British journal of Dermatology (1992) 126, 242-245.
Psoriasis, psoriatic arthritis and the possible association with Sjogren's syndrome P.COLLINS, SARAH ROGERS, J,JACKSON* AND B.McCARTAN City of Dublin Skin and Cancer Hospital, Dublin, Ireland *St James's Hospital, Dublin, Ireland
Accepted for publication 22 October 199t
Sutnmary
Thirty patients with psoriatic arthropathy (PA) were age- and sex-matched with patients with plaque psoriasis alone to investigate a possible link between Sjogren's syndrome (SS) and PA. The results of clinical examination, Schirmer's test, maximal stimulated salivary flow rate, haematological and serologlcal investigations were compared in the two groups. Median maximal stimulated salivary flow rate was significantly reduced in patients with PA suggesting that salivary glands are affected in this condition. One patient with PA had SS.
Sjogren's syndrome (SS) is an autoimmune exocrinopathy that predominantly affects the salivary and lacrimal glands.^ Primary SS, also known as sicca syndrome, comprises dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). Patients with primary SS have an increased risk of lymphoproliferative disease.^ In secondary SS, xerostomia and keratoconjunetivitis sicca are associated with a defined connective tissue disease. It has been suggested that patients with psoriatic arthropathy (PA) have a predisposition to subclinical lacrimo-salivary gland failure which may represent SS.^ If this is so, patients with PA may be predisposed to eye disease, oral infections and dental caries. In addition, many patients with PA take antiarthritic drugs which induce xerostomia^ and so mimic SS. The aim of this study was to investigate whether there is a link between SS and PA.
Methods
age-matched patient for an 83-year-old male with PA and so he was matched with a 68-year-oId male with psoriasis. Patients were asked about the duration of psoriasis, current medication and dry or gritty eyes. They were also questioned about symptoms of xerostomia: dysphagia, change in voice, glandular swelling, altered sense of taste and smell and a dry or burning mouth. The patients were subdivided into four groups: Group A, patients with PA taking xerostomogenic drugs: Group B, patients with PA not taking medication or taking non-xerostomogenic drugs: Group C, patients with psoriasis taking xerostomogenic drugs: Group D, patients with psoriasis not taking medication or taking non-xerostomogenic drugs. The oral cavity was examined for xerosomia, Candida infection or carriage, benign migratory stomatitis (e.g. geographical tongue), enlargement of major salivary glands, mucosal status including atrophy, inflammation, fissuring, ulceration and dental status.
Patients The study was approved by the Hume Street Hospital Ethics Committee. All patients had plaque psoriasis and were referred for the study from the skin clinics. Those with PA had been diagnosed by a rheumatologist. Patients with a history of any of the following factors affecting saliva production were excluded: radiotherapy to the head and neck, diabetes mellitus, chronic granulomatous disease and leukaemia. Patients with PA were age-matched to within 5 years and sex-matched with controls wbo had psoriasis alone. We could not find an
Schirmer's 1 test Schirmer's 1 test was performed using the standard method. Local anaesthetic drops (proxymetacaine hydrochloride) were instilled 5 min before the test to reduce reflex secretion. The wet fllter paper was measured after 5 min. Wetting over 10 mm was normal, 5-10 mm was borderline and less than 5 mm was abnormal. The test was done for each eye and the best result was selected. Parotid salivary flow-rate
Correspondence: Dr P.Collins, City of Dublin Skin and Cancer Hospital, Hume Street. Dublin 2, Ireland.
242
A Carlsson-Crittenden cup was placed over the parotid
PSORIASIS, PA AND THE POSSIBLE ASSOCIATION WITH SS
duct. One millilitre of 10% citric acid was placed in the oral cavity and held for as long as possible by the patient. The secreted saliva passed down a siliconized tube to a graduated cylinder. Flow was measured for 10 min. The mean flow per minute was calculated for right and left parotid glands and because a maximal flow was being sought, the best flow was recorded. Eive patients with PA had repeat stimulated salivary flow tests performed single blind (B McC) at the end of the study to check that the method and results were comparable. Mouth swab The gums, tongue and hard palate were rubbed with a cotton wool swab which was immediately immersed in transport medium. The swab was plated within 2 h on Sabouraud's agar medium and incubated for 48 h at 3 7°C. Candida colonies were counted as follows: 0, none; + , 1-9 colonies; -I-+, 10-99; + + +, 100-999; + + + + , 1000-9999; -h -f + + + , confluent, A colony count of -I- was regarded as commensal, + + as borderline and greater than + + as signiflcant (D. Coleman, personal communication), Sialography Sialograms were performed in half of the patients with PA by infusion of Iipiodol contrast medium from a syringe. An oblique lateral mandible projection was used.
