January 21, 2019

An endocrinology consultation should be considered in patients with psoriatic disease who present with thyroid symptoms.

Patients with psoriatic disease have an increased risk for thyroid disease, including hyperthyroidism, hypothyroidism, thyroiditis, and certain autoimmune thyroid conditions such as Grave’s disease and Hashimoto’s thyroiditis, according to study results published in the Journal of the American Academy of Dermatology.

The investigators identified a total of 13,266 patients with psoriatic arthritis (the psoriatic arthritis group), 149,576 patients with psoriasis alone (the psoriasis group), and 162,842 controls who did not have psoriasis (the control group) from data collected between January 1, 2000 and December 31, 2012. Mean patient age in the psoriasis, psoriatic arthritis, and control arms was 45.11±20.09, 43.17±17.72, and 44.95±19.91, respectively (P <.0001); women comprised 46.21%, 37.83%, and 40.65% of the groups, respectively (P <.0001). A significantly higher percentage of the patients in the psoriasis and psoriatic arthritis arms had hypertension, type 2 diabetes, and hyperlipidemia compared with patients in the control group (P <.0001).

Compared with the control group, the psoriatic arthritis and psoriasis groups had an elevated risk for incident hyperthyroidism (adjusted hazard ratio [aHR] 1.32; 95% CI, 1.07-1.65; P <.05 and aHR 1.22; 95% CI, 1.11-1.33; P <.0001, respectively) and Grave’s disease (aHR 1.38; 95% CI, 1.07-1.79; P <.05 and aHR 1.26; 95% CI, 1.131.41; P <.0001, respectively).

Moreover, both the psoriatic arthritis and psoriasis groups also had an increased risk for incident hypothyroidism (aHR 1.74; 95% CI, 1.342.27; P <.0001 and aHR 1.38; 95% CI, 1.231.56; P <.0001 respectively) and Hashimoto’s thyroiditis (aHR 2.09; 95% CI, 1.343.24; P <.01 and aHR 1.47; 95% CI, 1.181.82; P <.01, respectively) compared with the control arm.

A major study limitation was the lack of available data on psoriasis severity. In addition, in order to avoid overestimating the risk for incident thyroid diseases, patients with psoriasis diagnosed prior to 2000 were excluded from this study.

The investigators concluded that the findings demonstrate that an endocrinology consultation should be considered in patients with psoriatic disease who present with thyroid symptoms, particularly patients with psoriatic arthritis.

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Reference

Wang S-H, Wang J, Lin Y-S, Tung T-H, Chi C-C. Increased risk of incident thyroid diseases in people with psoriatic disease: a cohort study [published online December 5, 2018]. J Am Acad Dermatol. doi:10.1016/j.jaad.2018.11.049

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January 18, 2019

Oily skin was a risk factor for severe acneiform eruption.

Instrumental evaluation has demonstrated rapid inflammatory changes of the skin associated with epidermal growth factor receptor (EGFR) inhibitors and revealed that the presence of oily skin is a risk factor for severe acneiform eruption (AfE), according to the results of a multicenter, observational study conducted at the National Cancer Center Hospital, Tohoku University Hospital, and Mie University Hospital, all located in Japan. Findings from the analysis were published in The Journal of Dermatology.

Recognizing that EGFR tyrosine kinase inhibitors (TKIs) and anti-EGFR antibodies are often linked with the development of various dermatologic adverse events, and that the precise skin changes and risk factors for severe AfE remain unclear, the investigators sought to elucidate useful parameters for early sensitive detection of skin changes by EGFR inhibitors.

Skin surface hydration, transepidermal water loss, skin surface lipid levels, and erythema/melanin index were all measured serially for 2 weeks among 19 people treated with the EGFR-TKI afatinib/erlotinib and for 8 weeks among 20 people treated with the anti-EGFR antibody cetuximab.

Transepidermal water loss levels of the cheek were already elevated 7 days following initiation of afatinib/erlotinib therapy in patients who had AfE grade 2 or more compared with prior to therapy and compared with patients with AfE of grade 1 or less. Further, in cetuximab-treated patients with AfE, skin surface hydration on the cheek in those with grade 2 or more AfE decreased significantly compared with hydration in those with grade 1 or less AfE at weeks 2 and 6 (P <.05). Baseline skin surface lipid levels and erythema index on the cheek of patients with grade 2 or more AfE were significantly higher than in those with grade 1 or less AfE (P <.05).

