Maddalena Napolitano

Nutrition and psoriasis: is there any association between the severity of the disease and adherence to the Mediterranean diet?

BackgroundMany studies have evaluated the role of individual nutrients on the development of psoriasis. However, only few studies have investigated the effect of a healthy eating pattern, such as the Mediterranean diet. In this study, we aimed to investigate the relationship between adherence to the Mediterranean diet, the body composition and the severity of psoriasis in a group of naïve-treatment patients with psoriasis.MethodsThis is a cross-sectional case–control observational study. Sixty-two patients (49 males and 13 females, mean age: 50.2±10.5yrs) affected with mild-to-severe psoriasis were consecutively enrolled. Sixty-two age-, sex- and body mass index (BMI)-matched healthy subjects served as control group. A validated 14-item questionnaire (PREDIMED: PREvención con DIeta MEDiterránea) was used for the assessment of adherence to the Mediterranean diet. The severity of psoriasis was by assessed by standardized Psoriasis Area and Severity Index (PASI) score and C-reactive protein (CRP) levels. Body composition was analyzed with bioelectrical impedance analysis.ResultsA higher percentage of psoriatic patients had a lower PREDIMED score compared to the control group (30.6% vs 4.8%). PASI score was significantly associated with the percentage of fat mass (FM%) and CRP levels. PASI score and CRP levels were significantly associated with the dietary components included in the PREDIMED questionnaire or with the PREDIMED score. At multiple regression analysis, the major predictor of PASI score were FM among BIA parameters, (r2=0.537, β=0.740, p<0.001), and FM (r2=0.537, β=0.603, p<0.001) and PREDIMED score (r2=0.599, β=−0.296, p=0.007) among anthropometric measures, FM and PREDIMED score. Finally, among all items of the PREDIMED questionnaire, EVOO (r2=0.548, β=−0.741, p<0.001), and fish consumption (r2=0.139, β=−0.372, p=0.005) have an independent predictive value for PASI score and CRP levels.ConclusionsThis is the first study to evaluate the association between adherence to the Mediterranean diet and the severity of psoriasis. Moreover, our study highlights the usefulness of the assessment of body composition by bioelectrical impedance analysis in the evaluation of the psoriatic patients.

Insulin Resistance and Skin Diseases

In medical practice, almost every clinician may encounter patients with skin disease. However, it is not always easy for physicians of all specialties to face the daily task of determining the nature and clinical implication of dermatologic manifestations. Are they confined to the skin, representing a pure dermatologic event? Or are they also markers of internal conditions relating to the patients overall health? In this review, we will discuss the principal cutaneous conditions which have been linked to metabolic alterations. Particularly, since insulin has an important role in homeostasis and physiology of the skin, we will focus on the relationships between insulin resistance (IR) and skin diseases, analyzing strongly IR-associated conditions such as acanthosis nigricans, acne, and psoriasis, without neglecting emerging and potential scenarios as the ones represented by hidradenitis suppurativa, androgenetic alopecia, and hirsutism.

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.

Managing Moderate-to-Severe Psoriasis in the Elderly

Managing psoriasis in the elderly can be difficult for physicians, who must consider comorbidities, the resulting polypharmacy, and progressive functional impairment of several organs. Indeed, topical agents are the first-line treatment for limited disease. Phototherapy is recommended if topical drugs are not sufficient and the patient has multiple comorbidities and risk factors that make them a poor candidate for an oral or injectable systemic agent. The most important pharmacokinetic alteration in the elderly population is the decreased excretory capacity of the kidney; thus, cyclosporine should be considered a last resort treatment, and the administered dose of methotrexate should be lowered according to the reduction in estimated creatinine clearance. Acitretin can be used in the absence of severe renal insufficiency, paying attention to lipid profile, treating eventual hyperlipidemia, and closely monitoring liver enzymes. Available data on biological drugs in the elderly are limited. Biologics are associated with a small but significant overall risk of infections. However, there is no convincing evidence that the relative risk of infection with anti-tumor necrosis factor (TNF)-α therapy increases with age. Nevertheless, the package inserts for biologics recommend caution when administering these medications to the geriatric population, due to the high baseline risk of infection in such patients. Etanercept seems to be well tolerated, possibly because of its lower immunosuppressive characteristics compared with other biologics. However, studies with larger sample sizes are needed to confirm its safety.

Efficacy and safety of ustekinumab in a group of 22 elderly patients with psoriasis over a 2‐year period

