ORIGINAL ARTICLE Year : 2022  |  Volume : 42  |  Issue : 2  |  Page : 127-132

An observational study of Helicobacter pylori infection in patients with chronic plaque psoriasis

Mohammed Anas MD 1, Tarlok C Arora1, Rajni Gaind2, Monika Matlani2
1 Departments of Dermatology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
2 Departments of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission31-May-2021Date of Decision17-Jun-2021Date of Acceptance24-Jun-2021Date of Web Publication19-May-2022

Correspondence Address:
Mohammed Anas
Dermatology and Veneriology; Puthen Peedikakkal House, Kuzhalumpadi (Stop), Karalmanna (P.O.) Cherpulassery, Palakkad, Kerala 679506
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ejdv.ejdv_22_21

Objectives To determine the prevalence of Helicobacter pylori infection in patients with chronic plaque psoriasis and to determine the association of H. pylori infection with the severity of chronic plaque psoriasis.
Patients and methods The prospective case–control pilot study was conducted in the outpatient Department of Dermatology from November 2017 to April 2019. A total of 50 patients with chronic plaque psoriasis and 50 consenting healthy controls were included in the study. A cutaneous examination of the morphology, site, and extent of the lesions was done. Psoriasis area and severity index scores were calculated for all patients. H. pylori stool antigen test was performed for all cases and controls. The data were entered into MS Excel spreadsheet, and analysis was done using the Statistical Package for the Social Sciences (SPSS), version 21.0.
Results The mean age of patients with psoriasis was 37.24±11.7 years, with 64% males and 36% females. H. pylori was positive in 24/50 patients with psoriasis. Compared with controls, patients with psoriasis had significantly higher H. pylori positivity rate (48 vs. 26%, P=0.023). Compared with the patients with H. pylori negative status (n=26), H. pylori positivity (n=24) showed significant association with site and disease progression (P=0.016) but not with disease duration (P=0.907). The median psoriasis area and severity index score in H. pylori-positive patients was significantly higher than that in patients with negative H. pylori (13.55 vs. 4.65, P=0.002).
Conclusion The small number of patients studied showed that H. pylori infection is associated with psoriasis, with the progression and the severity of psoriasis, bearing a direct association with increased positivity for H. pylori.

Keywords: duration, psoriasis area and severity index score, psoriasis, severity

How to cite this article:
Anas M, Arora TC, Gaind R, Matlani M. An observational study of Helicobacter pylori infection in patients with chronic plaque psoriasis. Egypt J Dermatol Venerol 2022;42:127-32
How to cite this URL:
Anas M, Arora TC, Gaind R, Matlani M. An observational study of Helicobacter pylori infection in patients with chronic plaque psoriasis. Egypt J Dermatol Venerol [serial online] 2022 [cited 2022 May 22];42:127-32. Available from: http://www.ejdv.eg.net/text.asp?2022/42/2/127/345265   Introduction 

Psoriasis is one of the most typical chronic inflammatory diseases encountered in dermatological practice. Worldwide, it has a 2–3% prevalence [1],[2]. It is characterized by sharply delineated red scaly plaques [3] with the predominant involvement of extensors of limbs and scalp [4]. Owing to its widespread nature, it affects the quality of life of the patients and can lead to depression in 67% of cases and anxiety in 45% of cases [5].

Psoriasis is an autoimmune disease with an unknown etiology [6]. A dyad of genetics and environmental factors cause immunological dysfunctions and subsequent inflammations [2],[4]. It also shows a significant association with comorbidities such as hypertension, obesity, type 2 diabetes mellitus, and cardiovascular diseases [7],[8],[9]. The environmental factors include trauma, intake of drugs, smoking, alcohol, sunlight, and infections [3].

From the infection point of view, several micro-organisms have been identified as an etiological agent [10]. The role of Helicobacter pylori as a triggering factor for psoriasis has been recently proposed [11],[12].

H. pylori is a gram-negative bacterium inhabiting the gastric mucosa with a pathological role in gastritis and peptic ulceration [13],[14]. It shows a high prevalence in developing countries from early childhood (80–100%) and a slightly lower prevalence in developed countries from adolescence (30–70%) [14],[15].

