PSORIASIS and COMORBIDITIES – CARDIOVASCULAR DISEASE

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WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

 CHART 1: Comorbidities Associated with Psoriasis 1,2,3

Metabolic Syndrome – Cardiovascular Disease

  • Arterial hypertension/ Atherosclerosis
  • Myocardial infarction (MI)
  • Dyslipidemia (Raised cholesterol)

The immunological abnormalities that lead to the development of psoriasis suggest that these patients may be at increased risk for other diseases associated with an inflammatory state. Research is yet to establish whether other diseases occur as a direct result of the systemic inflammation associated with psoriasis, as a consequence of genetically determined selection, or whether it is possible that the link between psoriasis and Cardiovascular disease and myocardial infarction (MI)  may be mediated by other factors beyond inflammation, such as psychological stress, sedentary lifestyle, or possibly poor compliance with management of cardiovascular risk factors.. 4.5

There is increasing evidence to suggest that the immune response, including activated T cells, antigen presenting cells, cytokines, and markers of systemic inflammation such as C-reactive protein, are important to the development of atherosclerosis (hardening and narrowing of the arteries) and ultimately, MI. 2 Research has shown that patients with psoriasis have a higher incidence of MI compared with control patients, with patients who have severe psoriasis as having the highest rate. The risk of MI associated with psoriasis is greatest in younger patients (under the age of 40) with severe psoriasis. This reduces with age but still remains an increased risk even after treatment for traditional cardiovascular risk factors that are associated with aging. 5

Psoriasis is also associated with hypertension (increased blood pressure). In one study researchers examined the association among hypertension, antihypertensive medication use, and risk of incident psoriasis using prospective data from a large cohort of US women. A total of 121,701 participants, of which 2477 participants were diagnosed with psoriasis, were followed for 11 years with 2 yearly questionnaires. Researchers found that a prior history of hypertension was associated with an increased risk of psoriasis among women with hypertension for 6 years or more. Specifically, hypertensive women without medication use and with current medication use were more likely to develop psoriasis compared with women who did not have hypertension. Among the individual antihypertensive drugs, only ?-blockers were associated with an increased risk of psoriasis after regular use for 6 years or more. 6

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In a United Kingdom study using a large (7.5 million patients from 415 practices) electronic medical records database (The Health Improvement Network (THIN), a random sample of patients with psoriasis between the ages of 25 and 64 years were identified. The identification parameters were a diagnosis of hypertension; confirmed psoriasis diagnosis and classified psoriasis severity. The severity classification was identified according to the National Psoriasis Foundation classification system 1) mild (limited disease with ?2% BSA affected), moderate (scattered disease with 3%-10% BSA affected), or 2) severe (extensive disease with >10% BSA affected). Blood pressure was compared to the UK National Institute of Health and Care Excellence clinical guidelines, with uncontrolled hypertension being defined as systolic blood pressure of 140 mm Hg or higher or diastolic blood pressure of 90 mm Hg or higher. 

All patients with psoriasis who met the inclusion criteria were included in the study, yielding 680, 469, and 173 patients with mild, moderate, and severe psoriasis, respectively. The researchers found a significant positive relationship between psoriasis severity and uncontrolled hypertension independent of potential risk factors for poor blood pressure control. The likelihood of uncontrolled hypertension in patients with vs without psoriasis was greatest among those with moderate and severe skin disease, representing nearly half of the psoriasis patients seen by GPs in the United Kingdom. The findings have important clinical implications, highlighting a need for more effective management of blood pressure in patients with psoriasis, especially those with more extensive skin involvement (i.e. ?3% BSA affected).7 

The precise mechanisms that underlie psoriasis and hypertension are unknown. One theory proposed is that adipose (fat) tissue in psoriasis patients serves as a major source of angiotensinogen, which is subsequently converted to angiotensin II. Angiotensin II not only promotes salt retention by kidneys; it also stimulates T-cell proliferation. Angiotensin II also appears to promote inflammation and the development of atherosclerosis. Other theories suggest that increased visceral adipose tissue in psoriasis patients may contribute to hypertension development. Increased visceral adipose tissue may be associated with accumulation of perivascular fat, which can serve as a reservoir for activated effector T cells that promote dysfunction in both hypertension and psoriasis. Or that endothelin-1 may play an important role in the development of hypertension among psoriasis patients. Endothelin-1 is a protein that constricts blood vessels and increase blood pressure, and it is produced by several different cell types including keratinocytes. While the level of endothelin-1 is usually regulated through various mechanisms, their expression appears to be altered in psoriasis patients. 8 The connection between obesity and psoriasis, when taken in light of the above theories, is further strengthened. It is always advisable for those with moderate to severe psoriasis who are overweight to try to lose weight through sensible eating – reducing fast and fatty foods and increasing the intake of vegetables, especially green vegetables.

The development of atherosclerosis and its increased prevalence may be partially explained by the presence of atherosclerotic risk factors, e.g., diabetes, hypertension, obesity, and hyperlipidemia (increased levels of lipids in the blood, including cholesterol and triglycerides) as well as by the chronic inflammatory processes that are commonly observed in psoriasis. 9 

Researchers have found that psoriasis patients have impaired endothelial function and greater thickness of the innermost two layers of the wall of the carotid artery which leads to increased arterial stiffness. 9

Atherosclerosis, the underlying process resulting in cardiovascular events, is caused by the build up of atheromatous plaques in the inner layer of the arteries. Atheromatous plaques are an accumulation of degenerative material in the inner layer of an artery wall. The material consists of mostly macrophage cells, or debris, containing lipids, calcium and a variable amount of fibrous connective tissue. The interaction between metabolic abnormalities such as diabetes, high cholesterol etc. and the systemic proinflammatory mechanisms operating involved in psoriasis and psoriatic arthritis may explain the accelerated atherosclerotic process in these patients. Patients with psoriatic disease display abnormalities in the innate and adaptive immune system that result in high serum levels of proinflammatory cytokines that may upregulate cell-mediated immunity, promote inflammatory cell migration through the vascular endothelium (tissue that lines the interior surface of blood vessels), resulting in endothelial dysfunction and thus causing plaque formation and build up. 10

Recent studies clearly demonstrated that inflammation impairs reverse cholesterol transfer (High-density lipoprotein (HDL) cholesterol efflux) in vivo, providing evidence that inflammation impairs HDL function. HDL is a complex lipoprotein particle with a broad variety of functions, exerting atheroprotective activity via effects on the endothelium and by potent anti-inflammatory capabilities. Functional impairment of HDL may contribute to the increased cardiovascular mortality experienced by psoriatic patients. HDL from psoriasis patients and healthy controls was assessed for changed HDL composition. Researchers found that there was a significant reduction in apoA-I levels of HDL from psoriatic patients, whereas levels of apoA-II and proteins involved in acute-phase response, immune response, and endopeptidase /protease inhibition were increased. Psoriatic HDL also contained reduced phospholipid and cholesterol. The researchers found that the compositional alterations impaired the ability of psoriatic HDL to promote cholesterol efflux from macrophages. Importantly, HDL cholesterol efflux capability was more impaired as the psoriasis area and severity increased. 11

Efflux is a mechanism responsible for moving compounds, like cholesterol out of the cells.  The efflux process is extremely important because cholesterol overloading, such as occurs in the cells of the arterial walls, leads to the development of atherosclerotic plaque.12

Chronic systemic inflammation associated with psoriasis and psoriatic arthritis induces endothelial dysfunction, altered glucose metabolism, and insulin resistance that plays a significant role in the development of obesity, diabetes mellitus, dyslipidemia (high cholesterol), and cardiovascular disease such as atherosclerosis and myocardial infarction.

Those with moderate to severe psoriasis should ensure that they visit their General Practitioner to have their blood pressure and cholesterol checked and to have an ECG regularly to ensure the health of their heart.

