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
A total of 120 consecutive patients (53 females, 67 males) with
psoriasis were included in the study. They were categorized into
patients with and without facial psoriasis. The age of onset,
family history, nail involvement, joint involvement, disease
duration, associated skin or systemic disease, history of
phototherapy or systemic therapy, admission history, extent of
involvement, the effect of external factors, different therapies
prescribed for psoriasis throughout the patient’s entire lifetime,
hospitalization for psoriasis and the involved facial areas were
recorded. The effects of sunlight and occupation on facial
psoriasis were also recorded. To learn about the effects of season,
stress, infection and trauma, the following questions were asked:
‘Does your psoriasis get better or worse? in which season or at
times of sun exposure, psychological stress, infection or trauma?’
The severity of psoriasis on the whole body evaluated according to
the Psoriasis Area and Severity Index (PASI). Patients who had a
PASI score lower than 5 were excluded from the study.
Statistical analysis
Statistical data were analyzed using SPSS for WINDOWS®
VER 12 (SPSS Inc., Chicago, IL, USA) on a personal computer, where
p < 0.05 was accepted as statistically significant. Statistical
analysis was performed using comparative t test and the chi-square
test.
Results
Table 1 shows the demographic data of
both groups (with or without facial involvement) and table 2 summarizes the clinical details of the
patients. Facial involvement was found to be present in 49.2% of
the patients and was equally common in both males and females, but
was unrelated to the type of psoriasis lesions.
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
|
|
Facial involvement
|
|
|
No
|
50.8% (n = 61)
|
49.2% (n = 59)
|
n = 120
|
|
Age (years ± SD)*
|
38.30 ± 19.062
|
36.42 ± 14.983
|
37.38 ± 17.165
|
|
Age at onset (years ± SD)*
|
26.67 ± 16.320
|
22.80 ± 13.426
|
24.77 ± 15.238
|
|
Disease duration (years ± SD)*
|
11.62 ± 11.323
|
13.63 ± 12.060
|
12.61 ± 11.743
|
|
Female/Male
|
25/36
|
28/31
|
53/67
|
|
Positive family history*
|
37.93%
|
62.07%
|
24.17%
|
Table 2 Clinical features of patients
|
No facial involvement
|
Facial involvement
|
|
Whole body PASI score*
|
6.85 ± 5.885
|
15.59 ± 9.029
|
|
Nail involvement
|
50.0%
|
50.0%
|
|
Psoriatic arthritis
|
41.7%
|
58.3%
|
|
Pruritus
|
50.5%
|
49.5%
|
|
Koebner response*
|
29.8%
|
70.2%
|
Table 3 The effect of external factors and the
therapeutic history
|
No facial involvement
|
Facial involvement
|
|
Worsening
|
|
|
|
Seasonal*
|
42.7%
|
57.3%
|
|
Winter*
|
34.0%
|
66.0%
|
|
Stress
|
46.7%
|
53.3%
|
|
Infection*
|
38.1%
|
61.9%
|
|
Trauma*
|
31.9%
|
68.1%
|
|
Others
|
50.0%
|
50.0%
|
|
Therapeutic history
|
|
|
|
Phototherapy*
|
30.3%
|
69.7%
|
|
Systemic*
|
38.2%
|
61.8%
|
|
Topical
|
50.0%
|
50.0%
|
|
Hospitalization*
|
24.6%
|
37.3%
|
Discussion
Facial involvement may cause considerable concern to the patient.
Although Hellegren and Farber & Nall found low incidences of
facial involvement in the large series of patients, other
investigators have reported that a larger portion of patients with
psoriasis had facial involvement [9, 10]. Harrison & Walker
found that 57% of 100 patients hospitalized with psoriasis had
facial lesions [4]. Park et al. showed that 67.7% of patients had
facial involvement [7]. In our research, we found that 49.2% of 120
outpatients with psoriasis had facial involvement.
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
Financial support: none, conflict of interest: none.
References
1 Saxena VN, Dogra J. Long-term use o penicillin for the
treatment of chronic plaque psoriasis. Eur J Dermatol 2005; 15(5):
359-62.
2 Wang G, Li C, Gao T, Lıu Y. Clinical
analysis of 48 cases of inverse psoriasis: a hospital-based study.
Eur J Dermatol 2005; 15(3): 176-8.
3 Fullerton SH, Orenberg EK. Facial involvement as a
marker of severe psoriasis. Cutis 1987; 40(4): 309-10.
4 Harrison PV, Walker GB. Facial psoriasis. Clin Exp
Dermatol 1985; 10: 41-4.
5 Bernard JD. Facial sparing in psoriasis. Int J Dermatol
1983; 5: 291.
6 Wahl AK, Mork C, Hanestad BR, Helland S.
Coping with exacerbation in psoriasis and eczema prior to admission
in a dermatological ward. Eur J Dermatol 2006; 16(3): 271-5.
7 Park JY, Rim JH, Choe YB, Youn JI. Facial
psoriasis: Comparison of patients with and without facial
involvement. J Am Acad Dermatol 2004; 50(4): 582-4.
8 Bernard JD. Facial involvement is a sign of severe
psoriasis. In: Farber EM, Nall ML, Morhenn V, eds.
Psoriasis: proceedings of the fourth international symposium. New
York: Elsevier, 1987: 405-6.
9 Farber EM, Nall ML. The natural history of psoriasis
in 5600 patients. Dermatologica 1974; 1481: 1-18.
10 Hellegren L. Psoriasis. A statistical, clinical and
laboratory investigation of 255 psoriatics and matched healthy
controls. Acta Derm Venereol 1964; 44: 191-207.
11 Ferrandiz C, Pujol RM, Patos VG,
Bordas X, Smandia JO. Psoriasis of early and late onset:
A clinical and epidemiologic study from Spain. J Am Acad Dermatol
2002; 46: 863-73.
12 Cardoso CB, Uthida-Tanaka AM, Magalhaes RF,
Magna LA, Helena M, Kramer S. Association between
psoriasis vulgaris and MHC-DRB, -DQB genes as a contribution to
disease diagnosis. Eur J Dermatol 2005; 15(3): 159-63.
13 Nyfor SA. Psoriasis in children. Characteristics,
prognosis and therapy. A review. Acta Derm Venereol 1981;
95(suppl): 47-53.
14 Van De Kerkhof PCM, Kragballe K, Austad J,
et al. Psoriasis: severity assessment in clinical practice.
Conclusions from workshop discussions and a prospective multicentre
survey of psoriasis severity. Eur J Dermatol 2006; 16(2):
167-71.
15 Feng S, Lin L, Wu Q, Zhou W, Shao C.
Study on the expression of RXRα in patients with psoriasis
vulgaris. Eur J Dermatol 2006; 16(1): 33-8.
16 Melski JE, Bernard JD, Stem RS. The Koebner
(isomorphic) response in psoriasis: association with early age of
onset and multipl previous therapies. Arch Dermatol 1983; 12:
655-9.
17 Baker AJ, Wilkinson DS. Psoriasis. In:
Rook AJ, Wilkinson DS, Ebling FJ, eds. Textbook of
dermatology. Oxford: Blackwell Scientific Publications, 1979:
1315.
|
Version imprimable
Version PDF