Environmental Risk Factors in Psoriasis: The Point of View of the Nutritionist

Deciphering the Association Between Psoriasis and Obesity: Current Evidence and Treatment Considerations

PURPOSE OF REVIEW

Obesity and psoriasis represent chronic inflammatory states that are interconnected in a vicious cycle, sharing also a degree of synergy. In this review, we aim to decipher the various lines of evidence supporting the bidirectional association between psoriasis and obesity highlighting their pathophysiologic connections as well as we attempt to strategize a therapeutic holistic approach for obese psoriatic patients.

RECENT FINDINGS

Recent meta-analyses have shown that (1) genetically higher BMI increased the odds of psoriasis occurrence; (2) obesity is associated with higher incidence and prevalence of psoriasis as well as psoriasis severity; (3) obesity is associated with lower efficacy to anti-TNF agents and may predict biologic treatment discontinuation; and (4) weight loss through diet and physical exercise may improve pre-existing psoriasis and prevent from de novo psoriasis. Methotrexate, acitretin, and cyclosporine could worsen hypertension, liver steatosis, and dyslipidemia. Since infliximab and ustekinumab are weight adjusted, they may be ideal drugs to treat obese psoriatic patients. IL-17 inhibitors are very effective independently from body weight; however, they tend to present better clearance rates in normal weight patients. There is a paucity on weight data regarding the efficacious IL-23 inhibitors. Apremilast may induce weight loss as an adverse effect presenting also some beneficial metabolic actions. Finally, simvastatin and some antidiabetic drugs could decrease psoriasis severity. More mechanistic, observational studies and well-conducted RCTs are necessary to decipher the enigmatic link between psoriasis and obesity, and to provide evidence-based specific guidelines for the screening and management of obese psoriatic patients.

Phase Angle: Could Be an Easy Tool to Detect Low-Grade Systemic Inflammation in Adults Affected by Prader-Willi Syndrome?

Prader-Willi syndrome (PWS) is the most common genetic inherited obesity syndrome. Obesity-related complications, mostly related to chronic low-grade systemic inflammation (LGI), are the commonest cause of mortality and morbidity in PWS adults. Phase angle (PhA) is an easy tool to screen a state of LGI in healthy subjects and in subjects with obesity and is obtained from bioelectrical impedance analysis (BIA). The aim of this study was to validate the PhA in PWS adults as a potential biomarker of LGI. In this single-center, cross-sectional study, fifteen PWS adults (six males, aged 19-41 years, and body mass index (BMI) 31.0-68.0 Kg/m2) and fifteen control subjects matched by gender, age, and BMI were evaluated. PhA values were significantly lower (p < 0.001), while high-sensitivity C-reactive protein (hs-CRP) levels were significantly higher (p < 0.001) in PWS adults compared with controls (p < 0.001), without a gender difference in the latter. After adjustment for gender, BMI, and waist circumference, significant correlation was found between PhA and hs-CRP levels (r = -0.69, p = 0.01). At the ROC analysis, the threshold value of PhA predicting the highest hs-CRP levels above the median value was found at PhA ≤ 4.8° (p = 0.01; AUC, 0.82; standard error, 0.12; 95% CI, 0.58 to 1.00). These results suggest that PWS adults had a significant higher degree of LGI compared with their counterparts. Moreover, our finding suggest that PhA is a valid biomarker of LGI also in PWS adults.

Mediterranean Diet as a Tool to Combat Inflammation and Chronic Diseases. An Overview

Since ancient times, the quality of nourishment is a milestone for the maintenance of health and as it is stated 'prevention is better than cure', amongst the so-called 'healthy' diets Mediterranean diet (MD) claims the lion's share. It stands in good stead because of a variety of valuable macro- and micronutrients. So, adherence to a MD is associated with the reduction of inflammation and non-communicable (NCD) OR chronic diseases. Numerous studies try to scrutinize the role of MD components as regards reducing inflammation, lowering rate, and mortality for disorders and illnesses, and preventing NCD. MD regime of the inhabitants of the Mediterranean basin includes a variety of ethnic nutritional habits and regulates an array of effects and epigenetic changes that affect human wellbeing. The research is still ongoing and endeavors to elucidate every aspect of this issue. This review focuses on the impact of MD on inflammation highlights positive results regarding NCD and indicates the need for more high-quality experiments and trials in order to overcome any discrepancies.

Vitamin D and psoriasis: an update for dermatologists and nutritionists

Psoriasis is a common chronic immune-mediated inflammatory skin disease, now considered a systemic inflammatory process with several comorbidities. The skin produces vitamin D by the action of ultraviolet light. Vitamin D performs various immunomodulatory, anti-inflammatory, antioxidant and antifibrotic actions. The immunomodulatory effects of vitamin D offer opportunities to improve the treatment of several autoimmune diseases, such as psoriasis. In the literature, several significant associations are reported between low levels of vitamin D and psoriasis. Today, topical vitamin D represents an important therapeutic option due to its action on the proliferation and maturation of keratinocytes. The situation is different regarding the oral intake and integration of vitamin D in psoriasis patients. The use of vitamin D supplementation as an adjunctive treatment option in these patients is still discussed. This work aims to analyze the association between psoriasis and vitamin D levels according to dermatologists and nutritionists.