 

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Elgendy A, Alshawadfy E, Altaweel A, Elsaidi A (2016) Cardiovascular and Metabolic Comorbidities of Psoriasis. Dermatol Case Rep 1: 106.
  • Gelfand JM, Neimann AL, Shin DB, Wang X, Margolis DJ, et al. (2006) Risk of myocardial infarction in patients with psoriasis. JAMA 296: 1735-1741.
  • Wu S, Han J, Li W, Qureshi AA. Hypertension, Antihypertensive Medication Use, and Risk of Psoriasis.JAMA Dermatol. 2014;150(9):957-963. doi:10.1001/jamadermatol.2013.9957
  • Takeshita J, Wang S, Shin DB, et al. Effect of Psoriasis Severity on Hypertension Control: A Population-Based Study in the United Kingdom.JAMA dermatology. 2015;151(2):161-169. doi:10.1001/jamadermatol.2014.2094.
  • Wang Armstrong A. et al; Psoriasis and Hypertension Severity: Results from a Case-Control Study; PLoS ONE 6(3):e18227 · March 2011
  • Kalkan G , Karada? A.s.:The Association Between Psoriasis and Cardiovascular Diseases: Eur J Gen Med 2013; 10 (Suppl 1):10-16
  • Eder L. and Gladman D.D.; Atherosclerosis in psoriatic disease: latest evidence and clinical implications; Ther Adv Musculoskel Dis 2015, Vol. 7(5) 187–195 DOI: 10.1177/ 1759720X15591801
  • Holzer M. et al.; Psoriasis alters HDL composition and cholesterol efflux capacity; Journal of Lipid Research Volume 53, 2012
  • Phillips M.C.; Molecular Mechanisms of Cellular Cholesterol Efflux; J Biol Chem. 2014 Aug 29; 289(35): 24020–24029.

Types of Psoriasis – FLEXURAL/INTERTRIGINOUS (INVERSE PSORIASIS) and GENITAL PSORIASIS

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Inverse psoriasis

 also known as flexural or intertriginous psoriasis is a rare form of psoriasis that occurs in the flexural skin folds. Plaque psoriasis is most commonly found on the trunk and extensor surfaces of the body, such as the knees, elbows, sacral (lower back) area, and scalp whereas Inverse psoriasis is found in the folds of the axilla (armpits), submammary (breast) folds, and groin (inguinal) and buttock folds. It can occur in any area where two skin surfaces meet. The inguinal fold is the most commonly affected area, followed by the axilla and the external genitalia. The skin at the inverse body sites differs from skin at extensor sites with less epidermal keratinization (thinner skin) and more sweat glands. The most evident difference between classical plaque-type psoriasis and inverse psoriasis is the lack of, or less, scaling. The lesions are usually well demarcated, erythematous (red), and are often shiny, appear moist, weepy and fissured. The irritation may be increased in inverse psoriasis as a result of the rubbing and sweating involved in the skin folds. 1, 2   

Approximately 3–7% of psoriasis patients present with inverse psoriasis and patients with palmar psoriasis have a greater chance of having inverse psoriasis as compared with plaque psoriasis. In one study of 170 psoriasis patients with palmar involvement, 5.3 times more patients had inverse psoriasis than patients with plaque psoriasis. Development of inverse psoriasis has been reported as a paradoxical side effect to treatment with infliximab for Crohn’s disease and hidradenitis suppurativa. Inverse psoriasis has been observed to be more common in the obese population possibly due to the rubbing of the skin folds. 1, 2

Inverse psoriasis affecting the genitalia seems to be underreported and undertreated; and approximately 35% patients with genital psoriasis never speak to their physician about their genital lesions. Nearly 70% of Physicians do not offer treatment for genital lesions. 3

Flexural Psoriasis 3

A study on the quality of life and sexual life in 487 patients with genital psoriasis concluded that3:

  • patients with genital lesions report even significantly worse quality of life than patients without genital lesions;
  • sexual distress and dysfunction are particularly prominent in women;
  • sexual distress is especially high when genital skin is affected;
  • the attention given to possible sexual problems in the psoriasis population by healthcare professionals is perceived as insufficient by patients.     

Flexural Psoriasis 2

Results of several questionnaire-based surveys show that involvement of the genital skin region occurs in 29–40% of patients with psoriasis. The genital area may frequently be involved in cases of inverse psoriasis. Of 48 patients with inverse psoriasis, the external genitalia were involved in 38 (79.2%). 4

Flexural Psoriasis 1

In another report researchers stated that patients with genital psoriasis have significantly worse quality of life (QoL) scores compared with patients without genital lesions. In addition, numerous patients with psoriasis have sexual dysfunction. Between 25–40% of patients reported a decline of sexual activity since the onset of psoriasis, mainly due to diminished sexual desire, embarrassment of physical appearance and inconvenience caused by scaliness of the skin or topical therapy. Particularly in women with genital psoriasis, sexual distress is higher and sexual function is more significantly impaired compared to those without genital lesions. 4

Inverse psoriasis is often misdiagnosed for bacterial or fungal intertrigo. Intertrigo is inflammation of opposed skin folds caused by skin-on-skin friction that presents as erythematous, macerated (moist, broken, soft skin) plaques. Secondary bacterial and fungal infections are common because the moist, denuded skin provides an ideal environment for growth of microorganisms. Candida is the most common fungal organism associated with intertrigo. Intertriginous candidiasis also presents as well demarcated, erythematous patches but with tell tale satellite papules or pustules at the periphery (around the edges). Candida, Staphylococcus aureus and Malassezia furfur have been shown to colonize psoriatic skin lesions so diagnosis for flexural psoriasis is sometimes not easy. Candida species have been isolated from the skin of 15% of psoriasis patients compared to only 4% in the control group. 5, 6 However, some studies have also suggested that Candida is not commonly found in psoriatic lesions of inverse of genital psoriasis.

Application of topical treatment in the intertriginous areas is considered as treatment under occlusion due to enhanced hydration and increased skin absorption. However, the inverse areas are considered more sensitive and prone to side effects from topical steroids (i.e. due to thinner skin at these locations). 2

 

REFERENCES

  1. Syed Z. U. and Khachemoune A.; Inverse Psoriasis Case Presentation and Review; Am J Clin Dermatol 2011; 12 (2): 1-4 1175-0561/11/0002-0001/$49.95/0
  2. Silje Haukali Omland  and Robert Gniadecki; Psoriasis inversa: A separate identity or a variant of psoriasis vulgaris?; Clinics in Dermatology (2015) 33, 456–461
  3. Meeuwi  K.A.P. et al.; Genital Psoriasis: A Systematic Literature Review on this Hidden Skin Disease;  Acta Derm Venereol 2011; 91: 5–11
  4. Meeuwis KAP, et al.; Genital Psoriasis Awareness Program: Physical and Psychological Care for Patients with Genital Psoriasis. Acta Derm Venereol. 2015, 95, 211–216
  5. Wilmer E.N. et al.; Resistant “Candidal Intertrigo” ”: Could Inverse Psoriasis Be the True Culprit?; doi: 10.3122/jabfm.2013.02.120210
  6. Taheri Sarvtin, et al.;. Evaluation of candidal colonization and specific humoral responses against Candida albicans in patients with psoriasis. International Journal of Dermatology. Dec2014,Vol.53Issue12, pe555-e560. 6p.

PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – PART 3

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The last in our 3 part series addressing psychological and psychiatric disorders associated with psoriasis.

   Psychological and Psychiatric Disorders –

   Sleep Disorders

   Somatoform Disorders

   Substance dependence of abuse

1, 2, 3

Sleep Disorders

It is thought that psoriasis has a direct effect on the development of sleep disorders due to the cutaneous (skin) symptoms of the condition. The skin is the primary circadian mediator of core body temperature (CBT), and a decrease in CBT in the late evening is an important mechanism for sleep initiation. Psoriasis has been associated with problems with thermoregulation and researchers have indicated that the reduced ability to dissipate heat is one factor in the inability to initiate sleep. Pruritus (itch) is another contributor to sleep disturbance and it is also regulated by circadian mechanisms. The threshold for pruritus is lowered in the evening due to complex circadian-mediated factors such as lower cortisol levels, decreased epidermal barrier function, and increased distal-to-proximal (distant limbs-to-body centre) gradient in skin temperature. Thus pruritus in psoriasis typically manifests or exacerbates mainly in the evening and worsens at night. 4,5,6

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The inflammatory biological mechanism(s) that lead to initiation and exacerbation of psoriasis, also contribute to the development of systemic diseases e.g. depressive disease, hypertension (blood pressure), adverse cardiac events, diabetes, metabolic syndrome and obesity. All of these conditions are known to indirectly give rise to sleep-disordered breathing. The heightened pro-inflammatory state in conditions such as obstructive sleep apnoea syndrome (OSAS) and insomnia could in turn lead to exacerbations of psoriasis.4,5,6

A systematic review of the literature on the relationship between psoriasis, PsA, and formal sleep disorders identified an increased prevalence of OSAS with a 36-81% prevalence in psoriasis versus 2% for women and 4% for men in the general population.4,5  In one study researchers found that some patients with chronic psoriasis and concurrent OSAS showed improvement of their psoriatic lesions while on nasal continuous positive airway pressure (CPAP).6 OSAS leads to severe physical and, possibly, psychological stress to the body, e.g., by hypoxemia (low blood oxygen levels), increased blood pressure, tachycardia (fast or irregular heart rate), sleep fragmentation, reduction of deep sleep, reduction of REM sleep, hypersomnia (excessive sleepiness), and insomnia. It is known that OSAS also dysregulates the function of the patient’s autonomic nervous system and hormone system. It is felt that this might alter the homeostasis of the immune neuroendocrine network in the skin and may cause the initiation of psoriasis in the genetically predisposed individuals.4,5,6

Somatoform Disorders – psychosomatic symptoms

Somatization is the manifestation of psychological distress by the presentation of bodily symptoms such as feeling nausea due to anxiety, stress headaches, falling ill after a trauma and inability to cope with a disease. 

