Malabsorption in psoriatic patients: cause or consequence?

Small Intestinal Bacterial and Fungal Overgrowth: Health Implications and Management Perspectives

BACKGROUND/OBJECTIVES

Small Intestinal Bacterial Overgrowth (SIBO) and Small Intestinal Fungal Overgrowth (SIFO) are distinct yet often overlapping conditions characterized by an abnormal increase in microbial populations within the small intestine. SIBO results from an overgrowth of colonic bacteria, while SIFO is driven by fungal overgrowth, primarily involving Candida species. Both conditions present with nonspecific gastrointestinal (GI) symptoms such as bloating, abdominal pain, diarrhea, and malabsorption, making differentiation between SIBO and SIFO challenging. This review aims to elucidate the underlying mechanisms, risk factors, diagnostic challenges, and management strategies associated with SIBO and SIFO.

METHODS

A comprehensive review of current literature was conducted, focusing on the pathophysiology, diagnostic modalities, and therapeutic approaches for SIBO and SIFO.

RESULTS

SIBO is commonly associated with factors such as reduced gastric acid secretion, impaired gut motility, and structural abnormalities like bowel obstruction and diverticula. It is frequently diagnosed using jejunal aspirates (≥105 colony forming units (CFUs)/mL) or breath tests. In contrast, SIFO is linked to prolonged antibiotic use, immunosuppression, and gut microbiome dysbiosis, with diagnosis relying on fungal cultures from small intestinal aspirates due to the absence of standardized protocols.

CONCLUSION

The clinical overlap and frequent misdiagnosis of SIBO and SIFO highlight the need for improved diagnostic tools and a multidisciplinary approach to management. This review emphasizes the importance of understanding the mechanisms behind SIBO and SIFO, how they relate to other health outcomes, and potential management strategies to optimize patient care and therapeutic outcomes.

Psoriasis, bone and bowel: a comprehensive review and new insights

Psoriasis is a chronic immune-mediated disorder affecting about 2% of the population worldwide which is associated with significant morbidity. The disease usually presents as raised, well-demarcated erythematous plaques with adherent silvery scales. Psoriasis can appear at any age but it has two peaks occurring at 15–20 and 55–60 years of age. It affects males and females equally. Despite the multitude of investigations about psoriasis and even development of drugs with satisfactory results, its pathogenesis is not fully understood yet and its course is unpredictable. Various environmental triggers, e.g., obesity, stress and drugs may induce disease in genetically susceptible patients. Although psoriasis was considered primarily as a disease of the skin, more investigations have been revealed its systemic nature. Psoriatic arthritis (PsA) may complicate up to one-third of cases of psoriasis vulgaris (PV). Also, the association between psoriasis and a variety of other immune-mediated disorders such as inflammatory bowel disease (IBD) and celiac disease (CD) has been confirmed in various studies. Moreover, a growing body of evidences indicates that psoriasis shares some common histological and phenotypical properties with the spectrum of osteoimmunological diseases such as Paget’s disease of bone (PDB). Thus, exploring the common molecular and genetic mechanisms underlying psoriasis and related disorders is of paramount importance for better elucidating disease pathogenesis and designing more targeted treatments.

Positivity of celiac disease-specific antibodies and non-celiac hypersensitivity in psoriasis

INTRODUCTION

Plaque psoriasis and celiac disease are multisystemic diseases. The association of psoriasis and enteropathy with histological changes similar to celiac disease has already been described, and it has also been found that a gluten-free diet improves psoriatic changes. This study assesses the relationship between celiac disease antibodies and psoriasis.

METHODS

The study included 112 participants: 60 with psoriasis in a test group and 52 healthy subjects in a control group. Within the psoriasis group, participants were further divided into two subgroups: one consisting of patients with both psoriasis and psoriatic arthritis (n = 17) and another comprising patients with psoriasis alone (n = 43). After informed consent was obtained, the Dermatology Life Quality Index (DLQI) score and Psoriasis Area and Severity Index (PASI) score were evaluated. Laboratory tests included assessment of anti-deaminated gliadin peptide antibodies (DGP), anti-gliadin antibodies (AGA), and anti-tissue transglutaminase antibodies (tTG).

RESULTS

Immunoglobulin G (IgG) and immunoglobulin A (IgA) DGP antibodies were detected more frequently and at higher serum concentrations in patients with psoriasis compared to healthy controls (p = 0.03, p = 0.04, respectively). Similarly, elevated levels of IgG-tTG antibodies (p = 0.003) and IgA-DGP antibodies (p = 0.02) were observed in the same test group.

CONCLUSIONS

A relationship between positivity to celiac disease antibodies and psoriasis, particularly with regard to AGA, has been identified. Further studies are required to elucidate the nature, pathophysiology, and significance of these findings.

