Semaglutide therapy decreases epicardial fat inflammation and improves psoriasis severity in patients affected by abdominal obesity and type-2 diabetes

in Endocrinology, Diabetes & Metabolism Case Reports
Authors:
Alexis Elias Malavazos Endocrinology Unit, Clinical Nutrition and Cardiovascular Prevention Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy
Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milan, Italy

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Chiara Meregalli Endocrinology Unit, Clinical Nutrition and Cardiovascular Prevention Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy

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Fabio Sorrentino Endocrinology Unit, Clinical Nutrition and Cardiovascular Prevention Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy

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Andrea Vignati Endocrinology Unit, Clinical Nutrition and Cardiovascular Prevention Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy

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Carola Dubini Endocrinology Unit, Clinical Nutrition and Cardiovascular Prevention Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy

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Valentina Scravaglieri Endocrinology Unit, Clinical Nutrition and Cardiovascular Prevention Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy

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Sara Basilico Endocrinology Unit, Clinical Nutrition and Cardiovascular Prevention Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy

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Federico Boniardi Endocrinology Unit, Clinical Nutrition and Cardiovascular Prevention Service, IRCCS Policlinico San Donato, San Donato Milanese, Italy

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Pietro Spagnolo Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy

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Piergiorgio Malagoli Unit of Dermatology, IRCCS Policlinico San Donato, San Donato Milanese, Italy

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Paolo Romanelli Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA

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Francesco Secchi Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy

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Gianluca Iacobellis Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Miami, Florida, USA

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Correspondence should be addressed to A E Malavazos; Email: alexis.malavazos@grupposandonato.it
Open access

Summary

Psoriasis is often associated with abdominal obesity and type-2 diabetes (T2D). The inflammatory process in psoriasis can target adipose tissue depots, especially those surrounding the heart and coronary arteries, exposing to an increased risk of cardiovascular diseases. A 50-year-old female patient referred to us for abdominal obesity and T2D, which were not controlled with lifestyle modifications. She had suffered from psoriasis for some years and was treated with guselkumab, without success. Epicardial adipose tissue (EAT) attenuation and pericoronary adipose tissue (PCAT) attenuation for each coronary, defined as mean attenuation expressed in Hounsfield unit (HU), were assessed by routine coronary computed tomography angiography. At baseline, EAT attenuation was −80 HU and PCAT attenuation of the right coronary artery (RCA) was −68 HU, values associated with an increased cardiac mortality risk. Psoriasis area and severity index (PASI) was 12.0, indicating severe psoriasis, while dermatology life quality index (DLQI) was 20, indicating a negative effect on the patient’s life. Semaglutide (starting with 0.25 mg/week for 4 weeks, increased to 0.50 mg/week for 16 weeks, and then to 1 mg/week) was started. After 10 months, semaglutide treatment normalized glycated hemoglobin and induced weight loss, particularly at abdominal level, also followed by a reduction in computed tomography-measured EAT volume. EAT attenuation and PCAT attenuation of RCA decreased, showing an important reduction of 17.5 and 5.9% respectively, compared with baseline. PASI and DLQI decreased by 98.3 and 95% respectively, indicating an improvement in psoriasis skin lesions and an important amelioration of the patient’s quality of life, compared with baseline.

Learning points

  • Psoriasis patients affected by obesity and type-2 diabetes (T2D) are often resistant to biologic therapies.

  • Psoriasis is often associated with abdominal obesity, T2D, and cardiovascular diseases (CVD), given their shared inflammatory properties and pathogenic similarities.

  • Epicardial adipose tissue (EAT) inflammation can cause the distinctive pattern of CVD seen in psoriasis.

  • EAT and pericoronary adipose tissue (PCAT) attenuation, assessed by routine coronary computed tomography angiography (CCTA), can be used as biomarkers of inflammation and allow monitoring of medical anti-inflammatory therapies.

  • The actions of semaglutide to reduce energy intake, improve glycemic control, and produce effective weight loss, particularly at the visceral fat depot level, can diminish adipose tissue dysfunction, reduce EAT attenuation and PCAT attenuation of the right coronary artery (RCA) and concomitantly ameliorate the clinical severity of psoriasis.

  • Semaglutide therapy may be considered in psoriasis patients affected by T2D and abdominal obesity, despite low cardiovascular risk by traditional risk scores, who are resistant to biologic therapies.

Abstract

Summary

Psoriasis is often associated with abdominal obesity and type-2 diabetes (T2D). The inflammatory process in psoriasis can target adipose tissue depots, especially those surrounding the heart and coronary arteries, exposing to an increased risk of cardiovascular diseases. A 50-year-old female patient referred to us for abdominal obesity and T2D, which were not controlled with lifestyle modifications. She had suffered from psoriasis for some years and was treated with guselkumab, without success. Epicardial adipose tissue (EAT) attenuation and pericoronary adipose tissue (PCAT) attenuation for each coronary, defined as mean attenuation expressed in Hounsfield unit (HU), were assessed by routine coronary computed tomography angiography. At baseline, EAT attenuation was −80 HU and PCAT attenuation of the right coronary artery (RCA) was −68 HU, values associated with an increased cardiac mortality risk. Psoriasis area and severity index (PASI) was 12.0, indicating severe psoriasis, while dermatology life quality index (DLQI) was 20, indicating a negative effect on the patient’s life. Semaglutide (starting with 0.25 mg/week for 4 weeks, increased to 0.50 mg/week for 16 weeks, and then to 1 mg/week) was started. After 10 months, semaglutide treatment normalized glycated hemoglobin and induced weight loss, particularly at abdominal level, also followed by a reduction in computed tomography-measured EAT volume. EAT attenuation and PCAT attenuation of RCA decreased, showing an important reduction of 17.5 and 5.9% respectively, compared with baseline. PASI and DLQI decreased by 98.3 and 95% respectively, indicating an improvement in psoriasis skin lesions and an important amelioration of the patient’s quality of life, compared with baseline.