Patients with psoriasis exhibit higher scores of hypochondriasis, hysteria, and somatization. As previously exposed hypochondriasis and hysteria may be connected with specific personality traits of patients with psoriasis of late-onset. Psychosomatic factors, namely stressful life events, lack of social support, and attachment insecurity, may explain why patients with psoriasis have greater scores of somatization. Moreover, the presence of depression in psoriasis may modulate itch perception and then exacerbate symptoms of pruritus.7 (Refer to Part 1 of this series) A systematic review of the psychosocial burden of psoriasis found that social stigmatization, high stress levels, physical limitations, depression, employment problems and other psychosocial co-morbidities experienced by patients with psoriasis are not always proportional to, or predicted by, other measurements of disease severity such as body surface area involvement or plaque severity. Some psoriasis patients had, even when their lesions were small and mild, levels of stress and loss of confidence that was not in keeping with the severity of their condition – which leads to the conclusion that they had maladaptive coping mechanisms in play e.g. self blame, blaming parents, social phobia, avoidance behaviours, substance and alcohol abuse etc. 9

Substance – Dependence of Abuse

In our previous blog Psoriasis and Alcohol (ethanol), we stated that patients with psoriasis experience considerable emotional distress, depression and social isolation due to the visibility of skin lesions, especially when the lesions are widespread and severe. Whilst it would be demeaning to state that all psoriasis patients with mild to severe psoriasis suffer from alcoholism, it has been confirmed in several Quality of Life studies that the percentage of psoriasis patients who admit to having a drinking problem may be as high as 32%. Research indicates that men are more likely to use alcohol excessively as a coping mechanism with the psychosocial burden of psoriasis. Consequently they are at a higher risk of developing depression – with the alcohol misuse and psoriasis as underlying causes. 4 Another study indicated that for women, excessive alcohol intake above a certain threshold (?30.0 g/d), may be associated with a significantly increased risk of Psoriatic Arthritis (PsA).5

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Alcohol is known to inhibit inflammation and immune responses; however acute and chronic alcohol consumption have opposite effects on inflammatory cell activation. Results indicate that acute alcohol exposure is inhibitory, whereas chronic alcohol exposure leads to an increase in inflammatory cell responses.6

Research has confirmed that alcoholics are more susceptible to infections, as streptococcal infections are trigger factors for psoriasis, this increased susceptibility may be involved in the onset and progress of the disease. It is also known that measurable quantities of ingested ethanol are secreted through human skin. Transdermal ethanol derives from two processes: active secretion by eccrine glands, primarily sweat glands, and passive diffusion through the lipid layers of the skin. Ethanol disrupts the dermal barrier enhancing skin permeability for numerous chemicals and increases the solubility of penetrating chemical compounds.6

Research into the the use of illicit drugs and psoriasis is extremely limited. Methylenedioxymethamphetamine (MDMA), also called Ecstasy, has been reported to initiate Guttate Psoriasis. The researchers theorized that “While MDMA [the main ingredient in ecstasy] is taken for its psychomimetic effect, pharmacologically it increases the level of noradrenaline, serotonin and dopamine by inhibiting the reuptake mechanism. It is known that Patients with psoriasis already have increased levels of noradrenaline.”7 There are also anecdotal stories on support websites where psoriasis sufferers have spoken about the exacerbation of their psoriasis with the use of “meth” (Methamphetamine, Ice). Within our clinic we have had several patients whose psoriasis was initiated and exacerbated by the use of cannabis (street not medicinal), once they ceased the use of cannabis their psoriasis resolved. As long as they did not use cannabis they remained free of any psoriatic lesions.

REFERENCES

  • Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
  • Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
  • Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
  • Brenaut E. et al.; Alcohol consumption and psoriasis: a systematic literature review. J Eur Acad Dermatol Venerol. 2013 Aug;27 Suppl 3:30-5. doi: 10.1111/jdv.12164.
  • Shaowei Wu et al.; Alcohol Intake and Risk of Incident Psoriatic Arthritis in Women; J Rheumatol. 2015 May ; 42(5): 835–840. doi:10.3899/jrheum.140808.
  • Farkas A, Kemény L.; Psoriasis and alcohol: is cutaneous ethanol one of the missing links?; • British Journal of Dermatology 2010 162, pp711–716
  • Tan B., Foley P.; Guttate psoriasis following Ecstasy ingestion; Australasian Journal of Dermatology45(3):167-9 September 2004?

PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – PART 2

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WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

 CHART 1: Comorbidities Associated with Psoriasis

    Psychological and Psychiatric Disorders –

   Personality Traits and Personality Disorders

   Schizophrenia and other psychoses

   Sexual Dysfunction

1, 2, 3

Personality Traits and Personality Disorders

It has also been proposed by a number of researchers that patients with skin disease usually present with certain psychological traits that makes them vulnerable to stress. Although a specific personality structure for psoriasis patients has not yet been defined, psoriasis patients are reported to have more obsessive compulsive, avoidant, schizoid and passive-aggressive properties than healthy controls, however the research surrounding personality and psoriasis is still controversial. 4

The term personality represents the different behavioural styles that individuals present in their habitual habitats or environments.4 In one study of male psoriasis patients and a control group the psoriasis group scored significantly higher scores than the control group in Extravagance (NS3), Disorderliness (NS4), Novelty Seeking (NS), Anticipatory Worry (HA1), Shyness with Strangers (HA3), Fatigability and asthenia – weakness – lack of energy and strength (HA4), Harm Avoidance (HA), Dependence (RD3), Reward Dependence (RD), Self-forgetfulness (ST1), Transpersonal Identification (ST2), Spiritual Acceptance (ST3) and Self-Transcendence – the ability to focus attention on doing something for the sake of others (ST).5

Another study found that the severity of pruritus (itch) and the severity of psoriasis was associated with significantly higher scores for depression and anxiety, and showed the personality traits of somatic anxiety (physical reactions to anxiety e.g. sweating, nausea etc.), embitterment, mistrust, and physical trait aggressiveness. However, the researchers also found that the severity of itch was not associated with the severity of psoriasis from a PASI score perspective. In fact they found that there was a higher severity of itch reported in 30% of psoriasis patients in which the greater majority of these had very few lesions.6

Psoriasis Patients often report felt or perceived stigma, referring to the negative attitudes and responses that they perceive to be present in society and the sense of shame and fear of being discriminated against because of being ‘flawed’ due to the physical appearance of their lesions. The actual experiences of stigmatization range from –  people showing disgust or aversion, making negative comments or totally avoiding contact.6

Stigmatization contributes considerably to disability, depression and reduced quality of life in psoriasis patients, and can be considered a stressor. As distress can be a trigger for psoriasis exacerbation, this can become a vicious self-perpetuating cycle. The Type D personality has previously been associated with increased risk of cardiovascular morbidity and mortality and impaired health behaviour e.g. smoking and alcohol dependence, which are both frequently reported in psoriasis. The two main features – SI (social inhibition) and NA (negative affectivity) – may both increase the impact of perceived stigmatization. SI refers to conscious or subconscious avoidance of a situation or social interaction because of the possibility of others disapproving of their feelings or expressions.  Whilst NA refers to negative emotions, including anger, contempt, disgust, guilt, and fear, and nervousness. Furthermore, individuals with high levels of NA may be more likely to perceive social interactions as negative, due to the associated cognitive bias to negative feedback. In one study researchers found that perceived stigmatization was particularly predicted by disease impact, as well as by lower age, lower education, greater disease severity and visibility, longer disease duration, higher levels of SI, having a type D personality and being single. 6

The researchers concluded that it seems likely that patients with psoriasis who are prone to feelings of helplessness regarding the disease may also experience a larger impact of psoriasis and magnify negative reactions of others. Type D personality and its subcomponent SI were found to be significant predictors of perceived stigmatization. The fear of disapproval that leads individuals to inhibit emotions or behaviour in SI may explain its relation to perceived stigmatization. They stated that socially inhibited individuals may be more sensitive to the reactions of others and may therefore perceive themselves to be stigmatized more readily. They found that not only was SI in itself, but also the combination of higher levels of SI and NA (type D personality) was a significant predictor of perceived stigmatization, which  corresponded with previous studies that suggested that type D was associated with social impairments. 6

It was suggested that Practitioners should screen for feelings of Stigmatization and related problems, and implement with the patient, targeted interventions that may focus on the impact of the condition on daily life, considering that this was the largest predictor. Therapy, such as Cognitive Behavioural Treatment, which should include social skills training, has shown promise as an intervention treatment. Previous research indicates that it can decrease perceived stigmatization in skin conditions, improve psychological and disease-related outcomes in psoriasis patients, and decrease feelings of helplessness, which shows high correlations with disease severity and impact. 6

It is extremely important that psoriasis sufferers do not cut themselves off from social interactions and it is highly recommended that they join a support group that is not only internet based but one that meets socially on a face to face basis. 

