PSORIASIS AND COMORBIDITIES – Occular Inflammation

blog-7

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

 

ATOPIC DERMATITIS (ECZEMA) AND COMORBIDITIES

blog-link-post-img

Atopic dermatitis (AD), also known as atopic eczema, is a chronic inflammatory disorder that causes significant morbidity and has a wide range of allergic and non-allergic comorbid disorders.

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease. The patient with AD has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with AD.

 CHART 1: Comorbidities Associated with AD

Cutaneous (skin) infections including:-

Bacterial – Staphylococcal   / Impetigo contagiosum

Viral – eczema herpeticum

Fungal

 

Other Skin Conditions:

Vitiligo

Psychological and Psychiatric Disorders – Depression

Anxiety

Attention Deficit/Hyperactivity Disorder (ADHD)

Autistic spectrum disorder (ASD)

Food Allergies/Intolerances Cardiovascular Disease – Arterial hypertension/ Atherosclerosis

Stroke

Prediabetes

Diabetes

Obesity

Fatty Liver

Dyslipidemia (Raised cholesterol)

Allergic conjunctivitis

Cataracts 

Atopic keratoconjunctivitis (AKC) 

Allergic rhinitis

Hayfever

Asthma

Acute upper respiratory infection

Acute pharyngitis

Fatigue, insomnia  

1, 2, 3, 4, 5, 6, 7

Most cases of AD begin in childhood or adolescence, with more than 80% of pediatric patients having persistent symptoms of itch and dry skin in adulthood. The early age of onset and disease chronicity, plus impaired quality of life, secondary to AD weigh heavily on a child’s psychological and behavioural development, with delayed social development throughout life and very high rates of psychological and behavioural disorders and quality-of-life impairment.6 Various studies have consistently indicated an association between AD and ADHD which is independent of environmental exposures and other comorbidities. Particularly infant AD appears to be associated with later development of ADHD symptoms. Sleeping problems due to AD are suggested as playing an important role for the observed association between AD and ADHD. Children with previous or prevalent AD have an approximately 43 % increased risk to be diagnosed with ADHD or to display clinical ADHD symptoms.8

Researchers have found that adults with AD have higher rates of cigarette smoking, consumption of alcoholic, lower rates of exercise, and higher classification of obesity with category II / III consistently indicated in children and adults, hypertension, prediabetes, diabetes, and high cholesterol.6, 7

staph-infection

Bacterial superinfection by staphylococcal aureus is the most common complication in atopic dermatitis and is almost always present in AD flares.  S. aureus is an important human pathogen that causes a variety of  infections ranging from localised skin and soft-tissue infections (SSTIs) to severe necrotising fasciitis and life-threatening infections.7 , 8  S. aureus can be isolatedfrom 55–75% of unaffected AE skin, 85–91% of chronic lichenified lesions and 80–100% of acute exudative skin lesions.9 The correlation between AD severity and colonization with S. aureus has already been well documented, and it is generally known that this colonization is an important mechanism involved in the continued aggravation of the disease in patients.

S. aureus has shown a capacity to develop resistance to antimicrobials that were originally active against the species. In 1961, there were reports of strains that were methicillin resistant, and they were called methicillin-resistant Staphylococcus aureus (MRSA). By 1980, MRSA strains became an endemic problem in hospitals in several countries. Reports on MRSA infections in AD patients have been published since 2005. Some authors suggest that MRSA should be considered when patients with AD present with more intense and generalized erythemas (redness of the skin), and with the predominant location of infection in these patients being the face, and a fetid (fishy) odour present. Studies worldwide suggest that the prevalence of MRSA in the population with AD varies from 0 to 30.8% depending upon the country of research.10

Colonization by streptococcus generally precedes the development of impetignized lesions (by about 10 days). Group A streptococci often colonize the pharynx of asymptomatic people, especially school-age children. In cases of infected atopic dermatitis lesions, a high prevalence of co-infection by staphylococci and streptococci was reported, and these bacteria were present in about 70 to 85% of patients. B-hemolytic streptococci are the main cause of impetigo and are more commonly isolated on the skin of people with AD than on the skin of healthy individuals or of those with other skin diseases.11

Eczema herpeticum (EH) is caused by Herpes simplex virus-1 (HSV-1), Herpes simplex virus-2 (HSV-2), Herpes zoster virus, Coxsackie virus, etc. Also, EH may occur in children who have AD after smallpox vaccination. If corticosteroid therapy is used in these patients because of misdiagnosis, the lesions may worsen. Therefore, if skin lesions or another pre-existing dermatitis is aggravated after varicella (smallpox) infection then EH must be considered and antiviral therapy must be started immediately.11

