Multimorbidity and mortality risk in hospitalized adults with chronic inflammatory skin disease in the United States


Chronic inflammatory skin diseases (CISD) represent a significant burden of skin disease in the United States, and a growing number of studies demonstrate that CISD are associated with multiple comorbidities. However, few studies examined multimorbidity in adults with CISD. We sought to determine whether hospitalized US adults with chronic inflammatory skin disorders have increased multi-morbidity and mortality risk. Data from the 2002–2012 Nationwide Inpatient Sample were analyzed, including a representative 20% sample of US hospitalizations. Charlson comorbidity index (CCI) and mean estimated 10-year survival were calculated. Multivariable linear regression models were constructed with CCI score and mean estimated 10-year survival as the dependent variables and chronic inflammatory skin diagnosis, age and sex as the independent variables. CCI scores were significantly higher in bullous pemphigoid (P = 0.0005) and dermatomyositis (P < 0.0001), lower in hidradenitis suppurativa (P < 0.0001), pemphigus (P < 0.0001), rosacea (P < 0.0001), and not significantly different in atopic dermatitis, alopecia areata, and lichen planus compared to psoriasis. Conversely, the mean estimated 10-year survival was higher in pemphigus (P = 0.0451), lichen planus (P = 0.0352), rosacea (P < 0.0001), lower in bullous pemphigoid and dermatomyositis (P < 0.0001), and similar in atopic dermatitis, alopecia areata, and hidradenitis suppurativa compared to psoriasis. Each CISD had a distinct profile of comorbidities when compared to psoriasis. Hospitalized adults with multiple CISD have increased multimorbidity and decreased 10-year survival. Further studies are needed to develop multidisciplinary strategies aimed at preventing and treating multimorbidity, especially modifiable cardiovascular factors in adults with CISD.

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Data integrity statement

JI Silverberg had full access to all the data in the study and takes responsibility for the integrity of the data and accuracy of the data analysis. Study concept and design: JI Silverberg. Acquisition of Data: JI Silverberg, S Narla. Analysis and interpretation of data: S Narla, JI Silverberg, Drafting of the manuscript: S Narla, JI Silverberg. Critical revision of the manuscript for important intellectual content: S Narla, JI Silverberg. Statistical analysis: JI Silverberg, S Narla. Obtained funding: JI Silverberg. Administrative technical or material support: None. Study supervision: None. Financial disclosures: None. Design and conduct of the study? No. Collection, management, analysis and interpretation of data? No. Preparation, review, or approval of the manuscript? No. Decision to submit the manuscript for publication? No.



International Classification of Disease 9th edition Clinical Modification


Atopic dermatitis


Chronic obstructive pulmonary disease


Connective tissue disease


Acquired immunodeficiency syndrome


Myocardial infarction


Chronic kidney disease


Cerebrovascular accident


Transient ischemic attack


Congestive heart failure


Peptic ulcer disease


Diabetes mellitus


Bullous pemphigoid


Hidradenitis suppurativa


Alopecia areata


Lichen planus


Nationwide inpatient sample


Confidence interval


Charlson Comorbidity Index


Healthcare cost and utilization project


Agency for healthcare research and quality


Chronic inflammatory skin disease


  1. 1.

    Pefoyo AJK et al (2015) The increasing burden and complexity of multimorbidity. BMC Public Health 15:415–415

    PubMed  Google Scholar 

  2. 2.

    Organization WH (2014) Global status report on noncommunicable diseases 2014. WHO, Switzerland

    Google Scholar 

  3. 3.

    van Oostrom SH et al (2012) Multimorbidity and comorbidity in the Dutch population—data from general practices. BMC Public Health 12(1):715

    PubMed  PubMed Central  Google Scholar 

  4. 4.

    Barnett K et al (2012) Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 380(9836):37–43

    PubMed  Google Scholar 

  5. 5.