Gut microbiota and nutrient interactions with skin in psoriasis: A comprehensive review of animal and human studies

The intestinal tract (i.e., the gut), is where the body's nutrients are absorbed, and is simultaneously inhabited by numerous microbes. An increasing body of literature suggests a crucial role for the gut microbiome in modulating systemic inflammatory disease. Psoriasis is a chronic systemic inflammatory disease and its pathogenesis is related to the interaction between genetic susceptibility, immune response and environmental triggers. The omics era has allowed physicians to assess different aspects of psoriasis pathogenesis such as the microbiome, infectome, and autoinfectome. Furthermore, diet appears to play an important role in modulating disease activity, perhaps by influencing gut microbes. Given these observations, we aimed to summarize the current knowledge regarding skin-microbiome-gut-nutrients and psoriasis.

A single nucleotide polymorphism within HOX Transcript Antisense RNA (HOTAIR) is associated with risk of psoriasis

Recent studies have shown participation of long non-coding RNAs (lncRNAs) in the pathogenesis of psoriasis. Several mechanisms might be involved in the dysregulation of expression of lncRNAs in patients with psoriasis, among them is the presence of single nucleotide polymorphisms (SNPs) which modulate expression or function of these transcripts. In the present work, we genotyped three SNPs (rs12826786, rs1899663 and rs4759314) of the HOX Transcript Antisense RNA (HOTAIR) in 286 patients with psoriasis and 300 control subjects. The rs12826786 was associated with risk of psoriasis in dominant model (TC + TT vs. CC: OR (95% CI) = 1.59 (0.1.14-2.22), adjusted p-value = .02). In the allelic model, T allele of this SNP significantly increased the risk of psoriasis compared with the C allele (OR (95% CI) = 1.35 (1.06-1.71), adjusted p-value = .04). Other SNPs were not associated with risk of psoriasis in any inheritance model. No significant difference was found in haplotype frequencies between cases and controls. The current work shows association between a genomic variant within HOTAIR and risk of psoriasis. The clinical significance of this finding should be assessed in future studies.

Adalimumab changes the expression profile of selected BCL-2 family genes

Biological drugs are an alternative to treatment of psoriasis and psoriatic arthritis. Adalimumab is a representative of the anti-TNF group. The underlying of this disease is a cellular homeostasis disorder-apoptosis. Many proteins are involved in the apoptosis induction pathways, including those from the BCL-2 family. The aim of the study was to perform a transcriptional analysis of the genes coding selected proteins from the BCL-2 family in patients treated with adalimumab therapy, and to determine the direction of these changes. The test materials were peripheral blood mononuclear cells. The cells were obtained from 20 patients with psoriatic arthritis who were being treated with adalimumab (study group) and 20 healthy volunteers (control). The gene expression profile was determined using the real-time quantitative reverse transcription polymerase chain reaction technique. Statistically significant changes were observed in the expression level of the BNIP3, BNIP3L, and BCL2L1 genes (p < .05) during a 24-month observation of therapy. We indicated that adalimumab therapy has an impact on the expression of the analyzed genes, which may constitute a new class of molecular markers for assessing the effectiveness of a therapy. It appears that the BNIP3L gene could be used as a potential diagnostic marker of psoriasis.

A Comparison of The Effects of Clobetasol 0.05% and Photodynamic Therapy Using Aminolevulinic Acid With Red Light in the Treatment of Severe Nail Psoriasis

Introduction: The treatment of nail psoriasis is often difficult and unsatisfactory due to therapy resistance. This study aimed to compare the efficacy of clobetasol 0.05% ointment and photodynamic therapy (PDT) using aminolevulinic acid (ALA) and red light in the treatment of severe nail psoriasis. Methods: This open-trial study included 69 nails of 8 patients with severe nail psoriasis. Thirty-four nails were treated with clobetasol 0.05% ointment and 35 nails were treated with ALA-PDT. ALAPDT treatment was performed every 3 weeks for 5 cycles; the nails were treated with clobetasol under occlusion every day during the study. All the patients were followed up after 24 weeks. The severity of nail involvement was measured by the Nail Psoriasis Severity Index (NAPSI) scores at the baseline and during the treatment. Results: There were no significant differences in the NAPSI scores between the treatment groups in the baseline and weeks 3, 6 and 9 (all P>0.05), although significant differences were found in weeks 12, 15 and 24 (follow-up) (P<0.001). A significant time-effect improvement was found in all the nailmatrix, nail-bed and total NAPSI scores in both treatment groups (all P<0.001). The patients did not report intense pain and discomfort during irradiation. Conclusion: Clobetasol 0.05% ointment seems to be effective in treating nail psoriasis after a treatment period of 15 weeks. However, the efficacy of ALA-PDT at a 24-week follow-up was greater than that of clobetasol.

