the patients were found to have excess abdominal fat, 96% had high cholesterol, 52.8% hyperglycemia, or high blood sugar, 53.6% hypertension, and 44% elevated levels of ALT, an enzyme measure of liver damage.

Almost half the patients, 45.2%, had NAFLD. Those with NAFLD were younger and more obese than those with psoriasis alone. The NAFLD patients, mostly men, also had higher body-mass levels and more metabolic syndrome.

In addition, NAFLD patients had higher fibrosis scores than non-NAFLD patients. None of the NAFLD patients had cirrhosis of the liver, however.

“ is highly prevalent among our cohort of patients with psoriasis, occurring in 45.2% of patients,” the researchers wrote. “Comorbidity of NAFLD is highly associated with psoriasis, which emphasizes that both diseases may develop simultaneously. Healthcare providers should be mindful of this association since early evaluation and diagnosis of NAFLD in patients with psoriasis may play a vital role in alleviating the progression of liver disease.”

What You Should Know About Psoriasis and Nonalcoholic Fatty Liver Disease

Up to 47 percent of psoriasis patients develop nonalcoholic fatty liver disease (NAFLD), a potentially life-threatening condition involving fat deposits in the liver not caused by alcohol abuse. The connection between psoriasis and NAFLD is not entirely understood, but it may have something to do with a group of health risk factors known as metabolic syndrome.

Both psoriasis and NAFLD increase your risk for heart disease. “It remains unclear whether having psoriasis and NAFLD together results in an even higher risk of cardiovascular disease than having either condition alone,” says Junko Takeshita, MD, PhD, a dermatologist and epidemiologist at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.

RELATED: What Is Nonalcoholic Fatty Liver Disease?

NAFLD can progress to a more severe form known as steatohepatitis (NASH), which can lead to cirrhosis. About 25 percent of the people who develop cirrhosis will die within five years. The cause is complications from liver cancer or end-stage liver disease, which may require a liver transplant.

Metabolic Syndrome

The connection between the two diseases appears to be metabolic syndrome, which is more common in people with psoriasis, and is a risk factor for NAFLD.

Metabolic syndrome is a combination of health problems. To be diagnosed with metabolic syndrome, you must have at least three of the following health issues:

  • Elevated fasting blood sugar levels (hyperglycemia), defined as 100 milligrams per deciliter (mg/dL) or higher
  • High triglyceride levels (hypertriglyceridemia), defined as 150 mg/dL or higher
  • Abdominal obesity, defined as a waist measurement equal to or exceeding 40 inches, or 102 centimeters (cm), in men and 35 inches (88 cm) in women
  • High blood pressure (hypertension), defined as higher than 130/85 millimeters of mercury
  • Low high-density lipoprotein (HDL) cholesterol, defined as less than 40 mg/dL in men or 50 mg/dL in women

In a study published online in February 2016 in the Polish journal Gastroenterology Review, researchers found “that psoriasis with NAFLD was positively associated with three components of metabolic syndrome: hyperglycemia, hypertriglyceridemia, and abdominal obesity.”

The study reported a higher number of people with obesity having psoriasis and NAFLD, compared with those who just had psoriasis. It also found that people with both conditions had higher blood pressure.

“People who have psoriasis, particularly those with more severe disease, are more likely to have risk factors for NAFLD,” says Dr. Takeshita.

Screening Liver Function

When you’re diagnosed with psoriasis, your dermatologist or primary care doctor will likely take blood to test your liver’s function.

“Most NAFLD will be identified by dermatologists based on elevated liver function tests during routine drug-monitoring labs for oral systemic or biologic medications,” says Takeshita. But that may leave many cases undetected because the changes in liver enzymes may be unnoticeable or very slight. Also, the disease often doesn’t cause many symptoms until it’s advanced. You may also have elevated liver enzymes but not have NAFLD.

“To date, there are no U.S. guidelines on screening patients with psoriasis for NAFLD,” says Takeshita.

Like other researchers, Takeshita says further study on the association between psoriasis and NAFLD is needed in order to determine best screening recommendations.

Prevention Tips

Many NAFLD risks are behaviors that you have some control over. First, talk with your doctor about ways to keep your liver healthy. Also, consider these actions:

Stay at a healthy weight or lose weight if you’re overweight or obese. You can improve the health of your liver by losing 7 to 10 percent of your weight. For a 200-pound (lb) person, that means losing 14 to 20 lbs.

Eat a healthy diet. This can help you control your glucose and triglyceride levels as well as your blood pressure. Avoid saturated fats and fructose-sweetened drinks.

Exercise regularly. This can help increase your HDL levels.

