Psoriasis (PsO) is a chronic immune-mediated inflammatory disease with significant social and economic impact and well-established systemic involvement. Increasing evidence supports the concept that psoriasis represents a multisystem disorder rather than a condition limited to the skin.^[1]

Psoriasis is classified into two clinical types: type 1, which appears before the age of 40 and is frequently associated with a positive family history and more severe disease, and type 2, which appears after the age of 40 and is typically associated with a lower familial predisposition and more comorbidities.

In recent years, psoriasis has been increasingly associated with metabolic syndrome (MetS).^[2,3] This association is clinically relevant, as both conditions share common inflammatory pathways, particularly involving the IL-17/IL-23 and TNF-α axes.^[4,5]

The prevalence of metabolic comorbidities in patients with psoriasis is significantly higher than that in the general population, ranging from 20% to 65% across different populations.^[6,7] Gospodinov and Gospodinova reported a prevalence of 74% among psoriatic patients, compared with 55% in controls.^[8] Other authors also demonstrated a high frequency of MetS in psoriasis (64.81%) versus 27.5% in control subjects.^[9]

Some studies suggest that women with psoriasis may have a higher risk of developing MetS than men.^[10] These sex differences are thought to be influenced by hormonal, behavioral, and immunological factors.^[11] At the same time, elevated body mass index increases the risk of psoriasis, while chronic inflammation in psoriasis may in turn promote the development of metabolic disorders.^[5,12,13]

The aim of the present study was to evaluate the association between sex, psoriasis type, body mass index, disease severity, and metabolic comorbidities in patients with psoriasis.

The following tasks have been the focus of our research:

The study was carried out at Pleven Medical University’s Department of Dermatology, Venereology, and Allergology. The study included 184 patients with clinically and histologically confirmed psoriasis. Of these, 68 (37%) were women aged 5-78, while 116 (63%) were men aged 18-81.

A retrospective clinical and epidemiological analysis was performed among outpatients with psoriasis examined between July 2023 and August 2024. Data regarding medical history, physical and dermatological examination, laboratory investigations, and treatment were recorded using a standardized registration form.

Psoriasis was classified into two types: type 1 (early onset before 40 years of age) and type 2 (late onset at or after 40 years of age).^[14]

Body mass index was calculated using the formula: weight (kg) divided by height (m) squared, with patients grouped according to BMI into three categories - normal weight (BMI<25), overweight (BMI = 25–30) and obesity (BMI>30).

Data were entered and analyzed using IBM SPSS Statistics version 26.0. A p-value <0.05 was considered statistically significant. Descriptive statistics were used for qualitative and quantitative variables. Correlation, variance, and dispersion analyses, as well as appropriate parametric and nonparametric tests, were applied. Some data were additionally processed using Microsoft Excel. All patients provided written informed consent to participate in the study.

A total of 184 patients with different clinical forms of psoriasis were evaluated. Disease duration ranged from several months to 48 years (mean 13.50±10.93 years). A positive family history was reported by 42 patients (22.8%), psoriatic arthritis was present in 57 patients (31%) and PASI ranged from 1.5 to 54.0 (mean 18.47±11.64).

The demographic and clinical characteristics of the study population are presented in Table 1.

Among the study population, 96 patients (52.2%) had type 1 psoriasis and 88 (47.8%) had type 2 psoriasis. The mean age was 50.14±15.73 years. Women (n=68, 37%) had a mean age of 45.3±17.41 years, whereas men (n=116, 63%) had a mean age of 52.76±14.39 years. Early-onset psoriasis was observed in 53 men (28.8%) and 43 women (23.4%), while late-onset psoriasis was found in 63 men (34.2%) and 25 women (13.6%). When analyzed according to sex distribution, women more frequently presented with type 1 psoriasis, whereas men more frequently presented with type 2 psoriasis (χ²=5.289; p=0.021).

BMI ranged from 15.2 to 45.0 (mean 29.99±6.05). Normal BMI was observed in 44 patients (23.9%), overweight in 45 (24.5%) and obesity in 95 (51.6%). A BMI score of ≥25 was present in 82% of men (27.6% overweight, 54.3% obese) and in 66.2% of women (19.1% overweight, 47.1% obese). The difference in overweight/obesity prevalence between sexes was statistically significant (χ²=6.124; p=0.047).