Psoriasis and Metabolic Syndrome: Comorbidities and Environmental and Therapeutic Implications

Psoriasis (PS) is an incessant, fiery skin sickness characterized by erythematous plaques with thick silvery scales, white or red patches of the skin, which encompasses several immunological, biomolecular, genetic, and environmental factors that may lead to further development of metabolic syndrome (MS) and vice versa. Metabolic syndrome is composed of multiple components (high blood pressure, abdominal obesity, glucose intolerance, and dyslipidemia) of risk factors that arise primarily from insulin resistance, mostly mediated by inflammatory cytokines, such as tumor necrosis factor alpha (TNF-α), interleukin-6 (IL-6) together with leptin and adiponectin, which are molecules also found in PS. The incidence, severity, and poor prognosis of the psoriatic diseases could be influenced by cardiometabolic diseases, which are controllable or preventable with intense lifestyle modification such as diet, exercise, and weight control. We performed a far-reaching writing search of different databases as part of this review; 47 investigations were regarded as important based on our search. Fasting, proper weight management, and special diet modifications seemed to have a positive impact on the management of PS. This review agrees with previous literature that nutritionists and specialists of preventive medicine should play a central role in the evaluation and management of psoriatic patients. We recommended that the management of this disease should focus on the environmental factors first instead of the genetic and immunologic pathways.

Increased risk of psoriasis in children and elderly patients with asthma: a longitudinal follow-up study using a national sample cohort

BACKGROUND

Several previous studies reported the elevated risk of asthma in children with psoriasis. This study aimed to extend previous research regarding the risk of psoriasis in children with asthma to an entire population subdivided by age.

METHODS

The 2002-2013 Korean Health Insurance Review and Assessment Service-National Sample Cohort (HIRA-NSC) was used. The 167,693 participants with asthma were matched with 167,693 control participants for age, sex, income, region of residence, hypertension history, diabetes history, and dyslipidemia history. In both the asthma and control groups, the occurrences of asthma were investigated. The crude and adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for psoriasis with respect to asthma status were determined using stratified Cox proportional hazards models. Subgroup analyses were conducted according to age and sex.

RESULTS

The prevalence of psoriasis was 0.5% (95% CI, 0.4% to 0.5%; n = 771/167,693) in the asthma group and 0.4% (95% CI, 0.3% to 0.4%; n = 589/167,693) in the control group (p < 0.001). The asthma group (adjusted HR = 1.19; 95% CI, 1.07 to 1.33; p = 0.002) demonstrated higher HRs for psoriasis than did the control group. This result was consistent in the <15 years old, ≥60 years old, and women subgroups.

CONCLUSION

Asthma was associated with the elevated risk of psoriasis. The possible risk of psoriasis needs to be considered when managing asthma patients. Future study is warranted for the risk of psoriasis according to the endotypes of asthma.

Association Between Mediterranean Anti-inflammatory Dietary Profile and Severity of Psoriasis: Results From the NutriNet-Santé Cohort

Importance

Psoriasis is a chronic inflammatory disease. The Mediterranean diet has been shown to reduce chronic inflammation and has a positive effect on the risk of metabolic syndrome and cardiovascular events. Thus, we hypothesized a positive effect on the onset and/or severity of psoriasis.

Objective

To assess the association between a score that reflects the adhesion to a Mediterranean diet (MEDI-LITE) and the onset and/or severity of psoriasis.

Design, Setting, and Participants

The NutriNet-Santé program is an ongoing, observational, web-based questionnaire cohort study launched in France in May 2009. The present study was performed within the framework of the NutriNet-Santé program, with data collected and analyzed between April 2017 and June 2017. Patients with psoriasis were identified via a validated online self-completed questionnaire and then categorized by disease severity: severe psoriasis, nonsevere psoriasis, and psoriasis-free. Data on dietary intake (including alcohol) were gathered during the first 2 years of participation in the cohort to calculate the MEDI-LITE score (ranging from 0 for no adherence to 18 for maximum adherence). Potentially confounding variables (eg, age, sex, physical activity, body mass index, tobacco use, and a history of cardiovascular disease) were also recorded. Analyses used adjusted multinomial logistic regression to estimate the risk of having severe psoriasis or nonsevere psoriasis compared with being psoriasis-free.

Results

Of the 158 361 total NutriNet-Santé participants, 35 735 (23%) replied to the psoriasis questionnaire. The mean (SD) age of the respondents was 47.5 (14.0) years; 27 220 (76%) of the respondents were women. Of these 35 735 respondents, 3557 (10%) individuals reported having psoriasis. The condition was severe in 878 cases (24.7%), and 299 (8.4%) incident cases were recorded (those arising more than 2 years after participant inclusion in the cohort). After adjustment for confounding factors, a significant inverse relationship was found between the MEDI-LITE score and having severe psoriasis: odds ratio (OR), 0.71; 95% CI, 0.55-0.92 for the MEDI-LITE score's second tertile (score of 8 to 9); and OR, 0.78; 95% CI, 0.59-1.01 for the third tertile (score of 10 to 18).

Conclusions and Relevance

Patients with severe psoriasis displayed low levels of adherence to the Mediterranean diet; this finding supports the hypothesis that the Mediterranean diet may slow the progression of psoriasis. If these findings are confirmed, adherence to a Mediterranean diet should be integrated into the routine management of moderate to severe psoriasis.

Risk Factors for the Development of Psoriasis

Psoriasis is an immune-mediated genetic skin disease. The underlying pathomechanisms involve complex interaction between the innate and adaptive immune system. T cells interact with dendritic cells, macrophages, and keratinocytes, which can be mediated by their secreted cytokines. In the past decade, biologics targeting tumor necrosis factor-α, interleukin (IL)-23, and IL-17 have been developed and approved for the treatment of psoriasis. These biologics have dramatically changed the treatment and management of psoriasis. In contrast, various triggering factors can elicit the disease in genetically predisposed individuals. Recent studies suggest that the exacerbation of psoriasis can lead to systemic inflammation and cardiovascular comorbidity. In addition, psoriasis may be associated with other auto-inflammatory and auto-immune diseases. In this review, we summarize the risk factors, which can be divided into two groups (namely, extrinsic and intrinsic risk factors), responsible for the onset and exacerbation of psoriasis in order to facilitate its prevention.

