Alcohol consumption is a modifiable risk factor in psoriasis, with various studies showing links between the level of alcohol intake and psoriasis severity, treatment response, and the risk of developing comorbid conditions including arthritis, liver disease, heart disease, and cancer.1

In a 2020 study of 146 patients with chronic plaque psoriasis, Mahajan et al investigated the association between disease severity and scores on the Alcohol Use Disorders Identification Test (AUDIT). The results demonstrated more severe psoriasis in patients with AUDIT scores greater than 8 (indicating harmful levels of alcohol use) compared with patients with scores less than 8 (P <.05).2

In a multicenter, prospective cohort study published in the British Journal of Dermatology in 2021, Iskandar et al examined the relationship between alcohol misuse as indicated by scores on the Cut down, Annoyed, Guilty, Eye-Opener (CAGE) questionnaire and treatment response as assessed by change in scores on the Psoriasis Area and Severity Index (PASI) in 266 patients with psoriasis.3

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The findings demonstrated a significant association between higher CAGE scores and poor treatment response, with a regression coefficient of 1.40 (95% CI, 0.04-2.77) for each 1-point increase in CAGE scores. Accordingly, the authors noted that a maximum change in CAGE score from 0 to 4 would be associated with a PASI score change of 5.60 (95% CI, 0.16-11.08).3

In terms of alcohol use as a causative factor contributing to psoriasis onset, a 2022 Mendelian randomization study also published in the British Journal of Dermatology revealed no causal link between alcohol consumption and the risk of developing psoriasis. The findings of the study did, however, demonstrate a causal association between smoking and the risk of developing psoriasis.4

In addition to the risks of increased psoriasis severity and poor treatment response with high alcohol intake, liver health is an issue requiring consideration among patients with psoriasis in general, and alcohol use may complicate its management.

“Patients with psoriasis appear to be uniquely susceptible to developing serious liver disease such as cirrhosis,” according to Joel M. Gelfand, MD, MSCE, FAAD, who is the James J. Leyden Professor of Dermatology and Epidemiology, vice chair for clinical research in dermatology, and director of the Psoriasis and Phototherapy Treatment Center at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.

Research suggests an especially high risk of liver disease in patients with psoriasis treated with certain therapies. “In a large study of nearly 200,000 patients with psoriasis from the United Kingdom, we found that those who required treatment with systemic therapy or phototherapy were 2.6-times more likely to develop cirrhosis, and the risk of liver disease directly increased as the body surface area affected by psoriasis increased,” Dr Gelfand said.5

The findings further revealed a higher risk of liver disease in patients with psoriasis compared with those with rheumatoid arthritis, as reported in another population-based cohort study by Dr Gelfand and colleagues in which patients with psoriasis treated with methotrexate were 1.6- to 3.4-times more likely to develop liver disease compared with patients with rheumatoid arthritis receiving treatment with methotrexate.5,6

“Taken together, these studies validate the long-held concept of the ‘psoriatic liver,’” Dr Gelfand remarked.

Dr Gelfand is a coauthor of the current joint guidelines by the American Academy of Dermatology and the National Psoriasis Foundation regarding the use of systemic nonbiologic therapies in psoriasis management, which no longer recommend routine liver biopsy for monitoring hepatoxicity in patients with psoriasis treated with methotrexate.7

“There has been substantial progress in the ability to identify liver damage noninvasively with blood and imaging tests before any clinically important liver injury occurs,” Dr Gelfand explained. “Commercial blood tests such as FibroSure® — which should be done fasting overnight — and a liver elastography ultrasound such as FibroScan® are highly sensitive for identifying fibrosis, but false positives can occur with blood tests, so imaging tests are also indicated.”

Given the elevated risk of liver disease in patients with psoriasis and the potential impact of heavy alcohol use on psoriasis severity and treatment outcomes, dermatologists should be prepared to address these issues in clinical practice.

Steven Daveluy MD, FAAD, associate professor and program director of dermatology at Wayne State University School of Medicine in Detroit and president of the Michigan Dermatological Society, provides insight into the alcohol-psoriasis connection, as well as recommendations for broaching the topic with patients.

What does the evidence suggest about associations between alcohol use and psoriasis risk and severity? 

Many studies have demonstrated a connection between psoriasis and alcohol use. Patients with psoriasis are more likely to report an alcohol problem, with approximately one-third reporting an issue with use, and patients with excess alcohol consumption are also more likely to have psoriasis. The prevalence of psoriasis is approximately 2% in the general population and 15% in patients with alcoholic liver disease.1

A systematic review published in 2013 in the Journal of the European Academy of Dermatology and Venereology demonstrated an increased risk of developing psoriasis in patients who consume more alcohol, with 2- to 3-times increased odds.8 Some studies have failed to show an increased risk, although this finding may be influenced by the population being studied and their genetic susceptibility for psoriasis and alcohol metabolism.

Increased alcohol consumption has been correlated with increased psoriasis severity in several studies.1,2

We don’t know the underlying causes of the relationship between psoriasis and alcohol misuse. Psoriasis can have a profound impact on psychological health and quality of life. Patients with psoriasis who describe the condition as having a greater impact on their quality of life are at greater risk of alcohol misuse. Alcohol consumption in patients with psoriasis has been linked to alexithymia [reduced ability to recognize and describe one’s emotions], anxiety, and worry.1

How does alcohol affect the response to systemic therapies in psoriasis?    