Learning points

  • Psoriasis patients affected by obesity and type-2 diabetes (T2D) are often resistant to biologic therapies.

  • Psoriasis is often associated with abdominal obesity, T2D, and cardiovascular diseases (CVD), given their shared inflammatory properties and pathogenic similarities.

  • Epicardial adipose tissue (EAT) inflammation can cause the distinctive pattern of CVD seen in psoriasis.

  • EAT and pericoronary adipose tissue (PCAT) attenuation, assessed by routine coronary computed tomography angiography (CCTA), can be used as biomarkers of inflammation and allow monitoring of medical anti-inflammatory therapies.

  • The actions of semaglutide to reduce energy intake, improve glycemic control, and produce effective weight loss, particularly at the visceral fat depot level, can diminish adipose tissue dysfunction, reduce EAT attenuation and PCAT attenuation of the right coronary artery (RCA) and concomitantly ameliorate the clinical severity of psoriasis.

  • Semaglutide therapy may be considered in psoriasis patients affected by T2D and abdominal obesity, despite low cardiovascular risk by traditional risk scores, who are resistant to biologic therapies.

Background

Psoriasis is a systemic inflammatory disease affecting many organs besides the skin and has often been associated with abdominal obesity and type-2 diabetes (T2D), diseases characterized by increased local and systemic inflammation (1). Furthermore, psoriasis may be an independent risk factor for cardiovascular disease (CVD) given their shared inflammatory properties and pathogenic similarities (1). The inflammatory process in psoriasis can target adipose tissue depots, especially those surrounding the heart and coronary arteries (2).

Epicardial adipose tissue (EAT) is a unique and multifunctional fat compartment of the heart whose portion immediately contiguous with the adventitial layer of coronary arteries is called pericoronary adipose tissue (PCAT) (3, 4). Under physiological conditions, EAT displays biochemical and thermogenic cardioprotective properties, while, under pathological circumstances, it can locally affect the heart and coronary arteries through vasocrine or paracrine secretion of pro-inflammatory cytokines (3, 4). Due to its distinctive transcriptome and functional proximity to the heart, EAT can play a key role in the development and progression of coronary artery disease (CAD), atrial fibrillation, and heart failure (4).

Patients with psoriasis demonstrate an expansion of EAT mass, which is related to the degree of systemic inflammation and is associated with the presence and severity of CAD (2, 5). Therefore, it has been proposed that measuring EAT may serve as a useful subclinical measure of CVD and a therapeutic target in psoriasis patients (5, 6). Then, EAT inflammation can cause the distinctive pattern of CVD seen in psoriasis (2). Moreover, pro-inflammatory signals, released from EAT adjacent to coronary arteries, contribute to atherogenesis (7, 8, 9, 10). Vascular inflammation can inhibit lipid accumulation in PCAT, which can be assessed as an increase in computed tomography (CT) attenuation of PCAT surrounding the proximal right coronary artery (RCA) using coronary CT angiography (CCTA) (7, 8, 9, 10, 11, 12). Furthermore, increased CT attenuation in the proximal RCA reflects pathophysiological changes in the entire coronary vasculature and improved prediction of cardiac death over plaque features (7, 8, 9, 10, 11, 12, 13, 14).

CT attenuation (a measure of EAT and PCAT density, expressed in Hounsfield units, HU), ranges between −30 HU and −190 HU, where a lower negative means higher density (4, 7, 9, 10, 11, 12, 13, 14). Radiographic fat density is determined by adipocyte hypertrophy, hyperplasia, and fibrosis which oppositely influence fat CT attenuation (4). Hypertrophic and hyperplastic fat depots usually have low density (4, 7, 9, 13). Increased EAT and PCAT attenuation, reported in patients with CAD or severe COVID-19, could be caused by inflammation and fibrosis, mitigating the expected effects of hypertrophic or hyperplastic fat cells on fat CT attenuation (4, 9, 12, 13).

If inflammation was the source of such differences in radiodensity, its reversal may be desirable.

Clinically, EAT, given its rapid metabolism and simple measurability, can be considered a novel therapeutic target, owing to its responsiveness to drugs with pleiotropic and clear beneficial cardiovascular effects such as the glucagon-like peptide 1 receptor (GLP-1R) agonists (4, 15, 16, 17).

Interestingly, in patients affected by obesity and T2D, GLP-1R agonists exert pleiotropic effects related to a reduction of inflammation and improvement of psoriasis severity (18, 19, 20).

Whether treatment with GLP-1R agonists affects the CT attenuation of both EAT and PCAT, psoriasis severity, and thus potentially the inflammatory status, is unknown and unexplored.

Here, we describe the case of a patient with psoriasis affected by abdominal obesity and T2D with low cardiovascular risk by traditional risk scores, in which treatment with semaglutide for glycemic and weight control resulted in a consistent reduction in CT attenuation of both EAT and PCAT, assessed by CCTA, concurrent with a relevant and persistent improvement in psoriasis outcomes.