The association of H. pylori with dermatological conditions dates long back since it showed definite evidence for chronic urticaria and immune thrombocytopenic purpura; limited evidence for cutaneous pruritus, Behçet’s disease, nodular prurigo, and lichen planus; and only very less evidence (single case reports or few case reports) for rosacea, aphthous stomatitis, atopic dermatitis, alopecia areata, Schonlein-Henoch purpura and Sjögren syndrome, but these are only descriptive [16].

The association of H. pylori with psoriasis shows conflicting results. Literature review shows that some studies favor this hypothesis [7],[17],[18],[19], whereas others refute it [3],[20],[21].

The present study was conducted with an aim (a) to determine the prevalence of H. pylori infection in patients with chronic plaque psoriasis and (b) to determine the association of H. pylori infection with the severity of chronic plaque psoriasis.

  Patients and methods 

This prospective case–control study was conducted in the outpatient Department of Dermatology and STD and the Department of Microbiology in a Tertiary Care Hospital of New Delhi from November 2017 to April 2019. Institutional ethical clearance was obtained before the start of the study. The study group comprised 50 patients with chronic plaque psoriasis diagnosed clinically and histopathologically and an equal number of age and sex-matched consenting healthy controls. Any patient with a history of peptic ulcer disease or who were on NSAIDS, H2 blockers, oral corticosteroids, and antibiotics for H. pylori eradication were excluded from the study.

The sample size was calculated based on the study by Mesquita et al. [7], who observed that of 111 patients with psoriasis tested serologically, 80 (72.07%) were seropositive as compared with seven positive volunteers (33.33%; P=0.002). Taking these values as a reference, the minimum required sample size with 90% power of the study and 5% level of significance is 30 patients in each study group. To reduce the margin of error, the total sample size taken was 100 (50 patients per group).

After obtaining written informed consent, demographic details and history regarding the duration and progression of the psoriasis were taken. A cutaneous examination of the five sites were done. Psoriasis area and severity index (PASI) scores were calculated for all patients and categorized into less than 5 (mild), 5–10 (moderate), and more than 10 (severe) [7].

For performing H. pylori stool antigen test, patients and controls were informed to collect stool samples (1–2 ml or 1–2 g) in a clean, dry specimen collection container. The stool samples were transported to the Department of Microbiology immediately and processed on the same day as they were received. The test was performed by a rapid immunochromatographic assay using a commercially available kit (H

. pylori Antigen Test Device, AdvaCare (CE, ISO and USFDA approved) Pharma, USA – HYPAG030). The tests were performed as per the manufacturer’s instructions. The results were read as positive and negative.

Statistical analysis

Categorical variables were presented as number and percentage, and continuous variables were presented as mean±SD and median. Normality of data was tested by Kolmogorov–Smirnov test. If the normality was rejected, then a nonparametric test was used.

Statistical tests were applied as follows:

Quantitative variables were associated using Mann–Whitney test (as the data sets were not normally distributed) between the two groups.Qualitative variables were associated using the χ2 test.

A P value of less than 0.05 was considered statistically significant.

The data were entered into MS Excel spreadsheet, and analysis was done using the Statistical Package for the Social Sciences (SPSS) (IBM manufacturer, Chicago, USA), version 21.0.

  Results 

The mean age of the patients with psoriasis was 37.24±11.7 years, with 64% males and 36% females. The mean BMI was 22.99±3.56 kg/m2. The mean±SD duration of the disease was 3.98±3.82 years, with a range of 0.25–20 years ([Table 1]).

Table 1 Distribution of demographic characteristics of study participants

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H. pylori was positive in 24/50 patients with psoriasis. Compared with the age-matched and sex-matched healthy controls, patients with psoriasis had a significantly higher H. pylori positivity rate (48 vs. 26%, P=0.023) ([Table 2]).

