European Journal of Cardiovascular Medicine

Psoriasis, a chronic immune-mediated inflammatory disorder, affects about 2-3% of the global population, impacting physical and psychological well-being [1]. While traditionally regarded as a condition confined to the skin and joints, recent research has significantly broadened the scope of psoriasis, establishing it as a systemic inflammatory disease with widespread implications. One of the most concerning comorbidities associated with psoriasis is cardiovascular disease (CVD), a leading cause of global morbidity and mortality [2]. This growing body of evidence challenges our understanding of psoriasis and underscores the need for a multidisciplinary approach to managing this condition. The association between psoriasis and cardiovascular diseases is clinically significant and complex, as these conditions share overlapping inflammatory and immune pathways. This introduction aims to provide a detailed analysis of the relationship between psoriasis and cardiovascular diseases, focusing on the pathogenic mechanisms, risk factors, and clinical implications.

Psoriasis is primarily characterized by an overactive immune response, leading to hyperproliferation of keratinocytes and chronic inflammation, driven by T-helper 1 (Th1) and T-helper 17 (Th17) cells [3]. Cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-17 (IL-17), and interleukin-23 (IL-23) are critical mediators in the pathogenesis of psoriasis, creating a feedback loop that perpetuates inflammation. This systemic inflammatory state is not confined to the skin but extends to various organ systems, leading to an increased risk of comorbid conditions, particularly cardiovascular diseases [4]. The chronic, low-grade systemic inflammation observed in psoriasis patients has been linked to an increased prevalence of cardiovascular events such as myocardial infarction, stroke, and peripheral artery disease. These observations have prompted researchers to investigate the shared mechanisms driving the association between these two seemingly distinct conditions.

Atherosclerosis, the hallmark of cardiovascular diseases, is now recognized as an inflammatory condition in which immune cells and cytokines play a pivotal role in plaque formation and progression [5]. In psoriasis, the elevated levels of systemic inflammatory mediators, including TNF-α, IL-6, and C-reactive protein (CRP), contribute to endothelial dysfunction—a key early event in the development of atherosclerosis. Endothelial dysfunction is characterized by impaired vasodilation, increased vascular permeability, and a pro-thrombotic state, all promoting the formation of atherosclerotic plaques and increasing the risk of cardiovascular events [6]. The inflammation-driven damage to the endothelium observed in psoriasis mirrors the pathophysiological changes in atherosclerosis, suggesting a direct link between these two conditions. Moreover, the Th17 pathway, which is central to the development of psoriasis, has been implicated in promoting vascular inflammation, further accelerating atherosclerotic processes.

Psoriasis-related inflammation also triggers oxidative stress and alters lipid metabolism, both contributing to increased cardiovascular risk [7]. Oxidative stress, driven by reactive oxygen species (ROS) and inflammation, damages the vascular endothelium, further exacerbating the atherosclerotic process. This increases the risk of plaque rupture, thrombosis, and acute cardiovascular events. Therefore, the systemic inflammation seen in psoriasis accelerates the initiation and progression of atherosclerosis and makes cardiovascular events more likely. The association between psoriasis and cardiovascular disease is further compounded by the increased prevalence of metabolic syndrome in psoriasis patients. Metabolic syndrome, characterized by a cluster of risk factors including obesity, hypertension, dyslipidemia, and insulin resistance, is significantly more common in individuals with psoriasis [8]. Each of these components independently elevates the risk of cardiovascular disease, but their co-occurrence in psoriasis patients suggests a compounded effect on cardiovascular risk.

Obesity, particularly central adiposity, is a critical mediator of the psoriasis-CVD relationship. Adipose tissue is now recognized as an active endocrine organ that secretes pro-inflammatory cytokines such as TNF-α and IL-6, exacerbating psoriasis's systemic inflammation [9]. Moreover, obesity increases insulin resistance, dyslipidemia, and hypertension, further amplifying cardiovascular risk. Insulin resistance, a core feature of metabolic syndrome, leads to endothelial dysfunction, increases vascular inflammation, and promotes atherogenesis, thereby linking metabolic syndrome and cardiovascular diseases in psoriasis patients. Consequently, the combination of chronic inflammation and metabolic dysfunction creates a "perfect storm" of cardiovascular risk in individuals with psoriasis.