The investigators concluded that the major limitation of this study was the small sample size, particularly when performing logistic regression analysis.

The results of the current study revealed that AfEs resulting from EGFRIs develop subclinically as early as the first week of treatment in patients receiving EGFR-TKIs. In contrast, in patients who are treated with an anti-EGFR antibody, AfEs caused by EGFR inhibitors are observed during the second week of therapy. High skin surface lipid levels prior to EGFR inhibitor therapy and oily skin are both risk factors for severe AfE.

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Reference

Kikuchi K, Nozawa K, Yamazaki N, et al. Instrumental evaluation sensitively detects subclinical skin changes by the epidermal growth factor receptor inhibitors and risk factors for severe acneiform eruption. J Dermatol. 2019;46(1):18-25.

January 18, 2019

Passwords should not be visible to the public

The privacy of patient data is protected by the Health Insurance Portability and Accountability Act (HIPAA) and the 2009 Health Information Technology for Economic and Clinical Health Act.¹ However, the years between 2010 and 2013 saw data breaches involving at least 29.1 million patient records, and the continuing transition in healthcare to electronic health records (EHRs) is likely to increase these breaches.¹

A recent study¹ analyzed all breaches in health information reported to the US Health and Human Services Office for Human Rights from 2010 to 2017 and found that breaches increased almost every year during the study period. Analysis of 2149 breaches, comprising a total of 176.4 million records revealed that, although the largest number of breaches involved healthcare plans, the most commonly breached entities were healthcare providers.¹

The year 2017 was the worst year ever for general cybersecurity incidents, which doubled since 2016 across all industries, according to a report of the Online Trust Alliance.² And according to the Identity Theft Resource Center, of 1579 breaches in 2017, almost a quarter (23.7%) were in healthcare.³

To shed light on issues of cybersecurity in medical practices, MPR spoke to Michael J Sacopulos, JD, CEO of Medical Risk Institute (MRI), a firm that provides “proactive counsel” to the healthcare community to identify where liability risks originate and to reduce or remove those risks. He is also General Counsel to Medical Justice Services. Mr Sacopulos is the coauthor of Tweets, Likes, and Liabilities: Online and Electronic Risks to the Healthcare Professional (Phoenix, MD; Greenbranch Publishing: 2018).

What do you think the greatest threat is to cybersecurity in physicians’ practices?

People often think that the greatest protection against a data breach is having a good, strong firewall or other technical security features or tools. While obviously those are very important, that type of security doesn’t protect against the primary vulnerability of a practice to a data breach. The real threat lies at a human level, in how practice employees handle the technologies that contain sensitive patient information and EHRs. The majority of breaches aren’t through software or configuration errors but through human error.

What types of “human errors” are you talking about?

Let’s start with phishing scams. About half of data breaches in all industries are the result of a phishing scam. Phishing e-mails seem innocent enough, perhaps providing a coupon or offering a discount or even warning against an ostensible fraud. Some may even contain a legitimate-looking logo, such as that of a bank. But they are a type of e-mail or social engineering attack, in which the cyber criminal asks the reader to enter information into a website field or form, including user ID and password, and other personal information such as credit card number, address, and phone number. If one of your staff clicks onto this and fills in the form, the cyber criminal now has access to your user ID and password, and can then remotely log into your practice or hospital network, gaining access to your data and systems. 

Closely related are e-mails that contain malicious software (“malware”) attached. These too can seem to come from legitimate companies, such as banks or Amazon, warning that a bill is overdue or an account is scheduled for suspension. Clicking into the link installs the software, which is very destructive to your system and your network.

Your staff needs to learn how to recognize phishing scams and malware e-mails. Some clues are subject lines that include terms like “Final Notice,” have poor grammar or misspellings or peculiar or excessively formal sentence structure, ask you to update your information, or threaten you with dire consequences if you do not comply.

