Bariatric surgery and psoriasis Eric Y. Sako, BS,a Shannon Famenini, BS,a and Jashin J. Wu, MDb Los Angeles, California Obesity is associated with psoriasis and poses a significant obstacle to psoriasis management. Bariatric surgery is an effective procedure for weight loss, and some reports suggest that it may improve psoriasis. However, more evidence is needed before definitive conclusions can be drawn. Bariatric surgery procedures, in particular the Roux-en-Y gastric bypass, may one day be a viable option for obese patients with refractory psoriasis. ( J Am Acad Dermatol 2014;70:774-9.) Key words: bariatric; loss; psoriasis; surgery; treatment; weight.
O
besity, defined as a body mass index greater than 30 kg/m2, is a national epidemic, affecting one third of adults in the United States.1 The prevalence of obesity is higher in patients with psoriasis and correlates with psoriasis severity.2,3 Overall, patients with psoriasis are 1.3 to 2.2 times more likely to be obese.4,5 Whether obesity predisposes to psoriasis or psoriasis leads to obesity remains unclear, but strong evidence supports the former.6 The association is thought to be linked to the proinflammatory milieu created by excess adipose tissue. Levels of tumor necrosis factor (TNF)-alfa, implicated in the pathogenesis of psoriasis, have been found to be increased in both the adipose tissue and serum of obese patients with psoriasis.4 The proinflammatory adipose-derived hormones leptin, resistin, and omentin are also higher in patients with psoriasis.7,8 In addition, obese patients with psoriasis pose obstacles to effective psoriasis treatment. Higher body weight negatively affects the efficacy of medications, particularly those of the biologic class. Multiple studies have demonstrated obese patients are at higher risk for hepatic toxicity when treated with methotrexate. In obese patients, cyclosporine administration may lead to increased incidence of nephrotoxicity.4 The negative impact of obesity on psoriasis is clear and thus, strategies have emerged targeting weight loss in the psoriasis population. Initial weight loss
From the David Geffen School of Medicine at University of California, Los Angeles,a and Department of Dermatology, Kaiser Permanente Los Angeles Medical Center.b Funding sources: None. Disclosure: Dr Wu received research funding from Abbott Laboratories, AbbVie, Amgen, Eli Lilly, Merck, and Pfizer, which were not directly related to this study. Mr Sako and Ms Famenini have no conflicts of interest to declare. Accepted for publication November 5, 2013.
774
Abbreviations used: AGB: EWL: GLP: RYGB: TNF:
adjustable gastric banding excess weight loss glucagon-like peptide Roux-en-Y gastric bypass tumor necrosis factor
management includes implementing lifestyle changes such as consuming a healthier diet and exercise. Studies exploring the effect of weight loss through diet on psoriasis have shown mixed results.9-11 Bariatric surgery, however, provides another option for weight loss and has shown promise in the treatment of psoriasis. In this review, we will offer an overview of bariatric surgery, review the literature of the effect of bariatric surgery on psoriasis severity, and discuss its role in psoriasis management.
BARIATRIC SURGERY AND OBESITY Bariatric surgery procedures, including the laparoscopic adjustable gastric banding (AGB), standard Roux-en-Y gastric bypass (RYGB), and laparoscopic sleeve gastrectomy, have been found to be safe and effective treatments for weight loss.12,13 The number of bariatric surgeries worldwide has increased significantly in recent years, from 5000 surgeries between 1987 and 1989 to an estimated 350,000 in 2008.13
Reprint requests: Jashin J. Wu, MD, Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, 1515 N Vermont Ave, Fifth floor, Los Angeles, CA 90027. E-mail: jashinwu@ hotmail.com. Published online January 9, 2014. 0190-9622/$36.00 Ó 2013 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2013.11.010
J AM ACAD DERMATOL
Sako, Famenini, and Wu 775
VOLUME 70, NUMBER 4
Traditionally, the procedures were thought to cause gastrectomy works to lower appetite by removing weight loss solely through mechanical means, either the majority of ghrelin-secreting cells, and through decreased caloric intake and/or decreased decreasing stomach capacity.13 absorption. Recent data suggest the procedures, Bariatric surgery procedures are considered safe particularly the RYGB and sleeve gastrectomy, may and carry low perioperative morbidity and mortality. alter levels of gastrointestinal neuroendocrine transThe incidence of major postoperative complications is mitters, leading to decreased appetite, increased 4.3%, an acceptable rate considering morbidly obese satiety, and delayed gastric patients are at increased risk emptying.13 for surgical complications. CAPSULE SUMMARY Major complications include Indications for bariatric hemorrhage (1%-4%), pulmosurgery include body mass Because obesity negatively affects nary embolism (0.34%), and index greater than or equal psoriasis, weight loss has been targeted anastomotic dehiscence to 40 kg/m2 or body mass as a potential therapy. (0.5%-2.7%). Mortality varies index greater than or equal Limited evidence suggests bariatric by procedure and was lowest 35 kg/m2 with obesitysurgery, particularly Roux-en-Y gastric for AGB (0.01%-0.11%) related comorbidities. The bypass, may be associated with followed by RYGB patient must adhere to postpostsurgical improvement of psoriasis. (0.09%-0.23%) and sleeve operative care and managegastrectomy (0.19%). Higher ment, and have failed More evidence is needed before mortality was found in panonsurgical attempts at definitive conclusions can be drawn tients who were male, older