Article

The Role of a Gluten-Free Diet in Psoriasis

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Abstract

Recent evidence suggests that a group of psoriasis patients have silent gluten intolerance and may experience improvement of their psoriasis by going on a gluten-free diet. Although there is still controversy as to the prevalence of this subset of psoriasis patients, screening patients with moderate to severe psoriasis for antigliadin antibodies may be helpful in identifying this group. Evidence illustrates that patients with positive antigliadin antibodies who undertake a gluten-free diet experience significant improvement of their psoriasis compared with prediet measurements. To make definitive clinical recommendations, a large randomized, controlled trial is needed. Even though the evidence is limited, it may be beneficial to screen psoriasis patients for silent gluten intolerance to identify those who could benefit from a gluten-free diet.

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The American Journal of Gastroenterology is published by Nature Publishing Group (NPG) on behalf of the American College of Gastroenterology (ACG). Ranked the #1 clinical journal covering gastroenterology and hepatology*, The American Journal of Gastroenterology (AJG) provides practical and professional support for clinicians dealing with the gastroenterological disorders seen most often in patients. Published with practicing clinicians in mind, the journal aims to be easily accessible, organizing its content by topic, both online and in print. www.amjgastro.com, *2007 Journal Citation Report (Thomson Reuters, 2008)
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With the appreciation of the high prevalence of coeliac disease there is increasing use of serology in screening asymptomatic people and testing those with suggestive features. To compare the sensitivities and specificities of the endomysial antibody and the tissue transglutaminase antibody tests. Using electronic databases a search was made for relevant papers using the terms tissue transglutaminase and endomysial antibody. Both the endomysial antibody and tissue transglutaminase antibody have very high sensitivities (93% for both) and specificities (>99% and >98% respectively) for the diagnosis of typical coeliac disease with villous atrophy. Human recombinant tissue transglutaminase performs much better than guinea pig tissue transglutaminase. Review of studies comparing endomysial antibody with human recombinant tissue transglutaminase antibody shows that endomysial antibody more often has a higher specificity and human recombinant tissue transglutaminase antibody more often has a higher sensitivity. The human recombinant tissue transglutaminase antibody is the preferred test for screening asymptomatic people and for excluding coeliac disease in symptomatic individuals with a low pretest probability (i.e. <25%) for coeliac disease. Furthermore, it has a number of practical and financial advantages. If the pretest probability is >25%, biopsy is preferred as the post-test probability of coeliac disease with a negative test is still >2%.
Article
The etiopathogenesis of psoriasis is still unclear. Associations between gut and skin diseases are well known, since psoriatic patients show a high prevalence of coeliac disease. Small-bowel abnormalities can cause clinical or, more frequently, laboratory alterations that give rise to malabsorption. The aim of the study was to evaluate the prevalence of malabsorption in psoriatic patients. Fifty-five (29 M, 26 F, mean age 51+/-8 years) psoriatic patients in the Dermatology Centre of our hospital and 65 healthy controls (36 M, 29 F, mean age 47+/-9 years) were screened for malabsorption using a D-xylose test. Psoriatic subjects who resulted positive were further investigated in order to reach a better characterization of the malabsorption using serum antigliadin, anti-endomysium and anti-transglutaminase antibodies, H2 lactulose breath test, the parasitological faecal test and colonoscopy with retrograde ileoscopy. Altered D-xylose absorption was found in 60% (33/55) of psoriatic patients and in 3% (2/65) of controls. Of the former, 6% had coeliac disease, 21% had bacterial overgrowth, 3% had parasitic infections and 1 patient presented eosinophilic gastroenteritis. Malabsorption was more prevalent among psoriatic patients than among controls. Coeliac disease, bacterial overgrowth, parasitic infestations and eosinophilic gastroenteritis could be possible causes of malabsorption in these patients. Further studies are needed to clarify the pathogenesis and possible causative associations between gut and skin diseases.
Article
Palmoplantar pustulosis (PPP) is a chronic inflammatory disease affecting mainly smoking women. Some patients also have psoriasis. A subgroup of patients with psoriasis has been shown to have silent gluten sensitivity with relevance for their psoriasis. Nothing is known about gluten sensitivity in PPP. To find out whether any patients with PPP are gluten-sensitive and whether this might be relevant for the PPP activity. One hundred and twenty-three patients (113 women) with PPP participated. Screening for IgA antibodies against gliadin and tissue transglutaminase (tTG) was performed, the duodenal mucosa in patients with and without these antibodies was studied and the effect of a gluten-free diet (GFD) was followed up. Twenty-two patients (18%) had IgA antibodies against gliadin and nine of 94 (10%) against tTG. Twelve patients with antibodies and 11 without underwent gastro-duodenoscopy. Four displayed villous atrophy, whereas all other specimens were judged as essentially normal at routine staining. However, with immunohistochemistry, the numbers of CD3+ and CD8+ lymphocytes in the epithelium were found to be increased in patients with any type of antibody, although they were most numerous in those with both types of antibodies. Seven of 123 patients (6%) had coeliac disease (three previously diagnosed). Patients with antibodies who adhered to the GFD displayed total or nearly total clearance of the skin lesions and normalization of the antibody levels. Patients with PPP should be screened for antibodies against gliadin and tTG. Those with antibodies can be much improved on a GFD regardless of the degree of mucosal abnormalities.
Article
Aetiopathogenesis of psoriasis is complex and not yet well known. In recent years, it has been observed that psoriasis can coexist with clinically asymptomatic celiac disease and a gluten-free diet helps to obtain remission, even in patients with very chronic lesions. The aim of our work was to investigate how often the positive titres of antibodies characteristic for celiac disease occur in psoriatics' serum in exacerbation in comparison with controls. Serum samples from 67 patients with intensified psoriatic lesions were investigated. Serum from healthy people at a comparable age and with no familial predisposition to psoriasis and celiac disease was the control material. Antibodies against human tissue transglutaminase (recombinant antigen), against tissue transglutaminase isolated from guinea pig's liver and against gliadin were determined by enzyme-linked immunosorbent assay technique. Anti-endomysial antibodies were determined by indirect immunofluorescence method. Patients with psoriasis have significantly higher mean concentrations of antibodies against tissue transglutaminase (human recombinant and guinea pig-derived antigen) and against gliadin for IgA. IgA antibodies against tissue transglutaminase (both antigens) and gliadin positively correlate with psoriasis activity. No anti-endomysial antibodies for IgA were found in any serum. Our results seem to imply an association between psoriasis and asymptomatic celiac disease/gluten intolerance. High percentage of positive results to guinea pig-derived tTG could be due to cellular activity of tissue transglutaminase in psoriasis.
Malabsoprtion in psoriatic patients
  • V Ojetti
  • De Simone
  • C Sanchez
Ojetti V, De Simone C, Sanchez JA, et al. Malabsoprtion in psoriatic patients. Scand J Gastroenterol. 2006;41:1267-71.