The staff needs to be instructed not to open the e-mail or attachments, call any phone numbers in the e-mail, share any of your practice’s (or personal) information. The e-mail should not be forwarded to other employees either.

Every medical practice should have an IT consultant who should be notified of these e-mails and decide how to handle them.

What other types of human errors are there?

Most devices used by healthcare professionals lack any type of security protection, but devices with patient information — desktops, laptops, mobile devices, and tablets — should be password protected.

Passwords shouldn’t be visible to the public. I do security and privacy audits on medical practices and it’s almost a coin toss whether I’ll find the password to the computer on a little yellow Post-it note on the monitor, keyboard or some other vicinity near the computer. I call it “3M security,” since that’s the name of the company that manufactures Post-its.

Passwords should also not be obvious. I visited one practice where there were two passwords for the whole practice: “Doctor” and “Nurse.” Also, passwords should be changed regularly.

If you have encryption, security, and remote data-wiping features on your practice’s devices, if one of your devices is stolen, it will be harder for your data to be accessed.

Why would cyber criminals be interested in medical records?

Medical records are a gold mine of information — not only date of birth and social security number but also third-party payer information, where the person is employed, the person’s spouse, and so forth. These can be used to file false claims or fake tax returns. Sometimes information is taken from the chart and used for extortion — “unless you pay us, we will release such-and-such information about your psychiatric diagnosis or sexual orientation.” On average, if sold on the black market, a list of social security numbers might sell for $2 per number. Medical charts sell for $85-$125. It’s an entirely different order of magnitude and much more lucrative.

How can a practice increase its security?

There are several important steps to take. One is to engage a professional IT expert to conduct an annual risk analysis. You should also regularly review who in your practice has access to which type of information and remove those who do not need to access patients’ EHRs. Have policies in place regarding your employees’ use of social media, e-mails and access.

What practical barriers are there to implementing these suggestions?

I frequently hear doctors tell me that they don’t have the time or they don’t have the money to implement these suggestions. For example, you may think you’re economizing by downloading a checklist rather than paying an IT professional to conduct assessments. But just as you wouldn’t want your patients to diagnose themselves based on their Internet research, you shouldn’t be dealing with these technical areas of cybersecurity yourself.

I understand that many doctors have very packed schedules and are overwhelmed, but that isn’t a good enough reason to ignore this important area, not only for legal reasons — meaning a potential lawsuit in the event of a data breach — but because it concerns patient safety as well.

Unfortunately, in my experience, many doctors regard cybersecurity as merely a compliance issue, having to obey a law that’s not important. But there are ethical and patient safety issues as well. A growing body of research has found that a significant number of patients withhold information from their physician and one reason is that they don’t have confidence that the medical system will keep their information secure.

This is an extremely dangerous situation and the excuse of being busy cannot hold water. I once had a surgeon tell me with great irritation that if he needed to enter a password every time he used his computer, it would slow him down. I responded, “You wouldn’t run in off the street, grab a scalpel, and perform surgery without scrubbing down beforehand — even though it slows you down. Not ensuring your patients’ data is protected is just as harmful of a practice. This is a patient safety issue.”

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References

1. McCoy TH, Perlis RH. Temporal trends and characteristics of reportable health data breaches, 2010-2017. JAMA. 2018;320(12):1282-1283.

2. Online Trust Alliance.  Available at: https://otalliance.org/news-events/press-releases/online-trust-alliance-reports-doubling-cyber-incidents-2017-0. Accessed: December 13, 2018.

3. Identity Theft Resource Center (ITRC). 2017 Annual Breach Year-End Review. Available at: https://www.idtheftcenter.org/2017-data-breaches/. Accessed: December 13, 2018.

January 17, 2019

One-third of the respondents with severe psoriasis/psoriatic arthritis symptoms reported that they had never discussed systemic treatment with a physician.

The results of a Scandinavian survey strongly suggest that substantial numbers of Swedish, Danish, and Norwegian individuals with psoriasis (PsO) and/or psoriatic arthritis (PsA), particularly older patients, are not receiving optimal treatment from a patient perspective. The Nordic Patient Survey of Psoriasis and Psoriatic Arthritis (NORPAPP) was conducted during November and December 2015, with findings published in the Journal of the European Academy of Dermatology and Venereology.