weight reduction. Generally, about the effect of bariatric surgery on than 65 years, and superat least 6 months of conserpsoriasis. obese. The most common vative medical weight mancause of death was pulmoagement must be tried before nary embolism. Overall, mortality is 0.28% within 30 the procedure is covered by insurance.12 Relative days of surgery and 0.35% between 30 days and 2 contraindications include unstable coronary artery years after surgery.13 disease, end-stage lung disease, recent malignancy, cirrhosis, and severe heart failure. Preoperative Bariatric surgery is considered successful if excess evaluation is made in the setting of a multidisciweight loss (EWL) exceeds 50% as this benchmark is plinary team, including medicine, surgery, a nutricorrelated with high patient satisfaction rates and tionist, and psychology/psychiatry.12 decrease in obesity-related comorbidities. EWL is calculated as a percentage by dividing weight loss The 3 most common procedures are the RYGB by preoperative weight minus ideal weight. Short(47%), AGB (42%), and sleeve gastrectomy (5%). term mean EWL is 61.6%, 55.4%, and 47.5% for RYGB, Ninety percent are performed laparoscopically. The sleeve gastrectomy, and AGB, respectively. Long-term choice of procedure is made depending on a number studies have observed that patients tend to sustain of factors, including surgeon expertise, patient weight loss years after surgery, though the exact preference, and the risk of each procedure.13 amount varied by procedure. Mean EWL 14 years In RYGB, the upper stomach is divided and after the procedure was 50% and 15.6% for RYGB and connected to the jejunum, thereby bypassing most AGB, respectively. EWL was 46% at 8 years after of the stomach and upper small bowel (Fig 1). This sleeve gastrectomy. Comorbid conditions such as leads to decreased stomach capacity and decreased hypertension, diabetes, hyperlipidemia, obstructive absorption. In addition, the anatomic rearrangesleep apnea, and other obesity-related disease ment produces changes in levels of neuroendocrine improve after bariatric surgery. According to a recent gastrointestinal hormones, which contribute to the meta-analysis, 78.1% of diabetic patients who underweight loss. RYGB is a better choice for more obese went bariatric surgery had complete remission of or diabetic patients.13 The AGB consists of placing a diabetes.14 In addition, patients benefit from higher round silicone band with an inflatable cuff around the upper stomach (Fig 2). The band is tightened by self-confidence and improved social function.12 injecting saline into a subcutaneous port connected to the cuff, leading to reduced stomach capacity and BARIATRIC SURGERY AND PSORIASIS increased satiety. In sleeve gastrectomy, a narrow Limited evidence suggests that patients with psotubular stomach is created through resection of riasis who undergo bariatric surgery may experience most of the stomach body and fundus (Fig 3). improvement of psoriasis after surgery. This pheBecause ghrelin, an appetite stimulator, is mainly nomenon was first described in 1977 after a patient secreted from the gastric fundus, sleeve underwent jejunoileal bypass.15 The patient had d
d
d
776 Sako, Famenini, and Wu
J AM ACAD DERMATOL
APRIL 2014
Fig 3. Sleeve gastrectomy. Reproduced with permission from Elsevier.13
Fig 1. Roux-en-Y gastric bypass. Reproduced with permission from Elsevier.13
Fig 2. Adjustable gastric banding. Reproduced with permission from Elsevier.13
severe psoriasis and shortly after undergoing surgery, noticed significant improvement. After losing over 100 lb, the patient had only localized psoriasis 2 years after surgery.15 Three case reports have described similar results after patients underwent bariatric surgery8,16,17 (Table I). In all cases, patients with severe psoriasis achieved significant postprocedural improvement, with 2 patients gaining complete clearance. The procedure used in all 4 patients was RYGB and the average weight loss was 77 lb.
A retrospective chart review of 10 patients with psoriasis who underwent bariatric surgery was performed by Farias et al18 (Table I). Seventy percent of patients had complete remission after surgery at 6 months. All 7 of these patients underwent RYGB. Of the 2 patients who underwent sleeve gastrectomy, 1 patient had no change, whereas the other experienced worsening of psoriasis. The study also evaluated Dermatology Life Quality Index score and found a statistically significant improvement after undergoing surgery, from 14.9 6 6.8 before surgery to 5 6 6.3 at follow-up (P = .0045). Thus, in a limited sample size, bariatric surgery, particularly RYGB, was demonstrated to be associated with reduced psoriasis severity and increased quality of life. A recent study by Hossler et al11 evaluated a larger sample size of patients. In all, 104 patients who had psoriasis and had undergone a bariatric procedure were identified through a database. Of these, 34 patients completed an interview by telephone. Twenty-one patients (62%) reported improvement of psoriasis after surgery, 9 had no change (26%), and 4 worsened (12%). Of the 21 patients who improved, 3 subsequently worsened after initial improvement. The possible reasons for the delayed relapse of psoriasis in these patients were not discussed. The study does not note the type of bariatric procedure that was performed on patients who improved, though the vast majority of the sampled patients (88%) had undergone RYGB. In addition, there was a statistically significant de-escalation in the medication needed to treat their psoriasis (P = .046). Four patients who had been on systemic therapy now only needed topical treatment and 7 no longer required topical therapy.