Case presentation

A 50-year-old Caucasian woman was diagnosed with obesity in 2011 and treated unsuccessfully with lifestyle modification. The patient has never smoked and is not a current smoker. She had suffered from psoriasis since 2006, for which she had consulted many dermatologists during the past few years. In January 2019, she was treated with ixekizumab 80 mg, an anti-interleukin (IL)-17A antibody, interrupted after 2 months due to an allergic reaction and replaced with secukinumab 75 mg (anti-IL17A). In January 2020, given the lack of response to the previous treatment, the dermatologist replaced secukinumab with guselkumab 100 mg (anti-IL23), obtaining little effects and thus the patient discontinued the treatment in November 2020. It is assumed that the patient had not used other treatments for psoriasis such as biologic therapies or topical steroids, during the entire period of semaglutide administration. However, we cannot know that with certainty since the patient was followed in an outpatient setting and not in an institutionalized setting that would have allowed 100% monitoring.

Investigation

The baseline characteristics of our patient are depicted in Table 1 (T0). The patient came to our observation in February 2022 (T0) for obesity disease treatment. At our first examination, glycated hemoglobin (HbA1c) was 6.5%, which allowed us to diagnose her with previously unknown T2D. Waist circumference and body mass index (BMI) were 98 cm and 30.4 kg/m2, respectively.

Table 1

Baseline and 10-month follow-up characteristics of study patient.

Baseline After 4 months of treatment After 10 months of treatment Variation from T0 to T10
T0 T4 T10 ∆T0–T10
Anthropometric measures
 Weight, kg 77.8 66.9 57.8 −25.7%
 Height, m  1.6  1.6  1.6 -
 BMI, kg/m2 30.4 27.3 22.6 −25.7%
 Waist circumference, cm 98 87 72 −26.5%
Coronary CT
 EAT HU −80 −94 −17.5%
 LAD HU −65 −70 −7.7%
 Cx HU −77 −82 −6.5%
 RCA HU −68 −72 −5.9%
 SAT HU −94 −95 −1.1%
 EAT volume, cm3 198 190 −4.0%
 CAC score 0 0
Questionnaires
 PASI score 12.0 4.0 0.2 −98.3%
 DLQI score  20 5 1 −95.0%
 DAPSA score 31.0 8.0 4.0 −87.1%
 Framingham risk score  4.6 3.9 2.6 −43.5%
Biochemistry
 Fasting glucose, mg/dL 120 101 91 −24.2%
 HbA1c, %  6.5  6.1 5.1 −21.5%
 Insulin, uU/mL 11.2 10.3 3.8 −66.3%
 HOMA-IR   3.32 2.57 0.84 −74.7%
 Cholesterol level, mg/dL
 Total 222 215 196 −11.7%
 HDL  42  46  58 38.1%
 LDL 158 149 137 −13.3%
 Triglycerides, mg/dL 112  97  39 −65.2%
 CRP, mg/dL  4.3 2.4 <0.5 −88.4%
 IL-6, pg/mL  4.9 4.1 3.4 −30.6%
 Leukocytes, 109/L 4.95 6.16  4.56 −7.9%
 ESR, mm/h 21 13 12 −42.9%

BMI, body mass index; CAC, coronary calcium content; CRP, C-reactive protein; Cx, circumflex artery; DAPSA, disease activity index for psoriatic arthritis; DLQI, dermatology life quality index; EAT, epicardial adipose tissue; ESR, erythrocyte sedimentation rate; HbA1c, glycated hemoglobin; HDL, high-density lipoprotein; HOMA-IR, homeostasis model assessment of insulin resistance; HU, Hounsfield units; IL, interleukin; LAD, left anterior descending artery; LDL, low-density lipoprotein; PASI, psoriasis area and severity index; RCA, right coronary artery; SAT, subcutaneous adipose tissue.

At the same time (baseline-T0), the patient underwent CCTA that showed the absence of coronary plaques and a coronary calcium content (CAC) score of 0 (Agatston score). Total EAT density and PCAT density for each coronary, defined as mean attenuation expressed in HU, were assessed (Fig. 1-T0).

Figure 1
Figure 1

CT epicardial adipose tissue (EAT) attenuation, pericoronary adipose tissue (PCAT) attenuation of the left anterior descending (LAD) artery, PCAT attenuation of the circumflex (Cx) artery and PCAT attenuation of the right coronary artery (RCA) at baseline (T0) and after 10-month (T10) follow-up of treatment with semaglutide. CT exam was performed on a 128-row dual-source CT scanner (Somatom Flash, Siemens Healthineers, Erlangen, Germany), with retrospective electrocardiographic gating. The reconstruction parameters for the angiographic phase scan were set as follows: slice thickness 0.6 mm; reconstruction interval 0.6 mm; and matrix size 512 × 512. Tube voltage was set between 100 and 120 kVp with the tube current set accordingly, in relation to body size. A bolus of contrast material of 1 mL/kg (Iopamiro 400, Bracco Imaging S.p.A., Milan, Italy) followed by a saline solution in the range of 30–70 mL was intravenously injected by means of a power injector (Empower CTA, EZEM, Westbury, NY, USA) at a flow rate of 5.0 mL/s according to the patient’s venous access features. Total EAT density and volume were calculated by tracing a region of interest (ROI) in the pericardium including all the tissues inside this ROI and then volume and attenuation were calculated as the average attenuation of all voxels between −30 and −190 HU. For pericoronary EAT-CT attenuation (PCAT) measurement, 40-mm-long proximal segments of left anterior descending (LAD), circumflex (CX), and right coronary artery (RCA) were traced (after excluding the first 10mm of the RCA, due to anatomical variances). The vessel lumen and its inner/outer wall borders were tracked in an automatic fashion from 5 mm from the centerline. In this region of interest, pericoronary EAT-CT attenuation was then calculated as the average attenuation of all voxels between −30 and −190 HU (thresholds used for the identification of adipose tissue).

Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 3; 10.1530/EDM-23-0017

CT-EAT attenuation was −80 HU, CT-PCAT attenuation of the left anterior descending (LAD) artery was −65 HU, CT-PCAT attenuation of the circumflex (Cx) artery was −77 HU, and CT-PCAT attenuation of the RCA was −68 HU (Fig. 2A). Subcutaneous adipose tissue (SAT) attenuation was −94 HU. CT-EAT volume was 198 cm3 (Table 1-T0).

Figure 2
Figure 2

Coronary computed tomography angiography images of the right coronary artery (RCA) depicting the PCAT attenuation at baseline, T0 (A), and after 10 months, T10 (B), follow-up of treatment with semaglutide. Attenuation values are expressed in Hounsfield units (HU).

Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 3; 10.1530/EDM-23-0017

Psoriasis area and severity index (PASI) was 12.0 (due to erythematous plaques involving the right hand and the scalp) (Fig. 3A). Dermatology life quality index (DLQI) and disease activity index for psoriatic arthritis (DAPSA) were 20 and 31.0, respectively, indicating a negative impact on the patient’s life.

Figure 3
Figure 3

Psoriasis lesions of the upper hand at baseline (T0) and after 10 months (T10) of treatment with semaglutide. DAPSA, disease activity index for psoriatic arthritis; DLQI, dermatology life quality index; PASI, psoriasis area and severity index.

Citation: Endocrinology, Diabetes & Metabolism Case Reports 2023, 3; 10.1530/EDM-23-0017

Treatment

We added semaglutide therapy to lifestyle modification at a starting dose of 0.25 mg per week subcutaneously for the first 4 weeks of treatment, then we increased the dose to 0.50 mg per week. The maintenance dose of 1 mg once weekly was reached after 16 weeks and was subsequently maintained.

Outcome and follow-up

The patient was visited after 4 months (T4) of treatment. PASI improved to 4.0. The patient reported an amelioration of her quality of life as confirmed by DLQI and DAPSA scores, which improved to 5 and 8.0, respectively. Moreover, a reduction in HbA1c (6.1%) and waist circumference (87 cm) was observed (Table 1-T4).

At 10 months of treatment (T10), December 2022, the patient re-performed CCTA, which showed an important reduction in CT-EAT attenuation from −80 HU to −94 HU (−17.5%) and in CT-PCAT attenuation of LAD artery from −65 HU to −70 HU (−7.7%), CT-PCAT attenuation of Cx artery from −77 HU to −82 HU (−6.5%) and CT-PCAT attenuation of RCA from −68 HU to −72 HU (−5.9%) (Fig. 1-T10, Fig. 2B). SAT attenuation remained basically unchanged from −94 HU to −95 HU (−1.1%) (Fig. 1-T10). CT-EAT volume decreased from 198 cm3 to 190 cm3 (−4.0%). CAC score was still 0 without signs of coronary plaques (Table 1-T10).

In addition, PASI was 0.2 (−98.3%), DLQI was 1 (−95.0%), and DAPSA was 4.0 (−87.1%), while HbA1c was 5.1% (−21.5%) and waist circumference was 72 cm (−26.5%) (Fig. 3B).

Discussion

Our case reports a consistent reduction in both EAT and PCAT attenuation, concurrent with a relevant and persistent improvement in psoriasis outcomes in response to semaglutide therapy in a patient affected by abdominal obesity and T2D with a low cardiovascular risk. On the contrary, we found almost no changes in SAT inflammation. These observations support the notion that subcutaneous fat consists of white adipose tissue and may not be as inflamed as epicardial fat (3, 4). The positive effect on EAT and PCAT attenuation and the neutral effect on SAT attenuation reinforce the hypothesis that GLP-1R agonists may speed up EAT and PCAT metabolism and free fatty acids (FFAs) oxidation, ultimately causing a reduction in epicardial fat inflammation. EAT GLP-1 receptor was directly correlated with genes promoting FFA oxidation and white-to-brown adipocyte differentiation and inversely correlated with pro-adipogenic genes, suggesting targeting EAT GLP-1R by GLP-1R agonists may reduce local adipogenesis, improve fat utilization, and induce brown fat differentiation (21).

At baseline, in our patient, EAT attenuation and PCAT attenuation of RCA showed values of −80 HU and −68 HU, respectively (Fig. 1-T0, Fig. 2A), similar to the values found in patients with CAD (4, 7, 9, 10, 13, 14), despite our patient having no coronary plaques and no CAC score.

Over 10 months of semaglutide treatment, we observed an improvement in the attenuation of both EAT and PCAT of the three main coronary arteries (Fig. 1-T10). Notably, PCAT attenuation of RCA decreased to −72 HU (−4 HU (−5.9% change)), stigmatizing the consistent and beneficial anti-inflammatory effects of semaglutide in PCAT attenuation (Fig. 1-T10, Fig. 2B). Patients with a PCAT attenuation of RCA ≥ −70.5 HU, the most standardized method for PCAT analysis, were associated with an increased risk of all-cause mortality and cardiac mortality (8, 12).

More recently, Biesenbach et al. showed that, in multivariable linear regression analysis, liraglutide treatment was associated with lower PCAT attenuation values around the LAD artery when adjusted for age, sex, BMI, and T2D duration (22).

Epicardial fat attenuation and PCAT attenuation, assessed by routine CCTA, are considered novel imaging biomarkers of inflammation and they reflect inflammatory changes within the fat depot itself (4, 7, 9, 10, 13, 14). These potential sensors of coronary inflammation may help to identify patients at increased risk of high-risk plaque progression, over and above traditional clinical risk factors (8), and allow monitoring of the beneficial changes from medical anti-inflammatory therapy (4, 7, 9, 10, 12, 13, 14).

