EFFECT OF TONSILLECTOMY ON PSORIASIS: A SYSTEMATIC REVIEW
Rachakonda, T. D., Dhillon, J. S., Florek, A. G., & Armstrong, A. W. (2015). Journal of the American Academy of Dermatology, 72(2), 261-275.
Of the many possible triggers described in psoriasis, upper respiratory tract infections and, specifically, streptococcal infections have long been associated with the onset of both guttate and plaque forms of psoriasis.
The primary objective of this systematic review was to compile and assess the impact of tonsillectomy on psoriasis. Twenty studies of patients with psoriasis who had tonsillectomies were reviewed, including one retrospective controlled trial (n = 29), one retrospective questionnaire (n = 74), four prospective observational studies (n = 35, 101, 57, and 92), seven case reports (n = 12), and seven case series (n = 82).
In total, 545 patients with psoriasis were examined, with 410 who underwent tonsillectomies. Overall, 290 of the 410 patients (70%) experienced some form of improvement in psoriasis symptoms after tonsillectomy. The proportion of patients with improvement varied across studies, ranging between 30% and 90%, and was always higher than patients without tonsillectomies where they were included. Most of the studies used subjective assessment of psoriasis severity, with Psoriasis Area Severity Index only assessed in two studies, and many relied on patient assessments. There was a large variation in duration of follow-up, ranging from 2 months to 10 years.
In addition to subjective improvement in psoriasis, one study documented a decrease in both peptide-reactive skin-homing T-cells and Interleukin 8 in the blood after tonsillectomy and not in controls.
REMARKS: Although this review included a large number of patients, there are many limitations that should be considered when interpreting the findings. Only three studies originated from North America (two in the United States, one in Iceland; total N = 45), and only four done after the year 2000 (n = 74), raising concerns about the generalizability of the data to patients in other locations being treated with current management regimens. In addition, in general, the study quality was variable and suboptimal. Most of the data were from case reports or case studies, and only two studies used Psoriasis Area Severity Index values to track improvement, further limiting the reliability of the conclusions.
Although tonsillectomy may remove the source of potential trigger of psoriasis in some patients, there are innumerable other triggers that are left. These include other infections (including nonrespiratory streptococcal infections), physical trauma, psychological stress, climate, and/or medications. In addition, tonsillectomy is not an intervention without risk. Therefore, it should likely still only be reserved for patients with repeated flares linked to strep throat in whom the risks of the procedure are outweighed by potential benefits.
ASSOCIATION BETWEEN TOBACCO SMOKING AND PROGNOSIS OF OCCUPATIONAL HAND ECZEMA: A PROSPECTIVE COHORT STUDY
Brans, R., Skudlik, C., Weisshaar, E., Gediga, K., Scheidt, R., Wulfhorst, B., [horizontal ellipsis] ROQ Study Group. (2014). The British Journal of Dermatology, 171(5), 1108-1115.
Hand eczema (HE) is the most common occupational skin disease with detrimental socioeconomic consequences. The etiology of occupational HE is usually complex and often includes both endogenous (genetic predisposition, atopy) and exogenous (exposure to irritants and allergens at work) factors. Tobacco smoking is a known risk factor for delayed wound healing and premature skin aging and can also aggravate certain skin diseases. However, little is known about how tobacco smoking can affect the course and prognosis of occupational HE.
The aim of this study was to assess the impact of smoking on the severity and prognosis of occupational HE.
This was a prospective, multicenter, cohort study that included 1608 patients with occupational HE taking part in a tertiary individual prevention program (TIP). Participants were recruited and followed up for 3 years; study included an equal number of smokers and nonsmokers. The clinical and self-reported outcome data of smokers and nonsmokers were compared. The TIP consisted of a 3-week inpatient and a 3-week outpatient phase. During the inpatient phase, smoking patients were counseled on adverse effects of smoking and smoking cessation methods. After the TIP, patients returned to their workplaces. Assessments were carried out on admission to TIP, upon discharge, and at different time points after return to work.