J AM ACAD DERMATOL
Sako, Famenini, and Wu 777
VOLUME 70, NUMBER 4
Table I. Review of literature No. of patients
Study type 8
Surgery type
Preprocedure psoriasis
Preprocedure BMI, kg/m2
Maximum weight loss
Results
Hossler et al (2011), case series
2
RYGB (2)
BSA 75%
52
111 lb
BSA 5% at 6 y
Higa-Sansone et al17 (2004), case report de Menezes Ettinger et al16 (2006), case report Farias et al18 (2012), retrospective review
1
RYGB
BSA 25% BSA 90%
55.69 41
60 lb 86 lb
BSA 9% at 13 mo BSA 0% at 2 y
1
Open RYGB
Severe
46.9
51 lb
BSA 0% at 4 mo
10
RYGB (8), sleeve gastrectomy (2)
NA
38.76 5.5
Hossler et al11 (2013), cross-sectional
34
RYGB (30), AGB (3), unknown (1)
NA
48.5 6 8.5
Perez-Perez et al22 (2009), case report Nowlin and Solomon21 (1976), case report
1
NA
NA
56.9
1
Jejunoileostomy and ileocolostomy
NA
NA
88.2% EWL 6-mo Follow-up: 70% with complete remission, 2 patients with no change, 1 with more lesions Long-term follow-up (0.5-2.5 y): 4 of the 7 patients who obtained complete remission at 6 mo had mild flares NA 21 Patients improved, 9 patients had no change, 4 patients worsened. Younger patients (mean 38.5 years) tended to worsen compared with older patients (mean 52.7 y) (P = .039) Age \45 y and family history of psoriasis less likely to improve (P = .007) 143 lb More frequent and severe psoriasis flares 116 lb Psoriasis flare with nail pitting, onycholysis, and joint pain
AGB, Adjustable gastric banding; BMI, body mass index; BSA, body surface area; EWL, excess weight loss; NA, not available; RYGB, Roux-en-Y gastric bypass.
This was the first study that attempted to identify predictive factors of patients who would improve after surgery. They found that those who improved tended to be older than those who worsened (P = .039). Furthermore, those who were younger than 45 years and had a family history of psoriasis were less likely to improve after surgery (P = .007). The main weaknesses of this study were the heavy reliance on patient recall and the low total response rate (33%).11 Overall, this study provided further evidence of the benefit of bariatric surgery in the context of a larger patient population. Although the exact reason for the response of psoriasis to surgery remains unknown, bariatric
surgery is thought to improve psoriasis through multiple mechanisms.8 One hypothesis is weight loss leads to decreased TNF-alfa levels. Indeed, 1 study demonstrated weight loss generates lower levels of TNF-alfa messenger RNA in adipose tissue.19 Another theory centers on the role of leptin. Leptin is an adipose-derived protein that drives appetite suppression. Leptin is also proinflammatory, leading to increased T-helper-1 cell activity while suppressing T-helper-2 cell activity. It also increases TNF-alfa production in peripheral blood monocytes. Obese patients possess higher levels of leptin, which have been shown to positively correlate with body fat percentage. Bariatric surgery
778 Sako, Famenini, and Wu
leads to reduced leptin levels and thus, a lower level of inflammation.8 Lastly, an increase of gut incretin hormone glucagon-like peptide (GLP)-1 is thought to contribute to psoriasis improvement in patients who undergo RYGB. GLP-1 has a potent anti-inflammatory effect and lowers blood glucose levels. GLP-1 increases up to 20 times after RYGB and it is theorized to be the reason for the high rate of diabetes resolution. Interestingly, this effect is specific to RYGB, as patients who underwent AGB did not show increased GLP-1. GLP-1 may also play a role in maintaining peripheral regulatory T cells and regulating lymphocyte proliferation.20 Contrary to the above findings, there have also been cases describing psoriasis exacerbation after bariatric surgery. In the aforementioned studies, a subset of 10% to 12% of patients developed worsening psoriasis even with substantial weight reduction.11,18 In fact, the first report in the literature of psoriasis and bariatric surgery was of a psoriasis exacerbation after a jejunoileostomy and ileocolostomy in 1976.21 These procedures, however, are no longer used as standard bariatric procedures. P erez-P erez et al22 reported a case of a 52-year-old woman who experienced more frequent and severe flares of her psoriasis despite losing 143 lb. The case report does not mention the type of bariatric procedure that was performed on the patient. The reasons for postsurgical psoriasis exacerbation are unknown. Conclusion There is conflicting evidence regarding the benefit of bariatric surgery for psoriasis. A limited number of case reports and studies suggest bariatric surgery has a positive impact on psoriasis. Specifically, patients with psoriasis who undergo RYGB, as opposed to sleeve gastrectomy or AGB, may derive the most benefit. However, a subset of patients also experienced psoriasis exacerbation. Thus, more evidence is needed before a definitive conclusion can be drawn. In the future, the bariatric surgery procedure may offer another option for patients with refractory psoriasis who are also obese. This population is difficult to treat as a result of numerous comorbidities and lower efficacy of standard medications. Further large controlled prospective studies are needed to assess long-term outcome and identify patients who would have the highest success rate after the procedure. As for now, clinicians should become knowledgeable of the procedure, its risks and its indications, so that basic patient questions can be answered and proper referrals can be made.