Throughout treatment with semaglutide, we observed a concomitant and relevant improvement of severe psoriasis skin lesions between baseline and 4 months and a persistent healing response over 10 months (Table 1). PASI decreased from 12.0 to 4.0 after 4 months and to 0.2 after 10 months (98.3% improvement), while DLQI decreased from 20 to 5 after 4 months and to 1 after 10 months (95.0% improvement). Semaglutide treatment normalized HbA1c and induced weight loss, particularly at the abdominal level, also followed by a reduction in CT-measured EAT volume, a more accurate marker of the visceral fat depot. Even a lowering in biochemical markers of inflammation, such as IL-6 and C-reactive protein (CRP), was observed.

Recently, Costanzo et al. demonstrated how, in a patient with T2D and obesity, treatment with semaglutide, besides improving glycemic parameters and decreasing body weight, induces a rapid amelioration of severe psoriasis skin lesions (19). Moreover, in patients with T2D, GLP-1R agonists induce a reduction of both dermal γδT cells number and the expression of IL-17 mRNA in psoriasis plaques (23). The efficacy of GLP-1R agonists is presumably because improving adipose tissue dysfunction minimizes an important source of adipocytokines which may promote dermal inflammation.

Interestingly, GLP-1Rs expression has been shown in human psoriasis plaques but not in human keratinocyte cell cultures, suggesting the presence of these receptors in psoriatic plaques is due to immune cell infiltration (24).

Moreover, either daily or weekly GLP-1R agonists (liraglutide and semaglutide, respectively) induced a substantial reduction of EAT mass (ranging between 20 and 35%) (15, 16, 17). The presence of the GLP-1R within the human EAT, first demonstrated by our group, suggests the direct effect of the GLP-1R agonist on epicardial adipocytes as a possible mechanism behind the positive cardiovascular outcomes (25).

In a cohort study of patients with moderate to severe psoriasis, biologic therapy was associated with a decrease in coronary inflammation as assessed by perivascular fat attenuation index, a marker of coronary inflammation, without a consistent change in BMI, lipids, or glucose (26).

Nevertheless, psoriasis in patients with obesity and T2D is often resistant to treatment; a prospective analysis reported that the concomitant presence of obesity, T2D, and/or hypertension correlated with a lower efficacy of response to treatment with biological therapy than in patients without these comorbidities (27).

Weight reduction can improve the severity of psoriasis in individuals with obesity. The results of a randomized trial including patients affected by obesity with psoriasis showed that the intervention group, which underwent a low-calorie diet, had a greater weight loss than the control group and a considerable reduction in PASI (mean PASI reduction −2.3) (28). Furthermore, weight loss and the beneficial effect on psoriasis severity were shown to be largely maintained after 1 year (29).

In these patients, a single therapy could be effective not only for skin disease but also for cardiometabolic control. The actions of semaglutide to reduce energy intake, improve glycemic control, and produce effective weight loss, particularly at the visceral fat depos level, can diminish adipose tissue dysfunction, reduce EAT volume and inflammation, and concomitantly ameliorate the clinical severity of psoriasis (2).

However, it cannot be ruled out that the improvements in plaque psoriasis highlighted in this case report may be due to other factors as well as sun exposure. The psoriasis skin lesions described in this case report are localized on the hands, an area easily photo-exposed.

Further studies on larger populations may confirm the role of semaglutide in psoriasis and in the improvement of the associated epicardial fat inflammation.

In this case report, EAT and PCAT attenuation, assessed by CCTA, may be used to track response to anti-inflammatory therapies, such as semaglutide, for cardiometabolic and skin diseases, given their shared inflammatory properties and pathogenic similarities.

Declaration of interest

There is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported.

Funding

This study was partially supported by Ricerca Corrente funding from the Italian Ministry of Health to IRCCS Policlinico San Donato.

Patient consent

Written consent has been obtained from the patient after full explanation of the purpose and nature of all procedures used and for the publication of the submitted article and accompanying images.

Author contribution statement

AEM, CM, and AV were directly involved in the management of the patient. AEM and GI drafted the case report. All of the authors contributed to and approved the final draft of the report.