243
Results Thirty patients with PA (16 male, 14 female; mean age 40-9±10-9 years, range 25-83 years) were matched with 30 patients who had psoriasis (mean age 39-9 ± 9 - 4 years, range 23-68 years). The results of the history and examination are shown in Table 1, Clinical xerostomia was more prevalent in the PA group but more of them were on xerostomogenic drugs. There were no signiflcant differences between the groups for Schirmer's 1 test (Fisher's exact test) or Candida colonization (>-I--I-) (;(2 test). Eighteen patients (60%) with PA and flve patients (16%) with psoriasis had reduced salivary flow, using 0-4 ml/min as the lower limit of normal (Fig, 1). It has been stated that salivary flow in not normally distributed.'' However, the values in our study appeared to have a relatively normal distribution and so, in the flrst instance, we examined differences by disease category and drug status using ANOVA. The results suggested that there was a signiflcant interaction between drug status and disease category. The mean flow rates for Groups A and C (the two groups on xerostomogenic drugs) were very similar (0-29 ±0-21 vs. 0-36±0-32 ml/min) but it must be borne in mind that the groups were small (flve cases only in Group A), Mean flow rates for Groups B and D showed a much larger difference (0-28±0-26 vs, 0-68±0-27 ml/min). Accordingly we re-examined the
Table 1. Data of patients with psoriasis and with psoriatic arthritis (percentages in parentheses)
Laboratory investigations Full blood count (FBC), antinuclear antibodies (ANA), antibodies to extractable nuclear antigen (ENA) and rheumatoid factor (RhF) were measured. ANA was measured by indirect immunofluorescence using rat liver and human epithelial cells as substrate,* Antibodies to ENA were measured by countercurrent immunoelectrophoresis using known reference sera as controls,^ RhF was measured by latex agglutination. Double-stranded DNA was measured by indirect immunofluorescence using Crithidia luciliae as substrate.*
Psoriasis
Nail change
Psoriatic arthritis
No
%
No
%
19
(63)
27
(90)
History of: dry mouth burning mouth dry eyes gritty eyes
2 2 3 5
(fi) (6) (10) (16)
6 2 4 6
(20) (6) (13) (20)
Clinical xerostomia
4
(13)
10
(33)
Benign migratory stomatitis
3
(10)
2
Medication
8
(26)
23
(6) (76)
Statistical analysis
Xerostomic drugs
5
(16)
16
(53)
Data were coded on to an IBM Personal Computer, Statistical analysis was carried out with EPISTAT and Statgraphics using the independent t-test, Mann-Whitney U-test, ANOVA, x^ test and Fischer's exact test as appropriate.
Schirmer's 1 test: normal borderline abnormal
23 2 5
(76) (6) (16)
22 1 7
(73) (3) (23)
3
(10)
4
(13)
Candida colonies (> + + )
244
P.COLLINS et al.
1-5
1-0
•
-
0-5
0-0 A. (/7 = 5)
B (/7=25)
C {/) = I6)
D (/I=I4)
Figure 1. Salivary flow values with median as: Group A. patients with psoriasis taking xerostomogenic medication: Group B. patients with psoriasis on non-xerostomogenic medication or not taking medication: Group C. patients with psoriatic arthropathy taking xerostomogenic medication: Group D. patients with psoriatic arthropathy taking nonxerostomogenic medication or not taking medication.
