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Metabolic abnormalities are absent in patients with generalized pustular psoriasis
Journal of Dermatological Science 78 (2015) 239–240
Contents lists available at ScienceDirect
Journal of Dermatological Science journal homepage: www.jdsjournal.com
Letter to the Editor Metabolic abnormalities are absent in patients with generalized pustular psoriasis Generalized pustular psoriasis (GPP) is an uncommon variant of psoriasis. It is characterized by the sudden onset of diffuse erythema, with the scattering of pustules, accompanied by high fever and hyperleukocytosis. Triggered by infection or drug exposure, GPP can occur with other forms of psoriasis or be the only manifestation of disease. GPP has been included within the spectrum of psoriasis, but the clinical and histologic (especially genetic) differences suggest it has a distinct pathogenesis [1]. In recent years, numerous studies have demonstrated that psoriasis is significantly associated with the metabolic syndrome or its components, such as obesity, insulin resistance, hypertension and atherogenic dyslipidemia [2]. A systematic review found that psoriasis was significantly associated with the incidence of dyslipidemia [3]. Also, greater severity of psoriasis appears to be associated with a higher prevalence of dyslipidemia [3]. Laboratory abnormalities (e.g., hyperleukocytosis in the acute stage) of GPP patients are common. Mansur et al. [4] demonstrated that eosinophilia in peripheral blood is associated with GPP. However, a study focusing on the clinical and laboratory features of the metabolic syndrome in GPP patients are lacking. We undertook a case–control study involving 40 patients (age, 40.44 16.87 years) with GPP hospitalized in Anhui Provincial Hospital (Anhui, China) from January 2001 to April 2013 and
86 matched controls (39.4 15.26 years; patients with condyloma acuminatum) (Table 1). GPP patients who had received systemic treatment, phototherapy or photo-chemotherapy within the previous 4 weeks before hospital admission were excluded. Blood samples used for evaluation were taken from all subjects at 8 am to 9 am before initiation of any specific therapy for the disease. Levels of triglycerides (TG), total cholesterol (TC), and fasting blood sugar (FBS) were measured using a 7600-020 Automatic Biochemical Analyzer (Hitachi, Tokyo, Japan). White blood cell count, absolute neutrophil count, and eosinophil count were obtained using a HST-302 Automatic Blood Analyzer (Sysmex, Kobe, Japan) Statistical analyses were carried out using SPSS v13 (IBM, Armonk, NY, USA). In our 40 patients with GPP, comorbidities included chronic infection of the respiratory tract (22.5%), autoimmune disease (5%), and disorders in the hematologic system (2.5%). No patients had a history of diabetes mellitus or diseases of the cardiovascular system. GPP patients had a significantly lower serum level of cholesterol as well as a significantly higher white blood cell count and neutrophil count than controls (all P < 0.01). TG level was lower in GPP patients than in controls, but the difference was not significant. Blood pressure, FBS, and eosinophil cell count were comparable to those of controls (Table 1). Based on differences in disease history, we divided GPP patients into two subgroups: one with a history of psoriasis vulgaris (PsV)
Table 1 The comparison of metabolic index and blood routine index between GPP group and controls. Groups
GPP group (n = 40)
GPP without PsV (n = 16)
GPP with PsV (n = 24)
Control group (n = 86)
GPP group vs controls t
Gender Male 21 39 Female 19 47 Age (year) 40.44 16.87 39.4 15.26 The blood pressure Systolic pressure 122.08 18.59 111.87 17.71 125.92 17.34 120.83 15.41 (mmHg) 72.12 11.89 63.2 9.88 77.71 9.47 75.17 9.97 Diastolic pressure (mmHg) Metabolic index FBS (mmol/L) 4.96 1.13 4.8188 1.14 5.065 1.136 4.76 0.55 TC (mmol/L) 3.74 0.82 3.59 0.93 3.82 0.77 4.31 0.93 TG (mmol/L) 1.17 0.53 1.02 0.43 1.25 0.57 1.41 0.82 Blood routine index White blood cell 10.39 3.77 9.74 4.03 5.7 1.98 10 3.89 count (109) 7.63 3.93 8.52 3.92 3.49 1.60 Absolute neutrophil 8.12 3.88 count (109) 0.159 0.16 0.47 1.31 0.15 0.26 Eosinophils 0.33 0.99 count (109) *
GPP without PsV vs controls P*
P
t
GPP with PsV vs controls P*
P
t
P*
P
0.454
0.568
1.705
0.733
0.814
0.102
0.919
0.919
2.035
0.045
0.072
1.405
0.168
0.336
1.489
0.139
0.278
4.298
0.00004
0.0001 1.351
0.268
0.357
1.334 3.205 1.625
0.3 0.002 0.059
0.5 0.323 0.0067 2.578 0.098 1.662
0.841 0.011 0.1
0.961 0.022 0.13
0.233 0.02 0.286
0.323 0.053 0.286
1.353 2.213 1.212
8.154 <0.01
<0.01
7.342 <0.01
<0.01
6.021 <0.01
<0.01
6.231 <0.01
<0.01
5.288 <0.01
<0.01
4.841 <0.01
<0.01
1.028
0.31
0.442
0.122
False discovery rate-adjusted P value.
