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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 36  |  Issue : 2  |  Page : 29-33

Serum concentration of 25-hydroxy vitamin D in psoriatic patients in a tertiary care hospital: a case–control study


Department of Dermatology and Venereal Diseases, Narayana Medical College Hospital, Nellore, Andhra Pradesh, India

Date of Submission21-Nov-2015
Date of Acceptance07-Apr-2016
Date of Web Publication21-Mar-2017

Correspondence Address:
Latha Srirama
Department of Dermatology and Venereal Diseases, Narayana Medical College Hospital, Chinthareddypalem, Nellore 524003, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-6530.202642

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  Abstract 


Background Vitamin D is a fat-soluble vitamin and synthesized in the skin from 7-dehydroxy cholesterol during exposure to ultraviolet B. Vitamin D is essential for calcium homeostasis, bone growth, and immune regulation. Vitamin D deficiency causes rickets, osteomalacia, osteoporosis, and muscle weakness. Vitamin D deficiency is associated with cancers, cardiovascular diseases, schizophrenia, wheezing illness, and autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, type 1 diabetes mellitus, multiple sclerosis, Crohn’s disease, psoriasis, vitiligo, and chronic urticaria.
Objective The main objective of this study was to analyze the 25-hydroxy vitamin D status of patients with psoriasis in comparison with controls without psoriasis.
Patients and methods This study included 30 patients (age-matched and sex-matched controls) from the Outpatient Department of Narayana Hospital Dermatology Department in Nellore, Andhra Pradesh. All patients and controls were studied during the 4-month period from July 2015 to October 2015.
Results Serum 25-hydroxy vitamin D levels were significantly lower in psoriatic patients than in controls even after adjusting for confounding factors in a multivariate analysis. Low 25-hydroxy vitamin D levels were positively associated with psoriasis and BMI in multiple linear regression analysis. Psoriatic patients with BMI greater than or equal to 27 kg/m2 had a higher risk for 25-hydroxy vitamin D insufficiency.
Limitations Further studies with larger numbers of patients are required to analyze the pathogenic mechanisms underlying the relationship between 25-hydroxy vitamin D deficiency and psoriasis.
Conclusion The 25-hydroxy vitamin D values are significantly lower in psoriatic patients than in controls. Low 25-hydroxy vitamin D levels are positively associated with psoriasis and with obesity.

Keywords: body mass index, 25-hydroxy vitamin D, psoriasis


How to cite this article:
Srirama L. Serum concentration of 25-hydroxy vitamin D in psoriatic patients in a tertiary care hospital: a case–control study. Egypt J Dermatol Venerol 2016;36:29-33

How to cite this URL:
Srirama L. Serum concentration of 25-hydroxy vitamin D in psoriatic patients in a tertiary care hospital: a case–control study. Egypt J Dermatol Venerol [serial online] 2016 [cited 2018 Aug 18];36:29-33. Available from: http://www.ejdv.eg.net/text.asp?2016/36/2/29/202642




  Introduction Top


Psoriasis is a chronic, immune-mediated inflammatory skin disease, associated with metabolic and cardiovascular disease [1]. Psoriasis is considered to be a T-cell-mediated inflammatory skin disease, which is characterized by hyperproliferation and poor differentiation of epidermal keratinocytes. Psoriasis is estimated to affect about 2-4% of the population in western countries [2]. From the available studies, the prevalence of psoriasis in India ranges from 0.44 to 2.8% [3]. A number of risk factors have been recognized in the etiology and pathogenesis of psoriasis, including family history and environmental risk factors, such as diet, obesity, smoking, stress, and alcohol consumption [4]. Moreover, dietary factors can also affect both drug pharmacokinetics and pharmacodynamics. A number of single food components have been suggested to play a role in psoriasis. The ability of dietary antioxidants, such as omega-3 polyunsaturated fatty acids from fish oil, some vitamins (A, E, and C), and oligoelements (iron, copper, manganese, zinc, and selenium), which decrease oxidative stress and the production of reactive oxygen species, might be of particular relevance mainly in a chronic systemic inflammatory diseases, such as psoriasis [5]. In addition, due to its role in the proliferation and maturation of keratinocytes, vitamin D has become an important therapeutic option in the treatment of psoriasis [5].

