Psoriasis

 What Is Psoriasis?

Psoriasis is a chronic, autommune relapsing skin disorder characterized by scaling, erythema (redness), and less commonly, pustulation.1 

The body surface area affected and the degree to which psoriasis is a problem varies considerably among patients and over time.2 Often there are additional manifestations in the nails and in joints.3

Q: Are there different forms of psoriasis?

A: There are five forms of psoriasis. The lesions in all forms are itchy and red but vary in appearance and severity. Plaque psoriasis is the most common form observed in more than 80% of patients. Atypical forms include guttate, inverse, pustular, and erythrodermic psoriasis.4

• Plaque psoriasis features thickened or raised red areas that have a distinct edge and are covered with silvery white buildup of flaky skin typically on elbows, knees, scalp and buttocks.
• Gutate psoriasis appears as small, flat red patches with shiny buildup that are not usually painful, just itchy. There may be a few or many patches and they can group together.
• Inverse psoriasis affects folds of skin, armpits and the groin area. Lesions are deep red with shiny buildup. It can be a thin red area along a crease line or involve, for example, the whole armpit.
• Pustular psoriasis features an itchy, red base followed by blisters of white, non-infectious pus that appears glossy after a day or two and then sloughs in cycles. These areas may be limited to certain areas such as the hands and feet or be more widespread.
• Erythrodermic psoriasis involves large areas of the body’s surface, inflaming normal skin and changing it into very red, raw looking flesh that is painful, swollen and itchy. This form requires extensive treatment, and complications can be life-threatening. Fortunately, this form of psoriasis is the least common.

Psoriasis in children has been reported to differ from that among adults being more frequently itchy and plaque lesions are relatively thinner, softer, and less scaly, face and flexural involvement is common and guttate type is the characteristic presentation.5

In children, psoriasis is a common skin disorder with about one third of all patients having onset of disease in the first or second decade of life. A chronic disfiguring skin disease, such as psoriasis, in childhood is likely to have profound emotional and psychological effects, and hence requires special attention.6

What Is Psoriasis In Celiac Disease and/or Gluten Sensitivity?

• Relationship between psoriasis and celiac disease. Psoriasis is an associated autoimmune disorder of celiac disease.
• Relationship between psoriasis and gluten. The association between celiac disease and other immune disorders may be due to the sharing of a common genetic background, such as HLA antigens. However, in a very large study, involving 909 patients with celiac disease, Ventura and his associates found that the development of immune disorders in celiac disease was clearly related to the duration of exposure to gluten.7
• Relationship between psoriasis and diet. Psoriasis patients with elevated anti-gliadin antibodies might improve on a gluten free diet even if they have no celiac specific endomysium antibodies or if the increase in duodenal intraepithelial lymphocytes is slight or seemingly absent. After gluten free diet, the anti-gliadin antibodies values were lower in 82% of study patients who improved. When the ordinary diet was resumed, the psoriasis deteriorated in 18 of the 30 patients with anti-gliadin antibodies who had completed the gluten free diet period.8

How Prevalent Is Psoriasis In Celiac Disease and/or Gluten Sensitivity?

There is a high prevalence of celiac disease (4.3%) in psoriasis.9 In a nationwide study based on histopathological evidence of celiac disease, 42% of all psoriasis in patients with celiac disease could be attributed to the underlying celiac disease.10

What Are The Symptoms Of Psoriasis?

• Psoriasis is marked by gradual onset of red, scaly plaques with sharply defined borders appearing on scalp, knees, shins, elbows, umbilicus, lower back, buttocks, ears, and along hairline.
• Depending on the form of psoriasis, plaques may appear as a few patches, or they may be appear as many small patches, or patches may progressively enlarge and become extensive.
• Pustules may develop in some, and in few persons, the entire body skin surface may be involved.
• Nails involvement can appear as pitting and/or opaque thickened areas with vertical ridges that may affect one or more fingernails and/or toenails and can be mistaken for a fungal infection.
• Splinter hemorrhages under nails appear more commonly in psoriasis than in psoriatic arthritis.11
• Pain or irritation of the eyes in some because of inflammation of the uveal tract (called uveitis) caused by autoimmune antibodies produced in psoriasis.  The uveal tract located in the front of the eye has a rich supply of blood vessels.

How Does Psoriasis Develop In Celiac Disease and/or Gluten Sensitivity?