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Schizophrenia and other psychoses

 The psychiatric morbidity in psoriasis is considered an important indicator of the disability experienced by the patient than the dermatologic aspects of the disorder, sometimes more so than the physical aspect of the lesions. Some studies have found a possible connection between psoriasis and psychosis, including schizophrenia. Schizophrenia is a polygenic (involvement of 2 or more genes), multifactorial disorder and recent neuroanatomical and neurobiological being related to the nervous system as well as environmental and genetic studies have suggested that inflammatory pathways are also involved in its pathogenesis. Because psoriasis is also considered a state of chronic systemic inflammation involving several genes and is a related immune processes might explain the link between psoriasis and its comorbidities.7

In a systematic review researchers reviewed the published clinical papers on the link between psoriasis and Schizophrenia and other psychoses. The results of the systematic review found that there is some evidence of a relationship between schizophrenia and/or disorders with psychotic features and psoriasis. In one case-controlled study the authors concluded that schizophrenic patients have a higher probability of having a diagnosis of psoriasis whilst other studies highlighted that psoriasis patients have a higher risk of having schizophrenic traits. The main characteristics of schizoid character are social isolation, intimacy avoidance and restricted affections. Although for a long time was considered that a schizoid character was related to schizophrenia, this has been found to be not always true. Nevertheless, schizoids may be more susceptible to psychosis. This personality shares with schizophrenia, although with its own subtleties, the problem of the distinction between the “self” and the “other”. Several studies have reported on the occurrence of psoriasis in schizophrenia patients being treated with cyclosporine A and olanzapine. And other schizophrenia patients with existing psoriasis found that treatment with haloperidol and levomepromazine actually also improved the patients psoriasis.7

 For some psoriasis patients it was found that whilst they were experiencing a worsening of their skin lesions their existing psychotic condition also worsened, and as their skin improved so too did their psychotic condition.7 The hypothesis is that psoriasis, schizophrenia and other psychotic conditions share similar pathways.

Sexual Dysfunction

Sexual health is an important part of general health and sexual dysfunctions can negatively affect self-esteem, confidence and interpersonal relationships. The impact of psoriasis upon sexual function seems to be substantial and it has a significant impact in quality of life. One study found that when compared to a control group, the psoriasis group showed significant impairment of all the components of sexual function: sexual interest, sexual arousal, orgasm, erection and sexual satisfaction. “Sexual interest” and “global sexual satisfaction” were the most negatively affected components. Male patients with psoriasis showed an increase in erectile dysfunction compared to controls. The prevalence of sexual dysfunction was 53.7% in patients with psoriasis vs. 17.5% in the healthy control group. The researchers also found that psoriasis lesions on the genitals, buttocks, abdomen or lumbar (back) region were significantly linked to sexual dysfunction and those psoriasis patients with sexual dysfunction had higher scores for depression (32.5%) and anxiety (50%). 9

Certain components of sexual response, such as sexual interest, depend primarily on psychological factors, and are impaired by conditions such as anxiety and depression, while others such as erection and orgasm can be affected by psychological and physical causes.

It has also been suggested that the sexual dysfunctions might not be as a direct result of depression, but rather of low self-esteem or other emotional problems. As sexual impairment in psoriasis patients was seen to occur in all components of the sexual response, the researchers concluded that this suggested that sexual dysfunction in psoriasis must be a consequence of several combined factors.9,10

If you have a concern about depression, bipolar, schizophrenia or sexual dysfunction please discuss your concerns with your General Practitioner.

Read also PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – Part 1

REFERENCES

  • Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
  • Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
  • Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
  • Martín-Brufau R. et al.; Personality in Patients with Psoriasis; Chapter 11 rfrom the book Psoriasis Downloaded from: http://www.intechopen.com/books/psoriasis
  • Ak M. et al.; Temperament and character properties of male psoriasis patients; Journal of Health Psychology; pg 1-8; 2011; DOI: 10.1177/1359105311423863
  • Remröd ;  Pruritus in Psoriasis: A Study of Personality Traits, Depression and Anxiety; Acta Derm Venereol 2015; 95: 439–443;
  • Ferreira BR, Pio Abreu JL and Figueiredo A.; Psoriasis, Schizophrenia and Disorders with Psychotic Features: Are They Linked?; J Schizophr Res. 2015;2(1): 1006.
  • Molina-Leyva A. et al.; Distribution pattern of psoriasis, anxiety and depression as possible causes of sexual dysfunction in patients with moderate to severe psoriasis; An Bras Dermatol. 2015;90(3):338-45
  • Sarbu, Maria Isabela; Tampa, Mircea; Sarbu, Alexandra Elenda; and Georgescu, Simona Roxana (2014) “Sexual Dysfunctions in Psoriatic Patients,” Journal of Mind and Medical Sciences: Vol. 1: Iss. 1, Article 5.

PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – Part 1

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WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

CHART 1: Comorbidities Associated with Psoriasis

Psychological and Psychiatric Disorders – Depression

anxiety

Suicide

Addiction

1, 2, 3

Psychophysiologic disorders are associated with skin conditions, such as psoriasis, that are frequently precipitated or exacerbated by emotional stress. For many sufferers of psoriasis associated depression, anxiety, addictions to alcohol etc. and even suicidal thoughts are common.

As far back as the 1940s and 1950s researchers explored the relationship between emotions and psoriasis theorizing various ideas such as “chronic psoriasis is often linked with deeply repressed emotional conflicts”, that “nervous exhaustion” may play a role in the causation and aggravation of the disease”, and that “in emotionally maladjusted individuals the psychological factor may ‘take charge’ of the psoriasis and determine its onset, persistence and relapses.” 1  

Since the 1970’s numerous studies have been conducted by researchers in the bid to understand the subtleties involved in the interplay between mental and emotional stresses, anxieties and depression with psoriasis. Research in the 2000s has greatly defined the psychological and psychiatric disorders associated with psoriasis, they include:-

Anxiety Disorders 1, 2

  • Acute stress disorder–anxiety symptoms occur immediately following a trauma, but are short-lived.
  • Adjustment disorder with anxious features–anxiety symptoms in relation to a major life-changing event – like getting married or moving to another city. Symptoms generally start within three months of the stressful event and occur for six months or less.
  • Substance-induced anxiety disorder– generally resolves when the substance is discontinued or when withdrawal from the substance is over.

INCLUDING:

  • Panic Disorder (With Or Without Agoraphobia) – consists of severe, immediate anxiety symptoms (a panic attack) due to a broad range of fears, such as of open spaces, public transportation or about being trapped or about being safe when outside the home, as well as the worry over having another panic attack.
  • Generalized anxiety disorder (GAD)– is characterized by excessive, exaggerated anxiety and worry about everyday life events with no obvious reasons for worry. People with symptoms of generalized anxiety disorder tend to always expect disaster and constantly worry about health, money, family, work, or school, which is often totally unrealistic or out of proportion for the situation. Day to day life becomes a constant state of worry, fear, and dread.
  • Social Anxiety Disorder (SAD)

       People with social anxiety disorder (sometimes called “social phobia”) have a marked fear of social or performance situations in which they expect to            feel embarrassed, judged, rejected, or fearful of offending others.