J AM ACAD DERMATOL
APRIL 2014
REFERENCES 1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010; 303:235-41. 2. Wu JJ, Poon KY, Channual JC, Shen AY. Association between tumor necrosis factor inhibitor therapy and myocardial infarction risk in patients with psoriasis. Arch Dermatol 2012; 148:1244-50. 3. Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol 2006;55:829-35. 4. Bremmer S, Van Voorhees AS, Hsu S, Korman NJ, Lebwohl MG, Young M, et al. Obesity and psoriasis: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol 2010;63:1058-69. 5. Koebnick C, Black MH, Smith N, Der-Sarkissian JK, Porter AH, Jacobsen SJ, et al. The association of psoriasis and elevated blood lipids in overweight and obese children. J Pediatr 2011; 159:577-83. 6. Herron MD, Hinckley M, Hoffman MS, Papenfuss J, Hansen CB, Callis KP, et al. Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol 2005;141: 1527-34. 7. Takahashi H, Tsuji H, Honma M, Ishida-Yamamoto A, Iizuka H. Increased plasma resistin and decreased omentin levels in Japanese patients with psoriasis. Arch Dermatol Res 2013;305: 113-6. 8. Hossler EW, Maroon MS, Mowad CM. Gastric bypass surgery improves psoriasis. J Am Acad Dermatol 2011;65: 198-200. 9. Del Giglio M, Gisondi P, Tessari G, Girolomoni G. Weight reduction alone may not be sufficient to maintain disease remission in obese patients with psoriasis: a randomized, investigator-blinded study. Dermatology 2012;224:31-7. 10. Gisondi P, Del Giglio M, Di Francesco V, Zamboni M, Girolomoni G. Weight loss improves the response of obese patients with moderate-to-severe chronic plaque psoriasis to low-dose cyclosporine therapy: a randomized, controlled, investigator-blinded clinical trial. Am J Clin Nutr 2008;88:1242-7. 11. Hossler EW, Wood GC, Still CD, Mowad CM, Maroon MS. The effect of weight loss surgery on the severity of psoriasis. Br J Dermatol 2013;168:660-1. 12. Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician 2011;84: 805-14. 13. Kissler HJ, Settmacher U. Bariatric surgery to treat obesity. Semin Nephrol 2013;33:75-89. 14. Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009;122: 248-56, e245. 15. Porres JM. Jejunoileal bypass and psoriasis. Arch Dermatol 1977;113:983. 16. de Menezes Ettinger JE, Azaro E, de Souza CA, dos Santos Filho PV, Mello CA, Neves M Jr, et al. Remission of psoriasis after open gastric bypass. Obesity Surg 2006;16:94-7. 17. Higa-Sansone G, Szomstein S, Soto F, Brasecsco O, Cohen C, Rosenthal RJ. Psoriasis remission after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obesity Surg 2004;14: 1132-4. 18. Farias MM, Achurra P, Boza C, Vega A, de la Cruz C. Psoriasis following bariatric surgery: clinical evolution and impact on quality of life on 10 patients. Obesity Surg 2012;22:877-80. 19. Hotamisligil GS, Arner P, Caro JF, Atkinson RL, Spiegelman BM. Increased adipose tissue expression of tumor necrosis
J AM ACAD DERMATOL VOLUME 70, NUMBER 4
factor-alpha in human obesity and insulin resistance. J Clin Invest 1995;95:2409-15. 20. Faurschou A, Zachariae C, Skov L, Vilsboll T, Knop FK. Gastric bypass surgery: improving psoriasis through a GLP-1-dependent mechanism? Med Hypotheses 2011;77:1098-101.
Sako, Famenini, and Wu 779
21. Nowlin N, Solomon H. Weight loss and psoriasis [letter]. Arch Dermatol 1976;112:1465. 22. Perez-Perez L, Allegue F, Caeiro JL, Zulaica JM. Severe psoriasis, morbid obesity and bariatric surgery. Clin Exper Dermatol 2009;34:e421-2.
