Benjamin Kaffenberger, MD, Physician and Associate Professor of Dermatology at The Ohio State University talks about how oral health and diet may improve Psoriasis.
I wanted to start by asking you about Psoriasis. Can you explain what the condition is and what causes it?
Dr. Kaffenberger: Psoriasis is a chronic autoimmune skin disease and it is quite a common skin disease. About 2 percent of the population in America has this disease. Most patients have it mildly, but some patients have it dramatically and it can be over every possible area of the skin. But most patients have it mildly. Things that make you think you have psoriasis is it usually shows up in certain areas of the body and they are red scaly plaques. It usually starts on just the elbows but then the same distribution in the scalp but with more than plain dandruff. It is more consistent. Those are the classic locations that it would start. It is a quite common disease and a significant disease for several patients.
Is it something that has other implications?
Dr. Kaffenberger: It has multiple implications. For a long period of time we thought it was a disease that was skin deep, and it was not an autoimmune disease but that the skin was growing too fast for these patients. The final path we see is the skin is thick and that is what causes all the scaling and cracking in the skin. As far as more significant implications? So, the more we learn about this disease the more the autoimmune connection is present for these patients and it has been associated with numerous quality of life issues and health care outcomes as well. The strongest association is that patients with psoriasis have a much higher risk of having heart disease and dying of heart disease. So, the inflammation that is causing the skin to swell and thicken, is much more than skin deep. It causes a full body inflammatory process. It is not uncommon to have patients complaining because their spouse or loved one keep complaining that they are leaving scale-flakes everywhere. So, it also affects quality of life and self-esteem. There are also several mental health conditions associated with the disease. So again, it is much more than just skin deep.
What are the common treatments?
Dr. Kaffenberger: Things have changed dramatically with psoriasis and it was not always that way. 15 or 20 years ago there were not good treatments that were out there. The new treatments have revolutionized how we think about psoriasis because with each new step, we learn a little bit more about psoriasis, what’s causing it, and what’s the most strong signaling pathway between the white blood cells and skin. That is the final step. As far as patients, it really depends on the severity of the disease. If you have a mild disease, the best possible treatment is a topical anti-inflammatory, which is inexpensive, readily available, generic, and safe for use and they have been used for 40 or 50 years. So that is for patients that have low body surface spread of the psoriasis. But it has really been revolutionary for the patients with the most severe disease because 20 years ago, our treatments really were lacking. We had very non-specific medications that decreased the immune system and put patients at higher risk for liver damage and infections. We had cumbersome treatments like having patients bathe in a bathtub of tar and then getting in ultraviolet light immediately afterwards and doing that every day for a series of weeks. But starting from 2000 to 2005, a new class of inhibitors that we call biologics have come out, and this is what has really revolutionized the treatment for patients with moderate to severe psoriasis. We have gone from blockage of a single chemical message between white blood cells to blood cells to skin cells and have been able to learn, that there is a more upstream chemical message that can block and even more effectively target the psoriasis. So, the most effective treatments that are out there for patients with moderate to severe psoriasis are the general class of therapies called biologics. There is at least six to eight, and several more coming out within the next couple of years. As far as their effect on the skin, it is life-altering for our patients because we can really clear the skin like we never could before.
Can you explain the link between oral health and psoriasis?
Dr. Kaffenberger: We still have this big challenge of what causes psoriasis, why people get psoriasis and why it is so prevalent. Two percent of the population with an autoimmune disease is very prevalent. As far as why it is common to have psoriasis, we really do not know. We do not think that there is a reason for why it has become so prevalent. But ultimately, there is a lack of understanding at that first initiation. We do know that there is a genetic link, but it is not the classic type of genetic link where, if your mom or dad has it, you have a 25% or 50% risk of getting it. It is more likely 6% to 8% if you have a close relative that has had it. So, there is a genetic component to this disease. But if you look beyond that, the studies are very unclear as to what causes it. The studies have consistently shown that one of the most common associations is infections, and specifically a strep throat infection that we see primarily in kids, and it causes a very discrete type of psoriasis which is called a guttate form of psoriasis. Almost certainly, if you see a child develop guttate psoriasis it is associated with a strep throat infection. So, we know that there is a strong association with infection and specifically a strep infection in the mouth. Why, it is not clear, but it seems the streptococcal bacteria has developed a protein that mimics one of our own. So, when your body is attempting to fight these bacteria, it develops a cross-reaction with the skin at the same time. We think that is probably the association, but more work still needs to be done. But it is not just kids. So, guttate psoriasis, looks like a thousand little raindrops that show up on the skin immediately or very rapidly after an infection and that is a small subset of psoriasis patients. More commonly we see people that have these classic large plaques on their elbows and knees. For those patients, the streptococcal association has not consistently been shown. So that was the starting point where we wanted to look specifically at oral health. How do you take care of your teeth? How do you take care of your gums? And we started with a WHO survey. There is already a WHO survey that has been validated for other diseases, so we took some questions from that. Then we built in specific questions for psoriasis and autoimmune diseases so we could compare the different risk factors that are out there.