AD, is an immunoglobulin E (IgE)-mediated disease with a complex etiology (cause) that is accompanied by superficial inflammation and itchy rashes. An association with asthma and Allergic rhinitis (Hayfever) is well documented. Fifty percent of all those with AD develop other allergic symptoms within their first year of life. In the International Study of Asthma and Allergies in Childhood (ISAAC), among the 56 countries, the prevalence of AD in children varied significantly from 0.3% to 20.5% but shows consistent trends in increasing disease prevalence over time. The main risk factors for progression and persistence of asthma are early onset, IgE sensitization, and severity of AD. Approximate 70% of patients with severe AD develop asthma compared with 20-30% of patients with mild AD and approximately 8% in the general population. Epidemiologic studies have consistently demonstrated strong associations between rhinitis and asthma. Recent clinical and basic science evidence indicated that the two diseases share anatomical, physiological, immuno-pathological, and therapeutical factors. Allergic rhinitis is an inflammatory condition affecting nasal mucosal membranes. In sensitized individuals, allergens such as pollens, moulds, and animal dander provoke this allergic response.12, 13

The relationship between food allergy and AD is complex and the presence of food sensitization and allergy earlier in life predicts a prognosis of severe AD. Around 50–70% of children with an early onset of AD are sensitized to one or more allergens. These are mainly food allergens (cow’s milk, hen’s egg and peanuts being the foods most frequently involved). Food allergy is actually much more common in children with AD with studies reporting ranges from 20 to 80% of children being affected.12,13

Allergic conjunctivitis (AC), either seasonal and/or perennial, is one of the most common types of ocular inflammation which causes redness and swelling of the eyes. Estimates vary, but these types of allergy are said to affect at least 15–20% of the population and higher incidences in those with AD. Its pathophysiology also involves a type I IgE-mediated immune reaction triggered by allergens contacting surface of the eye.2 Atopic keratoconjunctivitis (AKC) is a bilateral chronic inflammatory disease of the ocular surface and eyelid. Its pathomechanism involves both a chronic degranulation of the mast cell mediated by IgE, and immune mechanisms mediated by Th1- and Th2-lymphocyte derived cytokines. It is considered the ocular counterpart of AD. Eczematous lesions may be found on the eyelids, or any place on the body. Skin lesions are red and elevated. They often occur in the antecubital (inner elbow) or popliteal (behind the knees) regions. Typically, eczematous lesions are itchy, and scratching them makes them itchier. Ocular findings vary. The eyelid skin may be chemotic (inflamed eyelid) with a fine sandpaper-like texture. There may be mild, or severe, red and swollen eyes.14

If you have any questions please do not hesitate to contact our clinic by either emailing us at info@goodskincare.com.au or message us on our Facebook page https://www.facebook.com/PsoriasisEczemaClinic/

 

 REFERENCES

  • Simpson EL.; Comorbidity in Atopic Dermatitis; Curr Dermatol Rep. 2012 March 1; 1(1): 29–38. doi:10.1007/s13671-011-0003-5
  • Augustin M. et al.; Epidemiology and Comorbidity in Children with Psoriasis and Atopic Eczema; Dermatology 2015;231:35–40 DOI: 10.1159/000381913
  • Deckert S. et al.; Nonallergic comorbidities of atopic eczema: an overview of systematic reviews; Allergy 69 (2014) 37–45 © 2013
  • Ellis CN. et al.; Validation of Expert Opinion in Identifying Comorbidities Associated with Atopic Dermatitis/Eczema; Pharmacoeconomics 2003; 21 (12)
  • Gradman J. et al.; Allergic conjunctivitis in children with asthma, rhinitis and eczema in a secondary outpatient clinic.
  • Silverberg J.I.; Eczema and cardiovascular risk factors in 2 US adult population studies; J Allergy Clin Immunol 2015;135:721-8.
  • Silverberg J.I. and Silverberg N.B.; Atopic Dermatitis: Update on Pathogenesis and Comorbidities
  • Baviera G. et al.; Staphylococcus Aureus And Atopic Dermatitis: Which Came First, The Chicken Or The Egg?; EMJ Dermatol. 2015;3[1]:92-97.
  • Leung DYM.; The role of Staphylococcus aureus in atopic eczema; Acta Derm Venereol 2008; Suppl 216: 21–27
  • Petry V. et al.; Bacterial skin colonization and infections in patients with atopic dermatitis; An Bras Dermatol. 2012;87(5):729-34.
  • Celtik C. et al.; A Life-Threatening Condition In A Child With Chicken Pox: Eczema Herpeticum; Open Journal of Pediatrics 1 (2011) 1-3
  • Tao Zheng et al.; The Atopic March: Progression from Atopic Dermatitis to Allergic Rhinitis and Asthma; Allergy Asthma Immunol Res. 2011 April;3(2):67-73. doi: 10.4168/aair.2011.3.2.67
  • Nutten S.; Atopic Dermatitis: Global Epidemiology and Risk Factors; Ann Nutr Metab 2015;66(suppl 1):8–16
  • La Rosa M. et al.; Allergic conjunctivitis: a comprehensive review of the literature; Italian Journal of Pediatrics 2013, 39:18 http://www.ijponline.net/content/39/1/18