Inverse relation between severity of psoriasis and serum 1,25-dihydroxy-vitamin D level

Vitamin D Receptor Expression in Chronic Plaque Psoriasis Before and After Narrowband Ultraviolet B Phototherapy

Background/Purpose

Psoriasis is a multifactorial disease. It is a combination of genetic, immunological, and environmental factors. Vitamin D receptor (VDR) is a nuclear receptor that regulates epidermal cell growth through the inhibition of proliferation and induction of keratinocytes terminal differentiation. Aim of the study was to investigate the effect of Narrow-band UVB (NB-UVB) therapy on VDR expression in the skin of psoriasis patients.

Materials and Methods

Forty patients with different severities of psoriasis were assessed using the psoriasis area and severity index (PASI) score. Lesional and non-lesional skin biopsies were obtained from each patient before NB-UVB therapy, and then a third lesional biopsy was performed after completing 24 sessions of NB-UVB. Immunohistochemistry for VDR was performed on all specimens.

Results

There was a significant decrease in VDR expression in psoriatic lesions compared to that in non-lesional skin before treatment. A statistically negative correlation was detected between the degree of VDR expression before treatment and PASI score, family history, and duration of psoriasis. There was a significant increase in VDR expression at the sites of psoriasis lesions post-NB-UVB therapy compared to pretreatment lesional skin.

Conclusion

VDR expression was down-regulated in psoriatic lesions compared to non-lesional skin, and NB-UVB therapy improved VDR expression in psoriasis skin lesions.

Comparing Vitamin D Level Between Patients with Psoriasis and Healthy Individuals: A Systematic Review and Meta-Analysis

BACKGROUND

Psoriasis is nowadays regarded as a systemic inflammatory disorder. Among the topicals, vitamin D derivates are often applied on the skin for their anti-inflammatory and immune-modulatory properties. Vitamin D serum levels in psoriasis (PsO) patients are still debated and an eventual depletion may offer the rational to integrate anti-psoriatic therapies with oral vitamin D. Then, we aimed to perform a systematic review and meta-analysis on the current evidence towards serum vitamin D level in PsO.

METHODS

We searched in PubMed, Scopus, Web of Sciences, ScienceDirect and Science Information Database (SID) using the terms "Vitamin D" and "Psoriasis" including manuscripts in English, Italian and Persian. Duplications were excluded using EndNote software and records were screened by title, abstract and full-text. Quality assessment of studies was assessed using Newcastle Ottawa Checklist (NOS). Psoriasis odds ratio (OR) and mean serum vitamin D levels were calculated and displayed in Forest-plots. Heterogeneity indexes were evaluated using I2 and Q. Sensitivity analysis and publication biases were also considered.

RESULTS

From 3006 records extracted, after removing duplicates and analyzing full texts we finally included 19 manuscripts involving a total of 1387 PsO cases and 6939 controls. PsO patients exhibited a substantial odds ratio (3.07, 95% CI: 1.56-6.04) for lower serum vitamin D levels compared to the control group. Standardized Mean Difference (SMD) of vitamin D in PsO versus controls was -0.92 (-1.33 to -0.51).

CONCLUSION

Psoriatic patients displayed higher risk to have a vitamin D deficiency. Interventional studies to verify the preventive value are mandatory.

Vitamin D Signaling in Psoriasis: Pathogenesis and Therapy

Psoriasis is a systemic, chronic, immune-mediated disease that affects approximately 2–3% of the world’s population. The etiology and pathophysiology of psoriasis are still unknown, but the activation of the adaptive immune system with the main role of T-cells is key in psoriasis pathogenesis. The modulation of the local neuroendocrine system with the downregulation of pro-inflammatory and the upregulation of anti-inflammatory messengers represent a promising adjuvant treatment in psoriasis therapies. Vitamin D receptors and vitamin D-mediated signaling pathways function in the skin and are essential in maintaining the skin homeostasis. The active forms of vitamin D act as powerful immunomodulators of clinical response in psoriatic patients and represent the effective and safe adjuvant treatments for psoriasis, even when high doses of vitamin D are administered. The phototherapy of psoriasis, especially UVB-based, changes the serum level of 25(OH)D, but the correlation of 25(OH)D changes and psoriasis improvement need more clinical trials, since contradictory data have been published. Vitamin D derivatives can improve the efficacy of psoriasis phototherapy without inducing adverse side effects. The anti-psoriatic treatment could include non-calcemic CYP11A1-derived vitamin D hydroxyderivatives that would act on the VDR or as inverse agonists on RORs or activate alternative nuclear receptors including AhR and LXRs. In conclusion, vitamin D signaling can play an important role in the natural history of psoriasis. Selective targeting of proper nuclear receptors could represent potential treatment options in psoriasis.

