more than 2000 years ago , psoriasis was considered to be a form of leprosy . ferdinand von hebra used the term  psoriasis .  in the 1960s , psoriasis was described as a disease of epidermal proliferation , and in the 1980s as a disease of the immune system . today patients with psoriasis are at increased risk of developing diabetes , hypertension , hyperlipidemia , obesity , and smoking , which are known cardiovascular risk factors . it is believed that psoriasis constitutes an independent risk for developing myocardial infarction and stroke , particularly in young patients and those with severe disease . patients with severe psoriasis on average die about five years younger than those without the disease . elevated levels of inflammatory biomarkers , vascular endothelial growth factor ( vegf ) , c - reactive protein , and p - selectin have been described in severe psoriasis . further , it has been hypothesized that psoriatic systemic inflammation causes insulin resistance that triggers endothelial cell dysfunction , atherosclerosis , and myocardial infarction or stroke . although this  psoriatic march  needs further confirmation , its import for sufferers of the disease can not be overlooked . it would seem logical to screen and follow up patients with severe psoriasis for cardiovascular events . even those with a borderline risk profile must receive a physician 's evaluation , mindful of their inflammatory psoriatic burden , . considering the chronic nature of psoriasis and the ensuing cardiovascular risk , timely manipulation of psoriatic inflammation could avert both mortality and morbidity . it is reasonable to speculate that certain antipsoriatic drugs may be more potent to check relapses and stop the progression of comorbidities than others , depending on their mode of action . tnf - alpha seems to be a particularly attractive target as it is known to induce endothelial cell dysfunction and atherosclerosis . a retrospective study of the tnf - alpha blocking drug , etanercept , in psoriasis documented a reduction of c - reactive protein as a biomarker for cardiovascular risk . there is some evidence that il-12/il-23 targeted by ustekinumab may also play a role in attenuation of atherosclerosis . in a recent study , major cardiovascular event rates among ustekinumab - treated patients with psoriasis were found to be lower than similar estimates from the general population . biologic drugs could thus be effective in limiting both cutaneous and systemic impact of psoriasis . in the context of the metabolic syndrome amelioration of chronic systemic inflammation of psoriasis , however , demands continuous immunosuppression for which traditional systemic drugs may be better suited . in general , methotrexate ( mtx ) , acitretin , cyclosporine , and others have been available for far longer than biologics ( mtx was approved for psoriasis in 1971 ) , with toxicity profiles that are well known . traditional systemic agents are given orally ( mtx may also be given by injection ) and are also less expensive than injectable biologic agents . a large retrospective analysis concluded that continuous systemic therapy with mtx for psoriasis also reduced risk for myocardial infarction . recent evidence suggests that diabetes risk is mitigated in patients with psoriasis on disease - modifying antirheumatic drugs ( dmards ) . a small study on psoriasis patients receiving continuous dose fumaric acid esters documented improvement in endothelial cell function , and hence , cardiovascular risk at 24 weeks . another study documented a 26% reduction in cardiovascular mortality among psoriasis patients receiving more than the mean number of puva treatments suggesting that aggressive treatment of psoriasis might improve health outcomes . it must be borne in mind , however , that acitretin and cyclosporine may aggravate pre existing dyslipidemia or hypertension . intake of statins ( for dyslipidemia ) along with cyclosporine could also lead to rhabdomyolysis and renal failure . for psoriatic arthritis ( psa ) however , because of its propensity to hamper physical function , therapies are shifting from mere interference with its inflammatory response ( traditional systemic drugs ) to abrogation and halting of joint damage ( biologics ) . data on the use of infliximab in psa suggest that therapeutic intervention early in the disease course limits joint destruction . results from the respond trial that investigated an aggressive treatment strategy in early , severe polyarticular psa indicate that patients receiving a combination of infliximab and mtx showed more profound levels of disease suppression than infliximab alone , lending weight to a  hit early and hard against a background of systemic inflammation , clinical metrics alone ( psoriasis area severity index ( pasi)/american college of rheumatology ( acr ) criteria ) may not be enough for gauging disease severity and response to treatment . inflammatory markers , particularly , p - selectin , c - reactive protein and to a lesser extent , fibrinogen and esr , have been shown to be useful in this regard . a combination of selected inflammatory markers and pasi might reflect the inflammatory status in psoriasis more accurately than each one separately . severe psoriasis needs to be managed as a systemic disease with likely comorbidities . early systemic therapy continued in effective dosage will check disease progression and conceivably prevent cardiovascular events , thus maximizing treatment outcomes .
psoriasis is increasingly considered a systemic disease with comorbidities . 
 there is sufficient evidence that systemic inflammation lies at the heart of these developments . considering the chronic nature of psoriasis and its comorbidities , timely manipulation of systemic inflammation 
 could avert both mortality and morbidity . 
 data from retrospective studies suggest that aggressive treatment of psoriasis with traditional systemic agents and/or biologic drugs improves health outcomes . to maximize treatment outcomes , severe psoriasis needs to be managed as a systemic disease with likely comorbidities .