Managing comorbid disease in patients with psoriasis
BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.b5666 (Published 15 January 2010) Cite this as: BMJ 2010;340:b5666
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Historically psoriasis has been considered as one of the
‘prototypical’ cutaneous conditions, wherein the interplay of psyche and
soma can be recognised. In recent times, about 5 years back, a
comprehensive issue on ‘Psychocutaneous Disease’ has highlighted the same
(1). A scholarly review in the same issue highlights the psychological co-
morbidity in psoriasis i.e. high levels of depression and anxiety; higher
disability, poor quality of life, and stigmatization (2). It has further
been mentioned that ‘due to the high levels of distress and proposed
interaction between psoriasis and psychological processes, incorporation
of structured psychological interventions will benefit patients suffering
with psoriasis (2).
My clinical experience as a liaison psychiatrist supports the same
notion, and is further substantiated by research (3). Hence, it was indeed
surprising and disheartening to read that co-morbid presence of mental
illness and psychological aspects/reactions are not considered important
enough to merit a more detailed discussion in the clinical review (4);
additionally the authors only briefly touch upon the presence of
depression, but do not provide tips on its management.
I am unsure as to the reasons behind not considering psychological co
-morbidity to be important enough! Maybe the answer lies in already
available research evidence indicating that dermatologists may not have an
accurate perception of the extent of psychiatric co-morbidity (2,5) and
that they demonstrate inaccuracies in identifying psychological co-
morbidity and/or appropriately referring on such patients (2).
A collective, integrative bio-psycho-social approach is required from
dermatologists and mental health professionals’ alike to [a] address the
misconceptions and lack of knowledge, and [b] bridge the management gap in
order to help patients afflicted with this chronic and disabling disorder.
REFERENCES
[1] Gupta MA. Psychocutaneous Disease. DCNA 2005; 23 (4): 591-780.
[2] Fortune DG, Richards HL, Griffiths CEM. Psychologic factors in
Psoriasis: Consequences, mechanisms, and Interventions. DCNA 2005; 23: 681
-94.
[3] Mattoo SK, Handa S, Kour I, Gupta N, Malhotra R. Psychiatric
morbidity in vitiligo and psoriasis: a comparative study from India. J
Dermatol 2001; 28: 424-32.
[4] Boehncke WH, Boehncke S, Schon MP. Managing comorbid disease in
patients with psoriasis. BMJ 2010; 340: b5666.
[5] Sampogna F, Picardi A, Melchi CF et al. The impact of skin
diseases on patients’: comparing dermatologists’ opinions with research
data collected on their patients. Br J Dermatol 2003; 148: 989-95.
Competing interests:
None declared
Competing interests: No competing interests
Boehncke and colleague elegantly highlighted that every patient with
psoriasis should be screened for psoriatic arthritis and to look for other
important comorbidities such as metabolic syndrome, Crohn’s disease,
depression and cancer.1
However they did not mention HIV infection, which is an important
comorbid disease in patients with psoriasis. The prevalence of psoriasis
in HIV population was 6.4% 2 and in general UK population was 1.5%. 3 HIV
infection can cause psoriasis to flare up or psoriasis may even be the
initial clinical manifestation of HIV infection thus HIV testing should be
considered in those circumtances.4
References:
1. Boehnke WH, Boehnke S, Schon MP. Managing comorbid disease in patients
with psoriasis. BMJ 2010; 340:200-3.
2. Garbe C, Husak R, Orfanos CE. HIV associated dermatoses and their
prevalence in 456 HIV infected patients. Hautarzt. 1994; 45(9): 623-9.
3. Gelfand JM, Weinstein R, Porter SB, Neimann AL, Berlin JA, Margolis DJ.
Prevalence and treatment of psoriasis in the United Kingdom. Arch
Dermatol.2005; 141:1537-41.
4. Rigopoulos D, Paparizos V, Katsambas A. Cutaneous markers of HIV
infection. Clin Dermatol.2004; 22(6): 487-98.
Competing interests:
None declared
Competing interests: No competing interests
Tonsillectomy: does it improve the severity of psoriasis?
Tonsillectomy: does it improve the severity of psoriasis?