Oral isotretinoin is known to cause ocular side effects, most commonly dry eyes and very rarely, corneal opacity and keratitis. We describe what we believe is the first case of recurrent corneal epithelial erosion (RCES) precipitated by the commencement of isotretinoin therapy for acne vulgaris. A 38-year-old woman presented to her optometrist with severe, spontaneous, sudden-onset pain, along with photophobia, watering and redness of her left eye. She had persistent excoriated acne, which had been treated successfully over the previous 18 months with oral isotretinoin 20 mg daily. On physical examination, an area of corneal epithelial loss was detected, and standard treatment with topical antibiotic ointment was commenced. One month later, the patient re-presented to the ophthalmology clinic with the same symptoms in the same eye. Corneal examination revealed epithelial microcysts, typical of recurrent corneal erosion syndrome, as well as a corneal epithelial defect. Long-term prophylactic ocular lubrication was prescribed. On further enquiry, the patient described minor trauma to her left eye 2 years previously, for which she had received treatment at a different centre. It was deemed probable that the isotretinoin was having an exacerbating effect on the ocular surface environment, and thus the dose was reduced. The patient continued to use regular lubrication and had no further episodes of recurrent corneal erosion over a follow-up period of 6 months. Recurrent corneal epithelial erosion is an acutely painful relapsing ocular condition caused by defective attachment of the basal cells of the corneal epithelium to their basement membrane, and is typically associated with a history of previous traumatic corneal abrasion. In the months/years following an abrasion, episodes of corneal epithelial breakdown (erosions) are experienced by an affected individual, usually overnight or on waking, when the ocular surface is less well lubricated by the blink mechanism. Salient clinical features include pain, photophobia and epiphora. Long-term ocular lubrication is the mainstay of prophylaxis in order to maintain tear film stability and ensure corneal protection. A stable tear film is essential for normal vision, ocular comfort and maintenance of a healthy ocular surface environment. The meibomian glands secrete the lipid layer of the tears, and are essential to reduce tear evaporation and maintain tear film stability. Isotretinoin has a direct effect on the function of these glands, causing atrophy and hypoplasia. In a study of 1741 adverse drug reactions related to isotretinoin, there were no reports of RCES. Any cause of tear film instability or meibomian gland dysfunction could precipitate or exacerbate RCES in vulnerable patients, and we believe that isotretinoin should be considered a risk factor for RCES in such cases. We advise that clinicians commencing patients on isotretinoin should ask about previous ocular conditions, including previous trauma and corneal abrasions. For patients with such conditions, the low-risk prophylactic intervention of commencing ocular lubricants should be suggested, as well as making the patient aware of the symptoms of RCES.

Hidradenitis suppurativa: from pathogenesis to diagnosis and treatment

Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease primarily affecting apocrine gland-rich areas of the body and presenting with painful nodules, abscesses, sinus tracts, and scarring. HS is a multifactorial disease in which genetic and environmental factors play a key role. The primary defect in HS pathophysiology involves follicular occlusion of the folliculopilosebaceous unit, followed by follicular rupture, and immune responses (perifollicular lympho-histiocytic inflammation), finally leading to the development of clinical HS lesions. HS has a destructive impact on the patient’s quality of life, being a very challenging disease. Available treatments are limited, mostly off-label and with high variability in the reported efficacy. Fortunately, a monoclonal antibody against tumor necrosis factor alpha has been recently approved for treatment of moderate to severe HS, offering patients a promising new option. This review focuses on the main features of HS, including epidemiology, clinical aspects, pathogenesis, severity classifications, comorbidities, and currently available treatments.

Nonalcoholic fatty liver disease, spleen and psoriasis: New aspects of low-grade chronic inflammation.

AIM To investigate spleen status in psoriasis and its relationship with hepatic steatosis, Psoriasis Area and Severity Index, and insulin resistance. METHODS Seventy-nine psoriatic patients who were not suffering from any chronic inflammatory disease were retrospectively selected for inclusion in this study, and their complete medical records were accessed. An age- and sex-matched group of 80 non-psoriatic, obese patients was included as a control. The following relevant data were collected: age, sex, weight, height, body mass index, waist circumference, blood pressure, insulin resistance status, age at psoriasis onset, and severity of psoriasis. Abdominal ultrasonography was performed to determine spleen longitudinal diameter (SLD), and hepatic steatosis grade. RESULTS The SLD of control obese patients was greater than that of psoriatic subjects (P = 0.013), but body mass index predicted the size of the spleen in psoriatic patients (P < 0.001). The SLD of psoriatic patients with normal weight was significantly reduced with respect to the overweight/obese psoriatic patients (P = 0.002). A multiple regression analysis revealed that body mass index was a unique predictor of the spleen size (P < 0.001). Finally, the disease duration predicted the spleen size in psoriatic subjects (P = 0.038). CONCLUSION This study shows a correlation between the SLD and the duration of psoriasis.

Acrodermatitis continua of Hallopeau (ACH): two cases successfully treated with adalimumab.

Abstract Acrodermatitis continua of Hallopeau (ACH), also known as dermatitis repens or acrodermatitis perstans, is a rare acropustular eruption, characterized by sterile pustules, paronychia and atrophic skin changes, onychodystrophy and osteolysis of the distal phalanges of the fingers and toes. While some consider ACH a distinct entity, many believe it to be a variant of pustular psoriasis, especially as cases of ACH progressing to generalized pustular psoriasis. The treatment options used are various; however, its typical cyclic recurrences, which induce important physical and psychological morbidity, may render this pathology difficult to treat. Hence, it was considered important to review the evolution of treatment options available thus far including use of biologics. Hereby, we report two patients with ACH who were successfully treated with adalimumab. By analogy to the efficacy of TNF-α antagonists in the treatment of generalized pustular psoriasis, the two patients we report illustrate the long-term efficacy and safety of adalimumab in the treatment of  Hallopeau’s acrodermatitis refractory to therapies.

Effects of climate changes on skin diseases

Global climate is changing at an extraordinary rate. Climate change (CC) can be caused by several factors including variations in solar radiation, oceanic processes, and also human activities. The degree of this change and its impact on ecological, social, and economical systems have become important matters of debate worldwide, representing CC as one of the greatest challenges of the modern age. Moreover, studies based on observations and predictive models show how CC could affect human health. On the other hand, only a few studies focus on how this change may affect human skin. However, the skin is the most exposed organ to environment; therefore, it is not surprising that cutaneous diseases are inclined to have a high sensitivity to climate. The current review focuses on the effects of CC on skin diseases showing the numerous factors that are contributing to modify the incidence, clinical pattern and natural course of some dermatoses.

Psoriasis and sport: a new ally?

Psoriasis is a common chronic multifactorial disease which can result in restrictions to social and recreational activities. Psoriasis subjects are at high risk to develop metabolic and cardiovascular diseases. Physical activity, a vital component in prevention and management of these diseases, is reported to be potentially associated in a negative way with psoriasis.