Elsevier

Clinics in Dermatology

Volume 28, Issue 1, January–February 2010, Pages 88-92
Clinics in Dermatology

Malignancy concerns with psoriasis treatments using phototherapy, methotrexate, cyclosporin, and biologics: facts and controversies

https://doi.org/10.1016/j.clindermatol.2009.03.003Get rights and content

Abstract

Cancer is one of the several comorbidities that have been linked with psoriasis. Not surprisingly, tumors associated with well-documented risk factors for the dermatosis, such as smoking and obesity, have been found with increased incidence in psoriatic patients. They include lung, kidney, and colon cancers. For unknown reasons, the risk of lymphoma is also increased in psoriatic patients. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. The best-documented association is nonmelanoma skin cancer with psoralen plus ultraviolet A therapy and cyclosporin. More recently, an increased risk of cancer has been a concern with newly introduced biologic agents. The documentation of such a purported increased risk requires long-term follow-up of treated patients.

Section snippets

The risk of cancer in psoriasis: the issue of comorbidities

Cancer is one of several comorbidities that have been linked with psoriasis. Before discussing the available data, some methodologic difficulties involved when studying cancer association should be considered. The first is related to the overall rarity of most cancers. The incidence of cancer is usually much less than a few cases per 10,000 people/year; hence, a large sample of patients should be recruited and followed up prospectively to document associations in a reliable way. A further

Cancer and treatment for psoriasis: methodologic challenges

Psoriasis is a chronic, recurrent disease. Continuous or rotational treatment is usually required to maintain clearance, and relapse is a regular feature once treatment is stopped. Timing of exposure, its duration, the cumulative dose, interaction with other carcinogens or predisposing factors, and latency are all factors to consider when assessing the relation between a purported causative factor such as treatment for psoriasis and cancer. The same methodologic difficulties when dealing with

Treatment-specific cancer risks in psoriasis

Despite the several difficulties that have been mentioned, enough evidence to guide clinical decisions has been accumulated in the last few decades about the relation between selected cancer types and specific treatments for psoriasis. Not surprisingly, in view of its highest incidence rates, the most reliable data concern nonmelanoma skin cancer (NMSC). A large body of evidence indicates that individuals with a personal history of NMSC, especially in younger age groups, have an increased risk

Biologic agents

The biologic agents are a heterogenous group of naturally occurring molecules, mainly proteins, engineered in the laboratory for pharmaceutical use. Because they are processed by the same pathways as naturally occurring proteins in the human body, in principle, biologic agents are expected to offer a better safety margin than most synthetic small molecules. They can also induce a variety of adverse events related with immunotoxic effects. Infections and cancer are the main possible consequences

Conclusions

Because no standard therapeutic approach exists for patients with moderate to severe psoriasis, the benefits and risks of phototherapy or systemic therapy must be weighed carefully for each patient and treatment individualized accordingly. Considering that psoriasis is a lifelong disease, the patient's lifetime cumulative exposure to these agents must be taken into consideration, and cancer risk should be a concern, especially in patients already at higher risk for developing it, such as

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