The risk and prevalence of hepatic diseases in psoriasis: A systematic review and meta‐analysis

Psoriasis, well documented for its associations with metabolic syndrome, cardiovascular disorders and psychiatric comorbidities, also has recognized links to liver diseases.1-3 However, a comprehensive review of this association is lacking. A systematic search across Scopus, Embase, Web of Science and Cochrane identified observational studies evaluating psoriasis and hepatic diseases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines.4 The protocol was registered in PROSPERO (CRD42023422616). This meta-analysis used a random effects model to calculate pooled odds ratios (ORs) and number needed to screen (NNS) with 95% confidence intervals (CIs) to examine the prevalence of liver disease among individuals with and without psoriasis. Comprehensive details about eligibility, sources and search strategy, criteria, study selection, risk of bias and statistical analyses are available in data availability via Mendeley. Thirty-five studies involving 8,680,818 psoriasis patients and 133,591,542 non-psoriatic controls were included (Figure 1). The meta-analysis showed psoriasis patients had nearly twice the risk of developing liver disease compared to controls, with a pooled OR of 1.85 (95% CI: 1.66–2.05). Subgroup analysis revealed significant associations between psoriasis and specific liver diseases, including metabolic dysfunction-associated fatty liver disease (MAFLD) (OR: 2.22, 95% CI: 1.84–2.70), hepatitis C virus (HCV) (OR: 1.79, 95% CI: 1.38–2.32), autoimmune hepatitis (OR: 2.25, 95% CI: 1.45–3.49), primary biliary cholangitis (OR: 1.92, 95% CI: 1.16–3.16), liver cancer (OR: 1.61, 95% CI: 1.48–1.75) and advanced liver fibrosis (OR: 2.06, 95% CI: 1.43–2.98). No significant association was found with hepatitis B (HBV) (OR: 1.20, 95% CI: 0.96–1.51, p = 0.11). Importantly, most MAFLD studies accounted for obesity or BMI, reinforcing psoriasis as an independent risk factor (OR: 2.05, 95% CI: 1.68–2.49, n = 12), possibly due to shared inflammatory pathways involving TNF-α and IL-23.5 Geographical analysis suggested variability, with patients from Asia showing the highest OR (2.13, 95% CI: 1.62–2.81), followed by North America (1.75, 95% CI: 1.51–2.02) and Europe (1.57, 95% CI: 1.28–1.92), though differences were not statistically significant (p > 0.05). Sensitivity analysis of eight studies showed that psoriasis severity, measured by the Psoriasis Area and Severity Index, was greater among those with hepatic disease (SMD: 0.29, 95% CI: 0.13–0.45), suggesting psoriasis severity might correlate with hepatic risk. NNS calculations highlighted MAFLD and HCV as conditions with significant associations, showing NNS values of 12 (8–26) and 29 (15–448), respectively (Figure 2). Study quality, assessed using the Newcastle Ottawa scale, yielded scores ranging from 6 to 9, with a mean of 7.86 ± 1.15. A symmetrical funnel plot and Egger's regression test (p = 0.841) indicated no significant publication bias. Significant associations were identified between psoriasis and various hepatic conditions, particularly MAFLD and HCV. The differential association with HCV versus HBV mirrors findings in other autoimmune conditions, such as systemic lupus erythematosus, lichen planus and Sjögren's syndrome, where HCV is consistently more prevalent than HBV.6, 7 Such differences likely reflect distinct viral immunopathogenesis. HCV elicits a pronounced inflammatory response more consistent with psoriasis cytokine profiles, whereas HBV's relatively muted immune activation, in addition to widespread vaccination, may underlie its non-significant association. Although one-time HCV screening is recommended for all adults, selective additional screening may be reasonable in psoriasis patients with added risk factors. The evidence supporting routine MAFLD screening in psoriasis patients is more compelling and may warrant a more systematic approach. Maintaining vigilance and a lower threshold for hepatic evaluation in high-risk subgroups could facilitate earlier detection and intervention, ultimately contributing to improved outcomes for psoriasis patients. Limitations include heterogeneity among studies, reliance on some pre-direct-acting antiviral data, potential unmeasured confounders and the observational nature of the data, which may limit generalizability. None. Mr. Parsa Abdi, Dr. Luis F. Andrade and Dr. Sepideh Emam have no conflicts of interest to disclose. Dr. Robert Gniadecki has served on advisory boards for Eli Lilly. Not applicable. Not applicable. Data supporting this study are available in Mendeley Data at https://data.mendeley.com/datasets/s9yszydzrd/1.