Table 2 Comparison of Helicobacter pylori stool Ag test between cases and controls

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Among the 50 patients with psoriasis, scalp involvement was seen in 32 (64%), palms/soles involvement was seen in 28 (56%), and nail involvement was seen in 21 (42%). Compared with the patients with H. pylori-negative status (n=24), H. pylori positivity showed significant association with scalp involvement (79.17 vs. 50%, P=0.032) but statistically nonsignificant association with the involvement of palms/soles (62.5 vs. 50%, P=0.374) and nails (41.67 vs. 42.31%, P=0.963).

The disease was found to be progressive in 34 (68%) cases and nonprogressive in 16 (32%) cases. H. pylori positivity showed a significant association with disease progression, being significantly more positive in those who had gradual (54.17 vs. 34.62%) or rapid progression (33.33 vs. 15.38%) than those who had nonprogressive disease (12.5 vs. 50%), with a P value of 0.016. The median duration of the disease showed no significant association with H. pylori positivity (P=0.907).

The severity of psoriasis assessed by PASI score also showed a significant association with H. pylori positivity (P=0.001). The median PASI score in H. pylori-positive patients was 13.55, which was significantly higher than 4.65 in patients with negative H. pylori stool test result. On categorizing PASI scores into less than 5, 5–10, and more than 10), it was found that H. pylori positivity significantly increased in patients with PASI score more than 10 as compared with those with PASI score less than 10 (P=0.002).

The association of various psoriasis-related factors with H. pylori positivity has been shown in [Table 3].

Table 3 Association of parameters with Helicobacter pylori stool antigen test

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  Discussion 

We found that patients with psoriasis had a significantly higher H. pylori positivity rate than that in controls (48 vs. 26%, P=0.023).

In a study by Mesquita et al. [7], where 126 patients were compared with 21 healthy controls, serology was positive in 80 (72.07%) patients with the disease and seven (33.33%) volunteers in the control group, which was statistically significant (P=0.002). The higher prevalence of infection (compared to ours) could be because of different psoriasis population, as they had more than 50% severe type, which is strongly related to infection. Qayoom and Ahmad [17] detected the presence of anti-H. pylori antibodies in 40% of the patients with psoriasis and 10% in the control group. The low prevalence in the control population (compared with ours) could be owing to the specific exclusion of healthy participants without gastrointestinal complaints. Moreover, Halasz [12] showed that the prevalence of immunoglobulin G (IgG) against H. pylori was seen in 54% of the psoriatic patients, but this study had no control group for comparison.

In contrast to the present study, the study by Onsun et al. [18], in which 300 patients with plaque psoriasis and 150 healthy controls were evaluated by stool antigen test, the prevalence of H. pylori infection was comparable in both groups, with 61.3% in patients with psoriasis and 59.3% in the control group (P>0.05). A study by Azizzadeh et al. [3] also reported no significant relationship between anti-H. pylori serum IgG levels and psoriasis. In the study by Fabrizi et al. [20] in Italy, which was done on psoriatic children and adolescents, it was seen that 10% of people with psoriasis and 17% of the control group had H. pylori infection with no significant difference between them.

The differences in the results (compared to ours) may be accounted for by the method of detecting H. pylori infection, which affects the reported prevalence of H. pylori infection in the patient population, especially for serological tests, as the cutoff depends on the prevalence of H. pylori infection in the general population of their respective areas [22].

The sensitivity and specificity of serological tests have been reported to be 85 and 79%, respectively. In contrast, the urea breath test has a sensitivity of 75–100% and specificity of 77–100%, and the stool antigen test has a sensitivity of 67–100% and specificity of 61–100% [23]. Therefore, the serological test is not the recommended diagnostic test as compared with the urea breath test and fecal antigen test to diagnose H. pylori active infection because the titer levels can remain elevated for long after treatment, and the seropositivity rate relies on the local H. pylori prevalence rate, bacterial strains, and positive cutoff of the detection kits [23]. Each of the three methods has its advantages and disadvantages, and different methods might affect the results of the study. It is expected that there can be uniform and accurate detection methods to provide more evidence in the future.

In the latest meta-analysis by Yu et al. [24], which included studies on serological test, breath test, and stool antigen test, the results showed that the overall incidence of H. pylori in patients with psoriasis was 10.7%, being higher than that of the control group (pooled RR=1.70, P<0.01), which indicated that psoriasis might be associated with H. pylori infection, as was seen in the index study.