Association of rs1544410 and rs7975232 Polymorphisms and Serum Vitamin D Levels with Psoriasis Susceptibility and Severity: A Case-Control Study in Egyptian Patients

Background

Vitamin D is a regulatory factor for skin immune functions through vitamin D receptor, which is expressed on many immune cells. Vitamin D receptor is located on chromosome 12q 13.11 and has many single nucleotide polymorphisms. Some of them were hypothesized to be associated with psoriasis. Psoriasis is a genetic disease that is greatly affected by environmental factors.

Methods

A total of 135 psoriasis patients and 114 healthy controls were recruited. Both had a measurement of serum vitamin D and two vitamin D receptor variants:, rs1544410: G > A (HGVS:NC_000012.12:g.47846052) and rs7975232: C > A (HGVS: NC_000012.12:g.47845054). We assessed the relationship between vitamin deficiency as well as the two gene polymorphisms with psoriasis susceptibility and severity.

Results

Serum vitamin D levels were not significantly different between cases and controls. However, a significant association between vitamin D levels and severity was observed. We attributed this to our finding that rs7975232 was more significantly polymorphic among cases than controls, while rs1544410 polymorphism did not show a significant difference among the 2 groups.

Conclusion

We did not find a significant difference in serum vitamin D levels between cases and controls. Yet, psoriasis severity was significantly associated with serum vitamin D levels. We attributed this to other findings that the vitamin D receptor rs7975232 gene is polymorphic in psoriasis patients. At the same time, rs1544410 was not significantly more polymorphic in psoriasis patients. Both genes’ polymorphisms were associated with severe psoriasis.

Relationship Between Vitamin D Level and Mortality in Adults With Psoriasis: A Retrospective Cohort Study of NHANES Data

PURPOSE

Studies have shown an increased risk for mortality in patients with psoriasis. Furthermore, research has demonstrated an inverse relationship between 25-hydroxyvitamin D (25[OH]D) level and all-cause mortality. This study investigated the association between 25(OH)D level and all-cause mortality in US adults with psoriasis.

METHODS

Data from NHANES (1999-2014 and mortality data through December 31, 2015) were analyzed. Quartiles of 25(OH)D level were created based on 25(OH)D levels among patients. Cox proportional hazards models were used for estimating hazard ratios (95% CI) for all-cause mortality.

FINDINGS

A total of 82,091 participants were enrolled in the NHANES study from 1999 to 2014. Overall, 610 patients with psoriasis were identified in NHANES. The mean (SD) duration of follow-up was 5.61 (3.38) years (3427.92 person-years). The hazard ratio for mortality in the fully adjusted model was 0.12 (95% CI, 0.02-0.60; P_trend = 0.01) in patients with a high 25(OH)D concentration compared to those with 25(OH)D deficiency.

IMPLICATIONS

The 25(OH)D concentration was significantly inversely associated with all-cause mortality among these patients with psoriasis. Studies have shown an increased risk for mortality in patients with psoriasis compared to the general population. Vitamin D is not regularly metabolized in patients with psoriasis due to their skin abnormality. Vitamin D supplementation has been associated with a reduced mortality in patients with psoriasis. In practice, attention to vitamin D level is crucial, as is the use of vitamin D supplementation, for improving the health of these patients.

Low Vitamin D in Psoriasis: Reality or Myth?

Context:

Psoriasis is a chronic, systemic disease with the beneficial effect of topical vitamin D3 analogs, known for a long time. Low levels of vitamin D are increasingly found to be associated with the initial development of some autoimmune diseases. There are contradictory reports of low serum levels of vitamin D3 in the pathogenesis of psoriasis.

Aims:

(1) To determine the serum levels of vitamin D, calcium and C-reactive protein (CRP) in patients with psoriasis vulgaris, (2) To compare these levels with the serum levels of controls, and (3) To correlate them with the severity of the disease.