The relationship between psoriasis and cardiovascular diseases is not solely driven by inflammation and metabolic disturbances. Genetic predispositions also play a crucial role. Genome-wide association studies (GWAS) have identified several shared genetic loci between psoriasis and cardiovascular diseases, including polymorphisms in genes involved in immune regulation and inflammation, such as the IL-12/23 pathway [10]. These shared genetic factors may predispose individuals to both psoriasis and cardiovascular diseases, further strengthening the observed association. Environmental factors, such as smoking, physical inactivity, and stress, also contribute to the heightened cardiovascular risk in psoriasis patients. Smoking, in particular, is a well-established risk factor for both psoriasis and cardiovascular diseases [11]. It exacerbates the systemic inflammation seen in psoriasis and accelerates endothelial dysfunction and atherosclerosis, thereby increasing the risk of cardiovascular events. Similarly, physical inactivity, more common among individuals with psoriasis due to joint pain and psychological distress, contributes to obesity, insulin resistance, and dyslipidemia, further increasing cardiovascular risk.

Given the strong association between psoriasis and cardiovascular diseases, it is essential to adopt a comprehensive approach to managing psoriasis, one that addresses dermatological symptoms and cardiovascular risk factors. While traditional treatments for psoriasis, such as topical therapies and phototherapy, primarily target skin symptoms, they may not sufficiently address the underlying systemic inflammation [12]. On the other hand, biologic therapies targeting specific inflammatory mediators, such as TNF-α inhibitors and IL-17 blockers, have demonstrated efficacy in reducing both psoriasis severity and systemic inflammation, potentially mitigating cardiovascular risk. However, long-term studies are needed to determine the impact of these therapies on cardiovascular outcomes.

In the study, psoriasis is a systemic inflammatory disease with significant cardiovascular implications. Shared inflammatory pathways, genetic predispositions, and traditional cardiovascular risk factors, including metabolic syndrome and environmental influences, drive the association between psoriasis and cardiovascular diseases. The heightened cardiovascular risk observed in psoriasis patients underscores the need for a multidisciplinary approach to psoriasis management, focusing on skin symptoms and mitigating cardiovascular risk. Understanding the complex interplay between psoriasis and cardiovascular diseases is crucial for developing effective treatment strategies that address the disease's dermatological and systemic aspects.

Aims and Objective

This study aims to investigate the relationship between psoriasis and cardiovascular diseases in patients at Hamdard Institute of Medical Sciences and Research. The objective is to assess the prevalence of cardiovascular risk factors among psoriasis patients and analyze the correlation between disease severity and cardiovascular complications.

Study Design

This prospective observational study was conducted at Hamdard Institute of Medical Sciences and Research, New Delhi, from January 2023 to May 2024. A total of 65 psoriasis patients were enrolled based on predefined inclusion criteria. Each patient underwent a thorough clinical evaluation, including a detailed medical history, physical examination, and laboratory tests. Cardiovascular risk factors such as hypertension, dyslipidemia, obesity, and metabolic syndrome were assessed. Psoriasis severity was measured using the Psoriasis Area and Severity Index (PASI).

Inclusion Criteria

Patients aged 18 years or older diagnosed with psoriasis by a dermatologist were eligible for inclusion. Participants must have a confirmed clinical diagnosis of psoriasis based on established diagnostic criteria, with varying degrees of severity. Patients with no prior history of cardiovascular disease but willing to undergo cardiovascular risk assessment were included. Additionally, those who provided informed consent to participate in the study and were available for follow-up during the study period were considered for inclusion.

Exclusion Criteria

Patients with a prior history of cardiovascular diseases, such as myocardial infarction or stroke, were excluded from the study. Individuals with concurrent autoimmune diseases, malignancies, or chronic inflammatory conditions other than psoriasis were excluded. Pregnant or breastfeeding women and patients on long-term systemic medications affecting cardiovascular health, such as corticosteroids or biologics, were not eligible. Those who declined participation or failed to comply with study protocols were also excluded.

Data Collection

Data were collected from 65 psoriasis patients between January 2023 and May 2024 at Hamdard Institute of Medical Sciences and Research. Clinical evaluations, including detailed medical histories, physical examinations, and laboratory tests, were performed to assess cardiovascular risk factors such as hypertension, dyslipidemia, and obesity. Psoriasis severity was measured using the Psoriasis Area and Severity Index (PASI). Electrocardiograms (ECG) and blood tests were conducted to evaluate cardiovascular health. All data were recorded in a structured format and anonymized for analysis.