data and a comparison was made of mean salivary flow between those PA (Group B) and psoriasis cases (Group D) who were not taking xerostomogenic drugs. There was a significantly lower mean salivary flow in the PA group (independent £-test, P
Psoriasis, psoriatic arthritis and the possible association with Sjogren's syndrome P.COLLINS, SARAH ROGERS, J,JACKSON* AND B.McCARTAN City of Dublin Skin and Cancer Hospital, Dublin, Ireland *St James's Hospital, Dublin, Ireland
Accepted for publication 22 October 199t
Sutnmary
Thirty patients with psoriatic arthropathy (PA) were age- and sex-matched with patients with plaque psoriasis alone to investigate a possible link between Sjogren's syndrome (SS) and PA. The results of clinical examination, Schirmer's test, maximal stimulated salivary flow rate, haematological and serologlcal investigations were compared in the two groups. Median maximal stimulated salivary flow rate was significantly reduced in patients with PA suggesting that salivary glands are affected in this condition. One patient with PA had SS.
Sjogren's syndrome (SS) is an autoimmune exocrinopathy that predominantly affects the salivary and lacrimal glands.^ Primary SS, also known as sicca syndrome, comprises dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia). Patients with primary SS have an increased risk of lymphoproliferative disease.^ In secondary SS, xerostomia and keratoconjunetivitis sicca are associated with a defined connective tissue disease. It has been suggested that patients with psoriatic arthropathy (PA) have a predisposition to subclinical lacrimo-salivary gland failure which may represent SS.^ If this is so, patients with PA may be predisposed to eye disease, oral infections and dental caries. In addition, many patients with PA take antiarthritic drugs which induce xerostomia^ and so mimic SS. The aim of this study was to investigate whether there is a link between SS and PA.
Methods
age-matched patient for an 83-year-old male with PA and so he was matched with a 68-year-oId male with psoriasis. Patients were asked about the duration of psoriasis, current medication and dry or gritty eyes. They were also questioned about symptoms of xerostomia: dysphagia, change in voice, glandular swelling, altered sense of taste and smell and a dry or burning mouth. The patients were subdivided into four groups: Group A, patients with PA taking xerostomogenic drugs: Group B, patients with PA not taking medication or taking non-xerostomogenic drugs: Group C, patients with psoriasis taking xerostomogenic drugs: Group D, patients with psoriasis not taking medication or taking non-xerostomogenic drugs. The oral cavity was examined for xerosomia, Candida infection or carriage, benign migratory stomatitis (e.g. geographical tongue), enlargement of major salivary glands, mucosal status including atrophy, inflammation, fissuring, ulceration and dental status.
Patients The study was approved by the Hume Street Hospital Ethics Committee. All patients had plaque psoriasis and were referred for the study from the skin clinics. Those with PA had been diagnosed by a rheumatologist. Patients with a history of any of the following factors affecting saliva production were excluded: radiotherapy to the head and neck, diabetes mellitus, chronic granulomatous disease and leukaemia. Patients with PA were age-matched to within 5 years and sex-matched with controls wbo had psoriasis alone. We could not find an
Schirmer's 1 test Schirmer's 1 test was performed using the standard method. Local anaesthetic drops (proxymetacaine hydrochloride) were instilled 5 min before the test to reduce reflex secretion. The wet fllter paper was measured after 5 min. Wetting over 10 mm was normal, 5-10 mm was borderline and less than 5 mm was abnormal. The test was done for each eye and the best result was selected. Parotid salivary flow-rate
Correspondence: Dr P.Collins, City of Dublin Skin and Cancer Hospital, Hume Street. Dublin 2, Ireland.
242
A Carlsson-Crittenden cup was placed over the parotid
PSORIASIS, PA AND THE POSSIBLE ASSOCIATION WITH SS
duct. One millilitre of 10% citric acid was placed in the oral cavity and held for as long as possible by the patient. The secreted saliva passed down a siliconized tube to a graduated cylinder. Flow was measured for 10 min. The mean flow per minute was calculated for right and left parotid glands and because a maximal flow was being sought, the best flow was recorded. Eive patients with PA had repeat stimulated salivary flow tests performed single blind (B McC) at the end of the study to check that the method and results were comparable. Mouth swab The gums, tongue and hard palate were rubbed with a cotton wool swab which was immediately immersed in transport medium. The swab was plated within 2 h on Sabouraud's agar medium and incubated for 48 h at 3 7°C. Candida colonies were counted as follows: 0, none; + , 1-9 colonies; -I-+, 10-99; + + +, 100-999; + + + + , 1000-9999; -h -f + + + , confluent, A colony count of -I- was regarded as commensal, + + as borderline and greater than + + as signiflcant (D. Coleman, personal communication), Sialography Sialograms were performed in half of the patients with PA by infusion of Iipiodol contrast medium from a syringe. An oblique lateral mandible projection was used.