Subjects and Methods:

A hospital-based case–control study with 61 patients of psoriasis and 61 age- and sex-matched controls was undertaken. A detailed history was taken and examination including body mass index, Psoriasis Area and Severity Index (PASI) was done. Estimations of serum vitamin D, serum calcium, and CRP levels were done.

Results:

Mean 25(OH) vitamin D level was not significantly different between persons with and without psoriasis. Mean vitamin D level in cases was 18.41±9.41 and that in controls was 17.24±13.03 (P =0.63). However, vitamin D level were significantly lower in females than in males in both cases (P =0.02) and controls (P =0.006). There was no significant correlation between the severity of psoriasis and serum levels of vitamin D, serum calcium, and CRP.

Conclusions:

Serum level of vitamin D did not correlate with the severity of psoriasis in our study.

Association between psoriasis and vitamin D: Duration of disease correlates with decreased vitamin D serum levels: An observational case-control study

Recent literature has focused on the association of psoriasis with lower than normal or highly deficient vitamin D blood levels.To investigate the controversial association between psoriasis and vitamin D levels.From 2012 to 2014, 561 subjects were assessed, of which 170 had psoriasis, 51 had an autoimmune bullous, and 340 were healthy patients. Anagraphical data, 25(OH)D blood levels, and seasons of vitamin D levels assessments were recorded for each group.Vitamin D levels were significantly different among the 3 groups (K = 151.284; P = .0001). Psoriatic patients had significantly lower serum levels of 25(OH)D (21.8 ng/mL) than healthy controls (34.3 ng/mL) (chi-square = 11.5; P = .0007). Patients with bullous diseases showed the lowest vitamin D mean values (18.2 ng/mL). The linear multiple regression model showed 25(OH)D levels to be influenced by age, season of blood vitamin D levels assessment, and psoriasis duration.These results confirm the reduced vitamin D levels in psoriatic patients when compared to healthy controls, and provide new evidence regarding the association of vitamin D levels and psoriasis duration. The limits of our study include its observational nature and the small number of patients undergoing biological immunosuppressive therapies.

The relevance of serum vitamin D in psoriasis: a review

Observational research has identified low serum levels of 25-hydroxyvitamin D (25[OH]D) in many non-skeletal diseases. Whether this is causal or due to underlying illness is unknown. Low serum 25[OH]D levels are also reported in the general population. Observational and experimental studies identify that vitamin D supplementation may be beneficial in reducing all-cause mortality in elderly women, as well as cancer mortality. Our aim was to review the literature to identify the relevance of serum 25[OH]D levels in psoriasis. Forty-five studies were included in our analysis. Most of these studies identified low serum 25[OH]D levels in psoriasis patients. Evidence of causality is lacking. Treatment with phototherapy leads to an increase in serum 25[OH]D. There is little evidence that the increase in 25[OH]D after phototherapy correlates with improved disease severity. Multiple studies report an improvement in psoriasis with vitamin D supplementation. These data are predominantly from small observational or non-randomised interventional studies. Randomised controlled trials to date have had small numbers and short follow-up periods. The optimal dose of supplementation is unknown and dosing is not standardised across different studies. The definition of vitamin D insufficiency varies across studies. Low serum 25[OH]D levels may be associated with comorbidities in psoriasis patients, including metabolic syndrome and cardiovascular risk. Evidence of causation is absent. Until further high-quality evidence is available, the relevance of low serum 25[OH]D levels in psoriasis patients is unknown, as is the benefit of supplementation on disease control. Supplementation in patients with low 25[OH]D is of benefit to those at risk of impaired bone health.

Vitamin D and psoriasis pathology in the Mediterranean region, Valencia (Spain)

Vitamin D has important immunomodulatory effects on psoriasis in the Mediterranean region. To measure vitamin D intake in subjects with and without psoriasis, and to find an association with relevant clinical features, a case-control study was performed using cases (n = 50, 50% participation rate) clinically diagnosed with psoriasis and 200 healthy subjects (39.5% participation rate), leaving a final sample of 104 people. A survey was conducted using a food frequency questionnaire and clinical histories. Cases and controls were compared using univariate and multivariate analyses. We observed insufficient intake of cholecalciferol (vitamin D3) or ergocalciferol (vitamin D2) for both cases and controls. Patients with psoriasis were at greater risk of associated pathologies: dyslipidaemia (OR: 3.6, 95% CI: 0.8–15.2); metabolic syndrome (OR: 3.3, 95% CI: 0.2–53.9); hypertension (OR: 1.7, 95% CI: 0.4–7.2). Insufficient vitamin D intake in both psoriasis patients and controls in the Mediterranean population, and cardiovascular comorbility is more frequent in patients with psoriasis.