The potential pathogenesis for the link between psoriasis and H. pylori is hypothesized to be (a) chronic inflammation caused by H. pylori that might trigger a release of cytokines through immune cells [25]; (b) heat–shock protein, leading to increased production of interleukin 6 (IL-6) [26],[27]; and (c) cytotoxin-associated gene A-mediated secretion of IL-8, which plays an important role in psoriasis [28],[29].

In the present study, among the 50 patients with psoriasis, compared with the patients with H. pylori-negative status (n=24), H. pylori-positive patients showed a significant association with scalp involvement (79.17 vs. 50%, P=0.032) but statistically nonsignificant association with the involvement of palms/soles (62.5 vs. 50%, P=0.374) and nails (41.67 vs. 42.31%, P=0.963). Previously, Mesquita et al. [7] showed a significant association of severe type of psoriasis with scalp involvement and high seropositivity. However, there is a paucity of data on this participant, and further studies, including psoriatic arthritis, will be able to throw more light on this participant.

We also found that H. pylori positivity showed a significant association with disease progression (P=0.016) but not with the duration of the disease (P=0.907). In contrast, Azizzadeh et al. [3] found a substantial relationship between the duration of psoriasis and the serum IgG level against H. pylori. It was hypothesized that this might be owing to topical or systemic immunosuppressive drugs over time that gave psoriatic patients greater susceptibility to H. pylori infection.

The difference in the results (compared with ours) can be explained by the fact that the mean±SD duration of psoriasis in their study was 9.8 (8.3) years. In contrast, in our study, it was 3.98 years, which was comparably lower, and cases on immunosuppressants were excluded from our study, thus removing susceptibility to infection.In our study, the severity of psoriasis assessed by PASI score also showed a significant association with H. pylori positivity (P=0.001). The median PASI score in H. pylori-positive patients was 13.55, which was significantly higher than 4.65 in patients with negative H. pylori stool test result. Similarly, in a study by Mesquito et al. [7], seropositivity for H. pylori occurred in 49 (79.03%) patients with severe psoriasis, in 25 (69.45%) patients with moderate psoriasis, in six (46.15%) patients with mild psoriasis and seven volunteers (33.33%) of the control group, with a statistically significant difference between the groups when severity was related to serology (P=0.045). A similar association of PASI score with H. pylori positivity was seen in other studies as well. Similarly, in Campanati et al. [30], H. pylori-positive patients showed a significantly higher PASI score compared with H. pylori-negative patients (17.9 3.16 vs. 13.7 4.20, respectively). It seems that H. pylori infection aggravates the clinical expression of psoriasis. However, it could also be postulated that patients with psoriasis with higher PASI often need systemic therapy that might increase the risk of H. pylori infections. In a meta-analysis by Yu et al. [24], the infection rate of H. pylori was higher in patients with moderate and severe psoriasis than the patients with mild psoriasis, indicating that H. pylori infection and the severity of psoriasis required more attention in clinical treatment.

In contrast, in the study by Azizzadeh et al. [3], no significant differences were found between psoriasis severity and IgG levels against H. pylori (P=0.302) owing to the lack of homogeneity between the two groups in terms of age (P=0.001, confidence interval=0.41–1.42).

Today, the existing controversy about the relationship between psoriasis and H. pylori infection is perhaps owing to the difference in sample sizes, the severity of disease, and the difference in the level of public health. So, it appears that the relationship between psoriasis and H. pylori infection needs standardized testing and association models to clarify this issue.

Limitations of the study

The study had certain limitations. First, the patients with arthritis and other comorbidities were excluded. Second, serological testing for H. pylori was not done in the study. Lastly, the improvement in psoriasis after H. pylori eradication was not assessed.

  Conclusion 

The small number of patients studied showed that H. pylori infection is associated with psoriasis, with the progression and the severity of psoriasis, bearing a direct association with increased positivity for H. pylori.

The duration of the disease needs further assessment, as the increasing duration may increase the odds ratio of occurrence of immunological disturbances related to H. pylori.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

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  [Table 1], [Table 2], [Table 3]