Vitamin D [25-hydroxy vitamin D; 25(OH)D] is a hormone whose synthesis is stimulated by cutaneous exposure to ultraviolet B radiation. It acts on calcium homeostasis, on bone metabolism, and has immune-regulating functions that have been recently recognized. Some studies have demonstrated a relationship between vitamin D deficiency and psoriasis [6],[7]. The immune-regulatory role of vitamin D affects both the innate and adaptive immune system, contributing to the immune-tolerance of self-structures. 1,25(OH)2D3 is one of the most important gene regulators, as a ligand binds to vitamin D receptors, enters the nucleus, and by binding to different genes regulates mRNA synthesis. The major function of 1,25(OH)2D3 vitamin D is that it increases the absorption of calcium and phosphate from the intestinal tract, inhibits the secretion of parathormone and the proliferation of the parathyroid glands, and thus positively regulates bone formation [8][9][10]. Active vitamin D has a regulatory function in the calcium homeostasis, endocrine system, proliferation of skin keratinocytes, and importantly plays a significant role in the regulation of the immune system [11].

Defining a level of serum 25(OH)D as low or insufficient depends on the level that is defined as normal. Health authorities used different cutoffs for their definitions of sufficient and optimal status. The Institute of Medicine Committee found 20 ng/ml to be the level that is needed for good bone health for all individuals [12]. Substantial evidence suggests that vitamin D plays a pivotal role in modulating dendritic cell function and regulating keratinocytes and T-cell proliferation [13],[14]. Epidemiological data have also confirmed that vitamin D deficiency may be a risk for the development of autoimmune diseases, including rheumatoid arthritis, multiple sclerosis, systemic lupus erythematosus, and Crohn’s disease [15][16][17][18].

Previous studies on the relationship of diet and nutrition with psoriasis have focused on either individual nutrients (e.g. fish oil, omega-3, vitamin B12, vitamin D, vitamin A, selenium, inositol, and zinc and antioxidants) or individual food groups (e.g. fruit, vegetables, and fish) [7],[19].

Although many studies have evaluated the role of vitamin D in psoriatic disease, there are less/no studies that have been investigated in the coastal Andhra region. Hence, the current study was conducted to analyze vitamin D levels in psoriasis at this region in comparison with age-matched and sex-matched controls.


  Patients and methods Top


Sample size

The study included 30 cases and 30 controls.

Setting

The study was conducted in the Department of Dermatology, Venerology (DV), Narayana Medical College Hospital, Nellore, Andhra Pradesh.

Cases

Thirty outpatients, 20 male and 10 female, diagnosed clinically with psoriasis were enrolled in this study.

Control

Thirty age-matched and sex-matched controls, 20 male and 10 female, were taken from patients coming for routine health checkup from the Department of DVL in our hospital.

Inclusion criteria

Clinically diagnosed cases of psoriasis and patients older than 18 years were included in the study.

Exclusion criteria

Exclusion criteria were as follows: pregnancy or lactation; topical or ultraviolet B therapy within previous 2 weeks; systemic corticosteroids, PUVA, or laser phototherapy within previous 4 weeks; other systemic therapies or biologics within previous 12 weeks; and age younger than 18 years. Moreover, patients on vitamin D supplement/receiving steroid preparations or those having any other autoimmune disease were excluded from both the case and the control group.

Investigation

After informed consent was obtained from patients, blood samples were drawn from all participants for estimating vitamin D levels. The electrochemiluminescence method was used to analyze 25(OH)D. Mean vitamin D levels were calculated for both groups.

Statistical analysis

Data recorded on a predesigned proforma were entered on an excel spreadsheet and entries were double checked for any errors. The Pearson test was used to explore the linear correlation between Psoriasis Area and Severity Index (PASI) and 25(OH)D serum levels. Independence of the association of vitamin D deficiency and presence of psoriasis was assessed using multivariate regression analysis. In the fully adjusted regression model, age, sex, smoking habit, BMI, psoriasis, psoriasis duration, and PASI score were also included as independent covariates. A P-value of less than 0 · 05 was considered statistically significant.


