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Morbid obesity and psoriasis: Disease remission after laparoscopic sleeve gastrectomy
ORCP-661; No. of Pages 3
ARTICLE IN PRESS
Obesity Research & Clinical Practice (2017) xxx, xxx—xxx
CASE REPORT
Morbid obesity and psoriasis: Disease remission after laparoscopic sleeve gastrectomy Graziella Babino ∗, Alessandro Giunta, Luca Bianchi, Maria Esposito Department of Dermatology, University of Rome ‘‘Tor Vergata’’, Rome, Italy Received 29 September 2016 ; received in revised form 13 April 2017; accepted 20 April 2017
KEYWORDS Sleeve gastrectomy; Psoriasis; Obesity; Weight loss
Summary Psoriasis is more frequent and severe in populations with obesity, and both have been associated with a higher cardiovascular risk. Recent studies suggest that weight loss may improve psoriasis and metabolic comorbidities in individuals with obesity. We present a case of a female patient affected by psoriasis, morbid obesity and other metabolic comorbidities, who experienced dramatic improvement in skin and joint symptoms and metabolic parameters after weight loss surgery with sleeve gastrectomy. © 2017 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Case report A 42-year-old woman with severe plaque-type psoriasis and psoriatric arthritis was referred for evaluation after having been unsuccessfully treated and/or intolerant to oral acitretin, NSAIDs, oral corticosteroids and methotrexate. She presented a body weight of 145 kg (body mass index 53.3) and a medical history of type-2 diabetes mellitus, ∗ Corresponding author at: Department of Dermatology, University of Rome ‘‘Tor Vergata’’, Viale Oxford, 81 - 00133 - Rome, Italy. Fax: +39 06 20902742. E-mail address: [email protected] (G. Babino).
hypertension, hypercholesterolemia and hypertriglyceridemia. Clinical examination revealed a severe plaque-type psoriasis (Psoriasis Area Severity Index, PASI, score: 24) associated to intense itching and joint symptoms symmetrically localised at wrists, knee, ankles, proximal interphalangeal and metatarsophalangeal joints (subjective pain Visual Analogue Scale, pain-VAS, of 90 and a Disease Activity Score 28-C-reactive Protein 4, DAS28-CRP4, of 5.89) (Fig. 1). Instrumental and complete laboratory tests revealed normal results with the exception of inflammation indexes, triglycerides, total and LDL cholesterol, glycemia and glycosylated haemoglobin, increased of about 15% up
http://dx.doi.org/10.1016/j.orcp.2017.04.008 1871-403X/© 2017 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Babino G, et al. Morbid obesity and psoriasis: Disease remission after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2017), http://dx.doi.org/10.1016/j.orcp.2017.04.008
ORCP-661; No. of Pages 3
ARTICLE IN PRESS
2
G. Babino et al.
Figure 1 Baseline patient condition characterised by a moderate-to-severe plaque-type psoriasis (PASI score: 24) associated to intense itching, mainly on the trunk (A) and upper extremities (B).
Figure 2 Consistent clinical improvement of psoriasis (A, B) following weight loss by bariatric surgery and concomitant etanercept treatment (PASI score: 1.2).
to normal values. Hence, etanercept 50 mg was administered twice weekly for 12 weeks, and reducted to 50 mg once weekly as maintenance treatment. After 24 weeks a partial improvement of the disease (PASI 8, pain-VAS 30, DAS28-CRP4 3.51) was observed, with no variation in inflammation and metabolic markers. Consequently in order to improve the general patient health, and in consideration of the uncomplete treatment success, the patient underwent laparoscopic sleeve gastrectomy (LSG), after a temporary (4 weeks) etanercept discontinuation. After 12 months, her weight decreased to 85 kg (total loss 60 kg), and she noted a marked improvement of etanercept efficacy (PASI 1.2, pain-VAS 10, DAS28-CRP4 2.83) and amelioration of the blood parameters correlating to type-2 diabetes, hypercholesterolemia and hypertriglyceridemia (Fig. 2). Patient follow-up lasted for a total of 4 years after LSG without psoriasis recurrence (PASI 0, pain-VAS 0, DAS28-CRP4 1.17) and side effects.