    Wolff JL, Starfield B, Anderson G (2002) Prevalence, expenditures, and complications of multiple chronic conditions in the elderly. Arch Intern Med 162(20):2269–2276

    PubMed  Google Scholar 

  6. 6.

    Marengoni A et al (2011) Aging with multimorbidity: a systematic review of the literature. Ageing Res Rev 10(4):430–439

    PubMed  PubMed Central  Google Scholar 

  7. 7.

    Willadsen TG et al (2018) Multimorbidity and mortality: a 15-year longitudinal registry-based nationwide Danish population study. J Comorbidity 8(1):2235042X18804063

    CAS  Google Scholar 

  8. 8.

    Brunner PM et al (2017) Increasing comorbidities suggest that atopic dermatitis is a systemic disorder. J Investig Dermatol 137(1):18–25

    CAS  PubMed  Google Scholar 

  9. 9.

    Silverberg JI (2017) Selected comorbidities of atopic dermatitis: atopy, neuropsychiatric, and musculoskeletal disorders. Clin Dermatol 35(4):360–366

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Silverberg JI et al (2018) Association of atopic dermatitis with allergic, autoimmune, and cardiovascular comorbidities in US adults. Ann Allergy Asthma Immunol 121(5):604 e3–612 e3

    Google Scholar 

  11. 11.

    Narla S, Silverberg JI (2019) Association between atopic dermatitis and autoimmune disorders in US adults and children: a cross-sectional study. J Am Acad Dermatol 80(2):382–389

    PubMed  Google Scholar 

  12. 12.

    Andersen YMF et al (2017) Autoimmune diseases in adults with atopic dermatitis. J Am Acad Dermatol 76(2):274–280.e1

    PubMed  Google Scholar 

  13. 13.

    Mohan GC, Silverberg JI (2015) Association of vitiligo and alopecia areata with atopic dermatitis: a systematic review and meta-analysis. JAMA Dermatol 151(5):522–528

    PubMed  Google Scholar 

  14. 14.

    Rudwaleit M et al (2002) Atopic disorders in ankylosing spondylitis and rheumatoid arthritis. (Extended Report). Ann Rheum Dis 61:968

    CAS  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Schmitt J et al (2016) Atopic dermatitis is associated with an increased risk for rheumatoid arthritis and inflammatory bowel disease, and a decreased risk for type 1 diabetes. J Allergy Clin Immunol 137(1):130–136

    PubMed  Google Scholar 

  16. 16.

    Silverberg JI et al (2015) Sleep disturbances in adults with eczema are associated with impaired overall health: a US population-based study. J Investig Dermatol 135(1):56–66

    CAS  PubMed  Google Scholar 

  17. 17.

    Dreiher J, Weitzman D, Cohen AD (2009) Psoriasis and osteoporosis: a sex-specific association? J Investig Dermatol 129(7):1643–1649

    CAS  PubMed  Google Scholar 

  18. 18.

    Li X et al (2015) Association between psoriasis and chronic obstructive pulmonary disease: a systematic review and meta-analysis. PLoS ONE 10(12):e0145221

    PubMed  PubMed Central  Google Scholar 

  19. 19.

    Ungprasert P, Srivali N, Thongprayoon C (2016) Association between psoriasis and chronic obstructive pulmonary disease: a systematic review and meta-analysis. J Dermatol Treat 27(4):316–321

    Google Scholar 

  20. 20.

    Gelfand JM et al (2006) The risk of lymphoma in patients with psoriasis. J Investig Dermatol 126(10):2194–2201

    CAS  PubMed  Google Scholar 

  21. 21.

    Kwa MC, Silverberg JI (2017) Association between inflammatory skin disease and cardiovascular and cerebrovascular co-morbidities in US adults: analysis of nationwide inpatient sample data. Am J Clin Dermatol 18(6):813–823

    PubMed  Google Scholar 

  22. 22.