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    Mahabadi AA, Balcer B, Dykun I, Forsting M, Schlosser T, Heusch G, & Rassaf T. Cardiac computed tomography-derived epicardial fat volume and attenuation independently distinguish patients with and without myocardial infarction. PLoS One 2017 12 e0183514. (https://doi.org/10.1371/journal.pone.0183514)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Goeller M, Achenbach S, Cadet S, Kwan AC, Commandeur F, Slomka PJ, Gransar H, Albrecht MH, Tamarappoo BK, Berman DS, et al.Pericoronary adipose tissue computed tomography attenuation and high-risk plaque characteristics in acute coronary syndrome compared with stable coronary artery disease. JAMA Cardiology 2018 3 858863. (https://doi.org/10.1001/jamacardio.2018.1997)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Goeller M, Tamarappoo BK, Kwan AC, Cadet S, Commandeur F, Razipour A, Slomka PJ, Gransar H, Chen X, Otaki Y, et al.Relationship between changes in pericoronary adipose tissue attenuation and coronary plaque burden quantified from coronary computed tomography angiography. European Heart Journal. Cardiovascular Imaging 2019 20 636643. (https://doi.org/10.1093/ehjci/jez013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Iacobellis G, Secchi F, Capitanio G, Basilico S, Schiaffino S, Boveri S, Sardanelli F, Corsi Romanelli MM, & Malavazos AE. Epicardial fat inflammation in severe COVID-19. Obesity 2020 28 22602262. (https://doi.org/10.1002/oby.23019)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Iacobellis G, & Mahabadi AA. Is epicardial fat attenuation a novel marker of coronary inflammation? Atherosclerosis 2019 284 212213. (https://doi.org/10.1016/j.atherosclerosis.2019.02.023)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Iacobellis G, & Villasante Fricke AC. Effects of semaglutide versus dulaglutide on epicardial fat thickness in subjects with Type 2 diabetes and obesity. Journal of the Endocrine Society 2020 4 bvz042. (https://doi.org/10.1210/jendso/bvz042)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Iacobellis G, Mohseni M, Bianco SD, & Banga PK. Liraglutide causes large and rapid epicardial fat reduction. Obesity 2017 25 311316. (https://doi.org/10.1002/oby.21718)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Berg G, Barchuk M, Lobo M, & Nogueira JP. Effect of glucagon-like peptide-1 (GLP-1) analogues on epicardial adipose tissue: a meta-analysis. Diabetes and Metabolic Syndrome 2022 16 102562. (https://doi.org/10.1016/j.dsx.2022.102562)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Xu X, Lin L, Chen P, Yu Y, Chen S, Chen X, & Shao Z. Treatment with liraglutide, a glucagon-like peptide-1 analogue, improves effectively the skin lesions of psoriasis patients with type 2 diabetes: a prospective cohort study. Diabetes Research and Clinical Practice 2019 150 167173. (https://doi.org/10.1016/j.diabres.2019.03.002)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Costanzo G, Curatolo S, Busà B, Belfiore A, & Gullo D. Two birds one stone: semaglutide is highly effective against severe psoriasis in a type 2 diabetic patient. Endocrinology, Diabetes and Metabolism Case Reports 2021 21-0007. (https://doi.org/10.1530/EDM-21-0007)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Lin L, Xu X, Yu Y, Ye H, He X, Chen S, Chen X, Shao Z, & Chen P. Glucagon-like peptide-1 receptor agonist liraglutide therapy for psoriasis patients with type 2 diabetes: a randomized-controlled trial. Journal of Dermatological Treatment 2022 33 14281434. (https://doi.org/10.1080/09546634.2020.1826392)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Dozio E, Vianello E, Malavazos AE, Tacchini L, Schmitz G, Iacobellis G, & Corsi Romanelli MM. Epicardial adipose tissue GLP-1 receptor is associated with genes involved in fatty acid oxidation and white-to-brown fat differentiation: a target to modulate cardiovascular risk? International Journal of Cardiology 2019 292 218224. (https://doi.org/10.1016/j.ijcard.2019.04.039)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Biesenbach IIA, Heinsen LJ, Overgaard KS, Andersen TR, Auscher S, & Egstrup K. The effect of clinically indicated liraglutide on pericoronary adipose tissue in Type 2 diabetic patients. Sadamatsu K, Ed. Cardiovascular Therapeutics. 2023 2023 5126825. (https://doi.org/10.1155/2023/5126825)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Buysschaert M, Baeck M, Preumont V, Marot L, Hendrickx E, Van Belle A, & Dumoutier L. Improvement of psoriasis during glucagon-like peptide-1 analogue therapy in type 2 diabetes is associated with decreasing dermal γδ T-cell number: a prospective case-series study. British Journal of Dermatology 2014 171 155161. (https://doi.org/10.1111/bjd.12886)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Faurschou A, Pedersen J, Gyldenløve M, Poulsen SS, Holst JJ, Thyssen JP, Zachariae C, Vilsbøll T, Skov L, & Knop FK. Increased expression of glucagon-like peptide-1 receptors in psoriasis plaques. Experimental Dermatology 2013 22 150152. (https://doi.org/10.1111/exd.12081)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Iacobellis G, Camarena V, Sant DW, & Wang G. Human epicardial fat expresses glucagon-like peptide 1 and 2 receptors genes. Hormone and Metabolic Research 2017 49 625630. (https://doi.org/10.1055/s-0043-109563)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Elnabawi YA, Oikonomou EK, Dey AK, Mancio J, Rodante JA, Aksentijevich M, Choi H, Keel A, Erb-Alvarez J, Teague HL, et al.Association of biologic therapy with coronary inflammation in patients with psoriasis as assessed by perivascular fat attenuation index. JAMA Cardiology 2019 4 885891. (https://doi.org/10.1001/jamacardio.2019.2589)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Enos CW, Ramos VL, McLean RR, Lin TC, Foster N, Dube B, & Van Voorhees AS. Comorbid obesity and history of diabetes are independently associated with poorer treatment response to biologics at 6 months: a prospective analysis in Corrona Psoriasis Registry. Journal of the American Academy of Dermatology 2022 86 6876. (https://doi.org/10.1016/j.jaad.2021.06.883)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Jensen P, Zachariae C, Christensen R, Geiker NRW, Schaadt BK, Stender S, Hansen PR, Astrup A, & Skov L. Effect of weight loss on the severity of psoriasis: a randomized clinical study. JAMA Dermatology 2013 149 795801. (https://doi.org/10.1001/jamadermatol.2013.722)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Jensen P, Christensen R, Zachariae C, Geiker NR, Schaadt BK, Stender S, Hansen PR, Astrup A, & Skov L. Long-term effects of weight reduction on the severity of psoriasis in a cohort derived from a randomised trial: a prospective observational follow-up study. American Journal of Clinical Nutrition 2016 104 259265. (https://doi.org/10.3945/ajcn.115.125849)

    • PubMed
    • Search Google Scholar
    • Export Citation

 

