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CLINICAL REPORT Advances in dermatology and venereology ActaDV Acta Dermato-Venereologica ActaDV
Patient-reported Outcomes and Clinical Response in Patients with Moderate-to-severe Plaque Psoriasis Treated with Tonsillectomy: A Randomized Controlled Trial
Ragna Hlin THORLEIFSDOTTIR 1, 2, Sigrun Laufey SIGURDARDOTTIR 3, Bardur SIGURGEIRSSON 1, Jon Hjaltalin OLAFSSON 1, Martin Ingi SIGURDSSON 4, Hannes PETERSEN 5, Johann Eli GUDJONSSON 6, Andrew JOHNSTON 6 and Helgi VALDIMARSSON 3
1
Faculty of Medicine, Section of Dermatology, University of Iceland, Reykjavik, Iceland, 2 Department of Medical Sciences, Dermatology, Uppsala University, Uppsala, Sweden, 3 Department of Immunology, 4 Department of Anesthesiology and Critical Care, 5 Department of Otolaryngology-Head and Neck Surgery, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland, and 6 Department of Dermatology, University of Michigan Medical School, Ann Arbor, MI, USA
Psoriasis is a chronic inflammatory skin disease with profound effects on patients’ health-related quality of life( HRQoL). Twenty-nine patients with plaque psoriasis and a history of streptococcal-associated psoriasis exacerbations were randomly assigned to tonsillectomy( n = 15) or control( n = 14) groups and followed for 24 months. Patients were evaluated with the Psoriasis Disability Index, Psoriasis Life Stress Inventory and Psoriasis Area and Severity Index. HRQoL and psoriasis-related stress improved significantly in the tonsillectomy group compared with the control group( p = 0.037 and p = 0.002, respectively), with a mean 50 % improvement in HRQoL and a mean 59 % improvement in psoriasis-induced stress. Clinical improvement correlated significantly with improved HRQoL( r = 0.297, p = 0.008) and psoriasis-related stress( r = 0.310, p = 0.005). Of the tonsillectomized patients, 87 % concluded that the procedure was worthwhile. Tonsillectomy may improve quality of life for selected patients with plaque psoriasis.
Key words: chronic plaque psoriasis; streptococcal throat infection; tonsillectomy; health-related quality of life; Psoriasis Disability Index; Psoriasis Life Stress Inventory.
Accepted Nov 2, 2016; Epub ahead of print Nov 6, 2016 Acta Derm Venereol 2017; 97: 340 – 345.
Corr: Ragna Hlin Thorleifsdottir, Department of Medical Sciences, Dermatology, Uppsala University, Akademiska University Hospital, SE-751 85 Uppsala, Sweden. E-mail: ragnahlin @ gmail. com
Psoriasis is a complex multifactorial disease caused by a combination of genetic and environmental factors( 1), affecting approximately 2 – 3 % of the world’ s population( 2). Psoriasis has a significant negative impact on many areas of health-related quality of life( HRQoL), including physical, occupational, social, psychological, and sexual wellbeing( 3 – 5). Patients with psoriasis have reduced HRQoL, similar to that caused by major chronic illnesses such as cancer, myocardial infarction and diabetes mellitus( 6). Many patients have low self-esteem and feel embarrassed, helpless, and stigmatized due to the visible nature of psoriasis( 7, 8), which causes significant daily stress for patients( 9). Clinical assessments, such as the Psoriasis Area and Severity Index( PASI)( 10), do not adequately reflect the general impact that the disease has on the lives of patients with psoriasis, but instead give a static score of clinical disease severity( 11).
Many environmental factors have been implicated in psoriasis; in particular, throat infection with β-haemolytic streptococci has been associated with both the initiation and exacerbation of psoriasis( 12 – 15). T cells primed by streptococcal antigens in the tonsils may react with homologous antigens in the skin( 16 – 18), and there are several reports of partial or complete remission of psoriasis after tonsillectomy( reviewed by( 19 – 21)). We reported previously on a randomized controlled trial examining the clinical efficacy and immunological impact of tonsillectomy on plaque psoriasis. The results indicated that tonsillectomy can lead to a significant clinical improvement in plaque psoriasis, with a significant reduction in the frequency of skin-homing T cells that recognize homologous streptococcal M-protein and skin keratins( 22). We report here findings related to patient HRQoL and psoriasis-induced stress and their association with clinical improvement after tonsillectomy.
METHODS Patients
Patient eligibility criteria have been detailed previously( 22). Briefly, eligible patients were: ≥ 18 years of age; had moderateto-severe chronic plaque psoriasis diagnosed by a dermatologist; had a history of sore throat-associated psoriasis exacerbation; and were willing to undergo tonsillectomy. Exclusion criteria were: underlying medical conditions, such as heart and lung diseases and bleeding disorders; alcohol or drug abuse; pregnancy; and previous tonsillectomy. Before study initiation patients were required to discontinue all psoriasis treatment except moisturizers within the previous 4 weeks.
Fifty-four patients were screened for the study, the majority of whom were referred by a dermatologist( 44 %) or responded to an advertisement( 46 %). A few patients had heard about the study by other means( 6 %) or were referred by an otolaryngologist( 4 %). Written informed consent was obtained from each patient before initiation of study participation. A total of 29 patients met the inclusion criteria.
Study design
This was a single-centre, 24-month, parallel, assessor-blind, randomized controlled trial. Data were collected within the de- doi: 10.2340 / 00015555-2562 Acta Derm Venereol 2017; 97: 340 – 345
This is an open access article under the CC BY-NC license. www. medicaljournals. se / acta Journal Compilation © 2017 Acta Dermato-Venereologica.