Data Analysis

Data were analyzed using SPSS version 26. Descriptive statistics, such as means and percentages, were used to summarize the demographic and clinical characteristics of the study population. The prevalence of cardiovascular risk factors among psoriasis patients was calculated. Pearson correlation was used to assess the relationship between psoriasis severity (PASI score) and cardiovascular risk factors. Chi-square tests were conducted to evaluate the association between categorical variables. A p-value of less than 0.05 was considered statistically significant. Multivariate regression analysis was performed to identify independent predictors of cardiovascular risk among psoriasis patients.

Ethical Considerations

Ethical approval for this study was obtained from the Institutional Ethics Committee of Hamdard Institute of Medical Sciences and Research, New Delhi. All participants provided informed written consent before enrollment, ensuring their voluntary participation. Confidentiality and anonymity of patient data were strictly maintained throughout the study. The study adhered to the principles of the Declaration of Helsinki, ensuring participants' safety and well-being. No invasive procedures were performed, and patients had the right to withdraw from the study at any time without consequence.

The study included 65 psoriasis patients, and the results were analyzed to assess the association between psoriasis severity and cardiovascular risk factors. The key findings from the demographic characteristics, psoriasis severity, cardiovascular risk factors, and their statistical relationships are presented in the tables below.

Table 1: Demographic Characteristics

Figure 1: Distribution of patients according to Sex

The mean age in this psoriasis patient cohort was 43.7 years (±12.5). Males constituted 60% of the group (p = 0.031), while smokers made up 43% (p = 0.045). Both gender and smoking status were statistically significant, suggesting higher prevalence among males and smokers, emphasizing the need for targeted cardiovascular risk assessment.

Table 2: Psoriasis Severity (PASI Scores)

Most patients (42%) had moderate psoriasis, while 27% had severe psoriasis. The PASI score showed a significant correlation with cardiovascular risk factors (p = 0.012).

Figure 2: Cardiovascular Risk Factors in Psoriasis Patients

Psoriasis patients exhibit elevated cardiovascular risk factors, with hypertension (40%), dyslipidemia (35%), metabolic syndrome (30%), and obesity (28%) being significant. These conditions are statistically associated with psoriasis, as indicated by their p-values (all <0.05), highlighting the importance of monitoring cardiovascular health in these patients.

Table 3: Association Between PASI Scores and Cardiovascular Risk Factors

Patients with severe psoriasis (PASI > 20) showed the highest prevalence of cardiovascular risk factors, with 67% having hypertension, 55% having dyslipidemia, and 40% suffering from metabolic syndrome. There was a statistically significant correlation between higher PASI scores and cardiovascular risk factors.

Table 4: Prevalence of Cardiovascular Events

Cardiovascular events were observed in 12% of patients, with 8% having suffered myocardial infarction, 5% having a stroke, and 11% reporting angina. These events were more common in patients with severe psoriasis.

Figure 3: Multivariate Analysis for Independent Predictors of Cardiovascular Risk

The analysis shows significant associations between severe Psoriasis Area Severity Index (PASI) scores and cardiovascular risk factors. Severe PASI increases the odds of hypertension (OR 2.5, p = 0.009), hypertension (OR 2.1, p = 0.017), dyslipidemia (OR 1.8, p = 0.023), and obesity (OR 1.5, p = 0.035). These findings highlight the need for cardiovascular monitoring in patients with severe psoriasis.

Table 5: Outcomes of Psoriasis Patients

After treatment and follow-up, 54% of patients improved their PASI scores, significantly reducing disease severity. However, 12% of patients experienced cardiovascular events during the study period. Patients with no improvement in psoriasis severity were at higher risk of experiencing cardiovascular complications.

The most notable finding of our study is the significant correlation between psoriasis severity and cardiovascular risk factors [13,14]. We observed that 69% of psoriasis patients had at least one cardiovascular risk factor, with hypertension (40%) and dyslipidemia (35%) being the most common. These results are in line with existing literature that suggests psoriasis, particularly in its severe form, is associated with increased cardiovascular morbidity and mortality. The underlying pathophysiological mechanisms are believed to involve systemic inflammation, endothelial dysfunction, and immune dysregulation, which are shared between psoriasis and cardiovascular diseases.