Dietary compounds as potential modulators of microRNA expression in psoriasis

Nutrigenomic DNA reprogramming in different chronic diseases and cancer has been assessed through the stimulation of gene expression and mRNA synthesis versus DNA silencing by CpG DNA modification (methylation); histone modification (acetylation, methylation) and expression of small noncoding RNAs, known as microRNAs (miRNAs). With regard to the specific nutrigenomic effects in psoriasis, the influence of specific diets on inflammatory cell signaling transcriptional factors such as nuclear factor (NF)-κB and Wnt signaling pathways, on disease-related specific cytokine expression, pro/antioxidant balance, keratinocyte proliferation/apoptosis and on proliferation/differentiation ratio have been documented; however, the influence of dietary compounds on the balance between 'good and bad' miRNA expression has not been considered. This review aims to summarize knowledge about aberrant microRNAs expression in psoriasis and to emphasize the potential impact of some dietary compounds on endogenous miRNA synthesis in experimental conditions in vivo and in vitro. Among the aberrantly expressed miRNAs in psoriasis, one of the most prominently upregulated seems to be miR-21. The beneficial effects of phenolic compounds (curcumin and resveratrol), vitamin D, methyl donors, and omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid) are discussed. Highly expressed miR-155 has been downregulated by flavonoids (through a quercetin-rich diet) and by vitamin D. Quercetin has been effective in modulating miR-146a. On the other hand, downregulated miR-125b expression was restored by vitamin D, Coenzyme Q10 and by microelement selenium. In conclusion, the miRNA profile, together with other 'omics', may constitute a multifaceted approach to explore the impact of diet on psoriasis prevention and treatment.

Psoriasis: Obesity and Fatty Acids

Psoriasis is chronic inflammatory skin disease affecting skin, joints, cardiovascular system, brain, and metabolism. The pathogenesis of psoriasis is mediated by a complex interplay between the immune system, inflammatory mediators of different pathways, e.g., TNF-alpha and the IL-23/IL-17 pathways, psoriasis-associated susceptibility loci, autoantigens, and multiple environmental factors. Psoriasis is triggered by the combination of genetic and environmental factors. A novel environmental risk factor with rising importance is obesity. Several studies proved that obesity is an independent risk factor for the onset and severity of psoriasis. Due to the dramatic increase of obesity worldwide this minireview focuses on obesity as a major environmental risk factor for psoriasis and the mechanisms of obesity-mediated exacerbation of psoriasis.

Phase Angle: A Possible Biomarker to Quantify Inflammation in Subjects with Obesity and 25(OH)D Deficiency

Obesity is associated to chronic low-grade metabolic inflammation and hypovitaminosis D. Among extra-skeletal effects, an important role in inflammation has been described for vitamin D (25(OH)D). Phase angle (PhA) is a bioelectrical impedance analysis (BIA) parameter that represents an indicator of cellular health in chronic inflammatory states. However, it is still unknown whether a low 25(OH)D levels might correlate with PhA in obesity. Considering the lack of evidence correlating the 25(OH)D levels with PhA in obesity, the aim of this study was to investigate their possible relationship in a group of patients with obesity stratified according to body mass index (BMI) categories. Four hundred and fifty-five adult subjects (219 males and 236 females; 36 ± 11 years) were enrolled. Body composition, including PhA, was assessed using a BIA phase-sensitive system. Serum levels of 25(OH)D was determined by a direct competitive chemiluminescence immunoassay. Most of the participants were affected by grade III obesity (24%) and had 25(OH)D deficiency (67%). Subjects with 25(OH)D deficiency had highest BMI (p < 0.001). Stratifying the sample population according to the BMI classes, 25(OH)D levels decreased significantly along with the increase in BMI (p < 0.001), with the lowest 25(OH)D levels in the class III obesity. In addition, stratifying the sample population according to 25(OH)D categories, BMI and fat mass (FM) decreased, while PhA increased significantly along with the 25(OH)D categories (p < 0.001). The 25(OH)D levels showed significant positive associations with PhA (r = -0.59, p < 0.001), and this association remained significant also after adjusting for BMI and FM (r = 0.60, p < 0.001). The lowest values of PhA were significantly associated with the severity of obesity (OR 0.3, p < 0.001) and of 25(OH)D deficiency (OR 0.2, p < 0.001). To compare the relative predictive power of body composition parameters associated with the 25(OH)D levels, we performed a multiple linear regression analysis. The most sensitive and specific cut-off for 25(OH)D levels to predict the PhA above the median was >14 ng/mL (p < 0.001). In conclusion, we provided preliminary insights into a novel link between 25(OH)D levels and PhA in the setting of obesity. This association uncovered a new potential usefulness of PhA as expression of cell membrane integrity and predictor of inflammation in low 25(OH)D status that might help in identifying high-risk patients with obesity who could benefit from careful 25(OH)D supplementation.

