Dermatology is becoming increasingly complex, systemic therapies more potent – and the connections between the skin and other organ systems are coming more sharply into clinical focus. One field that remains rather underdiagnosed today is the intersection of skin and heart diseases. We spoke about this with Prof. Dr. Carmen Salavastru.
Whether it is the increased cardiovascular risk in severe psoriasis, the targeted selection of biologics in cardiac patients, or the timely recognition of rare cardio-cutaneous syndromes – modern medical dermatology demands a holistic perspective.
Against this background, we spoke with Prof. Dr. med. Carmen Salavastru (Bucharest), co-editor of the Springer reference work “Skin and the Heart” and chair of a highly regarded symposium on this very topic. Looking back at the international exchange with her colleagues at the AAD Annual Meeting in Denver, the renowned expert in pediatric dermatology and dermato-oncology builds an important bridge from the congress directly into daily clinical practice. The focus: What should practitioners look out for during systemic therapy, which cutaneous warning signs require a cardiological workup, and how can the management of complex cardio-cutaneous cases succeed?
The Expert: Prof. Carmen Salavastru, MD, PhD
Prof. Carmen Salavastru is an internationally renowned dermatologist and Professor at the “Carol Davila” University of Medicine and Pharmacy in Bucharest, Romania. She practices at the Colentina Clinical Hospital, which is a certified EADV Center of Excellence. As a long-standing and active member of the European Academy of Dermatology and Venereology (EADV), she has played a pivotal role in shaping European guidelines and is a recognized expert in pediatric dermatology, atopic dermatitis, and advanced laser therapies. She contributes her extensive scientific expertise to leading academic publications as a Co-Editor, ensuring the highest standards of quality in dermatological research and clinical practice.
The interplay between dermatology and cardiology is often underestimated. What prompted you to dedicate yourself so intensively to this topic with the textbook “Skin and the Heart” published in 2021, and to start now to work on a subsequent edition?
Prof. Dr. med. Carmen Salavastru: “The concept for this book, which covers the links between skin diseases and cardiac diseases was first derived at the EADV congress in Copenhagen in 2015 during a meeting I had with Professor Dedee Murrell, from Sydney, Australia.
Having learned that, while training as a dermatologist, Dr Salavastru had completed her PhD in medical science in a cardiology related topic, Dr Murrell, who herself had considered cardiology as a career after training with some of the leading cardiologists in the UK and USA, thought that the many under-recognised links between cardiovascular disease and skin disease would be fascinating topics to bring together under one cover.
Dr James Otton, an academic cardiologist in Sydney with a PhD and an interest in dermatology thanks to his cardiac imaging work was the icing on the cake in terms of finding a cardiovascular co-editor.
The books covers skin and heart diseases and their relationship like genetic diseases with overlapping manifestations of the skin and heart but also inflammatory and infectious diseases that may induce both skin and cardiac clinical manifestations.
Furthermore, the book includes cardiac complications of drugs used in dermatology.
With a such a large range of pertinent subjects, the book aims reaching a high number of specialists who need to manage very complex cases during their daily practice.
The second edition is considered since so many new data have emerged on these topics since 2021 when the book was published. We plan to have the second edition within next 2 years.”
You recently brought this interdisciplinary topic to the big stage at the AAD Annual Meeting in Denver. Why is “cardio-dermatology” gaining so much importance right now?
Prof. Dr. med. Carmen Salavastru: “This topic highlights growing evidence that chronic inflammatory skin diseases, such as psoriasis, atopic dermatitis, and related conditions, are not limited to the skin but are associated with systemic inflammation that can affect the cardiovascular system. Newer data help clarify the mechanisms linking skin inflammation with increased cardiac risk and explore how disease severity, duration, and treatment choices may influence cardiovascular outcomes. This integrated, cross-disciplinary perspective is still emerging and represents an important shift in how these conditions are understood and managed.”
Psoriasis and atopic dermatitis are systemic diseases. How does systemic inflammatory syndrome affect patients’ cardiovascular risk?