http://dx.doi.org/10.1016/j.jdermsci.2015.03.011 0923-1811/ß 2015 Japanese Society for Investigative Dermatology. Published by Elsevier Ireland Ltd. All rights reserved.
0.903
0.903
1.35
0.284
0.324
240
Letter to the Editor / Journal of Dermatological Science 78 (2015) 239–240
and the other without a history of PsV. The results of differences between any one subtype of GPP patients and controls were similar to those between GPP patients and controls. Blood pressure (systolic and diastolic) was lower in GPP patients with a history of PsV than in controls (all P < 0 .01). Numerous studies have demonstrated that psoriasis patients are at risk of developing comorbidities, in particular metabolic syndrome, vascular disorders and dyslipidemia [3,5]. GPP is classified as a variant of psoriasis, but its striking clinical and histologic differences suggest that it is likely to be a disease of distinct etiology. In the present study, different to PsV, GPP patients showed no obvious metabolic abnormalities. Interestingly, in contrast to PsV, levels of TC and TG in peripheral blood were lower than those in the control group. Enrolled patients had a severe type of GPP and blood samples were taken on the first day of hospitalization. We suggest that, as important forms of energy reserves, serum levels of TG and cholesterol may be reduced because of the high level of energy consumption in the acute stage of GPP. Moreover, blood pressure was lower in GPP patients with a history of PsV. A study focusing on the association between blood pressure and GPP has not been conducted before. However, our results must be confirmed in a larger cohort or a cohort with other ethnicities. In conclusion, we found that patients with GPP were different to patients with PsV in terms of some clinical and laboratory features of metabolic syndrome. Our study reinforces the view that there are differences between GPP and PsV in terms of pathogenesis. Funding This work was supported by grants from the China Natural Science Foundation (81101186).
Acknowledgments We are most grateful to all the participants who have so willingly participated in this study. References [1] Sugiura K, Takemoto A, Yamaguchi M, Takahashi H, Shoda Y, Mitsuma T, et al. The majority of generalized pustular psoriasis without psoriasis vulgaris is caused by deficiency of interleukin-36 receptor antagonist. J Invest Dermatol 2013;133:2514–21. [2] Alsufyani MA, Golant AK, Lebwohl M. Psoriasis and the metabolic syndrome. Dermatol Ther 2010;23:137–43. [3] Ma C, Harskamp CT, Armstrong EJ, Armstrong AW. The association between psoriasis and dyslipidaemia: a systematic review. Br J Dermatol 2013;168: 486–95. [4] Mansur AT, Goktay F, Yasar SP. Peripheral blood eosinophilia in association with generalized pustular and erythrodermic psoriasis. J Eur Acad Dermatol Venereol 2008;22:451–5. [5] Sterry W, Strober BE, Menter A. Obesity in psoriasis: the metabolic, clinical and therapeutic implications. Report of an interdisciplinary conference and review. Br J Dermatol 2007;157:649–55.