       Social anxiety disorder symptoms include:

  •   Feeling highly anxious about being with other people and having a hard time talking to them
  •   Feeling very self-conscious in front of other people and worried about feeling humiliated, embarrassed, or rejected, or fearful of                                         offending others
  •   Being very afraid that other people will judge them
  •   Worrying for days or weeks before an event where other people will be
  •   Staying away from places where there are other people
  •   Having a hard time making friends and keeping friends
  •   Blushing, sweating, or trembling around other people
  •    Feeling nauseous or sick to your stomach when other people are around
  • Obsessive-compulsive disorder (OCD) – anxiety symptoms are in the form of intrusive, obsessive thoughts and compulsive behaviors (or mental acts). OCD is considered a chronic type of anxiety disorder.
  • Post traumatic stress disorder (PTSD)– anxiety symptoms that occur after a trauma and are long-term in nature.
  • Social phobia, also referred to as Social Anxiety Disorder – anxiety symptoms occur in social or performance situations and stem from the fear of being humiliated or embarrassed.
  • Specific phobia or a simple phobia– anxiety symptoms occur around a specific object or situation which results in avoidance.

Psoriasis sufferers have reported more stressful life events in comparison with control subjects. The link between psoriasis and anxiety can be analyzed in two ways – anxiety can lead to psoriasis and psoriasis can lead to anxiety. Also research has confirmed that an increase in severity of psoriasis leads to an increasing frequency of anxiety. The magnitude of this anxiety may be influenced by variables of disease e.g. severity, distribution of lesions, duration of condition and nail and joint involvement. Likewise it should also be noted that variables of life e.g. age, gender and marital status influence psoriasis associated anxiety and depression. 3

Eating Disorders – Obesity 4,5

Increasing evidence suggests that patients with psoriasis may be more obese compared with the general population. Although the exact mechanism underlying the association between psoriasis and obesity is uncertain, researchers have theorized that adipocytes (fat cells) as a rich source of pro-inflammatory cytokines may exacerbate psoriasis.

Which Comes First? Obesity or Psoriasis?

The answer to this question remains unknown as the precise mechanism underlying the association between psoriasis and obesity remains elusive. However, two longitudinal prospective cohort studies found weight gain or obesity; particularly from the age of 18 years was a risk for developing psoriasis in women. It still bust be noted that not all psoriasis sufferers are obese and not all obese individuals develop psoriasi

Mood Disorders (Depressive Disorders and Bipolar Disorder)6

Research has recently considered whether psoriasis is a psycho-dermatological disorder.

A psycho-dermatological disorder is a condition that involves an interaction between the nervous and the integumentary (skin) system. Psoriasis has been found to be associated with clinical depression commonly known as major depression through an immunological phenomenon. Research has shown the possibility of a relationship between common forms of psoriasis and major depressive disorder and an increase in stress and depressive symptoms has been found to have a significant statistical correlation with an increase in psoriasis flare-ups and pruritus severity along with a more clinically disfiguring disease. In addition, studies have shown that a decrease in depression/depressive symptoms due to medication or therapy is often associated with a decrease in psoriasis severity and vice versa. Other research has found that many inflammatory markers and cytokines which are released during depression are also released during psoriasis.

Research into depression has found that it leads to an increase in the concentration of proinflammatory cytokines systemically in patients afflicted with the disease, and that these same proinflammatory cytokines migrate towards the epidermis (skin) and cause psoriatic lesions in susceptible patients, either increasing psoriasis severity or potentially leading to its initiation or a flare up. Other research has found that mutations in genes related to psoriasis cause an increase in the same proinflammatory cytokines. These cytokines can cause HPA axis (hypothalamic–pituitary–adrenal axis) hyperactivity which is observed in major depressive disorder and that this then disturbs the negative feedback inhibition of circulating corticosteroids on the said axis and leads to lower serotonergic (5-HT) neurotransmitter levels, thus leading to a depressive disorder. READ ALSO OUR PREVIOUS BLOG: – STRESS, ANXIETY,

DEPRESSION AND PSORIASIS

Bipolar Disorders

Bipolar is a significant, serious and debilitating mood disorder. If it is not bad enough that a person may have this condition, Lithium, one of the most commonly prescribed psychotropic medications for this condition, has been associated with a wide range of cutaneous side effects including the initiation and exacerbation of psoriasis. In the general population prevalence of bipolar is estimated to be 3%, the prevalence of psoriasis varies from 1–5% in Western Countries; approximately 2% of these patients will suffer from bipolar.

Lithium, which has been in use for the treatment of bipolar for over 50 years, has a long history of systemic adverse effects, including the skin. The reported prevalence of the cutaneous side effects varies from 3% to 45% in different studies. Acne/acneiform and psoriasiform rashes are among the major cutaneous adverse effects of lithium and these may result in noncompliance. It should be noted; however, not all the patients with pre-existing psoriasis show flares while they are on lithium treatment. Male patients who take lithium are more likely to develop cutaneous reactions than their female counterparts.7

 Look out for our next edition on this topic –  PSORIASIS AND COMORBIDITIES – Psychological and Psychiatric Disorders – Part 2 

REFERENCES

  • Susskind W. and McGuire R.J.: The Emotional Factor in Psoriasis; Scot. med, J., 1959,4:503
  • Kessler R. C. et al.; Epidemiology of Anxiety Disorders; M.B. Stein and T. Steckler (eds.), Behavioral Neurobiology of Anxiety and Its Treatment, Current Topics in Behavioral Neurosciences 2, DOI 10.1007/7854_2009_9, # Springer?Verlag Berlin Heidelberg 2009, published online 3 September 2009
  • Nasreen S. et al.; Frequency and Magnitude of Anxiety and Depression in Patients with Psoriasis Vulgaris; Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 397-400
  • Toussirot É. Et al.; Relationships between adipose tissue and psoriasis, with or without arthritis; Frontiers in Immunology; August 2014 | Volume 5 | Article 368 ; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4129363/pdf/fimmu-05-00368.pdf
  • Aldeen, et al; Obesity and Psoriasis: Can Bariatric Surgery Trigger Psoriasis?; J Clin Exp Dermatol Res 2015, 6:6 http://dx.doi.org/http://dx.doi.org/ 10.4172/2155-9554.1000305
  • Tohid H. et al.; Major Depression and Psoriasis: A Psychodermatological Phenomenon; Skin Pharmacol Physiol 2016;29:220–230 DOI: 10.1159/000448122

 

PSORIASIS and COMORBIDITIES – PSORIATIC ARTHRITIS

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WHAT IS COMORBIDITY?

 Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

Psoriatic Arthritis

Spondyloarthropathies

CHART 1: Comorbidities Associated with Psoriasis 1,2,3

Psoriatic arthritis (PsA) is an inflammatory arthropathy, which is associated with psoriasis in approximately 25% of patients. It is characterized by stiffness, pain, swelling, and tenderness of the joints as well as the surrounding ligaments and tendons. It affects men and women equally and typically presents at the age of 30 to 50 years. Skin lesions usually precedes the onset of PsA by an average of 10 years in the majority of patients but 14– 21% of patients with PsA develop symptoms of arthritis prior to the development of skin lesions.4

human_hand_bones-en The Foot

                  The Hand                                                                                             The Foot

The presentation of PsA is variable and can range from a mild, non-destructive arthritis to a severe, debilitating, erosive arthropathy.

There are various classifications for PsA:-

• Monoarthritis of the large joints – inflammation and arthritis in one joint.

PsN 1 Finger

          Swelling evident in the joint between the Intermediate and Proximal Phalanges in the index finger

  • Distal interphalangeal arthritis – affecting the joint between the Distal and Proximal phalanges.
  • Spondyloarthritis – affecting the spine and, in some people, the joints of the arms and legs.

Symmetrical deforming polyarthropathy – similar to that of rheumatoid arthritis

PsN all Distal Joints

Deformity of the Distal interphalangeal joints with varying degrees of severity seen across all of the fingers from severe to mild.

If PsA is left untreated, a percentage of patients may develop chronic inflammation with progressive deforming joint damage which leads to severe physical limitations and disability. So it is very important for a patient with psoriasis who is experiencing joint swelling or pain to be reviewed by a Rheumatologist as soon as possible. However, as there is no specific test for PsA, the diagnosis of PsA is based on clinical judgement. The main aspect is the absence of rheumatoid factor (91-94%), this key finding together with the specific presentation of joint pain and inflammation plus the presence of psoriasis skin lesions all combine to lead the Practitioner and the Rheumatologist to diagnose PsA. X-rays may aid diagnosis and can show the extent and location of joint damage. Other types of scans such as MRI or CT scans can also be used to look at the joints in more detail.