Discussion Psoriasis is a chronic inflammatory immunemediated disease, occurring more frequently in association with comorbid metabolic disorders
including diabetes, obesity, dyslipidemia, hypertension and cardiovascular diseases [1]. Obesity and metabolic syndrome are proinflammatory states associated with high levels of tumour necrosis factor (TNF)-alpha, which plays an important aetiopathogenic role in psoriasis. Particularly, adipose tissue produces TNF-alpha, and in individuals with obesity the TNF-alpha mRNA levels are 2.5 times more than in healthy ones [2,3]. Subsequently, weight loss results in a significant reduction of TNF-alpha expression in adipose tissue, leading to psoriasis improvement. Bariatric surgery, performed by Roux-en Y gastric bypass (RYGB) or LSG, is the most effective long-term surgical treatment for morbid obesity [4]. A number of cases of psoriasis remission after weight loss due to RYGB have been reported to date [5—9]. Farias et al. described 10 patients with psoriasis who underwent bariatric surgery: 7/8 patients after RYGB experienced complete psoriasis resolution, while among 2 patients undergoing LSG, one had a very mild skin disease and did not experience any change, and the other reported a psoriasis rebound probably correlated to the interruption of methotrexate. When compared, RYGB and LSG showed similar results in terms of weight loss and comorbidities resolution [9]. On the contrary, we report the case of a patient with psoriasis and metabolic abnormalities who experienced dramatic
Please cite this article in press as: Babino G, et al. Morbid obesity and psoriasis: Disease remission after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2017), http://dx.doi.org/10.1016/j.orcp.2017.04.008
ORCP-661; No. of Pages 3
ARTICLE IN PRESS
Morbid obesity and psoriasis
3
improvement of skin and joint disease as well as metabolic parameters after weight loss surgery by LSG. In our patient bariatric surgery resulted as an adjuvant treatment to etanercept therapy. Weight loss and psoriasis improvement were maintained throughout the follow-up lasting 4 years. It is conceivable that weight loss may have had a significant impact on the disease not only for the obesity control but also for a possible amelioration of drug distribution and pharmacodynamic profile. Further studies are needed to support weight loss by bariatric surgery as a potential therapy for severe psoriasis associated to morbid obesity and/or to confirm its role in selected cases as adjuvant strategy to systemic medical therapies for psoriasis.
Funding sources None.
Conflict of interest All authors declare to have no conflict of interest in this work neither financial nor personal and affirm that the manuscript has not been published previously and is not being considered currently by another publication. We also affirm that all
authors and contributors have read and approved the manuscript.
References [1] Voiculescu V, Lupu M, Papagheorghe L, Giurcaneanu C, Micu E. Psoriasis and Metabolic Syndrome —– scientific evidence and therapeutic implications. J Med Life 2014;7(October—December (4)):468—71. [2] Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome [comment]. Lancet 2005;365:1415—28. [3] Kern PA, Saghizadeh M, Ong JM, Bosch RJ, Deem R, Simsolo RB. The expression of tumor necrosis factor in human adipose tissue. Regulation by obesity, weight loss, and relationship to lipoprotein lipase. J Clin Invest 1995;95(5):2111—9. [4] Perry CD, Hutter MM, Smith DB, Newhouse JP, McNeil BJ. Survival and changes in comorbidities after bariatric surgery. Ann Surg 2008;247:21—7. [5] Higa-Sansone G, Szomstein S, Soto F, Brasecsco O, Cohen C, Rosenthal RJ. Psoriasis remission after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2004;14:1132—4. [6] De Menezes Ettinger JE, Azaro E, de Souza CA, dos Santos Filho PV, Mello CA, Neves Jr M, et al. Remission of psoriasis after open gastric bypass. Obes Surg 2006;16:94—7. [7] Hossler EW, Maroon MS, Mowad CM. Gastric bypass surgery improves psoriasis. J Am Acad Dermatol 2011;65:198—200. [8] Pérez-Pérez L, Allegue F, Caeiro JL, Zulaica JM. Severe psoriasis, morbid obesity and bariatric surgery. Clin Exp Dermatol 2009;34:421—2. [9] Farias MM, Achurra P, Boza C, Vega A, de la Cruz C. Psoriasis following bariatric surgery: clinical evolution and impact on quality of life on 10 patients. Obes Surg 2012;22:877—80.