O
besity, defined as a body mass index greater than 30 kg/m2, is a national epidemic, affecting one third of adults in the United States.1 The prevalence of obesity is higher in patients with psoriasis and correlates with psoriasis severity.2,3 Overall, patients with psoriasis are 1.3 to 2.2 times more likely to be obese.4,5 Whether obesity predisposes to psoriasis or psoriasis leads to obesity remains unclear, but strong evidence supports the former.6 The association is thought to be linked to the proinflammatory milieu created by excess adipose tissue. Levels of tumor necrosis factor (TNF)-alfa, implicated in the pathogenesis of psoriasis, have been found to be increased in both the adipose tissue and serum of obese patients with psoriasis.4 The proinflammatory adipose-derived hormones leptin, resistin, and omentin are also higher in patients with psoriasis.7,8 In addition, obese patients with psoriasis pose obstacles to effective psoriasis treatment. Higher body weight negatively affects the efficacy of medications, particularly those of the biologic class. Multiple studies have demonstrated obese patients are at higher risk for hepatic toxicity when treated with methotrexate. In obese patients, cyclosporine administration may lead to increased incidence of nephrotoxicity.4 The negative impact of obesity on psoriasis is clear and thus, strategies have emerged targeting weight loss in the psoriasis population. Initial weight loss
From the David Geffen School of Medicine at University of California, Los Angeles,a and Department of Dermatology, Kaiser Permanente Los Angeles Medical Center.b Funding sources: None. Disclosure: Dr Wu received research funding from Abbott Laboratories, AbbVie, Amgen, Eli Lilly, Merck, and Pfizer, which were not directly related to this study. Mr Sako and Ms Famenini have no conflicts of interest to declare. Accepted for publication November 5, 2013.
774
Abbreviations used: AGB: EWL: GLP: RYGB: TNF:
adjustable gastric banding excess weight loss glucagon-like peptide Roux-en-Y gastric bypass tumor necrosis factor
management includes implementing lifestyle changes such as consuming a healthier diet and exercise. Studies exploring the effect of weight loss through diet on psoriasis have shown mixed results.9-11 Bariatric surgery, however, provides another option for weight loss and has shown promise in the treatment of psoriasis. In this review, we will offer an overview of bariatric surgery, review the literature of the effect of bariatric surgery on psoriasis severity, and discuss its role in psoriasis management.
BARIATRIC SURGERY AND OBESITY Bariatric surgery procedures, including the laparoscopic adjustable gastric banding (AGB), standard Roux-en-Y gastric bypass (RYGB), and laparoscopic sleeve gastrectomy, have been found to be safe and effective treatments for weight loss.12,13 The number of bariatric surgeries worldwide has increased significantly in recent years, from 5000 surgeries between 1987 and 1989 to an estimated 350,000 in 2008.13
Reprint requests: Jashin J. Wu, MD, Department of Dermatology, Kaiser Permanente Los Angeles Medical Center, 1515 N Vermont Ave, Fifth floor, Los Angeles, CA 90027. E-mail: jashinwu@ hotmail.com. Published online January 9, 2014. 0190-9622/$36.00 Ó 2013 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2013.11.010
J AM ACAD DERMATOL
Sako, Famenini, and Wu 775
VOLUME 70, NUMBER 4
Traditionally, the procedures were thought to cause gastrectomy works to lower appetite by removing weight loss solely through mechanical means, either the majority of ghrelin-secreting cells, and through decreased caloric intake and/or decreased decreasing stomach capacity.13 absorption. Recent data suggest the procedures, Bariatric surgery procedures are considered safe particularly the RYGB and sleeve gastrectomy, may and carry low perioperative morbidity and mortality. alter levels of gastrointestinal neuroendocrine transThe incidence of major postoperative complications is mitters, leading to decreased appetite, increased 4.3%, an acceptable rate considering morbidly obese satiety, and delayed gastric patients are at increased risk emptying.13 for surgical complications. CAPSULE SUMMARY Major complications include Indications for bariatric hemorrhage (1%-4%), pulmosurgery include body mass Because obesity negatively affects nary embolism (0.34%), and index greater than or equal psoriasis, weight loss has been targeted anastomotic dehiscence to 40 kg/m2 or body mass as a potential therapy. (0.5%-2.7%). Mortality varies index greater than or equal Limited evidence suggests bariatric by procedure and was lowest 35 kg/m2 with obesitysurgery, particularly Roux-en-Y gastric for AGB (0.01%-0.11%) related comorbidities. The bypass, may be associated with followed by RYGB patient must adhere to postpostsurgical improvement of psoriasis. (0.09%-0.23%) and sleeve operative care and managegastrectomy (0.19%). Higher ment, and have failed More evidence is needed before mortality was found in panonsurgical attempts at definitive conclusions can be drawn tients who were male, older weight reduction. Generally, about the effect of bariatric surgery on than 65 years, and superat least 6 months of conserpsoriasis. obese. The most common vative medical weight mancause of death was pulmoagement must be tried before nary embolism. Overall, mortality is 0.28% within 30 the procedure is covered by