In many patients articular patterns change or overlap in time. Enthesitis, inflammation at the sites where tendons or ligaments insert into the bone, may occur at any site, but more commonly at the insertion sites of the plantar fascia (the fibrous band of tissue (fascia) connecting the heel bone to the base of the toe bones), the Achilles tendons, and ligamentous attachments to the ribs, spine, and pelvis. PsA is unusual in that it can affect joints on only one finger or toe, several joint on one side or on affect joints on both sides of the body. PsA symptoms often resemble those of rheumatoid arthritis. Both diseases cause the joints to become inflammed, painful, swollen and warm to the touch.4

The most common symptoms are:-

  • Swollen fingers and/or toes.  PsA can cause a painful, sausage-like swelling of the fingers and/or toes. Swelling and deformities in the hands and feet before having significant joint symptoms may occur.

  • Foot pain. Psoriatic arthritis can also cause pain at the points where tendons and ligaments attach to the bones — especially at the back of the heel or in the sole of the foot.
  • Lower back pain.Some sufferers develop a condition called spondylitis as a result of PsA which causes inflammation of the joints between the vertebrae of the spine and in the joints between your spine and pelvis (sacroiliitis).

Skin lesions in patients with PsA and psoriasis may vary from a mild to a severe presentation and the skin activity is commonly not indicative of the severity of the arthritis symptoms. It is important to note that skin lesions and symptoms normally precede arthritic signs and symptoms in 80% of psoriatic arthritis patients. Whilst simultaneous onset of arthritic and psoriatic symptoms will occur in approximately 13% of patients, only 3% of patients will have joint involvement preceding the development of skin lesions.5

People with PsA often experience pain, stiff joints and muscle weakness and often this is due to lack of use so a regime of light exercise is very important to improve overall health and to keep the joints as flexible as possible. It may be of benefit for people with PsA to consult with an exercise physiologist / remedial therapist who can give advice as the most suitable exercises that are patient specific, including how to get started safely, so that the potential to aggravate the joints are kept to a minimum.

Some of the types of exercise that should be discussed with your physiologist / therapist are:-

  • Aerobic exercises – walking, swimming or gentle water aerobics
  • Muscle-strengthening exercises – light weights
  • Muscle-stretching exercises
  • Hydrotherapy – supervised structured exercises of specific extremities and joints in warm water.

Use of Assistive Devices

An assistive device is a tool or implement that makes a particular function or action easier or possible to perform, e.g.:-

Clothing Aids

  • Velcro on clothes and shoes or elastic shoelaces.
  • Button and zipper hooks.
  • Leg-Up Leg Lifter allows users with limited mobility to avoid having to bend down or hold onto clothing to lift their leg.
  • Long handled shoe horns.

Grooming Aides

  • Fit Combs, brushes and toothbrushes with easier-to-hold handles for ease of use.
  • Or use Long handled brushes and combs that have anti-slip handles.
  • Use a toothpaste dispenser that automatically dispenses a set amount of toothpaste onto a brush.

Bathing and Showering Aides

  • Use a long handled hair washer that can be used to apply shampoo and massage the user’s scalp while reducing strain on the hands, shoulders, or arms.
  • Long handled foot wash brush to assist people with limited access to their feet.
  • Long handled sponge or cloth body washers.
  • Long handled lotion or ointment applicators.

Cooking and Cleaning Aides

  • Finger loop utensils.
  • Oven knob turner.
  • Cut resistance gloves and Finger protector (slicing) guard.
  • Easy glide plastic bag opener.
  • Jar “pop” openers.
  • Tin pull top openers.

Walking Aides

  • Walkers, canes, knee and ankle braces.

Remember there are many websites available where you can purchase any number of assistive devices.

It is important not to lock oneself away and use immobility as an excuse not to socialize. Use group exercise classes to not only improve one’s fitness and mobility but also use the opportunity to talk to other class member’s, or join a support group ….. just the act of talking and sharing can be enough to ensure that you do not become depressed.

 

 

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Lloyd P. et al.; Psoriatic Arthritis: An Update; Hindawi Publishing Corporation Arthritis Volume 2012, Article ID 176298, 6 pages doi:10.1155/2012/176298
  • Gottlieb A.B. et al.; Clinical characteristics of psoriatic arthritis and psoriasis in dermatologists’ offices; Journal of Dermatological Treatment. 2006; 17: 279–287

 

 

PSORIASIS and COMORBIDITIES and INFLAMMATORY BOWEL DISEASE

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WHAT IS COMORBIDITY?

 Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

INCREASED RISK

The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

CHART 1: Comorbidities Associated with Psoriasis

Inflammatory Bowel Disease (IBD) –

Crohn’s Disease

Ulcerative Colitis

Irritable Bowel Syndrome (IBS)

1, 2, 3

Gastro Intestinal (GI) disorders are present in 28% of patients with psoriasis. Common abnormalities in psoriasis patients include changes in the mucous membrane of the duodenum. Psoriasis may cause dermatogenic enteropathy and intestinal inflammation.

Irritable bowel syndrome (IBS) is one of the most common ‘functional’ gastrointestinal disorders accounting for 3% of all primary care consultations, with a strong female predominance. The main features are recurrent abdominal pain and/or discomfort, whose clear relationship to changes in stool frequency or consistency and its relief by defecation implies that they originate in the colon. In addition to these gastrointestinal (GI) symptoms, patients commonly report non-GI symptoms of lassitude, headache, backache, dysmenorrhoea (painful periods/menstruation), and dyspareunia (painful intercourse). Symptoms characteristically wax and wane. IBS patients, in common with other sufferers with functional GI disorders, are more anxious than healthy controls, showing greater anxiety and depression. Many patients believe that stress induces their symptoms.10

Inflammatory Bowel Disease (IBD) are a group of inflammatory conditions in which the body’s own immune system attacks parts of the digestive system. The two major types of IBD are ulcerative colitis (UC) and Crohn’s disease (CD). UC is limited to the colon and/or rectum (normally continuous lesions in the rectum and colon), and affects only the inner lining (mucosal and submucosal layers) of the gut. In contrast, CD can affect any part of the gut from mouth to anus as non-continuous or skip lesions (a majority of cases start in the terminal ileum), and affect the whole thickness of the bowel wall.4

stomach_etc_diagram-en-wikkip

Within the IBD group is also Microscopic Colitis, an inflammation of the colon that can only be detected with a microscope. There are two types of microscopic colitis – collagenous colitis and lymphocytic colitis. Under a microscope an increase in the number of lymphocytes, a type of white blood cell, can be seen in the epithelium—the layer of cells that lines the colon.15

The two types of colitis affect the colon tissue in slightly different ways:

  • Lymphocytic colitis – The number of lymphocytes is higher, whilst the tissues and lining of the colon are of normal thickness.
  • Collagenous colitis – The layer of collagen, a threadlike protein, underneath the epithelium builds up and becomes thicker than normal.

 The most common symptom of microscopic colitis is chronic, foul smelling, watery, non-bloody diarrhoea. Episodes of diarrhoea may last for weeks, months, or if chronic, even years, however, there may be intermittent periods without diarrhoea. During these periods the patient may even experience bouts of constipation.

Other signs and symptoms of microscopic colitis include15:-

  • A strong urgency to have a bowel movement.
  • Faecal incontinence – accidental passing of stool or fluid from the rectum – especially at night.
  • Pain, cramps, or bloating in the abdomen – that is usually mild but can be incapacitating.
  • Weight loss/gain
  • Nausea – usually without vomiting.
  • Dehydration – as a result from not drinking enough liquids to replace fluids lost through diarrhoea.
IBD SYMPTOMS IBS SYMPTOMS
Frequent and/or Urgent Bowel Movements

Diaorrhea

Bloody Stools

Abdominal Pain & Cramping

Fatigue

Weight Loss

Lack of Appetite

Joint, Skin or Eye Problems

Abdominal Pain & Cramping

Diaorrhea

Bloating

Gas

Mucus in Stools

 

As far back as 1968 studies reported a prevalence of 2-3% of psoriasis in first-degree relatives of patients with CD compared to 0–3% of controls. Later studies found psoriasis in 7–11% of the IBD population compared to 1–2% of general population. In one study, psoriasis was found to be more prevalent in CD (11.2%) than UC (5.7%). 5

In one study5 the Researchers studied the presence and characteristics of psoriasis were recorded and further classified as follows: sebopsoriasis, scalp psoriasis, plaque type psoriasis [trunk, arms], palmo-plantar psoriasis, nail psoriasis, inverse psoriasis, psoriatic arthritis, guttate psoriasis, and pustular psoriasis. Psoriasis that developed after anti-TNF? treatments was also reported. Severity of psoriasis was defined as mild, moderate or severe [not applied to psoriatic arthritis]. The study involved some 251 IBD patients, there were 158 patients with CD [63%] and 93 with UC [37%]. These 251 IBD patients were referred to the dermatologist and psoriasis was detected in 62 [25%], including 36 [58%] with CD and 26 [42%] with UC. The non-IBD group included 62 patients with psoriasis. Mild psoriasis was more frequent in IBD vs non-IBD, whereas moderate and severe psoriasis were more frequent in non-IBD vs IBD. Plaque-type psoriasis was the most common phenotype in both IBD and non-IBD. The frequency of plaque-type, nail psoriasis and psoriatic arthritis was lower in IBD vs non-IBD.

