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Psoriasis and Anemia: What’s the Connection?

Posted on May 11, 2022
Medically reviewed by
Ariel D. Teitel, M.D., M.B.A.
Article written by
Kristopher Bunting, M.D.

Anemia is a common comorbidity (co-occurring condition) in people with psoriasis, psoriatic arthritis (PsA), or other inflammatory conditions. Anemia due to iron deficiency or other causes is a major contributor to fatigue, which can dramatically affect quality of life. Because fatigue is a common symptom of inflammatory diseases, it may be overlooked as a sign of anemia as well.

What Is Anemia?

Anemia is a condition that occurs when the blood cannot carry enough oxygen to meet the body’s needs. In anemia, the blood has low levels of hemoglobin, a protein found in red blood cells that carries oxygen.

Anemia can occur for several reasons. You may develop anemia if your body:

  • Is not making enough hemoglobin
  • Is not making enough red blood cells to carry the hemoglobin
  • Is losing blood due to bleeding
  • Is breaking down red blood cells faster than it should

The most common types of anemia with psoriasis are iron deficiency anemia and anemia of chronic disease. In some cases, people with psoriasis may experience pernicious anemia.

Iron Deficiency Anemia

Your body needs iron to make hemoglobin for new blood cells. Iron deficiency anemia can occur if you do not eat enough iron, have poor iron absorption in the gut, or experience blood loss.

Anemia of Chronic Disease

Anemia of chronic disease, also called anemia of inflammation, can occur in people with conditions that cause chronic inflammation, such as psoriasis, chronic kidney disease, and rheumatoid arthritis.

Anemia of chronic disease can prevent the normal production of red blood cells in several ways. Chronic inflammation can shorten the life span of red blood cells. Chronic inflammation can also cause iron to accumulate in macrophages (white blood cells that destroy aging red blood cells), making the iron unavailable to create new hemoglobin.

Additionally, chronic inflammation can decrease iron availability by increasing levels of hepcidin, a hormone that controls iron storage and transport. Inflammation causes high levels of cytokines in the body, which raises levels of hepcidin as well.

Pernicious Anemia

Pernicious anemia is a rare type of autoimmune anemia that sometimes occurs in people with psoriasis or PsA. Your body needs vitamin B12 to make red blood cells. Pernicious anemia causes vitamin B12 deficiency due to poor gastrointestinal absorption of B12.

Intrinsic factor is a protein produced in the stomach that is needed to absorb vitamin B12. Pernicious anemia occurs when the immune system attacks and destroys intrinsic factor or the cells that make it. Without enough intrinsic factor, the body cannot absorb enough vitamin B12 to make the amount of red blood cells it needs.

Other conditions can also cause vitamin B12 deficiency and anemia. These include celiac disease and inflammatory bowel disease, as well as surgeries affecting the stomach and small intestine.

What Causes Anemia With Psoriasis?

Anything that prevents hemoglobin from being made, prevents red blood cells from being made, or destroys blood cells can cause anemia. Research has found that people with psoriasis tend to have poor iron storage — especially people with low body mass. It is not understood how psoriasis causes abnormal iron metabolism and storage, but researchers believe it is not connected to the inflammation associated with psoriasis.

Chronic inflammation can also cause anemia in psoriasis. Chronic inflammation can decrease the production of erythropoietin, a protein produced by the kidneys that stimulates the production of red blood cells. Additionally, chronic inflammation can decrease the life span of red blood cells and prevent the recycling of iron to create more hemoglobin and red blood cells.

Symptoms of Anemia

If you have psoriasis, it’s a good idea to know the signs and symptoms of anemia in case you begin to experience them. Symptoms of all types of anemia can include:

  • Fatigue (tiredness that does not improve with rest)
  • Weakness
  • Shortness of breath
  • Dizziness or lightheadedness
  • Fast or irregular heartbeats
  • Headaches
  • Pale or yellowish skin
  • Cold hands and feet
  • Chest pain

Iron deficiency anemia can cause additional symptoms, including:

  • A sore or inflamed tongue
  • Brittle nails
  • Poor appetite (usually in infants and children)
  • Pica, which may involve eating ice, clay, chalk, or other nonfood items

Pernicious anemia can also cause symptoms of:

  • Numbness or tingling in the hands and feet
  • Difficulty walking or maintaining balance
  • Diarrhea
  • Confusion
  • Loss of smell

Fatigue is typically the most common symptom of anemia. The more severe the anemia, the more symptoms a person will generally experience. People with very mild anemia may not experience any symptoms at all.

Learn more about other causes of fatigue in psoriasis.

How Is Anemia Diagnosed?

Anemia can be diagnosed with a blood test. A complete blood count (CBC) is used to measure hemoglobin levels and the amount of red blood cells in blood. Results of a CBC also include other information that can help identify causes of anemia.

Anemia is defined as having a hemoglobin level less than 13.5 grams per deciliter (gm/dL) in men or 12.0 gm/dL in women. Additional tests can help your doctor diagnose the type and cause of anemia, including blood tests for iron, folate (folic acid or vitamin B9), and vitamin B12.

How Is Anemia Treated?

MyPsoriasisTeam members report that treating anemia has improved their well-being. As one member said, “I’m feeling better now that I’m not anemic anymore.”

Treatment for anemia typically depends on the cause. In the case of anemia with psoriasis, treating your underlying condition can often help improve anemia. Other approaches can also help you manage anemia.