Our multivariate analysis identified severe psoriasis, hypertension, and dyslipidemia as independent predictors of cardiovascular risk. These findings are consistent with previous research that highlights the role of systemic inflammation in both the development of atherosclerosis and the exacerbation of cardiovascular risk factors in psoriasis patients [15]. This suggests that the inflammatory pathways involved in psoriasis, including elevated levels of pro-inflammatory cytokines such as TNF-α, IL-6, and IL-17, may contribute to both the severity of the skin disease and the development of cardiovascular complications [16]. These cytokines promote endothelial dysfunction, oxidative stress, and lipid abnormalities, increasing cardiovascular risk in psoriasis patients.

Comparison with Other Studies

Several studies have reported similar findings regarding the relationship between psoriasis and cardiovascular diseases. For instance, a large population-based study by Gelfand et al. reported that patients with severe psoriasis had a 58% higher risk of myocardial infarction compared to the general population [17]. This aligns with our finding that 8% of our study population had a history of myocardial infarction, with the majority of these patients having severe psoriasis (PASI > 20). The slightly lower percentage of myocardial infarction in our study could be attributed to the smaller sample size or differences in population characteristics, such as the relatively younger mean age of 43.7 years compared to other studies. Additionally, regional differences in access to healthcare and lifestyle factors such as diet and physical activity may also contribute to the variation in cardiovascular outcomes between different studies.

In contrast to studies conducted in Western populations, our study found a slightly higher prevalence of hypertension (40%) in psoriasis patients. Studies from Europe and North America have reported hypertension prevalence ranging from 20% to 35% among psoriasis patients. This difference could be due to the unique lifestyle and dietary habits of the Indian population, where high salt intake and lower levels of physical activity are more common, predisposing individuals to higher rates of hypertension [18]. Moreover, genetic factors specific to South Asian populations, such as a higher predisposition to metabolic syndrome and insulin resistance, may also contribute to the increased cardiovascular risk in this group [19].

Our study also identified a significant correlation between PASI scores and metabolic syndrome, with 30% of patients presenting with this condition. This is in line with the findings of Mamizadeh et al., who reported a 30.1% metabolic syndrome prevalence in psoriasis patients [20]. However, our results differ from those of Dhana et al., who found a higher prevalence of 40-50% metabolic syndrome in severe psoriasis cases [21]. The lower prevalence in our study may be due to differences in diagnostic criteria for metabolic syndrome or variations in the study population, including differences in diet, physical activity, and genetic predispositions in the Indian population compared to Western populations.

The observed differences in cardiovascular risk factors between our study and other international studies can be attributed to several factors, including sample size, racial and ethnic variations, and geographical differences in healthcare systems. Our relatively smaller sample size of 65 patients, compared to larger cohort studies, may limit the generalizability of our findings. Larger studies, such as those by Gelfand et al., included thousands of patients, which may allow for more precise estimates of cardiovascular risk in psoriasis patients [22]. Ethnic and genetic factors also play a critical role in the varying prevalence of cardiovascular diseases in psoriasis patients across different populations. South Asians, including Indians, are known to have a higher predisposition to metabolic syndrome, insulin resistance, and central obesity, all of which increase the risk of cardiovascular diseases. This genetic predisposition may explain the higher prevalence of metabolic syndrome and hypertension observed in our study population compared to Western populations. Additionally, lifestyle factors such as dietary patterns (e.g., high carbohydrate and salt intake) and lower levels of physical activity in Indian populations may further contribute to the elevated cardiovascular risk in psoriasis patients in India [23].

Practical Significance and Implications

The findings of our study have significant clinical implications for managing psoriasis patients. Given the strong association between the severity of psoriasis and cardiovascular risk factors, clinicians must adopt a multidisciplinary approach to managing psoriasis. Routine cardiovascular screening, including blood pressure monitoring, lipid profile assessment, and evaluation for metabolic syndrome, should be incorporated into the care of psoriasis patients, particularly those with moderate-to-severe disease. Early identification and management of cardiovascular risk factors may help prevent the onset of cardiovascular events, such as myocardial infarction and stroke, in these patients.