Effect of narrowband ultraviolet B therapy on inflammatory markers and body fat composition in moderate to severe psoriasis

BACKGROUND

Previous studies have shown increased prevalence of metabolic syndrome in patients with psoriasis.

OBJECTIVES

To characterize the anthropometric and metabolic profile of Spanish patients with moderate to severe psoriasis compared with controls without psoriasis matched for gender, age and body mass index (BMI), and to evaluate the impact of narrowband ultraviolet B (NB-UVB) therapy on patient profiles.

METHODS

Baseline waist circumference, body fat composition, lipid, carbohydrate and calcium metabolism profile, inflammation markers, homocysteine, vitamins D, B(6) and B(12) and folic acid of 50 patients with psoriasis and 50 matched controls were recorded then evaluated after NB-UVB in patients with psoriasis and correlated with clinical outcome.

RESULTS

Despite very similar BMIs, 54% of patients met International Diabetes Foundation criteria for metabolic syndrome compared with 42% of controls (P = 0·01); body fat was 29·9% in patients and 28·0% in controls (P = 0·037), correlating with waist circumference; while patient atherogenic profiles were less favourable, with higher apolipoprotein B and low density lipoprotein cholesterol than controls, and both patients and controls showed insufficient vitamin D serum levels (< 20 ng mL(-1)). Mean improvement of Psoriasis Area and Severity Index (PASI) after NB-UVB was 78·2%. Ferritin, B(12) and C-reactive protein decreased significantly after NB-UVB therapy. Vitamin D levels reached adequate levels after phototherapy; however, no relationship with PASI improvement was observed.

CONCLUSIONS

We characterized inflammatory and atherogenic profiles of Spanish patients with psoriasis compared with matched controls. After NB-UVB therapy we demonstrated improvement in psoriasis and some systemic inflammation markers, which were not mediated by enhancement of vitamin D synthesis.

Toll-like receptors and antimicrobial peptides expressions of psoriasis: correlation with serum vitamin D level

To evaluate the association of Toll-like receptors (TLRs), antimicrobial peptides (AMPs) and vitamin D receptors (VDRs) in psoriasis, lesional (PP) and perilesional skin (PN) from psoriasis, atopic dermatitis (AD) patients and healthy controls (NN) were studied by immunohistochemistry. Compared with PN, AD and NN skin, dysregulated expression of TLRs, AMPs and VDR was detected in PP skin. Noteworthy, our results showed altered correlation between TLR2 and VDR expression in PP and PN skin. Human beta defensin 2 (HBD2) and cathelicidin (LL-37) expressions in the PP skin were higher in serum vitamin D sufficient (VDS) groups than serum vitamin D deficient (VDD) groups. Negative correlation was found between TLR2 and VDR expression in the PP skin of VDD groups. However, positive correlation was noted in the PP skin of VDS groups. Based on the present results, therapies targeting the activity of TLRs, AMPs and vitamin D, including modulation of the TLR-VDR pathways, might provide new therapeutic approaches to the psoriasis and other inflammatory skin diseases.

Foods, diet, and skin diseases

Human skin is continuously exposed to internal and external influences that may alter its condition and functioning. As a consequence, the skin may undergo alterations leading to immune dysfunction, imbalanced epidermal homeostasis, or other skin disorders. New theories are developing that link food intake and health. The objective of this review is to evaluate current knowledge about the interrelation of food and skin, particularly the effect of nutrients on some cutaneous immune disorders and therapeutic actions of nutrients in skin disorders.

Erythrodermic psoriasis. Report of a case associated with symptomatic hypophosphataemia

We describe a patient with a long history of psoriasis who developed severe erythrodermic psoriasis associated with lethargy, muscular weakness and collapse. Serum biochemical screening at the time revealed severe hypophosphataemia, and when this was corrected by intravenous phosphate replacement her symptoms resolved and her psoriasis improved. Hypophosphataemia may therefore be another metabolic complication of erythrodermic psoriasis.

