Differential risks of psoriatic arthritis development in patients with varied psoriasis manifestations: a sex- and ethnicity-specific analysis

Abstract

Objectives: This study investigated psoriatic arthritis (PsA) risk across varied psoriasis manifestations, considering sex and ethnicity.

Methods: Using TriNetX, a federated database encompassing over 120 million electronic health records (EHRs), we performed global retrospective cohort studies. Psoriasis vulgaris (Pso), pustulosis palmoplantaris (PPP), and generalized pustular psoriasis (GPP) cohorts were retrieved using ICD-10 codes. Propensity score matching, incorporating age, sex, and ethnicity, was employed. An alternative propensity matching model additionally included established PsA risk factors.

Results: We retrieved data from 486 (Black or African American-stratified, GPP) to 35,281 (Pso) EHRs from the US Collaborative Network. Significant PsA risk variations emerged: Pso carried the highest risk [hazard ratio (HR) 87.7, confidence interval (CI) 63.4-121.1, p < 0.001], followed by GPP (HR 26.8, CI 6.5-110.1, p < 0.0001), and PPP (HR 15.3, CI 7.9-29.5, p < 0.0001). Moreover, we identified significant sex- and ethnicity-specific disparities in PsA development. For instance, compared to male Pso patients, female Pso patients had an elevated PsA risk (HR 1.1, CI 1.1-1.2, p = 0.002). Furthermore, White Pso patients had a higher likelihood of developing PsA compared to their Black or African American counterparts (HR 1.3, CI 1.04-1.7, p = 0.0244). We validated key findings using alternative propensity matching strategies and independent databases.

Conclusion: This study delineates nuanced PsA risk profiles across psoriasis forms, highlighting the pivotal roles of sex and ethnicity. Integrating these factors into PsA risk assessments enables tailored monitoring and interventions, potentially impacting psoriasis patient care quality.

Keywords: TriNetX; arthritis; cohort study; psoriasis; psoriatic arthritis; pustular psoriasis; pustulosis palmoplantaris; risk.

Figure 1

Study flow chart. The aim of this study was to assess the risk of developing psoriatic arthritis among patients diagnosed with psoriasis vulgaris (Pso), pustulosis palmoplantaris (PPP), and generalized pustular psoriasis (GPP). This analysis includes subgroup stratification based on sex and ethnicity. For this, electronic health records (EHRs) indicative of Pso, PPP, and GPP were retrieved from the US Collaborative Network of TriNetX. For each patient cohort, an equally sized, propensity matched control cohort was built. We used two alternative strategies for propensity matching. In Model 1, matching was based on age, sex, and ethnicity, while in Model 2, risk factors for psoriatic arthritis were additionally considered. (A) In the initial analysis, the risk to develop psoriatic arthritis was contrasted between each matching case and control group. Subsequently two analyses were performed in parallel. (B) To investigate potential variations in the risk of developing psoriatic arthritis across different clinical presentations of psoriasis, we conducted a comparative analysis between Pso, PPP, and GPP. (C) To validate our findings, the analyses assessing the risk of developing psoriatic arthritis among patients diagnosed with Pso, PPP, and GPP was repeated in two independent Collaborative Networks within TriNetX, namely EMEA and LATAM.