Available online at www.sciencedirect.com
ScienceDirect
Please cite this article in press as: Babino G, et al. Morbid obesity and psoriasis: Disease remission after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2017), http://dx.doi.org/10.1016/j.orcp.2017.04.008
ARTICLE IN PRESS
Obesity Research & Clinical Practice (2017) xxx, xxx—xxx
CASE REPORT
Morbid obesity and psoriasis: Disease remission after laparoscopic sleeve gastrectomy Graziella Babino ∗, Alessandro Giunta, Luca Bianchi, Maria Esposito Department of Dermatology, University of Rome ‘‘Tor Vergata’’, Rome, Italy Received 29 September 2016 ; received in revised form 13 April 2017; accepted 20 April 2017
KEYWORDS Sleeve gastrectomy; Psoriasis; Obesity; Weight loss
Summary Psoriasis is more frequent and severe in populations with obesity, and both have been associated with a higher cardiovascular risk. Recent studies suggest that weight loss may improve psoriasis and metabolic comorbidities in individuals with obesity. We present a case of a female patient affected by psoriasis, morbid obesity and other metabolic comorbidities, who experienced dramatic improvement in skin and joint symptoms and metabolic parameters after weight loss surgery with sleeve gastrectomy. © 2017 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Case report A 42-year-old woman with severe plaque-type psoriasis and psoriatric arthritis was referred for evaluation after having been unsuccessfully treated and/or intolerant to oral acitretin, NSAIDs, oral corticosteroids and methotrexate. She presented a body weight of 145 kg (body mass index 53.3) and a medical history of type-2 diabetes mellitus, ∗ Corresponding author at: Department of Dermatology, University of Rome ‘‘Tor Vergata’’, Viale Oxford, 81 - 00133 - Rome, Italy. Fax: +39 06 20902742. E-mail address: [email protected] (G. Babino).
hypertension, hypercholesterolemia and hypertriglyceridemia. Clinical examination revealed a severe plaque-type psoriasis (Psoriasis Area Severity Index, PASI, score: 24) associated to intense itching and joint symptoms symmetrically localised at wrists, knee, ankles, proximal interphalangeal and metatarsophalangeal joints (subjective pain Visual Analogue Scale, pain-VAS, of 90 and a Disease Activity Score 28-C-reactive Protein 4, DAS28-CRP4, of 5.89) (Fig. 1). Instrumental and complete laboratory tests revealed normal results with the exception of inflammation indexes, triglycerides, total and LDL cholesterol, glycemia and glycosylated haemoglobin, increased of about 15% up
http://dx.doi.org/10.1016/j.orcp.2017.04.008 1871-403X/© 2017 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Babino G, et al. Morbid obesity and psoriasis: Disease remission after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2017), http://dx.doi.org/10.1016/j.orcp.2017.04.008
ORCP-661; No. of Pages 3
ARTICLE IN PRESS
2
G. Babino et al.
Figure 1 Baseline patient condition characterised by a moderate-to-severe plaque-type psoriasis (PASI score: 24) associated to intense itching, mainly on the trunk (A) and upper extremities (B).
Figure 2 Consistent clinical improvement of psoriasis (A, B) following weight loss by bariatric surgery and concomitant etanercept treatment (PASI score: 1.2).
to normal values. Hence, etanercept 50 mg was administered twice weekly for 12 weeks, and reducted to 50 mg once weekly as maintenance treatment. After 24 weeks a partial improvement of the disease (PASI 8, pain-VAS 30, DAS28-CRP4 3.51) was observed, with no variation in inflammation and metabolic markers. Consequently in order to improve the general patient health, and in consideration of the uncomplete treatment success, the patient underwent laparoscopic sleeve gastrectomy (LSG), after a temporary (4 weeks) etanercept discontinuation. After 12 months, her weight decreased to 85 kg (total loss 60 kg), and she noted a marked improvement of etanercept efficacy (PASI 1.2, pain-VAS 10, DAS28-CRP4 2.83) and amelioration of the blood parameters correlating to type-2 diabetes, hypercholesterolemia and hypertriglyceridemia (Fig. 2). Patient follow-up lasted for a total of 4 years after LSG without psoriasis recurrence (PASI 0, pain-VAS 0, DAS28-CRP4 1.17) and side effects.