Treatment of psoriasis with calcipotriol and other vitamin D analogues

The discovery of a high-affinity receptor for the bioactive form of vitamin D3, 1,25-dihydroxyvitamin D3 (1,25[OH]D3), in most skin cells has led to the finding of previously unknown effects of vitamin D on epidermal growth and on the skin immune system. 1,25(OH)2D3 inhibits epidermal proliferation and promotes epidermal differentiation. These properties provided the rationale for introducing 1,25(OH)2D3 in the treatment of psoriasis vulgaris. In addition to 1,25(OH)2D3, the synthetic vitamin D3 analogues 1 alpha(OH)D3, 1,24(OH)2D3, and calcipotriol have undergone clinical evaluation. Calcipotriol has been studied most extensively. Compared with 1,25(OH)2D3, calcipotriol is about 200 times less potent in its effects on calcium metabolism, although similar in receptor affinity. In double-blind, placebo-controlled, randomized studies, topical calcipotriol (50 micrograms/gm, up to 100 gm weekly) has been shown to be efficacious and safe for the treatment of psoriasis. A similar therapeutic profile has been seen in long-term studies. In comparative studies topical calcipotriol is slightly more efficacious than betamethasone 17-valerate and dithranol. The mode of action of calcipotriol and other vitamin D3 analogues in psoriasis is not known. Although vitamin D3 analogues affect epidermal growth, their immunosuppressive properties may be equally important for their antipsoriatic effect.

Vitamin D analogues in the treatment of psoriasis

Psoriasis is a chronic hyperproliferative skin disease in which inflammatory and immunologic processes may play important pathophysiologic roles. Recently the skin has been identified as a target tissue for vitamin D. Because 1,25-dihydroxy vitamin D3 inhibits epidermal proliferation and promotes epidermal differentiation, it has been introduced for the treatment of psoriasis vulgaris. In addition to 1,25-(OH)2-D3, synthetic vitamin D3 analogues have undergone clinical evaluation. Calcipotriol (INN) (calcipotriene [USAN]) has been studied most extensively. Compared with 1,25-(OH)2-D3, calcipotriol is about 200 times less potent in its effects on calcium metabolism, although similar in receptor affinity. Topical calcipotriol 50 micrograms/g applied twice daily is efficacious and safe for the treatment of psoriasis. Because topical calcipotriol is slightly more efficacious than betamethasone 17-valerate and dithranol, calcipotriol should be considered a first line drug in the management of psoriasis. These results illustrate that it is possible to separate the vitamin D effects on the cellular level from those on calcium metabolism not only in vitro, but also in a clinical setting.

Vitamin D3 and skin diseases

The physiologically active metabolite of vitamin D3, 1 alpha,25-dihydroxycolicalciferol [1,25(OH)2D3, calcitriol] has achieved the status of a hormone. It is believed to mediate its effects by binding to a specific receptor which belongs to the family of nuclear receptors for glucocorticoids, estrogens, thyroxine, and retinoid acid. It has been discovered that 1,25(OH)2D3 has the ability to regulate growth and differentiation in many cell types, including cancer cells, epidermal keratinocytes, and activated lymphocytes. This has set the stage for the development of a new class of compounds with potential usefulness in hyperproliferative and immune-mediated diseases. Ideally, such agents should possess potent effects as regulators of cell proliferation and differentiation at concentrations well below those that may induce side effects related to the classical vitamin D activity on calcium absorption and bone mineralization. In addition to 1,25(OH)2D3, the synthetic vitamin D3 analogues 1 alpha-OH-D3, 1,24(OH)2D3, and calcipotriol have undergone clinical evaluation. Calcipotriol has been studied most extensively. Compared with 1,25(OH)2D3, calcipotriol is about 200 times less potent in its effect on calcium metabolism although similar in receptor affinity. In double-blind, placebo-controlled multicenter studies, topical calcipotriol has been shown to be both efficacious and safe for the short- and long-term treatment of plaque-type psoriasis. Because some of the novel vitamin D analogues are potent regulators of cell growth and immune responses, they may be of potential interest in the treatment of ichthyoses, cancer, and autoimmune diseases.