Chi Zhang a,*, KunJu Zhub, HaiLin Zhoua, JinLi Liua, GuiXia Xua, Wei Liua a Department of Dermatology and Venerology, Anhui Provincial Hospital, Hefei, Anhui, China; bDepartment of Dermatology, Affiliated Hospital of Guangdong Medical College, Zhanjiang, Guangdong, China *Corresponding author. Tel.: +86 13865954760 E-mail address: [email protected] (C. Zhang). Received 25 October 2014
Contents lists available at ScienceDirect
Journal of Dermatological Science journal homepage: www.jdsjournal.com
Letter to the Editor Metabolic abnormalities are absent in patients with generalized pustular psoriasis Generalized pustular psoriasis (GPP) is an uncommon variant of psoriasis. It is characterized by the sudden onset of diffuse erythema, with the scattering of pustules, accompanied by high fever and hyperleukocytosis. Triggered by infection or drug exposure, GPP can occur with other forms of psoriasis or be the only manifestation of disease. GPP has been included within the spectrum of psoriasis, but the clinical and histologic (especially genetic) differences suggest it has a distinct pathogenesis [1]. In recent years, numerous studies have demonstrated that psoriasis is significantly associated with the metabolic syndrome or its components, such as obesity, insulin resistance, hypertension and atherogenic dyslipidemia [2]. A systematic review found that psoriasis was significantly associated with the incidence of dyslipidemia [3]. Also, greater severity of psoriasis appears to be associated with a higher prevalence of dyslipidemia [3]. Laboratory abnormalities (e.g., hyperleukocytosis in the acute stage) of GPP patients are common. Mansur et al. [4] demonstrated that eosinophilia in peripheral blood is associated with GPP. However, a study focusing on the clinical and laboratory features of the metabolic syndrome in GPP patients are lacking. We undertook a case–control study involving 40 patients (age, 40.44 16.87 years) with GPP hospitalized in Anhui Provincial Hospital (Anhui, China) from January 2001 to April 2013 and
86 matched controls (39.4 15.26 years; patients with condyloma acuminatum) (Table 1). GPP patients who had received systemic treatment, phototherapy or photo-chemotherapy within the previous 4 weeks before hospital admission were excluded. Blood samples used for evaluation were taken from all subjects at 8 am to 9 am before initiation of any specific therapy for the disease. Levels of triglycerides (TG), total cholesterol (TC), and fasting blood sugar (FBS) were measured using a 7600-020 Automatic Biochemical Analyzer (Hitachi, Tokyo, Japan). White blood cell count, absolute neutrophil count, and eosinophil count were obtained using a HST-302 Automatic Blood Analyzer (Sysmex, Kobe, Japan) Statistical analyses were carried out using SPSS v13 (IBM, Armonk, NY, USA). In our 40 patients with GPP, comorbidities included chronic infection of the respiratory tract (22.5%), autoimmune disease (5%), and disorders in the hematologic system (2.5%). No patients had a history of diabetes mellitus or diseases of the cardiovascular system. GPP patients had a significantly lower serum level of cholesterol as well as a significantly higher white blood cell count and neutrophil count than controls (all P < 0.01). TG level was lower in GPP patients than in controls, but the difference was not significant. Blood pressure, FBS, and eosinophil cell count were comparable to those of controls (Table 1). Based on differences in disease history, we divided GPP patients into two subgroups: one with a history of psoriasis vulgaris (PsV)
Table 1 The comparison of metabolic index and blood routine index between GPP group and controls. Groups
GPP group (n = 40)
GPP without PsV (n = 16)
GPP with PsV (n = 24)
Control group (n = 86)
GPP group vs controls t
Gender Male 21 39 Female 19 47 Age (year) 40.44 16.87 39.4 15.26 The blood pressure Systolic pressure 122.08 18.59 111.87 17.71 125.92 17.34 120.83 15.41 (mmHg) 72.12 11.89 63.2 9.88 77.71 9.47 75.17 9.97 Diastolic pressure (mmHg) Metabolic index FBS (mmol/L) 4.96 1.13 4.8188 1.14 5.065 1.136 4.76 0.55 TC (mmol/L) 3.74 0.82 3.59 0.93 3.82 0.77 4.31 0.93 TG (mmol/L) 1.17 0.53 1.02 0.43 1.25 0.57 1.41 0.82 Blood routine index White blood cell 10.39 3.77 9.74 4.03 5.7 1.98 10 3.89 count (109) 7.63 3.93 8.52 3.92 3.49 1.60 Absolute neutrophil 8.12 3.88 count (109) 0.159 0.16 0.47 1.31 0.15 0.26 Eosinophils 0.33 0.99 count (109) *
GPP without PsV vs controls P*
P
t
GPP with PsV vs controls P*
P
t
P*
P
0.454
0.568
1.705
0.733
0.814
0.102
0.919
0.919
2.035
0.045
0.072
1.405
0.168
0.336
1.489
0.139
0.278
4.298
0.00004
0.0001 1.351
0.268
0.357
1.334 3.205 1.625
0.3 0.002 0.059
0.5 0.323 0.0067 2.578 0.098 1.662
0.841 0.011 0.1
0.961 0.022 0.13
0.233 0.02 0.286
0.323 0.053 0.286
1.353 2.213 1.212
8.154 <0.01
<0.01
7.342 <0.01
<0.01
6.021 <0.01
<0.01
6.231 <0.01
<0.01
5.288 <0.01
<0.01
4.841 <0.01
<0.01
1.028
0.31
0.442
0.122
False discovery rate-adjusted P value.