What did you find?
Dr. Kaffenberger: We looked at two different factors. First, we looked at patients who developed psoriasis versus patients who did not have psoriasis. This is a small study with 265 patients, 100 who had psoriasis, 165 were our control patients who had other skin diseases. When we looked at patients who had psoriasis compared to patients who did not have psoriasis, we saw certain things. Age was a risk factor for the diagnosis. Older patients were associated with the development of psoriasis. We found a history of autoimmune diseases that we screen for rheumatoid arthritis was an association. Similarly, a history of psoriasis in the family, was an association as well. Also, patients who were having pain eating or who rated their gum health as poor were found to have an association with psoriasis, but not our control patients.
How does this information help clinicians and patients?
Dr. Kaffenberger: With a lot of skin diseases right now, patients come in saying, I know there is great medications out there, but what can I do on my own? Specifically, a lot of patients will ask about the anti-inflammatory diet or other diets and I tell these patients I do not know if that is going to help because we do not have good data. I do not have a problem so long as there is not any evidence that this is going to harm you. I do not have any problem with you eliminating dairy for your diet, trying it for two months, and seeing if this helps. But that is not a very systematic approach to looking at why psoriasis happens or looking at more options that patients can control on their own without taking an aggressive biologic inhibitor or immune-changing medication. So that is where I think that this helps. This is a start into some associations so when patients come in with psoriasis and ask, are there things that I can do on my own to help with this? No, you cannot help your family history. No, you cannot help your personal history of autoimmune diseases. But there are certain things that you can do. Protect your gum health, decrease or stop smoking, decrease your alcohol consumption, eat more fresh fruits, fresh vegetables, less processed foods. That looks like an association here. Making sure that you floss your teeth every day and brush your teeth twice a day. These are common things that we recommend to anyone as is. But as physicians, we probably get tied up in things that really affect us with the patient. But unfortunately, a lot of patients don’t have good access to dental care or maybe they are too busy at a certain time frame, so they may not be getting that message when they have this disease in the first place. So, this should be a call to dermatologists to reinforce that they need to get routine dental care. And if they cannot afford it, to provide information on good practices to protect your gum and teeth health.
Could gum disease be an early warning sign of something that is about to happen?
Dr. Kaffenberger: It absolutely could be an early warning sign, but gum disease is a chronic process. Gingivitis is the early process and periodontitis is the late process. So, a small amount of gingivitis is a warning sign that it could develop into periodontitis, and that you could lose teeth, and we know that is a cause of systemic inflammation as well. So similarly, those patients that do not have psoriasis but just have gum inflammation are at a higher risk of heart disease and heart-related death than patients that do not have that. So, this can be caught early. Gingivitis treated early, and controlling the bacteria that is present on the gums, minimizing how much bacteria is present will prevent poor dental outcomes, poor systemic outcomes, and heart-related outcomes, and it could potentially prevent psoriasis as well.
Is the link between psoriasis and heart issues because of the autoimmune disease?
Dr. Kaffenberger: The inflammatory response is what we think is happening and that is controlling other factors that are associated with psoriasis like obesity, but it is controlling for these other diseases. These diseases cluster together. Psoriasis, intestinal diseases like Crohn’s disease and ulcerative colitis, and neurologic diseases like multiple sclerosis. These autoimmune diseases are clustered together, unfortunately.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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