Prof. Dr. med. Carmen Salavastru: “The key message is that inflammatory skin diseases may have important implications beyond visible symptoms. Recognizing and effectively managing inflammation may not only improve skin health but also potentially reduce long-term cardiovascular risk. Skin health and heart health are more closely connected than many people realize.”
What dilemma do dermatologists face when they have to choose a biologic for a patient who already has a pre-existing cardiac condition? Which guidelines or parameters can assist in the decision-making process at the European level?
Prof. Dr. med. Carmen Salavastru: “Currently, the challenge is rarely “which biologic is most effective?”. Most modern biologics achieve high skin clearance rates. Instead, the dilemma is balancing psoriasis control against cardiovascular safety.Severe psoriasis itself is associated with increased cardiovascular risk, including myocardial infarction, stroke, heart failure, and cardiovascular mortality. Effective systemic treatment may reduce systemic inflammation and potentially improve cardiovascular outcomes. However, certain biologics have historical or theoretical concerns in patients with established cardiac disease, especially heart failure.
Current European guidance (European S3 psoriasis guidelines, and cardiovascular risk frameworks such as SCORE2, etc.) supports an individualized assessment based on type of cardiac disease, overall cardiovascular risk profile and expected medication efficacy and safety.
In patients with established heart failure, especially NYHA III–IV, many psoriasis specialists preferentially select an IL-17 or IL-23 inhibitor rather than a TNF inhibitor, while coordinating management with cardiologists.“
Which early skin manifestations should immediately raise alarm bells in daily practice, signaling that the heart might also be affected?
Prof. Dr. med. Carmen Salavastru: “Several skin findings can serve as visible clues to underlying cardiovascular disease. While most dermatologic manifestations are not specific enough to diagnose heart disease on their own, some should prompt clinicians to consider cardiovascular evaluation because they may reflect systemic vascular, inflammatory, embolic, metabolic, or genetic disorders that affect both the skin and the heart. A few examples are: digital ischemia and painful acral lesions, xanthomas in young or middle-aged patients, psoriasis, especially severe or early-onset disease, sever atopic dermatitis, skin lesion suggestive of amyloidosis and many others.“
How can the diagnosis of rare, complex systemic diseases with cardio-cutaneous involvement be achieved within an often tightly scheduled daily practice routine?
Prof. Dr. med. Carmen Salavastru: “This type of diseases is usually diagnosed by multidisciplinary teams; however, in most of the cases, the dermatologists is the first specialist who may raise the possibility of such a disease by recognizing particular or specific cutaneous signs and refer the patient to other specialists.”
Your AAD symposium also addressed the cardiotoxicity of dermatological drugs. Which “classics” of dermatological therapy require particularly close cardiological monitoring?
Prof. Dr. med. Carmen Salavastru: “Janus kinase (JAK) inhibitors have emerged as a progressively utilized therapeutic approach for the management of various skin diseases. However, the complete determination of their cardiovascular safety remains a topic of further assessment. Regulatory agencies emphasize that this elevated CV risk is not uniform across all patients. The risk is disproportionately concentrated in specific patient demographics, including patients aged over 65 years and older, individuals with a history of heavy smoking, patients with pre-existing cardiovascular conditions or multiple CV risk factors.“
What does the ideal interdisciplinary collaboration between dermatologists and cardiologists look like in daily clinical and outpatient practice in your home country of Romania?
Prof. Dr. med. Carmen Salavastru: “The ideal collaboration with colleagues from any other specialty relies on good explanation of the case we wish to have feedback on. Clear and complete presentation of the case and the precise questions we need to answer to lead to the best collaboration, in my experience.”
What is your key take-home message for dermatologists practicing in Germany? What can be implemented with relatively little effort as soon as the “next patient consultation”?
Prof. Dr. med. Carmen Salavastru: “One very important key message that I find very useful is always remember the essentials of our medical and dermatology training and that skin is largest organ of the human body; therefore, it can provide hints to a huge variety of diseases.”
The interview was conducted by Sabine Mack.