The investigators sought to describe patients’ experiences with treatments for PsA/PsO in

3 Scandinavian countries, focusing on communication with physicians, satisfaction with therapy, and concerns about treatment options. NORPAPP was used to ask 22,050 adults who were randomly selected from the YouGov panels in Denmark, Norway, and Sweden whether they had PsO/PsA. Ultimately, 1264 individuals who reported having physician-diagnosed PsO/PsA were invited to participate in the survey, with 96.6% responding positively.

Use of systemic therapies was reported by 14.6% of respondents with PsO only (biologic agents in 8.1% of them), and by 58.5% of respondents with PsA only (biologic agents in 31.8% of them). The use of biologic treatments was reported more often among respondents who considered their disease to be severe vs nonsevere (26.8% vs 6.7%, respectively), as well as among those who were members of patient organizations vs nonmembers (40.7% vs 6.9%, respectively).

Having a discussion with their physician about systemic treatments was reported significantly more often by respondents with PsA, by those who perceived their disease as severe, and by those who reported being a member of a patient organization (P <.05), although 35.2% of respondents had never discussed systemic therapies with their physician. Many of the respondents reported concerns over long-term health risks associated with treatments and dissatisfaction with their therapy.

Of particular interest was the fact that respondents aged 45 to 75 years reported having less experience with biologic agents (8.1%) compared with those aged 18 to 44 years (21.5%). In addition, older respondents also reported more uncertainty with respect to long-term health risks linked to systemic treatments, with 66.7% to 72.9% responding “do not know” when asked about the risks associated with systemic treatment options.

The investigators concluded that it appears quite likely that considerable numbers of patients with PsO/PsA in Denmark, Norway, and Sweden are not receiving optimal therapy. In fact, one-third of the respondents with severe symptoms reported that they had never discussed systemic treatment with a physician. Future studies are warranted to evaluate whether better communication and increased awareness of available therapeutic options among both patients and treating physicians can help improve access to appropriate treatments among this population.

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Reference

Tveit KS, Duvetorp A, Østergaard M, et al. Treatment use and satisfaction among patients with psoriasis and psoriatic arthritis: results from the NORdic PAtient survey of Psoriasis and Psoriatic arthritis (NORPAPP) [published online September 22, 2018]. J Eur Acad Dermatol Venereol. doi: 10.1111/jdv.15252

January 17, 2019

Patients with plaque psoriasis have a reduced health-related quality of life, mainly in terms of emotional aspects.

Metabolic syndrome and psoriatic arthritis (PsA) are important comorbidities among patients with plaque psoriasis (PsO), with a reduced health-related quality of life (HRQoL) observed among patients with these comorbid disorders, thus highlighting the relevance of diagnosis and treatment beyond the care of skin lesions. A cross-sectional, observational study on the subject was conducted in 9 tertiary centers in southeastern, southern, and northern Brazilian regions that specialize in the treatment of PsO. Findings from the analysis were published in the Journal of Dermatology.

The investigators sought to assess the prevalence of metabolic syndrome and PsA, as well as to explore HRQoL and the prevalence of secondary comorbidities such as hypertension, type 2 diabetes mellitus, obesity, and dyslipidemia among the study population. Patients diagnosed with PsO responded to an interview and standardized questionnaires (ie, Dermatology Life Quality Index, 36-Item Short Form Health Survey, and EuroQoL Five-Dimension Questionnaire Three-Level version [EQ-5D-3L]). During 3 visits, a dermatologist and a rheumatologist conducted physical examinations, along with several tests, to evaluate the desired outcomes.

The prevalence of PsA was 41.8% (95% CI, 36.0%-47.6%) among patients who met Classification Criteria for Psoriatic Arthritis (35.7%) and/or had reported a medical history of PsA (23.1%). The prevalence of metabolic syndrome, based on physician diagnosis or history, was 50.0% (95% CI, 44.2%-55.8%). The most prevalent secondary comorbidity reported was dyslipidemia (74.5%), which was followed by hypertension (61.8%), obesity (52.5%), and type 2 diabetes mellitus (30.9%).