insurance.12 Relative days of surgery and 0.35% between 30 days and 2 contraindications include unstable coronary artery years after surgery.13 disease, end-stage lung disease, recent malignancy, cirrhosis, and severe heart failure. Preoperative Bariatric surgery is considered successful if excess evaluation is made in the setting of a multidisciweight loss (EWL) exceeds 50% as this benchmark is plinary team, including medicine, surgery, a nutricorrelated with high patient satisfaction rates and tionist, and psychology/psychiatry.12 decrease in obesity-related comorbidities. EWL is calculated as a percentage by dividing weight loss The 3 most common procedures are the RYGB by preoperative weight minus ideal weight. Short(47%), AGB (42%), and sleeve gastrectomy (5%). term mean EWL is 61.6%, 55.4%, and 47.5% for RYGB, Ninety percent are performed laparoscopically. The sleeve gastrectomy, and AGB, respectively. Long-term choice of procedure is made depending on a number studies have observed that patients tend to sustain of factors, including surgeon expertise, patient weight loss years after surgery, though the exact preference, and the risk of each procedure.13 amount varied by procedure. Mean EWL 14 years In RYGB, the upper stomach is divided and after the procedure was 50% and 15.6% for RYGB and connected to the jejunum, thereby bypassing most AGB, respectively. EWL was 46% at 8 years after of the stomach and upper small bowel (Fig 1). This sleeve gastrectomy. Comorbid conditions such as leads to decreased stomach capacity and decreased hypertension, diabetes, hyperlipidemia, obstructive absorption. In addition, the anatomic rearrangesleep apnea, and other obesity-related disease ment produces changes in levels of neuroendocrine improve after bariatric surgery. According to a recent gastrointestinal hormones, which contribute to the meta-analysis, 78.1% of diabetic patients who underweight loss. RYGB is a better choice for more obese went bariatric surgery had complete remission of or diabetic patients.13 The AGB consists of placing a diabetes.14 In addition, patients benefit from higher round silicone band with an inflatable cuff around the upper stomach (Fig 2). The band is tightened by self-confidence and improved social function.12 injecting saline into a subcutaneous port connected to the cuff, leading to reduced stomach capacity and BARIATRIC SURGERY AND PSORIASIS increased satiety. In sleeve gastrectomy, a narrow Limited evidence suggests that patients with psotubular stomach is created through resection of riasis who undergo bariatric surgery may experience most of the stomach body and fundus (Fig 3). improvement of psoriasis after surgery. This pheBecause ghrelin, an appetite stimulator, is mainly nomenon was first described in 1977 after a patient secreted from the gastric fundus, sleeve underwent jejunoileal bypass.15 The patient had d
d
d
776 Sako, Famenini, and Wu
J AM ACAD DERMATOL
APRIL 2014
Fig 3. Sleeve gastrectomy. Reproduced with permission from Elsevier.13
Fig 1. Roux-en-Y gastric bypass. Reproduced with permission from Elsevier.13
Fig 2. Adjustable gastric banding. Reproduced with permission from Elsevier.13
severe psoriasis and shortly after undergoing surgery, noticed significant improvement. After losing over 100 lb, the patient had only localized psoriasis 2 years after surgery.15 Three case reports have described similar results after patients underwent bariatric surgery8,16,17 (Table I). In all cases, patients with severe psoriasis achieved significant postprocedural improvement, with 2 patients gaining complete clearance. The procedure used in all 4 patients was RYGB and the average weight loss was 77 lb.
A retrospective chart review of 10 patients with psoriasis who underwent bariatric surgery was performed by Farias et al18 (Table I). Seventy percent of patients had complete remission after surgery at 6 months. All 7 of these patients underwent RYGB. Of the 2 patients who underwent sleeve gastrectomy, 1 patient had no change, whereas the other experienced worsening of psoriasis. The study also evaluated Dermatology Life Quality Index score and found a statistically significant improvement after undergoing surgery, from 14.9 6 6.8 before surgery to 5 6 6.3 at follow-up (P = .0045). Thus, in a limited sample size, bariatric surgery, particularly RYGB, was demonstrated to be associated with reduced psoriasis severity and increased quality of life. A recent study by Hossler et al11 evaluated a larger sample size of patients. In all, 104 patients who had psoriasis and had undergone a bariatric procedure were identified through a database. Of these, 34 patients completed an interview by telephone. Twenty-one patients (62%) reported improvement of psoriasis after surgery, 9 had no change (26%), and 4 worsened (12%). Of the 21 patients who improved, 3 subsequently worsened after initial improvement. The possible reasons for the delayed relapse of psoriasis in these patients were not discussed. The study does not note the type of bariatric procedure that was performed on patients who improved, though the vast majority of the sampled patients (88%) had undergone RYGB. In addition, there was a statistically significant de-escalation in the medication needed to treat their psoriasis (P = .046). Four patients who had been on systemic therapy now only needed topical treatment and 7 no longer required topical therapy.