Patients with psoriasis have a higher risk of schizophrenia: A systematic review and meta-analysis of observational studies

Background and Objectives

Patients with psoriasis are known to be at a higher risk of several comorbidities, but little is known about their risk of developing schizophrenia.

Methods

A systematic review and meta-analysis of cohort and case-control studies that reported relative risk, hazard ratio, odds ratio (OR), or standardized incidence ratio comparing risk of schizophrenia in patients with psoriasis versus subjects without psoriasis was conducted. Pooled OR and 95% confidence interval were calculated using random-effect, generic inverse-variance methods of DerSimonian and Laird.

Results

A total of five studies (one retrospective cohort study and four case-control studies) with more than 6 million participants met the eligibility criteria and were included in this meta-analysis. The pooled OR of schizophrenia in patients with psoriasis versus subjects without psoriasis was 1.41 (95% confidence interval, 1.19-1.66). The statistical heterogeneity was low with an I2 of 33%.

Conclusion

This systematic review and meta-analysis demonstrated a significantly increased risk of schizophrenia among patients with psoriasis.

Biomarkers of subclinical atherosclerosis in patients with psoriatic arthritis

Background: Psoriatic arthritis (PsA) is a chronic immune-mediated disease. It is associated with an increase in cardiovascular risk factors (obesity, hypertension, diabetes, and dyslipidemia), giving a higher risk of major adverse cardiovascular events. Patients with PsA have an increased incidence of subclinical atherosclerosis and endothelial dysfunction. The aim of this study is to perform a review of the biomarkers of subclinical atherosclerosis in patients with PsA. Methods: A search was performed in the electronic databases (PubMed, Web of Science, Scopus, and Embase) up until July 2017. Studies were considered if they included data on biomarkers of subclinical atherosclerosis in PsA, and each article was then reviewed for quality and clinical relevance. After completing the literature search, all screened literature was summarized and discussed in our study group (CaRRDs study group). Results: The initial search produced 532 abstracts, which were limited to 258 potentially relevant articles by preliminary review of the titles and by excluding review articles and case reports (n=274). A further 102 articles were deemed ineligible after examining the abstracts. Full texts of the remaining 156 articles were retrieved. Most articles were excluded because they were not relevant to the biomarkers of subclinical atherosclerosis in psoriasis and/or PsA. In the end, 54 articles were deemed eligible for this review. Conclusion: Patients with PsA showed more severe atherosclerotic disease compared with patients with only psoriasis. This may have been due to the higher systemic inflammatory burden from the combination of both diseases. In patients with PsA some molecules may be considered as markers of atherosclerotic disease, and their detection may be a prognostic marker, in addition to imaging procedures, for the development of atherosclerotic disease, and could be suitable for the management of patients with PsA.

Are new variants of psoriasis therapy (IL-17 inhibitors) safe?

Psoriasis is a chronic, recurrent, inflammatory, and proliferative skin disease. Its etiology has not yet been fully assessed, but undoubtedly it is a multifaceted disease. The key role in its pathomechanism is played by genetic, immunologic, and environmental factors and stress. If traditional methods of psoriasis treatment (phototherapy, methotrexate, retinoids, cyclosporine A) fail, we reach for the following biopharmaceuticals - infliximab, etanercept, adalimumab, or ustekinumab. However, genetic engineering progress discovers new possibilities - the pending clinical trials involve IL-17, IL-23 antagonists, PDE4 and -3 and -1. Psoriasis etiopathogenesis mainly involves the IL-17A, IL-17F, and IL-17A/F subtypes, which affect the keratinocytes. The biological therapy molecularly oriented with the antagonists of interleukin 17 is based mainly on the influence onto the cytokine in the manner that prevents it from binding with the receptor. Three biopharmaceuticals are currently under third phase studies: two fully humanized antibodies neutralizing IL-17 - ixekizumab and secukinumab, and one human monoclonal antibody, brodalumab. The below work will be devoted to the analysis of possible undesirable symptoms, which were observed during the studies. We will try to review the latest literature concerning the most important clinical trials conducted in many centers.

Choline metabolite, trimethylamine N-oxide (TMAO), is associated with inflammation in psoriatic arthritis

OBJECTIVES

Dietary intake of choline has been linked to systemic inflammation through the microbial production of two metabolites, trimethylamine (TMA) and trimethylamine-N-oxide (TMAO). Herein we explore the association between choline metabolites and inflammation in psoriatic arthritis (PsA) patients.

METHODS

Thirty-eight patients with PsA, all of whom satisfied the CASPAR classification criteria for PsA, were studied. Outcomes reflecting the activity of peripheral arthritis as well as skin psoriasis, Disease Activity Score (DAS)28, Clinical Disease Index (CDAI) and Body Surface Area (BSA) were assessed. Serum concentration of choline metabolites (choline, TMA, TMAO, betaine and carnitine) were determined by LC-MS, and metabolite levels associated with disease scores.

RESULTS

Among the 38 PsA patients included, the mean DAS28PCR was 2.74±1.29. Twenty-seven patients had active skin disease, with an average BSA of 7.2±16.22. TMAO, but not TMA or choline, significantly correlated with measures of disease activity for both skin and peripheral joints.