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  • Figure 1

    CT epicardial adipose tissue (EAT) attenuation, pericoronary adipose tissue (PCAT) attenuation of the left anterior descending (LAD) artery, PCAT attenuation of the circumflex (Cx) artery and PCAT attenuation of the right coronary artery (RCA) at baseline (T0) and after 10-month (T10) follow-up of treatment with semaglutide. CT exam was performed on a 128-row dual-source CT scanner (Somatom Flash, Siemens Healthineers, Erlangen, Germany), with retrospective electrocardiographic gating. The reconstruction parameters for the angiographic phase scan were set as follows: slice thickness 0.6 mm; reconstruction interval 0.6 mm; and matrix size 512 × 512. Tube voltage was set between 100 and 120 kVp with the tube current set accordingly, in relation to body size. A bolus of contrast material of 1 mL/kg (Iopamiro 400, Bracco Imaging S.p.A., Milan, Italy) followed by a saline solution in the range of 30–70 mL was intravenously injected by means of a power injector (Empower CTA, EZEM, Westbury, NY, USA) at a flow rate of 5.0 mL/s according to the patient’s venous access features. Total EAT density and volume were calculated by tracing a region of interest (ROI) in the pericardium including all the tissues inside this ROI and then volume and attenuation were calculated as the average attenuation of all voxels between −30 and −190 HU. For pericoronary EAT-CT attenuation (PCAT) measurement, 40-mm-long proximal segments of left anterior descending (LAD), circumflex (CX), and right coronary artery (RCA) were traced (after excluding the first 10mm of the RCA, due to anatomical variances). The vessel lumen and its inner/outer wall borders were tracked in an automatic fashion from 5 mm from the centerline. In this region of interest, pericoronary EAT-CT attenuation was then calculated as the average attenuation of all voxels between −30 and −190 HU (thresholds used for the identification of adipose tissue).

  • Figure 2

    Coronary computed tomography angiography images of the right coronary artery (RCA) depicting the PCAT attenuation at baseline, T0 (A), and after 10 months, T10 (B), follow-up of treatment with semaglutide. Attenuation values are expressed in Hounsfield units (HU).

  • Figure 3

    Psoriasis lesions of the upper hand at baseline (T0) and after 10 months (T10) of treatment with semaglutide. DAPSA, disease activity index for psoriatic arthritis; DLQI, dermatology life quality index; PASI, psoriasis area and severity index.

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    Packer M. Epicardial adipose tissue inflammation can cause the distinctive pattern of cardiovascular disorders seen in psoriasis. American Journal of Medicine 2020 133 267272. (https://doi.org/10.1016/j.amjmed.2019.08.027)

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    Iacobellis G, Malavazos AE, & Corsi MM. Epicardial fat: from the biomolecular aspects to the clinical practice. International Journal of Biochemistry and Cell Biology 2011 43 16511654. (https://doi.org/10.1016/j.biocel.2011.09.006)

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    Torres T, Bettencourt N, Mendonça D, Vasconcelos C, Gama V, Silva BM, & Selores M. Epicardial adipose tissue and coronary artery calcification in psoriasis patients. Journal of the European Academy of Dermatology and Venereology 2015 29 270277. (https://doi.org/10.1111/jdv.12516)

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    Kamath P, Benesh G, Romanelli P, & Iacobellis G. Epicardial fat: a new therapeutic target in psoriasis. Current Pharmaceutical Design 2019 25 49144918. (https://doi.org/10.2174/1381612825666191206091105)

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    Antonopoulos AS, Sanna F, Sabharwal N, Thomas S, Oikonomou EK, Herdman L, Margaritis M, Shirodaria C, Kampoli AM, Akoumianakis I, et al.Detecting human coronary inflammation by imaging perivascular fat. Science Translational Medicine 2017 9 eaal2658. (https://doi.org/10.1126/scitranslmed.aal2658)

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  • 8

    Oikonomou EK, Marwan M, Desai MY, Mancio J, Alashi A, Hutt Centeno E, Thomas S, Herdman L, Kotanidis CP, Thomas KE, et al.Non-invasive detection of coronary inflammation using computed tomography and prediction of residual cardiovascular risk (the CRISP CT study): a post-hoc analysis of prospective outcome data. Lancet 2018 392 929939. (https://doi.org/10.1016/S0140-6736(1831114-0)