  Results Top


Anthropometric and demographic characteristics

Thirty participants were included in this study. In the case group, the mean BMI was 24.56±3.8 kg/m2 and the mean weight and height were 63.4±10.6 kg and 159.0±8.2 cm, respectively. However, in the control group, the mean BMI was 25.47±3.4 kg/m2 and the mean weight and height were 63.4±10.6 kg and 159.0±8.2 cm, respectively.

The mean age in the psoriasis group was 47.8±12.8 years, whereas it was 49.8±10.5 years in the control group. Three participants in the case group and two participants in the control group were 20 years or younger. Eight participants in the case group and seven participants in the control group were between 21 and 40 years of age. Ten participants in the case group and 11 participants in the control group were between 41 and 60 years of age. Nine participants in the case group and 10 participants in the control group were between 61 and 80 years of age.

One male and two female participants were 20 years or younger. Three male and five female participants were between 21 and 40 years of age. Seven male and three female participants were between 41 and 60 years of age. Nine male and zero female participants were between 61 and 80 years of age. There was no significance difference observed among the age groups.

Eight participants in the case group and 10 participants in the control group were smokers. However, 10 participants in the case group and five participants in the control group were alcoholics. There was no significant difference observed as regards smokers/alcoholics.

Vitamin D levels

The mean vitamin D level in patients was 18.24±4.55 ng/ml (minimum: 4.2 ng/ml and maximum: 30.53 ng/ml), whereas in controls it was 24.23±10.64 ng/ml (minimum: 7.9 ng/ml and maximum: 34.3 ng/ml). There was a statistically significant difference between cases and controls (P<0.0001). Vitamin D deficiency was observed in 76% of psoriasis patients compared with 27% of controls (P<0.001). Vitamin D deficiency was seen in 13 nonobese and 10 obese individuals ([Table 1]).
Table 1 Vitamin D levels in cases and controls

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Palmoplantar psoriasis was recorded in one male and zero female patients. Psoriatic erythroderma was recorded in one male and one female patient. Psoriasis vulgaris was recorded in 17 male and nine female patients. Scalp psoriasis was recorded in one male and zero female patients. There was no significant difference observed between types of psoriasis.

Psoriasis Area and Severity Index

Sixteen cases showed PASI less than or equal to 10, 12 cases showed PASI of 11–20, no cases showed PASI of 21–30 and PASI of 31–40, one case showed PASI of 41–50, no cases showed PASI of 51–60, and one case showed PASI more than 60.

Fitzpatrick’s skin phototype

Eight participants in the case group belonged to type IV Fitzpatrick’s skin phototype (FPSP). Nineteen participants in the case group belonged to type V FPSP. Three participants in the case group belonged to type VI FPSP. There was no significant difference observed in these types.

Daily direct sun exposure

There were four cases with 30 daily direct sun exposure (DDSE)/min, three cases with 40 DDSE/min, 12 cases with 60 DDSE/min, five cases with 120 DDSE/min, one case with 240 DDSE/min, four cases with 480 DDSE/min, and one case with 600 DDSE/min ([Table 2]).
Table 2 Comparison of variables studied between the psoriasis group and the control group

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  Discussion Top


The major finding of this study is that vitamin D deficiency is very frequent in patients with psoriasis vulgaris. Gisondi et al. [20] found that this finding was more common in winter, but it was also found in summer in ∼50% of patients. The present study was conducted in summer months, and this coincides with the above study. The association between vitamin D insufficiency and psoriasis was confirmed independent of age, sex, BMI, and PASI score. Vitamin levels are higher in those who have greater BMI, and this finding also coincides with the studies by Orgaz-Molina et al. [21] and Rossini et al. [22]. Few studies explored low levels of 25(OH)D associated with vitiligo. In the present study, two patients with psoriasis also had vitiligo. This supports the above study and the study conducted by Marques et al. [23], which explored vitamin D deficiency related to autoimmunity.