CONCLUSIONS

In our cohort, only TMAO, but not TMA, choline, betaine or carnitine, was associated with inflammation in PsA patients, establishing a mechanistic link between TMAO and PsA phenotypes. Future studies will explore the modulation of TMAO and disease severity in PsA.

Study on the psychological health and related risk factors in 245 patients with psoriasis in Inner Mongolia

To investigate the psychological health and related risk factors in patients suffering from psoriasis. A total of 245 inpatients and outpatients with psoriasis were selected from January 2014 to December 2015. Patients with psoriasis were assessed a homemade questionnaire as well as the Psoriasis Area and Severity Index (PASI), Selfrating Anxiety Scale, Self-rating Depression Scale, Trait Coping Style Questionnaire and Social Avoidance and Distress Scale.Differences in sex, age, marital status, type of medical payment, occupation, economic situation, disease severity, and type of psychological state of psoriasis patients were significant, there was no significant difference in psychological health between psoriasis patients with different levels of educational attainment. Scores for anxiety, depression, social avoidance, and social distress were positively correlated with disease severity and negative-coping scores, but a significant negative correlation was observed with scores for social support and positive coping. Stepwise regression analysis of factors influencing psychological health showed that total social support and negative-coping scores could explain 65.2% of the variation. Patients with psoriasis can suffer from anxiety, depression, social distress, and social avoidance. Physicians should pay greater attention to deterioration in mental health of psoriasis patients.

Adherence to Mediterranean diet in Spanish patients with psoriasis: Cardiovascular benefits?

Several studies have evaluated the role of individual nutrients on psoriasis. Only a few of them have evaluated the benefits of healthy dietary patterns and the effect of the Mediterranean diet on psoriasis with promising results. Moderate-severe psoriasis is associated with chronic systemic inflammation and increased cardiovascular risk. In this study the present authors measure the adherence to the Mediterranean diet to determine the grade of association with severity of psoriasis, a cardiovascular profile, and systemic inflammation. Our aim was to determine a cut-off point that approximates the real clinical practice by differentiating patients with systemic or biological treatment.

Fasting and Its Impact on Skin Anatomy, Physiology, and Physiopathology: A Comprehensive Review of the Literature

Skin serves as the first protective line and barrier of the body. Like many other organs, skin can be affected by several disorders in response to external factors such as pathogens, ultraviolet light, and pollution, as well as endogenous alterations related to aging and/or oxidative stress disturbance. Researchers have reported new insights into how skin cells are altered in response to caloric restriction diets in mammals. One of the most well-known caloric restriction diets is the Ramadan intermittent fasting, which is a radical change in the diet plan of practitioners for the period of one lunar month. Ramadan fasting represents the fourth of the five pillars of the Islamic creed. Even though infirm individuals are waived to take part in this religious duty, patients with various health problems, including those with different skin disorders, might choose to share this event with peers and family members. No standardized protocols or guidelines exist, however, to advise their physicians on the proper management of their patients' condition during fasting. With an increasing Muslim population living in Western countries, this topic has started to draw substantial attention, not only of Middle-Eastern physicians, but also of clinicians in the West. For this purpose, we carried out a comprehensive overview on the topic. Our main findings are that: (1) there is a strong need for evidence-based suggestions and guidance. Literature on the impact of the Ramadan fasting, as well as of other kinds of fasting, on skin diseases is scarce and of poor quality, as well as the information available from the Internet; (2) patients willing to fast should be advised about the importance of taking proper treatments or consider alternative options including administration of trans-dermal/topical drugs, as they are permitted during daylight hours. Further, non-compliance has important, clinical and economic implications for an effective patient management.

Relationship between human leukocyte antigen DRB1 and psoriasis in Iraqi patients

Objectives:

To investigate the role of Human leukocyte antigen (HLA) Class II DRB1 in susceptibility to psoriasis in Iraqi patients.

Methods:

A cross-sectional comparative study including 40 patients with psoriasis attending the Department of Dermatology, Al-Kindy teaching hospital in Baghdad, Iraq, between September 2013-2015. Patient selection was carried out by the dermatologists. Ninety healthy individuals were included in the study. Human leukocyte antigen genotyping was carried out by the sequence specific oligonucleotide (SSO) method using Auto LiPA 48 (Innogenetics, Belgium) in the HLA typing research unit of the Al-Kindy College of Medicine, Baghdad, Iraq.

Results:

There is an increased frequency of HLA-DRB1*0102, *0306 in psoriatic patients with psoriasis p-values=0.001, confidence interval(CI)=2.492-37.487 and odds ratio(OR)=9.666. Human leukocyte antigen-DRB1*1101 is significantly associated with plaque-type psoriasis with p=0.0434, CI=1.04-1.69, and OR=4.2. Human leukocyte antigen-DRB1*0102 is significantly associated with other types of psoriasis with p=0.018, CI=0.0223-0.701, and OR=0.125.

Conclusion:

Human leukocyte antigen-DRB1*0102 and *0306 are significantly associated with psoriasis. Human leukocyte antigen-DRB1*1101 is significantly associated with plaque-type psoriasis. Human leukocyte antigen-DRB1*0102 is significantly associated with other types of psoriasis rather than plaque-type psoriasis.

Methotrexate restores the function of peripheral blood regulatory T cells in psoriasis vulgaris via the CD73/AMPK/mTOR pathway

BACKGROUND

Methotrexate (MTX) is used to treat psoriasis, a chronic inflammatory skin disease.