• Psoriasis has been classified as a T-cell-mediated, autoimmune disease because of the primacy of the immune system in the development of psoriasis.12 A complex interplay between environmental and genetic factors allows activation of the immune system and generation of immune dendritic cells and effector T cells that reside in the skin and interact with keratinocytes (skin cells).13 Dendritic cells and effector T-cells produce cytokines (chemical messengers) that stimulate keratinocytes to multiply rapidly and increase the movement of inflammatory cells into the skin. The result is inflammation and excessive growth of the epidermis.14
• While the development of psoriasis in celiac disease is thought to involve four various mechanisms below, the risk of psoriasis was found to be higher in patients with vitamin D deficiency compared to controls. (7% vs. 3%).15 showing that psoriatic lesions in celiac disease patients may be partly due to vitamin D deficiency.16

•  Malabsorption in celiac disease, both before and after diagnosis, increases the risk of vitamin D deficiency, and also, the gluten-free diet is often low in vitamin D. Exposure to sun light as well administration of vitamin D analog creams have a beneficial effect on psoriasis.17
• Inflammation in patients with celiac disease (before and after diagnosis), exposure to gliadin will trigger a CD4+ T-cell response and a cascade of pro-inflammatory cytokines such as IFN-γ. The increased number of T cells in the blood may affect also the dermis and epidermis, thereby stimulating the development of psoriasis. The psoriatic plaque is characterized by a marked infiltration of activated CD4+ and CD8+ T cells. CD4+ T cells infiltrate mainly the dermis, whereas CD8+ T cells are present in the epidermis.
• Shared genetic factors could have a role. Liu et al. (2008) first described a psoriatic locus on chromosome 4q27 that harbors both IL-2 and IL-21. This locus (IL2/21) has previously been linked to celiac disease.
•  Increased intestinal permeability (leaky gut) is seen in patients with psoriasis. Disturbed intestinal permeability is a hallmark of celiac disease.18

Does Psoriasis Respond To Gluten-Free Diet?

Yes. Celiac disease-related psoriasis can be improved by a gluten free diet by restoring normal absorption and vitamin D levels.16,19,20

6 Steps To Improve Psoriasis In Celiac Disease and/or Gluten Sensitivity:

• 1Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

• 2 Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

• 3 Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• 4 Manage Your Medications Safely:

• 5Nutritional Supplements To Help Correct Deficiencies:

• 6Manage Natural Remedies: 

What Do Medical Research Studies Tell About Psoriasis In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Vitamin D status and concomitant autoimmunity in celiac disease.” This retrospective cross-sectional study investigated whether 530 adult patients with celiac disease and low vitamin D levels at Columbia University Medical Center also had a higher prevalence of other autoimmune diseases as compared with patients with normal vitamin D levels. Researchers found that the risk of psoriasis is increased in vitamin D-deficient celiac disease patients but while vitamin D deficiency in celiac disease is common, it does not predict autoimmune disease.

One hundred thirty-three patients (25%) had vitamin D deficiency. The prevalence of autoimmune disease was similar among those with normal vitamin D levels (11%), insufficiency (9%), and deficiency (12%, P=0.66). On multivariate analysis, adjusting for age of celiac disease diagnosis and sex, vitamin D deficiency was not associated with autoimmune disease. The risk of psoriasis was higher in patients with vitamin D deficiency (7% vs. 3%). Vitamin D deficiency was more common in those who presented with anemia (39%) than in those who did not (23% P=0.002).Assessment of vitamin D seems to be a high-yield practice, especially in those CD patients who present with anemia.15.

“Psoriatic arthritis and onycholysis — results from the cross-sectional Reykjavik psoriatic arthritis study.” This study investigating the different patterns of nail disease in psoriasis and psoriatic arthritis (PsA) with respect to the frequency of linear pitting and splinter hemorrhages found that both occurred more frequently in psoriasis.

A total of 173 patients were recruited: 121 PsA cases and 52 psoriasis cases. All patients had a standardized assessment of the nails for lesions including pitting, splinter hemorrhages and onycholysis.

RESULTS: The overall modified Nail Psoriasis Severity Index scores did not differ between the two groups (psoriasis mean 8.5, SD 7.1; PsA mean 8.3, SD 9.4). In the nail matrix, linear pitting appeared to be more common in skin psoriasis (OR 0.27, 95% CI 0.18-0.41). There were no significant differences in the distribution of nail plate abnormalities other than splinter hemorrhages which were more commonly seen in psoriasis cases (OR 0.23, 95% CI 0.14-0.39).23

“Psoriasis in a Nationwide Cohort Study of Patients with Celiac Disease.” This study investigating the association between celiac disease and psoriasis by assessing the risk of psoriasis in patients with biopsy-verified celiac disease found that individuals with celiac disease were at increased risk of psoriasis both before and after celiac disease diagnosis.