The mean Dermatology Life Quality Index score reported was 6.5±6.9. The mean physical and mental 36-Item Short Form Health Survey measures were 45.2±10.4 and 45.5±12.3, respectively. Regarding the EQ-5D-3L, the mean utility index was 0.68±0.27, and the mean EQ-5D-3L visual analog scale was 72.7±19.7. Among the 5 dimensions on the EQ-5D-3L, self-care was the least affected, with 84.6% of the respondents reporting an absence of problems. Moreover, the highest impairment was reported for the dimension of pain and discomfort, with 66.4% of respondents reporting experiencing problems, some problems, or extreme problems. Overall, 9.4% of respondents reported experiencing extreme problems on the dimension of anxiety and depression.

The investigators concluded that the results of this study demonstrate that patients with plaque PsO have a reduced HRQoL, mainly in terms of emotional aspects, thus reinforcing existing data on feelings of stigmatization among these individuals. The findings also demonstrate the relevance of HRQoL scores among this population to evaluate patient response to therapy in a more comprehensive fashion.

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Reference

Souza CS, de Castro CCS, Carneiro FRO, et al. Metabolic syndrome and psoriatic arthritis among patients with psoriasis vulgaris: Quality of life and prevalence [published online November 26, 2018]. J Dermatol. doi: 10.1111/1346-8138.14706.

January 15, 2019

Patients with rosacea tended to have more coexisting psychiatric disorders, including anxiety, depression, phobic disorder, and obsessive-compulsive disorder.

Patients with rosacea have a 2.76-fold increased risk for developing psychiatric disorders, including anxiety, depression, phobic disorder, and obsessive-compulsive disorder (OCD), according to the results of a nationwide, population-based, cohort study conducted in Taiwan. Findings from the analysis were published in The Journal of Dermatology.

The investigators sought to elucidate the role played by rosacea in various psychiatric disorders via the use of a nationwide database in Taiwan. Data were obtained from the National Health Insurance Research Database (NHIRD) of Taiwan between 2000 and 2013. Overall, 7881 patients with rosacea and 31,524 age- and gender-matched controls were enrolled in the study.

Patients with rosacea tended to have more coexisting psychiatric disorders compared with controls. After adjusting for age, gender, comorbidities, season of the year, geographic area of residence, urbanization level of residence, and level of care (ie, hospital center, regional hospital, local hospital, or physician clinics), the hazard ratio (HR) of psychiatric disorders in patients with rosacea was 2.761 (95% CI, 2.650-2.877; P <.001). Among the possible psychiatric disorders, the highest adjusted HRs were for phobic disorder (HR 7.841; 95% CI, 7.526-8.170; P <.001) and OCD (HR 6.389; 95% CI, 6.132-6.657; P <.001).

In the study, younger patients with rosacea (ie, younger than 45) were at a lower risk for the development of psychiatric disorders.

A major limitation of the study was the fact that the NHIRD of Taiwan does not include information about rosacea subtypes, disease severity, and laboratory parameters; thus, the researchers were unable to clarify whether these factors affect the association of rosacea with psychiatric disorders.

The investigators concluded that rosacea is linked to a number of psychiatric disorders. Additional studies are warranted in order to explore the pathophysiology of rosacea and thus better understand the association of the disease with various psychiatric disorders. By recognizing the psychosocial burden of rosacea, clinicians should be mindful that careful follow-up of the mental health of patients with the disease is critical.

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Reference

Hung C-T, Chiang C-P, Chung C-H, Tsao C-H, Chien W-C, Wang W-M. Risk of psychiatric disorders in rosacea: a nationwide, population-based, cohort study in Taiwan [published online November 22, 2018]. J Dermatol. doi:10.1111/1346-8138.14705

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January 10, 2019

Pooling data from 11 of 14 relevant studies, patients with atopic dermatitis were 44% more likely to experience suicidal ideation compared with participants without atopic dermatitis.

According to study results published in JAMA Dermatology, individuals with atopic dermatitis are at greater risk of experiencing suicidal ideation and suicide attempts than people without atopic dermatitis.