243
Results Thirty patients with PA (16 male, 14 female; mean age 40-9±10-9 years, range 25-83 years) were matched with 30 patients who had psoriasis (mean age 39-9 ± 9 - 4 years, range 23-68 years). The results of the history and examination are shown in Table 1, Clinical xerostomia was more prevalent in the PA group but more of them were on xerostomogenic drugs. There were no signiflcant differences between the groups for Schirmer's 1 test (Fisher's exact test) or Candida colonization (>-I--I-) (;(2 test). Eighteen patients (60%) with PA and flve patients (16%) with psoriasis had reduced salivary flow, using 0-4 ml/min as the lower limit of normal (Fig, 1). It has been stated that salivary flow in not normally distributed.'' However, the values in our study appeared to have a relatively normal distribution and so, in the flrst instance, we examined differences by disease category and drug status using ANOVA. The results suggested that there was a signiflcant interaction between drug status and disease category. The mean flow rates for Groups A and C (the two groups on xerostomogenic drugs) were very similar (0-29 ±0-21 vs. 0-36±0-32 ml/min) but it must be borne in mind that the groups were small (flve cases only in Group A), Mean flow rates for Groups B and D showed a much larger difference (0-28±0-26 vs, 0-68±0-27 ml/min). Accordingly we re-examined the
Table 1. Data of patients with psoriasis and with psoriatic arthritis (percentages in parentheses)
Laboratory investigations Full blood count (FBC), antinuclear antibodies (ANA), antibodies to extractable nuclear antigen (ENA) and rheumatoid factor (RhF) were measured. ANA was measured by indirect immunofluorescence using rat liver and human epithelial cells as substrate,* Antibodies to ENA were measured by countercurrent immunoelectrophoresis using known reference sera as controls,^ RhF was measured by latex agglutination. Double-stranded DNA was measured by indirect immunofluorescence using Crithidia luciliae as substrate.*
Psoriasis
Nail change
Psoriatic arthritis
No
%
No
%
19
(63)
27
(90)
History of: dry mouth burning mouth dry eyes gritty eyes
2 2 3 5
(fi) (6) (10) (16)
6 2 4 6
(20) (6) (13) (20)
Clinical xerostomia
4
(13)
10
(33)
Benign migratory stomatitis
3
(10)
2
Medication
8
(26)
23
(6) (76)
Statistical analysis
Xerostomic drugs
5
(16)
16
(53)
Data were coded on to an IBM Personal Computer, Statistical analysis was carried out with EPISTAT and Statgraphics using the independent t-test, Mann-Whitney U-test, ANOVA, x^ test and Fischer's exact test as appropriate.
Schirmer's 1 test: normal borderline abnormal
23 2 5
(76) (6) (16)
22 1 7
(73) (3) (23)
3
(10)
4
(13)
Candida colonies (> + + )
244
P.COLLINS et al.
1-5
1-0
•
-
0-5
0-0 A. (/7 = 5)
B (/7=25)
C {/) = I6)
D (/I=I4)
Figure 1. Salivary flow values with median as: Group A. patients with psoriasis taking xerostomogenic medication: Group B. patients with psoriasis on non-xerostomogenic medication or not taking medication: Group C. patients with psoriatic arthropathy taking xerostomogenic medication: Group D. patients with psoriatic arthropathy taking nonxerostomogenic medication or not taking medication.
data and a comparison was made of mean salivary flow between those PA (Group B) and psoriasis cases (Group D) who were not taking xerostomogenic drugs. There was a significantly lower mean salivary flow in the PA group (independent £-test, P