Through 28 pathology departments in Sweden, researchers identified individuals with celiac disease diagnosed between 1969 and 2008 (28,958 individuals with Marsh 3: villous atrophy). Cox regression was used to compare individuals with celiac disease with 143,910 sex- and age-matched controls regarding their risk of psoriasis. Celiac disease was a risk factor for future psoriasis. During follow-up, 401 individuals with celiac disease and 1,139 controls had a diagnosis of psoriasis. The absolute risk of future psoriasis in patients with celiac disease was 135/100,000 person-years (excess risk=57/100,000). In all, 42% of all psoriasis in patients with celiac disease could be attributed to the underlying celiac disease. Moreover, in children there was a positive association between celiac disease and psoriasis. The association between celiac disease and psoriasis seems to be independent of a temporal relationship, as researchers also found a positive association between celiac disease and psoriasis before celiac disease diagnosis.24

“Psoriasis patients with antibodies to gliadin can be improved by a gluten-free diet.” This study investigated the effect of a gluten-free diet in 33 anti-gliadin (AGA)-positive and six anti-gliadin (AGA)-negative psoriasis patients. Researchers found that psoriasis patients with elevated AGA might improve on a gluten free diet even if they have no celiac specific endomysium antibodies or if the increase in duodenal intraepithelial lymphocytes is slight or seemingly absent.

Of the 33 AGA-positive patients, two had IgA antibodies to endomysium (EmA) and 15 an increased number of lymphocytes in the duodenal epithelium, but in some this increase was slight. Two patients had villous atrophy. A 3-month period on a gluten free diet was followed by 3 months on the patient’s ordinary diet. The severity of psoriasis was evaluated with the psoriasis area and severity index (PASI). The examining dermatologists were unaware of the EmA and duodenal biopsy results throughout the study.

Thirty of the 33 patients with AGA completed the glutet free diet period, after which they showed a highly significant decrease in mean PASI. This included a significant decrease in the 16 AGA-positive patients with normal routine histology in duodenal biopsy specimens. The AGA-negative patients were not improved. After gluten free diet, the AGA values were lower in 82% of those who improved. There was a highly significant decrease in serum eosinophil cationic protein in patients with elevated AGA. When the ordinary diet was resumed, the psoriasis deteriorated in 18 of the 30 patients with AGA who had completed the gluten free diet period.19

CASE REPORT SUMMARIES

“Osteomalacia associated with cutaneous psoriasis as the presenting feature of coeliac disease: a case report.” This case report describes a patient with celiac disease who presented with osteomalacia and psoriasis without classical symptoms of celiac disease. A 25-year-old North African Tunisian white woman was admitted to the hospital because of a 1-year history of bone pain, weight loss and weakness. She had cutaneous psoriasis on dermatologic examination. She had also anemia, hypocalcemia and pathological fracture. She was diagnosed to have osteomalacia on the basis of clinical, biological and radiological findings. Further investigations revealed the presence of antiglutaminase antibodies, and histopathologic findings of the duodenal biopsy were consistent with celiac disease.

The patient showed a fast response to gluten-free diet, and full recovery with calcium and vitamin D replacement. Celiac disease is frequently misdiagnosed leading to major complications such as osteolamacia. In the other hand, osteomalacia can still be the presenting feature of undiagnosed celiac disease. Association between osteomalacia and cutaneous psoriasis is rarely reported.25

“Rapid regression of psoriasis in a coeliac patient after gluten-free diet.” This case report describes dramatic and rapid regression of significant and widespread psoriatic skin lesions in a celiac disease patient after a short time on a gluten free diet without pharmacologic support. Patient had not previously responded to pharmacological therapy. He had mild peripheral edema, iron deficiency anemia with microcytosis, low serum levels of folate, vitamin B12, vitamin D, and leukocytosis with neutrophilia. Anti-endomysial antibodies (EMA) were absent and IgA and IgG antibodies to gliadin serum levels were not raised, whereas total immuoglobulin IgA were increased. Duodenal biopsy showed total atrophy of intestinal villi and intra-epithelial inflammatory infiltrate. Steatorrhea was present and a severe degree of osteoporosis.16

1. Addolorato G, Parente A, de Lorenzi G, et al. Rapid regression of psoriasis in a coeliac patient after gluten-free diet. A case report and review of the literature. Digestion. 2003;68(1):9-12. [↩]
2. Stern, R. S., Nijsten, T., Feldman, S. R., Margolis, D. J. and Rolstad, T.

   Psoriasis is common, carries a substantial burden even when not extensive, and is associated with widespread treatment dissatisfaction. J. Invest. Dermatol. Symp.. 2004 Mar;9(2):136-9.. [↩]