http://dx.doi.org/10.1016/j.jdermsci.2015.03.011 0923-1811/ß 2015 Japanese Society for Investigative Dermatology. Published by Elsevier Ireland Ltd. All rights reserved.
0.903
0.903
1.35
0.284
0.324
240
Letter to the Editor / Journal of Dermatological Science 78 (2015) 239–240
and the other without a history of PsV. The results of differences between any one subtype of GPP patients and controls were similar to those between GPP patients and controls. Blood pressure (systolic and diastolic) was lower in GPP patients with a history of PsV than in controls (all P < 0 .01). Numerous studies have demonstrated that psoriasis patients are at risk of developing comorbidities, in particular metabolic syndrome, vascular disorders and dyslipidemia [3,5]. GPP is classified as a variant of psoriasis, but its striking clinical and histologic differences suggest that it is likely to be a disease of distinct etiology. In the present study, different to PsV, GPP patients showed no obvious metabolic abnormalities. Interestingly, in contrast to PsV, levels of TC and TG in peripheral blood were lower than those in the control group. Enrolled patients had a severe type of GPP and blood samples were taken on the first day of hospitalization. We suggest that, as important forms of energy reserves, serum levels of TG and cholesterol may be reduced because of the high level of energy consumption in the acute stage of GPP. Moreover, blood pressure was lower in GPP patients with a history of PsV. A study focusing on the association between blood pressure and GPP has not been conducted before. However, our results must be confirmed in a larger cohort or a cohort with other ethnicities. In conclusion, we found that patients with GPP were different to patients with PsV in terms of some clinical and laboratory features of metabolic syndrome. Our study reinforces the view that there are differences between GPP and PsV in terms of pathogenesis. Funding This work was supported by grants from the China Natural Science Foundation (81101186).
Acknowledgments We are most grateful to all the participants who have so willingly participated in this study. References [1] Sugiura K, Takemoto A, Yamaguchi M, Takahashi H, Shoda Y, Mitsuma T, et al. The majority of generalized pustular psoriasis without psoriasis vulgaris is caused by deficiency of interleukin-36 receptor antagonist. J Invest Dermatol 2013;133:2514–21. [2] Alsufyani MA, Golant AK, Lebwohl M. Psoriasis and the metabolic syndrome. Dermatol Ther 2010;23:137–43. [3] Ma C, Harskamp CT, Armstrong EJ, Armstrong AW. The association between psoriasis and dyslipidaemia: a systematic review. Br J Dermatol 2013;168: 486–95. [4] Mansur AT, Goktay F, Yasar SP. Peripheral blood eosinophilia in association with generalized pustular and erythrodermic psoriasis. J Eur Acad Dermatol Venereol 2008;22:451–5. [5] Sterry W, Strober BE, Menter A. Obesity in psoriasis: the metabolic, clinical and therapeutic implications. Report of an interdisciplinary conference and review. Br J Dermatol 2007;157:649–55.
Chi Zhang a,*, KunJu Zhub, HaiLin Zhoua, JinLi Liua, GuiXia Xua, Wei Liua a Department of Dermatology and Venerology, Anhui Provincial Hospital, Hefei, Anhui, China; bDepartment of Dermatology, Affiliated Hospital of Guangdong Medical College, Zhanjiang, Guangdong, China *Corresponding author. Tel.: +86 13865954760 E-mail address: [email protected] (C. Zhang). Received 25 October 2014