The investigators of this prospective study sought to evaluate the association between atopic dermatitis and suicidality by reviewing and synthesizing available literature.

A systematic search of relevant articles was conducted through PubMed, Embase, PsycINFO, and Cochrane databases, in which the investigators identified 15 observational studies that evaluated suicidal ideation, suicide attempts, and completed suicide among patients with atopic dermatitis. The investigators performed a meta-analysis to measure the risk between atopic dermatitis and suicidality as a primary end point using pooled odds ratios (OR); the quality of the studies was further assessed as a primary outcome. A total of 4,770,767 participants were analyzed: 310,681 were diagnosed with atopic dermatitis or eczema, and 4,460,086 were used as controls.

Pooling data from 11 of 14 relevant studies, patients with atopic dermatitis were 44% more likely to experience suicidal ideation (pooled OR 1.44; 95% CI, 1.25-1.65) compared with participants without atopic dermatitis. In 3 of 5 relevant studies, patients with atopic dermatitis were also 36% more likely to attempt suicide (pooled OR 1.36; 95% CI, 1.09-1.70) than the control group. The investigators found limited data on completed suicides among patients with atopic dermatitis, and the results from the only 2 relevant studies were inconsistent.

Limitations to the analysis were studies that included control groups of individuals with other medical conditions, potentially confounding results, and several studies that did not include controls or report control group values.

Based on the results, the investigators stressed that dermatologists be aware of this risk and screen for suicidality among their patients with atopic dermatitis.

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Reference                    

Sandhu JK, Wu KK, Bui TL, Armstrong AW. Association between atopic dermatitis and suicidality: a systemic review and meta-analysis [published online December 12, 2018]. JAMA Dermatol. doi: 10.1001/jamadermatol.2018.4566

January 07, 2019

Emerging evidence points to a potential link between H pylori infection and skin diseases including rosacea.

An estimated 25% to 30% of the general population is infected with Helicobacter pylori (H pylori), a gram-negative bacterium that represents a major cause of stomach ulcers and other gastric issues.¹ Research findings increasingly suggest a connection between H pylori infection and various other medical conditions, such as Parkinson disease, migraines, and iron deficiency anemia.² In addition, emerging evidence points to a potential link between H pylori infection and skin diseases including rosacea.

Numerous studies have demonstrated higher rates of H pylori infection in patients with rosacea compared with control subjects. For example, prospective research published in 2015 tested 90 patients with rosacea and 90 control subjects for H pylori (using the 13C Urea Breath Test and H pylori stool antigen test) and found infection rates of 48.9% and 26.7%, respectively (P =.003).¹ Similar results were not found for small intestinal bacteria overgrowth.

Within 10 weeks following treatment with clarithromycin-containing sequential therapy, skin lesions had decreased significantly or completely resolved in 97.2% of patients in whom H pylori was eradicated (P <.0001). For cases in which treatment did not eradicate H pylori infection, lesions were reduced or eliminated in 37.5% of patients. These results align with those of many other studies showing a higher prevalence of H pylori in patients with rosacea vs controls and showing resolution of symptoms following eradication of the bacteria.

Among the potential mechanisms underlying these associations, increased levels of reactive oxygen species and nitric oxide by H pylori have been associated with inflammation and vasodilatation in rosacea.³ Other evidence has revealed that “cytotoxin-associated gene A, known as a H pylori virulence factor, facilitated the secretion of proinflammatory cytokines in the gastric epithelium, and the presence of cytotoxin-associated gene A antibodies was observed in patients with rosacea.”³

Several other studies, however, have not found a higher prevalence of H pylori in people with rosacea or an improvement in symptoms after eradication of H pylori. As rosacea is a multifactorial disease, it is possible that H pylori is a contributing factor in certain patients with specific subtypes of the disease. In support of this, some studies have noted a more favorable treatment response among patients with papulopustular rosacea compared with other subtypes.

One such investigation conducted in 2012 found more frequent rates of gastric ulceration and an especially high response to eradication therapy in patients with papulopustular rosacea.⁴ The study authors concluded that “H pylori plays an important role in rosacea patients with concomitant dyspeptic problems, especially in the papulopustular subtype.”