Other researchers analyzed the health records of 174,646 participants from the Nurses’ Health Study (NHS) and NHS II in an effort to also determine whether IBD was associated with specific psoriasis phenotypes. In this study they found 4,400 cases of psoriasis and of these 423 participants had developed CD or UC with a prevalence of psoriasis that was four to six times greater in IBD patients than the estimated prevalence in the general public.6

Several neutralizing anti-TNF agents, such as etanercept and infliximab, have been successfully used to treat autoimmune diseases, including inflammatory bowel disease. However, paradoxically, Infliximab and adalimumab-induced psoriasis in Crohn’s disease has been identified as a side effect of TNF-alpha inhibitor therapy. Researchers reviewed 142 case articles of new-onset psoriasis with infliximab, adalimumab, and etanercept therapy and of these confirmed eighty-one cases of infliximab induced psoriasis.7 In another study the researchers found that the vast majority of the cases (76%) developed psoriasis while on infliximab, and the rest (24%) after switching to adalimumab or certolizumab, indicating that this phenomenon is not drug specific, but rather a pharmacological group effect 12

 In another systematic literature review Researcher reviewed 222 cases. Of the 222 patients, 78.38% were diagnosed with Crohn’s disease, and 48.20% were female. The mean patient age was 26.50 years, and 70.72% of patients had no prior history of psoriasis. Infliximab was the anti-TNF-? therapy that caused the cutaneous reaction in most patients (69.37%). Clinical presentation varied; psoriasis-form lesions were the most common form of psoriasis (55.86%), followed by typical plaque type lesions (20.72%), and pustular-type lesions (3.60%). Six patients (2.70%) concomitantly presented with alopecia, one patient (0.45%) presented with palmoplantar pustulosis, and another patient (0.45%) presented with palmoplantar pustulosis and psoriatic arthritis.9

 Celiac disease is defined as a disease of the small intestine characterized by mucosal inflammation, villous atrophy, and crypt hyperplasia upon exposure to dietary gluten. Several studies have found that psoriasis patients are at an increased risk for celiac disease. A retrospective cohort study compared 25,341 psoriasis patients to over 125,000 matched controls in the U.S. The comparison data showed an odds ratio of 2.2 for the association of psoriasis with celiac disease. They also examined whether patients with celiac disease also have increased risk of psoriasis. A cohort of 28,958 biopsy-confirmed celiac disease patients from Sweden was evaluated for risk of future psoriasis compared to 143,910 age and sex-matched controls. The authors found a positive correlation between celiac disease antibody positivity and an increase in the severity of psoriasis or psoriatic arthritis. Interestingly, in the psoriasis patients, elevated celiac disease antibodies did not necessarily correspond to a biopsy-confirmed diagnosis of celiac disease, suggesting that psoriasis may be associated with gluten “sensitivity” (marked by antibody positivity) but not necessarily fully developed Celiac disease.10

In summary both Psoriasis and IBD and IBS are related inflammatory diseases. The skin and bowel represent both barrier and connection between the inner and the outer sides of the body. On average approximately 25% of patients who experience some form of bowel complaint will be diagnosed with psoriasis. It is also interesting to note that smoking in both IBD/IBS and psoriasis is considered an exacerbating trigger.

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Huang B.L. et al.; Skin manifestations of inflammatory bowel disease; Frontiers in Physiology; www.frontiersin.org February 2012 | Volume 3 | Article 13 | 1
  • Skroza et al.; Correlations between Psoriasis and Inflammatory Bowel Diseases; Hindawi Publishing Corporation BioMed Research International Volume 2013, Article ID 983902, 8 pages ; http://dx.doi.org/10.1155/2013/983902
  • Lolli E. et al.; Psoriasis Phenotype in Inflammatory Bowel Disease: A Case-Control Prospective Study; Journal of Crohn’s and Colitis, 2015, 699–707 doi:10.1093/ecco-jcc/jjv068 Advanced Access publication April 23, 2015
  • Li W.Q. et al.; Psoriasis, psoriatic arthritis and increased risk of incident Crohn’s disease in US women; Ann Rheum Dis. 2013 July ; 72(7): 1200–1205. doi:10.1136/annrheumdis-2012-202143
  • Famenini S. and Wu J.J.; Infliximab-Induced Psoriasis in Treatment of Crohn’s Disease-Associated Ankylosing Spondylitis: Case Report and Review of 142 Cases; J Drugs Dermatol.2013;12(8):939-943.
  • Denadai R .et al.; REVIEW ARTICLE Induction or exacerbation of psoriatic lesions during anti-TNF-? therapy for inflammatory bowel disease: A systematic literature review based on 222 cases; Journal of Crohn’s and Colitis (2013) 7, 517–524
  • Bhatia B.K. et al.; Diet and Psoriasis: Part 2. Celiac Disease and Role of a Gluten Free Diet; J Am Acad Dermatol. 2014 August ; 71(2): 350–358. doi:10.1016/j.jaad.2014.03.017.
  • Spiller R.C.; Irritable bowel syndrome; Published Online March 14, 2005; British Medical Bulletin 2004; 72: 15–29
  • Longstreth GF, Thompson WG, Chey WD, Houghton LA, Mearin F, Spiller RC. Functional bowel disorders. Gastroenterology. 2006 Apr. 130(5):1480-91.
  • Bercik P. et al.; Is irritable bowel syndrome a low-grade inflammatory bowel disease?; Gastroenterol Clin North Am.2005 Jun;34(2):235-45, vi-vii.
  • Gionata Fiorino , Paolo D. Omodei; Psoriasis and Inflammatory Bowel Disease: Two Sides of the Same Coin?; Journal of Crohn’s and Colitis, 2015, 1–2
  • Microscopic colitis. Mayo Clinic website.mayoclinic.org/diseases-conditions/microscopic-colitis/home/ovc-20192308

PSORIASIS AND COMORBIDITIES – Occular Inflammation

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WHAT IS COMORBIDITY?

 Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, #psoriasis.

 INCREASED RISK

 The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

 CHART 1: Comorbidities Associated with Psoriasis

Occular Inflammation –

Iritis

Uveitis

Episcleritis

Conjunctivitis

1, 2, 3

Ocular Inflammation

eye-1516983  episcleritis-eye

Overall, ophthalmological manifestations occur in about 10% of the cases of psoriasis and include blepharitis, conjunctivitis, keratitis, xerophthalmia (a medical condition in which the eye fails to produce tears), corneal abscess, cataract, orbital myositis (inflammation of the eye muscles), symblepharon (adhesion of the eyelid to the eyeball), chorioretinopathy (detachment of the retina), uveitis and ectropion with trichiasis (inwardly growing eyelashes) and madarosis (loss of eyelashes) secondary to eyelid involvement. 1,2

Uveitis

Although the etiology of psoriasis and its association with ocular disease remains unknown, it has been suggested that activated neutrophils in peripheral blood may be responsible for the attacks of anterior uveitis associated with psoriatic arthritis. Uveitis tends to develop more often in patients with arthropathy or psoriasis pustulosa rather than the other forms of psoriasis. Psoriasis patients with uveitis tend to be older than those without psoriasis. 1,2

Uveitis is characterized by an intraocular inflammatory process resulting from various causes. Individual forms of uveitis may be differentiated as a function of the location of the inflammation within the eye, symmetry and continuity of the inflammation, associated complication and distribution of cells along the corneal endothelium. 1,2

schematic_diagram_of_the_human_eye_en-edit

The uvea is the mid-portion of the eye. Its anterior portion includes the iris and the ciliary muscle, and its posterior portion consists of the choroid. Anterior uveitis or iritis is the inflammation of the anterior uveal tract. When the adjacent ciliary body is also affected, the process is known as iridocyclitis. Anterior uveitis is four times more common than posterior uveitis.