Furthermore, biologic therapies targeting pro-inflammatory cytokines, such as TNF-α inhibitors and IL-17 blockers, have shown promise in reducing both psoriasis severity and systemic inflammation, possibly reducing cardiovascular risk [24]. However, further research is needed to evaluate the long-term impact of these therapies on cardiovascular outcomes. In the meantime, lifestyle interventions, such as promoting smoking cessation, encouraging regular physical activity, and implementing dietary changes, should be part of the comprehensive management plan for psoriasis patients to mitigate cardiovascular risk. Our findings align with the growing body of evidence that highlights the importance of systemic inflammation in the pathogenesis of psoriasis and cardiovascular diseases. Several studies have demonstrated that psoriasis is not merely a skin condition but a systemic inflammatory disease that affects multiple organ systems, including the cardiovascular system [25]. The elevated levels of pro-inflammatory cytokines observed in psoriasis patients contribute to the development of atherosclerosis, endothelial dysfunction, and other cardiovascular complications, as observed in our study and supported by previous research.

Our study reinforces the significant association between psoriasis and cardiovascular diseases, particularly in patients with severe psoriasis. The findings underscore the need for comprehensive cardiovascular risk assessment and management in psoriasis patients to prevent adverse cardiovascular outcomes. The higher prevalence of cardiovascular risk factors observed in our study compared to some Western studies may be due to genetic, ethnic, and lifestyle differences in the Indian population. Given the systemic nature of psoriasis, a multidisciplinary approach that includes dermatological and cardiovascular care is essential to improve the overall health outcomes of psoriasis patients.

The most notable finding of our study is the significant correlation between psoriasis severity and cardiovascular risk factors [13,14]. We observed that 69% of psoriasis patients had at least one cardiovascular risk factor, with hypertension (40%) and dyslipidemia (35%) being the most common. These results are in line with existing literature that suggests psoriasis, particularly in its severe form, is associated with increased cardiovascular morbidity and mortality. The underlying pathophysiological mechanisms are believed to involve systemic inflammation, endothelial dysfunction, and immune dysregulation, which are shared between psoriasis and cardiovascular diseases.

Our multivariate analysis identified severe psoriasis, hypertension, and dyslipidemia as independent predictors of cardiovascular risk. These findings are consistent with previous research that highlights the role of systemic inflammation in both the development of atherosclerosis and the exacerbation of cardiovascular risk factors in psoriasis patients [15]. This suggests that the inflammatory pathways involved in psoriasis, including elevated levels of pro-inflammatory cytokines such as TNF-α, IL-6, and IL-17, may contribute to both the severity of the skin disease and the development of cardiovascular complications [16]. These cytokines promote endothelial dysfunction, oxidative stress, and lipid abnormalities, increasing cardiovascular risk in psoriasis patients.

Comparison with Other Studies

Several studies have reported similar findings regarding the relationship between psoriasis and cardiovascular diseases. For instance, a large population-based study by Gelfand et al. reported that patients with severe psoriasis had a 58% higher risk of myocardial infarction compared to the general population [17]. This aligns with our finding that 8% of our study population had a history of myocardial infarction, with the majority of these patients having severe psoriasis (PASI > 20). The slightly lower percentage of myocardial infarction in our study could be attributed to the smaller sample size or differences in population characteristics, such as the relatively younger mean age of 43.7 years compared to other studies. Additionally, regional differences in access to healthcare and lifestyle factors such as diet and physical activity may also contribute to the variation in cardiovascular outcomes between different studies.

In contrast to studies conducted in Western populations, our study found a slightly higher prevalence of hypertension (40%) in psoriasis patients. Studies from Europe and North America have reported hypertension prevalence ranging from 20% to 35% among psoriasis patients. This difference could be due to the unique lifestyle and dietary habits of the Indian population, where high salt intake and lower levels of physical activity are more common, predisposing individuals to higher rates of hypertension [18]. Moreover, genetic factors specific to South Asian populations, such as a higher predisposition to metabolic syndrome and insulin resistance, may also contribute to the increased cardiovascular risk in this group [19].

Our study also identified a significant correlation between PASI scores and metabolic syndrome, with 30% of patients presenting with this condition. This is in line with the findings of Mamizadeh et al., who reported a 30.1% metabolic syndrome prevalence in psoriasis patients [20]. However, our results differ from those of Dhana et al., who found a higher prevalence of 40-50% metabolic syndrome in severe psoriasis cases [21]. The lower prevalence in our study may be due to differences in diagnostic criteria for metabolic syndrome or variations in the study population, including differences in diet, physical activity, and genetic predispositions in the Indian population compared to Western populations.