Discussion Psoriasis is a chronic inflammatory immunemediated disease, occurring more frequently in association with comorbid metabolic disorders
including diabetes, obesity, dyslipidemia, hypertension and cardiovascular diseases [1]. Obesity and metabolic syndrome are proinflammatory states associated with high levels of tumour necrosis factor (TNF)-alpha, which plays an important aetiopathogenic role in psoriasis. Particularly, adipose tissue produces TNF-alpha, and in individuals with obesity the TNF-alpha mRNA levels are 2.5 times more than in healthy ones [2,3]. Subsequently, weight loss results in a significant reduction of TNF-alpha expression in adipose tissue, leading to psoriasis improvement. Bariatric surgery, performed by Roux-en Y gastric bypass (RYGB) or LSG, is the most effective long-term surgical treatment for morbid obesity [4]. A number of cases of psoriasis remission after weight loss due to RYGB have been reported to date [5—9]. Farias et al. described 10 patients with psoriasis who underwent bariatric surgery: 7/8 patients after RYGB experienced complete psoriasis resolution, while among 2 patients undergoing LSG, one had a very mild skin disease and did not experience any change, and the other reported a psoriasis rebound probably correlated to the interruption of methotrexate. When compared, RYGB and LSG showed similar results in terms of weight loss and comorbidities resolution [9]. On the contrary, we report the case of a patient with psoriasis and metabolic abnormalities who experienced dramatic
Please cite this article in press as: Babino G, et al. Morbid obesity and psoriasis: Disease remission after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2017), http://dx.doi.org/10.1016/j.orcp.2017.04.008
ORCP-661; No. of Pages 3
ARTICLE IN PRESS
Morbid obesity and psoriasis
3
improvement of skin and joint disease as well as metabolic parameters after weight loss surgery by LSG. In our patient bariatric surgery resulted as an adjuvant treatment to etanercept therapy. Weight loss and psoriasis improvement were maintained throughout the follow-up lasting 4 years. It is conceivable that weight loss may have had a significant impact on the disease not only for the obesity control but also for a possible amelioration of drug distribution and pharmacodynamic profile. Further studies are needed to support weight loss by bariatric surgery as a potential therapy for severe psoriasis associated to morbid obesity and/or to confirm its role in selected cases as adjuvant strategy to systemic medical therapies for psoriasis.
Funding sources None.
Conflict of interest All authors declare to have no conflict of interest in this work neither financial nor personal and affirm that the manuscript has not been published previously and is not being considered currently by another publication. We also affirm that all
authors and contributors have read and approved the manuscript.
References [1] Voiculescu V, Lupu M, Papagheorghe L, Giurcaneanu C, Micu E. Psoriasis and Metabolic Syndrome —– scientific evidence and therapeutic implications. J Med Life 2014;7(October—December (4)):468—71. [2] Eckel RH, Grundy SM, Zimmet PZ. The metabolic syndrome [comment]. Lancet 2005;365:1415—28. [3] Kern PA, Saghizadeh M, Ong JM, Bosch RJ, Deem R, Simsolo RB. The expression of tumor necrosis factor in human adipose tissue. Regulation by obesity, weight loss, and relationship to lipoprotein lipase. J Clin Invest 1995;95(5):2111—9. [4] Perry CD, Hutter MM, Smith DB, Newhouse JP, McNeil BJ. Survival and changes in comorbidities after bariatric surgery. Ann Surg 2008;247:21—7. [5] Higa-Sansone G, Szomstein S, Soto F, Brasecsco O, Cohen C, Rosenthal RJ. Psoriasis remission after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2004;14:1132—4. [6] De Menezes Ettinger JE, Azaro E, de Souza CA, dos Santos Filho PV, Mello CA, Neves Jr M, et al. Remission of psoriasis after open gastric bypass. Obes Surg 2006;16:94—7. [7] Hossler EW, Maroon MS, Mowad CM. Gastric bypass surgery improves psoriasis. J Am Acad Dermatol 2011;65:198—200. [8] Pérez-Pérez L, Allegue F, Caeiro JL, Zulaica JM. Severe psoriasis, morbid obesity and bariatric surgery. Clin Exp Dermatol 2009;34:421—2. [9] Farias MM, Achurra P, Boza C, Vega A, de la Cruz C. Psoriasis following bariatric surgery: clinical evolution and impact on quality of life on 10 patients. Obes Surg 2012;22:877—80.
Available online at www.sciencedirect.com
ScienceDirect
Please cite this article in press as: Babino G, et al. Morbid obesity and psoriasis: Disease remission after laparoscopic sleeve gastrectomy. Obes Res Clin Pract (2017), http://dx.doi.org/10.1016/j.orcp.2017.04.008