J AM ACAD DERMATOL
Sako, Famenini, and Wu 777
VOLUME 70, NUMBER 4
Table I. Review of literature No. of patients
Study type 8
Surgery type
Preprocedure psoriasis
Preprocedure BMI, kg/m2
Maximum weight loss
Results
Hossler et al (2011), case series
2
RYGB (2)
BSA 75%
52
111 lb
BSA 5% at 6 y
Higa-Sansone et al17 (2004), case report de Menezes Ettinger et al16 (2006), case report Farias et al18 (2012), retrospective review
1
RYGB
BSA 25% BSA 90%
55.69 41
60 lb 86 lb
BSA 9% at 13 mo BSA 0% at 2 y
1
Open RYGB
Severe
46.9
51 lb
BSA 0% at 4 mo
10
RYGB (8), sleeve gastrectomy (2)
NA
38.76 5.5
Hossler et al11 (2013), cross-sectional
34
RYGB (30), AGB (3), unknown (1)
NA
48.5 6 8.5
Perez-Perez et al22 (2009), case report Nowlin and Solomon21 (1976), case report
1
NA
NA
56.9
1
Jejunoileostomy and ileocolostomy
NA
NA
88.2% EWL 6-mo Follow-up: 70% with complete remission, 2 patients with no change, 1 with more lesions Long-term follow-up (0.5-2.5 y): 4 of the 7 patients who obtained complete remission at 6 mo had mild flares NA 21 Patients improved, 9 patients had no change, 4 patients worsened. Younger patients (mean 38.5 years) tended to worsen compared with older patients (mean 52.7 y) (P = .039) Age \45 y and family history of psoriasis less likely to improve (P = .007) 143 lb More frequent and severe psoriasis flares 116 lb Psoriasis flare with nail pitting, onycholysis, and joint pain
AGB, Adjustable gastric banding; BMI, body mass index; BSA, body surface area; EWL, excess weight loss; NA, not available; RYGB, Roux-en-Y gastric bypass.
This was the first study that attempted to identify predictive factors of patients who would improve after surgery. They found that those who improved tended to be older than those who worsened (P = .039). Furthermore, those who were younger than 45 years and had a family history of psoriasis were less likely to improve after surgery (P = .007). The main weaknesses of this study were the heavy reliance on patient recall and the low total response rate (33%).11 Overall, this study provided further evidence of the benefit of bariatric surgery in the context of a larger patient population. Although the exact reason for the response of psoriasis to surgery remains unknown, bariatric
surgery is thought to improve psoriasis through multiple mechanisms.8 One hypothesis is weight loss leads to decreased TNF-alfa levels. Indeed, 1 study demonstrated weight loss generates lower levels of TNF-alfa messenger RNA in adipose tissue.19 Another theory centers on the role of leptin. Leptin is an adipose-derived protein that drives appetite suppression. Leptin is also proinflammatory, leading to increased T-helper-1 cell activity while suppressing T-helper-2 cell activity. It also increases TNF-alfa production in peripheral blood monocytes. Obese patients possess higher levels of leptin, which have been shown to positively correlate with body fat percentage. Bariatric surgery
778 Sako, Famenini, and Wu
leads to reduced leptin levels and thus, a lower level of inflammation.8 Lastly, an increase of gut incretin hormone glucagon-like peptide (GLP)-1 is thought to contribute to psoriasis improvement in patients who undergo RYGB. GLP-1 has a potent anti-inflammatory effect and lowers blood glucose levels. GLP-1 increases up to 20 times after RYGB and it is theorized to be the reason for the high rate of diabetes resolution. Interestingly, this effect is specific to RYGB, as patients who underwent AGB did not show increased GLP-1. GLP-1 may also play a role in maintaining peripheral regulatory T cells and regulating lymphocyte proliferation.20 Contrary to the above findings, there have also been cases describing psoriasis exacerbation after bariatric surgery. In the aforementioned studies, a subset of 10% to 12% of patients developed worsening psoriasis even with substantial weight reduction.11,18 In fact, the first report in the literature of psoriasis and bariatric surgery was of a psoriasis exacerbation after a jejunoileostomy and ileocolostomy in 1976.21 These procedures, however, are no longer used as standard bariatric procedures. P erez-P erez et al22 reported a case of a 52-year-old woman who experienced more frequent and severe flares of her psoriasis despite losing 143 lb. The case report does not mention the type of bariatric procedure that was performed on the patient. The reasons for postsurgical psoriasis exacerbation are unknown. Conclusion There is conflicting evidence regarding the benefit of bariatric surgery for psoriasis. A limited number of case reports and studies suggest bariatric surgery has a positive impact on psoriasis. Specifically, patients with psoriasis who undergo RYGB, as opposed to sleeve gastrectomy or AGB, may derive the most benefit. However, a subset of patients also experienced psoriasis exacerbation. Thus, more evidence is needed before a definitive conclusion can be drawn. In the future, the bariatric surgery procedure may offer another option for patients with refractory psoriasis who are also obese. This population is difficult to treat as a result of numerous comorbidities and lower efficacy of standard medications. Further large controlled prospective studies are needed to assess long-term outcome and identify patients who would have the highest success rate after the procedure. As for now, clinicians should become knowledgeable of the procedure, its risks and its indications, so that basic patient questions can be answered and proper referrals can be made.