Figure 2

Risk of developing psoriatic arthritis in psoriasis vulgaris, pustulosis palmoplantaris or generalized pustular psoriasis. We assessed the risk of developing psoriatic arthritis within patient cohorts diagnosed with psoriasis vulgaris (Pso), pustulosis palmoplantaris (PPP), or generalized pustular psoriasis (GPP), comparing them to corresponding control groups without any form of psoriasis using electronic health records from the US Collaborative Network of TriNetX. Propensity matching in the initial analysis was confined to age, sex, and ethnicity to allow for better comparability. (A) We document an elevated risk of psoriatic arthritis following Pso, PPP, or GPP diagnosis. Diamonds represent hazard ratio (HR) and error bars correspond to the 95% confidence interval (CI). Only significant results are displayed. (B–D) Nelson–Aalen plots contrast the risk of psoriatic arthritis of (B). Pso (HR 87.7, CI 63.4–121.1, p < 0.0001), (C) PPP (HR 15.3, CI 7.9–29.5, p < 0.0001), and (D) GPP (HR 26.8, CI 6.5–110.1, p < 0.0001) to that of the appropriate controls. Solid lines represent the HR and lighter shaded areas represent the CI. (E) To address the potential bias introduced by known risk factors for psoriatic arthritis, they were considered for propensity matching. Again, all psoriasis manifestations demonstrated consistent associations with increased psoriatic arthritis risk. Pso maintained the highest risk (HR 84.1, CI 61.8–114.3, p < 0.0001), while PPP and GPP displayed substantial risk elevations, with HRs of 8.7 (CI 4.8–15.8, p < 0.0001) and 258.8 (CI 7.0–1,118, p < 0.0001), respectively. (F) To directly compare PsA risks among different psoriasis manifestations, we contrasted this risk between patients with Pso-PPP, Pso-GPP and GPP-PPP. Here, Pso demonstrated a significantly greater risk of developing psoriatic arthritis compared to those with PPP (HR 5.7, CI 4.5–7.1, p < 0.0001) and GPP (HR 2.3, CI 1.7–3.2, p < 0.0001). In comparison to PPP, we documented a greater risk of psoriatic arthritis development in individuals with GPP (HR 1.9, CI 1.2–3.1, p = 0,0042).

Figure 3

Sex-specific risks for the development of psoriatic arthritis following a diagnosis of psoriasis vulgaris, pustulosis palmoplantaris or generalized pustular psoriasis. We assessed the risk of developing psoriatic arthritis within sex-stratified (female or male) patient cohorts diagnosed with psoriasis vulgaris (Pso), pustulosis palmoplantaris (PPP), or generalized pustular psoriasis (GPP), comparing them to corresponding control groups without any form of psoriasis using electronic health records from the US Collaborative Network of TriNetX. Propensity matching in the initial analysis was confined to age and ethnicity to allow for better comparability. (A) We document an elevated risk of psoriatic arthritis following Pso, PPP, or GPP diagnosis in both female (red) and male (blue) patients. Diamonds represent hazard ratio (HR) and error bars correspond to the 95% confidence interval (CI). Only significant results are displayed. (B) The Nelson–Aalen plot contrasts the risk of psoriatic arthritis in female (red) and male (blue) Pso patients. Compared to male Pso patients, the risk of psoriatic arthritis in their female counterparts is significantly greater (HR 1.1, CI 1.1–1.2, p = 0.002). Solid lines represent the HR and lighter shaded areas represent the CI.

Figure 4

Ethnicity-specific risks for the development of psoriatic arthritis following a diagnosis of psoriasis vulgaris, pustulosis palmoplantaris or generalized pustular psoriasis. We assessed the risk of developing psoriatic arthritis within ethnicity-stratified (Black or African American/White) patient cohorts diagnosed with psoriasis vulgaris (Pso), pustulosis palmoplantaris (PPP), or generalized pustular psoriasis (GPP), comparing them to corresponding control groups without any form of psoriasis using electronic health records from the US Collaborative Network of TriNetX. Propensity matching in the initial analysis was confined to age and sex to allow for better comparability. (A) We document an elevated risk of psoriatic arthritis following Pso, PPP, or GPP diagnosis in both Black or African American (blue) and White (red) patients. Diamonds represent hazard ratio (HR) and error bars correspond to the 95% confidence interval (CI). Only significant results are displayed. (B) The Nelson–Aalen plot contrasts the risk of psoriatic arthritis in Black or African American (red) and White (blue) Pso patients. Compared to Black or African American Pso patients, the risk of psoriatic arthritis in their White counterparts is significantly greater (HR 1.3, CI 1.1–3.2, p = 0.024). Solid lines represent the HR and lighter shaded areas represent the CI.