Results: Allergic contact dermatitis was more commonly observed in smokers, whereas in nonsmokers, irritant contact dermatitis component was more prevalent. HE was significantly more severe in smokers versus nonsmokers at all time points. It was also observed that smokers missed more working days upon return to work because of flares of HE compared with nonsmokers. However, there was no correlation between severity of HE or missed workdays and number of smoked cigarettes per day. Changes in smoking behavior after TIP were observed, with a decrease of cigarette consumptions by smokers during and after TIP, but only a minority ultimately quit smoking. In conclusion, the authors suggest that smoking is associated with severity of occupational HE, high workday absenteeism, and increased risk of contact sensitization.
REMARKS: Tobacco smoking has many adverse effects on a person's health. This study from Germany is the first to show that smoking is associated with severity and persistence of occupational HE. This study adds to existing data, obtained by other study groups, which indicate that smoking might be a risk factor for the development of allergic contact dermatitis. Overall, these findings suggest that dermatologists need to put more efforts into counseling patients about smoking cessation altogether with other medical specialists.
ASSOCIATION BETWEEN ECZEMA AND INCREASED FRACTURE AND BONE OR JOINT INJURY IN ADULTS: A US POPULATION-BASED STUDY
Garg, N., & Silverberg, J. I. (2015). JAMA Dermatology, 151(1), 33-41.
Eczema is a multifactorial chronic inflammatory disorder that causes significant morbidity related to itch, sleep impairment, and a wide range of comorbidities. Children with eczema have higher odds of injuries requiring medical attention, but it is unknown if this risk is also present in adults with eczema. Risk factors for injury include sleep impairment, sedating antihistamine use, and psychiatric comorbidities; in addition, systemic corticosteroid use and chronic inflammation may predispose to bone loss and subsequent bone fractures.
The objective of this study was to determine whether adult eczema is associated with increased risk of injury. Researchers used the 2012 National Health Interview Survey, which included questions about various health issues among noninstitutionalized adults in the United States. The survey was delivered to selected households, and the most representative data set was selected for each state.
In this study, 34,500 adults aged 18-85 years were included. The prevalence of self-reported eczema or skin allergy in the past 12 months among adults was 7.2%. The prevalence of any injury causing limitation was 2.0%. A fracture and bone or joint injury causing limitation was reported by 1.5%. Adults with eczema had higher odds of any injury (odds ratio = 1.99, 95% CI [1.52, 2.61], p < .001), including fracture and bone or joint injury (odds ratio = 2.27, 95% CI [1.68, 3.07], p < .001) and other injury causing limitation. This association remained in multivariable models controlling for demographics, socioeconomic status, other atopic diseases, and psychiatric or behavioral disorders. Among adults without eczema, the prevalence of injury increased gradually with age. Conversely, among adults with eczema, the prevalence of injuries increased initially, peaked at ages 50-69 years, and then decreased substantially in the age group of 70 years or older.
Significant interactions were observed between eczema and sleep disturbances such as fatigue, daytime sleepiness, or insomnia. Interestingly, patients with eczema and sleep disturbances had higher rates of injury compared with those with sleep disturbances alone. Similarly, patients with eczema and psychiatric or behavioral disorders had higher rates of severe injury compared with those with psychiatric disorder or eczema alone.
In conclusion, this study suggests that eczema in adulthood is an unrecognized risk factor for fractures and other injuries. Associated sleep disturbances and psychiatric disorders further increase this risk.
REMARKS: The major limitation of this study is that prevalence of self-reported eczema may not have reflected the true prevalence of eczema as the diagnosis was not necessarily confirmed by a specialist. It would be also interesting to include severity of the symptoms in the model and analyze if this affects a risk of injury. Further studies are needed to confirm the association between eczema and increased risk of injury. However, if the association is confirmed, inclusion of injury risk in patient's histories and implementation of injury risk reduction measures in patients with eczema could have a valuable impact.