Limit how much alcohol you drink. Alcohol increases your risk for liver disease. Ask your doctor how much is safe for you to drink. Takeshita says, “Alcohol can sometimes exacerbate psoriasis. Unless a patient with psoriasis has other contraindications to alcohol, such as taking methotrexate or having severe liver disease or cirrhosis, I personally don’t make recommendations to limit alcohol intake beyond the recommendations for the general population.”

Take any medicines that you’ve been prescribed. Follow your doctor’s advice on taking drugs to lower blood glucose, cholesterol, or triglycerides.

Liver Disease & Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis

Relatively little is known about the risk for incident liver disease in patients with psoriasis (PsO), psoriatic arthritis (PsA), or rheumatoid arthritis (RA). To help better treat this patient population, Joel M. Gelfand, MD, MSCE, and colleagues conducted a cohort study of patients with these conditions, and their results were published in the Journal of Investigative Dermatology.

“For decades, there has been the concept of ‘the psoriatic liver,’” says Dr. Gelfand. “Clinicians recognized that patients with psoriasis seemed to be more prone to liver problems. However, the hypothesis that psoriasis specifically predisposes patients to liver disease has not been rigorously tested. We tested the hypothesis that patients with psoriasis are more prone to liver disease while controlling for risk factors such as obesity and alcohol use. We evaluated these risks in patients with rheumatoid arthritis to determine if the risk appears specific to psoriasis or related in inflammation in general.”

The study team evaluated data from The Health Improvement Network from 1994 to 2014. When compared with matched controls, the adjusted hazard ratios (aHR) for any liver disease were elevated among patients with PsO (without systemic therapy , 1.37; with ST, 1.97), PsA (without ST, 1.38; with ST, 1.67), and RA without an ST (1.49) but not elevated in patients with RA prescribed ST (0.96). Incident nonalcoholic fatty liver disease was highest in patients with PsO prescribed ST (aHR, 2.23) and those with PsA on ST (aHR, 2.11). The risk of cirrhosis was highest among patients with PsO on ST (aHR, 2.62) and PsA not on ST (aHR, 3.15).

Dr. Gelfand says that hepatotoxic medications should be used cautiously in patients with psoriasis, especially when disease is more severe. The type of inflammation seen in psoriasis may also promote insulin resistance and hepatic inflammation.

Nonalcoholic fatty liver disease in psoriasis

Psoriasis is a chronic, patchy, red, scaly rash affecting around 2% of the population. People with psoriasis, while usually healthy, are more susceptible than others to arthritis, metabolic syndrome (MetS: type 2 diabetes, high blood pressure and obesity) and a liver disorder called non‐alcoholic fatty liver disease (NAFLD). NAFLD starts as excess fat deposits in the liver but can progress to inflammation (non‐alcoholic steatotic hepatosis NASH), cirrhosis and even liver cancer. This paper from researchers in the US and Italy reviews the links between psoriasis and NAFLD, which is more than twice as common, and more severe, in people with psoriasis than in those without. The risk of NAFLD in psoriasis increases with age and with the severity of the psoriasis, even when methotrexate (an effective medicine for psoriasis, known to cause liver damage) is taken out of the equation. Both conditions show increased levels of inflammatory chemicals produced by fat (adipokines), and decreased levels of an anti‐inflammatory adipokine. Adipokines have a role in energy balance, insulin sensitivity, blood pressure, and blood vessel maintenance, as well as inflammation. The liver responds to adipokines by producing hepatokines which can promote MetS and NAFLD. A multistep process involving these and other body chemicals with complicated feedback loops creates an imbalance between liver cell death and regeneration resulting in NAFLD. The inflammatory events in psoriasis feed in to this process. This review emphasises the importance of monitoring general health in psoriasis and raises the possibility that certain anti‐inflammatory medications may alleviate both disorders.

Original ArticleClinical Research: Epidemiology

Risk of Incident Liver Disease in Patients with Psoriasis, Psoriatic Arthritis, and Rheumatoid Arthritis: A Population-Based Study

Relatively little is known about the risk for incident liver disease in psoriasis (PsO), psoriatic arthritis (PsA), and rheumatoid arthritis (RA). We performed a cohort study among patients with PsO, PsA, or RA and matched controls in The Health Improvement Network from 1994 to 2014. Outcomes of interest were any liver disease, nonalcoholic fatty liver disease, and cirrhosis (any etiology). Among patients with PsO (N = 197,130), PsA (N = 12,308), RA (N = 54,251), and matched controls (N = 1,279,754), the adjusted hazard ratios for any liver disease were elevated among patients with PsO (without systemic therapy 1.37; with ST 1.97), PsA (without ST 1.38; with ST 1.67), and RA without an ST (1.49) but not elevated in patients with RA prescribed an ST (0.96). Incident nonalcoholic fatty liver disease was highest in patients with PsO prescribed an ST (2.23) and PsA with an ST (2.11). The risk of cirrhosis was highest among patients with PsO with an ST (2.62) and PsA without an ST (3.15). Additionally, the prevalence of liver disease and cirrhosis increased in a stepwise fashion with increasing body surface area affected by PsO (P for trend <0.001). More so than RA, PsO and PsA are associated with liver disease, particularly nonalcoholic fatty liver disease and cirrhosis, and this was true even among patients without ST exposure.