Treating Underlying Inflammation

Treating the underlying cause of inflammatory disease is an important part of treating anemia of chronic disease. Some biologic drugs used to treat psoriasis and PsA can help improve anemia.

Research has shown that tumor necrosis factor alpha inhibitors can improve anemia in people with PsA, ankylosing spondylitis, and related diseases. These drugs include etanercept (Enbrel), adalimumab (Humira), infliximab (Remicade), and golimumab (Simponi).

Increasing Iron Intake

Iron deficiency can often be treated with dietary changes or iron supplements.

Foods that are rich in iron include:

  • Meat
  • Seafood
  • Legumes (beans, peas, and peanuts)
  • Leafy green vegetables like spinach and kale
  • Dried fruit (apricots and raisins)
  • Foods fortified with iron (cereal, bread, and pasta)

Eating foods rich in vitamin C — such as citrus fruits, broccoli, peppers, strawberries, melons, and tomatoes — can also help improve iron absorption.

Eating a balanced, nutritious diet can help prevent iron deficiency. Over-the-counter or prescription iron supplements may be needed to restore healthy iron levels as well. Intravenous iron can also be used to treat iron deficiency, especially in people who cannot tolerate or absorb oral iron supplements.

Learn more about the diet strategies for psoriasis.

Taking Vitamin B12 and Folate Supplements

Supplemental vitamin B12 or folate is often used to treat anemia in people with deficiencies in these vitamins. People who cannot absorb vitamin B12 well, such as those with pernicious anemia, may need synthetic vitamin B12 injections to raise B12 levels.

MyPsoriasisTeam members report that B12 shots have been effective. “My B12 depletes and I have a series of three shots, which bring my B12 levels up for a year or two, it seems,” said one member. Another said, “I was having some general blood tests and have since discovered a vitamin B12 deficiency. I have a regular injection quarterly and my psoriasis is 80 percent better.”

Taking Erythropoietin-Stimulating Agents

In some cases, erythropoietin-stimulating drugs may be used to increase the production of red blood cells. These are usually prescribed for people with low levels of red blood cells due to chronic inflammation, cancer, or chemotherapy.

Having a Blood Transfusion

Severe anemia that is potentially life-threatening may require a blood transfusion. A transfusion of red blood cells is typically only used to treat extremely low hemoglobin levels (less than 7 gm/dL, or about half of the normal minimum hemoglobin levels). A transfusion may also be used for severe anemia that has not responded to other treatments.

Talk With Others Who Understand

MyPsoriasisTeam is the social network for people with psoriasis and their loved ones. On MyPsoriasisTeam, more than 107,000 members come together to ask questions, give advice, and share their stories with others who understand life with psoriasis.

Are you living with psoriasis and anemia? Share your experience in the comments below, or start a conversation by posting on your Activities page.

References
  1. Anemia: Symptoms and Causes — Mayo Clinic
  2. Fatigue: A Main Component of Anemia Symptomatology — Seminars in Oncology
  3. Iron Deficiency Anemia: Symptoms and Causes — Mayo Clinic
  4. Deranged Iron Status in Psoriasis: The Impact of Low Body Mass — Journal of Cachexia, Sarcopenia, and Muscle
  5. Anemia of Chronic Disease — Cleveland Clinic
  6. Update on Inflammation in Chronic Kidney Disease — Blood Purification
  7. Anemia of Chronic Disease — National Organization for Rare Disorders
  8. How Do Red Blood Cells Die? — Frontiers in Physiology
  9. Iron and Hepcidin: A Story of Recycling and Balance — Hematology, ASH Education Program
  10. What Is Pernicious Anaemia? — Pernicious Anaemia Society
  11. Intrinsic Factor — MedlinePlus
  12. Anemia — American Society of Hematology
  13. Craving and Chewing Ice: A Sign of Anemia? — Mayo Clinic
  14. Anemia, Pernicious — National Organization for Rare Disorders
  15. Complete Blood Count (CBC) — Mayo Clinic
  16. Anemia — Cleveland Clinic
  17. Is Iron Deficiency Involved in the Pathogenesis of Chronic Inflammatory Skin Disorders? — Advances in Hygiene and Experimental Medicine
  18. Iron at the Interface of Immunity and Infection — Frontiers in Pharmacology
  19. Anemia of Inflammation — Hematology/Oncology Clinics of North America
  20. Management of Iron Deficiency Anemia — Gastroenterology and Hepatology
  21. Iron-Deficiency Anemia — American Society of Hematology
  22. Erythropoietin-Stimulating Agents — Cleveland Clinic
  23. The Effect of Golimumab on Haemoglobin Levels in Patients With Rheumatoid Arthritis, Psoriatic Arthritis, or Ankylosing Spondylitis — Rheumatology
  24. Anti-TNF-Alpha Effects on Anemia in Rheumatoid and Psoriatic Arthritis — International Journal of Immunopathology and Pharmacology

All updates must be accompanied by text or a picture.
Ariel D. Teitel, M.D., M.B.A. is the clinical associate professor of medicine at the NYU Langone Medical Center in New York. Review provided by VeriMed Healthcare Network. Learn more about him here.
Kristopher Bunting, M.D. studied chemistry and life sciences at the U.S. Military Academy, West Point, and received his doctor of medicine degree from Tulane University. Learn more about him here.

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