Health care providers should discuss alcohol use with their patients who present with psoriasis and should consider screening tools and intervention strategies. So, suggest the authors of literature review recently published in the American Journal of Clinical Dermatology.
Among dermatology practitioners, it is widely recognized that patients presenting with psoriasis tend to consume more alcohol than the general population. In addition, alcohol consumption is associated with more severe disease, reduced response to treatment, and increased risk of other conditions such as cardiovascular disease and arthritis.
Authors of this most recent review summarizing relevant literature on psoriasis and alcohol prepared it with the objective of better equipping their clinician colleagues to recognize the linkage of alcohol and psoriasis and more effectively engage patients with useful tools and interventions.
The stress-response cycle
According to the Arthritis Association, psoriasis affects ~7.5 million people in the US, making it the nation’s most prevalent autoimmune disease. Is it more common in women or men? Researchers don’t necessarily agree on the answer, but according to one study in the journal JAMA Dermatology, 3.2% of women in the United States have a formal psoriasis diagnosis versus 2.8% of men.
Almost one-third of patients with psoriasis report difficulties with alcohol. Among patients with alcoholic liver disease, 15% have psoriasis, compared with 2% in the general population. This problem may be related to the psychological distress seen in many patients with psoriasis.
Further, women with psoriasis may face challenges that men don’t. First, the mental health toll of psoriasis may be greater for women than men. According to the National Psoriasis Foundation (NPF), women are more likely than men to feel the stigma of having a visible skin condition, particularly untreated or undertreated individuals who experience frequent flare-ups.
This can cause stress, which can lead to more flare-ups, even absent problem alcohol consumption. Even though psoriasis tends to be more severe in men than in women, research suggests that women with psoriasis are more likely than men to experience depression, and that psoriasis can have a greater impact on women’s quality of life.
Female hormone connections
The female sex hormones estrogen and progesterone may also play a role in psoriasis, although the effect of hormonal changes on psoriasis will differ from patient to patient. Research reveals that estrogen levels on any given day can raise or lower the risk of a flare-up with clinical studies showing a correlation between skin inflammation and hormone levels (Misitzis A et al. 2019).
The dramatic hormonal changes that come with pregnancy appear to have a particular impact on psoriasis, studies indicate (Ceovic R et al. 2013). Many women experience a significant improvement in psoriasis symptoms during pregnancy, when estrogen and progesterone levels rise, and a worsening of psoriasis symptoms after giving birth, when these hormone levels plummet.
Psoriasis in the genital area
According to the NPF, as many as two-thirds of men and women with psoriasis may experience genital psoriasis at some point in their lives. Patients may feel extremely self-conscious if they are experiencing a psoriasis flare-up on or around the vagina, anus, or genital fold area.
“It’s important to properly identify if the skin condition is psoriasis or something else,” states Jennifer Soung, MD, director of clinical research at Southern California Dermatology in Santa Ana, California, and a clinical professor at Harbor-UCLA Medical Center.
“The number one question my patients ask is, ‘Are you sure it’s not a STD?’” Another question her patients ask is, “Can I still have sex?” (The American Academy of Dermatology Association offers useful tips on sex with genital psoriasis here.)
There are 2 forms of psoriasis that can occur in the genital area: plaque psoriasis and inverse psoriasis. Plaque psoriasis often appears on the scalp, knees, elbows, and torso, as well as the genital area. According to the NPF, plaque psoriasis in Caucasian skin can look red, with a scaly, silvery-white buildup of dead skin cells. Among people of color, the plaques may be darker and can range in color from purple to gray to dark brown.
Inverse psoriasis usually occurs in body folds such as the underarms, under breasts, and in the genital area. Symptoms include skin that looks smooth, glossy, and “tight.” Both forms of psoriasis can hurt, itch, or crack.
Health care providers may treat genital psoriasis with topical steroids, generally low-potency formulations for mild-to-moderate cases. Since the skin of the genital area is thin and extremely sensitive, it’s important for patients on topical drugs to contact their provider immediately about any side effects such as pain, bleeding, or stinging, including during urination or defecation. Soung counsels that pregnant patients should apply high-potency topical steroids sparingly or not at all during pregnancy.
If topical steroids aren’t working or are causing side effects, or if the genital psoriasis is severe, referral might be made to dermatologists to consider oral therapies or injectable biologics instead. If patients are pregnant or actively trying to conceive, there is concern is that certain psoriasis drugs could potentially harm a fetus.
Psoriatic arthritis can be more severe in women
The NPF estimates that of the nearly 8 million Americans with psoriasis, a third will develop psoriatic arthritis. While the prevalence of psoriatic arthritis is the same in women and men, some research has shown that the so-called burden of disease is greater for women than men: Women tend to have more disease “activity,” higher levels of joint pain, and lower functional capacity (Gossec L et al. 2022).
Screening tools to start the conversation
Many healthcare providers feel they have a role in screening for alcohol use, but no role in intervention. The review authors suggest that alcohol use be discussed with all patients presenting with psoriasis and encourage them to conduct even a brief intervention. These few quick and easy-to-use screening instruments can help identify disordered alcohol use and have previously been evaluated in patients with psoriasis:
Alcohol Use Disorders Identification Test (AUDIT)
The AUDIT-C version of the questionnaire is a condensed version of the full AUDIT questionnaire, containing just 3 questions intended to quickly identify at-risk drinkers. Patients with higher scores can proceed to the longer version of the AUDIT tool for a more detailed assessment. The AUDIT-C questionnaire was found by the review authors to have the highest reliability among the screening tools, with a sensitivity of 93% and specificity of 94%.
This questionnaire includes 4 questions: have you ever felt the need to cut down on your drinking; felt annoyed by criticism of your drinking; had guilty feelings about drinking; or taken a drink as a morning “eye-opener?” The questionnaire has a sensitivity of 93% and specificity of 76%.
Michigan Alcohol Screening Test (MAST)
Slightly more in-depth, the MAST tool contains 25 questions covering issues related to risk-taking, neglect of responsibilities, and loss of control, while creating a more detailed picture of a patient’s drinking tendencies and behaviors.
Taking just a minute during an outpatient consultation can raise patients awareness of how their drinking may be worsening their skin condition and provide a unique incentive to encourage alcohol reduction.
Read the full review article, “Alcohol and psoriasis for the dermatologist: Know, screen, intervene,” at no cost here.
The contents of this feature are not provided or reviewed by NPWH.