Is facial involvement a sign of severe psoriasis?

ARTICLE

Auteur(s) : Filiz Canpolat, Bengü Çevirgen Cemil, Fatma Eskioğlu, Havva Kaya Akis

Ministry of Health Dışkapı Yıldırım Beyazıt Training Hospital, Department of Dermatology

accepté le 23 Octobre 2007

Psoriasis is a relapsing scaly and hyperproliferative disorder that affects 1-3% of the world’s population. Although the definite reason is still unknown, some authors have suggested that the continuing sub clinical streptococcal infection might be responsible for refractory chronic plaque psoriasis [1]. As we know, psoriasis characteristically involves the trunk and extensor surfaces of the extremities in a symmetrical fashion [2]. Facial involvement in psoriasis receives little attention in standard descriptions of the disease. Clinicians have long noted that the face is rarely involved in psoriasis [3]. Although some authors have even commented on the rarity of facial involvement, others have reported that facial involvement with psoriasis is much more common than generally appreciated [4, 5]. It is well known that psoriasis may cause significant psycho-social problems and stress. Optimism, belief-in-oneself and confrontational coping strategies have most frequently been used to evaluate coping and quality of life in psoriasis patients [6]. Facial involvement of the disease leads to more emotional stress related to poorer quality of life. Some authors have suggested that facial involvement may be a sign of severe psoriasis [3, 7, 8]. Is facial involvement really a sign of severe psoriasis? The purpose of this study was to define the prevalence and characteristics of facial involvement, and to compare the severity of psoriasis between patients with and without facial involvement.

Materials and methods

Statistical analysis

Results

As to the age of onset, psoriasis occurred earlier in facial psoriasis than in patients without facial involvement (p < 0.05). The patients with facial psoriasis have a positive family history (p < 0.05). The areas of the face most often affected were upper forehead (52.5%), malar area (49.2%), lower forehead (37.2%), and periauricular area (35.6%).

When all patients with facial involvement were classified by age at onset of facial occurrence into 5-year groups, most patients were in the 20 to 25-year-old group, and the mean age of onset of psoriasis was 21.72 ± 8.33 years. When all the patients were classified by the age at onset of psoriasis on other areas into 5-year groups, most patients were in the 26 to 30-year-old group, and the mean age of onset of psoriasis was 26.89 ± 12.9 years.

Table 2 delineates the mean PASI score on the whole body, along with several other clinical manifestations in the two groups. The PASI score on the whole body was higher in the group with facial involvement (p < 0.05). The Koebner response was more frequently associated with the group with facial psoriasis (p < 0.05). The nail and joint involvement and pruritus did not appear to influence the presence of facial psoriasis (p > 0.05).

Table 3 shows the effect of external factors and the therapeutic history. The patients with facial psoriasis said sunlight had improved their psoriasis (p < 0.05) and described a worsening of psoriasis with trauma, infection and seasonal change, especially in winter (p < 0.05). The group with facial psoriasis had multiple previous systemic therapies and phototherapy (p < 0.05). 37.3% of patients with facial psoriasis and 24.6% of patients without facial involvement had been hospitalized at least one time (p < 0.05).
Table 1 Demographic data of the evaluated patients

Discussion

The importance of facial involvement is that it may be a marker of severe psoriasis [3, 7, 8]. Some investigators have suggested that early age of onset is associated with a severe course, the extent of lesions, recalcitrance to treatment, positive family history or frequency of relapse [3, 7, 8, 11]. In the report of Cardoso et al., it was shown that there was positive association of the HLA-DRB1*0102/DQB1*05 and HLA-DRB1*0701/DQB1*03 haplotypes and psoriasis vulgaris patients with early onset of the disease [12]. In concordance with these findings, in our series the disease tends to appear earlier in the group with facial involvement. A high incidence of facial involvement has also been found in children [13]. This may also be taken as an indication that it is a marker for patients with early age-at-onset. As has been previously pointed out [7], our series confirms that family occurrence seems to be more frequent in patients with facial psoriasis. In addition to the demographic evidence, a more extensive body surface involvement and higher PASI scores were observed in patients with facial psoriasis in comparison with those without facial psoriasis. Results from a recently published study by Van de Kerkhof et al. [14] suggest that a standardized protocol for the evaluation of psoriasis severity based on established severity scores (PASI, % Body Surface Area Score) appears to be unrealistic in day-to-day clinical practice. So, in clinical practice, a host of factors must be evaluated alongside possible metric measures. Disease severity is dependent not only on area involvement and sign scores, but also on the location of the disease, response to previous treatment, patient history, and the patient’s perception of his disease and quality of life. [14]. In addition, Feng et al. [15] found that the expression of retinoid x receptor alpha (RXR-α) which is a retinoic acid receptor, was lower in the progressive stage of the psoriasis than in the stable stage. So, RXR-α can also be used as severity index of psoriasis. The number of patients necessitating hospital admission was higher in the group with facial psoriasis. Although nail involvement and pruritus are suggested to be associated with an aggressive clinical course and facial involvement [7, 11], we found no significant differences between our two groups.

With regards to external factors, seasonal exacerbations and Koebner response are considered to be markers of severe psoriasis [5, 7, 16, 17]. In concordance with this data, in our research more patients in facial psoriasis group had Koebner responses and seasonal variation. Our patients with facial involvement described a significant improvement of their psoriasis following sun exposure. We suggested that ambient ultraviolet radiation may provide maintenance phototherapy. Although psoriasis does usually improve with sunlight, some patients may be adversely affected. Harrison and Walker suggested that sunlight had more of an adverse than beneficial effect on the facial psoriasis of hospitalized female patients [4].

In conclusion, facial involvement of psoriasis is much more common than generally appreciated. Due to its significance as a marker of severe disease, extra care must be taken during treatment to ensure clearance from this site.

Acknowledgments

References

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