Acta Dermato-Venereologica 99-10CompleteContent | Page 20
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SHORT COMMUNICATION
Non-random Plaque-site Recurrence of Psoriasis in Patients Treated with Dead Sea Climatotherapy
Thomas EMMANUEL, Dorte LYBÆK, Claus JOHANSEN and Lars IVERSEN
Department of Dermatology, Aarhus University Hospital, DK-8000 Aarhus, Denmark. E-mail: [email protected]
Accepted May 29, 2019; E-published May 29, 2019
Psoriasis is a chronic inflammatory skin disease cha-
racterized by scaly well-demarcated plaques and a high
comorbidity burden. Disease management is complex
and should include a patient-centred view (1). In Den-
mark, Dead Sea climatotherapy (DSC) has been used
successfully for many years as a treatment approach
to psoriasis, with excellent clearance rates (2). It is
generally believed that the cutaneous symptoms of
psoriasis often relapse in previously affected sites after
cessation of treatment, although this has not been do-
cumented or quantified. Relapse indicates the presence
of a “molecular scar” in clinically healed skin (3). The
aim of this study was to determine whether recurrence
of psoriasis after complete clearance occurs in a non-
random fashion. This was determined by automated
imaging in patients achieving complete clearance after
treatment with DSC.
METHODS
Six patients with moderate to severe plaque-type psoriasis were
included. All patients signed an individual written informed
consent to participate, and study approval was obtained from The
Central Denmark Region Committees on Health Research Ethics.
Procedures were conducted in accordance with ethical standards
on human experimentation and the Declaration of Helsinki 1975,
as revised in 1983. Clinical improvement was evaluated by the
reduction in the Psoriasis Area and Severity Index (PASI) and
the 5-point Investigator’s Global Assessment (IGA). Automated
Total Body Mapping (ATBM) images were acquired using the
FotoFinder Body-studio ATBM (FotoFinder Systems GmbH, Bad
Birnbach, Germany) (Fig. 1a). A digital reflex camera (Canon
EOS 700D; Canon, Lake Success, NY, USA; with Canon EF-S
18-55mm f/3.5-5.6 IS STM lens; Canon, Lake Success, NY, USA)
was attached to a motor-powered vertical rail. Camera movement
was powered by an automatic camera positioning system. Patients
were encouraged to assume different poses for automatic image
acquisition. Four pictures from 4 different views (frontal-, left
sagittal-, right sagittal- and dorsal plane) were acquired, creating
a total of 16 pictures per patient. Digital images were transfer-
red to Adobe Photoshop ® CC 2018 (Adobe, Park Avenue, San
Jose, CA, USA). Furthermore, a 4-mm punch biopsy specimen
was acquired from the same target lesion of a psoriatic plaque
at baseline (Fig. 1b), visit 1 (Fig. 1c) and visit X (Fig. 1d), and
from non-lesional psoriatic skin at baseline (Fig. 1e). Biopsies
were stored and stained with haematoxylin and eosin (HE), as
described previously (4). Fig. 1f–h shows representative pictures
from the same patient obtained at baseline, visit 1 and visit X,
respectively. The lesional area was marked manually at baseline
(Fig. 1i), visit 1 (Fig. 1j) and the number of pixels was counted.
Pictures from baseline and visit X were then overlaid, and the
overlapping area was calculated (Fig. 1k). Subsequently, for each
picture a ratio was calculated, based on both the overlapping
lesional area between baseline and visit X and the lesional area
compared with body surface area (BSA). The feet, hands, genital
area, intertriginous areas, head and non-overlapping areas were
not included in the BSA.
RESULTS
The patients comprised 5 males and 1 female. At baseline
and visit X mean PASI was 13.9 (standard deviation (SD)
5.5, range 8.08–19.6) and 4.53 (SD 2, range 1.34–7.71),
respectively. All patients enrolled in this part of the study
should have an IGA and PASI of 0 at visit 1. The results
showed that 60.2% (SD 23.6%, range 34.7–94.3%) of
the new plaque area reappeared inside the location of
former plaques. At baseline and at visit X, 14.1% (SD
17, range 1.56–46.45%) and 8.2% (SD 16.4%, range
0.07–41.58%), respectively, of the BSA was covered
by visible plaques. Histopathology examination showed
typical psoriatic features at baseline (Fig. 1b). Imme-
diately after treatment with DSC (Fig. 1c), a normal
phenotype was seen, similar to non-lesional skin (Fig.
1e). Histopathological examination at visit X confirmed
the reappearance of psoriasis (Fig. 1d).
DISCUSSION
This is the first study to investigate the plaque-site
specific recurrence of psoriasis using an ATBM system.
Furthermore, this study presents a method that allows for
the study of plaque-site specific recurrence of psoriasis
and other relapsing skin diseases. The drivers of this
site-specific disease memory are not yet understood,
and psoriasis represents an ideal model system as it al-
lows easy repeated sampling from the same area during
different phases of the inflammatory process. DSC is an
excellent model system for studying plaque-site specific
recurrence, since the short, intensive treatment often re-
sults in complete resolution of the cutaneous symptoms.
In addition, the abrupt treatment cessation allows for
the remission of symptoms. There are several limita-
tions when obtaining ATBMs. Firstly, when comparing
images acquired at different time-points, a high level of
standardization is required necessitating trained person-
nel and compliant patients. Secondly, slight deviations
in patient posture, a change in lighting, or a change in
ATBM set-up can affect the results. Thirdly, the feet,
hands, genital area, intertriginous areas, head and non-
overlapping areas were not evaluated. In future, ATBM
combined with computer-guided digital image analysis
This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta
Journal Compilation © 2019 Acta Dermato-Venereologica.
doi: 10.2340/00015555-3233
Acta Derm Venereol 2019; 99: 909–910