Tatiana Gutierrez, Stamatios Peridis, Claire Hopkins
Department of Otolaryngology Head and Neck Surgery, Guy’s and St
Thomas’
NHS Trust, London, United Kingdom
Corresponding author
Stamatios Peridis MD, Department of Otolaryngology Head and Neck Surgery,
Guy’s and St Thomas’ NHS Trust, Guy’s Hospital, Great Maze Pond, London,
SE1 9RT, United Kingdom.
E-mail: peridis@gmail.com
Competing interests: None declared.
The clinical review article by Boehncke WH et al, (1) states that
recent
developments have substantially changed the understanding of psoriasis:
TH17 cells (lymphocytes) have been found to be important effectors in
autoimmune diseases, psoriasis is now confirmed as a systematic disease,
and most importantly for the purposes of this letter, psoriasis has been
found
to frequently occur alongside other diseases. It is our view, that
although the
authors’ associated list of comorbidities in patients with psoriasis is
accurate
and extensive, such as metabolic syndromes, Crohn’s disease, cancer,
depression and cardiovascular risks, among others, it does not consider
other
potential comorbidities such as tonsillitis and there is no mention of
improvement of psoriasis after tonsillectomy.
It is our clinical experience that the severity of psoriasis improves
after
tonsillectomy. The literature review has confirmed there is sufficient
evidence
to support the association. Stukalenko, (2) first established the
connection of
these diseases on a 24-year old male from the patient’s history and
confirmed the cure of the psoriasis after tonsillectomy. Nyfors et al, (3)
conducted a retrospective study of the course of psoriasis after
tonsillectomy
in 74 patients and the results showed that the clearing of psoriasis
vulgaris
was statistically significant (p<_0.01 as="as" _1="_1" _3="_3" of="of" the="the" patients="patients" obtained="obtained" clearing="clearing" psoriasis="psoriasis" throughout="throughout" entire="entire" follow="follow" up="up" period.="period." wilson="wilson" et="et" al="al" _4="_4" on="on" other="other" hand="hand" reviewed="reviewed" efficacy="efficacy" antibiotic="antibiotic" therapy="therapy" and="and" tonsillectomy="tonsillectomy" treatments="treatments" for="for" childhood="childhood" psoriasis.="psoriasis." percentage="percentage" who="who" experienced="experienced" disease="disease" clearance="clearance" after="after" in="in" an="an" uncontrolled="uncontrolled" trial="trial" was="was" ranged="ranged" from="from" _32="_32" to="to" _53="_53" a="a" similar="similar" reported="reported" significant="significant" improvement="improvement" their="their" with="with" maximum="maximum" _7="_7" noting="noting" worsening="worsening" operation.="operation." p="p"/> Tonsillectomy is one of the most commonly performed operations in
otolaryngology. (5) The national prospective tonsillectomy audit, (6)
confirmed that it is a safe operation with a low incidence of post-
operative
complications. In a patient with recurrent sore throats, the possibility
of
improving psoriatic control should be noted when considering the role of
operative intervention.
References
1. Boehncke WH, Boehncke S, Schön MP. Managing comorbid disease in
patients with psoriasis. BMJ 2010;340:b5666.
2. Stukalenko AA. Recovery from psoriasis vulgaris after tonsillectomy.
Vestn
Otorinolaringol 1967;2:101-102.
3. Nyfors A, Rasmussen PA, Lemholt K, Eriksen B. Improvement of
recalcitrant
psoriasis vulgaris after tonsillectomy. J Laryngol Otol 1976; 90:789-794.
4. Wilson JK, Al-Suwaidan SN, Krowchuk D, Feldman SR. Treatment of
psoriasis in children: is there a role for antibiotic therapy and
tonsillectomy?
Pediatr Dermatol 2003;20:11-15.
5. Macfarlane PL, Nasser S, Coman WB, Kiss G, Harris PK, Carney AS.
Tonsillectomy in Australia: an audit of surgical technique and
postoperative
care. Otolaryngol Head Neck Surg 2008;139:109-114.
6. The Royal College of Surgeons of England. National prospective
tonsillectomy audit, 2005. Available at: http://www.rcseng.ac.uk, Accessed
on 25 January 2010.
Competing interests:
None declared
Competing interests: No competing interests