OBJECTIVES

To investigate the molecular mechanism of MTX in the treatment of psoriasis.

METHODS

Regulatory T cells (Tregs) and effector T (Teff) cells were isolated from the blood of patients with psoriasis and healthy controls. The proliferation of Teff cells was detected by carboxyfluorescein succinimidyl ester assay. The interferon (IFN)-γ and interleukin (IL)-17 levels were analysed by enzyme-linked immunosorbent assay. The expression of CD73 and FoxP3 were determined by flow cytometry. The expression of proteins in the AMPK/mTOR pathway were detected by Western blot analysis.

RESULTS

The data suggested that patients with psoriasis have Tregs with decreased immune suppression function and reduced expression of CD73 compared with healthy controls. Moreover, MTX could significantly restore the immunosuppressive function of IL-17-secreting Tregs. This, in turn, inhibits aberrant proliferation of Teff cells in patients with psoriasis, reverses downregulation of CD73, upregulates phosphorylated AMPK and inhibits phosphorylated mTOR, and downregulates IL-17 and IFN-γ levels.

CONCLUSIONS

We speculate that MTX can restore the immunosuppressive function of Tregs through upregulating CD73, activating AMPK and inactivating the mTOR pathway. These findings may partly explain the mechanism by which MTX treats psoriasis.

Overfed but undernourished: recognizing nutritional inadequacies/deficiencies in patients with overweight or obesity

Overweight and obesity are highly prevalent throughout the world and can adversely affect the nutritional status of individuals. Studies have shown that many people with obesity have inadequate intake of iron, calcium, magnesium, zinc, copper, folate and vitamins A and B₁₂, likely as a result of poor diet quality. Nutritional inadequacies or deficiencies may also occur due to altered pharmacokinetics in the individual with obesity and due to interactions in those with overweight or obesity with various pharmaceuticals. However, it has been demonstrated that the adult population in the United States as a whole is deficient in certain micronutrients as a result of the availability and overconsumption of high-calorie, low-nutrient processed foods. Poor nutrition may contribute to the development of certain chronic conditions, such as type 2 diabetes, which is already more prevalent in those with obesity. Clinicians need to be aware of these gaps, particularly in those individuals with obesity who are undergoing bariatric surgery or taking pharmaceutical products long term to facilitate weight loss. Patients with overweight or obesity likely struggle to achieve a balanced diet and may benefit from consultation with a dietitian. Along with providing recommendations for healthy eating and exercise, supplementation with specific micronutrients or multivitamins should be considered for individuals at the highest risk for or with established deficiencies. Further research is needed to understand the factors underlying nutritional inadequacies in individuals with overweight or obesity, as well as the outcomes of treatment strategies employed to address them.

Coffee consumption, metabolic syndrome and clinical severity of psoriasis: good or bad stuff?

Despite the wide consumption of coffee, its anti-inflammatory effect on clinical severity of psoriasis is still debatable. The aim of this study was to evaluate the association between the coffee consumption and clinical severity of psoriasis in a sample of patients stratified according to the presence of the metabolic syndrome (MetS) and smoking. This cross-sectional case-control observational study was conducted on 221 treatment-naïve psoriatic patients. Lifestyle habits, anthropometric measures, clinical and biochemical evaluations were obtained. Clinical severity of psoriasis was assessed by Psoriasis Area and Severity Index (PASI) score. Data on energy caloric intake and coffee consumption were collected using a 7-day food diary record. The coffee consumption was analyzed as coffee intake (consumers and non-consumers) and daily servings (range 0-4 servings/day). Coffee consumers have a lower PASI score vs non-consumers (p < 0.001). The lowest PASI score and MetS prevalence were found in patients consuming 3 cups of coffee/day (p < 0.001), which was also the most common daily serving (34.8%), whereas the highest PASI score was found among those drinking ≥ 4 cups/day. Grouping the case patients according to smoking and MetS, the best odds of PASI score was observed in those drinking 3 cups of coffee per day and no smokers, after adjusting for total energy intake (OR 74.8; p < 0.001). As a novel finding, we reported a negative association between coffee intake, MetS prevalence and clinical severity of psoriasis. The evaluation of the anti-inflammatory effect of coffee on clinical severity of psoriasis, whose metabolic risk increases along with its clinical severity, could be of great importance from a public health perspective.

Nutrition, inflammation and liver-spleen axis

Chronic low-grade systemic inflammation represents a mechanism common to many diseases linked to atherosclerosis-related pathways. There is a growing body of evidence indicating that the combination of food quantity and quality along with genetic susceptibility are able to induce the aberrant activation of innate immune signalling, which initially contributes to chronic low-grade inflammation. Liver represents the central player to inflammatory response. Dietary/metabolic factors contribute to the pathogenesis of Non-alcoholic Fatty Liver Disease (NAFLD), the main causes of liver disease in the Western world. Enlargement of the spleen, central organ in regulating the inflammation-related immune response, is commonly seen in patients with of NAFLD, depicting the so called "liver-spleen axis." The aim of this review was to provide an at-a-glance overview of the possible bi-directional mechanisms linking nutrition and inflammation, particularly pinpointing the inflammatory effects stemmed by nutrition on "liver-spleen axis." In particular, the role of unhealthy diet, healthy dietary patterns, such as the Mediterranean diet style, dietary vitamins and micronutrients, such as vitamin D or Magnesium, and Glucagon-Like Peptide-1, a well-known incretin released in response to meal intake, will be discussed. The highly variability of the inflammatory response highlights the role of expert nutritionists in refining methodologies apt to assess nutritional epidemiology and to apply appropriate dietary intervention to counteract diet-induced inflammation mechanisms.