The observed differences in cardiovascular risk factors between our study and other international studies can be attributed to several factors, including sample size, racial and ethnic variations, and geographical differences in healthcare systems. Our relatively smaller sample size of 65 patients, compared to larger cohort studies, may limit the generalizability of our findings. Larger studies, such as those by Gelfand et al., included thousands of patients, which may allow for more precise estimates of cardiovascular risk in psoriasis patients [22]. Ethnic and genetic factors also play a critical role in the varying prevalence of cardiovascular diseases in psoriasis patients across different populations. South Asians, including Indians, are known to have a higher predisposition to metabolic syndrome, insulin resistance, and central obesity, all of which increase the risk of cardiovascular diseases. This genetic predisposition may explain the higher prevalence of metabolic syndrome and hypertension observed in our study population compared to Western populations. Additionally, lifestyle factors such as dietary patterns (e.g., high carbohydrate and salt intake) and lower levels of physical activity in Indian populations may further contribute to the elevated cardiovascular risk in psoriasis patients in India [23].

Practical Significance and Implications

The findings of our study have significant clinical implications for managing psoriasis patients. Given the strong association between the severity of psoriasis and cardiovascular risk factors, clinicians must adopt a multidisciplinary approach to managing psoriasis. Routine cardiovascular screening, including blood pressure monitoring, lipid profile assessment, and evaluation for metabolic syndrome, should be incorporated into the care of psoriasis patients, particularly those with moderate-to-severe disease. Early identification and management of cardiovascular risk factors may help prevent the onset of cardiovascular events, such as myocardial infarction and stroke, in these patients.

Furthermore, biologic therapies targeting pro-inflammatory cytokines, such as TNF-α inhibitors and IL-17 blockers, have shown promise in reducing both psoriasis severity and systemic inflammation, possibly reducing cardiovascular risk [24]. However, further research is needed to evaluate the long-term impact of these therapies on cardiovascular outcomes. In the meantime, lifestyle interventions, such as promoting smoking cessation, encouraging regular physical activity, and implementing dietary changes, should be part of the comprehensive management plan for psoriasis patients to mitigate cardiovascular risk. Our findings align with the growing body of evidence that highlights the importance of systemic inflammation in the pathogenesis of psoriasis and cardiovascular diseases. Several studies have demonstrated that psoriasis is not merely a skin condition but a systemic inflammatory disease that affects multiple organ systems, including the cardiovascular system [25]. The elevated levels of pro-inflammatory cytokines observed in psoriasis patients contribute to the development of atherosclerosis, endothelial dysfunction, and other cardiovascular complications, as observed in our study and supported by previous research.

Our study reinforces the significant association between psoriasis and cardiovascular diseases, particularly in patients with severe psoriasis. The findings underscore the need for comprehensive cardiovascular risk assessment and management in psoriasis patients to prevent adverse cardiovascular outcomes. The higher prevalence of cardiovascular risk factors observed in our study compared to some Western studies may be due to genetic, ethnic, and lifestyle differences in the Indian population. Given the systemic nature of psoriasis, a multidisciplinary approach that includes dermatological and cardiovascular care is essential to improve the overall health outcomes of psoriasis patients.

This study confirms a significant association between psoriasis severity and cardiovascular risk factors, particularly hypertension, dyslipidemia, and metabolic syndrome. Patients with severe psoriasis are at a higher risk of cardiovascular events, emphasizing the importance of cardiovascular screening in psoriasis management. The findings underscore the need for a multidisciplinary approach to reduce the burden of comorbidities in psoriasis patients.

Recommendations

• Routine cardiovascular risk assessments should be included in psoriasis management.
• Promote lifestyle modifications like healthy diets and regular exercise.
• Consider biologic therapies that target inflammation for patients with severe psoriasis.

Acknowledgment
We sincerely thank the staff and faculty at Hamdard Institute of Medical Sciences and Research, New Delhi, for their invaluable support throughout this study. We thank the patients who participated in the study for their cooperation. Special thanks to the dermatology and cardiology departments for their assistance in patient assessments and data collection. This research would not have been possible without their contributions.

Funding: No funding sources

Conflict of interest: None declared

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