**EP412: Talking Psoriasis with Dr. Foo and Dr. Smith** **Dr Warrick Bishop:** Welcome, my name's Dr Warrick Bishop. I'm a cardiologist, an author, and a keynote speaker. I'm the CEO of the Healthy Heart Network. I'm all about trying to help people live as well as possible for as long as possible. Heart disease is huge in Australia. Every 20 minutes, someone suffers a heart attack. Most of these could probably have been avoided if only we knew what to do. This podcast is all about helping you understand blood pressure, weight, cholesterol, for better health. If you enjoy this podcast, I would be honoured for a five-star review. You can share it with your family and friends. It may well save someone you love. Hi, it's Dr. Warwick here, and welcome to my podcast and videocast station. I'm particularly pleased today. I've got two guests simultaneously. I've got Fiona Foo, who you will have heard on a number of occasions. Now, Fiona is a general and interventional cardiologist based out of the Sydney Cardiology Group. We've talked about all sorts of stuff, women-related cardiovascular health issues, environment, climate, and its impact on cardiovascular disease. So I'm really delighted to welcome Fiona back. But with Fiona, I've got Annika Smith, who is a consultant dermatologist. She works both in public and private. You could find her at the Skin Hospital in Darlinghurst, and her particular interest is complex inflammatory skin problems. Hi, Fiona, and hi, Annika. How are you? **Fiona Foo:** Hi, good morning. Lovely to be joining you. **Annika Smith:** Thank you. **Dr Warrick Bishop:** Look, for those listening, you will have picked up in the title already that we're talking about psoriasis. Psoriasis is a skin condition. It's itchy. It's flaky. You may have seen little pieces about it. You may have it. You may know someone who's had it. People often have scaly elbows. I'm not going to talk too much about it, but what I'd love to do is invite Annika to actually give us a nice definition about psoriasis, what the condition is, and how it can affect some individuals, what body parts, what organs, and what expectations people may have from the condition. Would you help us with that, Annika? **Annika Smith:** Absolutely. I think you've given a really nice preliminary introduction to psoriasis. As you've explained, it's a chronic inflammatory skin disease. In fact, it's common; it affects about 2% to 4% of the population. We know, in part, it's due to an immune system problem whereby the skin cells rapidly divide and turn over far more quickly than what they should normally, giving us that characteristic heaped-up scaly skin, typically affecting the elbows, knees, scalp, and other sides. I think perhaps more importantly, in recent times, we've learned that psoriasis is not just a skin condition; it's a systemic disorder. As you've already alluded to, it can affect organs well beyond the skin, namely the heart, which is in part why we're chatting here today. Excess cardiovascular mortality is common in this cohort owing to the increased rates of atherosclerosis in psoriatics. About 30% of patients will also have inflammation of their joints, known as psoriatic arthritis. It can affect brain neurochemistry responsible for depression and anxiety we see in this cohort and liver inflammation, to name a few. So I think it's really important that we raise awareness and understanding of the fact that this is not simply just a skin condition, both amongst patients and also the relevant clinicians involved in the care of these patients so that we can improve outcomes for this cohort. **Dr Warrick Bishop:** Annika, thank you for that. I didn't realise that it was a total body condition. This inflammation clearly goes beyond the skin. One of the things that you alluded to is people being aware. Do you sometimes see people who have psoriasis and are not aware of it, and they may take years to be diagnosed? **Annika Smith:** Absolutely. We actually conducted a national survey in recent times looking at the awareness of this relationship between psoriasis and cardiovascular disease amongst patients themselves, and only 20% of patients were aware of this relationship and indeed the gravity of this relationship. Psoriasis is regarded as an independent cardiovascular risk factor akin to having diabetes, hypertension, or hyperlipidemia. So we know that awareness is poor, and that's not confined to Australia. This has been demonstrated internationally as well. Yes, time to diagnosis is a massive issue. It's not uncommon for patients to languish in the community or in GP land for long periods of time before a definitive diagnosis is established and effective treatment is started. If there's one key message I'd like to impart today, it's that early diagnosis and the commencement of effective therapy early is absolutely critical to shaping the disease trajectory and also mitigating the development of comorbidities such as heart disease. So I'd really like to impress the importance of early diagnosis and early commencement of effective treatment. **Dr Warrick Bishop:** Okay, fantastic. Before I invite Fiona to speak on the cardiovascular risk associated with psoriasis that you've already touched on, what I'd really like to ask you, Annika, is what things should people be looking for to be aware that they should ask the question, could they be suffering from psoriasis? What are the things that they would find? What are their symptoms or signs? Are people in particular families at greater risk? So if it's within the family, would that raise someone's awareness? **Annika Smith:** Yeah, absolutely. Genetics do account for psoriatic onset and predisposition and environmental risk factors. So if you've got a parent or both parents involved, your risk is markedly elevated. It can be minimal in terms of its manifestation on the skin, but