It is also notable that there are different strains of H pylori with varying levels of virulence, a range of statistical methods and assessments for H pylori have been used in studies on the topic, and the previous use of antibiotics in people with rosacea may influence results.⁴ These factors may further explain the divergent findings observed across studies. Additional research is needed to clarify these points.

Dermatology Advisor spoke with Suzan Obagi, MD, director of the UPMC Cosmetic Surgery and Skin Health Center and the 2018 president of the American Academy of Cosmetic Surgery, regarding the potential significance of H pylori in rosacea.

Dermatology Advisor: What does the research suggest thus far about associations between rosacea and H pylori, as well as underlying mechanisms?

Dr Obagi: There is growing evidence of the link between what we eat and drink and inflammation in the body and skin. Like the digestive tract, skin is one of the largest organs and has its own immune system, and the link between these 2 systems is becoming clearer. The foods and drinks we consume can alter the gut microbiome, allowing unhealthier bacteria to grow and crowd out the healthier bacteria.

It turns out that the unhealthy bacteria can damage the intestinal lining and cause the gut to become “leaky,” thus allowing substances to enter the bloodstream that should be kept out. These are inflammatory substances, immune triggering proteins, and the very harmful endotoxins produced by bacteria. Additionally, ingesting even moderate amounts of alcohol can reduce the production of healthy bile acids by our gut and thus foster the growth of unhealthy bacteria. Lastly, high glycemic foods can feed the unhealthy bacteria and increase the systemic inflammatory response.

There is growing scientific evidence that gut health is intricately linked with overall health, beyond just skin. We are now finding ties between the microbiome and dementia, diabetes, heart disease, cancer, and skin conditions. H pylori is probably just one small example of this issue. H pylori infection causes stomach ulcers in many people but can be silent in others.

In some patients with active infection, their skin shows symptoms of inflammation such as a rosacea flare. In these people, treating the infection can help clear their skin. However, for some people with rosacea, they have active rosacea and no H pylori infection. That suggests a different contributing factor, and other causes of gut issues should be considered.

We know that there is a link between the skin and the gut in atopic dermatitis, acne, rosacea, and now, based on some convincing studies, probably a link with psoriasis, hidradenitis suppurativa, pyoderma gangrenosum, and inflammatory bowel disease as well. 

Dermatology Advisor: What are additional treatment recommendations for clinicians?

Dr Obagi: I think that any clinician who is keeping up with the science is starting to have discussions with their patients about mediating inflammation, which is the root cause of most of the conditions I mentioned above. One of the ways our patients can mitigate inflammation is to improve their overall gut health by taking probiotics (especially after taking antibiotics); eating a low glycemic diet; avoiding inflammatory foods such as dairy, gluten, soy, and peanuts; eliminating sugary drinks; and keeping alcohol intake to a minimum. 

Some patients may also require supplementation with vitamins such as quercetin and digestive acids such as bile acids for certain conditions. These suggestions should be implemented in collaboration with the patient’s primary care provider and dermatologist. 

Dermatology Advisor: What are some of the remaining research needs in this area?

Dr Obagi: We need more research on a larger population of patients of various ethnicities to see whether this link pans out across ethnically different patients. We are already hearing of universities investing in studying the gut microbiome and using that knowledge to create a clinic to evaluate and treat patients based on this research.

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References

1. Gravina A, Federico A, Ruocco E, et al. Helicobacter pylori infection but not small intestinal bacterial overgrowth may play a pathogenic role in rosacea. United European Gastroenterol J. 2015;3(1):17-24.

2. Wong F, Rayner-Hartley E, Byrne MF. Extraintestinal manifestations of Helicobacter pylori: a concise review. World J Gastroenterol. 2014;20(34):11950-11961.

3. Woo YR, Lim JH, Cho DH, Park HJ. Rosacea: molecular mechanisms and management of a chronic cutaneous inflammatory condition. Int J Mol Sci. 2016;17(9):1562.

4. Lazaridou E, Korfitis C, Kemanetzi C, et al. Rosacea and Helicobacter pylori: links and risks. Clin Cosmet Investig Dermatol. 2017; 10(10):305-310.