Psoriasis (PsO) patients at higher risk for serious liver disease

Compared to controls, patients with psoriasis (PsO) are at higher risk for serious liver disease than patients with rheumatoid arthritis – two autoimmune diseases often treated with similar drugs that can cause liver damage, reports a study this week in the Journal of Investigative Dermatology from researchers at the Perelman School of Medicine at the University of Pennsylvania. The study is the first population-based study to simultaneously address the risk for liver disease in patients with these inflammatory diseases and psoriatic arthritis (PsA), in a large population of more than 197,000 PsO patients, 12,000 PsA patients, 54,000 rheumatoid arthritis (RA) patients, and 1.2 million matched controls.

Independent of risk factors commonly seen in liver disease, such as alcohol use and diabetes, the study found that patients with psoriatic skin or joint disease, particularly patients with more severe skin psoriasis, had an elevated risk for serious liver disease. Patients with psoriasis taking a systemic therapy drug like methotrexate (under brand names like Trexall, Rasuvo, and Otrexup PF), had the highest risk, particularly for non-alcoholic fatty liver disease and cirrhosis, while RA patients taking the similar drugs had the lowest liver disease risk.

The study suggests systemic inflammation – which is present in all three diseases—may play a significant role in development of liver disease, particularly in those with psoriasis. At the same time, certain medications use to treat these diseases also can cause liver toxicity. The authors note that future research should delve into whether adequate control of inflammation reduces liver disease risk.

The findings could provide relief for the approximately 7.5 million Americans who suffer from psoriasis each year, a chronic inflammatory disease most commonly evidenced by patches of raised, reddish skin covered with silvery-white scale, the American Academy of Dermatology reports.

“These findings offer evidence for the long held view that psoriasis patients may be more predisposed to liver disease than patients with rheumatoid arthritis,” said first author Alexis Ogdie, MD, MSCE, an assistant professor of Medicine and Epidemiology. “Understanding the role of inflammation in liver disease and how the liver can perpetuate inflammation in these conditions can help us advise patients, and their clinicians, on how to more effectively manage their health.”

Previous studies have shown an increased prevalence of liver disease in psoriasis patients than in the general population, but this new research adjusts for risk factors for liver disease to determine if having PsO or PsA increases an individual’s risk of developing new liver disease, and sheds like on how common liver disease is among patients with these diseases.

The study also offers insights on how the liver responds to specific types and severity of chronic inflammation, and also yields information on how skin disease severity, obesity, diabetes, and medication use play a role in development of liver disease in patients with these conditions.

“Based on these data, physicians should educate psoriasis patients on the increased risk for liver disease and be cautious about the use of hepatoxic medications in these patients, especially when additional risk factors such as diabetes, obesity, or heavy alcohol use are present,” said senior author Joel M. Gelfand, MD, MSCE, a professor of Dermatology and Epidemiology.

In addition to Ogdie and Gelfand, the other authors on this study are Sungat K. Grewal, Megan H. Noe, Daniel B. Shin, Junko Takeshita, Zelma C. Chiesa Fuxench, and Rotonya M. Carr, all from Penn.

Ogdie has served as a consultant for Pfizer and Takeda and is a co-investigator on a research grant from Pfizer. Gelfand has served as a consultant for Pfizer Inc., receiving honoraria; and receives research grants from Pfizer Inc. Pfizer had no role in the design, analysis, or reporting of the data.

Journal information: Journal of Investigative Dermatology Provided by Perelman School of Medicine at the University of Pennsylvania Citation: Psoriasis (PsO) patients at higher risk for serious liver disease (2017, November 2) retrieved 2 February 2020 from This document is subject to copyright. Apart from any fair dealing for the purpose of private study or research, no part may be reproduced without the written permission. The content is provided for information purposes only.

Nonalcoholic Cirrhosis

The liver is a tough, resilient organ. We can flood it with toxins and expose it to nasty germs, and it still goes about its jobs of purifying blood, manufacturing bile, and keeping us alive. But even the liver has its limits. If it suffers too much damage over too many years, some of the cells will turn into scar tissue. This is called cirrhosis. If enough scar tissue forms, the liver will begin to shut down and severe complications will set in. Without proper treatment, cirrhosis can be fatal.