The relationship between 25(OH)D and psoriasis has been studied since the 1930s. In 1985, Morimoto et al. [24]

made a chance discovery that vitamin D3 administration improved psoriasis in isolated cases. It has been clearly established that vitamin D deficiency is a risk factor for osteoporosis and increases the risk of falling in the elderly [25].

The finding of vitamin D deficiency in patients with psoriasis could be relevant for several reasons. Deficient 25(OH)D levels in patients with psoriasis may be associated with alterations in isoenzymes that affect the synthesis of vitamin D. Some studies have shown differences in vitamin D receptor polymorphisms between patients with psoriasis and the general population [26]. However, few data are available on the isoenzyme polymorphisms that influence serum 25(OH)D levels, such as 7-dehydrocholesterol reductase (responsible for the availability of 7-dehydrocholesterol in the skin), liver 25-hydroxylase, CYP2R1 (involved in the conversion of vitamin D into 25(OH)D), and CYP24A1 (a key degradation enzyme). In addition, polymorphisms in GC gene, which encodes vitamin debinding protein, have a major effect on serum 25(OH)D concentration [27]. Deficient 25(OH)D levels in psoriatic patients may also be secondary to an inflammatory environment, and C-reactive protein was negatively correlated with 25(OH)D in the current study. A recent study showed low 25(OH)D levels to be associated with endothelial dysfunction and inflammatory activation markers (C-reactive protein and asymmetric dimethylarginine concentrations) [28].

Several conditions may contribute to low serum levels of vitamin D in the general population: poor dietary intake of vitamin D; sun avoidance and/or negligible sun exposure, possibly related also to impaired quality of life; malabsorption due to inflammatory bowel disease, gluten enteropathy, gastric surgery, biliary disease, or intestinal bacteria overgrowth; use of antiseizure medications (e.g. phenobarbital or phenytoin); and long-term use of glucocorticoids. The reason for the higher prevalence of vitamin D deficiency in patients with psoriasis is not clear. However, we can exclude the possibility that this difference was related to different sun exposure between groups. Vitamin D deficiency has been already reported in other chronic immune-mediated inflammatory skin diseases, including atopic dermatitis, vitiligo, and chronic urticaria. A possible role of vitamin D deficiency in the development of these conditions has been also proposed.

Once detected, vitamin D deficiency could be corrected, although no evidence of the possible benefits of vitamin D supplementation in reducing inflammation and/or the risk for other incident autoimmune diseases has yet been proven. Moreover, optimal dosage regimens for vitamin D remain uncertain. In general, for every 100 IU of vitamin D taken in, there is an increase of roughly 1 ng/ml (3 nmol/l) in the serum level of 25(OH)D. Most trials assessing the effectiveness of the supplementation of 25(OH)D levels and the risk for fractures and falling have used daily doses of vitamin D between 400 and 1000 IU. Toxicity from vitamin D supplementation is very rare and consists principally of acute hypercalcemia, which usually results from doses that exceed 10 000 IU per day. The tolerable upper level of daily vitamin D intake recently set by the Institute of Medicine is 4000 IU.

Morimoto et al. [29] detected less circulating vitamin D3 in patients with severe psoriasis. This relationship can be partially explained by the liposolubility of vitamin D and its reduced bioavailability in bodies with a high fat content. Obesity is associated with basic systemic inflammation, characterized by an increase in proinflammatory markers such as TNF-α and IL-6 [30]. Adipokines are also dysregulated, which might be the basis of vascular diseases [31], and of insulin resistance and subsequent diabetes mellitus. The quantity of 25(OH)D is very important for general population and psoriasis population, because this group display an altered metabolism [32]. Metabolic syndrome [33],[34] (diabetes, hypertension, dyslipidemia, being overweight, and obesity) is related to 25(OH)D. Thus, evaluating its optimum levels in blood could prevent less comorbidities from appearing.

In conclusion, vitamin D deficiency may be common in patients with psoriasis, and vitamin D has a role in immune regulation. Therefore, patients could be routinely screened for serum vitamin D levels for a more comprehensive management.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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