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  • 9

    Liu Z, Wang S, Wang Y, Zhou N, Shu J, Stamm C, Jiang M, & Luo F. Association of epicardial adipose tissue attenuation with coronary atherosclerosis in patients with a high risk of coronary artery disease. Atherosclerosis 2019 284 230236. (https://doi.org/10.1016/j.atherosclerosis.2019.01.033)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Mahabadi AA, Balcer B, Dykun I, Forsting M, Schlosser T, Heusch G, & Rassaf T. Cardiac computed tomography-derived epicardial fat volume and attenuation independently distinguish patients with and without myocardial infarction. PLoS One 2017 12 e0183514. (https://doi.org/10.1371/journal.pone.0183514)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Goeller M, Achenbach S, Cadet S, Kwan AC, Commandeur F, Slomka PJ, Gransar H, Albrecht MH, Tamarappoo BK, Berman DS, et al.Pericoronary adipose tissue computed tomography attenuation and high-risk plaque characteristics in acute coronary syndrome compared with stable coronary artery disease. JAMA Cardiology 2018 3 858863. (https://doi.org/10.1001/jamacardio.2018.1997)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Goeller M, Tamarappoo BK, Kwan AC, Cadet S, Commandeur F, Razipour A, Slomka PJ, Gransar H, Chen X, Otaki Y, et al.Relationship between changes in pericoronary adipose tissue attenuation and coronary plaque burden quantified from coronary computed tomography angiography. European Heart Journal. Cardiovascular Imaging 2019 20 636643. (https://doi.org/10.1093/ehjci/jez013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Iacobellis G, Secchi F, Capitanio G, Basilico S, Schiaffino S, Boveri S, Sardanelli F, Corsi Romanelli MM, & Malavazos AE. Epicardial fat inflammation in severe COVID-19. Obesity 2020 28 22602262. (https://doi.org/10.1002/oby.23019)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Iacobellis G, & Mahabadi AA. Is epicardial fat attenuation a novel marker of coronary inflammation? Atherosclerosis 2019 284 212213. (https://doi.org/10.1016/j.atherosclerosis.2019.02.023)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Iacobellis G, & Villasante Fricke AC. Effects of semaglutide versus dulaglutide on epicardial fat thickness in subjects with Type 2 diabetes and obesity. Journal of the Endocrine Society 2020 4 bvz042. (https://doi.org/10.1210/jendso/bvz042)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Iacobellis G, Mohseni M, Bianco SD, & Banga PK. Liraglutide causes large and rapid epicardial fat reduction. Obesity 2017 25 311316. (https://doi.org/10.1002/oby.21718)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Berg G, Barchuk M, Lobo M, & Nogueira JP. Effect of glucagon-like peptide-1 (GLP-1) analogues on epicardial adipose tissue: a meta-analysis. Diabetes and Metabolic Syndrome 2022 16 102562. (https://doi.org/10.1016/j.dsx.2022.102562)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Xu X, Lin L, Chen P, Yu Y, Chen S, Chen X, & Shao Z. Treatment with liraglutide, a glucagon-like peptide-1 analogue, improves effectively the skin lesions of psoriasis patients with type 2 diabetes: a prospective cohort study. Diabetes Research and Clinical Practice 2019 150 167173. (https://doi.org/10.1016/j.diabres.2019.03.002)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Costanzo G, Curatolo S, Busà B, Belfiore A, & Gullo D. Two birds one stone: semaglutide is highly effective against severe psoriasis in a type 2 diabetic patient. Endocrinology, Diabetes and Metabolism Case Reports 2021 21-0007. (https://doi.org/10.1530/EDM-21-0007)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Lin L, Xu X, Yu Y, Ye H, He X, Chen S, Chen X, Shao Z, & Chen P. Glucagon-like peptide-1 receptor agonist liraglutide therapy for psoriasis patients with type 2 diabetes: a randomized-controlled trial. Journal of Dermatological Treatment 2022 33 14281434. (https://doi.org/10.1080/09546634.2020.1826392)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Dozio E, Vianello E, Malavazos AE, Tacchini L, Schmitz G, Iacobellis G, & Corsi Romanelli MM. Epicardial adipose tissue GLP-1 receptor is associated with genes involved in fatty acid oxidation and white-to-brown fat differentiation: a target to modulate cardiovascular risk? International Journal of Cardiology 2019 292 218224. (https://doi.org/10.1016/j.ijcard.2019.04.039)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Biesenbach IIA, Heinsen LJ, Overgaard KS, Andersen TR, Auscher S, & Egstrup K. The effect of clinically indicated liraglutide on pericoronary adipose tissue in Type 2 diabetic patients. Sadamatsu K, Ed. Cardiovascular Therapeutics. 2023 2023 5126825. (https://doi.org/10.1155/2023/5126825)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Buysschaert M, Baeck M, Preumont V, Marot L, Hendrickx E, Van Belle A, & Dumoutier L. Improvement of psoriasis during glucagon-like peptide-1 analogue therapy in type 2 diabetes is associated with decreasing dermal γδ T-cell number: a prospective case-series study. British Journal of Dermatology 2014 171 155161. (https://doi.org/10.1111/bjd.12886)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Faurschou A, Pedersen J, Gyldenløve M, Poulsen SS, Holst JJ, Thyssen JP, Zachariae C, Vilsbøll T, Skov L, & Knop FK. Increased expression of glucagon-like peptide-1 receptors in psoriasis plaques. Experimental Dermatology 2013 22 150152. (https://doi.org/10.1111/exd.12081)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Iacobellis G, Camarena V, Sant DW, & Wang G. Human epicardial fat expresses glucagon-like peptide 1 and 2 receptors genes. Hormone and Metabolic Research 2017 49 625630. (https://doi.org/10.1055/s-0043-109563)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Elnabawi YA, Oikonomou EK, Dey AK, Mancio J, Rodante JA, Aksentijevich M, Choi H, Keel A, Erb-Alvarez J, Teague HL, et al.Association of biologic therapy with coronary inflammation in patients with psoriasis as assessed by perivascular fat attenuation index. JAMA Cardiology 2019 4 885891. (https://doi.org/10.1001/jamacardio.2019.2589)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Enos CW, Ramos VL, McLean RR, Lin TC, Foster N, Dube B, & Van Voorhees AS. Comorbid obesity and history of diabetes are independently associated with poorer treatment response to biologics at 6 months: a prospective analysis in Corrona Psoriasis Registry. Journal of the American Academy of Dermatology 2022 86 6876. (https://doi.org/10.1016/j.jaad.2021.06.883)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Jensen P, Zachariae C, Christensen R, Geiker NRW, Schaadt BK, Stender S, Hansen PR, Astrup A, & Skov L. Effect of weight loss on the severity of psoriasis: a randomized clinical study. JAMA Dermatology 2013 149 795801. (https://doi.org/10.1001/jamadermatol.2013.722)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Jensen P, Christensen R, Zachariae C, Geiker NR, Schaadt BK, Stender S, Hansen PR, Astrup A, & Skov L. Long-term effects of weight reduction on the severity of psoriasis in a cohort derived from a randomised trial: a prospective observational follow-up study. American Journal of Clinical Nutrition 2016 104 259265. (https://doi.org/10.3945/ajcn.115.125849)

    • PubMed
    • Search Google Scholar
    • Export Citation