Most people associate cirrhosis with heavy drinking, but that’s not the whole story. While alcohol is the leading cause of cirrhosis in the United States, even teetotalers can develop the condition. Any scarring of the liver not caused by drinking is referred to by the broad term nonalcoholic cirrhosis.

What are the causes of nonalcoholic cirrhosis?

One of the liver’s jobs is clearing germs from the blood. Occasionally, however, the germs get the upper hand. A chronic infection by the hepatitis C virus is the most common cause of nonalcoholic cirrhosis in the United States. In most cases, it takes many years for the infection to lead to scarring. Still, only about 20 percent of people with chronic hepatitis C ever develop cirrhosis.

Chronic infections of hepatitis B can also lead to cirrhosis. Worldwide, this may be the most common cause of cirrhosis, but it is rare in the United States, where children are routinely vaccinated against hepatitis B. The virus that causes hepatitis A never sticks around long enough to cause cirrhosis.

Nonalcoholic steatohepatitis (NASH), a condition in which the liver contains extra fat and becomes inflamed, is another potential starting point for cirrhosis. The cause of NASH isn’t well-understood, but obesity, diabetes, protein malnutrition, heart disease, and corticosteroid drugs all seem to raise the risk.

Some people can trace cirrhosis to an overactive immune system. For unknown reasons, they produce antibodies that attack liver cells as if they were intruders. The liver becomes damaged and inflamed, a condition known as autoimmune hepatitis.

Other rare causes of cirrhosis include blocked or inflamed bile ducts, severe reactions to medications or supplements such as methotrexate or Vitamin A, frequent bouts of heart failure, and inherited conditions such as cystic fibrosis, alpha-1-antitrypsin deficiency, hemochromatosis, and Wilson’s disease.

In up to 10 percent of all cases, no cause of cirrhosis can be found. Doctors call these cases “cryptogenic cirrhosis.” Increasingly, however, researchers theorize that many of these cases are actually caused by NASH.

What are the symptoms of nonalcoholic cirrhosis?

Whether it comes from a virus or a liquor bottle, cirrhosis is a potentially disabling disease. You probably won’t notice any symptoms at first, but as the damage builds, you’ll feel weak and exhausted. You may also lose your appetite, become nauseated, and lose weight. Some women suddenly stop having periods, and men can develop erectile dysfunction, lose their sex drive, and have enlarged breasts that are painful.

As scarring progresses, your skin and eyes may become yellow (jaundiced). Your skin may also become intensely itchy, a condition called pruritis. Backed-up fluids can cause swelling in the abdomen (ascites), and internal bleeding can make you vomit blood. Because many medications are broken down in the liver, you may become extra-sensitive to your medications and extremely vulnerable to side effects. And if toxins normally removed by the liver begin to accumulate in the brain, you may become forgetful, unresponsive, and unconcerned about personal appearance.

How is nonalcoholic cirrhosis diagnosed?

Your doctor can detect liver damage by measuring the levels of certain enzymes in your blood. If the enzymes are high, an ultrasound or CT scan can often pinpoint the nature of the damage. If there’s still any question, doctors can remove a small sample of tissue (biopsy) through a needle to make a diagnosis and to determine the extent of the damage.

How is nonalcoholic cirrhosis treated?

In some cases, doctors can slow down cirrhosis by targeting the source. For instance, chronic infections of hepatitis B and hepatitis C can be controlled with antiviral drugs, and autoimmune hepatitis often responds to drugs that suppress the immune system.

No matter what caused your cirrhosis, protecting your liver should be a top priority for both you and your doctor. First and foremost, you should avoid alcohol. You may also need to reduce the dosage of your medications or stop taking them completely. Make sure your doctor knows about every drug you take, including nonprescription drugs and even natural remedies and supplements because many herbs can cause liver damage. You can give your liver an extra boost by eating a healthy, nutrient-rich diet.

With proper treatment, many people with cirrhosis can still lead active lives, especially if their condition is caught in the early stages. But not all patients can live with the damage. If severe complications set in, or if the liver shuts down completely, a liver transplant may be your best hope for survival. Once the new liver is in place, you have a good chance for recovery. The five-year survival rate for liver transplant patients is 75 percent. Unfortunately, livers are in short supply, the waiting lists can be long, and not every patient is healthy enough to withstand the operation. Ask your doctor if a liver transplant is a good option for you.

The American Gastroenterological Association. Cirrhosis of the liver. April 2008.

National Digestive Diseases Information Clearinghouse. Cirrhosis of the liver. December 2008.

American Liver Foundation. Cirrhosis. August 17, 2010.

American Liver Foundation. Liver Transplant. August 17, 2010.

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