Uveitis can be divided into four main subgroups according to the etiology of the inflammation – infectious disease, immune-mediated disease, syndromes limited to the eyes or idiopathic forms. Of the patients with uveitis, around 40% of cases are secondary to an immune-mediated disease; around 30% of the cases of uveitis do not fit into any well-defined etiology. 1,2

Uveitis may occur in 7-20% of the patients with psoriasis. In a cross-sectional study researchers found a prevalence of uveitis of 2% in patients with psoriasis irrespective of the severity of the dermatosis. The association between uveitis and chronic plaque psoriasis has also been found, and in these patients uveitis tends to be bilateral affecting both eyes), prolonged and more severe. Uveitis, particularly anterior uveitis, has also been associated with the arthropathic form of the disease and approximately 7% of the patients with psoriatic arthritis may develop uveitis. Some cases of uveitis have been reported to occur even before psoriatic skin disease, and uveitis has been reported as the first presenting sign of Spondyloarthropathies (SpAs – a family of long-term (chronic) diseases of joints) in up to 11.4% of cases. The severity of ocular inflammation does not necessarily correlate with extent of joint findings but may correlate with skin disease. 1,2

Stephen Bafico

Conjunctivitis is a commonly occurring eye condition that can be caused by psoriasis, but it is more commonly due to allergies, bacterial infection, or viral infection. The most common presentation is generalized conjunctival injection with mild photophobia, gritty discomfort, and possible discharge. Thick purulent (pus-like) discharge is a hallmark of bacterial infection and watery discharge is characteristic of viral infections. Increased rates of obstructive meibomian (tarsal – sebaceous gland at the rim of the eyelids) dysfunction were noted in psoriatic patients. Published articles have suggested conjunctivitis prevalence rates in psoriasis patients as high as 64.5%.4

allergicconjunctivitis

Dry eye (Keratoconjunctivitis sicca – Dry Eye Syndrome) has been cited at a prevalence rate of 2.7% of psoriatic arthritis patients. Studies have suggested prevalence rates of dry eyes as high as 18.00% of psoriasis patients.4

 Facial psoriasis can of course present on the eyebrows and on the eyelids.

psoriasis-eye-before psoriasis-eye-after

      Facial Psoriasis – Before                                 Facial Psoriasis – After

When psoriasis affects eyelids or eyelashes, these may become covered with fine plaques and the rims of the eyelids may become red and crusty. If the rims of the eyelids are irritated for long periods of time, the rims of the lids may turn up or down (Ectropion). If the rims turn down, the lashes have a tendency to rub against the surface of the eye and cause further irritation and possibly damage to the surface of the eye.

Psoriatic eye manifestations, uveitis in particular, can lead to serious consequences, including vision loss. It is important at the first sign of occular redness, weeping, blurred vision, for psoriasis sufferers to see their Practitioner immediately, as they may need to be referred to an Ophthalmologist depending upon the severity of the symptoms.

 

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Shiu-chung Au et al.; Psoriatic Eye Manifestations; FALL 2011; psoriasis forum, Vol. 17, No. 3; https://www.psoriasis.org/files/pdfs/forum/Psoriatic-Eye-Manifestations-Forum_Fall_11_WEB.pdf
  • Naiara Abreu de Azevedo Fraga et al.; Psoriasis and uveitis: a literature review; An Bras Dermatol. 2012;87(6):877-83. http://www.scielo.br/pdf/abd/v87n6/v87n6a09.pdf

 

PSORIASIS AND COMORBIDITIES

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WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

INCREASED RISK

The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

CHART 1: Comorbidities Associated with Psoriasis

Occular Inflammation –

Iritis

Uveitis

Episcleritis

Psychological and Psychiatric Disorders – Depression

anxiety

Suicide

Addiction

Inflammatory Bowel Disease –

Crohn’s Disease

Ulcerative Colitis

Celiac Disease

Irritable Bowel Syndrome

Metabolic Syndrome –

Cardiovascular Disease – Arterial hypertension/ Atherosclerosis Nonalcoholic fatty liver disease Lymphoma

Chronic obstructive pulmonary disease

Sleep apnea

Celiac disease

Parkinson’s disease

Lymphomas

Insulin Resistant Diabetes

Obesity

Dyslipidemia (Raised cholesterol)

Psoriatic Arthritis

Spondyloarthropathies

Periodontitis

Desquamative gingivitis 

Fissured and geographical tongue 

Renal Disease

Chronic Kidney Disease

Sudden sensorineural hearing loss (SSNHL) 

1, 2, 3

Overall, ophthalmological (eye) problems occur in about 10% of the cases of psoriasis and include blepharitis, conjunctivitis, keratitis, xerophthalmia, corneal abscess, cataract, orbital myositis, symblepharon, chorioretinopathy, uveitis and ectropion with trichiasis and madarosis secondary to eyelid involvement.

The association between obesity and psoriasis has been the subject of several reviews and studies confirm that a positive correlation exists between body weight and the prevalence and severity of psoriasis. It has been proposed that psoriasis might lead to obesity through progressive social isolation, poor eating habits, depression, increased alcohol consumption, and decreased physical  activity (more pronounced in patients with psoriatic arthritis). But another hypothesis is that obesity predisposes patients to psoriasis.

Dollarphotoclub_89167346 Obesity dollarphotoclub_78137972-liver-disease dollarphotoclub_92450146-diabetes

It is considered, however, that the low-grade chronic proinflammatory state present in both these conditions increases the risk of comorbidity, including a higher likelihood of developing diabetes or metabolic syndrome, and an increase in cardiovascular disease. 6

It is very important for newly diagnosed psoriasis patients to be screened for diabetes, liver disease, renal disease, and dyslipidaemia (high cholesterol) at the time of diagnosis, due to the fact that treatment for psoriasis may complicate treatment for the comorbid condition, or the comorbid condition may complicate the treatment for psoriasis.

SSNHL is defined as hearing loss of at least 30 dB (decibels) in 3 sequential frequencies in the standard pure tone audiogram for 3 days or less. The condition has an estimated incidence of between 5 and 30 cases per 100,000 per year. According to background information provided by the study authors, the average age at which SSNHL occurs is 50 to 60 years, and it equally affects men and women. Most cases are unilateral (one ear), with only 5% being bilateral (two ear involvement). The condition can be mild, moderate, or severe to profound and can affect high, low, or all frequencies. Tinnitus occurs in about 80% of patients and vertigo in about 30%. Up to 80% of patients report a feeling of ear fullness.7 Auto-immunity is described as an etiology of Sudden or Progressive Sensory neural Hearing Loss; similarly autoimmunity is described as an etiology for many skin diseases like Psoriasis etc. In one study researchers found that Psoriasis patients have, after 6 years of follow up; a 1.51 times higher risk incidence of developing SSNHL than those in the control group.8

For psoriasis patients who have had their psoriasis for several years, it is important that they have a yearly medical check up to ensure that they have not developed any comorbid conditions.

Changing one’s lifestyle may also be of benefit in either delaying comorbidity, or in controlling both their psoriasis and their comorbid condition. Such changes would include cessation of smoking, reducing or ceasing intake of alcohol, reducing sugar intake, changing ones diet to include more green vegetables, less red meat and if obese, losing weight.

 Read our BLOGS – Psoriasis and Diet – Part 1 and 2, Psoriasis and Alcohol, Psoriasis and Smoking

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Agnieszka B. Owczarczyk-Saczonek , Roman Nowicki; The association between smoking and the prevalence of metabolic syndrome and its components in patients with psoriasis aged 30 to 49 years; Postep Derm Alergol 2015; XXXII (5): 331–336 DOI: 10.5114/pdia.2015.54743
  • Dediol I. et al.; ASSOCIATION OF PSORIASIS AND ALCOHOLISM: PSYCHODERMATOLOGICAL ISSUE; Psychiatria Danubina, 2009; Vol. 21, No. 1, pp 9–13
  • Carrascosa J.M. et al.; Obesity and Psoriasis: Inflammatory Nature of Obesity, Relationship Between Psoriasis and Obesity, and Therapeutic Implications; Actas Dermosifiliogr.2014;105:31-44 – Vol. 105 Num.1 DOI: 10.1016/j.adengl.2012.08.024
  • Schreiber BE. et al.; Sudden sensorineural hearing loss.; Lancet.2010 Apr 3;375(9721):1203-11. doi: 10.1016/S0140-6736(09)62071-7.
  • Sesha Prasad, M. Sreedhar Rao, A. V. S. Hanumantha Rao, D. Satyanarayana, S. Muneeruddin Ahmed, M. Mahendra Kumar. “Audiological Evaluation in Auto: Immune Skin Diseases- A Clinical Study of 124 Patients”. Journal of Evolution of Medical and Dental Sciences 2015; Vol. 4, Issue 30, April 13; Page: 5128-5137, DOI: 10.14260/jemds/2015/749