you're looking out for often well-demarcated red areas accompanied by scale, often on the elbows, knees, the lower back, sometimes the belly button, the scalp. It can also affect what we call high-impact sites, so the armpits, the groin, the genitals, even the face. The nails, so pitting and buildup of scale underneath the nails can be a sign of psoriasis and, in fact, potentially a predisposition for psoriatic arthritis. Early morning pain and stiffness in the joints may also be indicative of inflammation in the joints, which is linked to psoriasis of the skin. An important point to note is that you don't need a lot of psoriasis on your skin for it to have an impact on your life. It's been well documented that you only need 3% surface area involvement, which is not much at all, for people to be significantly psychologically affected by the disease. More importantly, it can still pertain to cardiovascular risk, irrespective of the degree of surface area involvement. We know that the more surface area involved by psoriasis, the greater your risk of cardiovascular disease. But it's also been established that you don't need a huge amount involved for that risk to still be elevated. **Dr Warrick Bishop:** Well, what a great moment to segue over to Fiona and get her input on, from a cardiological perspective, how we consider psoriasis in that mix of cardiovascular risks. Can you help us with that? **Fiona Foo:** Yeah, so I think Annika touched on that already, but essentially, as she said, psoriasis is an independent risk factor for cardiovascular disease. It's also been associated with increased cardiovascular risk factors, so all the ones that Warwick talks about all the time—obesity, hypertension, diabetes, high cholesterol, and metabolic syndrome. All of these risk factors have been shown to be increased in patients with psoriasis. On top of that, the inflammatory disease of psoriasis itself also contributes to increasing atherosclerosis. So they have a substantially higher risk of heart attacks and strokes, up to about 50% in some studies of a heart attack. It's that combination of increased cardiovascular risk factors as well as that inflammation that increases atherosclerosis. They present with a heart attack earlier than someone without psoriasis. It's really important, and Annika touched on these things, but part of it also relates to severity. The more severe the disease, the more likely you're going to have those risk factors. For example, obesity is greater in those with more severe psoriasis, greater hypertension, and diabetes. They need more medications; they're not as well controlled. Even if the diabetes is not as well controlled, they have more severe risk factors as well as if they have severe disease. We can talk about those markers of severity that Annika alluded to, but some of them are the body surface area—it's more than 10%—but the other risk factors are longer disease duration, which goes to why we need to diagnose it early. The longer you keep the inflammation elevated, the greater the risk. The longer you have it, the more severe the disease, and the more inflammation, that's when you're going to have an even greater risk on top of your already elevated risk. **Dr Warrick Bishop:** So, Fiona, as I'm listening to you, I'm really getting the picture that when you see someone with psoriasis, you're considering—you're really having a red flag go up. Does that mean as you're dealing with these people, you're looking to get those targets even lower? You're looking to get the blood pressure a bit lower, you're looking to implement lifestyle changes just a bit more, you're looking to get that cholesterol down and really not compromise because you know that there's that underlying inflammatory risk that's going to be driving the future event for those individuals? **Fiona Foo:** Agree, I think so. I think you need to be treating them like someone who, you know, you're kind of borderline about whether they should have a cholesterol-lowering medication or not. I think having psoriasis would really kind of push you to say, yes, you need to have lower targets because you're already at this increased risk. Some of the European and American guidelines talk about psoriasis as being something called a risk enhancer. It adds to the risk that, you know, we use these risk calculators, but this adds to the risk above it. Risk calculators that we and general practitioners use may underestimate the risk in psoriasis patients because it's not included in these risk calculators. We need to be adding to their risk, and hence why you should be treating these patients as if they are high risk, as if they have diabetes, for example. These are high-risk patients, and so the blood pressure, the cholesterol, diabetes all needs to be treated to a lower, like, you know, as aggressively as someone who is high risk. And again, like you were mentioning, the lifestyle factors—definitely diet and exercise. Treating that, keeping that weight low is good because obesity is one of these things that, you know, it’s kind of that vicious cycle. They don't exercise, and then they gain weight. Obesity actually makes it worse, and then there's more inflammation and more psoriasis, and the severity increases. It's quite a big loop. **Dr Warrick Bishop:** So as you're dealing with these individuals, which obviously have a skin condition, but it's a total body inflammatory process, as Annika has alluded to, what I'd like to do is just ask you about your thoughts when we think about coronary artery disease, which we know has some components of inflammation. I'm particularly interested if you think about having a low threshold for using some of the medications that we now use in cardiology for reducing cardiovascular risk, which we believe modulate the inflammation process. Now, I'm going to ask you to specifically comment