Psoriasis Workup Expanding to Account for More Associated Conditions

 In a paper published last fall, lung disease was added to a list of comorbidities that appear to be pathologically associated with psoriasis, which is just another reason why Douglas DiRuggiero, DMSc, MHS, PA-C, believes a workup limited to the skin and joints is no longer sufficient for a clinician intent on a comprehensive evaluation in patients with psoriasis.  

The risk of some psoriasis-associated pathologies, such as cardiovascular disease, are better recognized than others, but the addition of lung disease draws attention to the need for broad questions about other organ systems when first examining a patient with psoriasis as well as at subsequent follow-ups, according to DiRuggiero, of the Skin Cancer & Cosmetic Dermatology Center, Rome, Georgia. 

This need for a comprehensive workup is reflected in the growing use of the term psoriatic disease (PsD) — not just psoriasis and/or psoriatic arthritis (PsA) — in publications and by groups like the National Psoriasis Foundation (NPF), DiRuggiero said. On the NPF website, PsD refers not only to skin and joint complaints but to “related systemic inflammation,” he noted. 

This is an evolution that has changed how DiRuggiero addresses each case of psoriasis, he said at the Society of Dermatology Physician Associates (SDPA) Annual Summer Conference 2026.

Pulmonary Abnormalities Associated  

Strong evidence of an association between pulmonary abnormalities was drawn from a literature review and a retrospective study of 251 adults with psoriasis, DiRuggiero noted. In the study, published in November 2025 in Respiratory Medicine, lung disease was found in 50% of patients with psoriasis undergoing chest CT imaging. 

The association suggested that these conditions might be mutually exacerbating, given that respiratory symptoms predicted worse outcomes in psoriatic patients, DiRuggiero said.

For the patient presenting with psoriasis, this association, like so many other common comorbidities “is just another reminder that we are caring for the whole person and not just their plaques,” DiRuggiero said.

In practical terms, he does not screen for every potential comorbidity at the initial visit for a patient newly diagnosed with psoriasis. A standard workup is conducted for joint involvement, including completion of the Psoriasis Epidemiology Screening Tool (PEST) form and a physical examination that involves palpation and examination of joints most commonly implicated in PsA. He also conducts routine screening for cardiovascular risk factors. Evidence of joint or cardiovascular disease leads to a referral.

However, information about many of the organ systems at risk involves general questions at the time of the initial examination about symptoms and well-being. Gastrointestinal inflammation is an example.

Pointing to the evidence of a “very strong crossover between psoriasis and inflammatory bowel disease,” DiRuggiero focuses on eliciting symptoms of gut involvement that might prompt him to order further testing. 

“I ask a lot of general questions about the organ systems I think might be involved, covering such issues as exercise tolerance, bowel habits, and chronic pain,” DiRuggiero told Medscape Medical News. “I am looking for signals.”

Depression Is Another Association 

Of the questions he routinely poses, mental health is not ignored. DiRuggiero said that psoriasis has been closely associated with major depression and suicidal ideation, but it is not entirely clear whether mood disorder is a function of the disease burden or another comorbidity linked to upregulated inflammation.

“Typically, I tell the patient that it would be understandable if their skin condition is affecting their mood as a way to give them permission to voice this problem,” he said. He also asks them a general question about what activities psoriasis prevents them from doing.

Much of this information is elicited during the initial history and is not a definitive survey of the patient’s health status but an opportunity to consider issues beyond the skin and joints. “The reality is that you do not have time at an initial visit to order tests for any possible comorbidity, but the goal is to ask questions that will provide a rationale for further testing when appropriate,” DiRuggiero said.

He acknowledged that at the level of the skin, psoriasis represents an immune dysregulation, but he has doubts about its characterization as an autoimmune disease. Not least, neither psoriasis nor PsA has been linked to an autoantigen or self-reactive T cells, even if upregulated cytokines do otherwise parallel autoimmune pathology.

Yet, it is important to recognize that the immune dysregulation that drives psoriasis is shared with many other conditions. While the association of psoriasis with cardiovascular disease might be related only to a shared upregulation in systemic inflammation, other diseases — such as inflammatory bowel disease — appear to at least share features of the underlying pathophysiology. 

Commenting on DiRuggiero’s presentation, the medical director of the SDPA Summer Conference, Whitney High, MD, professor of dermatology at the University of Colorado Anschutz, Aurora, agreed that the new data on lung involvement is a reminder of the systemic nature of psoriasis.

“The term psoriatic disease is an appropriate umbrella label to cover the systemic involvement beyond the skin,” said High, who believes that the association between psoriasis and pulmonary dysfunction is not yet widely appreciated. 

Like DiRuggiero, he also prefers the term immune dysregulation over autoimmune disease to characterize a disease driven by inflammation that might not be a strictly autoimmune process. Yet, he thinks this is a semantic issue less important than the core concept that psoriasis is associated and travels with a long list of comorbidities.

DiRuggiero reported financial relationships with AbbVie, Amgen, Arcutis, Galderma, Lilly, Johnson & Johnson, Organon, Novartis, Pfizer, Sanofi/Regeneron, Takeda, UCB, Amgen, Biogen, EMD Serono, Novartis, Roche, Sanofi Aventis, and Touch IME. High reported no potential conflicts of interest.

https://www.medscape.com/viewarticle/psoriasis-workup-expanding-account-more-associated-2026a1000jwf