Patients with normal BMI were more frequently observed in type 1 psoriasis (29.2%) than in type 2 (18.2%). The prevalence of overweight was similar in both groups (24% in type 1 and 25% in type 2), whereas obesity was more common in type 2 psoriasis (56.8%) compared to type 1 psoriasis (47%). No significant difference in mean BMI between psoriasis types was found (p=0.086).

No statistically significant association was found between PASI score and BMI. However, BMI showed a weak positive correlation with diabetes (r=0.186; p<0.01) and moderate positive correlations with dyslipidemia (r=0.342; p<0.001) and hypertension (r=0.369; p<0.001).

Multinomial logistic regression analysis demonstrated that, compared with normal-weight patients, hypertension was significantly associated with both overweight (OR=2.22, 95% Cl: 1.19-4.14, p<0.01) and obesity (OR=3.32, 95% Cl: 1.70-6.47; p<0.001). Diabetes was a significant predictor of obesity (OR=3.00, 95% Cl: 1.40-6.43, p<0.01) but not of overweight (p=0.45). Dyslipidemia showed borderline significance for overweight (OR=1.82; p<0.05) and a significant association with obesity (OR=2.46; p<0.03). Psoriasis type was not significantly associated with the BMI category.

These findings confirm that psoriasis is frequently accompanied by components of metabolic syndrome, particularly obesity, supporting the concept of shared inflammatory mechanisms between the two conditions. The data emphasize the importance of active screening of metabolic syndrome in patients with psoriasis, especially in men and in those with late-onset disease, to allow timely cardiovascular risk management.

Based on age at disease onset, 52.2% of patients had type 1 psoriasis and 47.8% had type 2. Among women, type 1 psoriasis was more frequent than type 2 psoriasis, whereas among men, type 2 psoriasis was more frequent than type 1 psoriasis. Although the psoriasis type was not significantly associated with BMI categories, patients with type 2 demonstrated higher rates of overweight and obesity. These findings suggest that late-onset psoriasis may represent a clinical indicator of increased metabolic and cardiovascular risk, particularly in male patients.^[10,14]

Mean PASI scores showed a slight increase with rising BMI, although the differences were not statistically significant. This trend suggests a potential association between higher body mass and greater disease severity. Similar findings were reported by Lara et al., who demonstrated comparable PASI scores in overweight and obese patients, indicating that metabolic screening and intervention should not be restricted to obese individuals alone.^[15,16]

The present study demonstrates a high frequency of metabolic comorbidities among patients with psoriasis. Comparable high rates were reported by Dascălu et al. in Romania (64.82%), whereas lower prevalence has been described in other populations.^[6,9] Such variability may be related to geographic, ethnic, and lifestyle differences.

Central obesity represents a key component of metabolic syndrome and is frequently observed in patients with psoriasis. Abdominal adipose tissue acts as a metabolically active organ that produces leptin, TNF-α, and other proinflammatory cytokines, thereby contributing to systemic inflammation.^[3,17] This chronic inflammatory state is central to the pathogenesis of both psoriasis and metabolic syndrome and involves shared pathways such as the IL-17/IL-23 axis.^[4]

In the present study, men demonstrated higher BMI values than women. This finding contrasts with some reports showing a higher prevalence of metabolic syndrome in women.^[10] Such differences may be explained by variations in hormonal status, lifestyle factors, body fat distribution, and physical activity.

Beyond clinical and metabolic factors, genetic predisposition may also influence psoriasis-associated comorbidities. Dimitrov et al. reported that the rs5918T>C polymorphism in the integrin β3 gene is associated with differences in metabolic comorbidities among Bulgarian patients with psoriasis.^[18]

Clinically, the coexistence of psoriasis and metabolic syndrome represents a significant risk for cardiovascular disease, type 2 diabetes, hepatic steatosis, and reduced response to systemic and biologic therapies.^[19,20]

Our findings support routine screening from metabolic syndrome in patients with psoriasis, particularly in men and in those with type 2 disease. A multidisciplinary approach involving dermatologists, cardiologists, endocrinologists, and dietitians is recommended. Lifestyle interventions, including weight reduction, regular physical activity and balanced nutrition, should be an integral part of patient management.^[7,21]

The present study demonstrates that excess body weight is highly prevalent among patients with psoriasis, affecting 83% of men and 66% of women. Patients with late-onset psoriasis more frequently exhibit overweight or obesity and are at increased risk of hypertension, dyslipidemia and diabetes. The highest risk profile is observed in men with type 2 psoriasis. These findings are consistent with international data and emphasize the importance of early and routine screening for metabolic disorders in patients with psoriasis, particularly in high-risk groups.