on something like colchicine, which we historically have used for gout, but we know it possibly offers some benefit for coronary artery disease. Then I'm going to ask Annika to talk about the larger or the more holistic approach to management of psoriatic skin and body issues. **Fiona Foo:** So I think, well, technically, the guidelines don't say to use it, particularly just if you have psoriasis. But the guidelines, I guess, are in that space where someone who's had an acute coronary event still has that underlying inflammation. That's where the evidence of colchicine sits to reduce cardiovascular events. In that space, I think definitely the whole anti-inflammatory space, which is what you're alluding to, is that if we can reduce inflammation, you're going to help reduce atherosclerosis progression and reduce further events. So I agree. I think this is a space that definitely colchicine may eventually be something that we may use in these patients. There are those other monoclonal antibodies like canakinumab, you know, that's been shown to reduce inflammation and reduce cardiovascular events. So I think definitely that inflammation is very important that we should be treating, and it's very, very topical. We’ve been doing a lot of that. I think that is why it gets a lot of airplay because you've got all those other autoimmune diseases like rheumatoid arthritis and SLE that all benefit if you reduce the inflammation, reducing the risk. The other thing to say with that is that talking about just a simple one—the statins, you know, apart from cholesterol lowering, they also have that pleiotropic effect of that anti-inflammatory effect. They also see that there are benefits from statins in that anti-inflammatory effect as to why they are also of benefit in people who have plaque or who are at increased risk. **Dr Warrick Bishop:** Yeah, for sure. Look, that's fantastic, Fiona. What I might do is pivot back to Annika. Annika, you touched on managing psoriasis well, which reduces cardiovascular risk. I'd like you to just reiterate that for us. But then can you share with us in broad brush terms the sort of therapies that a consultant dermatologist uses to support someone who's got a diagnosis of psoriasis? **Annika Smith:** Sure. As Fiona alluded to, early intervention with effective therapy is key. One of the concerning things about this elevated cardiovascular risk is that there's a propensity for it to affect those that are young, those with early onset severe disease. From a therapeutic perspective, the treatment space has been completely revolutionized in recent times. I'm really fortunate in 2025 to say we've got remarkable therapies that have the capacity to switch off skin inflammation and improve quality of life. One would infer logically that if we're reducing systemic inflammation, we might also be able to switch off systemic inflammation and perhaps mitigate that cardiovascular risk. As we've already alluded to, there are similar inflammatory pathways that are upregulated in the skin and in the coronary circulation. We would infer that if we're targeting those pathways in the skin, we might also be able to do so in the coronary circulation. Now, at this point in time, it's certainly a focus of ongoing research, and it's a little too premature to infer that our fancy biologic therapies can have a meaningful reduction in cardiovascular events. What we've seen with mechanistic studies, so imaging studies, biomarker studies, and the like, we've seen reduction in inflammation. We've seen reduction in things like non-calcified coronary burden on coronary CT with biologic therapy in particular, which is remarkable and promising. But what we need to demonstrate is meaningful clinical benefit with reduction in cardiovascular events. At this point in the piece, we have an amazing armamentarium—topicals, phototherapy, oral systemics, and biologics—which by far have the greatest capacity to clear skin, which we know is intrinsically linked to improving one's quality of life. We hope with time this might translate to improved systemic inflammatory reduction and cardiovascular disease. I must say, though, as we've already alluded to, in the meantime, a renewed focus and perhaps a return to basics in terms of focusing on cardiovascular prevention, weight reduction or maintenance, as Fiona alluded to, dietary measures, and lifestyle management—essentially improving exercise, alcohol, and smoking reduction. I think here and now, while we're waiting to further establish the benefit of these various therapies, we really need to focus on getting the basics right in this cohort. **Dr Warrick Bishop:** I might jump in there momentarily, Annika. I know the listening audience has a broad interest across medical-related issues, and one of the things I've touched on in the past and had feedback on is the gut microbiome. One of the things that's fascinated me is some of the research and work that's looked at the impact of the gut microbiome and disruption to the gut microbiome and subsequent inflammatory processes within the body. So if someone were presenting with psoriasis, do you talk about specific diet or dietary interventions that might modulate that sort of microbiome-inflammatory combination? Is that an important aspect? **Annika Smith:** Look, it's a really interesting point, and it certainly is raised in conversations when we have discussions about lifestyle management and adjuncts to improve disease control or even response to therapy. In terms of where the evidence lies, there is certainly evidence for promoting adherence to a Mediterranean diet with inflammatory skin disease. That's a conversation I have with my patients often—what that consists of, how it might be beneficial to their skin control and management. Fiona's already alluded to it, but I've got to mention it again: maintaining a healthy