3. Weigle N, McBane S. Psoriasis. Am Fam Physician. 2013 May 1;87(9):626-33. [↩]
4. Weigle N, McBane S. Psoriasis. Am Fam Physician. 2013 May 1;87(9):626-33. [↩]
5. Dogra S, Kaur I. Childhood psoriasis. Indian J Dermatol Venereol Leprol. 2010 Jul-Aug;76(4):357-65. doi: 10.4103/0378-6323.66580. [↩]
6. Dogra S, Kaur I. Childhood psoriasis. Indian J Dermatol Venereol Leprol. 2010 Jul-Aug;76(4):357-65. doi: 10.4103/0378-6323.66580. [↩]
7. La Villa G, Pantaleo P, Tarquini R, Cirami L, Perfetto F, Mancuso F, Laffi G. Multiple immune disorders in unrecognized celiac disease: a case report. World J Gastroenterol. 2003;9(6):1377-1380, Available at: http://www.wjgnet.com/1007-9327/9/1377.asp. [↩]
8. Michaëlsson G, Gerdén B, Hagforsen E, Nilsson B, Pihl-Lundin I, Kraaz W, Hjelmquist G, Lööf L. Psoriasis patients with antibodies to gliadin can be improved by a gluten-free diet. Br J Dermatol. 2000 Jan;142(1):44-51. [↩]
9. Ojetti V, Aguilar Sanchez J, Guerriero C, et al. High prevalence of celiac disease in psoriasis. American Journal of Gastroenterology. Nov 2003;98(11):2574-5. [↩]
10. Ludvigsson J, Lindelöf B, Zingone F, and Ciacci C. Psoriasis in a Nationwide Cohort Study of Patients with Celiac Disease. Journal of Investigative Dermatology (2011) 131, 2010–2016; doi:10.1038/jid.2011.162. [↩]
11. Love TJ, Gudjonsson JE, Valdimarsson H, Gudbjornsson B. Psoriatic arthritis and onycholysis — results from the cross-sectional Reykjavik psoriatic arthritis study. J Rheumatol. 2012 Jul;39(7):1441-4. doi: 10.3899/jrheum.111298. [↩]
12. Kirby B, Griffiths CE. Novel immune-based therapies for psoriasis. Br J Dermatol. 2002 Apr;146(4):546-51. [↩]
13. Ruiz M, Valdés P, Tomecki K. Selected skin diseases with systemic involvement. Skin Therapy Lett. 2013 Jun;18(4):1-4. [↩]
14. Monteleone G, Pallone F, MacDonald TT, Chimenti S, Costanzo A. Psoriasis: from pathogenesis to novel therapeutic approaches. Clin Sci (Lond). 2011 Jan;120(1):1-11. doi: 10.1042/CS20100163. [↩]
15. Tavakkoli A, DiGiacomo D, Green PH, Lebwohl B. Vitamin D status and concomitant autoimmunity in celiac disease. J Clin Gastroenterol. 2013 Jul;47(6):515-9. doi: 10.1097/MCG.0b013e318266f81b [↩] [↩]
16. Addolorato G, Parente A, de Lorenzi G, et al. Rapid regression of psoriasis in a coeliac patient after gluten-free diet. A case report and review of the literature. Digestion. 2003;68(1):9-12. [↩] [↩] [↩]
17. Ludvigsson J, Lindelöf B, Zingone F, and Ciacci C. Psoriasis in a Nationwide Cohort Study of Patients with Celiac Disease. Journal of Investigative Dermatology. (2011) 131, 2010–2016; doi:10.1038/jid.2011.162; published online 9 June 2011. [↩]
18. Ludvigsson J, Lindelöf B, Zingone F, and Ciacci C. Psoriasis in a Nationwide Cohort Study of Patients with Celiac Disease. Journal of Investigative Dermatology. (2011) 131, 2010–2016; doi:10.1038/jid.2011.162; published online 9 June 2011. [↩]
19. Michaëlsson G, Gerdén B, Hagforsen E, Nilsson B, Pihl-Lundin I, Kraaz W, Hjelmquist G, Lööf L. Psoriasis patients with antibodies to gliadin can be improved by a gluten-free diet. Br J Dermatol. 2000 Jan;142(1):44-51. [↩] [↩]
20. Frikha F, Snoussi M, Bahloul Z. Osteomalacia associated with cutaneous psoriasis as the presenting feature of coeliac disease: a case report. Pan Afr Med J. 2012;11:58. Epub 2012 Mar 27. [↩]
21. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
22. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
23. Love TJ, Gudjonsson JE, Valdimarsson H, Gudbjornsson B. Psoriatic arthritis and onycholysis — results from the cross-sectional Reykjavik psoriatic arthritis study. J Rheumatol. 2012 Jul;39(7):1441-4. doi: 10.3899/jrheum.111298. [↩]
24. Ludvigsson J, Lindelöf B, Zingone F, and Ciacci C. Psoriasis in a Nationwide Cohort Study of Patients with Celiac Disease. Journal of Investigative Dermatology (2011) 131, 2010–2016; doi:10.1038/jid.2011.162. [↩]
25. Frikha F, Snoussi M, Bahloul Z. Osteomalacia associated with cutaneous psoriasis as the presenting feature of coeliac disease: a case report. Pan Afr Med J. 2012;11:58. [↩]