J AM ACAD DERMATOL
APRIL 2014
REFERENCES 1. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among US adults, 1999-2008. JAMA 2010; 303:235-41. 2. Wu JJ, Poon KY, Channual JC, Shen AY. Association between tumor necrosis factor inhibitor therapy and myocardial infarction risk in patients with psoriasis. Arch Dermatol 2012; 148:1244-50. 3. Neimann AL, Shin DB, Wang X, Margolis DJ, Troxel AB, Gelfand JM. Prevalence of cardiovascular risk factors in patients with psoriasis. J Am Acad Dermatol 2006;55:829-35. 4. Bremmer S, Van Voorhees AS, Hsu S, Korman NJ, Lebwohl MG, Young M, et al. Obesity and psoriasis: from the Medical Board of the National Psoriasis Foundation. J Am Acad Dermatol 2010;63:1058-69. 5. Koebnick C, Black MH, Smith N, Der-Sarkissian JK, Porter AH, Jacobsen SJ, et al. The association of psoriasis and elevated blood lipids in overweight and obese children. J Pediatr 2011; 159:577-83. 6. Herron MD, Hinckley M, Hoffman MS, Papenfuss J, Hansen CB, Callis KP, et al. Impact of obesity and smoking on psoriasis presentation and management. Arch Dermatol 2005;141: 1527-34. 7. Takahashi H, Tsuji H, Honma M, Ishida-Yamamoto A, Iizuka H. Increased plasma resistin and decreased omentin levels in Japanese patients with psoriasis. Arch Dermatol Res 2013;305: 113-6. 8. Hossler EW, Maroon MS, Mowad CM. Gastric bypass surgery improves psoriasis. J Am Acad Dermatol 2011;65: 198-200. 9. Del Giglio M, Gisondi P, Tessari G, Girolomoni G. Weight reduction alone may not be sufficient to maintain disease remission in obese patients with psoriasis: a randomized, investigator-blinded study. Dermatology 2012;224:31-7. 10. Gisondi P, Del Giglio M, Di Francesco V, Zamboni M, Girolomoni G. Weight loss improves the response of obese patients with moderate-to-severe chronic plaque psoriasis to low-dose cyclosporine therapy: a randomized, controlled, investigator-blinded clinical trial. Am J Clin Nutr 2008;88:1242-7. 11. Hossler EW, Wood GC, Still CD, Mowad CM, Maroon MS. The effect of weight loss surgery on the severity of psoriasis. Br J Dermatol 2013;168:660-1. 12. Schroeder R, Garrison JM Jr, Johnson MS. Treatment of adult obesity with bariatric surgery. Am Fam Physician 2011;84: 805-14. 13. Kissler HJ, Settmacher U. Bariatric surgery to treat obesity. Semin Nephrol 2013;33:75-89. 14. Buchwald H, Estok R, Fahrbach K, Banel D, Jensen MD, Pories WJ, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med 2009;122: 248-56, e245. 15. Porres JM. Jejunoileal bypass and psoriasis. Arch Dermatol 1977;113:983. 16. de Menezes Ettinger JE, Azaro E, de Souza CA, dos Santos Filho PV, Mello CA, Neves M Jr, et al. Remission of psoriasis after open gastric bypass. Obesity Surg 2006;16:94-7. 17. Higa-Sansone G, Szomstein S, Soto F, Brasecsco O, Cohen C, Rosenthal RJ. Psoriasis remission after laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obesity Surg 2004;14: 1132-4. 18. Farias MM, Achurra P, Boza C, Vega A, de la Cruz C. Psoriasis following bariatric surgery: clinical evolution and impact on quality of life on 10 patients. Obesity Surg 2012;22:877-80. 19. Hotamisligil GS, Arner P, Caro JF, Atkinson RL, Spiegelman BM. Increased adipose tissue expression of tumor necrosis
J AM ACAD DERMATOL VOLUME 70, NUMBER 4
factor-alpha in human obesity and insulin resistance. J Clin Invest 1995;95:2409-15. 20. Faurschou A, Zachariae C, Skov L, Vilsboll T, Knop FK. Gastric bypass surgery: improving psoriasis through a GLP-1-dependent mechanism? Med Hypotheses 2011;77:1098-101.
Sako, Famenini, and Wu 779
21. Nowlin N, Solomon H. Weight loss and psoriasis [letter]. Arch Dermatol 1976;112:1465. 22. Perez-Perez L, Allegue F, Caeiro JL, Zulaica JM. Severe psoriasis, morbid obesity and bariatric surgery. Clin Exper Dermatol 2009;34:e421-2.