Screening of antigliadin and antitissue transglutaminase antibodies in patients with chronic plaque psoriasis: a case-control study

BACKGROUND

In this study, we aimed to investigate different types of celiac antibodies in psoriasis patients and to see if the presenceof the antibodies was associated with other variables.

METHODS

We included patients with plaque psoriasis who were followed up in our dermatology clinic between February 2019 and February 2021 and added a healthy control group for comparison. The antibodies studied were serum antitissue transglutaminase (tTG)-IgA, tTG-IgG, antigliadin antibody (AGA)-IgA, and AGA-IgG. The patients' records were used to note age, sex, the pattern of psoriasis involvement, psoriasis area and severity index (PASI), presence of hypertension, presence of type 2 diabetes mellitus, use of methotrexate, and use of biologic agents.

RESULTS

Sixty-five psoriasis patients (31 F, 34 M, mean age: 38.9 ± 15.2) and 65 controls (42 F, 23 M, mean age: 40.7 ± 13.2) wereincluded in the study. There was no significant difference in antibody levels between the groups: tTG-IgA (2.4 U/mL vs 3.2 U/mL, p = 0.11), tTG-IgG (2.2 U/mL vs 3.2 U/mL, p = 0.74), AGA-IgA (2.4 U/mL vs 3.5 U/mL, p = 0.068), and AGA-IgG (3.2 U/mL vs 4.2 U/mL, p = 0.15). One patient from the psoriasis group only had borderline positive antibody levels whereas the rest of the psoriasis and control group had negative levels. Hypertensive psoriasis patients had significantly higher AGA-IgA titers compared to normotensive psoriasis patients (4.2 U/mL vs 2.3 U/mL, p = 0.005).

DISCUSSION

There was no increase in the AGA-IgA/IgG and tTG-IgA/IgG levels in psoriasis patients compared to the healthy population. However, hypertensive psoriasis patients had higher AGA-IgA levels compared to normotensive ones.

Could it be gluten? Additional skin conditions associated with celiac disease

Celiac disease is a multifactorial, inflammatory disorder initiated and sustained by the ingestion of gluten. Occurring across a broad population, the intestinal and extraintestinal manifestations of celiac disease are variable in severity and may be nonspecific in presentation. Given that environmental, genetic, and immune factors involved in the pathogenesis of celiac disease that the digestive tract and skin share many characteristics, and with a prevalence of 0.5-1% in most populations, it is reasonable to consider varying presentations of skin conditions that are linked with celiac disease. The association between celiac disease and skin conditions has been discussed earlier, but new studies have emerged suggesting cutaneous involvement in addition to dermatitis herpetiformis. We review the current literature identifying the relationship and potential mechanisms between celiac disease and various skin conditions.

Systematic review and meta-analysis: Effect of Helicobacter pylori eradication on chronic spontaneous urticaria

BACKGROUND

Helicobacter pylori (HP) infection is considered to play a role in the pathogenesis of chronic spontaneous urticaria (CSU). However, the efficacy of HP eradication therapy on CSU symptom improvement has not been well established. This meta-analysis was conducted to estimate the association between HP infection and CSU and to evaluate whether HP eradication therapy benefits patients with CSU.

MATERIAL AND METHODS

In October 2018, we searched databases for studies investigating the efficacy of HP eradication therapy for patients with CSU. Risk ratios (RRs) and 95% confidence intervals (CIs) were pooled using random effects models.

RESULTS

The meta-analysis included 22 studies with a total of 1385 patients with CSU. When comparing the spontaneous remission of urticarial symptom in patients with HP-positive to HP-negative patients, HP-negative patients showed significantly higher spontaneous remission of urticarial symptoms. (risk ratio 0.39; 95% confidence interval: 0.19-0.81). Among HP-positive CSU patients, remission of CSU was more likely shown in HP eradication therapy group compared to untreated group, aside from achieving HP elimination (risk ratio 2.10; 95% confidence interval: 1.20-3.68). However, there was no significant difference in the remission of CSU whether antibiotic therapy was successful in eradication of HP or not (risk ratio 1.00; 95% confidence interval: 0.65-1.54).

CONCLUSIONS

The results of this meta-analysis show that HP might be associated with the occurrence and persistence of CSU. The effectiveness of HP eradication therapy in suppressing CSU symptoms was significant. Interestingly, we found that resolution of CSU was not associated with successful eradication of HP infection. CSU Patients who were undergone antibiotic therapy for HP eradication showed significant higher CSU remission with or without HP eradication. Further studies are recommended to evaluate the mechanisms associated with relation of HP with CSU.