Associations between body mass index and severity of psoriasis

Objective

Compared with healthy people, overweight and obesity are more commonly found among those suffering from skin conditions such as psoriasis. The present study was an attempt to survey the relationship between obesity and intensity of psoriasis.

Patients and methods

A total of 42 patients with psoriasis who were referred to Farshchian Hospital, Hamadan, participated in this cross-sectional descriptive–analytical study. Patients were classified into mild, moderate and severe based on the intensity of the disease measured by Psoriasis Area and Severity Index (PASI). Body mass index (BMI), waist size, age, gender, smoking and drinking habits of the participants were measured and compared.

Results

A total of 15 (35.07%) patients had mild psoriasis, 9 (21.4%) patients had moderate psoriasis and 18 (42.9%) patients suffered from severe psoriasis. Mean BMI of mild psoriasis patients was 25.86±5.93 kg/m², and this figure for the moderate and severe psoriasis patients was 30.85±3.77 kg/m² and 26.96±5.68 kg/m², respectively (P=0.096). Mean waist size of the mild psoriasis patients was 91.54±11.49 cm, and for moderate and severe patients, it was 99±8.39 cm and 92.17±10.73 cm, respectively (P=0.211).

Conclusion

The results of this study showed no significant difference between mean value of body mass index, waist size, age and gender in mild, moderate and severe groups of the psoriasis patients.

Systemic Inflammation, Oxidative Damage to Nucleic Acids, and Metabolic Syndrome in the Pathogenesis of Psoriasis

In the pathogenesis of psoriasis, systemic inflammation and oxidative stress play mutual roles interrelated with metabolic syndrome (MetS). This study aims to map the selected markers of inflammation (C-reactive protein (CRP)), oxidative damage to nucleic acids (DNA/RNA damage; 8-hydroxy-2'-deoxyguanosine, 8-hydroxyguanosine, and 8-hydroxyguanine), and the parameters of MetS (waist circumference, fasting glucose, triglycerides, high-density lipoprotein (HDL) cholesterol, diastolic and systolic blood pressure) in a group of 37 patients with psoriasis (62% of MetS) and in 43 healthy controls (42% of MetS). Levels of CRP, DNA/RNA damage, fasting glucose, and triglycerides were significantly elevated in patients. MetS in conjunction with psoriasis was associated with high levels of CRP, significantly higher than in control subjects without MetS. Patients with MetS exhibited further DNA/RNA damage, which was significantly higher in comparison with the control group. Our study supports the independent role of psoriasis and MetS in the increase of CRP and DNA/RNA damage. The psoriasis contributes to an increase in the levels of both effects more significantly than MetS. The psoriasis also diminished the relationship between CRP and oxidative damage to nucleic acids existent in controls.

Vitamin D and its role in psoriasis: An overview of the dermatologist and nutritionist

Psoriasis is a chronic immune-mediated inflammatory skin disease. Psoriasis lesions are characterized by hyper-proliferation of epidermal keratinocytes associated with inflammatory cellular infiltrate in both dermis and epidermis. The epidermis is the natural source of vitamin D synthesis by sunlight action. Recently, a role for vitamin D in the pathogenesis of different skin diseases, including psoriasis, has been reported. Indeed, significant associations between low vitamin D status and psoriasis have been systematically observed. Due to its role in proliferation and maturation of keratinocytes, vitamin D has become an important local therapeutic option in the treatment of psoriasis. To date, the successful treatment based on adequate dietary intake of vitamin D or oral vitamin D supplementation in psoriasis represent an unmet clinical need and the evidence of its beneficial effects remains still controversial. This information is important either for Dermatologists and Nutritionists to increases the knowledge on the possible bi-directional relationships between low vitamin D status and psoriasis and on the potential usefulness of vitamin D in psoriasis with the aim not only to reduce its clinical severity, but also for delineating the risk profile for co-morbidities cardiac risk factors that may result from psoriasis. In the current review, we analyzed the possible bi-directional links between psoriatic disease and vitamin D.

Integrative Skin Care: Dermatology and Traditional and Complementary Medicine

Skin problems and diseases are extremely common globally and, due to their visibility, often result in severe distress and stigma for sufferers. Traditional (i.e., indigenous or local) and complementary health systems are widely used and incorporate many treatment modalities suitable for skin care, and a body of evidence for their efficacy and safety has built up over many decades. These approaches are often used as part of a broader "integrative medicine" (IM) approach that may also include, for example, nutrition and mind-body approaches. This article presents an overview of current knowledge about traditional and complementary medicine (T&CM) and IM principles and practices for skin health; reviews published epidemiologic studies, clinical trials, and wider literature; and discusses the challenges of conducting research into T&CM and IM. It also highlights the need for an innovative research agenda-one which is congruent with the principles of IM, as well as taking policy and public health dimensions into consideration.