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Celiac Disease Association Psoriasis patients at higher risk for celiac disease Aug 1, 2003 By: Barbara J. Rutledge, Ph.D. Dermatology Times Orlando, Fla. - Patients with psoriasis are at higher risk for celiac disease than the general population, according to Veronica Ojetti, M.D., a gastroenterologist at Gemelli Hospital in Rome. Celiac disease is an autoimmune disorder characterized by damage to the villi that line the small intestine, resulting in loss of the body's ability to absorb nutrients through the villi. Individuals with celiac disease are unable to tolerate gliadin, a glycoprotein subfraction of gluten found in wheat and many other grains. "In celiac individuals, gluten activates the immune system, damaging the intestinal mucosa," Dr. Ojetti said. "Diagnosis of celiac disease is based on specific serologic blood tests, on endoscopy, particularly upper gastrointestinal endoscopy with the evaluation of the second part of the duodenum, and on multiple biopsies." Specific serologic markers of celiac disease are IgA and IgG anti-gliadin antibodies (AGA), IgA anti-endomysium antibodies (EMA), and IgA anti-transglutaminase antibodies (TgA). Dr. Ojetti and colleagues presented findings of a study examining the prevalence of celiac disease in 92 patients with psoriasis referred to the department of dermatology and venereology, Catholic University in Rome, compared with 90 age- and gender-matched control patients without psoriasis. All subjects were screened for the presence of serum antibodies associated with celiac disease. Subjects who were positive for at least one serologic marker underwent intestinal biopsies. Biopsy specimens were evaluated by a pathologist unaware of the serology results for signs of severe to total villous atrophy, crypt hyperplasia, and lymphocyte infiltration. Seven subjects with psoriasis (7.61 percent) were positive for anti-AGA antibodies, compared to two subjects in the control group (2.22 percent). Anti-EMA antibodies and anti-TgA antibodies were detected in four (4.35 percent) and two (2.17 percent) subjects with psoriasis, respectively. No subjects without psoriasis were positive for either anti-EMA or anti-TgA antibodies. All psoriatic patients tested had an increased number of lymphocytes in the duodenal epithelium, compared to normal tissue samples. Villous atrophy was detected in biopsy specimens from four subjects with psoriasis (4.35 percent), confirming celiac disease, and in none of the control subjects (p<0.001). The four psoriatic patients with confirmed celiac disease, two men and two women, had not been aware of their celiac disease before the biopsy results, according to Dr. Ojetti. "They did not have specific symptoms but complained only about non-specific digestive symptoms such as dyspepsia." A relationship between psoriasis and celiac disease is not unexpected. "Previous studies showed that the same immune cells and the same inflammatory molecules are involved in the pathogenesis of both diseases. The activation of these cells and molecules may lead, in some individuals, both to psoriasis and celiac disease," Dr. Ojetti said. Alternatively, abnormal gut permeability in celiac patients could lead to absorption of allergens that may trigger skin lesions. Symptoms of classic celiac disease include chronic diarrhea, steatorrhea, abdominal pain and distension, weight loss, anorexia, and anemia. Children with celiac disease tend to have more severe symptoms than adults, often leading to growth retardation and significant weight loss with malnutrition and osteoporosis. Diagnosis of celiac disease in adults can be more difficult, as digestive symptoms may be mild or absent. "In adults, sometimes there are only extra-digestive symptoms, such as cutaneous manifestations, that may provide an early clue to diagnosis," Dr. Ojetti said. Gluten FreeTreatment for patients with celiac disease consists of lifelong adherence to a gluten-free diet. When patients with celiac disease maintain a gluten-free diet, gut permeability is reduced and villous regrowth occurs. Furthermore, by eliminating the continuous stimulation of the immune system, a gluten-free diet might decrease the likelihood of psoriatic disease in predisposed individuals, according to Dr. Ojetti. Serologic evaluation for celiac disease should be considered for patients with psoriasis, with endoscopic follow-up in patients who are positive for one or more serologic markers. "The early diagnosis of celiac disease and a gluten-free diet may lead to a better management of these patients," Dr. Ojetti said. "However, it is important to note that these are only preliminary results, and we need other studies to confirm an association between psoriasis and celiac disease." Dr. Ojetti has no conflict of interest to report.
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