Alcohol affects the skin by driving inflammation and keratinocyte proliferation. After consuming alcohol, ethanol can be detected in the skin, which promotes keratinocyte proliferation. This means psoriasis plaques will be thicker. Alcohol also activates proinflammatory cytokine pathways — including the Th17 pathway — that are critical in the pathogenesis of psoriasis.9,1

Alcohol can also decrease the efficacy of systemic treatments and increase the risk of biologic failure in patients with psoriasis. However, we don’t fully understand why alcohol can make therapies less effective. In 1 study that showed systemic therapies were less effective in patients with alcohol misuse, alcohol use did not have an impact on treatment adherence, so it appears to be a biological effect.3 The proinflammatory effects of alcohol may be responsible.

What are implications for dermatologists in terms of screening for alcohol misuse among their patients with psoriasis, and which screening tools should they use?

Patients with psoriasis are at increased risk for alcohol-related death with a hazard ratio of 1.58; this is mostly related to liver disease and a smaller portion to mental health disorders.1 Psoriasis is associated with comorbidities that can also have increased risks associated with alcohol misuse, such as psoriatic arthritis, cardiovascular disease, and liver disease. That’s why it’s important for dermatologists to screen patients with psoriasis for alcohol misuse, and it is recommended in the North American and European guidelines for psoriasis management.1

Three screening tools have been validated in psoriasis and are recommended for use.1

  • The CAGE questionnaire asks 4 questions: Have you ever felt the need to cut down on your drinking? Have you felt annoyed by criticism of your drinking? Have you had bad or guilty feelings about drinking? Have you ever taken a morning eye-opener drink? If a patient answers yes to 2 or more questions, there’s a sensitivity of 93% and specificity of 76% for problem alcohol use.
  • The AUDIT has a concise version with 3 questions, the AUDIT-Concise (AUDIT-C), or a full version with 10 questions, and it stratifies patients into low, medium, or high risk for alcohol use disorder.
  • The Michigan Alcohol Screening Test (MAST) is a bit more cumbersome, with 25 questions to assess alcohol misuse and dependency.

These tools have not been compared in patients with psoriasis specifically, but in the general population the AUDIT, which was created by the World Health Organization, has demonstrated superiority.

What are recommendations regarding intervention and referral to substance use disorder treatment?  

Kearny and Kirby recommended a nice algorithm for addressing alcohol use in patients with psoriasis.1 First, ask all patients with psoriasis about their alcohol intake. The Centers for Disease Control and Prevention (CDC) recommend a limit of 2 or fewer drinks per day for men and 1 or fewer for women.10 If patients do not consume alcohol, they should be encouraged to continue abstinence. If they drink within the limit established by the CDC, they should be encouraged to minimize alcohol consumption. If they drink above the limit, clinicians should administer the 3-question AUDIT-C tool.

If patients score less than 5 on the AUDIT-C, they should be encouraged to minimize alcohol intake. If they score higher than 5, clinicians should then administer the full AUDIT tool. Patients can be encouraged to minimize alcohol consumption (AUDIT score <7), clinicians can perform a brief intervention (8-15), patients can be advised to consider counseling (16-19), or clinicians can refer patients to specialist services (>20).

A brief intervention takes about a minute and is a simple yet effective tool. It should include a discussion of the impact that alcohol misuse can have on a patient’s psoriasis, such as by increasing severity, making treatment more difficult, and increasing risks from comorbidities.  

When a clinician is thinking about incorporating this screening into clinical practice, it is important to remember that it doesn’t have to be all or nothing. You can start small and then expand once you’re more comfortable, perhaps by starting with a goal of screening 1 or 2 patients per day. With experience, you’ll become skilled and comfortable, and screening and counseling will become second nature. 

Clinicians can also look for ways to incorporate screening into their workflow. For example, medical assistants can ask about alcohol consumption when first encountering a patient and then administer the AUDIT-C tool when appropriate. The responses will be ready when you enter the room to see the patient.

For referral, it is helpful to know the services available in your area for alcohol treatment; this may include primary care providers, mental health services, Alcoholics Anonymous, and inpatient services.

What are key remaining needs in terms of clinician education and research regarding the link between psoriasis and alcohol use?

Studies of dermatologists have shown that the majority recognize our responsibility for screening, but just above one-half feel responsible for counseling.1 Many dermatologists feel a need for more training on motivational interventions. Raising awareness among dermatologists, while also equipping them with practical measures they can enact, will help to improve screening and treatment of alcohol problems among their patients.

In terms of research, studies that evaluate alcohol reduction and cessation interventions among patients with psoriasis are lacking. We know that the problem exists, but we haven’t yet identified the best solution. We are drawing from the literature for the general population, which likely applies to patients with psoriasis. However, there may be other strategies that have the potential to be particularly effective for individuals with psoriasis, and this would be a huge asset for our patients.

This article originally appeared on Dermatology Advisor