340
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 .