    Yeung H et al (2013) Psoriasis severity and the prevalence of major medical comorbidity: a population-based study. JAMA Dermatol 149(10):1173–1179

    PubMed  PubMed Central  Google Scholar 

  23. 23.

    Miller IM, McAndrew RJ, Hamzavi I (2016) Prevalence, risk factors, and comorbidities of hidradenitis suppurativa. Dermatol Clin 34(1):7–16

    CAS  PubMed  Google Scholar 

  24. 24.

    Thyssen JP et al (2017) Assessment of major comorbidities in adults with atopic dermatitis using the Charlson comorbidity index. J Am Acad Dermatol 76(6):1088–1092.e1

    PubMed  Google Scholar 

  25. 25.

    Hsu DY et al (2017) Validation of international classification of disease ninth revision codes for atopic dermatitis. Allergy 72(7):1091–1095

    CAS  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Hsu D et al (2016) Validation of database search strategies for the epidemiological study of pemphigus and pemphigoid. Br J Dermatol 174(3):645–648

    CAS  PubMed  Google Scholar 

  27. 27.

    Kwa MC et al (2017) Validation of international classification of diseases codes for the epidemiologic study of dermatomyositis. Arthritis Care Res 69(5):753–757

    Google Scholar 

  28. 28.

    Icen M et al (2008) Potential misclassification of patients with psoriasis in electronic databases. J Am Acad Dermatol 59(6):981–985

    PubMed  PubMed Central  Google Scholar 

  29. 29.

    Asgari MM et al (2013) Validity of diagnostic codes and prevalence of psoriasis and psoriatic arthritis in a managed care population, 1996–2009. Pharmacoepidemiol Drug Saf 22(8):842–849

    PubMed  PubMed Central  Google Scholar 

  30. 30.

    Kim GE, Shlyankevich J, Kimball AB (2014) The validity of the diagnostic code for hidradenitis suppurativa in an electronic database. Br J Dermatol 171(2):338–342

    CAS  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Susser SR, McCusker J, Belzile E (2008) Comorbidity information in older patients at an emergency visit: self-report vs. administrative data had poor agreement but similar predictive validity. J Clin Epidemiol 61(5):511–515

    PubMed  Google Scholar 

  32. 32.

    Librero J, Peiro S, Ordinana R (1999) Chronic comorbidity and outcomes of hospital care: length of stay, mortality, and readmission at 30 and 365 days. J Clin Epidemiol 52(3):171–179

    CAS  PubMed  Google Scholar 

  33. 33.

    Katz JN et al (1996) Can comorbidity be measured by questionnaire rather than medical record review? Med Care 34(1):73–84

    CAS  PubMed  Google Scholar 

  34. 34.

    Quan H et al (2005) Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care 43(11):1130–1139

    PubMed  PubMed Central  Google Scholar 

  35. 35.

    Armstrong AW, Schupp C, Bebo B (2012) Psoriasis comorbidities: results from the national psoriasis foundation surveys 2003 to 2011. Dermatology 225(2):121–126

    PubMed  Google Scholar 

  36. 36.

    Elmets CA et al (2019) Joint AAD-NPF guidelines of care for the management and treatment of psoriasis with awareness and attention to comorbidities. J Am Acad Dermatol 80(4):1073–1113

    PubMed  Google Scholar 

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This publication was made possible with support from the Agency for Healthcare Research and Quality, grant number K12 HS023011, the Dermatology Foundation.

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Correspondence to Jonathan I. Silverberg.

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Narla, S., Silverberg, J.I. Multimorbidity and mortality risk in hospitalized adults with chronic inflammatory skin disease in the United States. Arch Dermatol Res 312, 507–512 (2020).

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  • Psoriasis
  • Bullous pemphigoid
  • Pemphigus
  • Atopic dermatitis
  • Hidradenitis suppurativa
  • Dermatomyositis
  • Rosacea
  • Lichen planus
  • Alopecia areata
  • Chronic inflammatory skin disease
  • Comorbidity
  • Multimorbidity