Cutaneous and Mucosal Manifestations Associated with Celiac Disease

Celiac disease (CD) is an immune-mediated, gluten-induced enteropathy that affects predisposed individuals of all ages. Many patients with CD do not report gastrointestinal symptoms making it difficult to reach an early diagnosis. On the other hand, CD is related to a wide spectrum of extra-intestinal manifestations, with dermatitis herpetiformis (DH) being the best characterized. These associated conditions may be the clue to reaching the diagnosis of CD. Over the last few years, there have been multiple reports of the association between CD and several cutaneous manifestations that may improve with a gluten-free diet (GFD). The presence of some of these skin diseases, even in the absence of gastrointestinal symptoms, should give rise to an appropriate screening method for CD. The aim of this paper is to describe the different cutaneous manifestations that have been associated with CD and the possible mechanisms involved.

Prevalence of psoriatic arthritis in patients with psoriasis: A systematic review and meta-analysis of observational and clinical studies

BACKGROUND

Wide-ranging prevalence estimates of psoriatic arthritis (PsA) in patients with psoriasis have been reported.

OBJECTIVES

To assess the prevalence and incidence of PsA in patients with psoriasis.

METHODS

Two authors independently searched 3 databases for studies reporting on the prevalence or incidence of PsA in patients with psoriasis. A proportion meta-analysis was performed to calculate the pooled proportion estimates of PsA in patients with psoriasis.

RESULTS

A total of 266 studies examining 976,408 patients with psoriasis were included. Overall, the pooled proportion (95% confidence interval [CI]) of PsA among patients with psoriasis was 19.7% (95% CI, 18.5%-20.9%). In children and adolescents (<18 years of age), the pooled prevalence was 3.3% (95% CI, 2.1%-4.9%). The PsA prevalence was 22.7% (95% CI, 20.6%-25.0%) in European patients with psoriasis, 21.5% (95% CI, 15.4%-28.2%) in South American patients with psoriasis, 19.5% (95% CI, 17.1%-22.1%) in North American patients with psoriasis, 15.5% (95% CI, 0.009%-51.5%) in African patients with psoriasis, and 14.0% (95% CI, 95% CI, 11.7%-16.3%) in Asian patients with psoriasis. The prevalence of PsA was 23.8% (95% CI, 20.1%-27.6%) in studies in which the Classification Criteria for Psoriatic Arthritis were applied. The incidence of PsA among patients with psoriasis ranged from 0.27 to 2.7 per 100 person-years.

LIMITATIONS

Between-study heterogeneity may have affected the estimates.

CONCLUSIONS

We found that 1 in 4 patients with psoriasis have PsA. With the growing recognition of the Classification Criteria for Psoriatic Arthritis, more homogenous and comparable prevalence estimates are expected to be reported.

Atopic dermatitis and the intestinal microbiota in humans and dogs

The prevalence of human and canine allergic diseases is commonly perceived to be increasing. Suggested predisposing factors in people and dogs include increased allergen load, increased exposure to pollutants, reduced family size, reduced microbial load and less exposure to infection at a young age, increasingly urbanised environment, and changes in dietary habits. Genetic make‐up may provide a template for phenotypic predisposition which is strongly influenced by our diet and environment leading to constant regulation of gene expression. One way in which diet can alter gene expression is via its effects on the gut flora or microbiota, the collection of microbes residing in the gastrointestinal tract. The resident microbiota is important in maintaining structural and functional integrity of the gut and in immune system regulation. It is an important driver of host immunity, helps protect against invading enteropathogens, and provides nutritional benefits to the host. Disruption of the microbiota (dysbiosis) may lead to severe health problems, both in the gastrointestinal tract and extra‐intestinal organ systems. The precise mechanisms by which the intestinal microbiota exerts its effects are only beginning to be unravelled but research is demonstrating close links between gut microflora and many factors involved in the pathogenesis of atopic dermatitis (AD). AD and indeed any other ‘skin disease’, may be seen as a possible manifestation of a more systemic problem involving gut dysbiosis and increased intestinal permeability, which may occur even in the absence of gastrointestinal signs. Manipulation of the canine intestinal microbiota as a method for modifying atopy, may be attempted in many ways including avoidance of certain foods, supplementation with probiotics and prebiotics, optimising nutrient intake, minimising stress, antimicrobial therapy, correction and prevention of low stomach acid, and faecal microbiota transplantation (FMT).

Diet and psoriasis, part II: celiac disease and role of a gluten-free diet

Patients with psoriasis have been shown to have a higher prevalence of other autoimmune diseases including celiac disease, a condition marked by sensitivity to dietary gluten. A number of studies suggest that psoriasis and celiac disease share common genetic and inflammatory pathways. Here we review the epidemiologic association between psoriasis and celiac disease and perform a meta-analysis to determine whether patients with psoriasis more frequently harbor serologic markers of celiac disease. We also examine whether a gluten-free diet can improve psoriatic skin disease.