weight and BMI is critical. We know that elevated BMI drives disease severity, but it also affects your response to treatment. Patients respond better to their biologic and advanced systemic therapies when they have a healthy weight. We have additional adjuncts in the therapeutic space to assist with that now. But getting back to your point about gut microbiome, there's still so much for us to unravel on this front when it comes to the interplay of this with chronic inflammatory skin disease. No doubt it plays a part. Yes, we certainly talk about all the things you can do from a dietary perspective to boost a healthy gut microbiome. But in terms of evidence base, it really rests on the Mediterranean diet, along with all the other lifestyle adjuncts that are helpful for both heart health and skin health. **Dr Warrick Bishop:** Sure. I'll just jump in with a case of a patient who actually, she was diagnosed with psoriasis. I said, "Oh, how does she manage it?" She said, "I managed it with diet." She actually changed, looked into different things, and particularly the Mediterranean diet. Yeah, she hasn't had an issue since. It was quite fascinating. Yeah, she just changed her diet. So yeah, I agree with the Mediterranean diet. It's certainly an interesting space. I mean, I've got a little bit of an interest in it, but anecdotally, I've given people omega-3 fish oils for ventricular ectopic beats or raised triglycerides, and those individuals have reported improvement in their arthritis and improvement in their inflammatory bowel disease. So there's certainly interplay, and it's a very interesting space. Look, I think we're coming close to the end of our long 10 to 15 minutes. It's an absolutely fascinating area. Fiona, is there anything in particular you want to add about how, over and above, how you bring a greater intensity to your cardiovascular risk in this cohort of people? Is there anything specific you'd like to flag before we wrap up? **Fiona Foo:** I think the main thing is that people need to be aware that they are at increased risk. They see the psoriasis as a skin condition, but they don't realize that actually it does affect your cardiovascular risk. I think it's making sure that patients, but also general practitioners, even cardiologists, dermatologists—we all need to work together to realize they are at increased risk, but also measuring and checking their risk. We can have a whole conversation about how we check; we need to know the numbers—the cholesterol, the blood pressure, their weight, their sugar levels—and then how do we reduce that risk? I think that's important. But I think firstly emphasizing the lifestyle factors because it does affect both your cardiovascular risk as well as your risk of severity of psoriasis. So I think, yeah, that would be our take-home message: really just to increase that awareness because it's such a common condition. **Dr Warrick Bishop:** Yeah, 100%. You know, and I didn't even know about this risk until I started working with Annika about it. Then you see it all the time in the patients. **Annika Smith:** Are there any take-home messages you'd like to leave the listeners with before we look to wrap up? **Annika Smith:** Look, I'd certainly echo Fiona's comments about awareness—not from an ominous perspective. We don't want people walking away feeling scared or burdened by this increased risk, but really to promote taking a proactive role in one's health. When you know, then you can seek intervention early and engage the right professionals. From a dermatological perspective, I think as I alluded to before, I'd really like to highlight that early diagnosis and effective treatment is key, as we know, not just for skin benefits but for related health benefits, namely the heart. The most important cause of excess mortality in this cohort is due to heart disease, and I think that's a really important point to take home. It's important for patients here and now to know that they deserve to have clear skin and optimal quality of life. In 2025, they absolutely should be able to achieve this. So seeking specialist intervention early is key. **Dr Warrick Bishop:** Yeah, fantastic. Look, my own takeaways, and I'm not across psoriasis. Of course, I deal with the occasional person, but it's really being brought onto my radar by both of you today and sharing with you today. Realising that 2% to 4% of the population can be impacted, that many people don't get diagnosed early—this is super important. Understanding that psoriasis is not just the skin; it's the entire body. Understanding that really good therapy, not only, as you said, Annika, improves quality of life based on the skin-related issues but reduces cardiovascular risk into the future. I think there's some really valuable take-homes here, and I'm so grateful to both of you for taking your valuable time and sharing this valuable information. Annika, thank you once more for joining me. It's been a pleasure. **Annika Smith:** Thank you. **Fiona Foo:** Thank you. Always a pleasure. **Dr Warrick Bishop:** Yeah, thank you again for sharing. I'm really deeply grateful for the time you've given. For those listening, I hope you got as much out of this particular podcast as I did. It was an absolute pleasure to share. As always, if you've got any queries or questions, drop us a note. I really do appreciate people tuning in and listening. For now, I'm going to sign off. I also say goodbye and hope you live as well as possible for as long as possible. Till next time. Bye for now. Did you know that coronary artery disease kills one in four people? So most of us are likely to carry some risk or know someone who does. If you're interested in finding out more about how to evaluate that risk, check out www.virtualheartcheck.com.au. It'll give you information about risk and what else can be done to be even more precise.