Should dermatologists care about hepatic fibrosis and steatosis? Psoriasis first, hidradenitis suppurativa second

Dear Editor,

The research conducted by Hanci et al.^[1] has captured our attention due to its detailed exploration of the prevalence of hepatic fibrosis and steatosis in patients suffering from psoriasis, utilizing vibration-controlled transient elastography (VCTE). Following a meticulous examination of 328 patients, the authors shared important findings about the prevalence of severe fibrosis (7.0%) and cirrhosis (10.1%), discerned through liver stiffness measurement values. Furthermore, they discovered a substantial segment of psoriatic patients (43.3%) with severe hepatic steatosis, denoted by a controlled attenuation parameter value exceeding 290 dB/m.^[1] The authors merit commendation for highlighting the critical need for screening a specific dermatological patient population for non-alcoholic fatty liver disease (NAFLD) and its potential complications. Patients with psoriasis are indeed known to form a particularly significant group, as they not only face an augmented risk of developing NAFLD but also tend to suffer from more severe disease compared to non-psoriatic individuals with NAFLD.^[2] In addition to psoriasis, we propose that subjects suffering from hidradenitis suppurativa (HS) – a chronic inflammatory/autoinflammatory skin condition predominantly impacting the apocrine gland-rich areas of the body and presenting with abscesses, painful nodules, and scarring^[3] – could also benefit from undergoing routine VCTE. In a cohort of 83 patients with HS, Damiani et al.^[4] detected NAFLD and non-alcoholic steatohepatitis (NASH) in 20 (24.1%) and 12 (14.4%) cases, respectively. In a Spanish study involving 70 patients affected by HS, the prevalence of NAFLD reached a striking 72.9%, with the presence of the disease being independent of classic metabolic risk factors.^[5] González-Villanueva et al.^[6] later corroborated an independent association between HS and NAFLD (odds ratio [OR]=2.79) after adjustment for age, body mass index, hypertension, and increased liver enzymes. In a recent meta-analysis, Gau et al.^[7] confirmed that HS is associated with NAFLD (OR=1.78) and hepatitis B (OR=1.48), but not hepatitis C. While a number of studies utilizing VCTE have demonstrated its potential benefits for psoriatic patients,^[8] the application of this imaging technique in the field of HS is still in the early stages of exploration.^[5] This may be due to the rarity of this skin disorder, estimated to affect only 0.7−1.2% of the European-US population.^[3] However, international registries have been set up^[9] and collaborative efforts among researchers are urgently needed to thoroughly explore the clinical benefits of using VCTE in this patient group. We propose that, moving forward, there should be a study of a stepwise approach^[10] for the detection of hepatic fibrosis in HS. This process would commence with the application of straightforward, non-invasive tests (NITs) derived from standard clinical and laboratory data. Should patients be categorized as high or intermediate risk for advanced fibrosis after NITs calculation, they would subsequently undergo second-tier VCTE examinations. We anticipate that this method could significantly alleviate the burden of NAFLD in HS patients, who are already grappling with substantial personal health challenges.

Peer-review

Externally peer-reviewed.

Author Contributions

Concept – EE; Design – EE; Supervision – EE; Fundings – PM; Materials – EE, PM; Data Collection and/or Processing – EE, PM; Analysis and/or Interpretation – EE, PM; Literature Search – EE; Writing – EE; Critical Reviews – PM.

Conflict of Interest

The authors have no conflict of interest to declare.

Financial Disclosure

The authors declared that this study has received no financial support.